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1 24 pissn : , eissn : Original Article J Korean Orthop Assoc 2019; 54: 경피적척추성형술후조기에발생한새로운척추압박골절 김종길 최병열 박영철 김동현 전주예수병원정형외과 Early Onset Subsequent Vertebral Compression Fracture after Percutaneous Verteroplasty Jong-Kil Kim, M.D., Byeong-Yeol Choi, M.D., Young-Chul Park, M.D., and Dong-Hyun Kim, M.D. Department of Orthopedic Surgery, Presbyterian Medical Center, Jeonju, Korea Purpose: To evaluate the characteristics and the risk factors of early onset subsequent vertebral compression fractures after percutaneous vertebroplasty. Materials and Methods: A total of 44 patients, who had a new subsequent vertebral fracture after percutaneous vertebroplasty for an osteoporotic vertebral compression fracture between January 2013 and December 2015, were recruited. The patients were divided into two groups according to the onset period of subsequent fracture. The number of patients who had a fracture within 3 months following vertebroplasty were 22 cases (Group A); after 3 months were 22 cases (Group B). Variables, including age, sex, bone mineral density (BMD), body mass index (BMI), preexisting vertebral compression fracture, location of the initial fracture, intradiscal cement leakage, injected cement volume, restoration of vertebral body height, and correction of kyphosis, in the two groups were analyzed and compared retrospectively. Results: The age, sex, BMD, BMI, preexisting vertebral compression fracture, location of the initial fracture, intradiscal cement leakage, and correction of kyphosis were similar in the two groups. Both a greater volume of bone cement injected and a greater degree of vertebral height restoration contributed significantly to the risk of fracture within 3 months. Conclusion: The cement volume and degree of height restoration are risk factors for early onset fracture at the adjacent vertebrae after percutaneous vertebroplasty and close attention is needed during the follow-up period. Key words: osteoporosis, compression fractures, risk factors, vertebroplasty 서론 경피적척추성형술은보존적치료에호전이없는골다공증성척 추압박골절의효과적인치료방법중하나이지만다양한합병증 이보고되고있다. 시술후인접부위의추체에새로운압박골절 이발생하는것도그중하나로이는골시멘트가주입된추체의 Received October 10, 2017 Revised November 29, 2017 Accepted December 22, 2017 Correspondence to: Byeong-Yeol Choi, M.D. Department of Orthopedic Surgery, Presbyterian Medical Center, 365 Seowon-ro, Wansan-gu, Jeonju 54987, Korea TEL: FAX: docby@hanmail.net ORCID: 증가된강성 (stiffness) 으로인하여인접분절척추체로의하중전달이변화되어발생하는것으로생각되고있다. 1) 이러한인접분절척추의새로운골절은시술후 1년이내에발생할가능성이높아추시과정에서이에대한주의가필요하다고하였는데 2) 이에대한예방으로보조기등의추가적인보호를하여도시술후조기에골절이발생하는경우가있다. 이에대하여저자들은골다공증성척추골절에대하여경피적척추성형술후조기에발생하였던인접분절의새로운골절에대하여분석해보고골절이조기에발생하는데영향을미치는위험인자에대하여알아보고자하였다. The Journal of the Korean Orthopaedic Association Volume 54 Number Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 25 Early Onset Subsequent Vertebral Fracture 대상및방법 1. 대상 2013년 1월부터 2015년 12월까지전주예수병원에서골다공증성척추압박골절로진단후경피적척추성형술을시행받은총 306 예중추시가가능했던 215예를대상으로후향적으로분석하였다. 전이성암이나골종양에의해발생한병적골절은연구대상에서제외하였다. 추시시간은평균 14.8개월 (5-50개월) 로시술후마지막방문했을때까지의기간, 또는인접분절에새로운골절이발생했을때까지의기간으로하였다. 2. 치료방법시술은복와위에서척추경접근을통하여국소마취하에시행되었으며시술후에는가능한조기에거동을권장하였다. 술후 3개월간흉요천추보조기를착용시켰으며골다공증에대한약물치료를병행하였다. 3. 연구방법골밀도 (bone mineral density, BMD) 의측정에는이중에너지방사선흡수검사 (dual-energy X-ray absorptiometry, Delphi; Hologic, Marlborough, MA, USA) 를시행하여요추부및대퇴경부의 T-score와골량을측정하였으며요추부 BMD는두개이상의추체를포함한것중에서가장낮은수치를골라평균값을이용하였다. 경피적척추성형술을시행한초기골절의위치에따라골절이주로발생하는흉요천추이행부 ( 제10 흉추에서제2 요추 ) 에발생한경우와그외부위 ( 제4 흉추에서제9 흉추, 제3 요추에서제5 요추 ) 에발생한경우로구분했다. 또한초기골절이전에존재하였던시술을받지않은척추골절의유무및골절의개수 ( 기존의골절이 2개이상인경우 ) 에대해서도조사하였다. 시술전후단순방사선촬영에서골절추체의전방높이회복률 (%) 과후만각회복정도를측정하였다. 방사선사진은환자를앙와위상태로촬영하였으며시술전최종추시사진과시술직후의사진을비교하였다. 척추체높이회복률은측면방사선사진상추체의전방에서측정하였고골절척추체상하의평균척추체높이에대한시술전후의높이차를백분율을통하여구하였다. 후만각회복정도는골절척추체에인접한상하척추체의상부종판과하부종판의연장선이이루는각도를측정하여시술전후차이를구해후만각의회복정도로정하였다. 추시중새로운골절이인접분절, 즉척추성형술을시행한추체의상하추체에골절이발생한환자를대상으로골절의발생시기에따라두군으로나누었다. 골절이시술후 3개월이내에발생한경우를 A군 (22예) 으로, 3개월이후에발생한경우를 B군 Table 1. Comparison between Subsequent Vertebral Fracture within 3 Months (Group A) and after 3 Months (Group B) Patient characteristic Characteristic Group A (n=22) Group B (n=22) p-value Age (yr) 81.0± ± Gender (female/male) 16/6 14/ BMD Lumbar (T-score) -4.19± ± Lumbar (g/cm 2 ) 0.62± ± Femur neck (T-score) -2.56± ± Femur neck (g/cm 2 ) 0.577± ± BMI (kg/m 2 ) 21.58± ± Imaging and technical characteristic Presence of other preexisting VCFs Number of preexisting VCFs Primary fracture (T-L junction/non-t-l junction) 17/5 18/ Volume of cement injected (ml) 5.53± ± Intradiscal cement leakage Kyphotic angle correction ( ) 2.18± ± Veretebral body height restoration (%) 16±13 9± Values are presented as mean±standard deviation or number only. The data is analyzed by Mann-Whitney U-test, chi-square test, and Fisher's exact test. p-values of <0.05 were considered statistically significant. BMD, bone mineral density; BMI, body mass index; VCF, vertebral compression fracture; T-L, thoracolumbar.

26 Jong-Kil Kim, et al. (22예) 으로정의한후두군간의평균나이, 성별, BMD, 체질량지수 (body mass index, BMI), 기존골절의유무및골절의개수, 초기골절위치, 시멘트주입량, 추간판내로의시멘트누출여부, 추체의전방높이회복률, 후만각회복정도의차이에대하여후향적으로비교분석하였다.

결과 추시중새로운골절이발생한경우는총 215예중 74예 (34.4%) 였고골절이인접분절, 즉척추성형술을시행한추체의상하추체에발생한경우는 44예 (20.5%) 였다.

고찰 골다공증성척추압박골절에대한골시멘트를이용한경피적척추성형술은최소침습적이며효과적인치료방법이다. 하지만시술과관련된다양한합병증이보고되고있으며척추성형술후다른부위에새로발생하는골절을척추성형술의합병증중하나로보고시술과의연관성을찾으려는여러연구가있었다.

특히시술후얼마되지않아새로운골절이발생하는경우에는입원기간이길어지고장기간의침상안정으로인하여내과적합병증의발생가능성이더욱증가하게된다. 또한시술후재골절의우려때문에환자및의사는새로발생한골절에대한적극적처치를주저하게된다 (Fig. 1). 실제로척추성형술후인접부위의척추압박골절이조기에발생할확률은높게보고되고있다.

Li 등 9) 도대부분 (43%) 의연속된골절이시술후 3개월내에발생하였고이후재골절의발생은급격히감소한다고하여이기간동안주의깊은보호가필요하다고하였다. 이에저자들은경피적척추성형술후조기에인접부위에연속된골절이발생하는환자의특성을파악하고그와연관된위험인자를찾고자하였다. 기존의논문을참고하여척추성형술후연속된척추골절이 3개월이전에발생한경우와그이후에발생한경우로나누어비교분석하였다.

3 26 Jong-Kil Kim, et al. (22예) 으로정의한후두군간의평균나이, 성별, BMD, 체질량지수 (body mass index, BMI), 기존골절의유무및골절의개수, 초기골절위치, 시멘트주입량, 추간판내로의시멘트누출여부, 추체의전방높이회복률, 후만각회복정도의차이에대하여후향적으로비교분석하였다. 통계분석에는 IBM SPSS statistics ver (IBM Co., Armonk, NY, USA) 을사용하였고, 각군의비교는 Mann-Whitney U-test, chi-square test 및 Fisher s exact test를사용하여 p-value가 0.05 이하인경우를통계적으로유의하다고판정하였다. 결과 추시중새로운골절이발생한경우는총 215예중 74예 (34.4%) 였고골절이인접분절, 즉척추성형술을시행한추체의상하추체에발생한경우는 44예 (20.5%) 였다. 척추성형술시행후 A군과 B 군간에나이, 성별, BMD, BMI, 기존척추골절의유무및골절의개수, 초기골절위치, 추간판내로의시멘트누출여부, 후만각회복정도에있어서는통계적으로유의한차이를보이지않았다 (p>0.05). 시멘트주입량및추체높이회복정도만이골절발생시기와유의한상관관계를보였다 (p<0.05) (Table 1). 고찰 골다공증성척추압박골절에대한골시멘트를이용한경피적척추성형술은최소침습적이며효과적인치료방법이다. 하지만시술과관련된다양한합병증이보고되고있으며척추성형술후다른부위에새로발생하는골절을척추성형술의합병증중하나로보고시술과의연관성을찾으려는여러연구가있었다. 3-5) 반면경피적척추성형술후다른척추골절이더많이발생한다는증 거는없으며보존적치료로치료한척추압박골절에서도마찬가지로새로운골절은발생하고있어이를골다공증성척추골절의자연경과로보는의견도있다. 6,7) 척추성형술후발생하는새로운척추압박골절은통증및활동제한의재발로인하여환자뿐아니라의사에게도시술의만족도를떨어뜨리는주된원인중하나이다. 특히시술후얼마되지않아새로운골절이발생하는경우에는입원기간이길어지고장기간의침상안정으로인하여내과적합병증의발생가능성이더욱증가하게된다. 또한시술후재골절의우려때문에환자및의사는새로발생한골절에대한적극적처치를주저하게된다 (Fig. 1). 실제로척추성형술후인접부위의척추압박골절이조기에발생할확률은높게보고되고있다. Kim 등 8) 은인접분절의척추압박골절은시술후 3개월이내에잘발생한다고하였고, 시술후통증감소에따른활동의증가가원인이될수있어시술후점차적으로활동을증가시킬것을권유하였다. Uppin 등 1) 은시술후 1개월내에인접분절의새로운골절이발생하는경우가 67% 나된다고하였고마찬가지로시술후빠른임상적호전에의한활동증가를원인으로생각하였다. Li 등 9) 도대부분 (43%) 의연속된골절이시술후 3개월내에발생하였고이후재골절의발생은급격히감소한다고하여이기간동안주의깊은보호가필요하다고하였다. 이에저자들은경피적척추성형술후조기에인접부위에연속된골절이발생하는환자의특성을파악하고그와연관된위험인자를찾고자하였다. 기존의논문을참고하여척추성형술후연속된척추골절이 3개월이전에발생한경우와그이후에발생한경우로나누어비교분석하였다. 본연구에서는시술시사용된시멘트양과술후추체높이회복정도가골절발생시기에따라분류한양군의비교에서유의한차이를보였고, 척추성형술시많은양의시멘트를주입하여추체높이회복정도가컸던경우에조기에골절이발생하는것 A B C D E Figure 1. A 73-year-old female. Plain radiograph shows T11 compression fracture (A) and treated via percutaneous vertebroplasty (B). Total volume of cement inejected was 8 ml and restoration of anterior body height was 40%. T1-sagittal magnetic resonance image 4 weeks after vertebroplasty shows new compression fracture in T12 vertebra (C) and treated via vertebroplasty again (D). The patient developed severe recurrent back pain at 10 days after second vertebroplasty. (E) Adjacent-level fracture was noted at L1. The patient refused suqbequent vertebroplasty and was treated conservatively for new fracture.

4 27 Early Onset Subsequent Vertebral Fracture 을확인할수있었다. 시술후추체회복정도와인접분절의골절발생위험과의상관관계는기존의여러연구에서확인된바있다. Kim 등 8) 은압박된추체높이의회복이큰경우인접분절의새로운골절의발생가능성이증가한다고하였고, 추체높이의회복이추체주변의연부조직의긴장을유발하여주변척추의부하를증가시켜영향을줄것이라고하였다. Kim 등 2) 도인접추체골절이발생했던경우에서경피적척추성형술후추체높이회복률이높아시술및추시과정에서이에대한주의와관심이필요하다고하였다. Li 등 9) 은추체높이회복정도가인접추체에발생하는연속된골절의발생위험에영향을주는반면비인접추체의골절발생에는영향을주지않는다고하였다. 경피적척추성형술시주입되는시멘트의이상적인양에대해서는아직이견이있다. 시멘트주입량과임상결과가일치하는것은아니며시멘트주입량이증가할수록시멘트누출가능성이높기때문에굳이많은양의시멘트를주입할필요는없다는주장이있는반면 10-12) Uppin 등 1) 은시멘트로채워진부위가더많을수록더안정적이며추체의최대한많은부분을시멘트로채우는것이좋다고하였다. Li 등 9) 은주입된시멘트양이많으면후만변형의교정에효과적이라는장점이있는반면인접추체의골절발생이증가하여후만교정과임상결과와의관계에대한더많은연구가필요하다고하였다. 척추성형술시많은양의시멘트가주입된경우에는추체에서시멘트로채워지지않은부분이가지고있는완충효과가감소하여인접추체로가는스트레스가증가함에따라골절의위험이증가할것이라는의견도있다. 13) 저자들은본연구를통해시멘트주입량이많을경우압박된골절의높이회복에는용이하나인접분절골절이발생할가능성이증가할수있다는기존의연구결과와더불어조기에골절이발생할가능성도같이증가할수있음을확인할수있었다. 인접척추의연속된조기골절의발생을예방하기위한적절한시멘트양및추체회복정도에대해서는추가적인연구가필요할것으로생각된다. 기존의연구에서새로발생한압박골절의위험인자로제시하였던낮은 BMD 5,14) 와 BMI, 15) 기존척추골절의존재여부 4,7,14) 는골절발생시기에따른양군간의비교에서의미있는차이를보이지않았다. 이는연구대상이된환자들이모두새로운압박골절이발생한환자로양군의환자대부분이 BMD 및 BMI 지수가낮고기존의척추골절을가지고있었기때문으로생각된다. 또한초기골절이비교적움직임이많은흉요추이행부에서발생하는경우인접분절에발생하는압박골절이증가하는것으로보고되어있으나 8) 본연구에서는대부분의초기골절 (80%) 이흉요천추이행부에서발생하였기때문에초기골절위치는골절의발생시기에의미있는위험인자로작용하지못했다. 추간판내로의시멘트유출은인접추체의압력을증가시켜연속된골절을유발할수있는위험인자로알려져있으나 14,16,17) 본 연구에서는골절발생시기와의연관성은확인할수없었다. 하지만시멘트누출사례수가적어더많은대상환자군을통한연구에서는다른결과를보일수도있을것으로생각된다. 후만각의회복은주변연부조직의스트레스를증가시켜인접부위의골절위험성을증가시키는것으로알려져있으나 15) 본연구에서는조기골절의발생에는영향을주지않았다. 본연구는후향적으로진행되었으며거동이불편한고령의환자특성상시술후연속적인추시가되지않고중도탈락된환자가많아대상수가적은단점이있다. 시술후환자의활동정도의차이등결과에영향을줄수있을것으로생각되는다양한변수에대한추가적인고려및연구도필요할것으로생각된다. 결론 경피적척추성형술시골시멘트주입량과시술후추체높이회복정도가인접분절에발생하는척추골절빈도뿐아니라발생시기에도영향을줄수있는인자로확인되었다. 따라서척추성형술시골시멘트주입량이많고추체높이회복률이높은경우에는추시과정에서인접분절골절의조기발생에대한주의가필요할것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Uppin AA, Hirsch JA, Centenera LV, Pfiefer BA, Pazianos AG, Choi IS. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Radiology. 2003;226: Kim CH, Hwang JK, Park JS. Adjacent vertebral compression fracture after percutaneous vertebroplasty. J Korean Soc Spine Surg. 2013;20: Tseng YY, Yang TC, Tu PH, Lo YL, Yang ST. Repeated and multiple new vertebral compression fractures after percutaneous transpedicular vertebroplasty. Spine (Phila Pa 1976). 2009;34: Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001; 285: Kim SS, Lee DH, Kim JH, et al. Risk factors for subsequent vertebral compression fracture following osteoporotic compression fracture. J Korean Orthop Assoc. 2016;51:

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6 29 pissn : , eissn : Original Article J Korean Orthop Assoc 2019; 54: 경피적척추성형술후조기에발생한새로운척추압박골절 김종길 최병열 박영철 김동현 전주예수병원정형외과 목적 : 골다공증성척추압박골절에대한경피적척추성형술후조기에발생하였던새로운연속골절의특성과위험인자에대하여알아보고자하였다. 대상및방법 : 2013년 1월부터 2015년 12월까지골다공증성척추압박골절로경피적척추성형술을시행받은환자중인접추체에새로운골절이발생한 44예를대상으로하였으며골절발생시기에따라 2군으로나누었다. 3개월내에골절이발생한경우가 22예 (A군) 였고 3개월이후에발생한경우가 22예 (B군) 였다. 두군간의나이, 성별, 골밀도, 체질량지수, 기존척추골절의존재, 초기골절위치, 추간판내시멘트누출, 시멘트주입량, 추체의높이회복정도, 후만각교정정도의차이에대하여후향적으로비교분석하였다. 결과 : 두군간의나이, 성별, 골밀도, 체질량지수, 기존척추골절의존재, 초기골절위치, 추간판내시멘트누출, 후만각교정정도에는유의한차이는없었다. 시멘트주입량이많은경우와추체높이회복정도가큰경우에서 3개월내에골절이발생한빈도가유의하게높았다. 결론 : 경피적척추성형술시시멘트양과추체높이회복정도는 3개월이내에발생하는조기인접척추골절의위험인자로판단되며추시과정에서주의가필요할것으로판단된다. 색인단어 : 골다공증, 압박골절, 위험인자, 척추성형술 접수일 2017 년 10 월 10 일수정일 2017 년 11 월 29 일게재확정일 2017 년 12 월 22 일책임저자최병열 54987, 전주시완산구서원로 365, 전주예수병원정형외과 TEL , FAX , docby@hanmail.net, ORCID 대한정형외과학회지 : 제 54 권제 1 호 2019 Copyright 2019 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical