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1 online ML Comm CLINICAL ARTICLE J Kor Neurotraumatol Soc 9;5:3- ISSN 경추추간판탈출증치료에서경추추간판전치환술과전방고정술의임상적결과및방사선학적결과분석 울산대학교의과대학서울아산병원신경외과학교실 박은석 노성우 박진훈 전상룡 임승철 김창진 Clinical and Radiological Analysis of Cervical Compared to Anterior Cervical Discectomy and in Cervical Disc Disease Eun-Suk Park, MD, Sung-Woo Roh, MD, Jin-Hoon Park, MD, Sang-Ryong Jeon, MD, Seung-Chul Rhim, MD and Chang-Jin Kim, MD Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Objective: Although anterior cervical discectomy and fusion (ACDF) is the most common treatment for degenerative cervical disc disease, concerns about adjacent level degeneration and loss of motion have led to suggestions that total disc replacement may be a better alternative. Methods: Since April, 35 cases of cervical arthroplasty have been performed at our institute. Here we compare clinical and radiological results in patients who have cervical disc herniations treated with arthroplasty or with ACDF. We evaluated 7 patients treated for cervical disc herniations with radiculopathy and neck pain, of whom 35 underwent cervical arthroplasty using the Mobi-C (LDR medical, Troyes, France) implant and 3 underwent ACDF using the Solis cage (Stryker Spine, Allendale, NJ). Clinical measurements of outcome included the numeric rating scale (NRS) score for radiculopathy and neck pain, neck disability index (NDI) score, duration of hospital stay and convalescence time. All patients were assessed radiologically by measuring overall cervical lordosis (Cobb s angle), segmental lordosis and segmental range-of-movement (ROM) of operated disc levels and adjacent disc levels. Results: Mean hospital stay (5.5 vs.. days, p<.5) and interval between surgery and return to work (1.15 vs..9 months, p<.5) were significantly shorter in the arthroplasty than in the ACDF group. After 1 months, mean NDI and neck and extremity NRS scores had improved in both groups. Patients in the arthroplasty group, but not in the ACDF group, maintained their baseline overall preoperative cervical and segmental lordosis scores after surgery. Segmental ROM of adjacent levels were higher in the ACDF group than in the arthroplasty group, and segmental motion of operated level scores in the arthroplasty group were maintained at the last follow-up assessment. The ROM of adjacent segment were smaller in the arthroplasty group than in the ACDF group, but the difference was not statistically significant (p>.5). In addition, segmental motion of operated level in the arthroplasty group were maintained at the last follow-up assessment. In two cases of arthroplasty group, new bony growth at the treated level, indicating heterotrophic ossification, was suspected based on radiographic (film) results. Conclusion: Although clinical results were similar in the two groups, postoperative recovery was significantly shorter in the arthroplasty group. Postoperative overall cervical and segmental lordosis were reduced in the ACDF group compared with preoperative levels, but not in the arthroplasty group. (J Kor Neurotraumatol Soc 9;5:3-) KEY WORDS: Anterior cervical discectomy and fusion Cervical arthroplasty Outcome. Received: September, 9 / Revised: September, 9 / Accepted: September 3, 9 Address for correspondence: Sung-Woo Roh, MD Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Asanbyeongwon-gil, Songpa-gu, Seoul 13-73, Korea Tel: , Fax: , swroh@amc.seoul.kr Copyright c 9 Journal of Korean Neurotraumatology Society 3

2 Clinical Analysis of Cervical Compared to Anterior Cervical Discectomy and 서론 경추전방고정술 (anterior cervical discectomy and fusion) 는경추신경근병증과척수병증환자치료의한방법으로가장널리이용되는방법이다. 그러나수술후인접분절의퇴행성변화 (adjacent segment degeneration: ASD) 같은합병증의발생은경추추간판전치환술 (cervical arthroplasty) 의개발을촉진하였다. 1,3,,9) 경추추간판전치환술에대한가장중요한이론적근거역시움직임을유지하여인접분절의퇴행성변화를감소시키는것에있으며, 15) 생리적굴곡및운동의보존은, 환자가빠른속도로회복하게하고빨리일상활동을수행할수있게하는장점이있다. 경추추간판전치환술의또다른이점은뼈이식에의한이환율의감소및전방금속판고정술과관련된합병증을감소시키는것이다. 1,17) 이논문에서는 Mobi-C (LDR medical, Troyes, France) 를이용한경추추간판전치환술과 Solis cage(stryker Spine, Allendale, NJ) 를이용한경추전방고정술을수술적방법으로사용하였으며, 경추추간판전치환술과경추전방고정술의임상적결과및방사선학적결과에대해후향적으로연구하였다. 특히이환부운동의보존및인접부운동의보존여부에대해방사선학적으로평가하였다. 대상및방법 본원에서수술받은상지의경추신경근병증을동반한단일분절의연성디스크 (soft disc) 환자를대상으로하였으며, 복수분절의디스크환자및방사선학적으로심한변성을보인환자, 이전에수술을받았던병력이있는환자는제외하였다. 이에속하는경추전방고정술환자군은 5 년 월부터 년 1월까지치료받은총 3 명 ( 남자 명, 여자 1명 ) 환자들로, 평균나이는 7세 ( 범위는 ~3 세 ) 였으며, 평균추적관찰기간은 35개월 ( 범위는 ~5 개월 ) 이었다. 경추추간판전치환술환자군은 년 월부터 년 1월까지치료받은총 35 명 ( 남자 1명, 여자 17명 ) 환자들로평균나이는 5.3 세 ( 범위는 31~1 세 ) 였으며, 평균추적관찰기간은 개월 ( 범위는 ~33 개월 ) 이었다. 수술부위는경추전방고정술환자군에서는제-5 경추간이 1명, 제5- 경추간이 1 명, 제-7 경추간이 명이었으며, 경추추간판전치환술환자군에서는제3- 경추간이 명, 제-5 경추간이 3명, 제5- 경추간이 명, 제-7 경추간이 명이었다. 두환자군간에연령및성별, 수술분절에는통계학적차이는없었다 (p>.5)(table 1). 저자들은전례에서우측접근법을사용하여디스크제거술을시행하였으며, 시험용삽입물 (trial implant) 을디스크공간에넣어적절한크기, 높이, 위치를확인후삽입물 (Mobi-C 혹은 Solis cage) 을디스크공간에삽입하였다. 삽입물을디스크공간에삽입후투시장치 (fluoroscopic guidance) 를이용하여정렬및위치를확인하고교정하였다. Mobi-C 를이용하여경추추간판전치환술을시행하였고, Polybone (Kyungwon medical, Seoul, Korea) 과 Solis cage 를이용한경추전방고정술을시행하였다. 임상적결과 (clinical outcomes) 는 neck disability index (NDI) 와 numerical rating scale (NRS) 을이용하여평가하였다. 전반적인경추전만도 (lordosis), 수술한분절의전만도및운동범위 (range of motion) 및인접분절의운동범위를방사선학적으로평가하였다. 전반적경추전만도는제 경추의하종판과제7경추의하종판이이루는각으로정의하였으며, 분절의전만도는측정분절의상위척추의하종판과하위척추의상종판이이루는각으로정의하여측정하였다. 경추운동범위는측면방사선사진을통해측정되는경추의굴곡과신전시발생하는각의차이로정의 TABLE 1. Baseline demographic and clinical characteristics group (n=35) ACDF group (N=3) Age range (mean), years 31-1 (5.3) -3 (7) Sex (male : female) 1 : 17 : 1 Operation period April - September February 5-December Followed-up period (mean), months -35 () 7-9 (35) Operation level C3- C C5-1 C-7 ACDF: anterior cervical discectomy and fusion J Kor Neurotraumatol Soc 9;5:3-

3 Eun-Suk Park, et al. 하였다. 분절의운동범위는역동방사선사진 (dynamic X- ray) 을통해굴곡과신전시발생하는분절의각의차이로정의하고측정하였다. 수술후방사선사진을통해새로발생한이소성골화증 (heterotrophic ossification) 에대해평가하였다. 통계적분석방법으로는 Mann-Whitney test과 Repeated Measures Analysis of Variance를이용하였으며, p-value 가.5 이하시통계적의의가있는것으로평가하였다. 결과 임상적결과평균수술시간은경추추간판전치환술환자군에서 1 분, 경추전방고정술환자군에서 153 분으로비슷하였으며 (p>.5), 재원일은경추추간판전치환술환자군이 5.5 일, 경추전방고정술환자군이. 일이었으며, 회복기는경추추간판전치환술환자군이 1.15 개월, 경추전방고정술환자군이.93 개월로경추추간판전치환술환자군에비해긴것으로확인됐다 (p>.5). 환자의만족도는마지막외래경과관찰에서평가되었으며, 두환자군간에차이가없는것으로평가됐다 (p>.5)(table ). NDI 점수는수술후 1개월후부터두환자군모두감소를보였다. 경추추간판전치환술환자군은.9 에서.5로, 경추전방고정술환자군은 3.3 에서.3으로감소하였다 (Figure 1A). 상지의 NRS 점수도수술후 1개월후평가상두환자군모두에서감소를보였으나, 두환자군간의큰차이는없었다 (Figure 1B). 방사선학적결과수술후 1개월에서검사한경추전만도는경추추간판전치환술환자군에서 9.79 도에서.59 도로감소하였으며, 경추전방고정술환자군에서는.7 도에서 17.9 도로감소하였다. 경추추간판전치환술환자군의경우경추전만도가수술직후에는 3.75 도로증가를보이다가점차감소하였으며, 경추전방고정술환자군에서는수술직후부터점차적으로감소하는양상을확인할수있었다 (Figure A). 분절전만도의경우경추추간판전치환술환자군에서는.7 도에서. 도로증가를보인반면, 경추전방고정술환자군에서는 3.93 도에서. 도로감소를보였다 (Figure B). 상위분절의운동범위는경추추간판전치환술환자군에서 1. 도에서 1.5 으로감소를보였으나, 경추전방고정술환자군에서는.3 도에서 11. 도로증가를 TABLE. Clinical outcomes in the arthroplasty and fusion groups group (n=35) group (n=3) p value Operation time (minutes) Length of hospital stay (days) Time to return to household work (months) Patient s satisfaction (1-) Neck Disability Index (NDI) Radiculopathy (VAS) A Pre op. 1.5 mon 3 mon mon 1 mon p=.5 B Pre op. 1.5 mon 3 mon mon 1 mon p=.179 FIGURE 1. A: Neck disability index (NDI) scores in the arthroplasty and fusion groups (p>.5). The scores of both groups decreased gradually; however, the greatest decrease was seen in the immediate postoperative period. B: NRS scores of radiculopathy in the arthroplasty and fusion groups (p>.5). The scores of both groups decreased gradually, but the decreases were greatest in the immediate postoperative period. NRS: nume ical rating scale, VAS: visual analogue scale. 5

Clinical Analysis of Cervical Compared to Anterior Cervical Discectomy and 보였다. 그러나, 이러한결과는통계적의의는없었다 (p>.5)(figure C). 하위분절의운동범위의경우는두환자군모두에서증가를보였다 (p>.5)(figure D).

A Overall cervical lordosis B Segmental lordosis 35 3 5 15 5 3.75 9.79 3.7.59.7 19.33 17. 17.9 Pre op. 3 mon mon 1 mon 1 1 11.7 9...7.3 3.93 3.1. Pre op. 3 mon mon 1 mon (p=.) (p=.9) (p=.1) (p=.

755 E Segmental ROM of arthroplaty group F 1 15. 1.9 1 1.7 1. 1 Pre op. 1.5 mon mon 1 mon FIGURE. A: Overall cervical lordosis in the arthroplasty and fusion groups.

4 Clinical Analysis of Cervical Compared to Anterior Cervical Discectomy and 보였다. 그러나, 이러한결과는통계적의의는없었다 (p>.5)(figure C). 하위분절의운동범위의경우는두환자군모두에서증가를보였다 (p>.5)(figure D). 수술부위분절의운동범위의경우, 경추추간판전치환술환자군에서는수술직후잠시감소를보이다가수술후 1개월까지 1.7 도에서 1.9 도로점차적으로증가를보였다 (Figure E). 경추추간판전치환술환자군중 예에서이소성골화증이수술분절에서관찰되었다 (Figure F). A Overall cervical lordosis B Segmental lordosis Pre op. 3 mon mon 1 mon Pre op. 3 mon mon 1 mon (p=.) (p=.9) (p=.1) (p=.137) C Adjacent segmental ROM (upper segment) D Adjacent segmental ROM (lower segment) Pre op. Post op. (1 m) 9.5 Pre op. Post op. (1 m) p=.57 p=.755 E Segmental ROM of arthroplaty group F Pre op. 1.5 mon mon 1 mon FIGURE. A: Overall cervical lordosis in the arthroplasty and fusion groups. Measurement was performed as shown in the left panel. In the arthroplasty group, cervical lordosis increased immediately after surgery, then decreased to preoperative levels. Cervical lordosis in the fusion group gradually decreased after surgery and did not return to preoperative levels. B: Segmental lordosis in the arthroplasty and fusion groups. Measurement was performed as shown in the left panel. In the arthroplasty group, segmental lordosis score increased immediately after surgery, but then decreased after months and returned to preoperative levels. In the fusion group, however, segmental lordosis increased immediately after surgery, then decreased but did not return to preoperative levels. C: Adjacent ROM of the upper level in the arthroplasty and fusion groups. After surgery, upper ROM decreased in the arthroplasty group but increased in the fusion group (p>.5). D: Adjacent ROM of the lower level in the arthroplasty and fusion groups. After surgery, lower ROM increased in both groups, but the increase was greater in the fusion group (p>.5). E: Segmental ROM in the arthroplasty group decreased immediately after surgery before increasing to a level greater than the preoperative level. F: In two cases of arthroplasty group, new bony growth at the treated level, indicating heterotrophic ossification, was suspected based on postoperative X-ray. ROM: range of movement. J Kor Neurotraumatol Soc 9;5:3-

5 Eun-Suk Park, et al. 고찰 현재경추전방고정술은퇴행성경추질환환자들에서가장많이쓰이는수술적치료이다. 3) 비록경추전방고정술이수술적인측면에서여러장점이있지만, 인접분절디스크의이상유발이나, 목움직임제한등과같은부작용이따를수있다. 수술후의운동장애는인접한척추분절에대한과도한운동부화와관련이있으며, 이러한운동부화는인접분절의퇴행성변화를유발하거나악화시킬수있다.,9,1) 척추운동장애의부작용이없는경추추간판전치환술은인접분절의퇴행성변화와같은부작용을감소시킬수있다. 지금까지의연구들은인접분절의운동장애증가와병적인퇴행 (pathogenic degeneration) 간에뚜렷한관련성이있음을보여주고있으며, 19) 같은맥락으로우리연구역시수술후인접분절운동장애의증가를보여주고있다. 경추추간판전치환술에대해서, 우리는상대적으로조작이쉬우며경추전방고정술의술기와유사점이있는 Mobi-C 를사용하고있다. Mobi-C 의수술적삽입은삽입의위치, 각도, 깊이의조정을편리하게해주는이식물고정장치 (implant holder) 로인하여, 쉽고, 안전하고, 재현이가능하다는특징이있다. 마찬가지로, 우리가사용하는 Solis cage 역시간단한장치이며, 유일한차이점인장골이식을제외한다면, Mobi-C 만큼이나간편한이식방법이다. 이논문에서저자들은두환자군간의평균수술시간은비슷하고, NDI 와 NRS 점수로평가된임상결과역시차이가없음을확인하였으며, 이는과거의몇몇연구들의결과와같이병변의감압과고정이증상의호전과유사한관계가있음을알수있다.,11) 이러한과거연구들은, 또한두환자군모두에서큰차이없이목과팔의통증이현저하게감소하였다고보고하였다. 11) 다른연구들에서볼수있듯이, 유발병변을제거하는수술후에즉각적으로 NDI 와 NRS 점수가향상되었다. 우리연구에서가장빠른경우는수술후한달반만에통증과증상의감소를보인경우였다. 입원기간과회복시간으로평가되는수술후회복 (postoperative recovery) 은경추전방고정술환자군보다경추추간판전치환술환자군에서훨씬더짧은것으로나타났다. 우리는수술후보조기착용이나장골이식이경추전방고정술환자에서수술후회복에영향을미친다고결론을내렸다. 우리는경추전방고정술환자군에서수술후의전체혹은부분적인경추전만도가수술전의수준으로까지회복 되지못함을발견하였다. 이결과는경추후만증 (kyphosis) 을시사한다. 몇몇연구들은경추전방고정술후이식물의침전을보고하고있다. 예를들어, 경추의전방고정판이없는환자의약 % 이상에서경추고정술수술후비대칭적 cage 침전 (subsidence) 을보이게된다. 1) 실제로, 현재의연구에서전방경유추간판절제술및골유합술환자군의몇몇환자들은수술후 cage 침전을의미하는경추후만증이더심해진소견을보이고있다. 그러나, 경추추간판전치환술환자군에서는환자들의전체혹은부분경추전만증이수술이전수준을유지하고있었다. 또한, 척추배열의유지가인접분절들의퇴행 (degeneration) 을막아주는것으로보고되고있다. 5-) 다른연구들에서도경추추간판전치환술을받은환자들이치료받은분절의운동성이훨씬더유지가잘되어, 인접분절의운동성에영향을적게미친다는것을보여주었다.,11,1,1) 본연구역시수술후분절의운동범위가보존됨을보여주었다. 우리는상위인접분절에서의운동범위가경추추간판전치환술환자군에서는감소하는반면, 경추전방고정술환자군에서는증가함을발견하였다. 게다가, 하위분절의운동범위증가는경추추간판전치환술환자군보다경추전방고정술환자군에서더컸다. 이러한결과들을종합해보면, 경추전방고정술에비해경추추간판전치환술이인접분절의과운동성예방에더큰장점을가진다고결론을내릴수있다. 최근경추추간판전치환술후발생한이소성골화증에대해발표되고있으며, Wenger 등 ) 의연구에서는경추추간판전치환술후약 % 에서이소성골화증이수술분절에발생하였다고발표하였다. 이소성골화증의발생이유에대해서는아직명확히밝혀져있진않으나, 수술부위의해면골 (cancellous bone) 의노출에의한것으로설명하고있다. 13) 우리연구에서도 35예의경추추간판전치환술환자중약 예 (5.7%) 에서이소성골화증이발생하였다. Mobi-C 를이용한경추추간판전치환술의경우수술분절의종판 (endplate) 에손상없이비교적쉽게삽입이가능하므로, 이소성골화증의발생을줄이는데도움이될수있을것으로생각되며, 이에대한연구를위해좀더많은증례와추적관찰이필요할것으로생각된다. 결론 두환자군을비교할때 NDI 점수, NRS 점수와같은임상적결과에있어서유의한차이는없었다. 그러나, 수술후회복기간에있어서, 경추추간판전치환술환자군의 7

6 Clinical Analysis of Cervical Compared to Anterior Cervical Discectomy and 회복시간이빨랐는데, 그것은수술후보조기착용이나장골이식이없었던점과관련이있는것으로추정된다. 경추전방고정술을시행한환자군에서, 경추추간판전치환술을시행한환자군에비해서수술후후만증이더많이발생하는경향을보였는데, 이것은몇몇의증례에서수술후이식물침전 (postoperative graft subsidence) 과연관이되어있는것으로판단된다. 마지막외래경과관찰에서경추추간판전치환술환자군에서는분절운동 (segmental motion) 이유지되었으며, 비록통계적으로유의하지는않지만, 인접한분절의운동범위가경추전방고정술환자군에비해경추추간판전치환술환자군에서더작았다. 그러나우리가시행한연구는짧은경과관찰기간과대상환자수가적다는점에서한계점을지닌다. 두수술간에차이점을명확히밝히기위해서는좀더많은환자와장기간의경과관찰기간이필요하다. 중심단어 : 경추전방고정술 경추추간판전치환술 결과. REFERENCES 1) Cummins BH, Robertson JT, Gill SS. Surgical experience with an implanted artificial cervical joint. J Neurosurg :93-9, 199 ) Eck JC, Humphreys SC, Lim TH, Jeong ST, Kim JG, Hodges SD, et al. Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion. Spine (Phila Pa 197) 7:31-3, 3) Goffin J, Geusens E, Vantomme N, Quintens E, Waerzeggers Y, Depreitere B, et al. Long-term follow-up after interbody fusion of the cervical spine. J Spinal Disord Tech 17:79-5, ) Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 1:519-5, ) Katsuura A, Hukuda S, Saruhashi Y, Mori K. Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J :3-3, 1 ) Kim SH, Shin HC, Shin DA, Kim KN, Yoon do H. Early clinical experience with the mobi-c disc prosthesis. Yonsei Med J :57-, 7 7) Kim SW, Limson MA, Kim SB, Arbatin JJ, Chang KY, Park MS, et al. Comparison of radiographic changes after ACDF versus Bryan disc arthroplasty in single and bi-level cases. Eur Spine J 1:1-31, 9 ) Kim SW, Shin JH, Arbatin JJ, Park MS, Chung YK, McAfee PC. Effects of a cervical disc prosthesis on maintaining sagittal alignment of the functional spinal unit and overall sagittal balance of the cervical spine. Eur Spine J 17:-9, 9) Kulkarni V, Rajshekhar V, Raghuram L. Accelerated spondylotic changes adjacent to the fused segment following central cervical corpectomy: magnetic resonance imaging study evidence. J Neurosurg (1 Suppl Spine):-, ) Mummaneni PV, Burkus JK, Haid RW, Traynelis VC, Zdeblick TA. Clinical and radiographic analysis of cervical disc arthroplasty compared with allograft fusion: a randomized controlled clinical trial. J Neurosurg Spine :19-9, 7 11) Nabhan A, Ahlhelm F, Pitzen T, Steudel WI, Jung J, Shariat K, et al. Disc replacement using Pro-Disc C versus fusion: a prospective randomised and controlled radiographic and clinical study. Eur Spine J 1:3-3, 7 1) Pickett GE, Rouleau JP, Duggal N. Kinematic analysis of the cervical spine following implantation of an artificial cervical disc. Spine (Phila Pa 197) 3: , 5 13) Sasso RC, Best NM, Metcalf NH, Anderson PA. Motion analysis of bryan cervical disc arthroplasty versus anterior discectomy and fusion: results from a prospective, randomized, multicenter, clinical trial. J Spinal Disord Tech 1: , 1) Sasso RC, Smucker JD, Hacker RJ, Heller JG. Artificial disc versus fusion: a prospective, randomized study with -year follow-up on 99 patients. Spine (Phila Pa 197) 3:933-9, 7 15) Shim CS, Lee SH, Park HJ, Kang HS, Hwang JH. Early clinical and radiologic outcomes of cervical arthroplasty with Bryan Cervical Disc prosthesis. J Spinal Disord Tech 19:5-7, 1) Silber JS, Anderson DG, Daffner SD, Brislin BT, Leland JM, Hilibrand AS, et al. Donor site morbidity after anterior iliac crest bone harvest for single-level anterior cervical discectomy and fusion. Spine (Phila Pa 197) :13-139, 3 17) St John TA, Vaccaro AR, Sah AP, Schaefer M, Berta SC, Albert T, et al. Physical and monetary costs associated with autogenous bone graft harvesting. Am J Orthop 3:1-3, 3 1) van Jonbergen HP, Spruit M, Anderson PG, Pavlov PW. Anterior cervical interbody fusion with a titanium box cage: early radiological assessment of fusion and subsidence. Spine J 5:5-9, 5 19) Weinhoffer SL, Guyer RD, Herbert M, Griffith SL. Intradiscal pressure measurements above an instrumented fusion. A cadaveric study. Spine (Phila Pa 197) :5-531, 1995 ) Wenger M, Hoonacker P, Zachee B, Lange R, Markwalder TM. Bryan cervical disc prostheses: preservation of function over time. J Clin Neurosci 1:-5, 9 1) Yoon DH, Yi S, Shin HC, Kim KN, Kim SH. Clinical and radiological results following cervical arthroplasty. Acta Neurochir (Wien) 1:93-95, J Kor Neurotraumatol Soc 9;5:3-

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar