Journal of Korean Society of Spine Surgery Factors Associated with Conversion from Conservative to Surgical Treatment in Single-Level Lumbar Spinal St

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Journal of Korean Society of Spine Surgery Factors Associated with Conversion from Conservative to Surgical Treatment in Single-Level Lumbar Spinal Stenosis Patients Young-Joon Ahn, M.D.

):6-68. Originally published online December 3, 8; https://doi.org/.8/jkss.8.5.

1 Journal of Korean Society of Spine Surgery Factors Associated with Conversion from Conservative to Surgical Treatment in Single-Level Lumbar Spinal Stenosis Patients Young-Joon Ahn, M.D., Se-Hyuk Im, M.D., Byung-Kyu Park, M.D. J Korean Soc Spine Surg 8 Dec;5():6-68. Originally published online December 3, 8; Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 3 Gil, Songpa-gu, Seoul, 555, Korea Tel: Fax: Copyright 7 Korean Society of Spine Surgery pissn eissn The online version of this article, along with updated information and services, is located on the World Wide Web at: This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/.) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Original Article J Korean Soc Spine Surg. 8 Dec;5(): Factors Associated with Conversion from Conservative to Surgical Treatment in Single-Level Lumbar Spinal Stenosis Patients Young-Joon Ahn, M.D., Se-Hyuk Im, M.D., Byung-Kyu Park, M.D. Department of Orthopedic Surgery, National Police Hospital, Seoul, Korea Study Design: Retrospective study of prospectively-collected data. Objectives: To determine the factors associated with conversion from conservative to surgical treatment in single-level lumbar spinal stenosis patients. Summary of Literature Review: Various reports have presented clinical outcomes after the surgical and nonsurgical treatment of spinal stenosis. However, few reports have investigated factors predicting conversion to surgery during the course of conservative treatment. Materials and Methods: We analyzed patients who visited our hospital from May to May 5 and were traceable for at least 3 years after being advised to undergo surgery following 3 months of conservative treatment. Of these patients, underwent surgery and did not. We then investigated the factors associated with conversion to surgical treatment. Clinical assessments were conducted using a questionnaire, and the overall area of the spinal canal and the muscle area within the spinal canal were measured using magnetic resonance imaging. Results: The average area of the spinal canal was 8.±53.6 mm in the surgical group, compared to 7.75±8.55 mm in the nonsurgical group (p=.). The muscle area in the spinal canal was 5.7±.3 cm in the surgical group, whereas it was 6.±.56 cm in the nonsurgical group (p=.). The patients in the surgical group were more likely to have experienced repetitive strain and to have frequently visited health clubs (p=.7, p=.37, respectively). However, regular stretching was more common in the nonsurgical group (p=.8). Conclusions: The factors associated with conversion to surgical treatment were a narrow spinal canal, a small muscle area within the spinal canal, visiting health clubs, repetitive sprain, and not stretching. A small muscle area within the spinal canal can be considered as a key factor related to surgical conversion. Key Words: Lumbosacral region, Spinal stenosis, Amount of lumbar muscle 서론 요추의척추관협착증은하지에저린감, 요통및간헐적파행과같은신경학적증상을나타내며, 이는요추부에서신경의통로역할을하는추간공 (intervertebral foramen) 과척추관 (spinal canal) 이좁아져생긴다. ) 이러한증상으로인해요추부척추관협착증은특히노인에게서삶의질을감소시키는중요한위험인자이다. 고령화사회와함께요추부척추관협착증을가진환자수가급격히증가할것으로예상되며, 이에요추부척추관협착증은일차의료에서자주접하게될질환이될것이다. 요추부척추관협착증예후와관련해서, 기존의보고들은척추관협착증환자의수술및비수술적치료후임상결과와예후에초점을맞추어왔다.,3) 또한보존적치료를한척추관협 착증환자에서주관적증상완화의예측요인을보고한논문 예 ) 가있었으나, 보존적치료중수술적치료로전환시연관된 Received: October 9, 8 Revised: October 3, 8 Accepted: December, 8 Published Online: December 3, 8 Corresponding author: Young-Joon Ahn, M.D. ORCID ID: Young-Joon Ahn: https//orcid.org/ x Se-Hyuk Im: https//orcid.org/ Byung-Kyu Park: https//orcid.org/-3--7 Department of Orthopedic Surgery, 58, Garakbon-dong, Songpa-gu, National Police Hospital, Seoul, 575, Korea TEL: , FAX: osahnyj@nate.com 6 Copyright 8 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn 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.

Journal of Korean Society of Spine Surgery Factors Related to Conversion to Surgical Treatment in Spinal Stenosis 요인에대한연구는많지않았고, 어떠한환자에서수술적치료를권장하는가에대한명확한기준이없는실정이다.

3 Journal of Korean Society of Spine Surgery Factors Related to Conversion to Surgical Treatment in Spinal Stenosis 요인에대한연구는많지않았고, 어떠한환자에서수술적치료를권장하는가에대한명확한기준이없는실정이다. 이에저자들은보존적치료중인단분절요추관협착증환자에서수술적치료전환과관련된연관인자들에대한분석결과를보고하고자한다. 대상및방법 년 5월부터 5년 5월까지본원외래에서단분절의중심성요추부척추관협착증으로진단후수술적치료를권유받았으며수술권유후최소 3년이상추시가가능했던환자 6 명중다음과같은기준을만족하는환자를대상에포함하였다. 기준이란 ) 방사선소견과임상증상이일치하고 ) 하지방사통이주증상이며 3) 3개월간의물리치료, 약물치료, 운동치료및신경근차단술등보존적치료에반응을하지않아지속적인통증이나불편감을호소하여수술을권유받은환자를대상으로하였다. 제외대상인주증상이하지방사통이아닌요통인경우, 외측부 (lateral) 나척추공에협착이있는경우, 선천성혹은외상으로발생한척추관협착증, 마미증후군, 진행성의신경마비증상이나운동소실을보이는경우, 감염의가능성이보이거나스테로이드에과민한반응을보이는경우, 환자가신경근차단술을원치않고바로수술한경우, 척추분리증, 추간판탈출증이동반한경우, 기존요추부수술력이있는경우의 7명은제외하여총 55명이최종적으로포함되었다. 환자추시및면담은외래에서 명의정형외과전공의및전문의에의해직접면담및설문지조사를통하여이루어졌으며, 추시기간은최소 3년부터최장 9년 개월까지로평균 년 개월이었다. 수술권유후수술적치료를받은수술군과지속적인보존적치료로수술을받지않은비수술군을나누어설문지를통해역학인자인연령이나성별, 체질량지수, 최종학력, 재직상태, 거주형태, 동반된전신질환, 수술권유전유병기간, 수술권유후추시기간, 신경근차단술횟수, 물리치료, 약물치료, 동통유발점주사, 체외충격파, 도수치료와임상인자인운동력, 술, 담배, 외상력, 교통사고및산업재해유무, 협착증가족력, 병변부위, 척추관면적, 요추부근육량, 퇴행성전방전위증, 척추측만증, 척추불안정성, VAS (Visual analogue scale) 와한국어판 Oswestry Disability Index (K-ODI) 값을두그룹사이비교하였고, 수술적치료결정및예후에어떠한영향을미치는가에대해서분석하였다. 최종학력은대학교졸업자와비졸업자로분류하였고, 재직상태는재직과비재직혹은퇴직으로분류하였으며, 거주형태는독거와동거로나누었다. 수술권유전유병기간은초기증 상발생시부터수술권유시까지의기간으로 개월미만, 개월이상에서 59 개월미만, 6 개월이상으로나누었으며, 수 술권유후추시기간은 개월미만, 개월이상에서 36 개월 미만, 36 개월이상으로분류하였다. 신경근차단술횟수는 5 회 미만, 5 회이상으로나누었다. 헬스는지속적으로주 회이상 한경우로하였으며, 외상력은요추부골절이동반된경우를제 외한 3 회이상의반복적인단순요추부염좌기왕력으로보았 다. 협착증가족력은환자의부모, 형제, 자매, 자식중협착증 기왕력이있는경우로하였다. 통증의정도는 VAS (Visual analogue scale) 값을이용하여초 진시, 수술권유시, 수술권유 3 년후의하지방사통을객관화 하기위하여사용하였으며전혀통증을느끼지못하는것을 점, 참을수없는고통을 점으로측정자의눈금을환자가스 스로표시하게하여측정하였다. 하부요추부기능적평가는 한국어판 Oswestry Disability Index (K-ODI) 를이용하였다. 5) VAS 및 K-ODI 는추시관찰중외래에서검사하는것을원칙 으로하였다. 척추관면적은자기공명영상에서 Infinitt PACS system 의 free line ROI calculator 를이용해자기공명 T 강조영상을사용하 였다. 병변의가장좁은척추관부위를축상면 (Axial) 영상에서 전방은추체, 양옆은추간공내측경계까지, 후방은추궁판을 기준으로골성구조물이아닌실제척추관의내경인연부조직 을따라 명의정형외과전공의및전문의에의해독립적으로 측정되었다 (Fig. ). 6,7) 요추부근육량은자기공명영상에서 Infinitt PACS system 의 free line ROI calculator 를이용해자기공명 T 강조영상을사 Fig.. We measured the spinal canal dimensions using the free-line region of interest calculator of the Infinitt picture archiving and communication system for axial magnetic resonance images. These dimensions are represented as an inverted triangle on the image. 6

Young-Joon Ahn et al Volume 5 Number December 3 8 Assessed for eligibility (n=6) Excluded (n=7) Not meeting inclusion criteria Allocation (n=55) Surgical group (n=8) Nonsurgical group (n=7) Fig.

4 Young-Joon Ahn et al Volume 5 Number December 3 8 Assessed for eligibility (n=6) Excluded (n=7) Not meeting inclusion criteria Allocation (n=55) Surgical group (n=8) Nonsurgical group (n=7) Fig.. The individual paraspinal muscles were outlined using the freeline region of interest calculator of the picture archiving and communication system. m, m: psoas major; m3, m: quadrates lumborum; m5, m6: multifidus; m7, m8: erector spinae. 용하였다. 요추 번척추체상단의축상면영상에서척추주변 근 (paraspinal m.) 인요근 (psoas major), 요방형근 (quadrates lumborum), 다열근 (multifidus), 척추기립근 (erector spinae) 의 횡단면적 (Cross-sectional areas) 을 명의정형외과전공의및 전문의에의해독립적으로측정하여합산하였다 (Fig. ). 8) 통계학적분석은 SPSS (Ver..) 프로그램을이용하여 T-test, Mann-Whitney test, Chi-square test, Linear by linear association, Simple 및 multiple linear regression analysis 방법을 시행하였으며유의수준은.5 미만으로하였다. 본논문은본 원 IRB 승인 (76-8-HR-5) 을받은이후진행 되었다. 결과 최종추시시수술을권유받은환자 55 예중사망, 정신장 애, 뇌졸중, 해외이주및설문지거부 5 예를제외한총 예가 최종적으로포함되었다. 예 (5.%) 가본원에서수술적치료 를시행하였으며, 예 (5.%) 에서는지속적인보존적치료를 통해수술적치료를시행하지않았다 (Fig. 3). 병변부위는요추 3 번과요추 번간협착증은 3 예 (7.5%), 요 추 번과요추 5 번간협착증은 33 예 (8.5%), 요추 5 번과천 추 번간협착증은 예 (.%) 였고, 하지방사통은좌측 9 예 (.5%), 우측 9 예 (.5%), 양측 예 (55.%) 였다. 성별은남자가 33 예 (8.5%), 여자가 7 예 (7.5%) 이었으며, 평균연령은 6.8 세 (5~75) 세였고, 5 대가 3 예 (3.5%) 로가 장많았으며, 7 대는 예 (7.5%), 6 대는 예 (5.%), 대 는 6 예 (5.%) 로분포되었다. 수술을권유받은후보존적치료를시행한비수술군과수 술적치료를받은수술군두군사이연령이나성별, 체질량지 수, 최종학력, 재직상태, 거주형태, 동반된전신질환, 수술권 유전유병기간, 신경근차단술횟수, 물리치료, 약물치료, 동 통유발점주사, 체외충격파, 도수치료, 술, 담배, 교통사고및 산업재해유무, 협착증가족력, 병변부위, 퇴행성전방전위증, 척추측만증, 척추불안정성에유의한차이를보이지않았다 (Table, ). 수술권유전유병기간은 개월부터 5 년까지로평균 3 년 7 개월이였으며, 유병기간이 개월미만인 예중 6 예 (.9%), 개월이상에서 6 개월미만인 5 예중 9 예 (6.%), 6 개월이상인 예중 5 예 (5.5%) 에서수술적치료를시행하 였다. 운동력중걷기, 달리기, 자전거, 골프, 테니스, 배드민턴, 등 산은수술적치료와상관관계가없었으나, 허리강화운동및 요추부스트레칭 (p=.8) 과헬스 (p=.37) 는유의한결과를 보였다. Lost to follow up (n=8) Withdrew (3) Stroke () Mental disorder () Died () Analysed (n=) Follow up Analysis Lost follow up (n=7) Withdrew (5) Moved abroad () Died () Analysed (n=) Fig. 3. Flow of the patients through each stage of the study. 이전에골절이아닌 3 회이상의반복적인요추부염좌외상 력이있던 예중 예 (7.%) 에서수술을시행하였고, 이는 통계학적으로유의미한결과를보였다 (p=.7). 교통사고및 산업재해기왕력은수술군과비수술군모두에서없었다. 척추관면적은평균 96.53(±56.65) mm (6.33~3.) 의 6

5 Journal of Korean Society of Spine Surgery Factors Related to Conversion to Surgical Treatment in Spinal Stenosis Table. Base line characteristics, compared between the patients with single level lumbar spinal stenosis who received surgical or nonoperative treatment Base line factors Surgical (n=) Nonsurgical (n=) p-value Age (years), mean (SD) 6.75± ± Gender (Male) BMI (kg/m ), mean (SD) 5.3±.7.8±3..68 Educational background (At least a college graduate) 8.68 Work related features (Employed). Residence type (Alone) Comorbid illnesses Hypertension DM Hypothyroid BPH Hyperlipidemia Stroke Arrythemia RA ds Onset of symptoms (months) 3.5± ± Duration of illness (months), (After op recommended) < Nerve block (<5) 6.9 Conservative treatment PT PO medication TPI ESWT Manual therapy 정규분포를따랐으며, 수술군의척추관면적평균은 8.(± 53.6) mm 이며, 비수술군의평균은 7.75(±8.55) mm 으로, 수술군에서비수술군보다척추관면적이더좁았으며유의미한소견을보였다 (p=.). 요추부근육량은평균 5.78(±.55) cm (.9~.) 의정규분포를따랐으며, 수술군의요추부근육량평균은 5.7(±.3) cm 이며, 비수술군의평균은 6.(±.56) cm 으로, 수술군에서비수술군보다요추부근육량이더적었으며유의미한소견을보였다 (p=.). 수술적치료전환시연관된인자들의단순회귀분석에서헬스를할수록, 요추부스트레칭을안할수록, 반복적인요추부외상이있을수록, 요추부근육량이적고척추관면적이좁을수록수술적치료가증가하는경향을보였고, 다중회귀분석에서도요추부근육량의감소는수술적치료증가에유의미한결과를 보였다 (Table 3). 통증및기능적평가에서 VAS 값은수술권유시수술군에서평균 8.55(±.5) 점비수술군에서평균 7.(±.) 점으로 (Table ), 수술군이비수술군보다수술권유시더높은동통을보였다 (p<.5). K-ODI 값은수술권유 3년후수술군에서평균.7(± 7.9) 점, 비수술군에서평균 9.5(±7.) 점으로 (Table 5), 수술군이비수술군보다수술권유 3년후 K-ODI 값이더작았다 (p<.5). 고찰 척추관협착증에서척추관면적과증상과의관련성은 Porter 등 9) 에의해처음으로조사되어돌출된추간판의증상을악화 63

6 Young-Joon Ahn et al Volume 5 Number December 3 8 Table. Base line characteristics, compared between the patients with single level lumbar spinal stenosis who received surgical or nonoperative treatment Base line factors Surgical (n = ) Nonsurgical (n = ) p-value Activity Walking Running Bicycle Golf Tennis Badminton Hiking Fitness Back Stretching Alcohol use 5 5. Cigarette use (current or quit in past 6 months) Trauma history.7 Traffic / Industrial accident Spinal stenosis Family history 6. Level affected on MRI L3-L L-L5 L5-S Spinal canal dimension (mm ), mean (SD) < ± ±8.55 Back muscle (cm ), mean (SD) 5.7±.3 6.±.56. Degenerative spondylolisthesis (<5 mm) 5.73 Scoliosis (<5 ) 9.3 Instability 시킬수있는위험성은척추관면적의크기와반비례함을보고하였다. Shim 등 7) 에의하면자기공영영상을이용한한국정상성인을대상으로한연구에서추간판위치에서의평균척추관면적은 9~88 mm 이었고, 본저자는 7년척추관협착증환자에서척추관면적에따른선택적신경근차단술의단기추시결과 ) 에대해보고하였는데, 환자의협착이가장진행되어보이는위치에서측정된척추관면적은평균.8(±9.7) mm (38.~99.9) 의정규분포를따랐으며, 이를기준으로평균 -sd 값 (73. mm ) 과평균 +SD 값 (7.5 mm ) 을정하고 3 개의군으로나누어각각의범위는 7.5 mm 이상, 73. mm 이상 7.5 mm 미만, 73. mm 미만으로정하였고, 척추관면적이 73. mm 미만인경우시술의효과가적을가능성이높은반면척추관면적이 7.5 mm 이상인경우좋은예후를보이는것으로분석하였다. 본연구에서수술군은비수술군보다 척추관면적이유의미하게좁았으며, 수술적치료에영향을미친다는것을확인하였다. 73. mm 미만의환자 8명중 명 (77.8%) 이수술을받았으며, 7.5 mm 이상의환자 5명중 명 (8%) 은지속적인보존적치료로수술을피할수있었다. 이는척추관면적이보존적치료중수술적치료전환시영향을미치는인자이며, 향후수술을결정에도움을줄수있다고사료된다. 또한수술에영향을미치는인자로주목할만한사실은요추부근육량이다. 제 3요추부는전신근육분포와밀접한상관관계가있어서신체의근육양을측정하는데중요한지표가될수있으며,,) 요추 3번과요추 번간요추부근육량이가장넓게측정되었다. 3,) 기존연구 5,6) 에따르면추간판탈출증이있는환자에서신경근병증이나추간판과후관절의퇴행성변화등요추의병적변화가있을시다열근이민감한지표가된다하였 6

7 Journal of Korean Society of Spine Surgery Factors Related to Conversion to Surgical Treatment in Spinal Stenosis Table 3. Simple and multiple linear regression analysis of associated factors of surgical treatment Base line factors Simple Multiple Coefficient±SE* p-value Coefficient±SE* p-value Fitness (yes/no).39±..38.±..55 Back Stretching (yes/no) -.36± ± Trauma history (yes/no).3± ±.85.7 Spinal canal dimension (mm ) -.± ±..99 Back muscle (cm ) -.± ±..8 Multiple model fit: R=.575; R =.33; adjusted R =.3. * SE: Standard Error Yes= or no=. Table. Changes of VAS over time in surgical group and nonoperative group 고, 만성적인요통을가진환자들의경우건강한그룹보다전신 상태악화와요추부근육비사용에의해척추주변근의위축과 지방침투로인한지방증가등의변화가빈번하게발생한다하 였다. 7,8) OP group VAS score* Non-OP group p-value Initial 5.5±. 6.±.79. OP recommend 8.55±.5 7.±..6 After 3years.7± ±.6.5 * VAS: Visual Analog Scale. Table 5. Changes of K-ODI over time in surgical group and nonoperative group OP group K-ODI score* Non-OP group p-value OP recommend 3.35±.3 9.± After 3years.7± ±7..5 * K-ODI: Korean oswestry disability index. 척추주변근은척추의움직임에안정성을제공하는동적고 정자 (dynamic stabilizers) 로고려되는데, 특히다열근은요추 부안정성제공및분절운동의핵심역할을하는것으로알려 져있다. 9) 척추관협착증환자에서척추주변근의위축으로 인해요추부근육량이줄어들고약해지게되어척추안정성 이줄어들겠으며, 환자가호소하는요통이증가하고근피로성 (fatigability) 이증가되게된다. ) 본연구의결과에서도수술군 의요추부근육량이비수술군보다더적었으며, 단순및다중 회귀분석모두에서근육량이적을수록수술적치료전환은증 가함을확인할수있다. 척추관면적은환자가능동적으로바꿀수있는사항이아니지만, 요추부근육량은요추부강화운동과스트레칭을이용하여환자의개인적인의지와노력으로극복할수있는부분이며, 수술적치료로전환을줄이기위한좋은길을제시해주고있다. 운동력중허리강화운동및요추부스트레칭은본원외래에서척추관협착증환자들에게교육후종이로제공되는요추부근육및안정성강화운동프로그램으로, 지속적인허리강화운동및요추부스트레칭을통한재활은만성요추부통증환자의치료로흔히사용되며지지를받고있다. ) 이는요추부근육량의증가로이어져요통강도를감소시키고척추안정성을높이며, ) 근육의신장력, 가동성, 지구력을증가시켜구조적및기능적장애를복원시키는것이목적이겠으며 3) 본연구에서도통계적으로유의한결과를보여수술적치료로의전환을피할수있는하나의요인으로고려할수있겠다. 반면, 헬스의경우수술군에서비수술군보다헬스를지속적으로한환자가많은것으로보였다. 요추부강화운동및스트레칭과같이헬스도허리주변근을증가시킬수있으나, Callaghan 등 ) 에따르면요추부에과도한하중이실리는운동은오히려요통환자에서추가적인구조적손상을입힐수있어조심해야한다. 특히누운상태에서상체와하지를동시에드는경우, 요추부의최대운동범위를사용하여운동하는경우, 요추를굴곡시킨상태에서시행하는운동시높은요추부하중이실린다하였다. 본연구에선지속적인헬스를통해요추부근육량을증가시키는것도중요하나올바른자세와중량으로적절하게해야하며요추부외상을주의해야한다고판단하였다. 요추부외상은요추부골절이동반된경우와산업재해와같이이차적이득이동반될수있는경우를제외한 3회이상의반복적인단순요추부염좌기왕력으로보았고, 수술군에서비수술군에비해많았으며, 유의한결과를보였다. 여러연구 8,5) 에 65

8 Young-Joon Ahn et al Volume 5 Number December 3 8 의하면외상으로인한추간판및신경손상발생시척추주위근이위축되고지방침투가증가된다하였고, 이는요추부근육량감소로이어져요통의증가와척추안정성이감소되어결국수술적치료의가능성이높아질수있다고하였다. 수술권유후추시기간은수술군에서 예중 9예 (95%) 가 개월미만에수술을시행하였으며, 이는수술권유후 개월을보존적치료로버틸수있는환자들은향후수술가능성이낮음을알수있었다. 통증및기능적평가로사용한 VAS score 는수술권유당시수술군에서더높은경향을보여수술결정시고려할수있는하나의요인으로볼수있다. 또한수술군에서비수술군보다추시시 VAS score 결과가더좋았는데, 이는수술적치료를통해협착된신경공간을넓혀주고요추부분절불안정성을향상시키며퇴행성전방전위증의진행을방지한결과라할수있겠다. 3) 한계점으로이번연구에서대상으로선정된 명의환자가모두단분절협착증이나, 병변부위가한부위로통일되지않았고성별이동일하지않아척추관면적과요추부근육량의차이가발생할수있었다. 또한, 설문지를통한통증평가시협착증의심각한정도는주로환자방사통의강도로정의되곤하는데이에대한명확한기준이없어객관적인수치가아닌주관적표현으로만실제적인정도를유추할수있었으며, 환자들의질병의경과를정확하게파악하기어려운점이있었다. 약물치료, 물리치료및신경근차단술등의경우정확한약제명과복용기간및시술부위와횟수의오차발생가능성이있어보존적치료의강도및횟수파악에한계가있었다. 3회이상의반복적인요추부염좌에의한외상의경우하나의위험인자로고려해볼수있겠으나, 설문지를통한병력파악으로외상의정도와상태, 외상당시정밀검진미시행및시행여부확인에어려움이있었다. 저자는수술적치료결정에드는비용도하나의요인으로보았으나, 국내정서상수입에대한직접적인설문조사가현실적으로어려워최종학력과재직여부로대체하였지만한계가있었다. 외국논문의경우우울증및인지기능저하등의정신적인요인도중요시되었는데 K-ODI 에서정신적요인은제외되었다. 이에, 수술적치료를요하는비율은실제로더욱높을수있다는점등은다음연구에서는보완되어야할것으로생각된다. 결론 단분절요추관협착증환자에서지속적인보존적치료중척추관면적이좁은경우, 요추부근육량이적은경우, 헬스를하는경우, 반복적인요추부외상이있는경우와요추부스트레칭 을안하는경우수술의가능성이높았고향후수술적치료로전환과관련된연관인자들이다. 이중적은요추부근육량은수술적치료전환과관련된중요인자로고려해볼수있겠다. REFERENCES. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 8 Feb;358(8):88-5. DOI:.56/NEJMcp Atlas SJ, Keller RB, Wu YA, et al. Long-term Outcomes of Surgical and Nonsurgical Management of Lumbar Spinal stenosis: 8 to Year Results from the Maine Lumbar Spine Study. Spine. 5 Apr;3(8): DOI:.97/. brs c. 3. Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or Nonoperative Treatment for Lumbar Spinal stenosis? A Randomized Controlled Trial. Spine (Phila Pa 976). 7 Jan ;3():-8. DOI:.97/.brs d.. Matsudaira K, Hara N, Oka H, et al. Predictive Factors for Subjective Improvement in Lumbar Spinal Stenosis Patients with Nonsurgical Treatment: A 3-Year Prospective Cohort Study. PLoS ONE. 6 Feb;():e858. DOI:.37/journal.pone Jeon CH, Kim DJ, Kim SK, et al. Validation in the Crosscultural Adaptation of the Korean Version Of the Oswestry Disability Index. J Korean Med Sci. 6 Dec;(6):9-7. DOI:.336/jkms Bolender NF, Schonstrom N, Sepengler D. Role of computed tomography and Myelography in the diagnosis of central spinal stenosis. J Bone Joint Surg Am. 985 Feb;67():- 6. DOI:.6/ Shim DM, Choi YH, Yang JH, et al. Analysis and measurement of the lumbar spinal canal dimension using magnetic resonance imaging. J Korean Orthop Assoc. 8;3(5): DOI:.55/jkoa WAN Q, LIN C, LI X, et al. MRI assessment of paraspinal muscles in patients with acute and chronic unilateral low back pain. Br J Radiol. 5 Sep;88(53):56. DOI:.59/bjr Porter RW, Wicks M, Ottewell D. Measurement of the spinal canal by diagnostic ultrasound. J Bone Joint Surg Br. 978 Nov;6- B():8-. DOI:.3/3-6x.6b Ahn YJ, Im SH, Park SH. Short-Term Effects of Selective 66

9 Journal of Korean Society of Spine Surgery Factors Related to Conversion to Surgical Treatment in Spinal Stenosis Nerve Root Block in Spinal Stenosis Patients According to Spinal Canal Dimensions. J Korean Orthop Assoc. 7 Jun;():7-9. DOI:.8/jkss Shen W, Punyanitya M, Wang Z, et al. Total body skeletal muscle and adipose tissue volumes: estimation from a single abdominal cross-sectional image. J Appl Physiol (985). Dec;97(6): DOI:.5/japplphysiol.7... Baumgartner RN, Koehler KM, Gallagher D, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol. 998 Apr;7(8): DOI:.93/ oxfordjournals.aje.a D hooge R, Cagnie B, Crombez G, et al. Increased intramuscular fatty infiltration without differences in lumbar muscle cross-sectional area during remission of unilateral recurrent low back pain. Man Ther. Dec;7(6):58-8. DOI:.6/j.math Lee JC, Cha JG, Kim Y, et al. Quantitative analysis of back muscle degeneration in the patients with the degenerative lumbar flat back using a digital image analysis. Comparison with the normal controls. Spine. 8 Feb;33(3):38-5. DOI:.97/BRS.b3e38658f. 5. Knutsson B. Comparative value of electromyographic, myelography, and clinical neurological examination in the diagnosis of lumbar root compression syndrome. Arch Orthop Scand Suppl. 96;9:-35. DOI:.39/ ort.96.3.suppl Johnson EW, Melvin J. Value of electromyography in lumbar radiculopathy. Arch Phys Med Rehabil. 97 Jun;5(6):39-3. DOI:.39/ort.96.3.suppl Hides JA, Stokes MJ, Saide M, et al. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine (Phila Pa 976). 99 Jan;9():65-7. DOI:.97/ Hodges PW, Holm AK, Hansson T, et al. Rapid atrophy of the lumbar multifidus follows experimental disc or nerve root injury. Spine (Phila Pa 976). 6 Dec;3(5): DOI:.97/.brs b. 9. MacDonald DA, Lorimer Moseley G, Hodges PW. The lumbar multifidus. Dose the evidence support clinical beliefs? Man Ther. 6 Nov;():5-63. DOI:.6/ j.math Roy SH, De Luca CJ, Casavant DA. Lumbar muscle fatigue and chronic lower back pain. Spine (Phila Pa 976). 989 Sep;(9):99-. DOI:.97/ Twomey L, Taylor J. Exercise and spinal manipulation in the treatment of low back pain. Spine. Spine (Phila Pa 976). 995 Mar;(5):65-9. DOI:.97/ Hides JA, Stanton WR, McMahon S, et al. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Phys Ther. 8 Mar;38(3):-8. DOI:.59/ jospt Mannion AF, Taimela S, Muntener M, et al. Active therapy for chronic low back pain. part. Effects on back muscle activation, fatigability, and strength. Spine (Phila Pa 976). Apr;6(8): DOI:.97/ Callaghan JP, Gunning JL, McGill SM. The relationship between lumbar spine load and muscle activity during extensor exercises. Phys Ther. 998 Jan;78():8-8. DOI:.93/ptj/ Elliott JM, Jull G, Noteboom JT, et al. Fatty infiltration in the cervical extensor muscles in persistent whiplashassociated disorders. a magnetic resonance imaging analysis. Spine (Phila Pa 976). 6 Oct;3():E DOI:.97/.brs

10 Original Article J Korean Soc Spine Surg. 8 Dec;5(): 보존적치료중인단분절요추관협착증환자에서수술적치료로전환과관련된연관인자 안영준 임세혁 박병규 국립경찰병원정형외과 연구계획 : 전향적으로수집된자료의후향적연구. 목적 : 보존적치료중인단분절요추관협착증환자에서수술적치료로전환과관련된연관인자에대한분석결과를보고하고자하였다. 선행문헌의요약 : 지금까지척추관협착증환자의수술및비수술적치료후임상결과와예후에대한다양한보고가있어왔다. 그러나보존적치료중수술적치료로의전환을예측할수있는요인에대한보고는드물다. 대상및방법 : 년 5월부터 5년 5월까지본원을방문한단분절요추관협착증환자중 3개월간의보존적치료후수술을권유받고최소 3년이상추적이가능하였던환자 예를대상으로, 수술을받은 예와보존적치료를통해수술을받지않은 예를분석해수술전환과관련된연관인자들을조사하였다. 임상적평가는설문지를통해시행하였고, 영상검사로수술권유전마지막으로촬영된자기공명영상에서척추관면적과요추부근육량을측정하였다. 결과 : 자기공명영상을사용하여측정한환자들의척추관면적의평균과표준편차를이용하여 그룹을비교한결과수술군은8.(±53.6) mm, 비수술군은 7.75(±8.55) mm 로수술군에서유의하게좁았다 (p=.). 요추부근육량은수술군은5.7(±.3) cm, 비수술군은 6.(±.56) cm 로수술군에서유의하게적었다 (p=.). 설문지항목중외상에의한반복적인요추부염좌와헬스는수술군에서유의하게많았다 (p=.7, p=.37). 그러나, 요추부스트레칭을지속적으로시행한환자는비수술군에서더많았다 (p=.8). 결론 : 보존적치료중수술적치료전환과관련된연관인자들로는척추관면적이좁은경우, 요추부근육량이적은경우, 헬스를하는경우, 반복적인요추부외상이있는경우와요추부스트레칭을안하는경우가있었다. 이중적은요추부근육량은수술적치료전환과관련된중요인자로고려해볼수있겠다. 색인단어 : 요추, 척추관협착증, 요추부근육량 약칭제목 : 요추관협착증에서수술적치료전환과관련된인자 접수일 : 8년 월 9일 수정일 : 8년 월 3일 게재확정일 : 8년 월 일 교신저자 : 안영준 서울특별시송파구가락본동 58번지국립경찰병원정형외과 TEL: -3-6 FAX: osahnyj@nate.com 68 Copyright 8 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn 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