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1 대한척추외과학회지제 13 권제 2 호 Journal of Korean Spine Surg. Vol. 13, No. 2, pp 81~86, 2006 경추전방추간판제거술및유합술의방사선학적및임상적결과의상관관계 유재원 손홍문 이자용 이철갑 # 조선대학교의과대학정형외과학교실, 산업의학과학교실 # The Correlation Between Radiographic and Clinical Results after Anterior Cervical Discectomy and Fusion Jae-Won You, M.D., Hong-Moon Sohn, M.D., Ja-Yong Lee, M.D., Chul-Gab Lee, M.D. # Department of Orthopaedic Surgery, College of Medicine, Chosun University, Gwangju, Korea Department of Occupational & Environmental Medicine, College of Medicine, Chosun University, Gwangju, Korea # Abstract Study design: This is a prospective study. Objectives: We wanted to analyse the correlation between the radiographic and clinical results after anterior cervical discectomy and fusion (ACDF) for treating degenerative cervical diseases. Summary of Literature Review: ACDF is a successful procedure for treating the degenerative cervical spine. Many studies have reported on radiographic results and clinical outcomes of this procedure. However, few studies have examined the relationships between the changes of the radiographic parameters and the clinical results after ACDF. Materials and Methods: 26 patients who had single level ACDF performed for degenerative cervical diseases during the period between Jan, 2000 and Dec, 2004 were evaluated. All the patients underwent autologous iliac bone graft and plate fixation. The radiographic parameters, including the disc height, the disc space angulation and the spinous process distance were measured at the preoperative period, post operative 1 month and the last follow up period, respectively. The clinical changes were measured using the visual analogue scale (VAS) for neck and arm pain at the preoperative and last follow up period. The correlations between the radiographic parameters and the clinical outcomes were assessed by Pearson correlation. Results: There were significant changes in disc height ( mm) as well as disc space angulation (kyphosis: 1.1, lordosis: 3.4 ). The reduction in the neck pain VAS score ( ) and the arm pain VAS score ( ) was significant. None of the correlations between the radiographic parameters and the clinical outcomes were significant (p>0.05). Conclusion: Although the clinical outcomes improved significantly, there was no significant correlation between the radiographic parameters and clinical results after performing single level anterior cervical discectomy and fusion for the degenerative cervical disease. Key Words: Degenerative cervical disease, Anterior cervical discectomy and fusion, Disc height, Disc angle, Spinous process distance Address reprint requests to Hong-Moon Sohn, M.D. Department of Orthopaedic Surgery, Chosun University Hospital 588 Seosuk-Dong, Dong-Gu, Gwangju , Korea Tel: , Fax: , hmsohn@chosun.ac.kr 본논문의요지는 2005 년도대한척추외과학회추계학술대회에서발표되었음. 이논문은 2003 년도조선대학교연구보조비지원에의하여연구되었음

2 대한척추외과학회지 Vol. 13, No. 2, 2006 서 론 퇴행성경추질환은보존적인치료후에도호전이없는경우수술적치료를하게된다. 수술방법에는전방이나후방도달법에의한감압술및유합술이있으나 Robinson 과 Smith 1) 에의해소개된전방감압술과유합술은후방으로돌출된추간판이나골극을병변이있는전방에서제거하여신경을감압시키고자가골편을삽입하여감소된추간판높이를회복하며, 또한병변부위를유합함으로써척추의안정성을얻을수있는장점이있어특히두분절이하의병변이있을때많이이용된다. 골이식물은최근에공여부의합병증을줄이기위해여러가지골이식대체물들이소개되어좋은결과를보고하고있지만장기추시가필요하며아직까지는자가장골이식술이보편적인방법이다. 전방추간판제거술및유합술에서이상적인이식물의높이는아직잘알려져있지않은데삽입된골편이높은경우추간공의높이및넓이뿐만아니라척추관의직경도커지게하여압박된신경을감압할수있지만추간판높이가과도하게신장될경우척추체종판에과도한압박력이생겨서이식물의실패나하강, 불유합이발생한가능성이있고후방관절에는압박력이줄어들고관절막은신연되어수술후경부동통이초래되어좋지않은임상결과를초래할수있다 2,3,4,5,6,7). 전방추간판제거술및유합술수술후에는이식골의유합외에도추간판높이의회복, 국소후만의회복등여러가지방사선학적검사를하게되는데골유합에대한연구나임상결과에대한연구는많이되어있지만방사선학적검사와임상적호전과의상관관계에대한보고는드문실정이다 8,9). 이에저자들은퇴행성경추질환에대한단분절전방추간판제거술및유합술을받은환자들을대상으로수술후경부통및상지통의변화를관찰하고이식물에의해변화된경추부의방사선학적검사치와상관관계가있는지알아보고자하였다. 인추간판제거술을, 12 예는현미경적추간판제거술을시행하였고전례에서자가장골이식및전방금속판이식술을병행하였다. 수술부위는제 3-4 경추간이 3 예, 제 4-5 경추간이 6 예, 제 5-6 경추간이 11 예, 제 6-7 경추간이 6 예이었다. 방사선학적변화는수술전과수술후 1 개월이내, 최종추시시의추간판높이, 추간판각, 극돌기간거리를측정하였다. 경추측면방사선사진을이용하여추간판높이는추간판중간부위에서상위척추체의하부종판과하위척추체의상부종판과의거리를측정하였고, 추간판각은상위척추체의하부종판의선과하위척추체의상부종판의선이만나는각을측정하였으며, 극돌기간거리는상위경추극돌기의가장후하위의점에서하위경추극돌기의같은점까지의거리를측정하였다 (Fig. 1). 관찰자간오차를줄이기위하여측정치는 2 명의척추외과의사와 1 명의정형외과수석전공의가측정한수치의평균치를이용하였다. 임상적변화는수술전과최종추시시의경부통과상지통의 VAS (Visual analogue scale) 를측정하였다. 각각의방사선적계측치와임상적인결과는 Pearson correlation 을이용하여상관관계를알아보았다. 연구대상및방법 2000 년 1 월부터 2004 년 12 월까지퇴행성경추질환으로단분절전방추간판제거술과유합술을받고최소 6 개월이상추적관찰이가능했던 26 예를대상으로하였다. 평균연령은 55 세 (35~74) 이었고남자가 15 예, 여자가 11 예이었으며경추신경근증이 21 예, 경추증성척수증이 5 예이었다. 전례에서 standard left-side Smith- Robinson 도달법을이용하여자가장골이식술과금속판을이용한고정술을시행하였다. 이중 14 예는전통적 Fig. 1. Radiograph showing linear and angular measurement. DH, disc height; A, disc space angle; SP, spinous process distance

3 경추전방추간판제거술및유합술의방사선학적및임상적결과의상관관계 유재원외 결 과 최종추시기간은평균 15.1 개월 (10~32 개월 ) 이었다. 1. 방사선학적계측치의변화 추간판높이는수술전 6.7 ± 1.1 mm 에서수술후 1 개월에는 8.8 ± 1.5 mm 로증가하였다가최종추시시에는 7.9 ± 1.5 mm 로약간감소하였다. 추간판각은수술전후만 1.1 ± 1.6 에서수술후 1 개월에는전만 3.4 ± 2.8 로호전되었다가최종추시시에는전만 1.8 ± 2.4 로약간감소하였다. 극돌기간거리는수술전 17.1 ± 4.9 mm 에서수술후 1 개월에는 15.6± 4.7 mm 로감소였다가최종추시시에는 15.9 ± 5.3 mm 로유지되었다 (Table 1). 월에는 35.3 ± 8.5 로상당히호전되었으며최종추시시에는 33.1 ± 6.1 로약간더호전되었다. 상지통의 VAS 는수술전 57.9 ± 7.7 에서수술후 1 개월에는 33.1 ± 3.5 로상당히호전되었으며최종추시시에는 29.7 ± 2.9 로약간더호전되었다 (Table 1). 3. 방사선계측치와임상결과와의상관관계 최종추시시의추간판높이와경부통및상지통의 VAS 와의상관계수는각각 , 이었으며, 추간판각의상관계수는각각 , 이었고, 극돌기간거리와의상관계수는각각 , 이었다 (Fig. 2, 3). 세가지방사선계측치모두임상적결과와는거의무시될수있는상관관계를보였으며통계학적으로도큰의미가없었다 (p>0.05). 2. 임상결과의변화 경부통의 VAS 는수술전 63.9 ± 6.9 에서수술후 1 개 4. 전통적감압술과현미경적감압술의비교 전통적인감압술을받은 14 예의경부통및상지통의 Table 1. Changes of radiographic parameters and clinical results. Preop PO 1M Last F/U DH (mm)* 6.7± ± ±1.5 A ( ) 1.1± ± ±2.4- SP (mm) 17.1± ± ±5.30 Neck VAS 63.9± ± ±6.10 Arm VAS 57.9± ± ±2.90 * DH: disc height A: disc space angle SP: spinous process distance VAS: visual analogue scale Fig. 2. Correlation between final disc height and neck pain and arm pain. There was no significant correlation. r, correlation coefficient

4 대한척추외과학회지 Vol. 13, No. 2, 2006 평균 VAS 는수술전각각 63.8 과 57.8 에서수술후각각 32.9 과 29.5 로호전되었으며, 현미경적감압술을받은 12 예의경부통및상지통의평균 VAS 는수술전각각 63.6 과 53.6 에서수술후각각 33.6 과 29.4 로호전되었으나두군간의임상적호전의차이는없었다 (Mann-Whitney test, p>0.05). 고 찰 퇴행성경추질환에는추간판퇴행증, 골극및추간판탈출에의한신경근증과척수증이있는데, 저자들의경우추간판퇴행증은대부분보존적인치료로호전되어수술의적응증을구분하기가어렵고수술후의예후도신경근증이나척수증보다예견하기가어렵다고생각하여단순한추간판퇴행증은수술적치료를하지않아서본연구는신경근증과척수증환자를대상으로임상적결과를판정하였다. 또한경추척수증은신경근증과전혀다른질환으로볼수있지만본연구의대상이되었던증례들은모두단분절의추간판탈출에의해척수증과신경근증의증상을나타내어서연구대상에포함을시켰다. 경추증성신경근증에대한수술적치료는 1940 년대에이질환에대한이해가깊어지면서압박된신경근에대한감압술로후방부분추궁절제술을이용하였는데 10), 경막외정맥출혈에의해수술시야가좋지않고골극이나탈출된추간판을제거하기위해신경근에손상을줄가능성이많은단점이있어, 1950 년대후반 Smith 와 Robinson 1) 이전방추간판제거술및유합술을보고한이후, 전방도달법은전방에서직접병변에접근함으로써신경을압박하고있는병변부위를더쉽고안 전하게제거할수있고, 성공적인골유합을이룸으로써계속적인골극의형성을방지하며, 유합으로이루어진안정성으로인해이미존재하던골극도퇴축이가능하고, 또한협소화된추간판간격을신연시킴으로써추간공을확장시켜신경근에대한감압을가능하게하는장점이있어최근까지가장많이이용되는방법이다 11,12). 전방추간판제거술후추간판을신연시키고골이식을하게되는데추간판신연이임상증상을호전시키는지에대해서는논란이많다. 오히려과도한신연은이식골과경추체경계부위에압박력을증가시켜이식골의붕괴를초래할수있고추간판높이의증가와추간공의높이의증가와비례하지만은않는다 5,7,13). 본연구의결과에서도추간판의높이는수술전에비해수술후최종평가에서평균 1.2 mm 증가했지만추간판의높이호전정도와임상적증상과는특별한상관관계가없었다. 추간판각은술전평균후만 1.1 이었으며추간판각을교정하기위해전례에서이식골의높이가전방이후방보다약간높게하여삽입하였으며, 최종평가에서평균 1.8 로전만상태로유지되었으나역시임상증상의호전과는특별한상관관계가없었고이는 Laing 등 14) 의보고와도유사하다. 극돌기간거리는추간판의높이가증가할수록또는추간판각의후만각이커질수록거리가넓어지는데수술전평균 17.1 mm 에서최종결과 15.1 mm 로변화하였지만이또한임상결과와특별한상관관계가없었고실지로이수치는앞의다른두가지변수에의하여변화하므로단독으로평가하는것은큰의미가없어보인다 년대후반부터미세수술기구의발달로경추증성신경근증에대한전방감압술에미세현미경수술이시도되어좋은결과를보고하고있고 15), 최근에는척추 Fig. 3. Correlation between final disc space angle and neck pain and arm pain. There was no significant correlation. r, correlation coefficient

5 경추전방추간판제거술및유합술의방사선학적및임상적결과의상관관계 유재원외 수술에수술현미경을이용한방법이자주이용되는데각각의결과만보고되었지전통적전방감압술과비교한보고는없는실정이다. 본연구의대상이초기 14 예는전통적방법, 후기 12 예는현미경적감압술을시행하여서이두군의임상결과를비교해본결과두군간에임상적호전의차이는없었다. 결 론 퇴행성경추질환에대한단분절전방감압술및유합술을시행한환자들의최종추시임상적결과와방사선학적결과의상관관계를알아본결과추간판높이, 추간판각, 극돌기간거리모두환자들의경부통이나상지통의호전정도와특별한상관관계는없었다. 퇴행성경추질환의수술적치료후임상결과는병변의직접적인제거가관계가있으며간접적인방사선상의호전은특별한상관관계가없는것으로사료된다. 참고문헌 01) Smith GW, Robinson RA: The treatment of certain cervical spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg 1958; 40-A: ) Albert TJ, Smith MD, Bressler E, Johnson LJ: An in vivo analysis of the dimensional changes of the neuroforamen after anterior cervical diskectomy and fusion: a radiologic investigation. J Spinal Disord 1997;10: ) An HS, Evanich CJ, Nowicki BH, Haughton VM: Ideal thickness of Smith-Robinson graft for anterior cervical fusion. A cadaveric study with computed tomographic correlation. Spine 1993;18: ) Bayley JC, Yoo JU, Kruger DM, Schlegel J: The role of distraction in improving the space available for the cord in cervical spondylosis. Spine 1995;20: ) Truumees E, Demetropoulos CK, Yang KH, Herkowitz HN: Effects of disc height and distractive forces on graft compression in an anterior cervical discectomy model. Spine 2002;27: ) Olsewski JM, Garvey TA, Schendel MJ: Biomechanical analysis of facet and graft loading in a Smith-Robinson type cervical spine model. Spine 1994;19: ) Truumees E, Demetropoulos CK, Yang KH, Herkowitz HN: Failure of human cervical endplates: a cadaveric experimental model. Spine 2003;28: ) Jenis LG, An HS, Simpson JM: A prospective comparison of the standard and reverse robinson cervical grafting techniques: radiographic and clinical analyses. J Spinal Disord 2000;13: ) Kwon B, Kim DH, Marvin A, Jenis LG: Outcomes following anterior cervical discectomy and fusion: the role of interbody disc height, angulation, and spinous process distance. J Spinal Disord Tech 2005;18: ) Spurling RG, Scoville WB: Lateral rupture of the cervical intervertebral discs. A common cause of shoulder and arm pain. Surg Gynecol Obstet 1944;78: ) Garvey TA, Transfeldt EE, Malcolm JR, Kos P: Outcome of anterior cervical discectomy and fusion as perceived by patients treated for dominant axial-mechanical cervical spine pain. Spine 2002;27: ) Bohlman HH, Emery SE, Goodfellow DB, Jones PK: Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg 1993;75: ) Farmer J, Albert TJ, Balderston RA, Vaccaro A: Foraminal pressure changes during intervertebral distraction simulating anterior cervical discectomy. J Spinal Disord 1998;11: ) Laing RJ, Ng I, Seeley HM, Hutchinson PJ: Prospective study of clinical and radiological outcome after anterior cervical discectomy. Br J Neurosurg 2001;15: ) Kozak JA, Hanson GW, Rose JR, Trettin DM, Tullos HS: Anterior discectomy, microscopic decompression, and fusion: a treatment for cervical spondylotic radiculopathy. J Spinal Disord 1989;2:

6 대한척추외과학회지 Vol. 13, No. 2, 2006 국문초록 연구계획 : 퇴행성경추질환의수술적치료후방사선학적변화와임상적결과와의상관관계를전향적방법으로분석하였다. 연구목적 : 퇴행성경추질환으로단분절전방추간판제거술과유합술을받은환자들을대상으로수술전후의방사선학적변화와임상적결과와상관관계가있는지알아보고자하였다. 대상및방법 : 2000년 1월부터 2004년 12월까지퇴행성경추질환으로단분절전방추간판제거술과유합술을받고최소6개월이상추적관찰이가능했던 26례를대상으로하였다. 평균연령은 55세 (35~74) 이었다. 남자가 15례여자가 11례이었으며, 전례에서자가장골이식술과금속판을이용한고정술을병행했다. 방사선학적변화는수술전과수술후 1개월이내, 최종추시시의추간판높이, 추간판각, 극돌기간거리를측정하였으며임상적변화는수술전과최종추시시의경부통과상지통의 VAS score를측정하였다. 각각의방사선적계측치와임상적인결과는 Pearson correlation을이용하여상관관계를알아보았다. 결과 : 추간판의높이는평균 6.7 mm에서 7.9 mm로, 추간판각은평균후만 1.1 에서전만 3.4 로호전되었다. 경부통의 VAS는평균63.9에서 33.1로, 상지통의 VAS는평균57.9에서 29.7로호전되었다. 그러나세가지방사선계측치모두임상적결과와는거의무시될수있는상관관계를보였으며통계학적으로도큰의미가없었다 (p>0.05). 결론 : 퇴행성경추질환에대한단분절전방감압술및유합술을시행한환자들의최종추시임상적결과와방사선학적결과의상관관계를알아본결과, 임상결과는의미있는호전을보였지만추간판높이, 추간판각, 극돌기간거리모두환자들의경부통이나상지통의호전정도와특별한상관관계는없었다. 퇴행성경추질환의수술적치료후임상결과는병변의직접적인제거가관계가있으며간접적인방사선상의호전은특별한상관관계가없는것으로사료된다. 색인단어 : 퇴행성경추질환, 전방추간판제거술및유합술, 추간판높이, 추간판각, 극돌기간거리 통신저자 : 손홍문광주광역시동구서석동 588 조선대병원정형외과 Tel: Fax: hmsohn@chosun.ac.kr

01-김환정

01-김환정 대한척추외과학회지제 15 권제 4 호 Journal of Korean Spine Surg. Vol. 15, No. 4, pp 215~222, 2008 경추전방유합술후인접분절의퇴행성변화 김환정 강종원 성환일 박건영 # 박재국 $ 강성일 최원식 을지대학교의과대학정형외과학교실, 대전보훈병원정형외과 #, 홍성의료원정형외과 $ Degenerative Changes of