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1 대한정형외과학회지 : 제 44 권제 1 호 2009 J Korean Orthop Assoc 2009; 44: 퇴행성요추측만증에서후방기기고정술과유합술후에발생한근위부인접분절질환 조규정ㆍ박승림ㆍ김명구ㆍ윤영현ㆍ이중선ㆍ석세일 * 인하대학교의과대학정형외과학교실, 인제대학교의과대학정형외과학교실 * Proximal Adjacent Segment Disease following Posterior Instrumentation and Fusion for Degenerative Lumbar Scoliosis Kyu-Jung Cho, M.D., Seung-Lim Park, M.D., Myung-Gu Kim, M.D., Yung-Hyun Yoon, M.D., Joong-Sun Lee, M.D., and Se-Il Suk, M.D.* Department of Orthopedic Surgery, Inha University College of Medicine, Incheon, Seoul Spine Institute, Inje University Hospital*, Seoul, Korea Purpose: Adjacent segment disease (ASD) is major complication following spinal instrumentation and fusion. The purpose of the current study was to determine the prevalence and risk factors of proximal ASD following posterior instrumentation and fusion for degenerative lumbar scoliosis. Materials and Methods: Seventy-two patients (mean age 64.8 years) who had undergone decompression and fusion with pedicle screw instrumentation were evaluated. The average follow-up was 4.7 years. Twenty-five patients had additional interbody fusion at the lower lumbar spine. The average number of levels fused was 5.1 segments (range 1-9). The upper instrumented vertebrae ranged from T9 to L4. The lower instrumented vertebrae were L5 and S1. Results: Proximal ASD developed in 17 (24%) of 72 patients, including compression fractures (n=6), junctional kyphosis (n=5), spinal stenosis (n=4), and symptomatic disc collapse (n=2). The preoperative scoliotic angle, lumbar lordosis, thoracic kyphosis, and coronal and sagittal C7 plumb were not associated with the development of proximal ASD. There was a close correlation between the level of the upper instrumented vertebrae and the development of ASD (p=0.001). When fusion did not extend beyond the lumbar vertebra, ASD occurred in 15 (38.5%) of 39 patients. In contrast, when fusion extended up to the thoracic vertebrae, ASD occurred in 2 (6.1%) of 33 patients. The improvement in the Oswestry score was superior to the group without ASD (p=0.001). Conclusion: The prevalence of symptomatic ASD at the proximal segment was 24% after posterior instrumentation and fusion for degenerative lumbar scoliosis. The cephalad extent of fusion was the most significant risk factor for the development of proximal ASD. Key Words: Degenerative lumbar scoliosis, Adjacent segment disease, Extent of fusion 서론척추기기고정술을시행한이후에인접분절질환이점점많이발생하고있다. Hilibrand 등 12) 에따르면인접분절질환을방사선적변화만있는인접분절질환과방사선 통신저자 : 박승림인천시중구신흥동 3 가 인하대학교의과대학정형외과학교실 TEL: ㆍ FAX: * 본연구논문은 AOSpine Korea 연구비지원기금의일부를지원받아작성하였음. 적변화와함께증상이있는인접분절질환으로나누었으며방사선적변화만있는인접분절질환을인접분절퇴행, 방사선적변화와함께증상을동반하는인접분절질환을인접분절질환이라명명하였다. 여러연구들을종합해보 Address reprint requests to Seung-Lim Park, M.D. Department of Orthopaedic Surgery, Inha University Hospital, 7-206, Sinheung-dong 3-ga, Jung-gu, Incheon , Korea Tel: , Fax:

2 110 조규정ㆍ박승림ㆍ김명구외 3 인 면방사선적변화만있는인접분절질환의발생률은 8-100% 까지, 방사선적변화와함께증상을동반하는인접분절질환의발생률은 % 로보고되고있다 2,14,15). 최근평균수명의증가로인하여노인인구가늘어남에따라척추관협착증이동반된퇴행성요추측만증환자또한증가하고있다 5). 퇴행성요추측만증의수술적치료로는기기고정술과유합술을많이사용하며 5,9), 기기고정술이긴분절에걸쳐서시행되기때문에일반적인척추질환에비해더많은인접분절질환을경험하고있다. 따라서인접분절질환을발생시킬수있는위험인자를파악하여사전에대비할필요가있다. 일반적으로퇴행성척추질환에유합술을시행한후에발생하는인접분절질환의위험인자로는기기고정, 인접분절의척추후관절의손상, 시상면상불균형, 유합술의범위, 환자의나이, 후방추체간유합술등이알려져있다. 그러나퇴행성척추측만증환자에발생하는인접분절질환에대한연구는아직미비한편이다. 저자들은이미보고한연구 4) 에서수술전에인접분절에존재했던추간판의단순퇴행성변성은인접분절질환을초래하지않았지만, 수술전에퇴행성척추측만증이나척추의후방전위가있었던인접분절에는수술이후에인접분절질환의발생률이높았다고보고하였다. 저자들은이번연구를통해서퇴행성척추측만증환자에시행한후방기기고정술과유합술후에발생하는근위부인접분절질환의발생률과위험인자를알아보았다. 대상및방법 1997년부터 2005년까지퇴행성요추측만증으로감압술과척추경나사못기기고정으로유합술을시행받고 1년이상추시가가능하였던환자 72명을대상으로평가하였다. 환자는두군데대학병원에서차트와방사선사진을분석하여측만각이적어도 10도이상이고, 최소나이가 40세이상인환자를대상으로하였다. 전체환자 72 명의평균연령은 64.8세였고, 남성이 14명, 여성이 58 명이었다. 추시기간은평균 4.7년간추적조사하였다. 72명의모든환자는척추경나사못고정술을받았으며그중 25명의환자는제 4-5 요추, 5 요추-1천추에후방추체간유합술을추가로받았다. 유합구간은평균 5.1구간이었다. 1구간이 2명, 2구간이 4명, 3구간이 11명, 4 구간이 18명으로가장많았으며 5구간이 8명, 6구간이 4명, 7구간이 15명, 8구간이 9명, 9구간이 1명이었다. 상위고정범위는 9흉추에서 4요추까지다양한부위에시행하였으며 9흉추가 3명, 10흉추가 18명으로가장많았으며, 11흉추가 6명, 12흉추가 5명, 1요추가 6명, 2요추가 17명이었고, 3요추가 11명, 4요추가 6명으로나타났다 (Fig. 1). 원위고정범위는모든환자에서 5요추와 1천추에시행되었다. 수술방법의선택은환자의나이, 수술전내과적질환을포함한전신상태, 측만각과시상면불균형등을고려하여가장최적의방법을선택하였다. 감압술은모든환자에서시행하였다. 감압술은척추협착증이확인되고증상과일치하는부위에시행하였다. 유합범위의선택은일반적으로척추측만증이심하지않고, 시상면상균형이유지되는환자는가능한적은분절을고정하였다. 척추측만증이심하고시상면불균형이나타나는환자는더많은분절을고정하였다. 하지만수술전에나이가초고령이거나, 내과적질환이많거나환자의전신상태가큰수술을견디기힘들때는심한측만증과시상면불균형환자에서도짧은분절고정을선택하였다. 인접분절질환의판정은수술후 6개월동안방사선상에서변화가없다가새로운이상이발견된환자중에서방사선변화와관련있는증상을보이는경우로정의하였다. 증상의발현없이방사선이상을보인환자는제외하였고, 증상을동반한환자만포함하였다. 즉수술이후일정기간동안증상없이지내다가하부요통또는다리로방사하는통증이다시발현되는경우를인접분절질환에포함시켰다. 인접분절질환이있는군과없는군으로나누어서인접분절질환을일으키는위험인자를비교분 Fig. 1. Distribution of upper instrumented vertebra.

3 퇴행성요추측만증에서후방기기고정술과유합술후에발생한근위부인접분절질환 111 석하였다. 그리고상위고정척추가흉추인군과요추인군으로나누어인접분절질환이어느군에서많이발생하는가를비교하였고, 유합술의범위가 4구간이하인군과 4구간초과인군으로나누어발생률을비교하였다. 지금까지보고된문헌상유합술후인접분절질환발생의위험인자라고알려져있는환자의나이, 유합분절의수, 관상면불균형, 시상면불균형, 추체간유합술여부등에대해분석하였다. 전신방사선사진에서 Cobb 각도, 요추전만각, 흉추후만각, 첨부척추의외측전위, 관상과시상불균형을측정하였다. 임상결과와만족도는 Oswestry 장애지수로측정하였다. 통계학적방법은 SPSS 11.0 프로그램으로 T-test 및로지스틱회귀분석을이용하여시행하였다. 결과근위부인접분절질환은전체 72명의퇴행성요추측만증환자중 17명 (24%) 에서발생하였다. 인접분절질환이발생한 17명의평균연령은 63.9세였으며남자는 3명, 여자는 14명이었다. 인접분절질환이발생하지않은 55 명의평균연령은 65.1 세였으며남자는 11명, 여자는 44 명이었다. 두군간에평균연령은차이가없었다 (p= 0.31). 인접분절질환에는압박골절이 6명, 인접부척추후만증 5명, 척추관협착증 4명, 흉요추부통증을동반한추간판붕괴 2명이있었다. 인접부척추후만증의진단기준은다음두개의기준중한가지를만족하는경우로하였다. 첫째, 최종추시사진상상위고정척추의원위골단판과그바로위척추의근위골단판사이의후만각도가 10도이상일때, 둘째, 최종추시시후만각이수술전보다 10도이상증가하였을때로정의하였다. 비교의편이를위해인접분절질환이발생한군을질환군, 인접분절질환이발생하지않은군을정상군으로명기하였다. 유합술을시행한구간의평균수는정상군에서 5.5 분절, 질환군에서 3.6 분절이었으며통계적으로유의한차이를보였다 (p=0.01). Cobb 각은수술전에정상군에서 20.7도, 질환군에 21도로차이가없었으나, 최종추시시는정상군이 6.9도, 질환군이 9.8도로나타나두군간에통계적으로의미있는차이를보였다 (p=0.002). 수술전에유합범위를결정할때측만이심한환자에서는장분절유합술을주로고려하였으나환자가초고령이거나, 내과적질환이심각할때는장분절고정술을시행 하지못하는경우도있었다. 유합범위가정상군에서질환군보다더길었으나, 수술전 Cobb 각이두군간에차이가나지않는이유는이로인한결과로생각된다. 요추전만각은정상군에서술전 27.4 o 에서최종추시시 25.7 o 로, 질환군에서는술전 31.1 o 에서최종추시시 26.2 o 로, 전만각의교정은두군간에통계적으로차이가없었다. 흉추후만각도수술전, 수술후, 최종추시시에두군간에통계적유의성은보이지않았다. 요추전만각과흉추후만각의차이를계산하였는데, 이수치또한수술전, 수술후, 최종추시시에는두군간에통계적인차이를발견할수없었다. 하지만수술전과최종추시시의변화정도는정상군에서 -1.6 o, 질환군에서 -1.8 o 로의미있는차이를보였다 (p=0.004)(table 1). 관상면수선은정상군에서술전 14.8 mm 에서수술후 Table 1. Comparison of Radiological Factors between the Patients with Proximal ASD and the Patients with no Proximal ASD Cobb's angle ( o ) Lumbar lordosis ( o ) Thoracic kyphosis ( o ) Lordosis-kyphosis ( o ) Sagittal C7 plumb (mm) Coronal C7 plumb (mm) ASD, adjacent segment disease. ASD ( ) (n=55) 20.7± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±17.0 ASD (+) (n=17) 21.0± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±26.2 p-value

4 112 조규정ㆍ박승림ㆍ김명구외 3 인 18.2 mm였고, 질환군에서술전 22.7 mm에서수술후 18 mm로변하여두군간에차이가없었다 (p=0.356). 시상면수선또한정상군에서술전 50.7 mm 에서수술후 62.2 mm 로변하였고질환군에서는술전 48.8 mm 에서수술후 32.6 mm 로변하여통계적인차이가없었다 (p= 0.083). 즉수술전의관상면과시상면수선은두군간에차이가없어인접분절질환의발생에중요한인자가아닌것으로나타났다. 인접분절질환의위험인자확인은로지스틱회귀분석으로통계처리를하였다. 인접분절질환의발생은상위유합범위와밀접한연관이있었으며, 상위고정범위가요추인가, 흉추인가에따라서발생률차이가현저하게나타났다. 즉상위고정척추가요추인 39명중 15명에서근위인접분절질환이발생하여 38.5% 의발생률을보였다. 반면에상위고정척추가흉추까지올라간 33명중에서는단지 2명에서근위인접분절질환이발생하여 6.1% 의발생률로차이가뚜렷하였다 (p=0.001). 로지스틱회귀분석상상위고정척추가요추인군의 odds ratio 는 9.688으로나타나흉추보다인접분절질환의발생률이약 10배정도차이가났다고볼수있었다 (Table 2). 이에비추어볼때근위부의유합범위가근위부인접분절질환의발생에있어서매우중요한요인인것을알수있다. 퇴행성요추측만곡의상위끝척추는제10흉추가 2명, 제11흉추가 4명, 제12흉추가 11명이었으며, 제1요추가 32명, 제2요추가 20명, 제3요추가 3명이었다. 대부분에서상위끝척추가제 12 흉추와제 2 요추사이에위치하기때문에요추부에서유합을멈춘다면측만변형전체를유합하는것이아니기때문에변형의일부가남아서이부위에서퇴행성변화가가속화된다고예측할수있다. 유합범위가 1구간이었던환자 (2명) 에서는인접분절 질환이 1명 (50%) 에서발생하였으며 2구간인환자 (4명) 에서는 3명 (75%) 에서인접분절질환이발생하였다. 3구간인환자 (11명 ) 에서는 2명 (18%) 에서인접분절질환이발생하였고, 4구간인환자 (18명 ) 에서는 9명 (50%) 에서인접분절질환이발생하였으며, 5구간인환자 (8명) 에서는인접분절질환이 1명 (13%) 에서발생하였다. 6구간 (4 명 ), 7구간 (15명 ), 9구간 (1명) 에서는인접분절질환이발생하지않았으며 8구간 (9명) 에서 1명의인접분절질환이발생하였다. 즉 4분절이하의유합술을시행받은 35명의환자중 15명 (40%) 에서인접분절질환이발생한반면에, 4분절초과의유합술을시행받은환자 37명중에서는 2명 (5.4%) 에서인접분절질환이발생하였다 (p=0.001). 재수술은근위부인접분절질환이발생한 17명의환자중 7명에서척추관협착증 (2명), 압박골절 (2명), 인접부척추후만증 (3명) 으로시행되었다. 정상군에서 Oswestry 점수는수술전 48.2에서마지막내원시에 31.8 로호전되 Table 2. Incidence of Proximal ASD according to the Level of Upper Instrumented Vertebra UIV=T-vertebra UIV=L-vertebra No. of pateints No. of ASD case 2 15 Prevalence 6.1% 38.5% Odds ratio (95%C.I) ( ) p-value UIV, upper instrumented vertebra. p=0.001 Fig. 2. erative radiographs of the lumbar spine. A 58- years-old woman with spinal stenosis and degenerative lumbar scoliosis. (A) Anteroposterior radiograph showing degenerative lumbar scoliosis. (B) Lateral radiograph showing a disc space narrowing at lumbar spine.

5 퇴행성요추측만증에서후방기기고정술과유합술후에발생한근위부인접분절질환 113 었고, 질환군에서점수는 57.1 에서 51.1 로변했다. 정상군에서 Oswestry 점수가훨씬많이호전되는것을확인할수있었다 (p=0.01). 58세여자환자로척추관협착증을동반한퇴행성요추측만증으로 (Fig. 2) 2요추 - 1천추까지척추고정및후방갑압술과유합술을시행받았다 (Fig. 3). 수술후 2년째시행한추적관찰시근위인접분절에신경관을압박하는척추후만증이발생하였다 (Fig. 4). 제 10흉추까지유합술을연장하였고현재까지증상호전된상태로일상생활에복귀한상태이다 (Fig. 5). 고찰퇴행성요추측만증환자의주증상은크게세가지로, 요통, 하지방사통, 척추의변형이다. 요통은척추관협착증과달리심한퇴행성변화로인해앉아서휴식을취할때도지속된다 9). 요통뿐만아니라하지의방사통도심하며, 방사통은주로척추관협착증과척추체외측전이에의한신경압박에의해발생된다 5,26). 척추의변형은측만증으로인한관상면상불균형뿐만아니라, 시상면 상불균형도자주동반된다. 이렇게다양한증상으로인해수술적치료방법도무척다양하다. 일반적으로는신경압박을풀어주는감압술과함께, 요통을치료하기위해후방기기고정술과유합술을사용한다 11,19). 척추의변형까지교정하기위해서는변형이있는척추분절전체를고정하게된다. 이러한척추기기고정술은인접분절특히근위인접분절의운동성에영향을미치며사체연구를통해서근위인접분절에서운동량의증가와추간판내의압력증가등을확인하였다 22). 생체역학연구에서도척추경나사못기기고정과유합술을시행한후에인접분절에서퇴행성변화의증가가확인되었고, 이러한퇴행성변화가진행하는까닭은유합된분절의인접분절에서스트레스의증가와운동량의증가가원인일수있다고하였다 8,17,23,24). 이러한인접분절질환은요통이나방사통등의증상을다시유발하여재수술에까지이르게하므로인접분절질환 Fig. 3. (A, B) Immediate postoperative anteroposterior and lateral radiographs showing posterior fusion to L2 from S1. Fig. 4. (A) Two years after surgery, the patient complained of claudication and radicular pain to both legs with junctional kyphosis at L1-2 on the radiographs. (B, C) MRI showed spinal stenosis at L1-2.

6 114 조규정ㆍ박승림ㆍ김명구외 3 인 Fig. 5. (A, B) We performed revision surgery extending fusion to T10. 의발생률과위험인자에대한분석이필요하다. 인접분절질환의발생률은보통 5-43% 로보고되고있다 7,18,21). Park 등 20) 이기존에발표된문헌을분석한결과가장흔한인접분절질환은심한추간판의퇴행이었고, 그다음으로척추불안정, 척추후관절퇴행성비후, 추간판탈출증, 척추관협착증이었다. 그외퇴행성측만증과척추골절도나타났다. 이러한문헌보고와유사하게본연구에서도추체의압박골절, 인접부척추후만증, 척추관협착증, 통증을동반한추간판간격붕괴순으로인접분절질환이 24% 에서발생하였다. 근위인접분절에발생하는추체의압박골절이 17명중 6명에서나타나가장많았는데이는대상환자의평균나이가 64.8 세로고령이었기때문에경미한외상으로도골절이쉽게발생한것으로추정된다. 모든압박골절은고정술을시행한바로근위분절에발생하였으며, 특별히심각한외상의병력없이압박골절이발생하였다. 수술전에골밀도검사를시행하여수술전골다공증여부가압박골절에미치는영향을분석하려고시도하였지만오래전에수술한환자들은골밀도검사를시행하지않았기때문에, 골밀도검사에 대한자료가불충분하여골밀도검사수치와압박골절과의인과관계를밝히기는어려웠다. Ahn 등 1) 은후방유합술후인접분절의퇴행성변화에기여하는위험인자로고령, 장분절유합술, 천골을포함한고정술, 불충분한요추전만, 요추전체의척추증, 최상위척추경나사못의상부위치, 원위인접분절의불안정성, 운동부족, 심한육체노동, 농촌주거등을제시하였다. 또한시상면의불균형이인접분절에퇴행성변화를일으킨다는연구도있었다 3,16). 이러한인접분절질환의위험인자는문헌에따라다양하게보고되고, 각각의위험인자에대해서아직논란의여지가있다. 본연구도일반적인퇴행성척추질환은포함시키지않고퇴행성요추측만증환자만을대상으로분석하였기때문에타연구와다른결과가도출될수있다. 본연구에서는연령과요추의전만각감소는인접분절질환의발생률과관계없고, 가장가능성이많은위험인자는근위부유합범위로확인되었으며, 상위고정척추가요추인경우에서흉추인경우보다인접분절질환의발생률이현저히많이나타났다. Shufflebarger 등 25) 의논문에서퇴행성요추측만증에서제 10 흉추까지유합한경우와제 1 요추까지유합한경우의장단점에대해서비교하였고, 특히근위인접분절질환만을주목하였을때 Suk 25) 은상위고정척추를 11 흉추-2요추사이로수술을시행하였을때인접분절질환의발생률이 50% 였던데비해, 상위고정척추를 10흉추이상으로시행했을때는 14% 로현저히감소하였다고보고하였다. 물론수술전에환자가가지고있던관상면및시상면상불균형, 불충분한요추전만각의회복등도위험인자일가능성이충분히있으나, 이번연구에서는퇴행성요추측만증에서후방기기고정술과유합술후발생하는근위인접분절질환에는유합술의범위, 특히상위고정척추의부위가가장밀접한관계가있는것으로확인되었다. 인접분절에수술전에존재하는추간판의단순한퇴행성변성이수술후인접분절질환으로진행하는가는아직논란이있다. Gillet 8) 은수술전부터퇴행성변화가있는분절은장기적인결과에차이가없어신경증상과관계있는분절만유합하였다고하였다. 이와반대로수술전인접분절에퇴행성변화가있는경우수술후그인접분절에서퇴행성변화가가속화되어인접분절질환의발생이증가한다고보고한논문도있다 4,6,10,27). Hsu 등 13) 은요

7 퇴행성요추측만증에서후방기기고정술과유합술후에발생한근위부인접분절질환 115 추에서후방기기고정술을시행한환자군에서인접분절의퇴행성변화가조기에일어나서임상적만족도가감소한다고하였고, Schlegel 등 24) 도후방기기고정술을사용한환자군에서인접분절의퇴행성변화가조기에발생한다고하였다. 저자들은이미발표한연구 5) 에서인접분절에수술전에존재하는퇴행성변화중에서추간판의단순퇴행성변성은수술이후에진행이별로되지않았던데비해요추측만이있거나, 후방전위가있던인접분절은수술이후에진행이많이되어인접분절질환으로진전되었다는결과를보고하였다. 이번연구에서도퇴행성요추측만증수술후인접분절질환의발생률이 24% 로나타났으며, 일반적인퇴행성척추질환에서발생하는인접분절질환보다는발생율이다소높아보인다. 일반적으로시상면상후만각변형이 도이상인부위는유합에포함시켜야한다고알려져있다 28). 특히흉요추부위에보이는후만변형을유합하지않았을때는추후인접부후만증으로진행할가능성이크기때문에반드시유합해야한다. 시상면상에서보이는변형뿐만아니라, 관상면상에서보이는변형도인접분절질환을유발할가능성이많다. 다시말하면퇴행성요추측만증환자에서유합술이후에도측만변형이남아있는분절에서퇴행성변화가가속화되어근위부인접분절질환으로진행할수있기때문에, 근위부인접분절질환을방지하기위해서는측만변형전체를유합하는것이바람직하다. 결론퇴행성요추측만증에서후방기기고정술과유합술후근위분절에발생하는, 증상을동반한인접분절질환의발생률은 24% 였다. 근위부인접분절질환의발생에가장중요한위험인자는근위부의유합범위이며특히, 상위고정척추가요추부일때인접분절질환이많이발생하였다. 요추부에발생한측만변형전체를유합하지않고일부만유합했을때, 남아있는분절에서퇴행성변화가더진행하여인접분절질환을유발시킨다고볼수있다. 따라서퇴행성요추측만증에서근위부인접분절질환의발생을줄이기위해서는측만변형이있는부위를모두유합해야하며, 가능한측만각의상위끝척추를유합범위에포함시켜야한다. 하지만이렇게유합범위를길게해야할경우, 퇴행성요추측만증환자가주로고령이고내과적질환을동반하고있어, 긴분절고정술로인한합 병증의가능성이높아지기때문에환자의상태를신중하게고려하여유합범위를선택해야하겠다. 참고문헌 1. Ahn DK, Lee S, Jeong KW, Park JS, Cha SK, Park HS: Adjacent segment failure after lumbar spine fusion-controlled study for risk factors. J Korean Orthop Assoc, 40: , Booth KC, Bridwell KH, Eisenberg BA, Baldus CR, Lenke LG: Minimum 5-Year results of degenerative spondylolisthesis treated with decompression and instrumented posterior fusion. Spine, 24: , Cho JL, Park YS, Han JH, Lee CH, Roh WI: The changes of adjacent segments after spinal fusion: follow-up more than three years after spinal fusion. J Korean Spine Surg, 5: , Cho KJ, Park SR, Moon KH, et al: Progression of preoperative degeneration of the adjacent segment after instrumented lumbar arthrodesis. J Korean Orthop Assoc, 42: , Epstein JA, Epstein BS, Jones MD: Symptomatic lumbar scoliosis with degenerative changes in the elderly. Spine, 4: , Etebar S, Cahill DW: Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg, 90(Suppl 2): S163-S169, Ghiselli G, Wang JC, Bhatia NN, Hsu WK, Dawson EG: Adjacent segment degeneration in the lumbar spine. J Bone Joint Surg Am, 7: , Gillet P: The fate of the adjacent motion segment after lumbar fusion. J Spinal Disord Tech, 16: , Grubb SA, Lipscomb HJ: Diagnostic findings in painful adult scoliosis. Spine, 17: , Ha KY, Kim KW, Park SJ, Lee YH: s of the adjacent-unfused mobile segment after instrumental lumbar fusion: more than 5-years follow-up. J Korean Spine Surg, 5: , Herkowitz HN, Kurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing

8 116 조규정ㆍ박승림ㆍ김명구외 3 인 decompression with decompression and intertransverse process arthrosis. J Bone Joint Surg Am, 73: , Hilibrand AS, Robbins M: Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? Spine, 4(Suppl 6): S190-S194, Hsu KY, Zucherman J, White AH, et al: Deterioration of motion segments adjacent to lumbar spine fusions. Presented at the Annual Meeting of the North American Spine Society, Colorado Springs, Colorado, Kanayama M, Cunningham BW, Weis JC, Parker LM, Kaneda K, McAfee PC: Maturation of the posterolateral spinal fusion and its effect on load-sharing of spinal instrumentation. An in vivo sheep model. J Bone Joint Surg Am, 79: , Kumar MN, Baklanov A, Chopin D: Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J, 10: , Kumar MN, Jacpuot F, Hall H: Long-term follow-up of functional outcomes and radiographic changes at adjacent levels following lumbar spine surgery for degenerative disc disease. Eur Spine J, 10: , Lee CK: Lumbar spinal instability (olisthesis) after extensive posterior spinal decompression. Spine, 8: , Lehmann TR, Spratt KF, Tozzi JE, et al: Long-term follow-up of lower lumbar fusion patients. Spine, 12: , Mardjetko SM, Connolly PJ, Shott S: Degenerative lumbar spondylolisthesis. A meta-analysis of literature Spine, 15(Suppl 20): S2256-S2265, Park P, Garton HJ, Gala MVC, Hoff JT, McGillicuddy JE: Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine, 29: , Penta M, Sandhu A, Fraser RD: Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion. Spine, 20: , Quinnel RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. Spine, 6: , Rohlman A, Neller S, Bergmann G, Graichen F, Claes L, Wilke HJ: Effect of an internal fixator and a bone graft on intersegmental spinal motion and intradiscal pressure in the adjacent regions. Eur Spine J, 10: , Schlegel JD, Smith JA, Schleusener RL: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Spine, 21: , Shufflebarger H, Suk SI, Mardjetko S: Debate: determining the upper instrumented vertebra in the management of adult degenerative scoliosis: stopping at T10 versus L1. Spine, 31(Suppl 19): S185-S194, Simmons ED Jr, Simmons EH: Spinal stenosis with scoliosis. Spine, 17(Suppl 6): S117-S120, Weinhofter SL, Guyer RD, Herbert M, Griffith SL: Intradiscal pressure measurements above an instrumented fusion. A cadaveric study. Spine, 20: , Yang SH, Chen PQ: Proximal kyphosis after short posterior fusion for thoracolumbar scoliosis. Clin Orthop, 411: , 2003.

9 퇴행성요추측만증에서후방기기고정술과유합술후에발생한근위부인접분절질환 117 = 국문초록 = 목적 : 척추기기고정술후발생하는인접분절질환의위험인자로환자의나이, 기기고정술사용, 유합술의범위, 시상면상불균형등이보고되고있다. 저자들은퇴행성요추측만증환자에후방기기고정술을시행한후에발생한근위부인접분절질환의발생률과위험인자를연구하였다. 대상및방법 : 감압술과척추경나사못기기고정술로치료한 72 명 ( 평균연령 64.8) 을평가하였고평균 4.7 년추적조사하였다. 25 명에서는하위요추부에후방추체간유합술을추가로시행하였다. 유합구간은평균 5.1 구간이었다 ( 범위 1-9 구간 ). 상위고정척추는제 9 흉추에서제 4 요추까지다양하였으며, 원위고정척추는제 5 요추혹은제 1 천추였다. 결과 : 72 명의환자중 17 명 (24%) 에서근위분절에인접분절질환이발생하였다. 인접분절질환에는압박골절 (6 명 ), 인접부척추후만증 (5 명 ), 척추협착증 (4 명 ), 통증을동반한추간판간격붕괴 (2 명 ) 가있었다. 수술전요추측만각, 흉추후만각, 관상면과시상면의수선은인접분절질환의발생과연관성이없었다. 근위부인접분절질환의발생은유합범위와밀접한관련이있었으며, 상위고정척추가요추인군에서는발생률이 38.5% 이었던데비해흉추인군에서는 6.1% 로나타나의미있는차이를보였다 (p=0.001). Oswestry 점수는인접분절질환이없는군에서많이호전되었다. 결론 : 퇴행성요추척추측만증에서후방기기고정술후발생한증상을동반한근위부인접분절질환의발생률은 24% 였다. 근위인접분절질환발생의위험인자는근위부유합범위로, 측만변형이남아있는요추부에서유합을멈추었을때인접분절질환이많이발생하였고, 측만변형전체를포함하여흉추부까지유합하였을때인접분절질환의발생률이낮았다. 색인단어 : 퇴행성척추측만증, 인접분절질환, 유합범위

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