Original Article J Korean Soc Spine Surg Dec;24(4): in Patients with Osteoporotic Vertebral C

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Journal of Korean Society of Spine Surgery in Patients with Osteoporotic Vertebral Compression Fractures Sung Lim You, M.D., Young Do Koh, M.D., Shin Woo Choi, M.D. J Korean Soc Spine Surg 2017 Dec;24(4):203-210.

84/jkss.2017.24.4.203 Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: +82-2-483-3413 Fax: +82-2-483-3414 Copyright 2017 Korean Society

1 Journal of Korean Society of Spine Surgery in Patients with Osteoporotic Vertebral Compression Fractures Sung Lim You, M.D., Young Do Koh, M.D., Shin Woo Choi, M.D. J Korean Soc Spine Surg 2017 Dec;24(4): Originally published online December 31, 2017; Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: Fax: Copyright 2017 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/4.0) 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 Dec;24(4): in Patients with Osteoporotic Vertebral Compression Fractures Sung Lim You, M.D., Young Do Koh, M.D., Shin Woo Choi, M.D. Department of Orthopedic Surgery, Ewha Womans University School of Medicine, Seoul, Korea Study Design: A retrospective study. Objectives: To investigate the risk factors associated with new compression fractures in patients with osteoporotic vertebral compression fractures. Summary of Literature Review: Previous studies have reported that a history of osteoporotic vertebral fractures and decreased bone mineral density were risk factors for new compression fractures. It is not certain whether vertebroplasty is a risk factor for new compression vertebral fractures. Materials and Methods: This retrospective study included a total of 52 patients who were diagnosed with an osteoporotic vertebral compression fracture and could be followed up for at least 1 year. Age, sex, bone mineral density, body mass index, osteoporosis treatment, fat infiltration of the back muscles, the sagittal index, vertebroplasty, and underlying diabetes mellitus or hypertension were compared between patients who developed new compression fractures during 1 year of follow-up and those who did not. For statistical analysis, the t-test and chi-square test were used to analyze the relationship of each factor with osteoporotic vertebral compression fracture incidence, and multiple logistic regression analysis was performed to analyze multifactorial explanatory factors. Results: No significant differences were found between the 2 groups regarding sex, underlying disease, the sagittal index, and fat infiltration of the back muscles. Patients who developed a new compression fracture were significantly older (p=0.011), had a lower body mass index (p=0.001), had lower bone mineral density (p=0.008), and were more likely to have taken osteoporosis medication for less than 6 months (including no medication, p=0.019). The logistic regression analysis showed that the risk of developing new compression fractures was significantly elevated in patients with a low body mass index (odds ratio [OR]=0.69, p=0.02), bone mineral density (OR=0.43, p=0.005), and less than 6 months of osteoporosis medication use (including no medication, OR=1.083, p=0.041). Conclusions: The risk of developing new compression fractures in patients with osteoporotic vertebral compression fractures was associated with body mass index, bone mineral density, and having taken osteoporosis medication for less than 6 months. Key words: Thoracolumbar spine, Osteoporosis, Vertebral compression fracture, New compression fracture, Risk factors 서론 이있는환자는그렇지않은환자에비해척추골절이다시발 노인인구가증가하면서, 골다공증및이로인한척추골절의유병률도증가하고있다. 1) 골다공증성척추골절은대부분가벼운외상으로발생하며, 침상안정및보조기착용, 골다공증에대한치료를함으로써임상적으로만족할만한결과를얻을수있다. 2,3) 그러나일부환자의경우재골절을경험하게되고, 지속되는통증, 후만변형및신경학적합병증이발생하여수술적치료의대상이되기도한다. 4) 이전의연구에서골다공증성척추골절진단된환자는일년내에재골절위험이상대적으로높고, 한개이상의척추골절 Received: February 21, 2017 Revised: February 28, 2017 Accepted: September 16, 2017 Published Online: December 31, 2017 Corresponding author: Young Do Koh, M.D. ORCID ID: Young Do Koh: Sung Lim You: Department of Orthopedic Surgery, Ewha Womans University MokDong Hospital, 1071 Anyangcheon-ro, Yancheon-gu, Seoul, Korea TEL: , FAX: ydkoh@ewha.ac.kr Copyright 2017 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. 203

3 Sung Lim You et al Volume 24 Number 4 December 생할위험이높다는역학적결과를발표하였다. 5,6) 또한, 재골절의위험인자로골밀도 (BMD) 를제시하였으나, 6) 그외에척추골절후재골절의발생과관련된위험인자는명확하지않다. 최근에는조기통증조절및거동을위해많이시술되고있는척추성형술이인접부위의새로운척추골절의위험인자인지에대해서도논란이있어연구가필요하다. 7-9) 따라서본연구는골다공증성척추골절을진단받고일년내에재골절된환자를분석하여재골절발생의위험인자를찾아내고자하였으며, 이를통해치료법선택및경과예측에도움이되고자하였다. 대상및방법 1. 연구대상본연구는이화여자대학교부속목동병원의생명윤리위원회 (IRB) 의승인을받아이루어졌다. 2014년 1월부터 2015년 9월까지본원에서골밀도 (BMD), 단순방사선검사및자기공명영상으로골다공증성척추골절진단후, 보존적치료또는척추성형술을시행하고, 단순방사선검사로 1년이상추시할수있었던 193명의환자들중이전에척추골절이있었던 141명을제외하고, 척추골절이처음진단된 52명의환자들을대상으로후향적연구를하였다. 환자의평균나이는 77.8세였으며, 성별은남자는 4명, 여자는 48명이었다. 모든환자는보존적치료로 TLSO 신전보조기를 12주동안착용하도록하였으며, TLSO 보조기착용및약물치료를포함한보존적치료를 6주이상하였음에도통증이지속되고, 시각통증척도 (VAS) 가수상당시와비교하여 50% 이하로감소하지않은경우에척추성형술을시행하였다. 수상기전은모두단순낙상과같은저에너지손상이었으며교통사고, 추락과같은고에너지손상은제외하였다. 또한, 자기공명영상에서급성골절이아닌경우, 불유합이발생한경우, 전이성병변에의한병적골절인경우도연구에서제외하였다. 2. 연구방법골다공증성척추골절환자 52명중일년이내에재골절이있었던 18명을환자군으로하고, 재골절이없었던 34명을대조군으로하여연령, 성별, 체질량지수 (BMI), 골밀도 (BMD), 고혈압, 당뇨병과같은기저질환유무, 후방신전근위축정도, 척추성형술시행여부, 골다공증치료여부, 시상지수 (sagittal index) 를비교하여분석하였다. 골다공증성척추골절의진단은자기공명영상을통해해당추체의지방억제 T2 강조영상에서고신호강도를보이고, T1 강조영상에서저신호강도를보일때진단하였으며, DEXA 를이용한골밀도검사에서골절부위를제외한요추들의평균 T-score 가 -2.5 미만인경우골다공증을진단하였다. 후방신전근의위축정도는자기공명영상의 T2 강조영상축상면 (axial image) 에서 Goutallier 10) 가회전근개의위축정도를평가하기위해근육과지방이차지하는비율에따라 0등급에서 4등급까지분류하여평가하는방법을사용하였다. 시상지수 (sagittal index) 는단순방사선검사측면사진에서골절된추체의하연과상위추체의하연사이의각도를 Cobb s 방법으로측정한후, 흉추부의정상후만곡과요추부의정상전만곡을보정한 Farcy 등 11) 의방법을이용하여산출하였다. 골다공증치료여부는약제의종류및치료기간을 6개월기준으로나누어, 골다공증약제를투여받지않았거나, 6개월미만으로투여받은군및 6개월이상투여받은군으로나누어분석하였다. 통계적분석은 IBM SPSS statistics software ver. 21 (IBM Co., Armonk, NY, USA) 을사용하였으며, 두군사이에위에서제시한요소들을분석하기위해독립표본 T-test, Chi-square test 를이용하여검증하였다. 또한, 나이및성별을보정한후각요소들을분석하기위해로지스틱회귀분석을시행하였으며, 신뢰구간은 95% 로설정하여진행하였다. 결과 재골절이발생한군은총 18명으로남자 2명, 여자 16명이었으며, 재골절이발생하지않은군은총 34명으로남자 2명, 여자 32명이었다. 평균연령은재골절이발생한군은 81.3세로, 재골절이발생하지않은군의 74세보다높았으며, 이는통계적으로유의하였다 (p=0.011). 재골절이발생한군은골밀도 (BMD) 가 T-score -4.23, 체질량지수 (BMI) 는 kg/m 2 였고, 재골절이발생하지않은군은골밀도 (BMD) 가 T-score -3.28, 체질량지수 (BMI) 는 kg/m 2 였으며, 이는모두통계적으로유의한차이가있었다 (p=0.008, p=0.001). 또한, 골다공증치료제제를복용중인환자들은모두 bisphosphonate 를복용중이었으며, 골다공증약물치료를받지않거나 6개월미만으로치료받은군은 6개월이상치료받은군에비해통계적으로유의하게재골절이많았다 (p=0.019). 척추성형술은재골절이발생한군에서는 2명을제외한 16명 (88.9%) 이시행받았으며, 재골절이발생하지않은군에서는 19명 (55.9%) 이시행받아, 척추성형술을시행받은군에서통계적으로유의하게재골절이많았다 (p=0.004). 그외성별, 기저질환유무, 후방신전근위축정도, 시상지수 (sagittal index) 는두군간통계적으로유의한차이가없었다 (Table 1). 척추성형술후재골절이발생한 16명에대해재골절이발생한부위를분석한결과, 척추성형술을시행한추체의인접부 204

4 Journal of Korean Society of Spine Surgery 위 (adjacent level) 에서재골절이발생한경우는 4명 (25%) 이었으며, 12명 (75%) 은인접부위가아니었다. 척추성형술후인접부위에서재골절이발생할 odd ratio 는 2.35 이었고이는통계적으로유의하지않았다 (p=0.741). 또한, 척추성형술을시행 한 35명에대해재골절이발생한군과재골절이발생하지않은군으로나누어, 주입한 PMMA 골시멘트의양을비교하여분석하였고, 재골절이발생한군은 4.21 cc, 재골절이발생하지않은군은 4.06 cc 주입하였고, 이는통계적으로유의하지않았다 Table 1. Single variable analysis to evaluate the differences of related factors between two groups Variable New vertebral fracture (n=18) No fracture (n=34) p-value Age (years) 81.3± ± Sex Male 2 1 Female BMD (T-score) 4.23± ± BMI (kg/m 2 ) 21.05± ± Osteoporosis medication >6 months 5 16 No medication and < 6 months Underlying diseases Yes 9 23 No 9 11 Back muscle atrophy (grade) 2.81± ± Sagittal index ( ) 0.86± ± Vertebroplasty Yes No 2 15 BMD: Bone mineral density, BMI: Body mass index. Table 2. Logistic regression analysis to evaluate the influence of related factors on the new vertebral compression fracture Variable Odds ratio 95% Confidence interval p-value BMD BMI Osteoporosis medication Underlying diseases Back muscle atrophy Sagittal index Vertebroplasty BMD: Bone mineral density, BMI: Body mass index

5 Sung Lim You et al Volume 24 Number 4 December (p=0.628). 성별과연령을보정한로지스틱회귀분석에서는골밀도 (BMD) 및체질량지수 (BMI) 의 odds ratio는각각 0.43, 0.69 였고, 이는모두통계적으로유의하였다 (p=0.005, p=0.02). 또한, 6개월을기준으로한골다공증약물치료여부의 odds ratio 는 이었고, 이는통계적으로유의하였다 (p=0.041). 척추성형술을시행받은군은그렇지않은군에비해 odds ratio 가 배로측정되었으나, 이는통계적으로유의하지않았다 (p=0.07) (Table 2). 고찰 일생중여성은 40~50%, 남성은 10~20% 정도에서골다공증성골절을경험하며, 일년이내에 20~30% 정도재골절이발생하게된다는보고가있다. 1,12,13) 또한, Lindsay 등은폐경후여성 2725명을대상으로일년동안추시한결과를분석하여, 골다공증성척추골절진단된환자에서일년내에 6.6% 에서재골절이일어나며, 한개이상의척추골절이있는환자는그렇지않은환자에비해척추골절이발생할위험이약 5.1배높다고보고하였다. 5) 이후 Ross 등은 380명의폐경후여성을 2.9 년간추시한결과, 하나이상의척추골절이있는경우그렇지않은환자에비해척추재골절이발생할위험이 7.4배증가하였고, 골밀도 (BMD) 가 2 표준편차감소하면골절위험이 5.8배증가한다고보고하였다. 6) 위에서언급된 Lindsay 등의연구는골밀도 (BMD) 를교정하여도한개이상의척추골절자체가재골절의위험인자라는역학적결과를보고하였지만, 재골절을일으키는원인에대해서는분석하지않았으며, Ross 등의연구에서도골밀도 (BMD) 및이전의척추골절이척추재골절발생의위험인자라는것을보고하였지만, 그외의위험인자에대해서는분석하지않았다. 따라서본연구는척추골절후재골절이발생한환자들을후향적으로분석하여척추재골절발생의위험인자를찾고자하였다. 골다공증성골절에서재골절발생이많은것은골다공증이전신적인질환으로골의질량감소및미세구조가변하기때문이다. 13) 임상적으로골다공증은 DEXA를이용한골밀도 (BMD) 를측정하여진단하게되며, 골밀도 (BMD) 가낮을수록골절뿐만아니라재골절의가능성역시높을것임을예측할수있다. Ross 등 6,14) 과 Lindsay 등 5) 도척추재골절의위험인자로서골밀도 (BMD) 및이전에진단된하나이상의척추골절로보고하였다. 본연구의결과도일년이내에척추재골절이발생한군의골밀도 (BMD) 가재골절이발생하지않은군에비해통계적으로유의하게낮았으며, 연령과성별을보정한로지스틱회귀 분석에서 T-score 가 1 단위증가할때마다재골절의 odds ratio 가 0.43배감소하는것으로분석되었다. 본연구에서두군의골밀도 (BMD) 는 T-score가 -2.5 미만이고, 골다공증성골절이있으므로두군모두심한골다공증 (severe osteoporosis) 으로진단할수있지만, 재골절의발생위험은같지않았다. 즉, 심한골다공증 (severe osteoporosis) 의진단기준을만족한환자들안에서도 T-score 가더낮을수록재골절의위험이증가하므로, 이를치료방법의선택및예후예측에고려하여야함을의미한다. Bisphosphonate 제제중하나인 Risedronate 의경우치료시작후 6개월부터골밀도증가가나타나므로 15), 6개월을기준으로골다공증약물투여력이없거나, 골다공증약물투여 6개월미만인군과치료기간이 6개월이상인군으로나누어재골절발생의차이를분석하였다. 골다공증약물을복용하지않거나 6개월미만복용한환자들은통계적으로유의하게재골절이많았다 (p=0.019). 이는이전의연구와같은결과이며, 골다공증약물을 6개월이상복용하면골밀도 (BMD) 증가효과가있으므로재골절을유의하게감소시켰을것으로생각된다. Ha 등 16) 은보존적치료를시행한골다공증성척추골절환자 84예를분석하여, 골다공증성척추골절후국소후만각이증가하고척추체내공기음영이발생하는진행성골다공증성척추골절의위험인자로체질량지수 (BMI>23) 를언급하였으며, Kim 등 17) 은폐경후여성 414명을분석하여골다공증성척추골절환자들은골다공증성비척추골절과는달리체중과체질량지수 (BMI) 가더높다고보고하였다. Tanaka 등 18) 은골다공증성척추골절에서비척추골절과는달리과체중및높은체질량지수 (BMI) 가척추골절의발생을증가시킨다고보고하였으며, Pirro 등 19) 은체질량지수 (BMI) 가증가할수록다발성척추골절의위험이증가한다고보고하였다. 높은체질량지수 (BMI) 가척추골절발생위험을증가시키는원인으로서, Finkelstein 등 20) 은체질량지수 (BMI) 가증가하면축성부하가증가하고신체운동성이감소하여수상가능성이높아지며, 당뇨병및대사증후군의동반가능성이높아져골절의위험이증가된다고하였다. 그러나체중및체질량지수 (BMI) 와골다공증성척추골절과의상관관계는아직명확하지않다. 많은연구들이있지만, 골다공증성골절에대해 De Laet 등 21) 이메타분석한결과, 저체중과낮은체질량지수 (BMI) 는골다공증성골절의위험인자라고분석하였다. 즉, 체중이증가하면골밀도 (BMD) 가증가하므로골절의보호인자로작용한다는것이다. 본연구에서도연령과성별을보정한로지스틱회귀분석을한결과, 체질량지수 (BMI) 가 1 kg/m 2 증가할수록척추재골절의위험은 0.69배감소하였다. 이는높은체질량지수 (BMI) 가의미하는축성부하증가, 당뇨병및대사증후군의동반보다낮은체질량지수 206

6 Journal of Korean Society of Spine Surgery Table 3. Single variable analysis to evaluate the differences between vertebroplasty and non-vertebroplasty groups Variable Vertebroplasty (n=35) Non-vertebroplasty (n=17) p-value Age (years) 80.7± ± BMD (T-score) 4.31± ± BMI (kg/m 2 ) 21.59± ± Osteoporosis medication Yes No 8 4 Underlying diseases Yes No 13 7 Back muscle atrophy (grade) 2.94± ± Sagittal index ( ) 12.26± ± BMD: Bone mineral density, BMI: Body mass index. (BMI) 가의미하는골밀도 (BMD) 의감소가척추재골절발생의위험과더관련이있음을나타낸다. 또한, 본연구에서다른변수인당뇨및고혈압과같은동반질환의유무가재골절발생의위험과유의한연관이없는것으로나타난것도위의내용을뒷바침한다. 최근척추압박골절에대한치료로서조기통증조절및거동을위해척추성형술이많이시술되고있다. 그러나해당추체의압박골절이진행하여국소후만각이증가하고, 인접분절에재골절이발생하는것을보고하며, 사용하는 PMMA 시멘트의탄성계수및강도가인체의골과다르기때문에발생하는생역동학적인문제를제기하였다. 22,23) 또한, Rohlmann 등 24) 은 PMMA 골시멘트를해당추체에주입할때인접추간판의압력이증가되고, 이로인해인접추체로증가된응력이전달되면서재골절이발생한다고하였다. 그러나 Kayanja 등 25) 은생역학적연구를통해골다공증성척추압박골절에서인접한척추에재골절이발생하는것은골밀도감소에의한자연적경과이고, PMMA 골시멘트에의해인접분절로전달되는하중이증가하기때문이아니라고하였다. 또한, Klazen 등 26) 은골다공증성척추골절환자 202명을대상으로전향적비교-대조군연구 (prospective randomized controlled study) 를시행한결과척추성형술은인접부위새로운척추골절의위험인자가아니라고하였다. 본연구에서는척추성형술을시행한군에서재골절이유의하게많았으나 (p=0.004), 연령과성별을보정한로지스틱회귀분석에서는통계적으로유의하지않아 (p=0.07), 추가적으 로환자들을척추성형술을받은군과받지않은군으로나누어분석을하였다. 그결과척추성형술을받은군에서통계적으로유의하게연령이높았고, 골밀도 (BMD) 가낮았으며, 시상지수가높았다 (Table 3). 즉, 보존적치료에도불구하고통증이 6주이상지속되는환자들을대상으로척추성형술을시행하였고, 이들은상대적으로고령, 낮은골밀도 (BMD), 높은시상지수를보였으며, 이중에서고령및낮은골밀도 (BMD) 는재골절의위험인자에해당하므로척추성형술을시행받은군에서재골절이많은결과가나왔을것으로생각된다. 또한, 척추성형술후인접부위 (adjacent level) 에서재골절이발생할 odd ratio 가통계적으로유의하지않았으며 (p=0.741), 주입한 PMMA 골시멘트의양도척추성형술후재골절이발생한군과재골절이발생하지않은군간의유의한차이가없었다 (p=0.628). 따라서, 척추성형술을재골절의위험인자로볼수없으며, 이는로지스틱회귀분석에서척추성형술여부가통계적으로유의하지않음으로써확인할수있다. Farcy 등 11) 은흉요추부골절에서시상지수 (sagittal index) 가 15도이상이면후만변형의가능성이높다고하였으며, Ha 등 27) 은골다공증성척추골절에서초기에압박률이 15% 이상증가하면척추압박이진행할위험이높아진다고하였다. 압박률의증가나후만변형의발생은척추의생역학적변화를유발하므로, 저자들은이런변화가재골절을유발시킬가능성을분석하기위해수상당시시상지수 (sagittal index) 를측정하여재골절과의연관성을분석하였으나, 두군간유의한차이는없었다 207

7 Sung Lim You et al Volume 24 Number 4 December (p=0.947). Sinaki 등 28,29) 은폐경후여성 50명을대상으로 10년동안추시한결과를분석하여, 후방신전근운동을통해근력을강화시킨군은그렇지않은군에비해척추골절위험이 2.7배감소한결과를보고하였고, 후방신전근의근력약화는후만변형과연관성이있음을발표하였다. 따라서저자들은후방신전근의위축을 Goutallier 등 10) 의방법으로평가하여, 두군간척추의생역학적차이에따라재골절발생의차이가있는지분석하였으나유의한차이는없었다 (p=0.919). 본연구는후향적연구로서두군이동일한조건에서진행된것이아니라는한계점이있다. 또한, 연구대상이 52명으로비교적적은수이고, 척추성형술을총 35명 (67.3%) 이시행받았으며, 두군간연령차이가존재하는점등은본연구결과를일반화하기에는한계점으로지적된다. 따라서추후더많은환자를대상으로한전향적연구가필요할것으로생각된다. 결론 골다공증성척추골절환자에서고령, 낮은골밀도 (BMD) 및체질량지수 (BMI), 골다공증치료기간이 6개월미만인경우는재골절의가능성이높음을의미하므로보다세심한추시관찰이필요할것으로생각된다. REFERENCES 1. Johnell O, Kanis J. Epidemiology of osteoporotic fractures. Osteoporosis Int Mar;16 (2 Suppl):3-7. DOI: /s Koh YD, Kim JO, Kim RG, et al. Survival Analysis of Conservative Treatement in Osteoporotic Vertebral Fracture. J Korean Soc Spine Surg Dec;19(4): DOI: /jkss Kim DH, Vaccaro AR. Osteoporotic compression fractures of the spine; current options and considerations for treatment. Spine J Sep-Oct;6(5): DOI: / j.spinee Kempinsky WH, Morgan PP, Boniface WR. Osteoporotic kyphosis with paraplegia. Neurology Mar;8(3): Lindsay R, Silverman SL, Cooper C. Risk of new vertebral fracture in the year following a fracture. JAMA Jan 17;285(3): DOI: jama Ross PD, Genant HK, Davis JW, et al. Predicting Vertebral Fracture Incidence from Prevalent Fractures and Bone Density Among Non-black, Osteoporotic Women. Osteoporosis Int May;3(3): Uppin AA, Hirsch JA, Centenera LV, et al. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Radiology Jan;226(1): DOI: /radiol Grados F, Depriester C, Cayrolle G, et al. Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Rheumatology (Oxford) Dec;39(12): DOI: /rheumatology/ Evans AJ, Jensen ME, Kip KE, et al. Vertebral compression fractures: pain reduction and improvement in functional mobility after percutaneous polymethylmethacrylate vertebroplasty retrospective report of 245 cases. Radiology Feb;226(2): DOI: /radiol Goutallier D, Postel JM, Bernageau J, et al. Fatty degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res Jul;(304): Farcy JPC, Weindenbaum M, Glassman SD. Sagittal index in management of thoracolumbar burst fractures. Spine (Phila Pa 1976) Sep;15(9): Lippuner K: Medical treatment of vertebral osteoporosis. Eur Spine J Oct;12(2 Suppl ): DOI: /s x. 13. Kutsal YG, Atalay A, Arslan S, et al. Awareness of osteoporotic patients. Osteoporos Int Feb;16(2): DOI: /s Ross PD, Davis JW, Epstein R, et al. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med Jun 1;114(11): Harris ST, Watts NB, Genant HK, et al. Effects of risedronate treatment on certebral and nonvertebral fractures in women with postmenopausal osteoporosis. JAMA Oct 13;282(14): DOI: / jama Sohn JM, Kim KW, Ha KY. Risk Factors for the Progressive Osteoporotic Spinal Fracture Journal of Korean Spine Surgery Sep;16(3): DOI: / jkss Kim HT, Seo HY. Association Between Osteoporotic Vertebral Fracture and Body Mass Index. J Korean Soc 208

8 Journal of Korean Society of Spine Surgery Spine Surg Sep;23(3): DOI: / jkss Tanaka S, Kuroda T, Saito M, et al. Overweight/obesity and underweight are both risk factors for osteoporotic fractures at different sites in Japanese postmenopausal women. Osteoporos Int Jan;24(1): DOI: / s Pirro M, Fabbriciani G, Leli C, et al. High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women. J Bone Miner Metab. 2010;28(1): DOI: /s Finkelstein EA, Chen H, Prabhu M, et al. The relation ship between obesity and injuries among U.S. adults. Am J Health Promot May-Jun;21(5): De Laet C, Kanis JA, Odén A, et al. Body mass index as a predictor of fracture risk: a meta-analysis. Osteoporos Int Nov;16(11): DOI: /s y. 22. Heo DH, Chin DK, Yoon YS, et al. Recollapse of previous vertebral compression fracture after percutaneous vertebroplasty. Osteoporosis Int Mar;20(3): DOI: /s Moon ES, Kim HS, Park JO, et al. The incidence of new vertebral compression fractures in women after kyphoplasty and factors involved. Yonsei Med J Aug 31;48(4): DOI: /ymj Rohlmann A, Zander T, Bergmann G. Spinal loads after osteoporotic vertebral fractures treated by vertebroplasty or kyphoplasty. Eur Spine J Aug;15(8): DOI: /s Kayanja MM, Evans K, Milks R, et al. Adjacent level load transfer following vertebral augmentation in the cadaveric spine. Spine (Phila Pa 1976) Oct 1;31(21):E DOI: /01.brs c 26. Klazen CA, Venmans A, de Vries J, et al. Percutaneous vertebroplasty is not a risk factor for new osteoporotic compression fractures:results from VERTOS II. AJNR Am J Neuroradiol Sep;31(8): DOI: /ajnr. A Ha KY, Kim YH. Risk factors affecting prosgressive collapse of acute osteoporotic spinal fractures. Osteoporos Int Apr;24(4): DOI: /s z. 28. Sinaki M, Itoi E, Wahner HW, et al. Stronger Back Muscles Reduce the Incidence of Vertebral Fractures: A Prospective 10 Year Follow-up of Postmenopausal Women. Bone Jun;30(6): DOI: /S (02) Sinaki M, Itoi E, Rogers JW, et al. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil Sep-Oct;75(5): DOI: /

9 Original Article J Korean Soc Spine Surg Dec;24(4): 골다공증성척추압박골절환자에서새로운척추골절발생의위험인자 유성림 고영도 최신우이화여자대학교의과대학정형외과학교실연구계획 : 골다공증성척추골절환자에대해보조기를이용하여보존적으로치료후추시결과에대한후향적연구이다. 목적 : 골다공증성척추골절환자에서재골절발생의위험인자를알아보고자한다. 선행문헌의요약 : 이전에골다공증성척추골절이진단된경우, 낮은골밀도 (BMD) 는재골절위험을높인다는연구결과가있으며, 척추성형술이재골절의위험인자인지에대해서는논란이있다. 대상및방법 : 본원에서골다공증성척추골절진단받고최소 1년이상추시가능했던환자 52명을대상으로후향적연구를진행하였다. 골다공증성척추골절진단후추시에서일년이내에재골절이있었던군과재골절이발생하지않은군간의연령, 성별, 체질량지수 (BMI), 골밀도 (BMD), 고혈압, 당뇨병과같은기저질환유무, 후방신전근위축정도, 척추성형술시행여부, 골다공증치료여부, 시상지수 (sagittal index) 를비교하였다. 두군사이에위에서제시한요소들을분석하기위해독립표본 T-test, Chi-square test를이용하여검증하였다. 또한, 나이및성별을보정한후각요소들을분석하기위해로지스틱회귀분석을하였다. 결과 : 평균연령은재골절이발생한군은 81.3세로, 재골절이발생하지않은군의 74세보다높았으며, 이는통계적으로유의하였다 (p=0.011). 재골절이발생한군은골밀도 (BMD) 가 T-score -4.23, 체질량지수 (BMI) 는 kg/m 2 였고, 재골절이발생하지않은군은골밀도 (BMD) 가 T-score -3.28, 체질량지수 (BMI) 는 kg/m 2 였으며, 이는모두통계적으로유의한차이가있었다 (p=0.008, p=0.001). 또한, 골다공증약물치료를받지않거나 6개월미만으로치료받은군은 6개월이상치료받은군에비해통계적으로유의하게재골절이많았다 (p=0.019). 성별과연령을보정한로지스틱회귀분석에서는골밀도 (BMD) 및체질량지수 (BMI) 의 odds ratio 는각각 0.43, 0.69였고, 이는모두통계적으로유의하였다 (p=0.005, p=0.02). 6개월을기준으로한골다공증약물치료여부의 odds ratio 는 이었고, 이는통계적으로유의하였다 (p=0.041). 결론 : 골다공증성척추골절환자에서고령, 낮은골밀도 (BMD) 및체질량지수 (BMI), 6개월미만의약물치료는재골절의가능성이높으므로보다세심한추시관찰이필요하다. 색인단어 : 흉요추부, 골다공증, 척추압박골절, 재골절, 위험인자 약칭제목 : 척추재골절발생의위험인자 접수일 : 2017년 2월 21일 수정일 : 2017년 2월 28일 게재확정일 : 2017년 9월 16일 교신저자 : 고영도 서울시양천구안양천로 1071 이화여자대학교목동병원정형외과학교실 TEL: FAX: ydkoh@ewha.ac.kr 210 Copyright 2017 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.

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