523_532특집_장태안

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1 Focused Issue of This Month Surgical Management of Chronic Low Back Pain TaeAhn Jahng, MD Department of Neurosurgery, Seoul National Univeristy College of Medicie taj@snu.ac.kr J Korean Med Assoc 2007; 50(6): Abstract Conservative therapy remains the mainstay treatment of chronic low back pain (LBP). If this has failed, surgical options may be considered in carefully selected patients. Still surgical treatment for chronic LBP is a matter of intensive and controversial discussions. Nevertheless, surgical management for chronic (LBP) has been evolved and increased gradually. Spinal fusion has been the established surgical option in cases that did not respond to conservative therapy. Besides spinal fusion, newer technologies such as artificial disc replacement, dynamic stabilization, and spinal cord stimulation are being increasingly considered. Although successful results of these procedures have been published, evidencebased data on the efficacy and benefits of most of these techniques are still lacking. However, empirical data show good or at least satisfactory clinical results of these procedures when they were applied under restrictive indication criteria. Further prospective randomized controlled studies are mandatory to determine the role of these procedures, and basic research is necessary to understand the pathogenesis of LBP at the molecular and genetic levels Keywords : Chronic low back pain; Surgical management; Spinal fusion; Artificial disc; Dynamic stabilization; Spinal cord stimulation 523

2 Jahng TA Figure 1. Schemas of posterolateral fusion techniques. 524

3 Surgical Management of CLBP Figure 2. Depiction of anterior lumbar interbody fusion(alif, left) and posterior interbody fusion(plif, middle), and postoperative lateral Xray of PLIF (right). 525

4 Jahng TA é 526

5 Surgical Management of CLBP A B Figure 4. Charite artificial disc (upper) and postoperative AP and lateral Xray after total disc replacement with Charite artificial disc (right A & B). Figure 3. PDN artificial nucleus (upper) and postoperative lateral Xray after PDN nucleus replacement. 527

6 Jahng TA Figure 5. Dynesys stabilization system consist of pedicle screw and spacer, and polyethylene cord (left) and postoperative Xray (middle and right). é 528

7 Surgical Management of CLBP Figure 6. NFlex dynamic stabilization system (left) and postoperative flexion/extension view shows maintenance of motion at L3L4 (middle and right). 529

8 Jahng TA Figure 7. Spinal cord stimulation leads (left upper) and totally implantable pulse generators (left lower), and postoperative AP Xray shows lead and generator (right). 530

9 Surgical Management of CLBP 11. Andersson GB. Epidemiological features of chronic lowback pain. Lancet 1999; 354: Barolat G. Current state of spinal cord stimulation. Neurosurg Q 1995; 5: Bertagnoli R, Kumar S. Indications for full prosthetic disc arthroplasty: a correlation of clinical outcome against a variety of indications. Eur Spine J 2002; 11: S Booth KC, Bridwell KH, Lenke LG, Baldus CR, Blanke KM. Complications and predictive factors for the successful treatment of flatback deformity (fixed sagittal imbalance). Spine 1999; 24: Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003; 28: Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20year literature review J Neurosurg(Spine) 2004; 100: Danielsson AJ, Nachemson AL. Radiologic findings and curve progression 22 years after treatment for adolescent idiopathic scoliosis: comparison of brace and surgical treatment with matching control group of straight individuals. Spine 2001; 26: Delamarter RB, Fribourg DM, Kanim LE, Bae H. ProDisc artificial total lumbar disc replacement: introduction and early results from the United States clinical trial. Spine 2003; 28: S Deyo RA, Nachemson A, Mirza SK. Spinalfusion surgerythe case for restraint. N Engl J Med 2004; 350: Frelinghuysen P, Huang RC, Girardi FP, Cammisa FP Jr. Lumbar total disc replacement part I: rationale, biomechanics, and implant types. Orthop Clin North Am 2005; 36: Fritzell P, Hagg O, Wessberg P, Nordwall A; Swedish Lumbar Spine Study Group Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 2001; 26: Geisler FH, Blumenthal SL, Guyer RD, McAfee PC, Regan JJ, Johnson JP, Mullin B. Neurological complications of lumbar artificial disc replacement and comparison of clinical results with those related to lumbar arthrodesis in the literature: results of a multicenter, prospective, randomized investigational device exemption study of Charite intervertebral disc. J Neurosurg Spine 2004; 1: German JW, Foley KT. Disc arthroplasty in the management of the painful lumbar motion segment. Spine 2005; 30: S Grob D, Benini A, Junge A, Mannion AF. Clinical experience with the Dynesys semirigid fixation system for the lumbar spine: surgical and patientoriented outcome in 50 cases after an average of 2 years. Spine 2005; 30: Hashimoto T, Oha F, Shigenobu K, Kanayama M, Harada M, Ohkoshi Y, Tada H, Yamamoto K, Yamane S. Midterm clinical results of Graf stabilization for lumbar degenerative pathologies. a minimum 2year followup. Spine J 2001; 1: Hoppenstein R. Electrical stimulation of the ventral and dorsal columns of the spinal cord for relief of chronic intractable pain: preliminary report. Surg Neurol 1975; 4: Kumar MN, Jacquot F, Hall H. Longterm followup of functional outcomes and radiographic changes at adjacent levels following lumbar spine fusion for degenerative disc disease. Eur Spine J 2001; 10: Lee CK. Accelerated degeneration of the segment adjacent to a lumbar fusion. Spine 1988; 13: Le Huec JC, Mathews H, Basso Y, Aunoble S, Hoste D, Bley B, Friesem T. Clinical results of Maverick lumbar total disc replacement: twoyear prospective followup. Orthop Clin North Am 2005; 36: Lemaire JP, Carrier H, Sariali el H, Skalli W, Lavaste F. Clinical and radiological outcomes with the Charite artificial disc: a 10- year minimum followup. J Spinal Disord Tech 2005; 18: Madan SS, Boeree NR. Comparison of instrumented anterior interbody fusion with instrumented circumferential lumbar fusion. Eur Spine J 2003; 12: Mulholland RC, Sengupta DK. Rationale, principles and experimental evaluation of the concept of soft stabilization. Eur Spine J 2002; 11: S North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neunaurgery 2005; 56: Oakley JC, Weiner RL. Spinal cord stimulation for complex regional pain syndrome: a prospective study at two centers. Neuromodulation 1999; 5: Ohnmeiss DD, Rashbaum RF. Patient satisfaction with spinal cord stimulation for predominant complaints of chronic, intractable low back pain Spine J 2001; 1: Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Hadley MN. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: intractable lowback pain without stenosis or spondylolisthesis. J Neurosurg Spine 2005; 2:

10 Jahng TA 27. Senegas L. Mechanical supplementation by nonrigid fixation in degenerative intervertebral lumbar segments: the Wallis system. Eur Spine J 2002; 11: S Sengupta DK. Dynamic stabilization devices in the treatment of low back pain. Orthop Clin North Am 2004; 35: Simpson AK, Cholewicki J, Grauer J. Chronic low back pain. Curr Pain Headache Rep 2006; 10: Stoll TM, Dubois G, Schwarzenbach O. The dynamic neutralization system for the spine: a multicenter study of a novel nonfusion system. Eur Spine J 2002; 11: S Thomas J, Errico. Lumbar disc arthroplasy. Clinical Orthopaedics and related research 2005; 435: Turner JA, Ersek M, Herron L, Haselkorn J, Kent D, Ciol MA, Deyo R. Patient outcomes after lumbar spinal fusions. JAMA 1992; 268: van Tulder MW, Koes B, Malmivaara A. Outcome of noninvasive treatment modalities on back pain: an evidence based review. Outcome of noninvasive treatment modalities on back pain: an evidencebased review. Eur Spine J 2006; 15: S Zigler JE. Clinical results with ProDisc: European experience and U.S. investigation device exemption study. Spine 2003; 28: S Zigler JE. Lumbar spine arthroplasty using the ProDisc II. Spine J 2004; 4: S Peer Reviewer Commentary 532

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R