274 Youn Soo Hwang, et al. 수상한환자에서뇌졸중유무에따른일반적인특성의차이에대한보고는드문실정이다. 그래서본연구에서는 65세이상고령환자에발생한대퇴골전자간골절에서예후에영향을미치는일반적특성을비교하고, 뇌졸중이대퇴골전자간골절의술후 1년사망률및보행회복에영향을미

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1 273 pissn : , eissn : Original Article J Korean Orthop Assoc 2016; 51: 뇌졸중이대퇴골전자간골절의술후예후에미치는영향 황연수 문규필 김경택 박원석 송준연 채정훈 동의의료원정형외과 The Influence of Stroke on Postoperative Prognosis of Femoral Intertrochanteric Fractures Youn Soo Hwang, M.D., Kyu Pill Moon, M.D., Kyung Taek Kim, M.D., Won Seok Park, M.D., Joon Yeon Song, M.D., and Jeong Hoon Chae, M.D. Department of Orthopaedic Surgery, Dong-Eui Medical Center, Busan, Korea Purpose: The purpose of this study was to compare the general characteristics that affect the prognosis and evaluate the influence of stroke on one-year postoperative mortality and recovery of ambulatory status in elderly patients over 65 years old with femoral intertrochanteric fracture. Materials and Methods: This study included 80 patients who were followed-up for one year after proximal femoral nailing for femur intertrochanteric fracture between January 2008 and December We analyzed the relationship among the one-year postoperative mortality, recovery of ambulatory status and the associated factors (age, gender, associated underlying disease, American Society of Anesthesiologists [ASA] grade, comminution of the fracture, dementia). Results: The one-year postoperative mortality rate in all patients and patients with stroke was 28.8% and 42.9%, respectively. The oneyear postoperative mortality rate was significantly higher in patients with stroke, high ASA grade, and unstable fracture. Decrease of the one-year postoperative ambulatory status was 50.9% in all patients and was significantly associated with grade III or IV ASA rating. No significant relationships were observed between the one-year postoperative recovery of ambulatory status and stroke. Conclusion: Stroke, ASA grade, and unstable fracture were prognostic factors associated with one-year postoperative mortality following intertrochanteric fracture. ASA rating was the only prognostic factor affecting one-year postoperative recovery of ambulatory status. Key words: intertrochanteric fractures, stroke, prognosis 서론 고령인구의증가와함께대퇴골전자간골절의발생률은점점증가하고있다. 대부분의고관절골절환자는고령이고내과적기저질환이있는경우가많으며, 장기간의침상안정으로유발되는여러가지합병증으로인하여높은이환율과사망률을나타낸 Received July 23, 2015 Revised October 26, 2015 Accepted November 19, 2015 Correspondence to: Kyu Pill Moon, M.D. Department of Orthopaedic Surgery, Dong-Eui Medical Center, 62 Yangjeong-ro, Busanjin-gu, Busan 47227, Korea TEL: FAX: moonkp@hanmail.net 다. 고령의고관절골절은술후 1년사망률이약 10%-36% 정도로높으며사망과직접적인연관이있는것으로보고되고있다. 1-5) 뇌졸중도고령인구증가에따라이환율이점점증가하고있다. 보고에의하면뇌졸중을동반한환자는고관절골절이생길확률이 2-4배증가하게되는데, 6) 이는낙상의위험이커지고, 마비부위에불용성골다공증이발생하기때문이다. 7) 여러연구에서나이, 8,9) 성, 9-11) American Society of Anesthesiologists (ASA) 등급, 8,12) 동반기저질환, 13,14) 치매 15) 등의다양한인자들이고관절골절이있는고령환자의술후 1년사망률과보행회복에영향을미친다고보고되고있다. 그러나고관절골절을 The Journal of the Korean Orthopaedic Association Volume 51 Number Copyright 2016 by The Korean Orthopaedic Association 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.

2 274 Youn Soo Hwang, et al. 수상한환자에서뇌졸중유무에따른일반적인특성의차이에대한보고는드문실정이다. 그래서본연구에서는 65세이상고령환자에발생한대퇴골전자간골절에서예후에영향을미치는일반적특성을비교하고, 뇌졸중이대퇴골전자간골절의술후 1년사망률및보행회복에영향을미치는지에대해분석하였다. 대상및방법 2008년 1월부터 2013년 12월까지동의의료원을내원하여대퇴골전자간골절을진단받은총 118명의환자중보존적치료를시행한 3명, 술전내과적합병증악화로사망한 4명및수술을시행한환자중압박고나사고정술 (5건), 인공관절치환술 (2건) 을시행했던환자를제외한근위대퇴골골수정삽입술을시행한환자 104명중에서 65세미만인환자 7명, 술후 1년째외래추시가불가능하거나연락이되지않아추시가불가능하였던 16명, 추시 6 개월이내에불유합으로술후재수술을시행한 1명을조사에서제외하고총 80명을대상으로하였다. 조사대상전체 80명중뇌졸중이있는환자는 35예이고, 양측마비가있는경우는 4예, 편측마비가있는 29예중편측마비가있는하지에골절이있는경우는 26예, 편측마비가없는하지에골절이있는경우는 3예였다. 평균연령은 77.6세 (65-93세) 였으며, 남자가 22명, 여자가 58명이었다. 대퇴골전자간골절에서술후 1년사망률과보행회복에영향을미치는인자로뇌졸중, 나이, 성별, 동반기저질환, ASA 등급, 골절의불안정성 (AO classification), 치매유무를조사하여통계적으로분석하였다. 뇌졸중병력이있는환자는뇌졸중 ( 뇌경 Table 1. Analysis of Ambulatory Status by Koval* Category of prefracture ambulation Category of ambulation at postoperative 1 year follow-up Community ambulator Household ambulator Nonfuctional ambulator Non-stroke Community ambulator Household ambulator Nonfuctional ambulator Stroke Community ambulator Household ambulator Nonfuctional ambulator *Categories of Walking Ability by Koval. 1) Community ambulator: independent community ambulator, community ambulator with cane, community ambulator with walker/crutches. 2) Household ambulator: independent household ambulator, household ambulator with cane, household ambulator with walker/crutches. 3) Nonfunctional ambulator. 색및뇌출혈 ) 으로진단받고약물치료및수술을받은환자를모두포함하였으며, 후유증이없는일시적뇌허혈 (transient ischemic attack) 은조사대상에제외하였다. 또한마비가있는하지는뇌졸중이환후하지근력정도가 grade IV 이하로떨어진상태로분류하였다. 연령의경우 65세부터 74세까지, 75세이상의환자군으로나누어분석하였고, 동반기저질환은고혈압, 당뇨, 심부전증, 허혈성심질환, 뇌졸중, 파킨슨병, 만성폐쇄성폐질환, 만성신부전, 치매, 암, 부정맥등을조사하여기저질환의수가두개이하인경우와세개이상인경우로나누어분석하였다. 또한객관적인술전건강상태분석을위해 ASA 등급을이용하여환자상태를분류하여분석하였으며, 골절의불안정성은대퇴골전자간골절의 AO 분류에따라 A2.2 이상의대퇴골전자간골절을불안정골절로분류하였다. 마지막으로치매를진단받았거나경구치매약복용여부에따라치매유무를분류하여분석하였다. 술전과술후보행평가는 Koval score의보행능력항목을지역사회보행 (community ambulators), 주거지보행 (household ambulators), 비기능적보행 (nonfunctional ambulators) 으로분류해술전및술후 1년보행정도를비교하여보행회복을분석하였다 (Table 1). 16,17) Table 2. General Characteristics of the Patient Groups Characteristic Overall Stroke Yes No p-value All patient 80 (100.0) 35 (43.8) 45 (56.3) Age (yr) (36.3) 12 (34.3) 17 (37.8) (63.8) 23 (65.7) 28 (62.2) Gender Male 22 (27.5) 15 (42.9) 7 (15.6) Female 58 (72.5) 20 (57.1) 38 (84.4) Comorbidity (71.3) 21 (60.0) 36 (80.0) 3 23 (28.8) 14 (40.0) 9 (20.0) ASA rating grade II 54 (67.5) 21 (60.0) 33 (73.3) grade III 26 (32.5) 14 (40.0) 12 (26.7) Fracture Stable 20 (25.0) 9 (25.7) 11 (24.4) Unstable 60 (75.0) 26 (74.3) 34 (75.6) Dementia No 65 (81.3) 27 (77.1) 38 (84.4) Yes 15 (18.8) 8 (22.9) 7 (15.6) Values are presented as number (%). ASA, American Society of Anesthesiologists.

3 275 The Influence of Stroke on Postoperative Prognosis of Femoral Intertrochanteric Fractures 정보수집은후향적으로본인또는직계가족과의전화를통한 설문기록과병원차트기록을이용하였다. 자료의통계처리는 IBM SPSS ver (IBM Co., Armonk, NY, USA) 을이용한카이제곱검정법 (chi-square test) 과다변량로지스틱회귀분석법 (multi-variable logistic regression) 을사용하였으며 p값이 0.05 미만인경우를통계적으로유의한상관관계가있는것으로간주하였다. 결과 대퇴골전자간골절로근위대퇴골골수정삽입술을시행한 65세이상의환자 80예에대해술후 1년뒤사망률및보행회복에영향을미칠수있는인자들과연구대상의기저특성이뇌졸중동반에따라차이가있는지알아보기위해카이제곱검정법을실시한결과, 성별을제외한나머지변수들은유의한차이가없는것으로나타났다 (Table 2). 총 80예의환자에서술후 1년사망률은 28.8% (23명) 였으며, 이중뇌졸중을동반한경우술후 1년사망률은 42.9% (15명), 뇌 Table 3. Analysis of Various Characteristics on One-Year Mortality Characteristic Survived (n=57) Died (n=23) p-value Stroke No 37 (64.9) 8 (34.8) Yes 20 (35.1) 15 (65.2) Age (yr) (40.4) 6 (26.1) (59.6) 17 (73.9) Gender Male 10 (17.5) 12 (52.2) Female 47 (82.5) 11 (47.8) Comorbidity (73.7) 15 (65.2) 3 15 (26.3) 8 (34.8) ASA rating grade II 44 (77.2) 10 (43.5) grade III 13 (22.8) 13 (56.5) Fracture Stable 19 (33.3) 1 (4.3) Unstable 38 (66.7) 22 (95.7) Dementia No 47 (82.5) 18 (78.3) Yes 10 (17.5) 5 (21.7) Values are presented as number (%). ASA, American Society of Anesthesiologists. 졸중이동반하지않은경우술후 1년사망률은 17.7% (8명) 로조사되었다. 술후 1년사망률과연관된인자를알아보고자카이제곱검정법을실시한결과, 뇌졸중이있는경우, 성별이남자일때, ASA 등급이높을수록, 골절양상이불안정할수록술후 1년사망률이더높은것으로나타났다 (Table 3). 또한술후 1년사망률에영향을미치는요인을파악하기위해후진제거법 (backward elimination method) 을사용하여다변량로지스틱회귀분석을한결과, 뇌졸중, ASA 등급, 골절의불안정성이술후 1년사망률에대한유의한예후인자인것으로나타났다 (Table 4, 5). 뇌졸중의경우 Table 1에서보는바와같이남성에서발생비율이높아뇌졸중동반여부와성별간연관성이통계적으로유의하였다 (p=0.007). 따라서다중공선성제거및모형의경제성추구를위해변수선택법을통해통계적으로유의한변수를최종모형으로선택할경우 Table 4의결과를도출하였으며, 이를통해성별보다뇌졸중동반여부가술후 1년사망률예측에더중요한예후인자라고추론할수있겠다. 구체적으로살펴보면, 뇌졸중을동반한경우 1년사망률 odds ratio는 4.303배높은것으로추정되었으며 (adjusted odds ratio []=4.303, p=0.014), ASA 등급이 III인경우는 II인경우 Table 4. Logistic Regression Analysis of Various Characteristics on One-Year Mortality Characteristic Crude Adjusted 95% CI p-value Stroke (yes) Gender (male) Age ( 75 yr) Comorbidity ( 3) ASA rating ( III) Unstable fracture Dementia (yes) , odds ratio; CI, confidence interval; ASA, American Society of Anes th e - siologists. Table 5. Logistic Regression Analysis of Various Characteristics on One-Year Mortality (Final Model by Backward Elimination Method) Characteristic Crude Adjusted 95% CI p-value Stroke (yes) ASA rating ( III) Unstable fracture , odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists.

4 276 Youn Soo Hwang, et al. Table 6. Analysis of Various Characteristics on Recovery of Ambulatory Status in One-Year Survived Patients Ambulatory status Characteristic Recovery (n=28) No Recovery (n=29) p-value Stroke No 17 (60.7) 20 (69.0) Yes 11 (39.3) 9 (31.0) Age (yr) (42.9) 11 (37.9) (57.1) 18 (62.1) Gender Male 5 (17.9) 5 (17.2) Female 23 (82.1) 24 (82.8) Comorbidity (71.4) 22 (75.9) 3 8 (28.6) 7 (24.1) ASA rating grade II 25 (89.3) 19 (65.5) grade III 3 (10.7) 10 (34.5) AO classification Stable 11 (39.3) 8 (27.6) Unstable 17 (60.7) 21 (72.4) Dementia No 24 (85.7) 23 (79.3) Yes 4 (14.3) 6 (20.7) Values are presented as number (%). ASA, American Society of Anesthesiologists. 대비 1년사망률 이 4.635배높은것으로나타났다 (adjusted =4.635, p=0.010). 그외, 불안정골절인경우가안정골절인경우보다 1년사망률 odds ratio가 배높은것으로나타났는데 (adjusted =16.276, p=0.014), Table 2에서알수있듯이안정골절환자 20명중사망자수가 1명이므로 추정값을해석하는데주의가요구된다. 술후 1년뒤생존해있는총 57예의환자에서술후 1년보행악화는 50.9% (29명) 였으며, 이중뇌졸중을동반한경우술후 1 년보행악화는 45.0% (9명), 뇌졸중을동반하지않은경우술후 1 년보행악화는 54% (20명) 로조사되었다. 술후 1년뒤생존해있는총 57명의연구대상자를대상으로 1 년보행회복정도와연관된인자를알아보고자카이제곱검정법을실시한결과, ASA 등급이 III 이상인경우는 II 이하인경우보다술후 1년보행회복정도가악화되는비율이통계적으로더높은것으로관측되었다 (Table 6). 또한다변량로지스틱회귀분석에서도 ASA 등급이 III 이상인경우는 II 이하인경우보다 1 Table 7. Logistic Regression Analysis of Various Characteristics on Recovery of Ambulatory Status in One-Year Survived Patients Characteristic Crude Adjusted 년보행회복정도가악화되는비율이통계적으로높게나타났다 (Table 7). 고찰 95% CI p-value Stroke (yes) Gender (male) Age ( 75 yr) Comorbidity ( 3) ASA rating ( III) Unstable fracture Dementia (yes) , odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists. 전세계적으로고령인구는증가하고있다. 고관절골절과뇌졸중은주로고령에서발생하며, 나이가증가할수록발생비율은증가하고있다. 뇌졸중환자는불용성골다공증이다수에서동반되고낙상가능성이증가하여고관절골절이쉽게일어날수있는데, 일반인구보다 2-4배정도높은발생률을보인다. 6,7) 전체고관절골절중에서뇌졸중환자가 4%-15% 를차지하고, 대부분 (80% 이상 ) 에서마비측하지에발생한다고보고된다. 6,7,18) 본원은뇌졸중환자치료에특성화된병원으로서전체대상 80명중뇌졸중을동반한환자는 35예로 43.8% 를차지하여, 뇌졸중유병률이상대적으로매우높게나타났으며, 다른보고에서와같이대부분 (90%) 마비측하지에골절이발생하였다. 연령의증가와사망률의연관성은저자들마다다르게보고되고있는데, 연령이증가함에따라사망률이증가한다는보고와 1,19) 오히려연령이증가할수록사망률이감소한다는보고가있다. 20) 몇몇국내보고들의경우연령과사망률에는유의한차이는없다고보고하였으며, 3,5,21) 본연구에서도연령의증가에따른사망률이통계적으로유의한차이를보이지않았다. 성별에따른사망률역시저자들마다다르게보고되고있으며, Kenzora 등 1) 은성별에따른사망률차이는없다고보고하였고, Miller 19) 는남성에서의사망률이더높다고보고하였으며, 반면 Choi 등 4) 은여성에서의사망률이더높다고보고하였다. 본연구에서는남성에서더높은사망률을보였으며, 카이제곱검정에서통계적유의한차이가있으나다변량로지스틱회귀분석을한결과, 통계적유의한차이를보이지않았다. 주로노령층에서대퇴골전자간골절이호발하며, 대부분환자에서수술전동반기저질환이있기마련인데수술전동반기저

5 277 The Influence of Stroke on Postoperative Prognosis of Femoral Intertrochanteric Fractures 질환과사망률은연관성이높은것으로알려졌다. Kenzora 등 1) 은동반기저질환이네개이상동반된경우세개이하의군보다사망률이높다고보고한연구가있지만, Kho 등 21) 과 Kim 등 22) 은기저질환이두개이상인환자군에서의사망률이더높다고하였으며, Suh 등 23) 은동반기저질환이적으면적을수록사망률이더낮다고보고하였다. 본연구에서는동반기저질환이세개이상일경우, 두개이하일경우보다사망률이통계적으로유의한차이를보이지않았다. Chang 등 24) 은대부분환자가노인성동반기저질환을가지고있어사망률과동반기저질환의수는유의한관계가없으며, 술후사망률에영향을미치는것은실질적으로환자의전신상태를나타내는 ASA 등급이라고보고하였다. White 등 20) 은 ASA 등급에따라고관절주위골절환자를분류하여 ASA 등급 II 이하의 1 년사망률이 8% 인데비해 ASA 등급 III 이상에서는 49% 로사망률이높다고하였고, Owens 등 25) 의연구에서도 ASA 등급과사망률과의관계에서통계적으로유의한결과를보였다. 본연구에서도수술전전신상태를 ASA 등급에따라분석한결과 ASA 등급 II 이하에서보다 ASA 등급 III 이상에서더높은사망률을보였으며, 통계적으로유의한결과를보였다. 또한술후 1년뒤보행회복정도의악화와관련하여유일하게 ASA 등급 II 이하인경우보다 ASA 등급 III 이상인경우악화하는비율이높게나타났으며, 통계적으로유의한차이가있었다. 골절의불안정성은대퇴골전자간골절의 AO 분류에따라 A2.2 이상의대퇴골전자간골절을불안정골절로분류하였다. 골절의불안정성이술후사망률과보행회복정도에미치는영향을나타내는연구는찾을수없었으며, 본연구에서불안정골절일경우사망률이높게나타났으며, 통계적으로도유의한결과를보였다. 치매의경우고관절골절에서술후사망률과보행회복정도를저해한다는여러보고가있다. 12,16,26) 중증의치매를지닌환자는낮은동기부여와지시이행의어려움이있어술후재활치료가제대로이루어질수없으며, 치매또한사망률을높이는동반기저질환으로영향을미치기때문이다. 그러나본연구에서는치매가술후사망률과보행회복정도에통계적으로유의한결과를보이지않았다. Feng 등 27) 은고관절골절시술후사망률과관련된예후인자는성별 ( 남성 ), ASA 등급, 동반기저질환, 골절수상전보행정도가영향을미치는인자로보고하였고, Suh 등 23) 은나이, 성별 ( 남성 ), 치매, 동반기저질환, 수상후수술까지지연된시간이예후에영향을미친다고보고하였다. 본연구에서는뇌졸중, ASA 등급, 골절의불안정성이사망률을예측할수있는예후인자로통계적으로유의한결과를보였다. 고관절골절시술후보행회복과관련된연구에서 Ishida 등 12) 은치매와척추골절의수가영향을미치는인자로보고하였고, Feng 등 27) 은 ASA 등급, 동반기저질환, 치매등이영향을미치는인자로보고하였다. 본연구에서는 ASA 등급만이술후보행회복에영향을미치는인자로통계적으로유의한결과를보였다. 여러연구에서뇌졸중은술후사망률을높이는예후인자로보고되고있으나, 8,27,28) 술후보행회복과관련하여 Youm 등 29) 은뇌졸중을동반한고관절골절환자의술후보행회복정도는뇌졸중이없는환자와거의동일하다고보고하였다. 본연구에서도뇌졸중을동반한고관절골절환자에서사망률은통계적으로유의하게높게나타났으나보행회복정도는통계적으로유의하지않은결과를보였다. 이러한결과에대한이유는지속적경과관찰및추가적연구가필요할것으로생각된다. 이번연구의제한점은후향적으로이루어진연구로서자료수집의제한및추시기간이짧다는점이다. 수술방법또한예후인자에영향을미칠수있는요소이나본원에서시행한수술의대부분이근위대퇴골골수정삽입술이며, 다른수술방법시행건수는통계적으로비교하기에너무수가적어근위대퇴골골수정삽입술을시행한환자만을대상으로조사한것이제한점으로생각된다. 또한대퇴골전자간수술과사망의인과관계도분명하지않으며, 술후보행회복에영향을줄수있는사회경제적요건과같은기타요소에대한정보도부족하다. 뇌졸중의중증도는술후사망률이나보행회복에큰영향을미치지만이에대해세분하지않았으며, 이에대한향후보완적연구가필요할것으로생각된다. 결론 본연구에서뇌졸중을동반한환자에서대퇴골전자간골절시술후 1년사망률증가는통계적으로유의한차이가나타났으며, 술후 1년보행회복과뇌졸중유무관계는통계적으로유의한차이를보이지않았다. 또한대퇴골전자간골절시술후 1년사망률에영향을미치는예후인자는뇌졸중, ASA 등급, 골절의불안정성이며, 술후 1년보행회복에영향을미치는예후인자는 ASA 등급만관련된것으로나타났다. 이러한인자들은뇌졸중을동반한고관절골절환자치료에있어예후와치료효과를판단하는데유용하다. 고령의뇌졸중을동반한고관절골절환자는동반된하지마비로인해재활치료에서어려움이있으나가능한한조기에적절한치료를시행한후보다적극적인재활치료를병행할경우수상전보행상태에가까운정도로의회복이가능할것으로생각된다. 또한뇌졸중을동반한고관절골절은사망률이높으므로고관절골절의예방에대한교육이더욱중요하며, 마비를동반한뇌졸중환자의고관절골절예방을위해골다공증과낙상의예방이필수적이라생각된다.

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8 280 pissn : , eissn : Original Article J Korean Orthop Assoc 2016; 51: 뇌졸중이대퇴골전자간골절의술후예후에미치는영향 황연수 문규필 김경택 박원석 송준연 채정훈 동의의료원정형외과 목적 : 65 세이상고령환자에발생한대퇴골전자간골절에서예후에영향을미치는일반적특성을비교하고, 뇌졸중이술후 1 년사 망률및보행회복에영향을미치는지에대해알아보고자하였다. 대상및방법 : 2008 년 1 월부터 2013 년 12 월까지대퇴골전자간골절환자중에서근위대퇴골골수정삽입술을시행하고수술 1 년 후추시가가능하였던 80명을대상으로하였다. 술후 1년사망률과보행회복에영향을미치는인자로뇌졸중, 나이, 성별, 동반기저질환, American Society of Anesthesiologists (ASA) 등급, 골절의불안정성, 치매유무를조사하여분석하였다. 결과 : 대퇴골전자간골절의술후 1년사망률은 28.8% 였으며, 뇌졸중을동반한경우술후 1년사망률은 42.9% 였다. 뇌졸중, 높은 ASA 등급, 불안정골절에서술후 1년사망률이유의하게높게나타났다. 술후 1년보행악화는 50.9% 였으며, ASA 등급이 III 이상인경우술후 1년보행악화비율이유의하게높게나타났고, 뇌졸중은보행악화와관계가없는것으로나타났다. 결론 : 대퇴골전자간골절의술후 1년사망률에영향을미치는예후인자는뇌졸중, 높은 ASA 등급, 골절의불안정성이며, 보행회복에영향을미치는예후인자는 ASA 등급만관련된것으로나타났다. 색인단어 : 대퇴전자간골절, 뇌졸중, 예후 접수일 2015 년 7 월 23 일수정일 2015 년 10 월 26 일게재확정일 2015 년 11 월 19 일책임저자문규필 47227, 부산시부산진구양정로 62, 동의의료원정형외과 TEL , FAX , moonkp@hanmail.net 대한정형외과학회지 : 제 51권제 4호 2016 Copyright 2016 by The Korean Orthopaedic Association 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