Original Article pissn eissn J Korean Soc Spine Surg Sep;19(3): The Progn

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Journal of Korean Society of Spine Surgery The Prognostic Factor of Posterolateral Fusion in Degenerative Spondylolisthesis Tae-Woo Sung, M.D., Ki-Chan An, M.D., Gyu-Min Kong, M.D., Dae-Hyun Park, M.

Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2011 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this

1 Journal of Korean Society of Spine Surgery The Prognostic Factor of Posterolateral Fusion in Degenerative Spondylolisthesis Tae-Woo Sung, M.D., Ki-Chan An, M.D., Gyu-Min Kong, M.D., Dae-Hyun Park, M.D., Tai-Yeon Yoon, M.D. J Korean Soc Spine Surg 2012 Sep;19(3): Originally published online September 30, 2012; Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, , Korea Tel: Fax: Copyright 2011 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/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Original Article pissn eissn J Korean Soc Spine Surg Sep;19(3): The Prognostic Factor of Posterolateral Fusion in Degenerative Spondylolisthesis Tae-Woo Sung, M.D., Ki-Chan An, M.D., Gyu-Min Kong, M.D., Dae-Hyun Park, M.D., Tai-Yeon Yoon, M.D. Department of Orthopaedic Surgery, School of Medicine, Inje University, Busan, Korea Study Design: A retrospective analysis of the posterolateral fusion in degenerative spondylolisthesis. Objectives: Posterolateral fusion has been performed for patients about Meyerding grade1, 2 with degenerative spondylolisthesis in L4-5. We evaluated the prognostic factors of posterolateral fusion, alone for degenerative spondylolisthesis. Summary of Literature Review: It is reported that posterolateral fusion has almost equal postoperative clinical and radiographic results with the interbody or circumferential fusion for spondylolisthesis. However, there have been some unsatisfactory results after posterolateral fusion alone and the causes are yet unknown. Material and Methods: From January 2002 to July 2008, we analyzed postoperative clinical outcomes of 42 patients who were diagnosed with Meyerding 1 or 2 grade degenerative spondylolisthesis at L4-5. All the patients were classified into group I and group II, based on the clinical outcome evaluation method by Kirkaldy-Willis. Ten patients (Group I) were found to have poor or fair clinical outcomes, while 32 patients (Group II) were found to have excellent or good clinical outcomes. The mean duration of the follow up was 16.3 (12-23) months. We looked into postoperative body mass index and bone mass density, and found degenrative lumbar disc through preoperative MRI, retrospectively. We measured angular motion by dynamic radiographs and preoperative slip angle through a Taillard method. Results: In group I, the average preoperative BMI was 25.7 (21.2~31.4) and the average T score of bone density was -3.0 (-1.9~-4.2). There was 1 case of Grade 3, 3 cases of Grade 4 and 6 cases of Grade 5 by preoperative Pfirmann classification. The average angular motion was 11.8 (9.1~14.2) and the average preoperative slip angle was 8.4 ( ). In group II, the average preoperative BMI was 24.3 (20.72~28.1) and the average T score of bone density was -2.1 (-0.9~-3.1). There were 26 cases of Grade 3, 5 cases of Grade 4 and 1 case of Grade 5 by preoperative Pfirmann classification. The average angular motion was 8.8 (6.2~12.1) and the average preoperative slip angle was 6.2 ( ). There were statistically significant differences between the two groups in BMI, stage of disc degeneration, preoperative angular motion, and slip angle. (p=0.04, 0.04, 0.05, 0.03, respectively) Conclusion: We concluded that posterolateral fusion has exhibited worse clinical results in cases of BMI less than 2.8, disc degeneration greater than grade 4, angular motion greater than 9.4 degrees, and slip angle greater than 7.1 degrees; as such, we need to consider other surgical methods. Key Words: Degenerative spondylolisthesis, Posterolateral fusion, Prognostic factor 서론 퇴행성척추전방전위증은요추체가전방으로전위되어불안정성및척추관의분절협착을야기하여척추관협착증의증상을일으키는질환이다. 보존적치료에도불구하고일상생활을하기힘든정도의지속적인요통이있거나방사통이있을경우혹은신경증상이진행될경우수술의적응증에해당되며 Meyerding 1,2단계의수술적응에있어서도동일하게적용될수있다. 1) 수술방법에는척추후궁절제술, 후측방척추유합술, 후방감압술과후측방유합술, 추궁판절제술및전방또는후방추체간유합술등다양한술식이있다. 유합술로는후측방유합 Received: February 17, 2011 Revised: October 20, 2011 Accepted: Sepember 6, 2012 Published Online: September 30, 2012 Corresponding author: Sung Tae-Woo, M.D. Department of Orthopedics, Busan Paik Hospital, College of Medicine, Inje University, Gaegeum-dong, Busan Jin-gu, Korea TEL: , FAX: staewoo81@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2012 Korean Society of Spine Surgery 97

3 Sung Tae-Woo et al Volume 19 Number 3 September 2012 술과전방혹은후방추체간유합술및환상유합술이있으며이들의치료결과는저자들에따라다양하게보고되고있다. 2,3,4,5) 또한전위된분절을정복해야하는가에대해서도아직은의견이분분한상태이다. 추체간유합술의경우후측방유합술에비해생역학적으로안정된유합및높은유합율을얻을수있을뿐만아니라디스크에서기인하는통증을효과적으로제거할수있으며간접적인신경근감압효과도얻을수있는장점이있으나추체간유합술의경우술식의기술적어려움과수술시간의연장, 출혈의심화와같은문제가발생할수있다. 6-10) 한편여러연구에서전방전위증에서는후측방유합술이환상유합이나추체간유합술과비교하여거의동등한술후임상적및방사선학적결과를얻을수있다고보고되며후측방유합술역시전방전위증의유용한술식으로인정되고있다. 6,8,10,11) 하지만실제전방전위증환자에서후측방단독유합술시행후만족치못한결과를얻는경우를종종볼수있는데이의원인에대한보고는아직미미한상태이다. 이에본연구에서는퇴행성 Meyerding 1,2단계요추전방전위증환자에서임상결과가보통 (fair) 및불량 (poor) 인례에대한후향적연구를통해후측방유합술시행후예후를예측할수있는인자에대해평가하고자하였다. 대상및방법 1. 연구대상 2002년 1월부터 2008년 7월까지본원정형외과에서 Meyerding I, II 단계퇴행성요추 4-5번전방전위증진단받고 8주간의물리치료, 근력강화운동등의보존적요법및신경증상이심한경우 (VAS score 7점이상 ), 경막외스테로이드주사를맞는등의치료를시행하였음에도지속적인요통혹은방사통및하지파행을호소하거나신경증상이진행되었던환자들중수술시행및이후 1년이상추시가능하였던 42명을대상으로하였다. 이중술후 1년째 Kirkaldy-Willis 방법을이용한임상적결과가보통 (fair) 혹은불량 (poor) 인 10례를 1군으로하였고그외우수 (excellen), 양호 (good) 인 32례를 2군으로하였다. 1군의경우남자가 2례, 여자가 8례였으며평균연령은 65.6(57-78) 세였다. 추시기간은평균 16.3(12-23) 개월이었다. 2군의경우남자가 8례, 여자가 24례였으며평균연령은 63.4(54-76) 세였다. 추시기간은평균 15.2(12-18) 개월이었다. 두군모두동일집도의가수술하였으며환자를복와위자세로후방감압술을시행한후자세에위한자연정복이나척추경나사못고정술에의한경도의정복및고정을시행하고동일한 후측방유합술식을사용하였다. 수술후 3일째부터흉요천추보조기 (TLSO) 를착용하여보행을시작하였고술후 3개월까지보조기착용을하였다. 2. 관찰방법술전모든환자에서체질량지수 (body mass index, BMI), 골밀도 (bone densiometry, BMD) 를측정하였고술전자기공명영상을통해 Pfirmann 분류 12) 를이용하여디스크퇴행정도를 5 단계로나누어기록하였다. 술전동적방사선검사를통하여시상면상에서각운동차이를측정하여기록하였다. 또한술전기립측면방사선사진을이용하여제 4-5 요추에대해 Wiltse 방법에의한전위각 (slip angle) 을측정하였으며술후 1년정복소실율 (loss of reduction) 을기록하였다. 이는계측오차를줄이기위해각각같은비율로영상을확대하여 Taillard 방법으로계측하였으며정복소실율은정복된전위도와술후 1년전위도의비율로평가하였다. 모든측정은 2명의다른정형외과전문의가각각 2번씩측정하였다. 술후임상적결과평가는 Kirkaldy-Willis 등 13) 의판정기준을적용하여우수, 양호, 보통, 불량의결과로판정하였다. 통증이없고생활활동에제한이없으면우수 (excellent), 경한통증은있으나진통제를사용하지않고활동제한이없는경우는양호 (good), 중등도의통증이있어계속진통제를복용하고활동제한이생긴경우는보통 (fair), 수술전과같거나나빠진경우로술전활동을할수없는경우는불량 (poor) 으로판정하였다. 양군간비교통계는 SPSS 12.0 를이용하여 Wilcoxon signed rank test 와 ROC curve 로분석하였으며 P-value 가 0.05 보다작은경우유의한것으로정의하였다. 결과 후측방유합술을시행받은두군에서 1년추시상감염, 후만변형, 불유합등의합병증은관찰되지않았다. I군의경우술전체질량지수는평균 25.7(21.2~31.4), 골밀도는 T score 평균 -3.0(-1.9~-4.2) 이었다. 술전 Pfirmann 분류상디스크퇴행정도 Grade 3가 1례, Grade 4가 3례, Grade5 가 6례였다. 술전동적방사선상각운동은 11.8(9.1~14.2 도 ), 술전전위각은 8.4도 ( 도 ) 였다. II군의경우술전체질량지수는평균 24.3(20.7~28.1), 골밀도는 T score 평균 -2.1(-0.9~- 3.1) 이었다. 술전 Pfirmann 분류상디스크퇴행정도 Grade 3가 26례, Grade4 가 5례였고 Grade5 가 1례였다. 술전동적방사선상각운동은 8.8(6.2~12.1 도 ), 술전전위각은 5.6도 ( 도 ) 였다. 두군간에성별및나이는통계학적차이가없었으나골 98

4 Journal of Korean Society of Spine Surgery Posterolateral Fusion in Degenerative Spondylolisthesis 밀도, 디스크퇴행단계, 술전동적방사선상각운동, 술전전위각에서통계적으로유의한차이가났다 (Table 1). I군과 II군을 ROC curve 를이용하여분석하였고민감도와특이도의합이가장큰경우를절단값 (cut off value) 으로설정하였다. 분석결과 BMD는 -2.8, 디스크퇴행정도는 Grade 4, 술전동적방사선상각운동은 9.4도, 술전전위각은 7.1도로절단값을얻을수있었다 (Fig. 1). 고찰 퇴행성척추전방전위증은 50대이상의연령층에주로여성에게서많이나타나며제 4-5요추에많이발생하고요통의중요한원인중하나이다. 증세가경미하여일상생활에큰지장을 초래하지않으면대개보존적요법이권유되나, 6개월이상증세호전이없거나지속적인요통, 방사통및신경근압박증상이있는경우에수술적치료를시행하게된다. 14,15,16,17) 수술적치료에있어정복의필요성여부, 기기고정술및유합술의방법등다양한논란이있어왔다. 최근에는후방감압술을시행하고전위를정복하고견고한내고정및유합술을통해생역학적안정성을얻은후골유합율을높이며조기보행을추구하는것이추세이다. 18,19) 유합방법에있어서도저자들마다다양한결과를보고하고있고아직까지최선의결과에대한논란이있지만퇴행성요추전방전위에서는후측방유합술만으로도좋은결과를얻었다는연구가많다. Campbell 14) 은척추전방전위증수술적치료에서후측방유합술이가장좋은방법이라고하였고이는골이식부위 Fig. 1. ROC curves 99

5 Sung Tae-Woo et al Volume 19 Number 3 September 2012 Table 1. Analyzation and comparision between each groups BMI * (p=0.42) BMD * (p=0.04) Disc degeneration (p=0.04) Angular motion (p=0.05) Slip angle (p=0.03) 가넓고주위에혈관이풍부하며횡돌기와척추후궁의협부등 광범위한이식부위에충분한골이식을할수있기때문이라고 하였다. 하지만이술식도견고한후외방골유합을얻었음에도 불구하고장기간추시에서전방전위가진행하거나척추경나 사못의실패를보이는경우가관찰되었으며수술직후에정복 된전위정도나추간판높이, 전만도등이추시과정중다시감 소된다고여러저자들에의해보고되었다. 4,15,16) 또한골유합에 필요한골표면적의부족, 척추의전방전위로인한유합평면의 불일치등으로후측방유합술만으로만족스러운골유합을얻기 어려울수도있으며이로인해가관절증이발생할수도있다. 이 는광범위한감압술후후방안정구조가소실되고전방지지가 부실해져서척추체에대한전단력이증하하게되어척추삼주에 불안정성을초래하게되어내고정물에대한응집력의증가로인 해발생하게된다. Group I Group II 25.7 (21.2~31.4) 24.3 (20.7~28.1) -3.0 (-1.9~-4.2) -2.1(-0.9~-3.1) Gr III : 1 Gr IV : 3 Gr V : 6 Gr III : 26 Gr IV : 5 Gr V : (9.1~14.2) 8.8 (6.2~12.1) 8.4 ( ) 5.6 ( ) (BMI - body mass index, BMD - bone densiometry) 척추경나사를이용한수술의경우가장중요한점은나사 와척추골사이의접합력 (strength of attachment) 이다. Pullout strength, cutout torque, maximum insertional torque 의경우골 밀도와직접적인연관이있다는보고가있으며추체에골다공 증이있는경우결과적으로기계적강도 (mechanical strength) 에 문제가생겨나사못이완 (loosening), 불유합, 병적움직임등을 초래할수있다. 8) Halvorso 등 20) 은심한골다공증환자에있어 서는척추경나사못을이용한기기술이덜효과적이었으며 (less effective) 전방전위증환자에서나사못고정술을이용한전위의 정복이장기간추시때소실율이증가되는결과를보인다고하 였다. 본연구에서도 I 군환자의경우유의하게 II 군에비해골밀 도가저하되어있는특징을볼수있으며술후 1 년정복소실율 도증가되어있었다. 추간판의퇴행성변성으로인해추간판의안정성과구조적지지가저하되어분절의병적움직임및불안정성이야기되며후관절로의부하증가로인해퇴행성변화가가속화되고결과적으로추체의전이증가와황색인대의비후로척추관협착이발생하게된다. 4,13,14,17) 즉, 추간판변성은병인의시작점이며통증의가장큰원인이될수있으며전방전위에의한전단력증가로추간판변성은더욱더가속화되는악순환을보이게된다. Pfirmman 12) 은자기공명영상에서추간판퇴행의정도를 5단계로구분하였으며이는관찰자간변이가적은객관적인분류가가능한신뢰도있는분류로널리사용되고있다. 추체간유합술의경우후측방유합술과달리체중부하의 80% 를담당하는전방지지의재건을가능하게하여생역학적으로정상척추에가깝게되며요추전만을회복해줄수있을뿐만아니라동통의원인이될수있는추간판을제거할수있는장점이있다. 본연구에서도추간판변성이많이진행된 I군의경우임상적결과가저하되어있었음을확인할수있었으며추간판변성이심한환자의경우후측방유합술보다는근본적으로변성된추간판에대한처치가가능한추체간유합술이더적절한치료법이될수있을것이다. 본연구에서전위각은제 4-5 요추에대해 Wiltse 방법으로측정하였고불안정정도를나타내는데가장예민한척도중하나이다. 이것은척추전방전위증환자에서수술후예후를결정하는데도움이되며전위각이클수록불안정하며진행하는경향이있고생역학적으로치유에불리하다. 본연구에서도 I군의경우 II 군에비해유의하게전위각이증가되어있었으며결과적으로예후에차이가있음을알수있었다. 이경우체중부하지지능력의향상및넓은면적과빠른골유합을도모할수있는추체간유합술이후측방단독유합술보다는더적절한치료법이될수있을것이다. O Brien 21) 은경도의척추전방전위증에서방사선적으로안정화된추간판에서는후측방유합술로충분하지만과운동성을보일때추가적인추체간유합술일필요하다고하였다. 이는과운동성이있을때에는나사못으로고정을하더라도과도한힘이반복적으로주어지기때문에전방전위가유지되지않고정복이소실될수있기때문이다. 또한 Montgomery 22) 등에의하면퇴행성전방전위증환자에서술중복와위에서는술전굴곡시전위정도의평균24% 가정복이된다고보고하였고이렇게술중불안정성을보이는환자의경우기구삽입술및유합술이필요함을의미한다고하였다. 100

6 Journal of Korean Society of Spine Surgery Posterolateral Fusion in Degenerative Spondylolisthesis 결론 Meyerding 1,2 단계퇴행성척추전방전위증환자의수술적치료에있어후측방유합술만으로도좋은결과를얻을수있지만술전평가시 BMD에서골감소증또는골다공증이확인된경우, 디스크퇴행정도가 Grade 4 이상인경우및술전동적방사선상각운동이 9.4도이상, 전위각이 7.1도보다큰경우에는후측방유합술만으로는술후불량한예후를가질것으로예측할수있는바보다안정적인유합술을고려해야할것으로사료된다. REFERENCES 1. Lionel N. Metz, BS Vedat Deviren. Low-grade spondylolisthesis. Neurosurg Clin N Am. 2007;18: Agazzi S, Reverdin A, May D. Posterior lumbar interbody fusion with cages : an independent review of 71 cases. J Neurosurg. 1999;91(suppl): Song KJ, Kim SJ. Surgical treatment for the low grade lumbar isthmic spondylolisthesis : comparison between posterolateral fusion and posterior lumbar interbody fusion. J Kor Soc Spine Surg. 1999;6: Herkowitz HN, Kurz ST. Degenerative lumbar spondylolisthesis with spinal stenosis. J Bone Joint Surg Am. 1991;73: Charles Dean Ray. Threaded titanium cages for lumbar interbody fusions. Spine. 1997;22: Gyorgy I, Csecsei ph D, Almos P. Klekner Jozsef Dobal. Posterior interbody fusion using laminectomy bone and transpedicular screw fixation in the treatment of lumbar spondylolisthesis. Spine. 2000;53: Jie Zhao, Yong Hai, Nathaniel R. Ordway, Choon Keun. Posterior lumbar interbody fusion using posterolateral placement of a single cylindrical threaded cage. Spine. 2000;25: Suk KS, Jeon CH, Lee HM, Kim NH, Kim HC. Comparison between posterolateral fusion with pedicle screw fixation and anterior interbody fusion with pedicle screw fixation in sondylolisthesis of the lumbar spine. J Kor Soc Spine Surg. 1999;6: Ricciard JE, Pflueger PC, Isaza JE, Whitecloud TS 3 rd. Transpedicular fixation for the treatment of isthmic spondylolisthesis. Spine. 1995;10: Shin BJ, Min KD, Kwon H, et al. Surgical results of isthmic spondylolisthesis-comparison of posterolateral fusion vs. PLIF. J Kor Soc Spine Surg. 1996;3: Csecsei G, Klekner AP, Dobai J, Lajgut A, Sikula J. Posterior interbody fusion using laminectomy bone and transpedicular screw fixation in the treatment of lumbar spondylolisthesis. Surg Neural. 2000;53: Christian W.A. Pfirmann, Alexander Metzdorf : Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine. 2001;26: Kirkaldy-Willis WH, Panie KWR, Cauchoix J, McIvor G. Lumba spinal stenosis. Clin Orthop. 1974;99: Crenshaw AH. Spondylolisthesis. Campbell s operative orthopedics. 8 th ed. 1992;14: Kim YT, Lee CS, Na HY, Lee CW. A comparison of surgical treatment in isthmic and degenerative spondylolisthesis. J Korean Orthop Assoc. 1998;33: Lombardi JS, Wiltes LL, Reynolds J, Widell EH. Treatment of degenerative spondylolisthesis. Spine. 1985;10: Dilip K. Sengupta, Hnarry N. Herkowitz. Degenerative spondylolisthesis. 2005;30(suppl): Lenke LG, Birdwell KH, Bullis D, Betz RR, Baldus C. Results of in situ fusions for isthmics spondylolisthesis. J Spinal Disorder. 1992;5: Kim SS, Denis F, Lonstein JE, Winter RE. Factors affecting fusion rate in adult spondylolisthesis. Spine. 1990;15: Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS 3rd, Cook SD. Effects of bone mineral density on pedicle screw fixation. Spine. 1994;19: O Brien MF. Low-grade isthmic/lytic spondylolisthesis in adults. Inst Course Lect. 2003;52: Montgomery DM, Fischgrund JS. Passive reduction of spondylolisthesis on the operating room table : a prospective study. J Spinal Disord. 1994;7:

7 Sung Tae-Woo et al Volume 19 Number 3 September 2012 요추부퇴행성전방전위증에서후측방유합술시행후예후관련인자 성태우 안기찬 공규민 박대현 윤태연인제대학교부산백병원정형외과학교실 연구계획 : 요추부퇴행성전방전위증에대한후측방유합술시행의후향적분석 목적 : 요추 4-5 번간 Meyerding 1,2 단계퇴행성척추전방전위증환자에대해후측방유합술시행후임상결과의후향적연구를통해예후에영향을 미치는인자를평가하고자하였다. 선행문헌의요약 : 요추부퇴행성전방전위증에서는후측방유합술이환상유합이나추체간유합술과비교하여거의동등한술후임상적및방사선학 적결과를얻을수있다고보고있으나실제후측방단독유합술시행후만족치못한결과를얻는경우를종종볼수있는데이의예후인자에대한보고 는아직미미한상태이다. 대상및방법 : 2002 년 1 월부터 2008 년 7 월까지요추 4-5 번간 Meyerding 1,2 단계퇴행성척추전방전위증으로진단받고후측방유합술시행받은환 자 42 명중 Kirkaldy-Willis 방법을이용하여술후임상적결과를평가하여보통및불량인환자 10 명을 I 군으로하고우수 (excellent) 와양호 (good) 인환자 32 명을 II 군으로하였다. 추시기간은평균 16.3(12-23) 개월이었다. 후향적으로술전체질량지수 (body mass index) 와골밀도 (bone mass density) 를조사 하였으며술전자기공명영상을통해디스크퇴행정도를관찰하였다. 술전동적방사선촬영을통해각운동 (Angular motion) 을측정하였으며, Taillard 방법을통해술전전위각 (slip angle) 을측정하였다. 결과 : I 군의경우술전체질량지수는평균 25.7(21.2~31.4), 골밀도는 T score 평균 -3.01(-1.9~-4.2) 이었다. 술전 Pfirmann 분류상디스크퇴행정 도 Grade3 가 1 례, Grade 4 가 3 례, Grade5 가 6 례였다. 술전동적방사선상각운동은 11.8(9.1~14.2 도 ), 술전전위각은 8.4( ) 도였다. II 군의경 우술전체질량지수는평균 24.3(20.7~28.1), 골밀도는 T score 평균 -2.1(-0.9~-3.1) 이었다. 술전 Pfirmann 분류상디스크퇴행정도 Grade3 가 26 례, Grade4 가 5 례였고 Grade5 가 1 례였다. 술전동적방사선상각운동은 8.8(6.2~12.1 도 ), 술전전위각은 5.6( ) 도였다. 두군간에골밀도, 디스크퇴 행단계, 술전동적방사선상각운동, 술전전위각에서통계적으로유의한차이가났다.(p=0.04, 0.04, 0.05, 0.03) 결론 : Meyerding 1,2 단계퇴행성척추전방전위증환자의수술적치료에있어후측방유합술을시행하였을때 BMD 가 -2.8 이하로골다공증이있는경 우, 디스크퇴행정도가 Grade 4 이상인경우및술전동적방사선상각운동은 9.4 도, 술전전위각은 7.1 도보다큰경우에는술후불량한예후를가질 것으로예측되어다른수술적방법들을고려해야할것으로사료된다. 색인단어 : 퇴행성척추전방전위증, 후측방유합술, 예후인자 약칭제목 : 요추부퇴행성전방전위증에서후측방유합술 102

KISEP Clinical Article J Korean Neurosurg Soc , 2002 퇴행성요추질환환자에서척추유합술후발생한인접분절의퇴행성변화에대한수술적치료 * 김영수 구성욱 조용은 진병호 윤영설 진동규 Surgical Treatment of

KISEP Clinical Article J Korean Neurosurg Soc 32323-328, 2002 퇴행성요추질환환자에서척추유합술후발생한인접분절의퇴행성변화에대한수술적치료 * 김영수 구성욱 조용은 진병호 윤영설 진동규 Surgical Treatment of Adjacent Segment Degeneration after Spinal Fusion in