발표내용과순서 1. 척추수술현황 2. 추간판절제술 3. 척추고정술 4. VP/KP 5. 후궁절제술 2

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1 척추질환에대한수술적접근의이해 ( 척추관련주요심사기준및사례 ) 어 환, M.D., Ph.D. 성균관대학교의과대학의학전문대학원신경외과학교실 10/26/ :00~14:50 교보타워 23F 이벤트홀 1

2 발표내용과순서 1. 척추수술현황 2. 추간판절제술 3. 척추고정술 4. VP/KP 5. 후궁절제술 2

3 척추, 척수질환 (1/2) 1. 선천성기형 (Developmental Anomalies) 1) 척추유합부전 (spinal dysraphism) 2) 두개척추접합부기형 (craniovertebral junction anomaly) 2. 척수종양 1) 경막외종양 (extradural tumor,ed) 2) 경막내수외종양 (intradural extramedullary tumor,idem) 3) 척수내종양 (intramedullary tumor,im) 3. 척수혈관질환 (vascular disease of spinal cord) 1) 척수허혈과경색 (spinal cord ischemia & infarcton) : 폐쇄성척수혈관장애 2) 척수출혈 (spinal hemorrhage) 3) 척수혈관기형 (spinal vascular malformation) 3

4 척추, 척수질환 (2/2) 4. 외상성척수질환 (Cord injury) 5. 감염및염증성척수염 (Myelitis) 6. 급성횡단척수염 (Acute Transverse Myelitis) 7. 유전경직하반신마비 (Hereditary Spastic Paraplegia; HSP) 8. 척수구멍증 (Syringomyelia) 9. 아급성연합변성 (Subacute Combined Degeneration; SCD) 10. 근육위축가쪽경화증 (Amyotrophic Lateral Sclerosis) 11. 다발성경화증 (Multiple Sclerosis) 12. 양성척추질환 1) 추간반탈출증 (intervertebral disc herniation) 2) 척추관협착증 (spinal stenosis) 3) 척추전방전위증 (spondylolisthesis) 4) 척추인대골화증 5) 척추굳음척수병증 (spondylotic myelopathy) 4

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7 Practising physicians per population, 1990 and AAGR Greece Belgium Netherlands Norway Switzerland Austria Iceland Italy Spain Sweden Czech Republic Portugal Germany France Denmark OECD OECD Slovak Republic Ireland Finland Luxembourg Australia Hungary United Kingdom United States New Zealand Poland Canada Japan Mexico Korea Turkey AAGR = Average Annual Growth Rate (%) Source: OECD Health Data

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11 CT / MRI During the past decade, there has been a rapid growth in the availability of diagnostic technologies such as computed tomography (CT) scanners and magnetic resonance imaging (MRI) in most OECD countries. Korea was no exception. The number of CT scanners per million population increased rapidly in Korea, from 12.2 in 1990 to 37.1 in (vs. OECD Median 15 in 2005; Canada 12, 2007) Similarly, the number of MRIs per million population also increased at a fast pace, from 1.4 in 1990 to 16.0 in (vs. OECD Median 7 in 2005; Canada 6 in 2007) Korea s per capita buying power nears $30,000!!! 11

12 MRI 세부산정기준 (1/2) 1. 일반원칙 : 자기공명영상진단 (MRI) 은질환별대상및산정기준에해당하지않는경우에는요양급여하지아니함. ( 비급여 ) 2. 질환별급여대상 가. 암 : 원발성암 ( 척추, 척수를침범한경우 ), 전이성암 ( 척추, 척수 ) 나. 뇌양성종양및뇌혈관질환 다. 간질, 뇌염증성질환및치매등 라. 척수손상및척수질환 (1) 척수손상 (2) 척수종양 ( 척추강내종양 ) (3) 혈관성척수병증 ( 척수경색, 척추동정맥기형, 척수내정맥염등 ) (4) 척수에발생한탈수초성질환 ( 급성횡단성척수염등 ) (5) 척수의염증성질환 ( 척수염, 척수내농양및육아종, 기생충등 ) (6) 척수기형 ( 척수공동증, 구공동증등 ) 12

13 MRI 세부산정기준 (2/2) 마. 척추질환 (1) 염증성척추병증 (2) 척추골절 (3) 강직성척추염 바. 관절질환 (1) 외상.. (2) 골수염 (3) 화농성 (4) 무릎관절및인대손상 ( 반달연골 ) 3. 산정횟수 가. 진단시 1) 위 2 의가 ~ 라에해당하는질환 1 회인정하되, 진료상추간촬영의필요성이있는경우별도인정함. 2) 위 2 의마 ~ 바에해당하는질환 1 회인정하되, 새로운병변이발생되어추가촬영한경우에는인정함. 나. 추적검사 (1) 추적검사는아래와같이시행함을원칙으로하되, 그외에환자상태변화가있어추가적으로촬영시에도인정함. - 아래 - ( 가 ) 수술후 ( 중재적시술포함 ) : 1 개월경과후 1 회 다만, 뇌종양, 뇌동정맥기형 (AVM), 척수농양, 혈관성척수병증, 척수기형등을수술또는시술후잔여병변을확인하기위해 48 시간이내촬영한경우인정함. ( 나 ) 방사선치료후 ( 뇌정위적방사선수술포함 ): 3 개월경과후 1 회 개정고시제 호 시행 13

14 행정해석 질의 응답 1. 급여대상질환중척추골절의경우골다공증성압박골절의포함여부 1. 사유에관계없이척추골절이의심되어촬영한 mri 는건강보험적용대상임. 2. 염증성척추병증의범주 3. 수술후또는경과관찰을위해추가촬영시건강보험적용여부 2. 척추의골수염, 척추결핵, 추간원반의 ( 화농성 ) 감염등을의미함. 3. MRI 급여대상중척추및관절의경우진단시 1 회인정하며, 수술후또는경과관찰을위해추가촬영시비급여대상임. 14

15 Aging Spine Changes Age 0-4-nucleus pulposus present 9-14: less nucleus, bilateral clefts form in annulus, at joints of Lushka 20-35: Clefts enlarge and dissect disc towards midline > 60: Disc is dry, no nucleus, ligamentlike, less volume, decreased ROM, more rigidity 15

16 Other age-related spinal changes Nucleus dries & becomes rigid (blends w/annulus) Hyaline endplates calcify Nutrients to disc decrease Decreased ligament elasticity (ROM) Flattened jts of Lushka Thicker ligamentum flavum Decreased muscle mass, bone density Increase thoracic kyphosis Anterior head carriage 16

17 Introducing Kirkaldy-Willis (KW) Dysfunction-Subluxation or poor biomechanics may produce a focal swelling, pain, muscle splinting. Instability- Trauma or prolonged dysfx. Leads to aberrant motion, inability to hold the adjustment, chronic pain, ms. fatigue, etc. Stabilization-The body tries to fuse or immobilize areas prone to disuse or trauma. 17

18 True or False? Degenerative changes, as seen on x-ray, are a fairly good indicator of the patient s pain and/or functional status. 18

19 False! Pain and disability are NOT predicted by radiographic findings. Disc herniation (visible on MRI/CT) does not usually predict problems with spinal function. 19

20 Fusion Surgery is not a Cure for Chronic Back Pain 77% increase of fusion procedure between 1996 and 2001 in USA : outcomes do not improve. (5yr) Bono C, et al:critical analysis of trends in fusion for degenerative disc disease over the past 20 years:influence of technique on fusion rate and clinical outcome. Spine 29(4):455-63,2004 I/F = Recommend that physicians curtail fusion surgery for the treatment of DDD pending better scientific data Deyo RD,et al:spinal fusion-the case for restraint. NEJM, 350(7):722-6, 2004 I/F =

21 Overuse of Surgery Surgery seems helpful for at most 2% of patients with back problems, and its inappropriate use can have a great impact on increasing the chance of chronic back pain disability Bigos & Battie Surgery should be reserved for those patients for whom function cannot be satisfactorily improved by a physical rehabilitation program Failure of passive non-operative treatment is not sufficient for the decision to operate. 21

22 New Technology In most areas of medicine, when new technology is introduced, old technology disappears. However that has not been the case in spine surgery. If anything, the opposite is true. There has been a pooling of new technology in the spine arena. Mendenhall S.: Back letter.18(3):27,

23 뉴클레오톰을이용한관혈적척추디스크수술 Automated Open Lumbar Discectomy (AOLD) 자 49- 가 (3) 관혈적추간판제거술 - 요추의소정점수를산정함. 소요재료 : Nucleotome kit ( 별도산정불가 ) 고시 시행 23

24 AMD kit 와 Inclusive Endoscope 및뉴크레오톰 kit의급여여부고시제 호 시행 내시경적미세추간판절제술 과 내시경 - 레이저병용추간판절제술 이급여되고있을뿐아니라뉴크레오톰 Kit 를이용한 경피적추간판수핵제거술 이전세계및국내에서도널리이용되고있는보편적인시술이라는의학계의의견이있음을감안할때각각의시술시사용하는소모성재료에대하여는다음과같이인정함. 경피적추간판수핵제거술 시샤용되는뉴크레오톰 Kit 실구입가로산정함. Arthroscopic Microdiscectomy 24

25 관혈적현미경요추디스크자동절제술 Arthrocare Openwand Automated Open Lumbar Microdiscectomy 자 49 가관혈적추간판제거술의소정점수를산정함. 관련치료재료고시 ( 고시제 호 ) : Arthrocare Spine Wand (BF0501DI) : 비급여 산정불가 고시제 호 ( 기결정 ) 시행 25

26 척추수술 3 항목 (AOLD, PELD, OLM) 용어정립 척추수술 3 항목의용어에대하여아래와같이결정함. 뉴클레오톰을이용한관혈적척추디스크수술 (AOLD, Automated Open Laser Discectomy) 및관혈적레이저미세수술적추간판절제술 (OLM, Open Laser Microdiscectomy) 은교과서및국내외학술용어로사용되지않으므로공식적인용어로볼수없음. 결피적 solrud- 레이저병용추간판절제술 (PELD, Percutaneous Endoscopic Laser Discectomy) 은교과서및국내외학술용어로사용되지않으므로공식적인용어로볼수없음. 다만 PELD 는일반적으로 Percutaneous Endoscopic Lumbar Discectomy 로사용됨. 사례

27 일시적유행수술 1. 화학적수핵용해술 (chemonucleolysis) : 1963 chymopapain by Smith 미국내사라짐 약물생산중단 2. 자동경피수핵제거술 (automated percutaneous lumbar discectomy, APLD) : Nucleotome Onik 3. 관절경수핵제거술 (arthroscopic discectomy) 4. 전방내시경수핵제거술 (anterior laparascopic discectomy) 5. 내시경추체유합술 (arthroscopic microsurgical fusion) 6. 레이저추간판성형술 (laser thermodiskoplasty) 7. Ozone therapy 8. IDET, Nucleoplasty 9. 다양한 Cage, screw & rod system, plate system 10. Graf, Dynesys 11. Amslu (cervical) 12. PDN, Arthroplasty (lumbar) 27

28 요추간판탈출증 1. Disc prolapse accounts for 5% of low-back disorders but is one of the most common reasons for surgery % of acute attacks of sciatica settle with non-surgical management. 3. Lumbar disk herniation is often seen on imaging studies in the absence of symptoms. 4. Lumbar disc herniation can regress over time without surgery. 5. Lumbar diskectomy is the most common surgical procedure performed in the US for patients having back and leg symptoms. 6. Up to 15-fold variation in regional diskectomy rates in the United States and lower rates internationally raise questions regarding the appropriateness of some of these surgeries. 28

29 인정기준 심사기준 ( 최소침습성추간판절제술의인정기준 ) 심사지침 6 주이상의보존적요법에도불구하고심한방사통이지속되는환자에서추간판의편심성탈출로인한신경근압박소견이확인되는경우에인정한다. 다만 40 세이상에서는본술식의유용성에대한의사소견서를첨부하도록한다 심사기준 ( 최소침습성추간판절제술의인정기준 ) 부터적용 6 주이상의보존적요법에도불구하고심한방사통이지속되는환자에서추간판탈출로인한신경근압박소견이확인되는경우에인정한다 ( 다만조기시행시그필요성에대한의사소견서를첨부 ). 1. Cauda equina syndrome : sphincter disturbance, incontinence of stool or urine 2. Progressive neurologic loss : Progressive motor weakness Less than 4 in quadriceps or foot DF Youmans p

30 6 주이상의보존적요법의학문적근거 (1) 척추학 (The Textbook of Spine) 대한척추신경외과학회 p845 수술의적응증 : 마미총증후군의발생 악화되는근력저하 심해지는통증 4~6 주간의보존적요법에도증세의차이가없는경우 Macnab 의적응증 (The Rule of Five) 2 Symptoms : 1.Leg pain, greater than back pain 2.Specific neurologic symptoms(paresthesia) 2 Signs: 3.SLR(<50% of normal) 4. Two of 4 neurologic signs(altered reflex, wasting, weakness, sensory loss) 1 Investigation : 5.Positive concordant imaging 30

31 6 주이상의보존적요법의학문적근거 (2) 척추외과학 요추추간판질환 1. 요추간판탈출증 치료 6-8 주간의보존적치료에도불구하고호전이없는경우.. (p244) (3) Youmans Neurological Surgery vol 4 Ch Intradiskal and percutaneous Treatment of Lumbar Disk Disease (p4771) Laser-Assisted Percutaneous Diskectomy (p4780) Indications (p4781) Although clinical experience with laser diskectomy techniques, the consensus is that the ideal patient is on who meets all the classic radiographic and clinical criteria for a herniated disk. Additionally, it is recommended that patients should have had at least 6 weeks of unsuccessful conservative therapy. 31

32 6 주이상의보존적요법의학문적근거 (4) Orthopaedic Knowledge Update (American Academy of Orthopaedic Surgeons, North American Spine Society) Ch. 34. Lumbar Disc Herniation : In most patients a nonsurgical approach is used initially.. surgery is not necessary for 6 to 12 weeks. ( p327) Operating before 4 to 6 weeks have passed is too soon,. (p328) (5) Synopsis of Spine Surgery. By Howard S. An Ch. 12. Lumbar Disc Disease : (p237) Invasive treatment indicated after at least 6 weeks of proper conservative treatment 32

33 6 주이상의보존적요법의학문적근거 (6) Principles of Spinal Surgery vol. 1. Ch. 39 Percutaneous Approaches to the Lumbar Disk Indications Clinical A supervised trial of conservative management including aggressive physical therapy of exercise and reconditioning of at least 6 weeks duration- is suggested. (p610) (7) The Lumbar Spine (The International Society for the STUDY of the LUMBAR SPINE) Optimal nonoperative treatment occurs for at least 4 to 6 weeks,. (p497) 33

34 Surgical Indications for Disc Herniation according to the Danish Guidelines 1. After 4-6 weeks of conservative care 2. when there is a positive correlation between clinical findings and imaging reports 3. and progressive weakness in the leg 4. or severe leg symptoms in spite of medication 34

35 Surgical Indications for Disc Herniation or Spinal Stenosis according to the Rand Corporation (1) Appropriate : Pain in lower limb, imaging positive for disc hernia or spinal stenosis, major or minor neurological findings, restricted activity for more than 6 weeks (2) Equivocal : Pain in lower limb, imaging positive for disc hernia or spinal stenosis, major neurological findings, restricted activity for less than 4 weeks Pain in lower limb, imaging equivocal for disc hernia or spinal stenosis, minor neurological findings, restricted activity for more than 6 weeks (3) Inappropriate : Pain in lower limb, imaging positive for disc hernia or spinal stenosis, minor neurological findings, restricted activity for less than 4 weeks Minor neuro findings (2 or more items) Asymmetric ankle reflex Dermatomal sensory deficit Positive ipsilateral SLR (straight leg raise) test Sciatica Major neurologic findings Progressive unilateral leg weakness, or Positive contralateral SLR test 35

36 Discectomy 1. Microdiscectomy : Malis 1955 still Gold Standard 2. MED (Micro-Endoscopic Discectomy) : Foly & Smith OLM : Open Laser Microdiscectomy 4. AOLD : Automated Open Lumbar Discectomy 5. OLDW : Open Lumbar discectomy with Wand 6. PELD : Percutaneous Endoscopic Lumbar (Laser) Discectomy 7. Percutaneous nucleotomy : Hijikata PLD : Percutaneous Laser discectomy : Asher & Heppner APLD : Automated Percutaneous Lumbar discectomy (Nucleotome) : Onik Arthroscopic microdiscectomy : Kambin IDET : Saal & Saal Nucleoplasty 13. Percutaneous Chymopapain Chemonucleolysis : Smith Laser thermodiskoplasty 15. Ozone therapy 36

37 요추부의최소침습추간판제거술인정기준 요추부의최소침습추간판제거술 ( 자 49 나내시경하추간판제거술, 자 49 다척추수핵용해술, 자 49 라척추수핵흡인술등 ) 의인정기준은다음과 같이함. 가. 적응증 - 다음 - 6 주이상의적극적인보존적치료에도불구하고심한방사통이지속되는환자에서추간판탈출로인한신경근압박소견이확인되는경우에인정하되, 조기시행이필요한경우에는의사소견서를첨부하여야함. 나. 금기증 협착증이동반된경우 고시제 호 ( 행위 ) 시행 37

38 관혈적추간판제거술 추간판탈출증과척추관협착증의치료는교과서등을참조할때수술적치료전정확한진단과적극적이고충분한보존적치료를시행하는것이원칙이므로영상자료및진료내역을참조하여결정함. 사례

39 복강경하추간판제거술등에대한수기료산정방법을다음과같이함. (1/2) 가. 복강경하요추간판제거술 ( 및골융합술 ) Laparascopic Lumbar Diskectomy (and Ant. Interbody Fusion) (1) 기술료 - 자 49 나내시경하추간판제거술의소정금액으로산정함. - 제 2 수술로골융합술을병행한경우는자 46 가 (3) 척추고정술 ( 전방고정 - 요추 ) 의 50% 를산정함. (2) 치료재료 복강경등내시경하수술시사용하는치료재료비용의산정방법에의거별도산정함. 골융합술을병행한경우골융합용치료재료별도산정함. 39

40 복강경하추간판제거술등에대한수기료산정방법을다음과같이함. (2/2) 나. 흉강경하흉추간판제거술 ( 및골융합술 ) Thoracosopic or Video-Assisted Thoracic Diskectomy (and Fusion) (1) 기술료 - 자 49 나내시경하추간판제거술의소정금액으로산정함. - 제 2 수술로골융합술을병행한경우는자 46 가 (3) 척추고정술 ( 전방고정 - 흉추 ) 의 50% 를산정함. (2) 치료재료 복강경등내시경하수술시사용하는치료재료비용의산정방법에의거별도산정함. 골융합술을병행한경우골융합용치료재료별도산정함. 다. 미세내시경하추간판제거술 Micro Endoscopic Diskectomy (MED) (1) 기술료 : 자 49 나내시경하추간판제거술의소정금액으로산정함. (2) 치료재료 Laser 시술을병용한경우 Laser Kit 는 748,380 원 ( 코드 N ) 을산정한다. 고시제 호 ( 시행 ) 40

41 경추부의최소침습성추간판제거술의인정기준 경추부에최소침습성추간판제거술 ( 자 49 나내시경하추간판제거술, 자 49 다척추수핵용해술, 자 49 라척추수핵흡입술등 ) 시인정기준은 다음과같이함. - 다음 - 가. 경추부의자 49 나내시경하추간판제거술은후외측 (postero-lateral) 으로전위된심한연성추간판탈출증으로인한신경근압박소견이명확하고 12 주이상의적극적인보존적치료에도불구하고상지방사통이있는경우에인정함. 나. 경추부에실시한자 49 다척추수핵용해술, 자 49 라척추수핵흡입술은인정하지아니함. 고시제 호 ( 행위 ),

42 척추유합술시사용하는고정기기 (Cage 단독사용또는 Cage 와 pedicle screw system 병용사용 ) 의인정기준고시제 호 ( 치료재료 ) 시행일 고정기기 (Cage 단독사용또는 Cage 와 pedicle screw system 병용사용 ) 를이용한척추유합술은적절한보존적요법에도불구하 고임상증상의호전이없는다음의경우에인정함. 가. 적응증 (1) 척추전방전위증 - 다음 - (2) 임상증상이동반된중등도 (MRI 상신경공의 perineural fat 의소실이확인된경우 ) 이상의추간공협착증 (3) 광범위한후방감압술 ( 편측후관절의전절제및양측후관절의각 ½ 이상절제 ) 불가피한다음의질환 1) 척추관협착증 2) 관혈적수술후재발한추간판탈출증 42

43 척추유합술시사용하는고정기기 (Cage 단독사용또는 Cage 와 pedicle screw system 병용사용 ) 의인정기준고시제 호 ( 치료재료 ) 시행일 (4) 3 개월이상의적절한보존적요법에도불구하고심한요통이지속되는퇴행성추간판질환중 1) MRI 상퇴행성변화가 1-2 개분절에만국한되어있으며, 뚜렷한추간간격협소가동반되고추간판조영술 (discography) 상병변이확인된경우 나. 금기증 2) 분절간불안정성이확인된경우 (1) 감염성질환 (2) 이전의추체간유합술부위 (3) 골다공증 (Cage 단독사용시에만해당 ) 상기기준은모든종류의 cage 에적용됨. 특수형 cage 와복강경하 cage 는병용을인정하지아니함. 43

44 분절간불안정성에대한방사선진단기준 척추유합술시사용하는고정기기 (Cage 단독또는 Cag 와 pediclw screw system 병용 ) 인정기준의적응증중 가 -(4)-2 분절간불안정이확인되는경우 의방사선적진단기준은다음과같이함. 요추부측면굴곡 - 신전사진에서 - 다음 - 가. 시상면전위 (sagittal plane displacement) 4mm 이상인경우 나. 시상면굴곡도 (sagittal plane angulation) 가 - L1-2, L2-3, L3-4 : 15º 이상 - L4-5 : 20º 이상 - L5-S1 : 25º 이상 측정방법은그림참조 44

45 Figure 7: Measurement technique of Dupuis et al (3). Sagittal translation is measured by drawing lines U and L along the posterior cortices of upper and lower vertebral bodies. A third line I along inferior endplate of the superior vertebral body is drawn and a fourth line R is drawn parallel to L through the intersection point of lines I and U. Translation is defined as the perpendicular distance between parallel lines L and R. To obviate inaccuracies due to x-ray magnification factor, translation is measured as percentage of the width of the upper vertebral body (W). Sagittal rotation is measured by drawing perpendicular lines to posterior body lines (U and L). If apex of the angle is posterior to vertebral body, the angle is positive; if it is anterior, the angle is negative. 45

46 요추퇴행성후만증 (Lumbar degenerative kyphosis, LDK) 수술의인정기준 ( 고시제 호, ) 요추퇴행성후만증 (Lumbar degenerative kyphosis, LDK) 수술은다음의가, 나조건을모두충족한경우에인정함. - 다음 가. 의무기록지와동영상에서아래임상증상이 3개이상확인된경우 1) 기립및보행중체간의구부러짐 (stooping) 2) 무거운물건들기의장애 3) 주관절부의굳은살형성 4) 언덕길또는계단보행장애 나. 기립전신척추방사선사진 (Standing whole spine) 에서국소적후만변형 ( 또는 0 도이상의요추부후만변형 ) 과시상불균형 (sagittal imbalance) 의소견이확인되며, 골다공성압박골절이없는경우 46

47 척추체보강용치료재료 (mesh-cylinder 등 ) 인정기준 척추체제거술시사용되는척추체 (vertebral body) 보강용치료재료 (mesh cylinder 등 ) 는다음과같이자가골사용이어려운경우에인정함. - 다음 가. 적응증 (1) 흉요추부의골절, 기형또는종양으로인해 1 개이상의추체전제거술이불가피한경우 (2) 경추부의골절, 기형, 종양또는척수압박으로인해 1 개이상의추체전제거술이불가피한경우 (3) 척추결핵으로인해 1 개이상의추체전제거술이불가피한경우 나. 금기증 : 화농성병소 척추체제거술시사용되는척추체 (vertebral body) 보강용치료재료 (mesh cylinder 등 ) 는다음과같이자가골사용이어려운경우에인정함. - 다음 가. 적응증 (1) 흉요추부의골절, 기형또는종양으로인해 1 개이상의추체전제거술이불가피한경우 (2) 경추부의골절, 기형, 종양또는척수압박으로인해 2 개이상의추체전제거술이불가피한경우 (3) 척추결핵으로인해 2 개이상의추체전제거술이불가피한경우 나. 금기증 : 화농성병소 고시제 호 ( 행위 ) 시행 지침 부터 47

48 Cage 와연성기구를동시에사용한경우인정여부 Cage 와연성기구는그작용원리가서로모순되는바, 동시에사용하는경우에는그타당성을인정할수없으므로연성기구인 Bioflex(Bio Flexible Spine Rod System, 비급여 ) 또는 Loop Fixing 등 ( 비급여 ) 과 Cage 를동시에사용한경우에는급여대상치료재료인 cage 를인정하지아니함. 사례

49 요추추간판전치환술고시제 호 시행 가. 적응증 25 세 60 세의환자에서 6 개월이상의적극적인보존적치료에도불구하고심한요통이지속되며, L4-5 또는 L5-S1 중단일분절에국한된퇴행성추간판질환이 MRI 와통증유발추간판조영술에서확인되는경우 ( MRI 의 T2 시상면영상에서추간판의신호강도저하소견이 L4-5 또는 L5-S1 중단일분절에만국한하여확인되고, 추간판조영술검사상동분절에서동형통증이발생하는경우 ) 나. 금기증 (1) 골다공증 (T-score -3.0 이하 ) (2) 신경근압박소견이있는경우 (3) 척추분리증, 척추탈위증또는척추관협착증 (4) 후관절의퇴행성변화또는후궁전절제술후상태 다. 치료재료 : 요추인공디스크 (lumbar disc prosthesis) 는치료재료급여, 비급여목록및급여상한금액표에의거비급여대상임. ( 시행 ) 49

50 경추추간판전치환술고시제 호 시행 가. 적응증 18(21) 세이상의환자에서제 3-4 경추간부터제 6-7 경추간사이의한분절또는인접한두분절에국한된병변으로 6 주이상의적극적인보존적치료에도불구하고, 연성추간판탈출에의한심한신경근성통증의지속이확인되는경우 ( 병변이분명하게확인되는경우에한하여최대 2 분절까지시행가능 ) 나. 금기증 (1) 감염성질환 (2) 골다공증 (T-score -3.0 이하 ) : 골밀도검사에서같은성, 젊은연령의정상치보다 3 표준편차이상 (QCT 의경우 110 mg / cm3이상 ) 감소된경우 (3) 굴신방사선사진상해당분절의불안정성이있거나, 분절운동이 3 도이하인경우 (4) 해당분절에골극형성이나후방종인대, 후관절또는황색인대의비후소견이있는경우 (5) 추간판의퇴행성변화가다분절 ( 세분절이상 ) 에서나타나는경우 다. 치료재료 : 경추인공디스크 (cervical disc prosthesis) 는치료재료급여, 비급여목록및급여상한금액표에의거비급여대상임. 50

51 경피적척추성형술 (Vertebroplasty) 인정기준 경피적척추후굴풍선복원술 (Kyphoplasty) 인정기준 경피적척추성형술 (Vertebroplasty) 인정기준은다음과같이함 - 다음 - 1. 골다공증압박골절로서 2 주이상의적극적인보존적치료에도불구하고심한배통이지속되는경우 ( 단, 폐렴, 혈전성정맥염, 약물로잘조절되지않는당뇨병환자, 투석을받는만성신부전환자, 80 세이상인환자는조기시행가능 ) 2. 종양에의한골절 3. Kummell's disease 확인방법 가. MRI 검사또는 CT 와동위원소검사에서증상을유발하고있는병소임이확인된경우 나. 단순방사선사진의비교검사에서진행성또는새로발생한압박골절임을분명히관찰할수있는경우 ( 시행 ) 자 47-1 경피적척추후굴풍선복원술 Kyphoplasty 은압박변형이 (10-50% 20-60%) 30-60% 인경우로서다음과같은경우에인정함. 다만, 골다공증성방출성골절은압박변형이 60% 이상인경우에도인정함. - 다음 - 가. 3주 (2주) 이상의적극적인보존적치료에도불구하고심한배통이지속되는골다공증성압박골절 ( 단, 폐렴, 혈전성정맥염, 약물로잘조절되지않는당뇨병환자, 투석을받는만성신부전환자, 80세이상인환자는조기시행가능 ) 나. 종양에의한압박골절 다. Kummell's disease 확인방법 (1) MRI 검사또는 CT 와동위원소검사에서증상을유발하고있는병소임이확인된경우 (2) 단순방사선사진의비교검사에서진행성또는새로발생한압박골절임을분명히관찰할수있는경우 " ( 시행 ) 51

52 경피적척추후굴풍선복원술 (Kyphoplasty) 시골다공증성압박골절의압박변형률측정방법 척추골다공증성압박골절시압박변형률측정방법은다음과같이하며, 단순방사선측면영상 (plain X-ray lateral view) 에서측정하는것을원칙으로한다. - 다음 - 가. 인접상, 하부추체에진구성골절이없는경우 - 인접상, 하부전방추체높이의평균에대한압박골절추체의전방높이감소비 - 인접상부또는하부의전방추체높이에대한압박골절추체의전방높이감소비 나. 인접상, 하부추체에진구성골절이있거나다발성골절인경우 - 인접한상부또는하부의정상추체전방높이에대한압박골절추체의전방높이감소비 지침 적용 52

53 의학적검토 (3) Kummell s disease 에대하여 1891 년독일외과의사 Hermann Kummell 에의하여처음소개 척추체의외상후지연성압박골절을보이는질환외상당시에는척추체의압박골절이없음. 그러나수주또는수개월후척추체의압박골절이발생. 척추체사이에공기 (gas, intravertebral vacuum cleft) 가특징. 원인 : 척추체의외상, 허혈, 영양공급저하, 그리고혈관장해 피고는의료자문결과를근거로환자 K 씨는 Kummell s disease 가아니다라고주장, but 원고의주장대로제 11 흉추척추체에공기가관찰되어 Kummell s disease 일가능성을배제할수없음. 그러나환자 K 씨가 Kummell s disease 라가정하면이 Kummell s disease 는이번교통사고로발생한것으로볼수없고사고이전부터있었던기왕증으로판단됨. 원고도 Kummell s disease 가기왕증으로있는상태에서최근교통사고로신선압박골절이추가된것으로판단하고있음. 53

54 심한척추관협착증또는관혈적수술후재발한추간판탈출증에서, 광범위한후방감압술이불가피한경우 심한척추관협착증이란? 척추관협착증 : 1. 중심부협착증 (central stenosis) 2. 외측부협착 (lateral stenosis) : 1함요부, 2추간공가 ) 입구대 (entrance zone) : 외측함요부 (lateral recess) 정상 : 5mm 이상, 2mm 이하 외측부협착증, 의심 :3-4 mm 나 ) 중간대 (mid-zone) : 척추경아래의추궁협부에부위다 ) 출구대 (exit-zone) : 거꾸러선눈물방울정상높이 / 폭 : 20-23mm/8-10mm, 15mm /4mm 미만인경우 80% 에서신경근압박이발생 ( 척추외과학 p ,2004) 54

55 척추관협착증 척추관 (spinal canal), 측부함요 (lateral recess), 신경공 (neural foramen) 등이좁아져척수, 신경근을압박하는상태 원인 선천성 : achondroplasia, 후천성 : 퇴행성 (degenerative) 인경우가대부분 추간판의퇴행성변화가기본적인병리현상 55

56 요추관협착증 50 대이후, 남자, 운동범위가큰 L4/5,L5/S1 부위에호발 추간판탈출증에비해요통, 둔부통이흔하고 SLR limitation, neurologic deficit 은없는경우가많다 신경인성파행 (neurogenic intermittent claudication, NIC): 특징적인증상 56

57 Neurogenic Claudication 서있거나걸을때찌르는듯, 쥐어짜는듯한통증, 허리를굽히거나쪼그려앉으면 (squatting position) 증상호전됨. Extension position 에서신경공이더좁아압박현상이심해지기때문 감별진단 : 혈관인성파행 (vascular claudication) Burger s disease 처럼근육혈류량의부족에의함, extension/flexion 에관계없이운동량이증가할때상대적인허혈현상으로통증이나타남 57

58 척추관협착증진단과수술적응증은다르고, 수술적응증과유합술의적응증은다르다. < 협착증의진단 > 경막낭의횡단면부가 100 mm2이하이거나, 중간시상봉합의직경 (sagittal diameter) 이 10mm 이하면임상증상일으킬수있다. 후방디스크높이가 4 mm 이하거나추간공높이가 15 mm 이하인경우에도신경을압박할수있다. ( 척추학 p785-6, 2008) MRI 상정중시상직경 (midsagittal diameter) 이 10mm 이하 : 절대적협착 (absolute stenosis) mm 인경우 : 상대적협착 (relative stenosis) ( 요추관협착증의진단과치료 p44, 2006) 58

59 척추관협착증진단과수술적응증은다르고, 수술적응증과유합술의적응증은다르다. < 수술권유 3 가지지침 > 1. 지속적인하지의동통이환자의삶의질에장애가될때. 환자의활동수준에따라다르며일률적으로적용되지않는다. 2. 최소한 2-3 개월간의여러가지보존적요법에실패하였을때. 심하지않은신경증상이있더라도수술을서두를필요는없다. 그러나비교적급격히진행되는신경장애나대소변기능의상실은조기에감압술을요함. 3. 척수강조영술, CT 혹은 MRI 상의소견이환자가가지는증상과부합되어야함. ( 척추외과학 p270, 2004) 59

60 보존적치료적응증 대체로 30 분이상걷거나서있어도괜찮을정도로심하지않다면고식적인요법을권하는것이낫다. 왜냐하면심하게파행통증을주로호소하는환자들이수술후 30 분이상걷거나서있을수있게되는것으로만족할수있기때문. ( 요추관협착증의진단과치료 p68, 2006) 60

61 골유합술과병행한감압술 요추부척추관협착증의수술적치료에서가장중요한치료는역시신경감압술이며골유합술이꼭필요한경우는많지않다. 골유합술의적응증 (1) 척추의불안정이있을경우 (2) 요추부의측만증이나후만증과같은변형이동반된경우이를교정할필요가있을때 (3) 재수술이필요한경우 ( 척추외과학 p271, 2004) 61

62 수술적치료 1. 감압후궁절제술 (wide decompressive laminectomy) 2. 개후궁수법 (laminotomy procedure) 3. 극돌간간격자감압술 (interspinous spacer) : interspinnous U, Wallis system, X-stop 4. 유합술과기구고정술 Grobe 등, 45 명환자, 3 군 (1 한분절에감압술만, 2 감압술 + 가장심한협착소견이있는분절만유합술, 3 여러분절감압술 + 무든부위유합술 ) 평균 78% 성공률 세군들사이에의미있는차이를볼수없음. 감압술만으로도비교적좋은결과를보여줄수있었고불안정이입증된경우에는유합술이필요. ( 척추학 p795-6, 2008) 62

63 척추관협착증에척추후궁절제술시수기료산정방법고시제 호 ( 행위 ) 척추관협착증에신경감압을위해시행하는척추후궁절제술은 level 당산정하되, 여러 level 을실시하더라도최대 200% 까지산정함. ( 예시 : L4-5 spinal stenosis 상병으로 L4, L5 laminectomy 시행시자 49-1 다 100% 산정 ) 시행 63

64 요양급여의적용기준및방법 ( 국민건강보험요양급여의기준에관한규칙제 5 조제 1 항관련 ) 제 5 조 ( 요양급여의적용기준및방법 ) 1 요양기관은가입자등에대한요양급여를별표 1 의요양급여의적용기준및방법에의하여실시하여야한다. 1. 요양급여의일반원칙 가. 요양급여는가입자등의연령, 성별, 직업및심신상태등의특성을고려하여진료의필요가있다고인정되는경우에정확한진단을토대로하여환자의건강증진을위하여의학적으로인정되는범위안에서최적의방법으로실시하여야한다. 나. 요양급여를담당하는의료인은의학적윤리를견지하여환자에게심리적건강효과를주도록노력하여야하며, 요양상필요한사항이나예방의학및공중보건에관한지식을환자또는보호자에게이해하기쉽도록적절하게설명하고지도하여야한다. 다. 요양급여는경제적으로비용효과적인방법으로행하여야한다. 라. 요양기관은가입자등의요양급여에필요한적정한인력, 시설및장비를유지하여야한다. 마. 바. 사. 64

65 임상연구문헌 임상연구문헌은연구유형에따라다음의 4 가지범주로분류하며, 허가초과 사용약제의비급여사용을위해서는범주 2 이상의근거가있어야한다. 다만, 희귀질환에사용하고자하는경우에는범주 4 까지인정할수있다. 범주 1 : 무작위대조군시험을대상으로한체계적문헌고찰 (systematic review, 메타분석 ) 범주 2 : 무작위대조군시험또는 category 3 을대상으로한체계적인문헌고찰 범주 3 : 준 - 무작위대조군시험, 환자 - 대조군연구 (case control study), 코호트연구 (cohort study) 및기타관찰적분석연구 (observational, analytic study) 범주 4 : 단면조사연구 (cross-sectional study), 전 / 후비교연구 (before/after study), 증례보고 (case report), 환자군연구 (case series), 비분석적연구 (non-analytic study) * 주 : 건강보험심사평가원의료기술평가사업단 EBH 팀 근거문헌수록지침 (EBRM: Evidence Based Review Mannual) 제 2 판 2006 년 12 월 65

66 Rates of Lumbar Disc Surgery Before and After Implementation of Multidisciplinary Nonsurgical Spine Clinics Rasmussen, Claus MD; Nielsen, Gunnar Lauge MD; Hansen, Vivian Kjaer MD; Jensen, Ole Kudsk MD; Schioettz-Christensen, Berit MD, PhD Abstract Study Design. Correlation study. Objectives. To assess the rates of lumbar disc surgery in North Jutland County, Denmark, before and after implementation of two nonsurgical spine clinics, and to compare the observed rates with those for the rest of Denmark in the same time periods. Summary of Background Data. Few studies have addressed initiatives to reduce high rates of lumbar disc surgery by improving nonsurgical care offered to patients with sciatica and low back pain. Methods. The study was conducted in North Jutland County, Denmark with 500,000 inhabitants (10% of the Danish population). In 1997, two nonsurgical spine clinics were established, along with an educational program for general practitioners. The clinics targeted patients with sciatica of 1 to 3 months' duration, with or without low back pain. Data on rates of lumbar disc surgery were obtained from the National Registry Spine: of Patients. Results. The annual rate of lumbar disc operations for patients in North Jutland County decreased from approximately 60 to 80 per 100,000 before 1997 to 40 per 100,000 in 2001 (P = 0.00), and the rate of elective, first-time disc surgeries decreased by approximately two thirds (P = 0.00). In contrast, the annual rate of lumbar disc operations for patients in the rest of Denmark remained unchanged during the same period. Conclusions. The implementation of multidisciplinary, nonsurgical spine clinics coincided closely with a significant reduction in the rate of lumbar disc surgery. The observed reduction seems most likely to be causally associated with educational activities and improved patient care provided by the clinics November Volume 30 - Issue 21 - pp

67 Which surgery or How operate? Which patient? 67

68 The art of medicine consists in amusing the patient while nature cures the disease. François-Marie Arouet (21 November May 1778) Voltaire 68