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1 대한정형외과학회지 : 제 44 권제 1 호 2009 J Korean Orthop Assoc 2009; 44: 추궁하감압술에의한최소침습적일측성경추간공요추추체간유합술 - 양측성접근법과의비교 - 민상혁ㆍ황성수 단국대학교의과대학정형외과학교실 Minimal Invasive Transforaminal Lumbar Interbody Fusion by Sublaminar Decompression - Comparison to Approach - Sang-Hyuk Min, M.D., and Sung-Su Hwang, M.D. Department of Orthopeadic Surgery, Dankook University College of Medicine, Cheonan, Korea Purpose: This is a comparison of the unilateral and bilateral es for minimal invasive transforaminal lumbar interbody fusion (TLIF), and we did so by measuring the clinical and radiological results. Materials and Methods: This study examined a consecutive series of 47 patients who underwent one-level TLIF (26 cases of the unilateral and 21 cases of the bilateral to the lumbar spine) and the follow-up data was compared with a minimum 1-year follow-up. Sublaminar decompression and contralateral foraminectomy were done in all the case of using the unilateral. The age of each patient, the amount of intraoperative blood loss, the postoperative drainage, the transfusion requirement and the surgery time were investigated. The clinical outcomes were analyzed using the visual analogue scale, the SF-36 Physical Composite Score (PCS) and the Oswestry disability index (ODI). The preoperative, postoperative & last follow-up changes in the height and angles of the disc in the fused segments and the lumbar lordotic angles were radiologically analyzed. Results: There was no statistical difference between the two s in terms of the clinical and radiographic results at the last follow-up. But the unilateral - was found to have a less blood loss, less postoperative drainage, a lesser requirement for transfusion and a shorter surgery time. Conclusion: This study confirms that the unilateral can be the better way if the technical problems are solved. Key Words:, Sublaminar decompression, Transforaminal lumbar interbody fusion 서론최근다양한척추질환의치료법으로전통적인후방도달법에의한연부조직손상및근위축등의단점을보완하기위해서최소침습적수술접근법을이용한신경감압술및추체간유합술에대한다양한논문들이보고되고있다 2-6,10). 이중최소침습적인경추간공요추추체간유합술은수술후요통이나근위축등의합병증을최소화하 통신저자 : 민상혁충남천안시안서동 16-5 단국대학교의과대학정형외과학교실 TEL: ㆍ FAX: osmin71@naver.com 고, 실혈량을줄일수있는장점이있다고하였으나전통적인후방도달법에비해수술시간이더걸리는단점이있다고하였다 13). 본연구는최소침습적경추간공요추추체간유합술시두개의정중방 (para median) 피부절개를통한양측성접근법과한개의정중방피부절개를통해추궁하감압술및반대측의신경공감압술을시행한일측성접근법의 Address reprint requests to Sang-Hyuk Min, M.D. Department of Orthopaedic Surgery, Dankook University Medical Center, 16-5, Anseo-dong, Cheonan , Korea Tel: , Fax: osmin71@naver.com 76

2 추궁하감압술에의한최소침습적일측성경추간공요추추체간유합술 77 임상결과와방사선학적결과에대해비교분석하고자하였다. 대상및방법 1. 연구대상및방법 2005년 3월부터 2007년 1월까지본원에서한명의술자에의해최소침습적경추간공요추추체간유합술을시행받은 76명의환자중척추관협착증으로단일분절유합술후최소 1년이상추시관찰이가능하였던 47예 ( 일측성접근법 26예와양측성접근법 21예 ) 를대상으로연구를시행하였다. 모든예에서협착증을동반한퇴행성요추질환으로양측성증상인경우만을대상으로하였으며, 척추전방전위증의예는대상에서제외하였다. 또한, 단분절의유합술후상하분절에대한감압술또는추간판제거술등을추가적으로시행한예는모두대상에서제외하였다. 일측성접근법은추궁하감압술및반대측의신경공감압술을포함하여시행한예를적용하였다. 일측성접근법과양측성접근법의선택은무작위적으로이루어졌으나일측성접근법으로시행한 2예에서수술중추체간기구 (shaver) 를이용하여추체간격을순차적으로신연시키는과정에서유연성이없이만족스러운추체높이를얻기어렵다고판단되어양측성접근법으로전환하였다. 그이외에는접근법의선택에있어서다른기준은없었다. 일측성접근법에서유합술을시행한방향은수술전임상증상이심한부위로하였으며, 임상증상이유사한경우는방사선검사상협착이심한부위를택하였다. 경추간공요추추체간유합술시전방지지를위하여모든예에서 cage 를사용하였으며, 유합에사용된골은후궁절제술시얻어진골을모든예에서이용하였으며, 부족시후상방장골극에서약 1 cm 크기의절개를통한골채취를시행하였다. 환자나이, 실혈량, 수술후배액량, 수혈량, 수술시간을조사하였고, 임상적결과는시각통증등급 (visual analogue scale), SF-36 의신체요소종합점수 (physical composite score), Oswestry 장애지수 (disability index) 를이용하여평가하였다. 방사선학적으로는수술전후및최종추시관찰시측정한추간판높이와추간판각의변화, 요추전만도를각각조사하였다. 환자의평균나이및추시기간은, 일측성접근군의 경우 세 (32 69세) 와 개월 (12-27 개월 ), 양측성접근군의경우는 세 (30-77세) 와 개월 (12-27개월) 이었다. 성별은일측성접근군의경우남자가 10명, 여자가 16명이었으며, 양측성접근군의경우남자가 11명, 여자가 10명이었다. 2. 방사선학적분석및임상적평가방사선학적분석은방사선과전문의 1인과정형외과전문의 1인이각각 2회씩측정한값의평균값을그측정값으로하였으며, 유합술과수술전후및최종추시관찰시측정한추간판높이와추간판각의변화그리고요추전만도를각각수술적접근법에따라나누어조사하였다. 추간판높이는유합술을시행한분절의상하골단판을잇는직선을긋고, 골단판의중심을서로연결하는수선의길이로측정하였으며, 추간판각은이들상하골단판이이루는각도로측정하였다. 요추전만도의경우요추 1번과천추 1번의상위골단판이이루는각도를측정하였다. 임상적결과의판정은 SF-36 의신체요소종합점수와 Oswestry 장애지수, 그리고시각통증등급을이용하여평가하였으며시각통증등급은요통과방사통을나누어비교하였다. 마취기록에의거하여수술중실혈량과수술시간을조사하였고, 수혈량과수술후배액량도수술적접근법에따라각각조사하였다. 통계학적유의성검증은 student t-test를이용하였으며 SF-36 의신체요소종합점수와 Oswestry 장애지수, 그리고시각통증등급의임상적평가요소는 Mann-Whitney 검정을시행하였다 (SPSS Ver. 12.0). 3. 수술방법양측성접근법의경우중앙에서약 2.5 cm 떨어진부위에두개의 2.5 cm 길이의정중방피부절개를가하고, 다열근과최장근을분리하여근육사이로접근하여추궁판과후관절까지도달하였으며, 후관절이노출되면미세척추견인기를걸고수술용미세현미경하에아래관절돌기및위관절돌기의상부반을잘라내고황색인대를제거하여상부척추경을돌아빠져나가는신경근과척추관내경막을노출시킨후추간판제거술을시행하였다 (Fig. 1). 다음으로추체간기구를이용하여순차적으로추체간격을신연시키고, 유합할상하요추종판을소파하여준비한후, 감압술시얻은자가골및자가채취골을이용하

78 민상혁ㆍ황성수 Fig. 1. The clinical photograph showing paramedian skin incision 2.5 cm from midline before surgery. Fig. 3.

A: The arrow indicates decompressed thecal sac by sublaminar decompression. B: The arrow indicates decompressed traversing root by contralateral foraminectomy. Fig. 2.

일측성접근법의경우일측에서추궁하감압술및반대측신경공감압술을시행하였다. 환자를술자반대쪽으로기울인후미세현미경하에고속드릴 (Anspach R ) 을이용하여신경감압이충분히된것을확인한후에일측에서두개의 cage 를삽입하고경피적척추경나사못고정술을시행하였다 (Fig. 2-4). 결과 1. 임상적결과및평가수술중실혈량및수술시간은일측성접근군은평균 315.2 cc와 134.

3 78 민상혁ㆍ황성수 Fig. 1. The clinical photograph showing paramedian skin incision 2.5 cm from midline before surgery. Fig. 3. Postoperative gross finding showing complete decompression spinal canal and foramen by sublaminar decompression & contralateral foraminectomy. A: The arrow indicates decompressed thecal sac by sublaminar decompression. B: The arrow indicates decompressed traversing root by contralateral foraminectomy. Fig. 2. Tilting patient against the operator makes it easy to during operation. 여 cage 를채운후추체사이에삽입하였다. 반대측또한동일한방법으로시행한후경피적척추경나사못으로고정술 (percutaneous pedicle screw fixation) 을시행하였다. 일측성접근법의경우일측에서추궁하감압술및반대측신경공감압술을시행하였다. 환자를술자반대쪽으로기울인후미세현미경하에고속드릴 (Anspach R ) 을이용하여신경감압이충분히된것을확인한후에일측에서두개의 cage 를삽입하고경피적척추경나사못고정술을시행하였다 (Fig. 2-4). 결과 1. 임상적결과및평가수술중실혈량및수술시간은일측성접근군은평균 cc와 134.7분, 양측성접근군은 cc와 176.2분으로실혈량및수술시간모두통계학적으로유의한차이를보였다 (p=0.03, <0.001). 수혈량은일측성접근법에의한경추간공요추추체간유합술시행군은 26예중 5예에서총 10 pints 를수혈받아평균 0.38 pint 였으며, 양측성접근법을시행한군에서는 21예중 11예에서총 27 pints를수혈받아수혈량은평균 1.29 pints 였다. 일측성접근군에서양측성접근군보다통계학적으로유의하게적은수혈량을보였다 (p=0.028). 수술후배액량은일측성접근군은평균 cc였고, 양측성접근군에서는 cc로일측성접근군에서통계학적으로유의하게적은배액량을보였다 (p< 0.001)(Table 1). 임상적평가는요통및방사통의시각통증등급, SF-36 의신체요소종합점수, Oswestry 장애지수를수술전, 수술후 2주, 6주, 6개월, 최종추시에각각측정하여비교한결과통계적으로유의한차이를보이지않았다 (Table 2-4). 일측성접근군및양측성접근군의입원기간은각각평균 7.04 일, 9.24일로측정되었으며 47예모두에서수술한다음날보행이가능하였다.

Perioperative Data of the Two Groups Variables Average intraoperative blood loss (cc) 315.19 422.38 0.03 Average postoperative drainage (cc) 122.08 330.43 <0.

4 추궁하감압술에의한최소침습적일측성경추간공요추추체간유합술 79 Fig. 4. (A) Preoperative CT film of a 50-year-old female patient. (B) Postoperative CT fim showing complete decompression of spinal canal and foramen by sublaminar decompression & contralateral for a- minectomy, comparing with preoperative one. Table 1. Perioperative Data of the Two Groups Variables Average intraoperative blood loss (cc) Average postoperative drainage (cc) <0.001 Average total blood replacement (pint) Average surgical time (minute) < 방사선학적결과추간판높이는일측성접근군에서는수술전평균 mm에서수술후 mm로증가하였고최종추시에서는 mm 로감소하였다. 양측성접근군에서는수술전평균 mm 에서수술후 mm 로증가하였고최종추시에서는 11.9 mm 로감소하였다. 수술전, 수술후, 최종추시시각군사이에통계학적으로유의한차이는없었다. 추간판각은일측성접근군에서는수술전평균 7.23 o 에서수술후 9.12 o 로증가하였고최종추시에서는 8.54 o 로감소하였다. 양측성접근군에서는수술전평균 6.67 o 에서수술후 9.33 o 로증가하였고최종추시에서는 9.05 o 로감소하였다. 수술전, 수술후, 최종추시시각군사이에통계학적으로유의한차이는없었다. 요추전만도는일측성접근군에서는수술전평균 o 에서수술후 o 로증가하였고최종추시에서는 o 였다. 양측성접근군에서는수술전평균 o 에서수술후 o 로증가하였고최종추시에서는 o 였다. 수술전, 수술후, 최종추시시각군사이에통계학적으로유의한차이는없었다 (Table 5). Table 2. VAS between Two Groups with the Last Follow up VAS VAS (Back pain) Preoperative score Postoperative 2 wks Postoperative 6 wks Postoperative 6 months Last follow-up VAS (Radiating pain) Preoperative score Postoperative 2 wks Postoperative 6 wks Postoperative 6 months Last follow-up 합병증일측성접근군및양측성접근군에서각각일시적인하지감각저하가 1예에서관찰되었다. 그외경막손상및불유합등의합병증은발생하지않았다.

5 80 민상혁ㆍ황성수 Table 3. ODI (Oswestry Disability Index) between Two Groups with the Last Follow up Preoperative score Postoperative 2 wks Postoperative 6 wks Postoperative 6 months Last follow-up Table 4. SF-36 Physical Composite Score between Two Groups with the Last Follow up Preoperative score Postoperative 2 wks Postoperative 6 wks Postoperative 6 months Last follow-up 고찰퇴행성요추질환의치료로널리사용되고있는전통적인후방요추추체간유합술은그도달법으로발생하는연부조직손상및주변근육통이과도한견인에의해후방근육의위축등의문제점과추간판에도달하여 cage나골을삽입할적절한공간을확보하기위하여양측성으로접근해야하고때때로경막및신경근을과도하게견인하여이에따른문제점을야기할수있는단점이있다 1,8,9,12,14,16,18). 경추간공요추추체간유합술은정중방피부절개를통해다열근과최장근사이를분리하여근육사이로접근함으로써연부조직및주변근육의손상을최소화하고과도한견인에따른신경근손상및마미손상을줄이고자추간공의외측으로추간판에도달하여추체간유합술을시행하는술식으로충분한공간확보가가능하므로일측성으로추체간유합술이가능하며, 이에따라연부조직손상을최소화할수있는장점이있다. 또한요추에가해지는생역학적변화가상대적으로적어수술후통증관리및회복이유리한장점이있다 4,6,15). 저자들은최소침습적경추간공요추추체간유합술시일측성접근법이양측성접근법에비해수술로인한요추부손상이적을것으로 Table 5. Radiographic Outcomes between the Two Groups with the Last Follow up Radiographic outcomes Mean disc space heights (mm) Preoperative Postoperative Last follow-up Mean disc angle Preoperative Postoperative Last follow-up Mean lumbar lordotic angle Preoperative Postoperative Last follow-up 가정하고수술접근법에따라비교분석하였다. 본연구에서양측성접근법에비해일측성접근법에의한신경감압술및추체간유합술시출혈량을줄일수있었으며, 이는경막외정맥울혈이심한환자에게서더욱효과적일것으로생각한다. Gejo 등 1) 에따르면후방요추추체간유합술을시행받은 20명의환자에대한술후 trunk muscle performance 변화를관찰한연구에서다열근손상이가장심하였으며수술시간이길수록근회복시간이오래걸렸다고하였다. 본연구에서일측성접근군과양측성접근군의평균수술시간은각각 135분과 176분으로일측성접근군이양측성접근군에비해수술시간이짧았으며, 이는오랜수술시간에따른근육의손상을최소화하는데도움이될것으로생각한다. 본연구에서술전일측성접근법으로계획하였던 2예에서수술중추체간격을순차적으로신연시키는과정에서유연성이없어만족스러운추체높이를얻기어려워결과적으로간접적신경감압 (indirect decompression) 에의한반대측의추간공감압효과가충분치않다고판단되어양측성접근법으로전환한예를볼때, 일측성으로시행한다른예와비교하여술전방사선사진상후관절의퇴행성정도및척추관협착의정도에명백한차이는발견할수없었으나반대측돌기관절절제술 (facetectomy) 시행후만족할만한추체높이를얻을수있

6 추궁하감압술에의한최소침습적일측성경추간공요추추체간유합술 81 는점으로미루어후관절의퇴행성정도가유연성정도와관계가있고, 일측성접근법을시행함에있어중요한변수로작용할것으로생각된다. 또한, 본연구에서저자의경험상불충분한신경감압, 경막및반대측의신경손상의기술적합병증의예는없었으나상기합병증을예방하기위해본저자들은추궁하감압술시황색인대를보존한상태에서 diamond burr 를이용하여충분한골절제를시행한후순차적으로황색인대를제거하였다. 이처럼황색인대를방어막으로이용하여신경감압을시행한다면일측성접근법의어려운술기에서기술적합병증을줄일수있을것으로생각된다. 본연구에서임상적평가의지표로사용된요통및방사통의시각통증등급, SF-36 의신체요소종합점수, Oswestry 장애지수는각각임상적평가의지표로서여러장단점을가지고있지만, 이미여러논문에서임상적평가의지표로사용된바있어이를적용하였으며 7,11,17), 세지표모두에서두실험군이모두통계적으로유의한차이가없다는결론을얻었다. 본연구는대상규모가작고추시기간이짧은한계점이있으나최소침습적경추간공요추추체간유합술을시행한환자를대상으로일측성및양측성접근법에따른결과의비교, 분석을시도한첫연구라는데의의가있다. 결론일측성접근법시미세현미경을이용한추궁하감압술및반대측신경공감압술에대한수술술기를습득하는데시간을필요로하지만, 수술술기가익숙해진다면양측성접근법에비해수술시간을단축시키고실혈량도줄일수있을것으로생각한다. 참고문헌 1. Gejo R, Matsui H, Kawaguchi Y, Ishihara H, Tsuji H: Serial changes in trunk muscle performance after posterior lumbar surgery. Spine, 24: , Guiot BH, Khoo LT, Fessler RG: A minimally invasive technique for decompression of the lumbar spine. Spine, 27: , Foley KT, Gupta SK: Percutaneous pedicle screw fixation of the lumbar spine: preliminary clinical results. J Neurosurg, 97(Suppl 1): S7-S12, Foley KT, Lefkowitz MA: Advances in minimally invasive spine surgery. Clin Neurosurg, 49: , Foley KT, Smith MM, Rampersaud YR: Microendoscopic to far-lateral lumbar disc herniation. Neurosurg Focus, 15: 7(5):e5, Foley KT, Holly LT, Schwender JD: Minimally invasive lumbar fusion. Spine, 28(Suppl 15): S26-S35, Glassman S, Gornet MF, Branch C, et al: MOS short form 36 and oswestry disability index outcomes in lumbar fusion: a multicenter experience. Spine J, 6: 21-26, Kawaguchi Y, Matsui H, Tsuji H: Back muscle injury after posterior lumbar spine surgery. A histologic and enzymatic analysis. Spine, 21: , Kawaguchi Y, Matsui H, Tsuji H: Back muscle injury after posterior lumbar spine surgery. Part 2: histologic and histochemical analyses in humans. Spine, 19: , Khoo LT, Palmer S, Laich DT, Fesseler RG: Minimally invasive percutaneous posterior lumbar interbody fusion. Neurosurgery, 51(Suppl 1): S166-S181, Lee SH, Kim DJ, Oh JH, Han HS, Lee HK, Kim HS: Evaluation of functional outcomes and quality of life assessments in patients with malignant tumors of the musculoskeletal system. J Korean Orthop Assoc, 36: , Mayer TG, Vanharanta H, Gatchel RJ, et al: Comparison of CT scan muscle measurements and isokinetic trunk strength in postoperative patients. Spine, 14: 33-36, Park Y, Ha JW, Sung SY, Oh HC, Yoo JH, Lee YT: Minimally invasive posterior lumbar interbody fusion: comparison with traditional open surgery. J Korean Orthop Assoc, 41: , Rantanen J, Hurme M, Falck B, et al: The lumbar multifidus muscle five years after surgery for a lumbar intervertebral disc herniation. Spine, 18: , Schwender JD, Holly LT, Rouben DP, Foley KT: Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech, 18(Suppl 1): S1-S6, Sihvonen T, Herno A, Paljärvi L, Airaksinen O, Partanen J, Tapaninaho A: Local denervation atrophy of

7 82 민상혁ㆍ황성수 paraspinal muscles in postoperative failed back syndrome. Spine, 18: , Slover J, Abdu WA, Hanscom B, Weinstein JN: The impact of comorbidities on the change in short-form 36 and oswestry scores following lumbar spine surgery. Spine, 31: , Styf JR, Willén J: The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine, 23: , = 국문초록 = 목적 : 최소침습적경추간공요추추체간유합술에서일측성접근법과양측성접근법의임상적결과와방사선학적결과를비교분석하고자하였다. 대상및방법 : 척추관협착증으로단분절의경추간공요추추체간유합술후 1 년이상의추시관찰이가능하였던 47 예 ( 일측성접근법 26 예와양측성접근법 21 예 ) 를대상으로하였다. 일측성접근법은추궁하감압술및반대측의신경공감압술을포함하여시행한예를적용하였다. 환자나이, 실혈량, 수술후배액량, 수혈량, 수술시간을조사하였고, 임상적결과는시각통증등급, SF-36 의신체요소종합점수, Oswestry 장애지수를이용하여평가하였다. 방사선학적으로는수술전후및최종추시관찰시측정한추간판높이와추간판각의변화, 요추전만도를각각조사하였다. 결과 : 술후최소 1 년추시한임상및방사선학적결과는두비교군에서통계적으로유의한차이를보이지않았으나, 일측성접근법에서양측성접근법보다출혈량, 수술후배액량, 수혈량, 수술시간이유의하게적었다 (p<0.05). 결론 : 수술술기의어려움을해결할수있다면일측성접근법은양측성접근법보다여러면에서유리한수술적방법으로생각한다. 색인단어 : 일측성접근법, 추궁하감압술, 경추간공요추추체간유합술

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untitled 대한정형외과학회지 : 제 44 권제 4 호 2009 J Korean Orthop Assoc 2009; 44: 429-435 저도전위척추전방전위증에서최소침습적경추간공요추추체간유합술 - 일측성및양측성접근법에따른비교 - 민상혁ㆍ이대희 단국대학교의과대학정형외과학교실 Minimally Invasive Transforaminal Lumbar Interbody Fusion