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1 대한정형외과학회지 : 제 43 권제 2 호 2008 J Korean Orthop Assoc 2008; 43: 요추추간판수술과관련된정형외과와신경외과병의원홈페이지에대한비교분석 심대무ㆍ정을오ㆍ김태균 * ㆍ김정우ㆍ박진영 * ㆍ권석현ㆍ박성규ㆍ최병산 원광대학교의과대학정형외과학교실, 원광대학교병원운영군산의료원정형외과학교실 * Analysis of Homepages Relating to Lumbar Disc Surgery in Orthopaedic and Neurosurgical Hospitals Dae Moo Shim, M.D., Ul Oh Jeung, M.D., Tae Kyun Kim, M.D.*, Jeong Woo Kim, M.D., Jin Young Park, M.D.*, Seok Hyun Kweon, M.D., Seong Kyu Park, M.D., and Byong San Choi, M.D. Department of Orthopedic Surgery, Wonkwang University, School of Medicine, Iksan, Department of Orthopedic Surgery, Gunsan Medical Center of Wonkwang University*, Gunsan, Korea Purpose: This study evaluated the operability for disease of lumbar intervertebral disc (LID) of practitioners and pay doctors of orthopedic surgeons and neurosurgeons by examining their websites. Materials and Methods: From March 2006 to April 2006, we searched the internet using the key words orthopedic surgery and neurosurgery, with NAVER as the portal site. There were 68 homepages of orthopedic hospitals and physician's offices (OHP) and 27 homepages of neurosurgical hospitals and physician's offices (NHP). Each homepage was visited in order to survey the operability for disease of an intervertebral disc and the number of board of orthopedists and neurosurgeons. Statistical analysis was carried out using a chi-square test. Results: In 45.6% (31/68) of OHP and 85.2% (23/27) of NHP, the operation for LID was performed and there was significant difference (p<0.001). In 16.2% (11/68) of OHP, neurosurgeons employed by OHP performed the operation for spinal disorders. In 29.4% of OHP, the orthopedic surgeon performed the operation for LID. Orthopedists were employed in 51.9% of NHP. NHP were significantly higher than OHP in the cases in whom the orthopedists and neurosurgeons worked together in a single hospital (p<0.001). Conclusion: In 70% of OHP, surgery for LID was not performed. A survey about reasons for not performing operation for LID and improvement of that reasons should be carried out by the medical association. Key Words: Internet, Orthopedic surgery, Neurosurgery, Lumbar herniated intervertebral disc, Operation for intervertebral disc 서론퇴행성요추질환에대한수술은고령화사회, 진단영상및수술기법의발달 4,11) 로 1,000명당 1명정도의꼴로이루어지고있으며 12), 점차증가하는추세에있다 2,16). 이중추간판수술은척추영역의수술중비교적쉬운수술로가장많이시행되고있다 16). 통신저자 : 정을오전라북도익산시신용동 번지원광대학교병원정형외과 TEL: ㆍ FAX: llwind@hanmail.net * 본연구는 2008 년도원광대학교연구처연구비지원을받아이루어진것임. 이러한추간판수술의대부분은정형외과와신경외과영역에서시행되고있으며, 이에대한교육또한두영역에서이루어지고있어, 두과의의사들은추간판질환을진단하고수술하는데있어서비슷한능력을가지고있을것으로예상되나, 보편적으로는신경외과의사들이척추수술에대해보다편하게느끼고있다고인식되어있다 15). Address reprint requests to Ul Oh Jeung, M.D. Department of Orthopedic Surgery, Wonkwang University Hospital, 344-2, Shinyong-dong, Iksan , Korea Tel: , Fax: llwind@hanmail.net 166

2 요추추간판수술과관련된정형외과와신경외과병의원홈페이지에대한비교분석 167 이러한점을증명하는보고는매우드문편으로, Dvorak 등 5) 만이설문조사를통하여정형외과수련의와신경외과수련의중, 척추분야에대한수련기간이보다긴신경외과수련의가척추수술에대해자기신뢰도 (selfconfidences) 가높음을언급하여증명한바있다. 신경외과의사들이추간판수술에대해자기신뢰도가높고편안하게생각한다면, 정형외과의사들에비해추간판수술을많이시행할것으로예상되지만, 전문의자격의취득한후, 개원을하거나봉직의로근무하는경우에, 추간판수술의시행정도에대해어떻게차이가나타나는지를보고하는연구는찾을수없었다. 이에많은수의병의원들이홍보의매체로서활용하고있으며 1), 초고속인터넷망을구축하여접근성용이해진웹사이트를이용하여, 두과간에요추추간판수술시행여부에대한차이가어떻게나타나는지를알아보고자하였다. 대한차이가있는지는 Fisher's exact test를이용하여알아보았다. 추간판수술의시행여부는각병의원의홈페이지내의의료진소개에서척추질환수술전문등의소개가있거나, 병의원에서시행하는시술에대한소개에서추간판수술대한상세한수술방법이소개되어있는경우는추간판수술을시행하는것으로분류하였으며, 진료분야에척추질환에대한내용이없고, 의료진소개에서도척추질환에대한전문의가없고, 병의원에서시행하는시술에서도추간판수술에대한내용이없는경우와, 병의원내에수술실이없는경우는추간판수술을시행하지않는것으로분류하였으며, 홈페이지상으로추간판수술시행여부를판단하기어려웠던 38개에대해서는직접전화를하여추간판수술시행여부를분류하였다. 각병의원의정형외과, 신경외과전문의현황은홈페이 대상및방법 2006년 3월부터 4월까지국내에서가장많이사용하고있는포털사이트인네이버 ( 에서, 정형외과와신경외과를검색어로하여검색하였다. 정형외과로검색된홈페이지는총 272개였으며, 신경외과로검색된홈페이지는총 182 개였다. 이중학회, 개인홈페이지, 대학병원, 수련병원, 종합병원의홈페이지및병의원이아닌홈페이지, 폐쇄된홈페이지는제외하였으며, 정형외과전문의가가장많은곳은정형외과병의원으로신경외과전문의가가장많은곳은신경외과병의원으로분류하였다. 정형외과병의원에서제작한홈페이지는 68개였으며, 신경외과병의원에서제작한홈페이지는 27개로, 총 95 개의홈페이지를직접방문하여요추추간판탈출증에대한정보의질, 요추추간판수술의시행여부및전문의현황에대해조사하였다. 병의원홈페이지에서제공하는요추추간판탈출증에대한정보를 United States Department of Health and Human Service 에서제시한 Information Quality Score (IQS) (Table 1) 의 25개기준유무에따라평가하여 20점이상은 " 상 ", 10~19점은 " 중 ", 9점이하는 " 하 " 로구분하였으며, 정형외과병의원의홈페이지와신경외과병의원의홈페이지에서제공하는정보의질점수에차이가있는지는 Student's t-test를, 정보의제공여부에 Table 1. Criteria of the Informational Quality Score according to the United States Department of Health and Human Services I. Disease summary 1. Neural anatomy/disc anatomy 2. Risk factors (at least 2 mentioned) 3. Symptoms: weakness 4. Symptoms: sciatica (leg pain) 5. Symptoms: numbness/tingling 6. Signs: reflex deficit 7. Signs: nerve root tension signs 8. Signs: sensation or motor deficit 9. Diagnostic studies (MRI, CT myelo, or EMG/DCS) II. Pathogenesis 10. Disc dehydration/degeneration 11. Annular disruption 12. Herniation of nucleus pulposus 13. Nerve root compression/inflammation III. Treatment options 14. Bed rest/activity modification 15. Exercise therapy 16. Pharmacologic treatment 17. Modalities (ice/heat/e-stim, etc) 18. Corticosteroid epidural injection 19. Chemonucleolysis 20. Physical treatment (chiro, traction, acupuncture) 21. Surgery IV. Complications/Results 22. Results: non-operative treatment 23. Results: operative treatment 24. Complications: non-operative treatment 25. Complications: operative treatment MRI, magnetic resonance imaging; CT, computed tomography; myelo, myelogram; EMG/NCS, electromyography/nerve conduction study; e-stim, electrical stimulation; chiro, chiropractor.

3 168 심대무ㆍ정을오ㆍ김태균외 5 인 지내의의료진소개에서조사하였으며, 추간판수술시행여부와전문의현황은 chi-square test 를이용하여비교하였다. 결과 68개의정형외과병의원의홈페이지중 17.6% (12/ 68) 에서는요추추간판탈출증에대한정보를제공하고있지않았으며, " 상 " 의질을보인홈페이지는없었고, " 중 " 의질을보인홈페이지는 42.6% (29/68), " 하 " 의질을보인홈페이지는 39.7% (27/68) 였다. 27개의신경외과병의원의홈페이지중 3.7% (1/27) 는 " 상 " 의질을, 59.3% (16/27) 는 " 중 " 의질을, 37% (10/27) 는 " 하 " 의질을보였다. 요추추간판탈출증에대해정보를제공하고있는정형외과와신경외과병의원홈페이지의정보의질평균점수는각각 9.44 (±4.7) 점, (±5.2) 점으로의의있는차이를보이지는않았으나 (p=0.304), 정보의제공여부는정형외과홈페이지는 68개중 12개에서정보를제공하고있지않아 27개모두에서정보를제공하고있는신경외과홈페이지와의의있는차이를보였다 (p=0.017) (Table 2). 추간판수술을시행하는정형외과병의원은 45.6% (31/68) 였지만, 11곳은신경외과전문의가추간판수술을담당하고있어실제정형외과전문의가추간판수술을시행하는정형외과병의원은 29.4% (20/68) 였다. 신경외과병의원중에서는 85.2% (23/27) 가추간판수술을시행하고있어, 추간판수술의시행여부는신경외과병의원에서의의있게높았다 (p<0.001)(table 2). 정형외과병의원의 16.2% (11/68) 에서신경외과전문 의가근무하고있었으며, 모두척추질환의진료및수술을담당하고있었다. 신경외과병의원중정형외과전문의가근무하는병의원은 51.9% (14/27) 로모두사지의질환및외상을담당하는정형외과전문의로, 정형외과와신경외과전문의가동시에근무하는경우는신경외과병의원이의의있게많았다 (p<0.001)(table 2). 고찰추간판탈출증은근골격계질환으로 4일이상입원한환자중가장많은원인을차지하고있으며 8), 또한추간판수술은증가하고있는척추영역의수술중가장많이시행되고있는수술로 2,16), 정형외과와신경외과간에우선권에대한논란이있긴하지만 3,7,13,14), 두영역모두에서수련이이루어지고있으며, 대부분의수술이두과에서이루어지고있다. 그렇지만, 실제수술에대해서는신경외과의사가정형외과의사보다편하게느끼고있으며 15), 이러한차이를잘보여줬던 Dvorak 등 5) 의보고에따르면척추외과분야에대한수련기간이정형외과수련의보다긴신경외과수련의가척추질환및외상에대한수술적치료에대한자기신뢰도가의의있게높은것으로나타나있다. 신경외과의사들이추간판수술에대해자기신뢰도가높고, 편안하게생각한다면, 정형외과의사들에비해추간판수술을많이시행할것으로예상되어, 개원을하거나봉직의로근무하는경우에추간판수술의시행정도에대해어떻게차이가나타나는지, 척추영역의수술중가장많이시행되고있는추간판수술의시행여부를가지고알아보았던본보고에서도신경외과병의원은 85.2% 에 Table 2. Comparison between Orthopedic and Neurosurgical Hospitals and Physician's Offices OHP (n=68) NHP (n=27) p-value Ho that provided information about HIVD 56 (82.4%) 27 (100%) Mean IQS (±SD) 9.44 (±4.7) (±5.2) High quality 0 (0%) 1 (3.7%) Middle quality 29 (42.6%) 16 (59.3%) Low quality 27 (39.7%) 10 (37%) Ho that provided no information about HIVD 12 (17.6%) 0 (0%) Ho in which operation for lumbar intervertebral disc were performed 31 (45.6%) 23 (85.2%) <0.001 Ho in which doctors of both disciplines worked together 11 (16.2%) 14 (51.9%) <0.001 OHP, orthopedic hospitals and physician's offices; NHP, neurosurgical hospitals and physician's offices; Ho, hospitals; HIVD, herniatied intervetebral disc; IQS, information quality score; SD, standard deviation.

4 요추추간판수술과관련된정형외과와신경외과병의원홈페이지에대한비교분석 169 서추간판수술을시행하고있었던반면, 정형외과병의원은절반에도못미치는 45.6% 였으며, 이중 16.2% 는신경외과전문의가추간판수술을담당하고있기때문에실제로는 29.4% 만이정형외과전문의가추간판수술을시행하고있어신경외과병의원과는저명한차이를보였다. 물론수련과정의초점이정형외과는근골격계이고, 신경외과는신경계로서로다르기때문에표본의편중 (selection bias) 에의한영향도고려해야하겠지만, 정확한평가는어려울것으로생각된다. 본보고에서추간판수술시행여부에대한정보를인터넷에서얻었는데, 물론보험공단의자료에서얻었다면보다객관성있는정보가되었을것으로생각한다. 하지만, 보험공단의자료를이용하는경우에는정형외과혹은신경외과전문의가추간판수술을할수있음에도불구하고, 환자가없거나, 경영상의이유등으로수술을하지못하고있는경우및간간히추간판수술을시행하는경우에는누락될수있는문제가있다. 인터넷을이용하는경우에는다소객관성이떨어지고추간판수술을시행할수있는능력이없음에도수술종류나, 수술방법을인터넷상에상세히작성하여, 수술을할수있는것으로분류될수있는단점이있다. 하지만, 정형외과혹은신경외과전문의가현시점에서본인스스로추간판수술을할수있는능력이있다고생각하는지, 없다고생각하는지를조사하기에는, 실제적으로추간판수술을했느냐, 하지않았느냐만을반영하는보험공단의자료보다는, 의사본인스스로가추간판수술을할수있다고생각하는지를반영할수있는인터넷상의자료가보다유용하다고생각되어, 인터넷을이용하게되었다. 정형외과와신경외과사이에서나타난추간판수술시행여부에대한극명한차이의원인은수련과정의초점이정형외과는근골격계질환, 신경외과는뇌척수질환으로다르다는점과 Dvorak 등 5) 이보고하였던척추분야에대한수련시간의차이에서비롯되는자기신뢰도의차이때문등으로생각된다. 또한, Vaccaro 15) 가보고한보험의형태도영향을미치는것으로생각된다. 특히우리나라처럼수술의위험도에대한고려가없는보험정책하 9) 에서, 정형외과영역에서의척추외과분야는다른분야에비해위험성이높아심리적부담감이큰반면, 신경외과영역에서는두부영역에비해상대적으로척추외과가위험성이낮아심리적부담감이적은것도이러한현상에 상당부분기여할것으로생각된다. 신경외과전문의가근무하고있는정형외과병의원은 16.2% 였던반면, 정형외과전문의가근무하고있는신경외과병의원은 51.9% 로의의있는차이를보이고있었다. 이는고령화사회에서환자들은척추이외의사지에다양한질환을동반하게되고 10), 이에따라사지와척추를전공한정형외과전문의보다는척추와두부를전공으로한신경외과전문의가상대과의필요성을훨씬크게느끼는것으로생각된다. 요추추간판탈출증에대해정보를제공하고있는정형외과, 신경외과병의원홈페이지의정보의질점수평균은각각 9.44 점, 10.63점으로의의있는차이를보이지않았으며, Greene 등 6) 의보고와비슷한정도로낮은점수를보였다. 하지만, 주목할점은 27개신경외과병의원의홈페이지는모두요추추간판탈출증에대해정보를제공하고있었으나, 정형외과병의원의홈페이지중 17.6% 는아예추간판탈출증에대해정보를제공하고있지않아의의있는차이를보였다는점이다. 물론, 홈페이지상에모든질환에대한정보를상세히제공할수는없겠지만, 요추추간판탈출증은근골격계질환으로 4일이상입원한환자중가장많은원인이되는질환이며 8), 척추질환중가장대표적질환으로정형외과전문의라면, 수술은시행하지않더라도관심과주의는기울여야하는질환으로여겨진다. 하지만이러한결과를보였다는것은추간판수술과마찬가지로정형외과병의원은요추추간판탈출증에대해신경외과보다주의와관심을덜기울이고있다는것으로생각된다. 결론인터넷을이용한조사상에서정형외과병의원은 29.4% 만이정형외과전문의가추간판수술을시행하고있으며, 17.6% 에서는추간판절제술에대한정보를제공하고있지않아, 신경외과병의원과의의있는차이를보였으며, 정형외과와신경외과의상대과에대한필요성은신경외과가의의있게높은것으로나타났다. 향후학회차원에서요추추간판탈출증에대해관심이떨어지는이유와, 추간판수술을잘시행하지않는이유에대해조사를시행하고, 이에대한개선이필요할것으로사료된다.

5 170 심대무ㆍ정을오ㆍ김태균외 5 인 참고문헌 1. Chun BC: E-health and internet in medicine: a strategic perspective. J Korean Med Assoc, 45: 4-16, Ciol MA, Deyo RA, Howell E, Kreif S: An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc, 44: , Couldwell WT, Rovit RL: Rethinking neurosurgical subspecialization. Surg Neurol, 58: , Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA: Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis and procedure. J Bone Joint Surg Am, 74: , Dvorak MF, Collins JB, Murnaghan L, et al: Confidence in spine training among senior neurosurgical and orthopedic residents. Spine, 31: , Greene DL, Appel AJ, Reinert SE, Palumbo MA: Lumbar disc herniation: evaluation of information on the internet. Spine, 30: , Hurlbert RJ: The growing pains of spinal surgery. Can J Neurol Sci, 31: 139, Jeong BG, Kim JY, Hong YS, et al: An analysis of the length of admission for some musculoskeletal disorders among the national health insurance corporation data. J Korean Orthop Assoc, 41: , Jeong ST: The proposals for improving and problems of Korean national health insurance system reviewed by orthopaedic surgeon -1st part: focus on general guide line and the cost of operation-. J Korean Orthop Assoc, 40: , Kadam UT, Jordan K, Croft PR: Clinical comorbidity in patients with osteoarthritis: a case-control study of general practice consulters in England and Wales. Ann Rheum Dis, 63: , Katz JN: Lumbar spinal fusion: surgical rates, costs and complications. Spine, 20(Suppl): S78-S83, Katz JN, Lipson SJ, Larson MG, McInnes JM, Fossel AH, Liang MH: The outcome of decompressive laminectomy for degenerative lumbar stenosis. J Bone Joint Surg Am, 73: , Koenig GH: Have neurosurgeons lost their chance to operate on spine problems? Surg Neurol, 46: 103, Ray CD: Clinical neurosurgery as it relates to the lumbar spine: what it does versus what it says. Neurosurgery, 29: , Vaccaro AR: Point of view: confidence in spine training among senior neurosurgical and orthopedic residents. Spine, 31: 838, Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES: United states' trends and regional variations in lumbar spine surgery: Spine, 31: , = 국문초록 = 목적 : 정형외과와신경외과의개원의및봉직의를중심으로, 요추추간판수술시행여부에대한차이가어떻게나타나는지를웹사이트를이용하여알아보고자하였다. 대상및방법 : 2006 년 3 월부터 4 월까지포털사이트인네이버에서, 정형외과와신경외과를검색어로하여검색하였다. 검색된 68 개정형외과병의원과 27 개신경외과병의원홈페이지를직접방문하여추간판수술시행여부와병의원에근무하고있는정형외과및신경외과전문의수에대해조사하였으며, 통계학적검증은 chi-square test 를이용하였다. 결과 : 추간판수술을시행하는정형외과병의원은 45.6% (31/68) 였으며, 신경외과병의원은 85.2% (23/27) 로, 의의있는차이를보였다 (p<0.001). 정형외과병의원중 16.2% (11/68) 는척추질환수술을시행하는신경외과전문의가근무하고있어, 실제정형외과전문의가추간판수술을시행하는병의원은 29.4% (20/68) 였다. 정형외과전문의가근무하는신경외과병의원은 51.9% (14/27) 로, 정형외과와신경외과전문의가동시에근무하는경우는신경외과병의원이의의있게많았다 (p<0.001). 결론 : 정형외과병의원의 70% 가추간판수술을시행하고있지않았으며, 향후학회차원에서추간판수술을잘시행하지않는이유에대한조사및이에대한개선이필요할것으로사료된다. 색인단어 : 인터넷, 정형외과, 신경외과, 요추추간판탈출증, 추간판수술

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