Journal of Korean Society of Spine Surgery ailure of Long Spinal Construct and Pseudarthrosis in a Patient with Parkinson Disease for the Treatment of

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Journal of Korean Society of Spine Surgery ailure of Long Spinal Construct and Pseudarthrosis in a Patient with Parkinson Disease for the Treatment of Degenerative Lumbar Spinal Disorder - Case

Dec;21(4):174-178. Originally published online December 31, 2014; http://dx.doi.org/10.4184/jkss.2014.21.4.174 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST.

1 Journal of Korean Society of Spine Surgery ailure of Long Spinal Construct and Pseudarthrosis in a Patient with Parkinson Disease for the Treatment of Degenerative Lumbar Spinal Disorder - Case Report Hong Kyun Kim, M.D., Hyun Woo Na, M.D., Kook Jin Chung, M.D. J Korean Soc Spine Surg 2014 Dec;21(4): Originally published online December 31, 2014; 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 2014 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 Case Report pissn eissn J Korean Soc Spine Surg Dec;21(4): Failure of Long Spinal Construct and Pseudarthrosis in a Patient with Parkinson Disease for the Treatment of Degenerative Lumbar Spinal Disorder - Case Report Hong Kyun Kim, M.D., Hyun Woo Na, M.D., Kook Jin Chung, M.D. Department of Orthopedic Surgery, Kangnam Sacred heart Hospital, College of Medicine, Hallym University, Seoul, Korea Study Design: Case report. Objective: We report a case of treated failure spinal construct and pseudarthrosis in a patient with Parkinson s disease. Summary of Literature Review: There have been no reports about revision surgery due to failure and pseuarthrosis of degenerative lumbar spine disease in patients with Parkinson s disease. Materials and Methods: A 55-year-old female who had been diagnosed with Parkinson s disease 4 years ago presented with back pain and radiating pain on both legs. Radiographic assessment showed spinal stenosis from L2 to L5 combined with degenerative spondylolisthesis at L3-4. Posterior decompression, instrumentation, and posterolateral fusion were performed and her symptoms improved. Results: Two years after the operation, she complained of severe back pain without injury. A simple X-ray showed the pull out of bilateral L5 screws, and revision surgery was performed. Three years after the revision, she underwent re-reoperation due to metal failure. The breakage of a unilateral pedicle screw at L5 was found, and her fusion level was extended to S1 with a posterior lumbar interbody fusion with cages and alar screws. Finally, she has not shown any further failure but, a sagittal imbalance and aggravation of pelvic incidence due to Parkinson s disease have been detected. Conclusions: Spine surgeons always should consider metal failure, pseudarthrosis, and aggravated spinal imbalance caused by natural history in patients with Parkinson s disease. Key Words: Parkinson disease, Failure, Spinal construct, Pseudarthrosis 파킨슨병은중추신경계의퇴행성질환으로중뇌의한영역인흑질 (subtantia nigra) 에서도파민을생성하는세포의사멸로발생하는것으로알려져있다. 파킨슨병은고령의환자에서일반적으로흔하지만대개발병은 50세이후에일어나는것으로알려져있다. 질병의초기에는운동과연관된증상으로보이게되는데진전 (tremor), 강직 (rigidity), 움직임의둔화 (slow voluntary movement) 및보행장애 (shuffling gait) 등이나타나며질병이진행될수록사고와치매로인한행동장애및우울증과같은정신적인증상이나타나게된다. Adams 등 1) 은미국내 50세이상의 1% 가파킨슨병에이환되어있다고보고하였으며우리나라는 60세이상의유병율을 1.47% 로보고한바있다. 2) 평균수명의연장으로파킨슨병환자의수가증가하며고령에서파킨슨병에이환된환자에서는비활동성 (inactivity) 및침상고정상태 (bedridden status), 골다공증이병합되어정상적인척추의노화가더 욱악화될수있다. 파킨슨병과관련한대퇴골경부골절에대한 국내연구보고는있으나 3) 파킨슨병에이환된환자의퇴행성요 추질환에서수술적치료후내고정물실패및불유합과관련된 보고가없어이를보고하고자한다. Received: August 14, 2014 Revised: October 2, 2014 Accepted: November 28, 2014 Published Online: December 31, 2014 Corresponding author: Kook Jin Chung, M.D. Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University Singilro 1, Yeongdeungpo-gu, Seoul, , Korea TEL: , FAX: chungkjmd@dreamwiz.com 174 Copyright 2014 Korean Society of Spine Surgery

Journal of Korean Society of Spine Surgery Failure of Spine surgery in Parkinson Disease patient 증례보고 55세여자환자가요통과양측하지방사통, 신경인성파행을주증상으로내원하였으며환자는 4년전부터파킨슨병으로진단받고

4) 신경학적검사에서근력및감각의저하는보이지않았으며단순방사선검사에서 2-3요추후방전위와 3-4요추간전방전위증의소견이관찰되며 (Fig. 1) MRI에서 2-3, 3-4, 4-5요추간척추관협착증의소견이관찰되었다 (Fig. 2).

환자는수술후요통과양측하지의방사통과신경인성파행의호전을보였다. 환자는수술후환 자는정상적인회복과정을보였다. 그러나수술후 1 년 6 개월에 특별한외상없이물건을줍기위해허리를숙인후심한요통이 발생하여응급실로내원하였으며방사선검사에서 5 요추에삽 Fig. 1. Preoperative simple radiographs show retrolisthesis of and spondylolisthesis of L3 on L4.

3 Journal of Korean Society of Spine Surgery Failure of Spine surgery in Parkinson Disease patient 증례보고 55세여자환자가요통과양측하지방사통, 신경인성파행을주증상으로내원하였으며환자는 4년전부터파킨슨병으로진단받고 L-도파민을경구투약중이었으며양측성이상운동증 (dyskinesia) 을보였으나체간불균형은없었으며독립적인일생생활이가능한상태였다 (Hoehn and Yahr scale 2). 4) 신경학적검사에서근력및감각의저하는보이지않았으며단순방사선검사에서 2-3요추후방전위와 3-4요추간전방전위증의소견이관찰되며 (Fig. 1) MRI에서 2-3, 3-4, 4-5요추간척추관협착증의소견이관찰되었다 (Fig. 2). 수술전혈액검사에서비타민 D 혈중농도는 15 ng/ml 였으며골밀도검사에서 T score- 4.1 로측정되었다. 환자는증상에대해경막외신경차단술을통한보존적치료를하였으나증상의호전이없어 2-3, 3-4, 4-5요추간광범위후방감압술, 기기고정술및국소자가골을이용한후측방유합술을시행하였다. 환자는수술후요통과양측하지의방사통과신경인성파행의호전을보였다. 환자는수술후환 자는정상적인회복과정을보였다. 그러나수술후 1 년 6 개월에 특별한외상없이물건을줍기위해허리를숙인후심한요통이 발생하여응급실로내원하였으며방사선검사에서 5 요추에삽 Fig. 1. Preoperative simple radiographs show retrolisthesis of and spondylolisthesis of L3 on L4. Fig. 2. Axial images of preoprative MRI show spinal stenosis at L Fig. 3. X-rays show halo (arrows) around bilateral L5 screws and loosening of L5 screws (circles) were found on dynamic study after revision. 175

2 year after revision, screw breakage of left L5 (arrow) was found and halo (circles) was found around right L5 pedicle screw. Fig. 5.

입한척추경나사의중심과 5요추의골단판이이루는각이최초수술시점과변화를보이면서척추경나사의최전방부위가척추체의중심으로이동되었으며척추경나사주변에골용해가형성된척추경나사의해리소견이관찰되었다 (Fig. 3).

4 Hong Kyun Kim et al Volume 21 Number 4 December 2014 Fig year after revision, screw breakage of left L5 (arrow) was found and halo (circles) was found around right L5 pedicle screw. Fig. 5. Re-revision was performed with posterior lumbar interbody fusion with cages at L4-5 and augmented with S1 screws and alarscrews. 입한척추경나사의중심과 5요추의골단판이이루는각이최초수술시점과변화를보이면서척추경나사의최전방부위가척추체의중심으로이동되었으며척추경나사주변에골용해가형성된척추경나사의해리소견이관찰되었다 (Fig. 3). 환자는침상안정및통증조절에도요통이호전되지않았으며통증으로보행이불가능한상태로재수술을시행받았다. 수술소견에서제 5요추양측척추경나사와제 4요추좌측척추경나사가척추로부터해리되었고 4-5요추간후측방유합술을시행하였던이식골은흡수되어불유합의소견을보였다. 이에대해해리를보인좌측 4요추척추경나사와양측 5요추척추경나사를직경이더큰나사로교체후후상장골극에서체취한자가골과동종이식골을이용하여내고정및후측방유합술을시행하였다. 환자는이후정기적인외래경과관찰에서특별한이상없었으나기저질환인파킨슨병의악화로이상운동증의정도가악화되었으며시상면불균형이생겨보행실조가악화되어투약을증량하고있는상태였다 (Hoehn and Yahr scale). 재 Fig. 6. At final follow-up after 10 year first operation, simple radiographs show sagittal imbalance. 176

5 Journal of Korean Society of Spine Surgery Failure of Spine surgery in Parkinson Disease patient 수술후 2년이경과한시점에서환자는다시갑작스러운요통이발생하였으며내원후촬영한방사선검사에서 5요추척추경나사의파단과함께고정물의해리가관찰되었다. 환자는조절되지않는요통에대해재재수술을시행하였으며수술소견에서이전불유합부위인 4-5요추간에다시골유합이되지않은소견을보였다 (Fig. 4). 이에 4-5요추간에자가골을채운 cage 를이용하여후방요추체간유합술을시행하였고 1천추나사와천추익나사삽입을통한유합범위의연장을하였다 (Fig. 5). 환자는재수술을시행한후 5년이지난현재최종수술시의고정술상태가유지되고있으나수술부위동통을호소하며최종방사선검사에서최초수술전과비교할때시상면불균형이악화되어있는소견을보이고있다 (Fig. 6). 고찰 국내역학조사를통한파킨슨병의유병율은 60세이상에서약 1.47% 인것으로보고된바있다. 2) 고령화사회현상으로노령인구의증가가지속되면서파킨슨병환자의수가증가함에따라환자들중척추수술이필요로하는경우가많아질것은분명한사실이다. 파킨슨병환자는대부분노령에서발생하며일반노인환자의특징인불량한골조직과파킨슨병으로동반된신경근육성질환으로척추수술을받을경우합병증이발생할가능성이높으며재수술의위험이높아지게된다. Babat 등 5) 은파킨슨병환자의척추수술결과를보고한연구결과에서파킨슨병환자들은생리적인척추후만 (camptocormia) 과유사한심한흉추후만과경추변형을보였다고기술하였으며 Laroche 등 6) 은연령보정대조군과비교하였을때환자들에서척추주변근육에서현저한결합조직의증가가관찰되었으며컴퓨터촬영과 MRI에서척추주변근육의국소적인위축이보였으며파킨슨병에서신경근육기능이상은척추후만환자에서보이는근육의이상과유사한효과로후만변형을유발할것이라고가정하였다. 파킨슨병환자에서근육의기능이상이변형에기여하는지의여부가확실하지는않지만많은증례에서보이는진행성후만변형은만성적인운동성질환이이들환자에서높은빈도의금속내고정물과유합의실패를가져오는것으로생각된다. 이런신경근육성척추변형에서의합병증에대해여러문헌보고가되었는데 Gau 등 7) 은후방유합술을받은신경근육성측만증환자에서 21% 는기기고정물의문제가있었으며 10% 에서불유합이있었다고보고하였으며 Bell 등 8) 은진행하는신경근육성변형에서 53% 의합병증이발생하였다고보고하였다. Banta 등 9) 은신경근육성척추측만증에대한치료를보고한 30개의연구분석에서불유합, 기기고정실패가흔하며기기고정술이된상위분절에서후만증이흔하게발생한다고보고하였다. 이런합병증 을극복하기위해서는적극적인수술이필요하게되는데 Swank 등 10) 은뇌성마비로인한척추변형에서후방기기고정술만으로치료한경우보다후방기기고정술, 유합술이외에추가적으로전방유리술을시행한경우불유합의빈도가훨씬낮았다고보고하였다. 본증례의경우파킨슨병의정도가심하지않은초기에해당하는증상만으로보여일반중년환자의척추관협착증과전방전위증으로판단하여후방감압술, 기기고정술및후측방유합술을하였다. 다행히환자가호소하는증상은수술후호전되었으나경과관찰중뚜렷한외상없이심한요통이발생하였고방사선검사결과및재수술소견에서불유합및금속고정물의실패가발생하였다. 이에대해직경이더큰척추경나사를이용하여재고정술을시행하였으며불유합이관찰된 4-5요추횡돌기간에후측방유합술만을시행하였다. 재수술후환자는파킨슨병의증상이심해져투약을증량하였으며체간의전방기울어짐이심해져독립적인보행이어려운상태로악화가되어재수술후 2년이경과한시점에서다시외상이없이기기고정물의파단과함께금속구조물의실패현상이발생하였다. 저자들은이러한일련의기기고정물의파단과불유합은비타민 D 결핍, 골다공증과함께파킨슨병으로인하여발생하는척추후만 (camptocormia) 으로인한시상면균형실조가중요한원인으로생각되며파킨슨병에이환된환자에서는척추관협착증과같은퇴행성질환으로인해수술이필요한경우특히, 장분절고정이필요한때에는반드시후방기기고정술과후측방유합술이외에후방또는전방추체간유합술이필요하며하부요추와천추에이르는고정이필요한경우장골나사를이용한견고한고정이필요할것으로생각된다. REFERENCES 1. Adams RD, Victor M Principles of Neruology 2nd ed. New York: McGraw-Hill;1981: Seo WK, Koh SB, Kim BJ, Yu SW, Park MH, Park KW, Lee DH Prevalence of Parkinson s disease in Korea. J Clin Neurosci. 2007;14: Yoon HK, Kim BK, Shin DE, Song SJ, Park HK, Chang JH. Bipolar hemiarthroplasty of displaced femoral neck fracutres ion Parkinsonism patients. J of Korean Fracture Society. 2005;18: Hoehn MM, Yahr MD Parkinsonim: onset, progression, and mortality. Neurology. 1967;17: Babat LB, McLain RF, Bingaman W, Kalfas I, Young P, Rufo-Smith C Spinal surgery in patients with Parkinson 177

6 Hong Kyun Kim et al Volume 21 Number 4 December 2014 s disease: contruct failure and progressive deformity. Spine (Phila Pa 1976). 2004;29: Laroche M, Delisle M, Aziza R, Laqarrique J, Mazieres B. Is camptrocormia a primary muscular disease? Spine (Phila Pa 1976). 1995;20: Gau YL, Lonstein JE, Winter RB, Koop S, Denis F Luque- Galveston procedure for correction and stabilization of neuromuscular scoliosis and pelvic obliquity: a review of 68 patients. J Spinal Disord. 1991;4: Bell DF, Moseley CF, Koresca J. Unit rod segmental spinal instrumentation in the management of patients with progressive mneuromuscular spinal deformity. Spine (Phila Pa 1976). 1989;14: Banta JV, Drummond DS, Ferguson RL. The treatment of neuromuscular scoliosis. Instruct Course Lect. 1999;64: Swank SM, Cohen DS, Brown JC. Spine fusion in cerebral palsy with L-rod segmental spinal instrumentation. A comparison of single and two-stage combined approach with Zilke instrumentation. Spine (Phila Pa 1976). 1989;14: 파킨슨병에이환된환자에서퇴행성요추질환의치료에서발생한장분절고정의실패및불유합 - 증례보고 - 김홍균 나현우 정국진한림대학교의과대학강남성심병원정형외과 연구계획 : 증례보고목적 : 파킨슨병환자에서발생한척추고정실패와불유합의치료증례를보고한다. 선행문헌의요약 : 파킨슨병이동반된퇴행성요추질환에대해척추고정실패와불유합으로재수술을하였던증례는보고된적이없다. 대상및방법 : 4년전파킨슨병을진단받은 55세여자환자가요통과양측하지방사통을증상으로내원하였다. 영상의학검사에서 요추간척추관협착증과 3-4요추간척추전방전위증으로진단되었으며후방감압술, 기기고정술및후측방유합술을받았으며수술후증상은호전되었다. 결과 : 수술후 2년에환자는외상없이갑자기발생한심한요통을호소하였다. 방사선검사에서양측 5요추척추경나사의해리가관찰되었고재수술을하였다. 재수술 3년후다시외상없이심한요통이발생하였으며방사선검사에서 5요추의척추경나사의일측파단이관찰되었으며 cage 를이용한후방요추체간유합술, 장골나사를이용한고정술로유합범위를연장하였다. 현재까지금속파단, 추가적인고정실패의소견은보이지않고있으나시상면불균형및골반지표의악화를보이는상태이다. 결론 : 파킨슨병환자에서요추수술을고려할경우의사는반드시금속고정실패, 불유합및질병의자연경과에의해악화되는시상면, 관상면의불균형을염두해야할것으로생각된다. 색인단어 : 파킨슨병, 실패척추기기고정, 불유합 약칭제목 : 파킨슨병에서척추수술실패 178

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