Journal of Korean Society of Spine Surgery Specific Sagittal Curve Patterns of Cervical Spine in Adolescent Idiopathic Scoliosis (AIS) Sang Min Lee, M

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Journal of Korean Society of Spine Surgery Specific Sagittal Curve Patterns of Cervical Spine in Adolescent Idiopathic Scoliosis (AIS) Sang Min Lee, M.D., Se-Il Suk, M.D., Myeong-Sang Moon, M.D., Seung-Soo Kim, M.

Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2013 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this

1 Journal of Korean Society of Spine Surgery Specific Sagittal Curve Patterns of Cervical Spine in Adolescent Idiopathic Scoliosis (AIS) Sang Min Lee, M.D., Se-Il Suk, M.D., Myeong-Sang Moon, M.D., Seung-Soo Kim, M.D., Sang-Yeop Lee, M.D., Min-Geun Yun, M.D. J Korean Soc Spine Surg 2013 Jun;20(2): Originally published online June 30, 2013; 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 2013 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 Jun;20(2): Specific Sagittal Curve Patterns of Cervical Spine in Adolescent Idiopathic Scoliosis (AIS) Sang Min Lee, M.D., Se-Il Suk, M.D.*, Myeong-Sang Moon, M.D., Seung-Soo Kim, M.D., Sang-Yeop Lee, M.D., Min-Geun Yun, M.D. Department of Orthopedic Surgery, Cheju Halla General Hospital, Seoul Spine Institute, SanggyePaik Hospital* Study Design: A retrospective study. Objectives: To evaluate the sagittal alignment of cervical spine in AIS. Summary of Literature Review: Little has been known about the sagittal curve patterns of cervical spine in AIS patients. Materials and Methods: One-hundred-thirty-three AIS patients were checked by scanographs and followed up for more than 2 years were divided into cervical kyphosis ( +5 ), lordosis ( -5 ) and straight (-4 ~+4 ) groups according to the sagittal curves of cervical spine (C2~C7). Each group was evaluated for thoracic kyphosis, lumbar lordosis, sagittal balance and Cobb s angle on coronal plane. Of the patients, 49 were treated by braces, 84 were surgically corrected (rod derotation in 52, direct vertebral rotation (DVR) in 32). Results: At the initial radiographs, cervical kyphosis was found in 97, lordosis in 23 and straight in 13 patients. In the kyphosis group, cervical kyphosis showed typical patterns of angular kyphosis. Thoracic and upper T-kyphosis (T1~T5) were lower than those in the cervical lordosis group (p=0.000, 0.001, respectively.) Other factors showed no significant differences between the groups. Patients treated by conservative management or by rod derotation had no significant differences in cervical kyphosis during the follow-up periods, though the thoracic hypokyphosis was surgically corrected. On the contrary, patients who were treated by DVR restored cervical lordosis (14/32=43.8%) from initial state showed significant differences in both conservative and rod derotation groups (p=0.008, 0.002, respectively) Conclusions: Cervical kyphosis in AIS was a compensatory curve correlated with both thoracic hypokyphosis and rotational deformity. Rotational corrections should be considered during the surgical treatment. Key Words: Adolescent idiopathic scoliosis (AIS), Cervical kyphosis, Thoracic rotation, Direct vertebral rotation (DVR) 서론 특발성척추측만증은관상면, 시상면및횡단면변형이모두포함된 3차원척추변형이다. 그러나, 현재까지측만증의 3차원변형및근-골격계에대한논문대부분은흉추및요추에대해서만국한되어있을뿐, 측만증이경추에미치는영향에대한연구는극히미진한실정이다. 이는, 임상적으로관상면상경추를포함하는측만증은극히낮은빈도를보이기때문에경추만곡에대한관심은흉추및요추에비해상대적으로적을수밖에없었으며, 대부분의논문이시상면상제 7 경추 ( 또는제 1흉추 ) 를기준으로하였기때문에시상면상경추만곡은관심의대상에서제외될수밖에없었다. 시상면상경추만곡에대한이전의문헌을살펴보면 Hilibrand 등 1) 은흉추에저후만증이있는환자에서경추후만의빈도가높다고하였으며, Canavese 등 2) 은흉추척추측만증에서 후방고정술로흉추후만이교정되어도경추후만은교정되지 않았다고보고하였다. 만약, 특발성척추측만증에서경추후만 Received: September 17, 2012 Revised: November 22, 2012 Accepted: June 5, 2013 Published Online: June 30, 2013 Corresponding author: Sang Min Lee Department of Orthopedic Surgery, Cheju Halla General Hospital, 65 Doryeongro [Yeon-dong], Jeju-city, Jeju Special Self-governing Provine TEL: , FAX: snoopy5@unitel.co.kr 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 2013 Korean Society of Spine Surgery 35

Sang Min Lee et al Volume 20 Number 2 June 2013 을야기하는원인이오로지흉추의저후만증이라면, 수술로흉추의저후만증을교정하였을경우자연적으로경추의후만도교정되어야할것이다. 그럼에도불구하고경추의후만이교정되지않았다면다른원인이존재할수도있다고저자들은생각하였다.

3 Sang Min Lee et al Volume 20 Number 2 June 2013 을야기하는원인이오로지흉추의저후만증이라면, 수술로흉추의저후만증을교정하였을경우자연적으로경추의후만도교정되어야할것이다. 그럼에도불구하고경추의후만이교정되지않았다면다른원인이존재할수도있다고저자들은생각하였다. 이에저자들은, 특발성척추측만증환자의시상면상경추만곡을측정하여, 척추측만증의어떤요인이경추후만과연관되어있는지를조사하였으며, 치료방법에따른시상면상경추만곡의변화여부도살펴보았다. 대상및방법 특발성척추측만증환자중기립측면척추전장사진 (lateral scanographs) 으로 2년이상추시관찰한 133례를대상으로하였으며, 이때, 보존적으로치료한환자는 49례, 수술적가료를시행한환자는 84례이었다. 수술한환자들은모두척추경나사고정술로교정하였으며, 이중, 52례는강봉감염술 (rod derotation) 로치료하였고 32례는추체회전술 (direct vertebral rotation, DVR) 로교정하였다. 초진시시상면상경추만곡의유형에따라, 경추후만 ( +5 o ), 일자형 (-4 o ~+4 o ), 전만 ( -5 o ), 세군으로나누어조사하였다. 이때, 측면척추전장사진 (lateral scanographs) 은환자의주먹을쇄골에얹혀서찍거나, 어깨를전방 30도굴곡하여손을수평대위에올려놓고촬영하였다. 저자들은환자의자세에따른만곡의변화, 불분명한만곡의유형및측정상의오차로인하여후만군으로분류되는오류를최소화하기위해경추후만을 5도이상인경우로국한시켰다. 각군별로관상면상측만증의유형및만곡의크기 (Cobb 각 ), 시상면상흉추후만각 (C7 상부골단판 ~T12 하부골단판 ) 및요추전만각 (T12 하부골단판 ~ 제1천추상부골단판 ), 시상면상체간 ( 불 ) 균형여부를측정하여, 경추후만과상관관계를조사하였다. 이때, 시상면상흉추후만이 25도미만인경우를저후만증으로, 이보다큰경우를정상후만으로정하였으며, 시상면상체간균형은제 7 경추추체의중심이시상면상축 ( 제 1천추의후상방모서리에서올린수선 ) 보다전방에위치할경우 (+) 로, 후방에위치할경우 (-) 로표기하여, -2cm~+2cm 사이에위치할경우시상면상균형을이룬것으로보았으며, 이범위를벗어난경우에불균형되었다고규정하였다. 이외에도, 최종추시사진상보존적치료및수술적치료에따른시상면상경추만곡의변화를조사하였다. 통계학적분석은시상면상경추만곡과흉추 ( 또는요추 ) 만곡의상관관계는 Pearson correlation coefficient 로분석하였으며, 각군간의흉추후만각, Cobb s angle 의비교와치료방법에따 른경추만곡의변화는 Kruskal-Wallis test 로분석하였다. 결과 1. 초진시시상면상경추만곡의유형및각도 초진시경추만곡의유형은후만 97 례 (72.9%), 전만 23 례 (17.3%), 일자형 13 례 (9.8%) 로관찰되어정상적인경추전만 의소실을보인경우는 110 례 (82.7%) 이었다. 이때, 각도 (C2 하 부골단판 ~C7 상부골단판 ) 는평균 6.9±10.2 도후만을보였다. 시상면상제 7 경추는시상면상축에비해평균 9.6mm 후방에, 제 2 경추는평균 4.4mm 전방에위치하였으며, 시상면상균형 (-2cm~+2cm) 은 71 례, 후방불균형 (>-2cm) 은 44 례, 전방불균 형 (>+2cm) 은 18 례로관찰되었다. 흉추 (C7 상부골단판 ~T12 하 부골단판 ) 는평균 27.7 도의후만으로측정되었으며, 이때, 흉추 저후만증 (< 25 도 ) 은 44 례, 정상후만은 89 례이었다 (Table 1). 경추의후만군에서시상면상만곡의모양은 상부경추후 만 - 하부경추전만 의특징적인 angular kyphosis 의형태를보 였으며, 이때전이추체 (transitional vertebra) 는제 4 경추 63 례, 제 5 경추 32 례, 제 3 경추 2 례순이었다. 경추만곡의크기는평 균 11.6±6.1 도후만으로측정되었다. 시상면상제 7 경추는평 균 11.9mm 후방에, 제 2 경추는평균 2.5mm 전방에위치하였으 며, 시상면상균형은 50 례, 후방불균형 35 례, 전방불균형 12 례 로관찰되었다. 흉추후만은평균 25.7 도이었으며, 흉추저후만 증 (< 25 도 ) 은 47 례, 정상후만은 50 례이었다. 경추의전만군에서경추만곡은평균 10.3±5.9 도전만으로 측정되었다. 시상면상제 7 경추는평균 2.5mm 후방에, 제 2 경추 Fig. 1. Negative correlations of sagittal angles between Cervical and Thoracic curves (r=-.496, P <0.01, Pearson coefficients). 36

Journal of Korean Society of Spine Surgery Sagittal Curves of Cervical Spine in AIS 는평균 10.3mm 전방에위치하였으며, 체간균형은 15례, 후방불균형 5례, 전방불균형 3례이었다. 흉추후만은평균 35.7 도로측정되었으며, 흉추저후만증은 2례, 정상후만은 21례이었다.

4 Journal of Korean Society of Spine Surgery Sagittal Curves of Cervical Spine in AIS 는평균 10.3mm 전방에위치하였으며, 체간균형은 15례, 후방불균형 5례, 전방불균형 3례이었다. 흉추후만은평균 35.7 도로측정되었으며, 흉추저후만증은 2례, 정상후만은 21례이었다. 흉추후만의크기가감소할수록경추후만의크기가증가하였으며, 비교적강한음의상관관계가있었다 (r=-0.496, P<0.01, Pearson coefficients)(fig. 1). 반면, 시상면상제 7 경추위치와경추후만사이에는에서는매우약한상관관계 (r=-0.183, P<0.05) 가있었으나, P<0.01 level 에서는연관이없었다. 경추후만군과전만군사이에는흉추저후만증빈도에통계적으로유의한차이가있었다 (p=0.000, Kruskal-Wallis test). 그러나, 관상 면상만곡의유형, 시상면상요추만곡의크기, 시상면상제 7 경추의위치및체간불균형은두군간에통계적으로유의한차이를보이지않았다. 경추의일자형군은후만군과전만군의중간형태를보였다. 2. 보존적치료한환자 49례에서경추만곡의변화보존적치료 ( 흉요천추보조기착용 ) 한환자에서, 초진시경추후만은 37례 (75.5%), 전만 6례 (12.2%), 일자형 6례 (12.2%) 이었으며, 최종추시상경추후만 35례 (71.4%), 전만 7례 (14.3%), 일자형 7례 (14.3%) 로관찰되어, 추시기간동안시상면상경추만 Fig. 2. (A, B) A twelve-year-old AIS patient with mild thoracic scoliosis showed cervical kyphosis of 6 degrees at the initial radiographs. She had trunk balance both in coronal and sagittal planes. (C, D) The curves were not progressed in the coronal plane during the follow-up periods of 30 months.cervical curve was remained and was checked cervical kyphosis of 8 degrees in the sagittal plane. 37

Sang Min Lee et al Volume 20 Number 2 June 2013 곡은의미있는변화를보이지않았다. 경추및흉추후만의각도역시추시기간동안통계적으로유의한차이를보이지않았다 (Fig. 2). 3. 수술적치료한환자에서경추만곡의변화수술로치료한 84례중, 강봉감염술은 52례이었으며추체회전술은 32례이었다.

5 Sang Min Lee et al Volume 20 Number 2 June 2013 곡은의미있는변화를보이지않았다. 경추및흉추후만의각도역시추시기간동안통계적으로유의한차이를보이지않았다 (Fig. 2). 3. 수술적치료한환자에서경추만곡의변화수술로치료한 84례중, 강봉감염술은 52례이었으며추체회전술은 32례이었다. 1) 강봉감염술 (Rod derotation) 으로교정한결과강봉감염술로교정한환자에서초진시경추후만은 37례 (71.2%), 전만 9례 (17.3%), 일자형 6례 (11.5%) 이었으며, 최종추시상경추후만 34례 (65.4%), 전만 11례 (21.2%), 일자형 7례 (13.5%) 로관찰되어, 술후시상면상경추만곡이의미있는변화를보이지않았다. 또한, 시상면상경추만곡각은초진시평균 6.1 ±10.4 도후만에서최종추시상평균 3.9 ±11.0 도후만으로측정되어평균 2.2도전만교정되었으나, 통계적으로유의한차 Fig. 3. (A, B) A fourteen-year-old AIS patient with double major curves showed cervical kyphosis of 18 degrees and thoracic hypokyphosis of 24 degrees (T1~T12) at the initial radiographs. (C, D) The patient was operated by pedicle screw fixation with rod derotation maneuver. Thoracic hypokyphosis was well corrected to normokyphosis of 34 degrees. However, cervical kyphosis was not changed though thoracic hyphokyphosis was well corrected. Preoperative cervical kyphosis of 18 degrees was slightly changed to kyphosis of 15 degrees with no significant difference. 38

Journal of Korean Society of Spine Surgery Sagittal Curves of Cervical Spine in AIS 이는없었다. 반면, 흉추후만은초진시평균 27.4 도에서술후평균 33.0 도로교정되었으며, 흉추저후만증빈도도초진시 22례 (42.3%) 에서최종추시상 8례 (15.4%) 로감소하였다.

6 Journal of Korean Society of Spine Surgery Sagittal Curves of Cervical Spine in AIS 이는없었다. 반면, 흉추후만은초진시평균 27.4 도에서술후평균 33.0 도로교정되었으며, 흉추저후만증빈도도초진시 22례 (42.3%) 에서최종추시상 8례 (15.4%) 로감소하였다. 즉, 수술후흉추의저후만증이교정되었음에도불구하고, 시상면상경추만곡은통계적으로의미있는변화를보이지않았다 (Fig. 3). 2) 추체회전술 (DVR; direct vertebral rotation) 으로교정한결과추체회전술로교정한환자에서초진시경추후만은 23례 (71.9%), 전만 8례 (25.0%), 일자형 1례 (3.1%) 이었으며, 최종 추시상경추후만 12례 (37.5%), 전만 14례 (43.8%), 일자형 6례 (18.8%) 로관찰되어, 술후경추후만이통계적으로의미있게감소되었다. 경추만곡은초진시평균 7.6±12.5 도후만에서최종추시상평균 -0.1±11.9 도전만으로측정되어평균 7.7도전만교정되었다. 흉추후만은초진시평균 29.1 도에서수술후평균 34.7도로교정되었으며, 초진시흉추저후만증은 12례 (37.5%) 에서최종추시상 4례 (12.5%) 로감소하였다. 술후시상면상경추만곡의교정및경추후만의빈도는술전에비해통계적으로의미있는변화를보였다 (Fig. 4). 또한, 추체회전술은강봉감염 Fig. 4. (A, B) A fifteen-year-old AIS patient with King type II curve showed cervical kyphosis of 7 degrees and thoracic hypokyphosis of 26 degrees at the initial radiographs. (C, D) She was operated by direct vertebral rotation (DVR). Postoperative cervical curve in the sagittal plane showed a noticeable change. Preoperative cervical kyphosis of 7 degrees was changed to cervical lordosis of 5 degrees after the operation with a statistically significant difference. 39

7 Sang Min Lee et al Volume 20 Number 2 June 2013 Table 1. Characteristics in Cervical Curves Groups Group Total Kyphosis Lordosis Straight p* Sagittal angle C- angle( ) 6.9± ± ± ± T-angle( ) L-angle( ) >0.05 Sagittal balance C2 (mm) >0.05 C7 (mm) >0.05 L1 (mm) >0.05 Coronal angle T-curves >0.05 L-curves >0.05 No. of pts (%) (72.9) 23(17.3) 13(9.8) T-Hypok (<25) Normok(>25) Sagittal balance Sagittal imbalance Negative (<-20mm) >0.05 Positive (>+20mm) Coronal Curves Single T Double T Double M L or T-L *p: statistics between kyphosis group and lordosis group 술과비교하여흉추후만의교정에는유의한차이가없었으나, 술후시상면상경추만곡의교정에통계적으로우수한결과를보였다 (p=0.018, Kruskal-Wallis test)(table 2). 고찰 골반과머리를연결해주는척추는체간균형과에너지의소모를효과적으로하기위하여시상면상전만과후만이조화를이루는 S자형만곡을이루고있다. 이들각각의해부학적분절은인접분절과밀접한관계가있어, 천추의후만은요추전만에영향을미치며, 흉추의후만은경추및요추전만에영향을주게된다. Winter 등 3) 은척추측만증에서흉추의후만증이감소된경우경추의전만이소실된다고보고하였으며, Berthonnaud 등 4) 은시상면상경추만곡은흉추의후만과비교적약한 (r=0.36) 의상관관계가있다고보고하였다. Takeshima 등 5) 은시상면상경 추만곡을전만, 일자형, 후만, 상부경추전만-하부경추후만, 상부경추후만-하부경추전만의다섯가지유형으로구분하였으며, Penning 6) 은머리와척추의상대적위치에따라경추만곡이변하여, 머리를체간에비해전방으로이전시키는기전은 상부경추신전-하부경추굴곡 의모양을보이며, 반대로머리를후방으로이전시키는기전은 상부경추굴곡-하부경추신전 의소견으로나타난다고보고하였다. 이전논문들을종합해보면, 정상적인경추만곡은시상면상전만을보이나, 독립적으로존재하기보다는흉추후만의크기, 체간균형또는정면주시, 머리균형을유지하기위한기전등, 여러원인에의해변화될수있고개인및연령에따른넓은편차를보여정상적인경추전만의소실을보이는경우는약 7~40% 까지보고되어있다. 특발성척추측만증은 3차원척추변형으로시상면상흉추의저후만증과요추의저전만증을동반하는경우가흔하다. 임상적으로경추에후만증이종종관찰되었음에도불구하고, 위저자 40

8 Journal of Korean Society of Spine Surgery Sagittal Curves of Cervical Spine in AIS Table 2. Changes of Curves Angles and Types according to the Treatment Methods Conservative Derotation DVR p* No. of pts C-kyphosis (initial) 35 (37) 34 (37) 12 (23) Lordosis(initial) 7 (6) 11 (9) 14 (8) Straight(initial) 7 (6) 7 (6) 6 (1) T hypok (initial) 16 (18) 8 (22) 4 (12) NormoK (initial) 33 (31) 44 (30) 28 (20) Cervical angle Initial 7.4± ± ±12.5 Last F/U 7.1± ± ±11.9 Corrected angle Thoracic angle Initial Last F/U Corrected angle *p: statistics between DVR group and Derotation group 들이발표한인접분절과의상관관계및다양한경추만곡의유형등을고려할때특별히의미있는소견이아닐수도있다. 그러나, 흉추의저후만증이요추의저전만증 (hypolordosis) 으로인한보상성만곡이아닌것처럼, 시상면상비정상적인경추만곡에대한올바른검증을요할수밖에없다. 본연구의결과에서시상면상경추만곡은전만각이감소하기보다는, 상부경추후만-하부경추전만 의특징적인 angular kyphosis 를보였으며, 추시기간동안지속적으로관찰되며그빈도는역시 70% 이상되었다. 이는, 기존에발표된정상인에서의경추후만빈도보다높으며, Takeshima 등 5) 이보고한 하부경추전만-상부경추후만 의모양인 Group E(27/204= 13.2%) 의빈도와비교해볼때매우높은수치이다. 즉, 척추측만증에서보이는경추후만은일시적인현상이아니라척추측만증에서발현되는특이적으로소견임을알수있다. 저자들은이렇게특이적으로발생된경추후만의원인이먼저척추외적요인, 즉머리또는턱을굴곡시킴으로발생되었는지, 팔의위치에의해시상면상체간불균형을야기시켜발생되었는지, 아니면기립척추전장측면사진 (scanographs) 의기술적왜곡에의한현상인지여부를조사할필요가있었다. 저자들은본논문의대상환자들중일부환자에대해경추측면방사선사진을추가적으로촬영하여척추전장측면사진 (scanographs) 과비교하였는데, 이때각도오차가있는경우도있었으나특징적인 상부경추굴곡-하부경추신전 의모양에는변화가없었다. 이후저자들은역으로경추에 angular kyphosis 를보이는일 반환자에서흉요추기립방사선사진을촬영하여척추측만증 (neglected scoliosis) 을새롭게발견한경우를종종경험할수있었다. 본연구에서환자는주먹을쇄골에얹혀서찍거나, 손을수평대위에올려놓고측면사진을촬영하였는데, 이는기능적측면자세와유사하며, 체간의후방전이를최소화시키는자세에해당하는것으로알려져있다. 7,8) 저자들의결과에서시상면상제 7경추는평균 9.6mm 후방에, 제 2경추는평균 4.4mm 전방에위치하여경추가전방경사 ( 제 7경추에비해제 2경추가전방으로전이된각 ) 된소견을보였다. 이는머리균형을유지하고정면을보기 (forward vision) 위하여제 2경추가제 7 경추에비해상대적으로전방에위치 ( 전방경사 ) 하게되는것으로풀이할수있다. 그러나, Bernhardt 등 9) 은경추의경사는항상전방으로기울어져있다고하였으며, 본논문의 상부경추굴곡-하부경추신전 의모양은 Penning 6) 의보고에의하면오히려머리를후방으로이전시키는기전에해당하기때문에, 시상면상의체간불균형을교정하기위한기전또는정면을보기위한수단으로경추후만이발생되지않았다는것을의미한다. 또한, Harrison 등 10) 은경추후만이있는환자에서머리를일정각도를신전시켜도경추후만이전만으로바뀌지않았다고보고하였으며, 이는척추전장사진촬영시턱의위치를당기거나내미는자세로인하여경추만곡의크기가변할수는있어도, 유형이바뀌지않는다는것을의미한다. 따라서, 본논문의결과에서나타나는경추후만은척추외적요인에의하여나타나는기능적 (functional curves) 만곡이아니라, 척추내부요인에의해발생되었음을알 41

9 Sang Min Lee et al Volume 20 Number 2 June 2013 수있다. 척추내적요인으로는, 시상면상경추후만과흉추의저후만증이연관되어있다는문헌들이보고되고있다. Erkan 등 11) 은정상성인척추의 30% 에서경추전만이소실된소견을보였으며흉추저후만증과연관되었다고보고하였으며, Hilibrand 등 1) 은척추측만증환자에서경추후만과흉추저후만증이연관되어있다고하였으나, 술전흉추의저후만증환자는술후경추후만이진행되지않은반면, 정상적인흉추후만또는과후만환자는술후경추의후만이증가되었다고보고하였다. Canavese 등 2) 은흉추척추측만증에서후방고정술로흉추후만이교정되어도경추후만은교정되지않았다고보고하였으나, 그이유를설명하지못하였다. 본연구의결과에서도술전흉추의저후만증과경추의후만과는유의한상관관계를보였으나, 강봉감염술 (rod derotation) 로흉추저후만증을교정하였음에도경추후만은의미있는변화를보이지않았다. 반면, 추체회전술 (direct vertebral rotation, DVR) 로교정한환자에서는술후경추후만의빈도가현저히줄었으며, 만곡의크기도의미있게교정되었다 (p=0.018, Kruskal-Wallis test). 강봉감염술은강력한관상면및시상면상교정을얻을수있으나회전교정은거의효과가없다고알려진반면, 추체회전술은강봉감염술의장점에회전교정을추가적으로얻을수있는술식이다. 12) 본연구에서추체회전술과강봉감염술사이에경추후만교정에현저한차이를보였다는것은두술식의근본적인차이, 즉, 흉추에서의회전교정이경추후만변형을호전시키는데긍정적으로작용했으며, 이는특발성척추측만증에서경추후만은흉추의회전변형이연관되어있다는것을의미하는것이다. 현재로서는본연구의시상면상 angular kyphosis 를보이는경추만곡이향후임상적으로어떤결과를가져올지는예단할수없다. 다만, 이러한현상이경추의조기퇴행성변화또는경-흉추부동통과연관되어있는지에대해서는중장기적추시관찰을통해연구할필요가있을것으로사료된다. 결론 특발성척추측만증에서시상면상경추만곡은후만을보이는경우가많았으며, 특징적인 상부경추후만-하부경추전만 의 angular kyphosis 형태를보였다. 이는, 일시적현상이아니라추시기간동안지속되는대상성만곡 (compensatory sagittal curves) 이었다. 경추후만은흉추의저후만증과연관이있었으나, 수술 ( 강봉감염술 ) 로흉추의저후만증을교정하여도특별히교정되지않았다. 그러나, 추체회전술로치료한환자에서경추후만이의미있게감소되었다. 이는, 경추의후만변형은흉추의 저후만증뿐만아니라척추측만증의회전변형이복합적으로연관되었다것을의미한다. REFERENCES 1. Hilibrand AS, Tannenbaum DA, Graziano GP, Loder RT, Hensinger RN. The sagittal alignment of the cervical spine in adolescent idiopathic scoliosis. J Pediatr Orthop. 1995;15: Canavese F, Turcot K, De Rosa V, de Coulon G, Kaelin A. Cervical spine sagittal alignment variations following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis. Eur Spine J. 2011;20: Winter RB, Lovell WW, Moe JH. Excessive thoracic lordosis and loss of pulmonary function in patients with idiopathic scoliosis. J Bone Joint Surg Am. 1975;57: Berthonnaud E, Dimnet J, Roussouly P, Labelle H. Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters. J Spinal Disord Tech. 2005;18: Takeshima T, Omokawa S, Takaoka T, Araki M, Ueda Y, Takakura Y. Sagittal alignment of cervical flexion and extension: lateral radiographic analysis. Spine (Phila Pa 1976). 2002;27:E Penning L. Acceleration injury of the cervical spine by hypertranslation of the head: effect of normal translation of the head on cervical spine motion. Eur Spine J 1992;1: Faro FD, Marks MC, Pawelek J, Newton PO. Evaluation of a functional position for lateral radiograph acquisition in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2004;29: Marks M, Stanford C, Newton P. Which lateral radiographic positioning technique provides the most reliable and functional representation of a patient s sagittal balance? Spine (Phila Pa 1976). 2009;34: Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spines and thoracolumbar junction. Spine (Phila Pa 1976). 1989;14: Harrison DE, Harrison DD, Janik TJ, Holland B, Siskin LA. Slight head extension: does it change the sagittal cervical 42

10 Journal of Korean Society of Spine Surgery Sagittal Curves of Cervical Spine in AIS curve? Eur Spine J. 2001;10: Erkan S, Yercan HS, Okcu G, Ozalp RT. The influence of sagittal cervical profile, gender and age on the thoracic kyphosis. Acta Orthop Belg. 2010;76: Lee SM, Suk SI, Chung ER. Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2004;29: 특발성척추측만증환자의시상면상경추만곡의특이적소견 이상민 석세일 * 문명상 김성수 이상엽 윤민근제주한라병원, 상계백병원척추센터 * 연구계획 : 후향적연구 목적 : 척추측만증환자의시상면상경추만곡의유형과그원인을살펴보고, 치료방법에따른변화를조사하였다. 선행문헌의요약 : 특발성척추측만증에서시상면상경추만곡에대한문헌은극히드문실정이다. 대상및방법 : 기립척추전장방사선사진 (scanographs) 으로 2 년이상추시관찰이가능했던특발성척추측만증환자 133 례를대상으로하였으며, 이 중보존적가료는 49 례, 수술환자는 84 례 ( 강봉감염술 52 례, 추체회전술 32 례 ) 이었다. 조사방법은시상면상경추만곡 ( 제 2 경추 ~ 제 7 경추 ) 을후만 ( +5 ), 일자형 (-4 ~+4 ), 전만 ( -5 ) 의세군으로분류하였으며, 각군의흉추후만, 요추전만, 시상면상체간균형및관상면상 Cobb 각을측정하여경 추후만과의연관성여부를살펴보았다. 또한, 보존적가료및수술적치료에있어경추후만에변화가있는지조사하였다. 결과 : 총 133 례중, 초진시경추후만은 97 례 (72.9%), 전만 23 례 (17.3%), 일자형 13 례 (9.8%) 이었다. 경추후만군은특징적인 angular kyphosis 의모양을 보였으며, 경추전만군에비해흉추후만에유의한차이를보여저후만증이있는경우경추후만의위험도가높았다 (r=-0.496, P<0.001). 그러나, 두군 간의시상면상체간불균형또는관상면상 Cobb 각에는유의한차이가없었다. 최종추시상경추후만은 81 례 (60.9%), 전만 32 례 (24.1%), 일자형 20 례 (15.0%) 이었다. 보존적으로치료한환자에서경추후만은추시기간동안특별한 변화를보이지않았다 ( 초진시 37 례, 최종추시 35 례 /49=71.4%). 수술로치료한 84 례 ( 강봉감염술 52 례, 추체회전술 32 례 ) 에서흉추의저후만증은술후 의미있게교정되었다. 강봉감염술로치료한경우, 술전경추후만 37 례 (71.1%), 전만 9 례 (17.3%) 에서술후경추후만 34 례 (65.4%), 전만 11 례 (21.2%) 로경추만곡에의미있는변화를보이지않았다. 반면추체회전술은술전경추후만 23 례 (71.8%), 전만 8 례 (25.0%) 에서술후경추후만 12 례 (37.5%), 전만 14 례 (43.8%) 로관찰되어, 경추후만감소에유의한차이를보였다 (p=0.005). 또한, 추체회전술은보존적치료및강봉감염술로치료한경우와비 교해서도경추후만감소에통계적으로유의한차이를보였다 ( 각각 p=0.008, 0.002). 결론 : 특발성척추측만증에서경추후만은흉추의저후만증과회전변형이연관되어발현되어나타난다. 수술시흉추의저후만증뿐만아니라회전변 형도교정되어야만만족할만한시상면상경추만곡을얻을수있을것이다. 색인단어 : 특발성척추측만증, 경추후만, 흉추저후만증, 회전변형, 추체회전술 약칭제목 : 특발성측만증의시상면상경추만곡 43

Abstract Direct Vertebral Rotation (DVR): A New Technique of 3-D Deformity Correction with Segmental Pedicle Screw Fixation in Adolescent Idiopathic S

Abstract Direct Vertebral Rotation (DVR): A New Technique of 3-D Deformity Correction with Segmental Pedicle Screw Fixation in Adolescent Idiopathic Scoliosis (AIS) Sang-Min Lee, MD, Se-Il Suk, MD, Ewy-Ryong