Review Article J. of Advanced Spine Surgery Volume 3, Number 1, pp 14~24 Journal of Advanced Spine Surgery JASS Direct Lateral Interbody Fusion in Deg

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1 Review Article J. of Advanced Spine Surgery Volume 3, Number 1, pp 14~24 JASS Direct Lateral Interbody Fusion in Degenerative Disease of Lumbar Spine Sang-Hyuk Min, M.D., Jae-Sung Yoo, M.D. Department of Othopedic Surgery, Dankook University College of Medicine, Cheonan, Korea Intraoperative blood loss volume increases due to soft tissue injury or excessive traction generated by extensive approach including posterior fusion or posterior lumbar interbody fusion, leading to the occurrence of complication and delay in postoperative recovery, On the other hand, MI-TLIF minimizes injuries in soft tissue and surrounding muscle by approaching between multifidus muscles and longissimus dorsi after separating them, and reaching intervertebral disc from lateral vertebral foramen. The advantages of this surgical procedure are minimization of muscle or soft tissue injuries incurred by lateral approach, reduction of surgically related muscle damage, and decrease of postoperative blood loss. However, The size of cages are limited by transforaminal approach in MI-TLIF, eventually it could be difficult to maintain the correction of deformity(disc height, segmental and lumbar lordosis). Recently, DLIF(Direct lateral interbody fusion) is developed to improve the disadvantages of TLIF. DLIF allows to insert larger cage than TLIF, as a result larger cage have a advantage to maintain correction of disc height and lordosis because it can support both apophyseal rings of endplates. However, Transpsoas approach is essential for DLIF, so we need to understand the anatomy lumbosacral plexus in psoas, because nerve injury during the transpsoas approach is the most common and potentially the most devastating complication of the DLIF procedure. And many authors reported that various frequency of nerve injury according to surgeon s skill. Therefore, surgeon s skill and accurate understanding about the procedure are important factors to prevent the complications of DLIF. Key Words: Spine, Degenerative disease, Direct lateral interbody fusion 서론 전통적인척추경나사를이용한후방유합술이나후방추체간유합술은광범위한도달법으로발생하는연부조직의손상이나과도한견인에의해수술중출혈량이증가하게되며, 그로인해수술주위기간의합병증의발생의증가및술후회복속도의지연이문제점으로보고되고있다. 1-5) 따라서최근최소침습수술을통하여수술중출혈량을감소시키기위해노력하고있으며, 그중최소침습적경추간공요추추체간유합술 (Minimally Invasive Transforaminal Lumbar Interbody Fusion, MI-TLIF) 은다열근과최장근사이를분리하여근육사이로접근함으로써연부조직및주변근육의손상을최소화하고과도 한견인을줄이고자추간공외측으로추간판에도달하여 추체간유합술을시행하는술식으로, 외측부에서근육이 나연부조직을손상을최소화하여접근함으로써수술접 근과관련된근육의손상을줄이며술후출혈량을감소 시킬수있는장점이있다. 6-9) 그러나, 좁은경추간공을 통한 cage 의삽입은골유합을시행함에있어충분한크기 의 cage 사용에제한이있다. MI-TLIF 의장기추시결과 Corresponding author: Sang-Hyuk Min, M.D. Department of Orthopaedic Surgery, Dankook University College of Medicine, 16-5 Anseo-dong, Cheonan , Korea TEL: , FAX : osmin71@naver.com 14 Copyright 2013 Korean Society for the Advancement of Spine Surgery

Table 1. Radiologic Finding of Transforaminal interbody fusion Overall One Level (n=69) Two Level (n=40) Three levels or more (n=18) Disc Height(mm) Pre-operation 9.17±0.46 9.60±0.61 8.52±0.78 8.90±1.

2 Table 1. Radiologic Finding of Transforaminal interbody fusion Overall One Level (n=69) Two Level (n=40) Three levels or more (n=18) Disc Height(mm) Pre-operation 9.17± ± ± ±1.45 Post-operation 11.98± ± ± ±1.37 Final follow-up 10.81± ± ± ±1.38 Segmental Lordotic Angle( ) Pre-operation 15.22± ± ± ±5.43 Post-operation 19.37± ± ± ±4.14 Final follow-up 17.49± ± ± ±4.02 Lumbar Lordotic Angle( ) Pre-operation 34.14± ± ± ±8.24 Post-operation 42.65± ± ± ±7.45 Final follow-up 36.69± ± ± ±7.74 에서추간판높이의감소, 척추전만의소실등의교정소실이발생한다는보고들이있으며, 좁은접근공간으로인한 cage 크기의제한이그원인중하나로예상되고있다 (Table 1). 10) 최근이러한단점을보완하기위해, 장요근을통한측면접근법 (Transpsoas approach) 이사용되고있다. 측방추체간유합술 (Direct lateral Interbody fusion, DLIF) 을시행할경우충분한크기의 cage 를삽입이가능하므로양측척추종판의골단환 (apophyseal ring) 모두에기계적부하가능하여추간판높이유지에유리하다는장점이있고, 11) 실혈량을감소시키고수술시간을단축시켜주고회복기간및술후동통을감소시킨다는장점들이보고되면서그사용이증가하고있다 ) 이에저자들은기존의논문들과본교실의경험을토대로 DLIF 을통해기존의최소침습적추체간유합술의어떠한제한점을극복할수있었는지, 술기상의주의점은무엇인지, 또한측방추체간유합술의제한점및결과에따른극복과제는무엇인지에대해알아보고자하였다. 사체연구를통한요추신경총의해부학적위치를살펴보면, 17-20) 신경손상을피하기위한적절한안전지역 (Safety working zone) 을각분절에따라살펴보면일반적으로요추 1번에서 3번간에는추체의전방 1/3이내에서접근하는것이안전할것으로사료된다 (Fig. 1). 21) 그러나요추 4-5번간에서는요추신경총이일반적으로전 본론 DLIF 을시행함에있어장요근을통한측면접근법에서가장흔하고가장심각한합병증은장요근내부의요추신경총의손상이며, 15,16) 이를방지하기위해서는해부학적인이해가선행되어야할것이다. Fig. 1. Diagram shows safe zone and lumbosacral plexus 15

3 Table 2. Recent extreme lateral interbody fusion studies: Diagnoses in the study population Degenerative disc disease Degenerative disc disease with degenerative scoliosis Degenerative disc disease with degenerative scoliosis and lumbar stenosis Degenerative disc disease with degenerative scoliosis, lumbar stenosis, and degenerative Spondylolisthesis Degenerative disc disease with/without stenosis Degenerative scoliosis Degenerative scoliosis with radiculopathy and central and lateral stenosis Degenerative scoliosis with radiculopathy and intermittent radiculopathy and foraminal stenosis Degenerative spondylosis with/without listhesis Fractures secondary to metastasis Herniated nucleus pulposus Kyphosis (postlaminectomy, posttraumatic, postvertebroplasty) Osteomyelitis/discitis Pseudarthrosis Spondylolisthesis Spondylolysis with instability Stenosis Trauma Tumor 방으로위치하기때문에확장기 (dilator) 와견인장치 (retractor) 를위치함에있어특별히주의해야할것이 다. 17,19) Hu 등은자기공명영상을통해위에기술한바 와유사한요추신경총의위치를보고한바있으며, 22) 요 추신경총을피하여안전한수술적접근을위해서는수 술중근전도검사는필수적이라할수있다. 23) 그러면과연언제 DLIF 이사용가능하며, 또한그제한 점은무엇인지에대한이해가필요하다. DLIF 은흉요추 부위부터요추 5 번간에최소침습적접근법을통하여접 근이가능하여척추전방전위증, 추간판탈출증, 및퇴행 성추간판질환, 퇴행성측만증및전만증등을포함한퇴 행성요추질환에적용될수있으며, 24) 또한 Cage 삽입으로 추체의전만을회복하고추간판공간을높여줌으로써간 접감압술을통하여척추전방전위증및추간공협착증 에서도적용이가능하다. 최근에는일반적으로 cage 삽입 을통한추체간유합술만으로는충분한고정이부족하다 고판단하여후방의추가적기기고정술을함께시행하 므로간접감압술뿐만아니라직접감압이필요한경우에는후방기기고정술시추가적감압술을시행할수도있으므로직접감압이필요한경우에도적응이될수있다 (Table 2). 21) 그러나, DLIF 을시행함에있어장요근을통한측면접근법은천골과장골때문에요추5번, 천추 1번간추간판공간으로접근이불가능하다는제한점이있으며, 요추4 번, 5번간의접근도 50% 정도에서접근이불가능하였다는보고들이있다. 24,25) 또한, Smith 등은요추화된천골에서도요추 5번, 6번간의접근은요추화되지않은요추 5 번, 천추 1번간의해부학적구조와유사하기때문에요추화된천골에서도 DLIF 은적절한적응증이되기어려울것이라고보고하였다. 24) 저자들은이러한제한점을극복하기위해술전측면굴곡영상을이용하여술전계획을시행하였다. 술전측면굴곡영상을통해요추 4번, 5번간의접근이가능한지확인하고또한어느방향으로시행할것인지미리계획하였고, 모든예에서요추 4번, 5번간의접근에제한없이 DLIF 을시행할수있었다. 술전계획및수술방법 측면접근법을이용한 DLIF 은환자를굴곡측와위에서시행하므로술전측면굴곡영상을통하여정확한술전계획이선행되어야한다. 술전장골능선의위치와 11 번, 12번늑골의위치를함께고려하여적절한접근이가능할것인지평가해야하며, 접근방향의결정은환자의증상과영상학적검사결과를종합하여고려해야한다. 퇴행성측만증이동반된경우측면굴곡영상을통한유연성정도의판단이필요하다. 추체만곡이볼록한방향으로접근할경우추간판제거술이용이하다는장점이있지만다분절의경우각각의피부절개가필요하다는단점이있다. 반면에만곡이오목한방향으로의접근은단일피부절개만으로다분절에접근이가능하다는장점이있으므로이러한부분을함께고려하여결정해야할것이다. 본교실의증례를살펴보면, 요추퇴행성측만증동반된 53 세남자환자로측면굴곡방사선촬영후추체변형의유연성정도를평가하였다. 환자의경우유연성을갖는측만증변형이관찰되었으며, 측만증변형이좌측의신경공협착을유발하였고, 단일피부절개로다분절에접근하기위해좌측으로접근하기로술전계획하였다 (Fig. 2). 전신마취후, 수술중근전도검사를통한요추신경총 16

감시를위해서접근하는동측의하지에바늘형전극감시기 (Needle electrode monitoring setup) 를설치하였다 (Fig. 3). 성공적인수술을위해서는술전적절한환자의자세가필수적이다.

5cm~3cm 의피부절개를가한후복부의 3개의근육층을통해후복막공간으로접근하였다. 인지를이용하여사각요근 (quadratus lumborum) 을인지하며둔개 (blunt dissection) 를계속하여추체의가로돌기와장요근까지접근하였다 (Fig. 5).

X-PAK probe and dock 으로근전도검사 (EMG monitoring) 를하여반응이있는경우에는좀더전방으로탐침을이동하였다. 추간판공간까지진행하면내부 Fig. 4. Intraoperative photograph.

Bending views of radiographs of lumbar spine in a 81 years-old female with degenerative scoliosisfig. 2.

4 감시를위해서접근하는동측의하지에바늘형전극감시기 (Needle electrode monitoring setup) 를설치하였다 (Fig. 3). 성공적인수술을위해서는술전적절한환자의자세가필수적이다. 측방추체간유합술시행과정에서추체에평행한종판신연술과 cage 삽입을위해서는정확한측면자세를얻는것이중요하므로 fluoroscope 영상하에추간판공간에영상이평행하게촬영되는각도를확인하여환자의자세를결정하였다 (Fig. 4). 단일분절측방추체간유합술을시행할때는 2.5cm~3cm 의피부절개를가한후복부의 3개의근육층을통해후복막공간으로접근하였다. 인지를이용하여사각요근 (quadratus lumborum) 을인지하며둔개 (blunt dissection) 를계속하여추체의가로돌기와장요근까지접근하였다 (Fig. 5). NIM-SPINE (Nerve Integrity Monitor X-PAK Probe) 를이용하여신경전도검사를시행하였다. 전류는 6-8 ma로설정하였으며 fluoroscope 하에 coker clamp 를이용하여추체간공간전방 1/2에서 1/3지점을검사하였다. X-PAK probe and dock 으로근전도검사 (EMG monitoring) 를하여반응이있는경우에는좀더전방으로탐침을이동하였다. 추간판공간까지진행하면내부 Fig. 4. Intraoperative photograph. Patient s position is lateral decubitus on bended table to set parallel with disc space. Fig. 2. Bending views of radiographs of lumbar spine in a 81 years-old female with degenerative scoliosisfig. 2. Bending views of radiographs of lumbar spine in a 81 years-old female with degenerative scoliosis Fig. 3. Intraoperative photograph. Needle electrode monitoring should be attached ipsilateral lower extremity Fig. 5. Sectional image of anatomy. No. 1 is Quadratus lumborum, No. 2 is Transverse process of spine, No. 3 is Psoas. 17

삽입유도핀 (inner stylet) 을제거하고유도선 (guide wire) 을위치시킨뒤외부삽입관 (outer cannula) 을제거하였다 (Fig. 6). 유도선을따라확장기 (dilator) 를이용하여 22mm 까지순차적으로확장기를삽입하였으며, 확장기삽입전에신경전도검사를이용하여요추신경총이어느정도거리에있는지파악하여신경손상이가지않도록주의하였다.

신경손상을최소화하기위해다시한번장요근을통하여신경전도검사를시행한후, 일회용칼 (disposable knife) 을이용하여섬유륜절개 (annulotomy) 를시행하였다. Pituitaries, shavers, curettes 를이용하여추간판제거술를시행하였으며, 변형을교정하고양측골단골단환을모두지지하는골이식을시행하기위해반대측섬유륜또한절개하였다.

5 삽입유도핀 (inner stylet) 을제거하고유도선 (guide wire) 을위치시킨뒤외부삽입관 (outer cannula) 을제거하였다 (Fig. 6). 유도선을따라확장기 (dilator) 를이용하여 22mm 까지순차적으로확장기를삽입하였으며, 확장기삽입전에신경전도검사를이용하여요추신경총이어느정도거리에있는지파악하여신경손상이가지않도록주의하였다. Fluoroscope 하에확장기가척추체에평행하도록위치시키도록하였으며, 마지막확장기삽입후에는양측에핀고정을하면추체간공간의확장이불가능하므로일측에만핀을삽입하여고정하였다. 핀고정을한후에는 Flexible self-retaining arm과 Intraoperative light 를설치하였다 (Fig. 7). 신경손상을최소화하기위해다시한번장요근을통하여신경전도검사를시행한후, 일회용칼 (disposable knife) 을이용하여섬유륜절개 (annulotomy) 를시행하였다. Pituitaries, shavers, curettes 를이용하여추간판제거술를시행하였으며, 변형을교정하고양측골단골단환을모두지지하는골이식을시행하기위해반대측섬유륜또한절개하였다. 추간판공간을순차적으로신연하였으며 (Fig. 8), fluoroscope 하에양측골단환의거리를고려하여가삽 Fig. 6. Neuromonitor through Psoas under the fluoroscopic image (A) Intraoperative photograph. Dock NIM X-Pak probe is located into disc space. (B) Fluoroscopic image. Use coker clamp to target above the anterior 1/2 to 1/3 of the disc space. Fig. 7. Dilation & Retractor Placement (A) Fluoroscopic image. Dilator should be setted parallel with disc space and then pin fixation is helpful maintain the position of dilator (B) Intraoperative photograph. Flexible self-retaining arm and Intraoperative light were connected. 18

입물 (trial) 을삽입하여확인하였다 (Fig. 9). Curettate 시에얻은 local auto bone 과 Progenix( ) DBM을혼합하여 cage 를채운후, Clydesdale Spinal System 를이용하여 Cage 를삽입하였으며척추체양측골단환에지지가가능하도록 Cage 를위치시켰다 (Fig. 10).

결과 대부분의연구는후향적으로시행되었으며, 대부분의시술은단일분절및이분절에제한되어시행되었고금속판또는척추경나사못를이용한추가적고정을시행하였다. 12,13,16,26-30) Knight 등 16) 은 58명의퇴행성요추질환환자를대상으로 DLIF 을시행한결과총 22.4% 의합병증이발생하였으며, 그중 2명에서는신경손상으로인한근력약화가발생하였다.

Ozgur 등 31) 은 62명의환자를대상으로 2년간추시관찰한결과 91% 에서골유합을얻었으며, 75% 에서임상적결과의호전을보였고 19% 에서합병증이발생하였고, 가장흔한합병증은고관절굴곡의약화이며대부분술후 6주안에호전되었다고하였다. DLIF은충분한크기의 cage삽입을통하여추간공의간접감압이가능한술식이다.

6 입물 (trial) 을삽입하여확인하였다 (Fig. 9). Curettate 시에얻은 local auto bone 과 Progenix( ) DBM을혼합하여 cage 를채운후, Clydesdale Spinal System 를이용하여 Cage 를삽입하였으며척추체양측골단환에지지가가능하도록 Cage 를위치시켰다 (Fig. 10). Cage 삽입이끝난후에는상처를봉합하고환자의자세을복와위로변경한후 Sextant system(medtronic,memphis, TN, USA) 을이용하 Fig. 8. Fluoroscopic image. End plates were curetted by shaver. 여경피적척추경나사못고정술을시행하였다 (Fig. 11). 결과 대부분의연구는후향적으로시행되었으며, 대부분의시술은단일분절및이분절에제한되어시행되었고금속판또는척추경나사못를이용한추가적고정을시행하였다. 12,13,16,26-30) Knight 등 16) 은 58명의퇴행성요추질환환자를대상으로 DLIF 을시행한결과총 22.4% 의합병증이발생하였으며, 그중 2명에서는신경손상으로인한근력약화가발생하였다. Rodgers 등 29) 은 66명의환자를술후 1년째전산단층촬영으로평가하여 96.6% 의골유합을얻었으며, 90% 환자에서만족스러운임상적결과를보고하였다. Ozgur 등 31) 은 62명의환자를대상으로 2년간추시관찰한결과 91% 에서골유합을얻었으며, 75% 에서임상적결과의호전을보였고 19% 에서합병증이발생하였고, 가장흔한합병증은고관절굴곡의약화이며대부분술후 6주안에호전되었다고하였다. DLIF은충분한크기의 cage삽입을통하여추간공의간접감압이가능한술식이다. Inoue 등 32) 은추간판높이의회복및척추관의해부학적재정렬이술후좋은임상적결과를얻는데중요한인자가됨을보고한바있으며, Jeon 등 33) 은술후신경공의직경및면적의증가가충분한감압을의미하고이로인하여좋은임상적결과를얻게된다고하였다. Oliveira 등 12) 은 DLIF 을시행받은 15 Fig. 9. Fluoroscopic image. Trial insertion is to determine accurate location of cage. Fig. 10. Fluoroscopic image. Cage insertion should be located on both apophyseal ring of endplates 19

명의환자를대상으로모든방사선학적결과에서추간공높이가회복되는결과를보여퇴행성추간판질환및협착증에서 DLIF 을통해신경의간접감압이가능함을보고하였다. 또한 DLIF은퇴행성측만증에서도유용하여사용될수있다. Anand 등 34) 은 2008 년 12명의척추측만증환자들을대상으로평균 3.

35) Dakwar 등 36) 25예의흉요추부의퇴행성측만증에서 DLIF 을사용하였으며 2/3에서변형의교정을얻었으며만족스러운임상적결과를보고하였다.

7 명의환자를대상으로모든방사선학적결과에서추간공높이가회복되는결과를보여퇴행성추간판질환및협착증에서 DLIF 을통해신경의간접감압이가능함을보고하였다. 또한 DLIF은퇴행성측만증에서도유용하여사용될수있다. Anand 등 34) 은 2008 년 12명의척추측만증환자들을대상으로평균 3.64 분절에서 DLIF 을시행하여평균 13도의교정을얻었음을보고하였으며, 술후영구적인합병증은전례에서관찰되지않았다고하였다. 2010년같은저자들은퇴행성측만증환자 28예를대상으로모든예에서골유합을얻었으며만족스러운교정유지및합병증의감소재원기간의감소의결과를얻었음을보고하였다. 35) Dakwar 등 36) 25예의흉요추부의퇴행성측만증에서 DLIF 을사용하였으며 2/3에서변형의교정을얻었으며만족스러운임상적결과를보고하였다. Wang 과 Mummaneni 도 37) DLIF을이용하여평균 20도의교정을얻었음을보고하였다또한 Tormenti 등 38) 퇴행성측만증의치료로 DLIF 8예와 TLIF 4예를비교분석하였는데, DLIF 을시행한군에 서변형의교정정도가더우수하였음을보고하였다. Fig. 12. (A) Anteroposterior and lateral radiograph after multilevel direct lateral interbody fusion. Arrows indicate the malposition of cages. (B) Sagittal image of computed tomography of after multilevel direct lateral interbody fusion. Arrows indicate the fractures of endplates Fig. 11. Anteroposterior and lateral radiograph of preoperation and postoperation 20

8 합병증 DLIF 에서발생할수있는다양한합병증에대해서여러보고들이되고있다 ) Berjano 등 39) 97명의환자를대상으로평균 1년간추시관찰한결과, 일시적인고관절굴곡력약화및감각이상이 9% 에서발생하였다고보고하였으며모든예에서술후 1개월이내증상이호전되어영구적인장애는발생하지않았으며, 92% 의환자에서임상적으로만족스러운결과를얻었음을보고하였다. Le등 42) 101명의환자를대상으로다분절유합및변형교정을위해금속판을사용하여추가적인고정을하였으며, 5.9% 의합병증발생을보고하였는데내고정물실패가 3예, 척추체골절이 3예였고모든합병증은다분절인경우에서발생하였고모든예에서요통이재발하였다고하였다. Sharma 등 44) 43명의환자를대상으로 1년간추시관찰한결과 25% 에서일시적인대퇴부동통이발생하였으며 25% 에서술후고관절굴곡력및슬관절신전력의약화가발생하였다고보고하였다. 또한불유합 5예, 척추체골절 1예, 감염 1예, cage 의잘못된삽입 1예, 후복막공간내출혈 1예를보고하였다. Rodgers 등 45) 600명의환자를대상으로 6.2% 에서조기합병증발생을경험하였으며기존의전통적개방적수술과비교하여재원기간이감소하였으며, 혈관및신경손상과감염율이감소하였다고하였고, 4예에서일시적인신경증상을보였다고하였다. DLIF 에서가장흔한합병증은대퇴부감각이상, 하지의방사통과근력약화지만그외에도드문합병증이보고되고있다. Daffner 와 Wang 46) 은요추 3번 4번간 cage 가술후 1개월째이탈되어, cage 재삽입술및금속판고정술를이용하여재수술하였음을보고하였다. 그외에경막파열로인한뇌척수액누출, 감염, cage 및내고정물의실패등이보고되고있다. 45) Le등 42) 은 101명을대상으로 DLIF 을시행한결과척추체골절이 3예, 내고정물실패 3예를보고하였고, 또한 Santillan 등 47) 은요추 2번 3 번간에 DLIF 을시행한후에요추 2번척추경나사못의잘못된삽입으로인해좌측요추 2번뿌리동맥 (radicular artery) 에생긴가성동맥류 (pseudoaneurysm) 로다량의후복막공간의혈종이발생하여색전술을시행한예를보고하였다. 이와같이 DLIF 은다양한합병증이발생가능하며, 또 한그발생률은저자들마다큰차이를보이고있다. 이는술자간의술기에대한경험과이해가중요한요소일것이라예상되는부분이다. 본교실에서경험하였던합병증에대해살펴보면초기 1예에서신연과정중과도한척추종판의손실에의해척추종판의골절이동반되어 cage 의삽입후위치이동을보인 1예를경험하였으며 (Fig. 12), 이를예방하기위해서는추체간신연술에서척추종판이손상되지않도록주의해야할것으로생각된다. 또한저자들또한초기 1예에서일시적인고관절굴곡력약화및대퇴부이상감각을보였던예가있었다. 저자들은수술중술기과정중에확장기의미세한이동및장요근섬유의감입이발생가능하므로요추신경총손상을최소하하기위해수술술기중반복적으로신경전도검사를시행하였으며이를통하여이후에는한예에서도신경증상을보이지않았다. 또한요추신경총손상을방지하기위해서는적절한접근과 cage 의삽입의적절한위치가중요할것으로생각되며하부요추유합일수록 cage 삽입위치는요추신경총을피해전방으로위치시켜야할것으로생각된다 (Fig. 11). 결론 본교실의경험과기존의연구결과들을비교분석한결과, DLIF 에서측방접근을이용하여충분한간접갑압을얻고, 합병증을피하기위해서는술자의경험도가중요한요소라생각된다. 또한 DLIF 은기존의최소침습적추체간유합술의제한점을극복할만한장점이많은술식이나 DLIF 역시제한점과위험도를갖고있기때문에해부학적구조및술기에대한정확한이해가선행되어야할것이다. References 1. Steffee AD, Sitkowski DJ. Posterior lumbar interbody fusion and plates. Clin Orthop. 1988;227: McLaughlin MR, Haid RW, Rodts GE, et al. Posterior lumbar interbody fusion: indications, technique and results. Clin Neurosurg. 2000;47: Suk SI, Lee CK, Kim WJ, Lee JH, et al. Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis. Spine. 1997;22:

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11 퇴행성요추질환에서의측방추체간유합술 민상혁, 유재성단국대학교의과대학정형외과학교실 전통적인후방유합술이나후방추체간유합술은광범위한도달법으로발생하는연부조직의손상이나과도한견인에의해수술중출혈량이증가하게되며, 그로인해수술주위기간의합병증의발생의증가및술후회복속도의지연이문제점으로보고되고있다. 따라서최근최소침습수술을통하여수술중출혈량을감소시키기위해노력하고있으며, 그중최소침습적경추간공요추추체간유합술은추간공외측으로추간판에도달하여추체간유합술을시행하는술식으로, 외측부에서근육이나연부조직을손상을최소화하여접근함으로수술접근과관련된근육의손상을줄이며술후출혈량을감소시킬수있는장점이있다. 그러나, 좁은추간공을통한골이식과정은충분한크기의 cage 사용에제한이있으며, 이는추간높이, 척추전만의교정을장기적으로유지하는데제한점으로작용할수있다. 최근이러한제한점을보완하기위해측방추체간유합술이사용되고있다. 측방추체간유합술을시행할경우충분한크기의 cage 를삽입이가능하므로효과적인간접감압술이가능하며, 또한양측척추종판의골단환모두에기계적부하가능하여추간판높이유지에유리하다는장점이있어만족스러운결과들이보고되고있다. 그러나측방추체간유합술을시행하기위해서는장요근을통한접근법을사용해야하며, 그로인한요추신경총손상에의한합병증이가장흔하고심각한문제로알려져있다. 따라서신경손상을방지하지위해서는장요근내부의요추신경총에대한해부학적이해가선행되어야한다. 또한신경손상에의한합병증은여러저자들이보고하고있으나그발생률은술자의숙련도에따라매우다양하게보고되고있다. 따라서합병증을감소시키기위해서는술자의술기에대한정확한이해와숙련도가중요한요소가될것으로생각된다. 색인단어 : 척추, 퇴행성질환, 측방추체간유합술 24

KISEP Clinical Article J Korean Neurosurg Soc , 2002 퇴행성요추질환환자에서척추유합술후발생한인접분절의퇴행성변화에대한수술적치료 * 김영수 구성욱 조용은 진병호 윤영설 진동규 Surgical Treatment of

KISEP Clinical Article J Korean Neurosurg Soc 32323-328, 2002 퇴행성요추질환환자에서척추유합술후발생한인접분절의퇴행성변화에대한수술적치료 * 김영수 구성욱 조용은 진병호 윤영설 진동규 Surgical Treatment of Adjacent Segment Degeneration after Spinal Fusion in