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1 152 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 인공슬관절전치환술에서 Tranexamic Acid 의관절내도포및정맥투여방법에따른실혈량에대한비교 이광철 김동휘 이정우 강신욱 조성원 * 조선대학교의과대학정형외과학교실, * 광주첨단병원정형외과 Comparison of Blood Loss between Intra-Articular and Intravenous Tranexamic Acid Following Primary Total Knee Arthroplasty Gwang Chul Lee, M.D., Dong Hwi Kim, M.D., Jung Woo Lee, M.D., Sin Wook Kang, M.D., and Sung Won Cho, M.D.* Department of Orthopaedic Surgery, Chosun University School of Medicine, *Department of Orthopaedic Surgery, Cheomdan Medical Center, Gwangju, Korea Purpose: To investigate the difference in blood loss between two injection methods, intravenous (IV) and intra-articular (IA) methods via drain tube. Materials and Methods: A total of 183 patients who underwent total knee arthroplasty between October 2013 and March 2016 were included. The method of tranexamic acid (TXA) administration was intravenously injected before August 2015, and it was applied thereafter to the joint through a drainage tube post intra-articular suture. Our subjects were divided into the following groups: The intravenous unilateral (IVU), intravenous bilateral (IVB), intra-articular unilateral (IAU), and intra-articular bilateral (IAB) groups. Hemoglobin and hematocrit, drainage amount, transfusion frequency, mean transfusion volume, and blood loss, as well as complications were compared between the groups. Results: Drainage amount was ± ml in IVU, and ± ml in IAU; there was less drainage in IAU than in IVU, but without significance (p=0.262). Moreover, the drainage amount was 1,110.39± ml in IVB and ± ml in IAB, which was significantly lower in IAB (p=0.000). Transfusion frequency was 5 patients (10.0%) in IVU and 2 patients (4.5%) in IAU, but without significant difference (p=0.442). Moreover, the frequency was 16 patients (29.6%) in IVB and 1 patient (2.9%) in IAB, which was significantly lower in the IAB group (p=0.002). Mean transfusion volume was 44.80± ml in IVU and 21.80± ml in IAU, but without significant difference (p=0.389); the volume was ± ml in IVB and 18.30± ml in IAB, with statistical significance (p=0.001). Blood loss was 1,318.70± ml in IVU and ± ml in IAU, which was significantly lower in the IAU (p=0.006); blood loss was 1,837.40± ml in IVB, and 1,337.60± ml in IAB and it was significantly lower in IAB (p=0.000). Complications included deep vein thrombosis in one case in IVU. Conclusion: In TKA, IA injection of TXA significantly reduced blood loss compared with IV injection, especially in bilateral TKA. Key words: tranexamic acid, total knee arthroplasty, blood loss, blood transfusion Received April 3, 2017 Revised August 15, 2017 Accepted August 16, 2017 Correspondence to: Dong Hwi Kim, M.D. Department of Orthopaedic Surgery, Chosun University Hospital, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Korea TEL: FAX: oskdh@chosun.ac.kr *This study was supported by research fund from Chosun University Hospital, 서론 고령의환자에게진행된퇴행성슬관절염의치료로인공슬관절전치환술 (total knee arthroplasty, TKA) 은매우만족스러운결과를보이고있다. 그러나 TKA 시행후실혈로인해환자의 10%- The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 153 Comparison of Blood Loss According to Administration Route of TXA 38% 에서는혈액학적안정성 (hemodynamic stability) 을위해동종수혈을하고있다. 1-3) 그러나동종수혈은수혈의부작용및혈액전파감염병뿐만아니라인공관절치환술후치명적인합병증인감염발생률을증가시키고있어, 4-9) 최근 TKA 후수혈을줄이기위해실혈량을감소시키는여러방법을사용하고있다 ) 이중 tranexamic acid (TXA) 의사용은안전하고우수한효과를보이고있다. 16,17) 그러나아직까지이상적인 TXA의사용방법및용량에대해서는정립된것이없다. 이에본연구에서는 TXA의사용방법에따른실혈량의차이가있을것으로가정하고이를확인하고자 TXA (Tranexamic Acid Injection; Shinpoong Pharm. Co, Ltd. Ansan, Korea) 를정맥투여한군과배액관을통해관절내도포한군의실혈량의차이를후향적으로분석하였다. 대상및방법 2013년 10월부터 2016년 3월까지슬관절의퇴행성관절염으로 TKA를시행받은환자 311명 ( 단측 : 199, 양측 : 112명 ) 중, 80세이상이거나심근경색이나뇌경색과같은동맥폐쇄가있던자, 심부정맥혈전증과같이정맥성폐쇄가있던자, 술전혈색소수치가 10 g/dl 이하인자, 혈액응고에이상이있는자, 신기능에이상이있는자, 최근경련이나발작이있어 TXA를사용할수없는자를제외하고 2015년 8월부터 2016년 3월까지 TXA를관절내도포한 79예와그비교대상으로 2013년 10월부터 2015년 7월까지정맥내주사한 104예총 183명 ( 단측 : 94명, 양측 : 89명 ) 을후향적으로분석하였다. 모든환자에게지혈대를 300 mmhg의압력으로사용하였고, 수술은대퇴사두근하 (subvastus) 접근법을이용하였고, 경골대퇴골모두골수강내금속유도지침자를사용하였다. 대상을단측및양측, 정맥투여및관절내도포방법에따라정맥투여편 측군 (intravenous unilateral, IVU), 정맥투여양측군 (intravenous bilateral, IVB), 관절내도포편측군 (intra-articular unilateral, IAU), 관절내도포양측군 (intra-articular bilateral, IAB) 의 4군으로나눴다. TXA의투여방법은 2015년 8월을기준으로그이전에는 10 mg/kg의용량으로지혈대감압 30분전에정맥투여하였고, 2015 년 8월이후에는관절낭봉합후, TXA 30 ml (3 g) 에식염수 20 ml 를섞어총 50 ml를배액관을통해관절강내로도포하였다. 18,19) 모든환자에서배액관은수술후 3시간동안자연배액되도록음압을적용하지않은이후음압을적용하였으며, 수술후 2일째배액량을확인하고제거하였다. 수혈기준은수술후혈색소수치가 7 mg/dl 이하일때, 혈색소 1 mg/dl당농축적혈구 1 pack (320 ml) 씩수혈을시행하였으며, 혈색소수치가 7 mg/dl 이상이더라도빈맥이나창백등의빈혈증상을보이는환자에게는수혈을시행하였다. 술후심부정맥혈전증을예방하기위해 fondaparinux (Arixtra Injection; GlaxoSmithKline, Brentford, UK) 를수술일로부터 7일간사용하였다. 심부정맥혈전증은수술후하지의부종및통증을호소하는환자들을대상으로초음파를이용하여진단하였다. 수술당일부터적극적인대퇴하지거상운동및관절운동을시행하고, 보행기를통한체중부하보행을권장하였다. 모든환자들에게수술전체질량지수 (body mass index, BMI), prothrombin time (PT) 및 activated partial thromboplastin time (aptt) 를검사하였고, 수술전및수술후 3일까지혈색소및적혈구용적률 (hematocrit, Hct) 수치를검사하였으며, 배액량, 수혈빈도, 평균수혈량및실혈량과합병증발생여부를비교하였다. 수술전 Nadler 등 20) 의공식을이용하여환자의체중과신장으로술전총혈액량 (preoperative total blood volume) 을측정하였으며, 수술후 Sehat 등 21) 의공식을이용하여 Hct의감소량에따른실혈량을측정하였다. Table 1. Demographic Data of Patients Variable IVU IAU IVB IAB Case number Age (yr) 64.52± ± ± ±5.96 Sex (male/female) 8/42 8/36 7/47 5/30 BMI (kg/m 2 ) ± ± ± ±2.98 Preop Hb (g/dl) 12.89± ± ± ±1.13 Preop Hct (%) 37.97± ± ± ±2.83 Preop PT (s) 10.37± ± ± ±0.58 Preop aptt (s) 29.91± ± ± ±3.49 Preop blood volume (ml) 3,627.05± ,596.47± ,635.84± ,667.87± Values are presented as number only or mean±standard deviation. IVU, intravenous unilateral; IAU, intra-articular unilateral; IVB, intravenous bilateral; IAB, intra-articular bilateral; BMI, body mass index; Preop, preoperative; Hb, hemoglobin; Hct, hematocrit; PT, prothrombin time; aptt, activated partial thromboplastin time.

3 154 Gwang Chul Lee, et al. 통계적분석은 IBM SPSS ver (IBM Co., Armonk, NY, USA) 을이용하여배액량, 실혈량및평균수혈량은 t-test를통해, 수혈빈도는 chi-square를통해분석하였으며, p-value가 0.05 미만인경우를통계적으로유의한것으로판단하였고, G*Power 를이용하여 post hoc analysis 시행하였고표본수에대한통계적검정력을확인하였다. 본연구는조선대학교병원의기관생명윤리위원회의승인을받고이루어졌다 (IRB ). 결과 술전시행한 BMI, PT, aptt, 술전총혈액량은각군마다유의한차이는없었다 (Table 1). 배액량은단측 (unilateral TKA) 군의 IVU에서수술후 1일째 ± ml, 2일째 ± ml였고, IAU에서각각 ± ml, ±82.99 ml였으며, 총배액량은 IVU에서 ± ml, IAU에서 ± ml였다. 두군간의배액량은수술후 1일째 IAU에서 IVU에비해유의하게적었고 (p=0.015), 총배액량에서는두군간유의하지않았다 (p=0.62, power=0.84). 양측군에서는 IVB에서수술후 1일째 ± Table 2. Hb Level Concentrations, Amount of Drain, Total Blood Loss, Transfusion Rate, and Amount of Transfusion in Unilateral TKA Hb (g/dl) Variable IVU IAU p-value Power POD ± ± POD ± ± POD ± ± Amount of drain (ml) POD ± ± POD ± ± Total drain ± ± Total blood loss (ml) 1,318.70± ± Transfusion volume (ml) 44.80± ± Transfusion rate Values are presented as mean±standard deviation or percent only. Hb, hemoglobin; TKA, total knee arthroplasty; IVU, intravenous unilateral; IAU, intraarticular unilateral; POD, postoperative day. Table 3. Hb Level Concentrations, Amount of Drain, Total Blood Loss, Transfusion Rate, and Amount of Transfusion in Bilateral TKA Hb (g/dl) Variable IVB IAB p-value p-value POD ± ± POD ± ± POD ± ± Amount of drain (ml) POD ± ± POD ± ± Total drain 1,110.39± ± Total blood loss (ml) 1,837.40± ,337.60± Transfusion volume (ml) ± ± Transfusion rate Values are presented as mean±standard deviation or percent only. Hb, hemoglobin; TKA, total knee arthroplasty; IVB, intravenous bilateral; IAB, intraarticular bilateral; POD, postoperative day.

4 155 Comparison of Blood Loss According to Administration Route of TXA ml, 2일째 ± ml, IAB에서각각 ± ml, ± ml으로수술후 1일째 IAB에서유의하게양이적었으며 (p=0.00), 총배액량도 IVB에서 1,110.39± ml, IAB 에서 ± ml로 IAB가 IVB에비해유의하게적었다 (p=0.000). 수혈빈도는 IVU에서 5/50명 (10.0%), IAU에서 2/44명 (4.5%) 으로 IAU 가적었으나통계적으로유의하지는않았고 (p=0.442, power=0.95), IVB에서 16/54명 (29.6%), IAB에서 1/35명 (2.9%) 으로 IAB에서수혈빈도가유의하게적었다 (p=0.002). 평균수혈량은 IVU에서 44.80± ml, IAU에서 21.80± ml로 IAU가적었으나통계적으로유의하지않았고 (p=0.389, power=0.83), IVB에서 ± ml, IAB에서 18.30± ml로 IAB에서유의하게적었다 (p=0.001). 실혈량은 IVU에서 1,318.70± ml, IAU에서 ± ml로, IAU에서실혈량이유의하게감소했고 (p=0.006), IVB 에서 1,837.40± ml, IAB에서 1,337.60± ml로 IAB에서유의하게실혈량이감소했다 (p=0.000) (Table 2, 3). 합병증으로심부정맥혈전증이 IVU에서 1예 (2%) 발생하였으나통계적으로유의하지않았고양군모두감염등의심각한합병증은발생하지않았다. 고찰 본연구는 TXA를배액관을통해관절내도포한군이정맥투여한군에비해단측군과양측군모두실혈량을통계적으로유의하게줄일수있었고, 게다가양측군의경우배액량, 수혈빈도및평균수혈량도통계적으로유의하게감소시킬수있음을보였다. 저자들은관절내도포시에정맥투여시보다국소적으로 TXA의농도를높게유지할수있으며술후 3시간동안배액관에음압을유지하지않아 TXA가관절내흡수할시간을주었으며, TXA가출혈부위에직접적으로작용하게되어나타나는결과로판단하였다. 22) TKA는진행된퇴행성관절염에있어이상적인수술방법이나 TKA 후의실혈량은 1,450-1,790 ml로다른정형외과적수술에비해다량의출혈을유발하는것에대한염려가있다 ) TKA 시행시골이나연부조직의절제면에의한직접적인출혈이외에도연부조직으로소실되어감지하지못하는출혈량도많아서 TKA 시배액량으로만실혈량을평가하기가어렵다. 이에본연구에서는환자의신장과체중을측정하고 Nadler 등 20) 의공식을이용하여수술전총혈액량을구하였으며, Sehat 등 21) 의공식을이용하여수술전과후의 Hct의변화에따른실혈량을구함으로써연부조직으로소실되어감지하지못하는출혈량까지정확하게측정하려하였다. 실혈량을줄일수있는여러방법중 TXA는합성항섬유소용 해약제 (antifibrinolytic agent) 로 lysin에결합하여 tissue plasminogen과 plasmin에가역적인복합체를형성하고수술창주변의손상된미세혈관에수술시만들어진혈전이녹지않도록하여실혈량을줄이는목적으로사용되고있다. 16) TXA의사용용법으로는주로정맥투여가많이보고되고있으며그효과도인정받고있으나, 16,17) 심부정맥혈전증과같은합병증의염려가있어아직까지이상적인사용법에대해서는의견이분분하다. 때문에동맥, 정맥폐쇄성질환이나신장질환의경우사용에제한이있다. 이에최근들어 TXA를배액관을통해도포하거나또는관절강내직접도포하는방법이연구되고있다. 이에본저자들은정맥주사를통해시행한군과배액관을통해관절내로투여한군의결과를비교하여어느방법이더효율적이며, 안전한방법인지알아보고자하였다. TXA의관절내도포는다른연구들에서도좋은결과들이보고되고있는데, Alshryda 등 27) 은 TXA를관절내로도포하고 30분간 clamp한군과생리식염수를도포하고 30분간 clamp한대조군을비교하여실험군에서수혈빈도, 배액량, 실혈량이감소되었음을보고했고, Ishida 등 28) 은 TXA를배액관을통해관절내로 2 g 도포한뒤, 배액관을 clamp한군과생리식염수를 20 ml 투여한뒤배액관을 clamp한군을비교했을때, 실험군에서술후혈색소감소및배액량이대조군에비해유의하게적었음을밝혔으며, 대퇴와무릎, 종아리의부종역시대조군에비해유의하게감소하여재활및술후통증에장점이있음을보였다. TXA의정맥주사사용시심부정맥혈전증, 폐색전증의발생률이증가할수있다는염려가있으나본연구에서는 IVU군에서만 1예발생하였는데혈전은원위부인 soleal vein에위치하고있었으며 Xarelto (rivaroxaban; Bayer, Leverkusen, Germany) 을 3주간경구복용후호전되었다. 문헌보고에서도심부정맥혈전증또는폐색전증의발생률에는유의한차이는없었다. 16,28) 또한관절내도포역시심부정맥혈전증, 폐색전증등의부작용을유의하게증가시키지않는다고보고되고있다. 27) 정맥내투여할경우 TXA는혈관을통해이동하게되며, 혈청내농도와관절내농도가같아지면서관절내로확산되나관절내도포시에는상대적으로혈청내농도가정맥주사에비해적다고보고되고있다. 29) 이는관절내도포가상대적으로적은양으로보다나은효과를얻을수있으며, 또한혈청내 TXA의농도가정맥주사보다더적어전신적영향이더적을것으로판단된다. 이는동맥성및정맥성폐쇄증의과거력이있어심근경색, 심부정맥혈전증등의위험성이있는환자에있어전신적영향을최소화하여추후배액관을통한관절내도포의적응증이정맥투여의적응증보다더확대될수있을것으로생각되며, 이에대한연구가필요할것이다. 본연구에서는단측군과양측군모두배액관을통한관절내도포가정맥투여에비해총실혈량은유의하게감소함을보였으나단측군에서배액량, 수혈빈도및수혈량이 IAU가 IVU에비해

5 156 Gwang Chul Lee, et al. Table 4. Comparison of p-value between Meta-Analysis and Our Study 그양은더적었으나유의하지못하였다. 이는많은증례수를통 한연구시유의한결과를보일것으로생각된다. 정맥주사시에는 10 mg/kg 으로주었으나관절내도포시모 든환자에게 3 g 으로동일한양을주어정맥투여시 TXA 양의 차이에따른차이점을배제할수없다는점은본연구의제한점 으로지적할수있다. 또한기존의 meta-analysis 연구등에서정 맥투여군과관절내도포군의비교에서실혈량, 배약량, 수혈빈 도및수혈량의유의한차이를발견할수없었다는결과와는다 소다른결과를보였으나이는각각에연구에서각기다른 TXA 용량을사용함에영향을받았을가능성이높을것으로생각되고, 이는본연구에있어서제한점이된다고할수있겠다 (Table 4). 30) 결론 TKA 시행시, 단측군과양측군모두 TXA 의배액관을통한관절 내도포는정맥투여보다실혈량을유의하게감소시켰으며, 특히 양측인공관절치환술시수혈빈도와평균수혈량을유의하게 줄일수있는방법으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Frisch NB, Wessell NM, Charters MA, Yu S, Jeffries JJ, Silverton CD. Predictors and complications of blood transfusion in total hip and knee arthroplasty. J Arthroplasty. 2014;29:S Variable Meta-analysis Unilateral Our study Bilateral Total drain Total blood loss Transfusion volume Transfusion rate Park JH, Rasouli MR, Mortazavi SM, Tokarski AT, Maltenfort MG, Parvizi J. Predictors of perioperative blood loss in total joint arthroplasty. J Bone Joint Surg Am. 2013;95: Zhao-Yu C, Yan G, Wei C, Yuejv L, Ying-Ze Z. Reduced blood loss after intra-articular tranexamic acid injection during total knee arthroplasty: a meta-analysis of the literature. Knee Surg Sports Traumatol Arthrosc. 2014;22: Friedman R, Homering M, Holberg G, Berkowitz SD. Allogeneic blood transfusions and postoperative infections after total hip or knee arthroplasty. J Bone Joint Surg Am. 2014;96: Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J. Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. J Bone Joint Surg Am. 2014;96: Selvaratnam V, Fountain JR, Donnachie NJ, Thomas TG, Carroll FA. Does pre-operative tranexamic acid increase the incidence of thromboembolism in primary lower limb arthroplasty? Open J Orthop. 2013;3: Newman ET, Watters TS, Lewis JS, et al. Impact of perioperative allogeneic and autologous blood transfusion on acute wound infection following total knee and total hip arthroplasty. J Bone Joint Surg Am. 2014;96: Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OS- THEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion. 2003;43: Dodd RY. The risk of transfusion-transmitted infection. N Engl J Med. 1992;327: Karam JA, Bloomfield MR, DiIorio TM, Irizarry AM, Sharkey PF. Evaluation of the efficacy and safety of tranexamic acid for reducing blood loss in bilateral total knee arthroplasty. J Arthroplasty. 2014;29: Chen S, Li J, Peng H, Zhou J, Fang H, Zheng H. The influence of a half-course tourniquet strategy on peri-operative blood loss and early functional recovery in primary total knee arthroplasty. Int Orthop. 2014;38: Panni AS, Cerciello S, Vasso M, Del Regno C. Knee flexion after total knee arthroplasty reduces blood loss. Knee Surg Sports Traumatol Arthrosc. 2014;22: Yildiz C, Koca K, Kocak N, Tunay S, Basbozkurt M. Late tourniquet release and drain clamping reduces postoperative blood loss in total knee arthroplasty. HSS J. 2014;10: Licini DJ, Meneghini RM. Modern abbreviated computer navigation of the femur reduces blood loss in total knee arthroplasty. J Arthroplasty. 2015;30: Aggarwal AK, Shashikanth VS, Marwaha N. Platelet-rich plasma prevents blood loss and pain and enhances early functional outcome after total knee arthroplasty: a prospective randomised controlled study. Int Orthop. 2014;38:387-

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7 158 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 인공슬관절전치환술에서 Tranexamic Acid 의관절내도포및정맥투여방법에따른실혈량에대한비교 이광철 김동휘 이정우 강신욱 조성원 * 조선대학교의과대학정형외과학교실, * 광주첨단병원정형외과 목적 : 인공슬관절전치환술후실혈을줄이기위해 tranexamic acid (TXA) 를정맥주사하는것과배액관을통한관절내투여방법 에따른실혈량의차이를알아보고자하였다. 대상및방법 : 2013 년 10 월부터 2016 년 3 월까지인공슬관절전치환술을시행받은환자 183 명을대상으로하였다. TXA 의투 여방법은 2015 년 8 월이전에는정맥주사하였고, 그이후에는관절내봉합후관절내로배액관을통해도포하였다. 정맥주사편 측군 (intravenous unilateral, IVU), 양측군 (intravenous bilateral, IVB), 관절강내편측군 (intraarticular unilateral, IAU), 양측군 (intraarticular bilateral, IAB) 각각 4 군으로나눠혈색소및적혈구용적률수치, 배액량, 수혈빈도, 평균수혈량및실혈량과합병증 발생여부를비교하였다. 결과 : 배액량은 IVU 에서 ± ml, IAU 에서 ± ml 로 IAU 에서적었으나유의하지는않았고, IVB 에서 1,110.39± ml, IAB 에서 ± ml 로 IAB 에서유의하게적었다. 수혈빈도는 IVU 에서 5/50 명 (10.0%), IAU 에서 2/44 명 (4.5%) 으로 IAU 가적었으나유의하지는않았고, IVB 에서 16/54 명 (29.6%), IAB 에서 1/35 명 (2.9%) 으로 IAB 에서유의하게적었 다. 평균수혈량은 IVU 에서 44.80± ml, IAU 에서 21.80± ml 로 IAU 가적었으나유의하지않았고, IVB 에서 ± ml, IAB 에서 18.30± ml 로 IAB 에서유의하게적었다. 실혈량은 IVU 에서 1,318.70± ml, IAU 에서 ± ml 로, IAU 에서유의하게감소했고, IVB 에서 1,837.40± ml, IAB 에서 1,337.60± ml 로 IAB 에서유의하게감 소했다. 합병증으로심부정맥혈전증이 IVU 에서 1 예발생하였다. 결론 : 인공슬관절전치환술시행시 TXA 의관절내도포는정맥주사보다실혈량을유의하게감소시켰으며, 특히양측인공관절치 환술시수혈빈도를줄일수있는방법이었다. 색인단어 : 트라넥사민산, 인공슬관절전치환술, 실혈량, 수혈량 접수일 2017 년 4 월 3 일수정일 2017 년 8 월 15 일게재확정일 2017 년 8 월 16 일책임저자김동휘 61453, 광주시동구필문대로 365, 조선대학교병원정형외과 TEL , FAX , oskdh@chosun.ac.kr * 이논문은 2015 년도조선대학교병원선택진료학술연구비에의하여연구되었음. 대한정형외과학회지 : 제 53 권제 2 호 2018 Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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