KISEP Clinical Article J Korean Neurosurg Soc , 2002 불안정흉추골절환자에서척추경나사못고정술 * 한인호 송근성 Thoracic Pedicle Screw Fixation and Fusion in Unstable T

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1 KISEP Clinical rticle J Korean Neurosurg Soc , 2002 불안정흉추골절환자에서척추경나사못고정술 * 한인호 송근성 Thoracic Pedicle Screw Fixation and Fusion in Unstable Thoracic Spine Fractures In Ho Han, M.D., Geun Sung Song, M.D. Department of Neurosurgery, School of Medicine, Pusan National University, usan, Korea Objective:The goal of study is the evaluation of clinical and radiological outcome of thoracic pedicle screw fixation and fusion in unstable thoracic spine fractures. Methods:The authors retrospectively studied 21 patients with unstable thoracic fractures received thoracic pedicle screw fixation and fusion from 1995 to We analyzed the pre- and postoperative neurological findingfrankel functional classification, radiological findingsagittal index:si, Percentage of anterior body compression:c, complications, and displacement of screws. Results:ll five Frankel E grades remained E grade, 7 of 10 incompletes improved, and 6 complete deficits remained complete. No patients sustained an increase in neurologic deficit. These 21 patients had a mean preoperative SI as 19.3 degrees, which was corrected to 14.4 degrees after operation. fter 6 months follow-up, the SI was 14.2 degrees nd those had an mean preoperative C as 53.8% which was corrected to 34% after operation. t 6 months. the mean C was 34.4%. statistically significant difference existed between the preoperative, postoperative and follow-up SI and C. The complications were respiratory and urinary tract infection, decubitus et al., but the hardware failure was not occurred. The cortical violation of pedicle screw in 4 patients who had mid-upper thoracic fractures was 26.7%, but the displacement was less than 2 millimeter and any neurological, cardiovascular, or pulmonary injury were not revealed. The bone fusion and stabilization was successful in all patients. Conclusion:Pedicle screw fixation and fusion is an effective and safe method in unstable thoracic spine fractures, because of high fusion rate, good neurological and radiological outcome and low complication rate. Mild displacement of pedicle screw does not affect the clinical outcome. So, pedicle screw fixation can be an acceptable procedure in unstable mid-upper thoracic spine fracture or dislocations. KEY WORDS:Unstable thoracic spine fracture Pedicle screw fixation and fusion Cortical violation Mid-upper thoracic spine. 334 서 론 - - J Korean Neurosurg SocVolume 32October, 2002

2 대상및방법 - Table 1. Summary of characteristics in 21 patients who underwent pedicle screw fixation on the thoracic spine Patient no. Diagnosis Sex ge Cause Level of fusion Follow-upMonths 11 T3-4 burst Fx M 47 direct blow T1,T2,T5,T T4-5 burst M 18 T T2,T3,T6,T T4-6 compression M 33 T T2,T3,T7,T T6 Fx-D/L M 24 T T5,T T7-8 Fx-D/L F 21 T T6,T9,T T9 compression M 30 Fall down T8,T9,T T10-12 compression Fx M 36 Fall down T9,T10T11,T T11 compression M 27 Fall down T10,T11,T T11 compression F 40 T T10,T T11 burst M 42 Fall down T10,T T11 Fx-D/L F 12 T T10,T11,L T12 compression M 42 T T11,T12,L T12 compression F 21 T T11,L T12 compression M 46 Fall down T11,T12,L T12 compression M 53 T T11,L T12 compression F 50 Fall down T11,T T12 compression F 32 Fall down T11,T12,L T12 compression M 27 Fall down T11,T12,L T12 burst M 57 T T11,L T12 burst M 26 T T11,L T12 Fx-D/L M 32 T T11,L1 12 FxFracture, Fx-D/LFracture-dislocation, TTraffic accident, MMale, FFemale J Korean Neurosurg SocVolume 32October,

3 - 결과 Table 2. Neurological outcomefrankel fuctional classification dmission Follow up C D E Total C D E 5 85 absent Table 3. Correction of deformity according to radiologic finding Patient No. SI C% Preop. Postop. Final Preop. Postop. Final verage SISagittal index, CPercentage of anterior body compression, PreopPreoperative, PostopPostoperative J Korean Neurosurg SocVolume 32October, 2002

IH Han and GS Song 적인 신경손상이나 혈관손상 역시 없었다 나사못의 삽입위치의 확인은 17례의 중하부 골절의 경우 전후방 및 측방 단순촬영을 통해 척추경 및 척추체에서의 위 치를

$Radiogram of twenty one years old female patient with fracture and dislocation at T7-8.$ Preoperative computed tomography() shows the cord compression by bony fragments and anterior dislocation of

Preoperative computed tomography() shows the cord compression by bony fragments and anterior dislocation of

$Radiogram of forty seven-years-old male patient with T3-4 burst fracture who was neurologically intact.$ Preoperative computed tomography() reveals the cord compression by bony fragments at T3 level. C Fig. 4.

Preoperative computed tomography() reveals the cord compression by bony fragments at T3 level. C Fig. 4.

Postoperative plain anteroposterior() and lateral() films show pedicle screw instrumentation at T6-10 level.

고 찰 최근 척추 골절 환자에 있어서 기구를 이용한 내고정은 이 C Fig. 2. Postoperative radiogram of the same patient(fig.

Postoperative plain anteroposterior() and lateral() film show pedicle screw instrumentation at T1-T6 level.

4 IH Han and GS Song 적인 신경손상이나 혈관손상 역시 없었다 나사못의 삽입위치의 확인은 17례의 중하부 골절의 경우 전후방 및 측방 단순촬영을 통해 척추경 및 척추체에서의 위 치를 확인하여 이탈 없이 척추경내의 삽입위치가 모두에서 만족할 만한 소견을 보였으며 상중부 흉추골절 4례의 경우 단순방사선촬영으로 그 위치의 확인이 힘들어 술후 전산화 단층촬영을 통해 나사못의 위치를 확인하였으며(Fig. 1, 2) 4례에서 삽입된 전체 30개의 나사못 중 8개가 척추경의 피 Fig. 3. Radiogram of twenty one years old female patient with fracture and dislocation at T7-8. Preoperative plain lateral() film shows fracture-dislocation at T7-8. Preoperative computed tomography() shows the cord compression by bony fragments and anterior dislocation of T7 on T8. Fig. 1. Radiogram of forty seven-years-old male patient with T3-4 burst fracture who was neurologically intact. Preoperative plain lateral() film shows T3-4 burst fracture, but upper thoracic spines are not obvious. Preoperative computed tomography() reveals the cord compression by bony fragments at T3 level. C Fig. 4. Radiogram of the same patient(fig. 3) with pedicle screw instrumentation. Postoperative plain anteroposterior() and lateral() films show pedicle screw instrumentation at T6-10 level. Postoperative CT(C) reveals mild lateral displacement of screw on the left side. 및 안정성에는 문제가 없었다. 고 찰 최근 척추 골절 환자에 있어서 기구를 이용한 내고정은 이 C Fig. 2. Postoperative radiogram of the same patient(fig. 1) with pedicle screw instrumentation. Postoperative plain anteroposterior() and lateral() film show pedicle screw instrumentation at T1-T6 level. Postoperative computed tomography(c) reveals good placement of pedicle screws without cortical violation of the vertebral body at T1-2 level. 미 광범위하게 이용되고 있으며 척추경 나사못을 이용한 고 정은 생역학적 연구 결과 다른 후방고정술에 비해 안정성 및 골유합율의 우수성이 보고되어 그 사용이 보다 확대 되고 있다7)22)23). 척추경 나사못을 이용한 고정은 요추부 골절에서는 그 우수성이 확인되었으나 흉추골절의 경우 흉추의 해부학적 질골을 관통하여 외측 및 내측으로 삽입되어 26.7%의 이탈 특성상 추경이 척수와 인접하여 신경관의 손상 위험이 있으 율을 보였으나 모두 2mm 이내로 이탈에 의한 추가적인 통 며 추경이 요추부에 비해 협소하여 나사못의 위치가 잘못될 증 및 기타 합병증은 없었다(Fig. 3, 4) 가능성이 높고 나사의 직경이 너무 큰 경우 추경 골절이 위 21례의 환자 모두에서 마지막 추적 시점에서 만족할 만한 험이 있으며 너무 작을 경우 나사못의 골절을 초래할 수도 골유합 및 안정성을 확인할 수 있었고, 전산화단층촬영으로 있어 그 사용이 제한되어 왔다14)20)21). 특히 상부 흉추의 경 이탈이 확인되었던 상부 흉추골절 환자에 있었어도 골유합 우 단순방사선촬영으로 해부학적 구조의 확인이 힘들어 수 J Korean Neurosurg Soc/ Volume 32 / October,

5 338 J Korean Neurosurg SocVolume 32October, 2002

6 Table 4. Review of thoracic pedicle screw literatures No. of patients or cadavers No. of thoracic screws Means of placement Miss percentage% Gertzbein et al. 10), patients 867 Landmark Fluoroscopy 15 Jiang et al. 11), cadavers 810 Image guidance 80 Vaccaro et al. 22), cadavers 890 Landmark 41 Liljenqvist et al. 15), patients 120 Landmark Fluoroscopy 25 Youkilis et al. 25), patients 266 Image guidance 88.5 This study 84 patients 830 Landmark 결 론 References 1. oucher HH method of spinal fusion. J one Joint Surg 41248, Denis FThe tree-column spine and it s significance in the classification of acute thoracolumbar spinal injuries. Spine 8 J Korean Neurosurg SocVolume 32October,

7 , Dvorak M, MacDonald FS, Gurr KR, ailey SI, Haddad RG n anatomic, radiologic, and biomechanical assessment of extrapedicular screw fixation in the thoracic spine. Neurosurgery , Esses SI, atsford DJ, Kostuik JPEvaluation of surgical treatment for burst fractures. Spine , Faber GL, Place HM, Mazur R, Jones DE, Damiano TR ccuracy of pedicle screw placement in lumbar fusions by plain radiographs and computed tomography. Spine , Farcy JC, Weidenbaum M, Glassman SDSagittal Index in Management of thoracolumbar burst fractures. Spine , Ferguson RL, Tencer F, Woodard P, llen L Jriochemical comparisons of spinal fracture models and the stabilizing effects of posterior instrumentation. Spine , Ferrick MR, Kowalski JM, Simmons ED JrReliability of roentgenog-ram evaluation of pedicle screw position. Spine , disscusssion 1253, Gertzbein SD, Robbins SEccuracy of pedicular screw placement in vivo. Spine , Hou S, Hu R, Shi YPedicle morphology of the lower thoracic and lumbar spine in a Chinese population. Spine , Jiang Z, King P, Zamorano LInteractive image-guided spine surgery. Presented at the 46th nnual Meeting of the Congress of Neurosurgical Surgeons, Montreal, Quebec, Canada, September 28-October 3, 1996(abstr) 12. King DInternal fixation for lumbo-sacral fusion. m J Surg , Kothe R, Panjabi MM, Liu WMultidirectional instability of the thoracic spine due to iatrogenic pedicle injuries during transpedicular fixation. biomechanical investigation. Spine , Liljenqvist UR, Halm HF, Link TMPedicle screw instrumentation of the thoracic spine in idiopathic scoliosis. Spine , McCormark M, enzel EC, dam MS, aldwin NG, Rupp FW, Maher DJnatomy of the thoracic pedicle. Neurosurgery , Mumford J, Weinstein JN, Spratt KF, Goel VKThoracolumar burst fracturesthe clinical efficacy and outcome of nonoperative management. Spine , Roy-Camille R, Saillant G, Salgado VOsteogenesis of thoracolumbar spine fractures with metal plates screwed through the vertebral pedicle. Reconstr Surg Traumatol , Sasso RC, Costler HPosterior Instrumentation and fusion for unstable fractures and fracture-dislocations of the thoracic and lumbar spine. Spine , Sjostrom L, Jacobsson O, Karlstrom G, Pech P, Rauschning W CT analysis of pedicles and screw tracts after implant removal in thoracolumbar fractures. J Spinal Disord , Suk SI, Lee CK, Kim WJ, Choe SY, Park SDSegmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine , Suk SI, Lee CK, Min HJ, Cho KH, Oh JHComparison of Cotrel-Dubousset pedicle screws and hooks in the treatment of idiopathic scoliosis. Int Orthop Vaccaro R, Rizzolo SJ, llardyce TJ, Ramsey M, Salvo J, alderston R, et alplacement of screw in the thoracic spine Part I- Morphometric analysis of the thoracic vertebrae. J one Joint Surg , Wood K, Wentorf F, Ogilvie JW, Kim KTTorsional rigidity of scoliosis constructs. Spine , Xu R, Ebraheim N, Ou Y, Skie M, Yeasting Rnatomic considerations of pedicle screw placement in the thoracic spine Roy-Camille technique versus open-lamina techinque. Spine , Youkilis S, Ouint DJ, McGillicuddy JE, Papadapoulos SM Stereotactic navigation of placement of pedicle screw in the thoracic spine. Neurosurgery , J Korean Neurosurg SocVolume 32October, 2002

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