Journal of Korean Society of Spine Surgery Acute Epidural Hematoma Following Cervical Spinal Fracture in a Patient with Ankylosing Spondylitis Natural

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Journal of Korean Society of Spine Surgery Acute Epidural Hematoma Following Cervical Spinal Fracture in a Patient with Ankylosing Spondylitis Natural History of Lumbar Degenerative Kyphosis with

1 Journal of Korean Society of Spine Surgery Acute Epidural Hematoma Following Cervical Spinal Fracture in a Patient with Ankylosing Spondylitis Natural History of Lumbar Degenerative Kyphosis with Conservative Treatment Whoan Jeang Kim, M.D., Shann Haw Chang, M.D., Gyu Sang Lee, M.D., Yong Ho Kim, M.D., Kun Young Park, M.D., Kyung Hoon Park, M.D., Won Sik Choy, M.D. J Korean Soc Spine Surg 2017 Mar;24(1): Originally published online March 31, 2017; Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: Fax: Copyright 2017 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/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Original Article J Korean Soc Spine Surg Mar;24(1): Natural History of Lumbar Degenerative Kyphosis with Conservative Treatment Whoan Jeang Kim, M.D., Shann Haw Chang, M.D., Gyu Sang Lee, M.D., Yong Ho Kim, M.D., Kun Young Park, M.D., Kyung Hoon Park, M.D., Won Sik Choy, M.D. Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea Study Design: Retrospective study. Objectives: To evaluate the natural history of conservatively treated lumbar degenerative kyphosis (LDK). Summary of Literature Review: The correlations between the clinical and radiologic parameters of general adult spinal deformity (ASD) are widely known. However, in LDK, dynamic sagittal imbalance is present during ambulation, meaning that its pathogenesis and natural history are different and not widely recognized compared to those of other forms of ASD, resulting in many controversies regarding treatment. To elucidate the natural history of LDK, we analyzed the clinical and radiologic outcomes of patients, comparing their first and final follow-up visits, and evaluated correlations among clinical and radiologic parameters. Materials and Methods: From June 2006 to January 2014, 31 patients diagnosed with LDK who underwent conservative treatment were studied. The mean age of the patients was 72.5 years, and the mean follow-up period was 59.2 months. Clinical and radiologic evaluations were conducted on the first and final follow-up visits. Clinical evaluations were done using a visual analog scale and the Oswestry disability index, and radiologic evaluations were performed using spinal and pelvic parameters over a follow-up period of at least 24 months. Results: Patients who were diagnosed with LDK and underwent conservative treatment showed no significant differences in their clinical outcomes between the first and final follow-up. Some radiologic parameters significantly progressed. There were no significant differences between clinical and radiologic parameters at the initial and final follow-up visits. Conclusions: During the follow-up period of patients diagnosed with LDK, some radiologic parameters progressed. However, the progress of LDK and the clinical symptoms reported by the patients did not significantly change. Decisions regarding the treatment of LDK should not be made according to radiologic parameters showing the degree of deformity, but by carefully determining the patients clinical symptoms and disability level. Key words: Lumbar degenerative kyphosis, Natural history, Conservative treatment 서론 정상적인척추에서의시상면균형은흉추부후만과요추부전만이이중 S형곡선의형태를이루는것을특징으로하는데이는정상적인척추의기능에매우중요하다. 이정상적인만곡은척추체를시상면상에서정위시켜추간판이나후관절에비정상적인하중을감소시켜척추근육의효율성을증대시키고, 시상면상균형유지를위한근육의피로도를감소시키며, 이는척추의퇴행성변화를방지하는효과를나타내기때문이다. 1) 이러한시상면상균형이소실되게되면요통이발생하며심한경우에는체간이전방으로굽게되어보행에장애를초래하게된다. 2, 3) 요추부전만곡은직립자세에가장중요한역할을담당하고, 요추에서의전만의감소는척추의시상면불균형을일으키 는주된요인이되어이를편평배부증후군 (Flatback syndrome) 이라하였고그원인으로는서양에서는신연기기술을이용한 흉, 요추부후방유합술을시행후나타나는요추부전만소실에 의해발생하는경우가많다고보고되었다. 4) 하지만동양에서의 요추시상면변형은서양에서의양상과는차이가있는데, 1988 Received: December 26, 2016 Revised: January 2, 2017 Accepted: February 2, 2017 Published Online: March 31, 2017 Corresponding author: Shann Haw Chang, M.D. Department of Orthopedic Surgery, Eulji University Hospital 95, Dunsanseoro, Seo-gu, Daejeon, Korea, TEL: , FAX: smartguy1000@hotmail.com 24 Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn 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.

3 Journal of Korean Society of Spine Surgery Natural History of Lumbar Degenerative Kyphosis with Conservative Treatment 년 Takemitsu 등 5) 은일본농촌의고령의여성에서장시간에걸쳐쪼그려않는자세로인해발생하는배부신전근의광범위한퇴행성변화와근력약화로인하여요추체또는추간판의퇴행성변화로인한후만변형을보고하였고, 이를퇴행성요추부후만증 (Degenerative lumbar kyphosis) 라고명명하였다. 이는누운상태의방사선검사상에서는시상면균형에경미한이상소견을보이지만기립상태에서는심한후만변형이발생하는동적불안정성 (dynamic instability) 을특징으로한다. 1,2,5,6) 심한요추후만변형은보행의장애를초래할뿐만아니라삶의질에지대한영향을미치고최근에는수술술기및기구의발달등으로적극적인치료가증가되는추세에있다. 하지만대부분환자들의연령이고령인경우가많고, 수술을시행할시유합분절의수가많고장시간의수술시간및출혈등으로인하여내과적합병증이발생할가능성이많으며, 수술후에도지속적인통증을호소하거나수술에대한불만족을호소하는경우도있기때문에요추퇴행성후만증을수술적으로치료해야하는가에대해서는아직도논란이있다. 6) 이에저자들은퇴행성요추후만증을진단받은환자들중수술적치료를받지않고보존적치료를시행한환자들에대하여처음내원시와최종추시시의임상적결과및방사선학적결과를측정하고두결과간의연관성을분석하여임상적증상이악화되는지, 또는방사선학적지표들이진행되는지자연경과를밝히고자본연구를시행하였다. 대상자는모두여자였다. 2. 임상적평가임상적평가는 visual analogue scale (VAS) 7) 와 Oswestry disability index (ODI) 8) 를이용하여처음내원시와최종추시시에측정하였다. VAS 는 0점에서 10점까지범위안에서통증이심할수록 10점에가깝게측정하였다. ODI는 0~20% 까지는경도의장애 (minimal disability), 21~40% 까지는중등도의장애 (moderate disability), 41~60% 까지는중증의장애 (severe disability), 61~80% 까지는불구상태 (crippled), 81~100% 까지는침상안정상태로분류하여측정하였다. 3. 방사선학적평가모든환자에서단순방사선사진은 36인치필름을사용하여추체들이잘보이는동시에시상수직축의후방전위를최소화시키며평상시의기능적인자세를재현하기위해서 Spinal Deformity Study Group (SDSG) 방법9) 에따라상지는주관절을굴곡하고수부를쇄골위에위치시키는 fists-on-clavicle position(fig. 1A) 과 Kim 등 10) 의연구에서추천하는양팔을끌어안은자세 (cross-arm position; Fig. 1B) 를취하고고관절과슬관절은최대한신전한상태에서경추와고관절을포함한기립상 대상및방법 1. 연구대상본연구는본원에서 2006 년 6월부터 2014 년 1월까지임상및방사선소견상요부변성후만증으로진단후보존적치료를받은모든환자들중골다공증성압박골절이있거나, 척추수술을받은과거력이있는경우, 슬관절이나고관절의퇴행성질환으로수술을받은경우, 퇴행성측만증이있는경우를제외하고최소 2년이상추시가가능했던 31예의환자들을대상으로후향적으로시행하였다. 모든환자에서몸이앞으로굽어지면서생기는보행장해, 몸앞으로무거운물건을들기가어렵고, 주방일을할때나세수할때팔꿈치를싱크대나세면대에고여야하며, 언덕길을올라가기힘든증상등의네가지특징적인증상 (Four Cardinal symptoms) 을보였으며, 방사선소견상시상수직축 (Sagittal vertical axis) 이 5 cm 이상인시상면불균형을보였다. 본연구에서는모든환자에게약물치료, 물리치료등에보존적치료를추시관찰기간동안시행하였으며, 수술적치료를시행받은환자는연구대상에서제외시켰다. 연령분포는평균 72.5 세 (54~84 세 ), 추시기간은평균 59.2 개월 (25~106 개월 ) 이었고, A Fig.1. The fists-on-clavicle (A) or cross-arm position (B) is recommended with an extended hip and knee while taking radiographs. B 25

4 Whoan Jeang Kim et al Volume 24 Number 1 March 2017 전척추측면방사선촬영을각각시행하였다. 11) 방사선학적계측은첫내원시, 최종추시관찰시에각각시상수직축 (Sagittal vertical axis), 흉추후만각 (thoracic kyphosis angle), 흉요추후만각 (thoracolumbar kyphosis angle), 요추전만각 (lumbar lordosis), 골반경사각 (pelvic tilt), 천추경사 (sacral slope), 골반입사각 (pelvic incidence), 골반입사각과요추전만각의차이값을측정하였다. 각각의전, 후만각은기립상전척추측면방사선사진에서 Cobb 의방법 12) 을사용하였으며, 시상수직축은제 7경추체중심에서내린수선 (C7 plumb line) 에서제 1천추후상연까지의거리 (cm) 로측정하였고, 흉추후만각은제 4흉추에서제 12흉추, 흉요추부후만각은제 10흉추에서제 2요추, 요추전만각은제 1요추에서제 1천추사이로하였다. 골반경사각은제 1천추상연의중심에서고관절축을잇는선과 고관절중심을지나는수직선과의각으로측정하였고골반입사각은제 1천추의상연과수평선과의각으로측정한천추경사와골반경사의합으로정하였다 (Fig. 2). 4. 통계학적분석임상적지표인 VAS, ODI와방사선학적지표인시상수직축, 흉추후만각, 흉요추후만각, 요추전만각, 골반경사각, 천추경사, 골반입사각, 골반입사각과요추전만각 (lumbar lordosis) 의차이값들은모두연속변수이며, 이지표들의처음내원시와최종추시시값들에대하여 paired t-test 를시행하였다. 임상적지표값과방사선학적지표값들간의상관성을분석하기위하여, 처음내원시와최종추시시의 ODI 및 VAS 와 Schwab 등 13) 이제시한시상면조절인자들 (sagittal modifiers) 인시상수직축 (SVA), 골반경사각 (PT), 골반입사각과요추전만각의차이값 (PI-LL) 들간에 Pearson 상관분석을시행하였다. 통계학적으로 SPSS v20.0 을이용하였으며 p-value 가 0.05 미만인경우통계적으로유의한것으로간주하였다. 결과 퇴행성요추후만증으로진단받은 31명의환자들에서비수술적치료시임상적결과는 VAS 와 ODI를이용하여평가하였다. VAS 는처음내원시평균 3.3(2~6), 최종추시시평균 3.4(2~5) 였고, ODI 점수는처음내원시평균 31.9(19~58), 최종추시시평균 34.7(20~52) 로측정되었으며두지표모두처음내원시와최종추시시간에통계적으로유의한차이는없었다 (Table 1). 방사선학적지표들중시상수직축은내원시평균 8.5 cm (5.5~24.3 cm), 최종추시시평균 17.0 cm (5.8~45.8 cm) 으로증가되었고, 요추전만각은내원시평균 6.2도 (-15.6~24.9 도 ), 최종추시시평균 -5.4도 (-20.3~8.4 도 ) 로감소하였으며, 흉요추후만각은내원시평균 15.9 도 (1.4~31.6 도 ), 최종추시시평균 19.5 도 (2.3~37.8 도 ) 로증가하였고, 골반지수와요추전만각의차이값은내원시평균 51.1 도 (35.4~76.1 도 ), 최종추시시평균 67.4 도 (-39.7~101 도 ) 로증가하는것으로측정되었고, 이 4가지항목은통계적으로유의하였다 (Table 2). 흉추후만각, 골반경사각, 천추경사, 골반입사각은처음내원시 Fig. 2. Schema displaying Cobb s method for thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, and the sagittal vertical axis. The pelvic parameters (pelvic tilt, sacral slope, and pelvic incidence) are also indicated for the lateral whole spine. LL, lumbar lordosis; TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; SVA, sagittal vertical axis; PI, pelvic incidence; SS, sacral slope; PT, pelvic tilt. Table 1. Average results of clinical index in initial and last follow-up Initial Last follow-up p-value VAS* 3.3 (2~6) 3.4 (2~5) ODI 31.9 (19~58) 34.7 (20~52) *VAS: visual analogue scale, ODI: Oswestry disability index. 26

5 Journal of Korean Society of Spine Surgery Natural History of Lumbar Degenerative Kyphosis with Conservative Treatment 와최종추시시간에통계적으로차이가없었다 (Table 2). 또한 처음내원시와최종추시시의임상적지표인 VAS 및 ODI 와 방사선학적인지표중시상수직축, 골반경사각, 골반입사각과 요추전만각의차이값들간각각모두에서통계적인유의한차 이는없었다 (Table 3, Fig. 3). 고찰 척추만곡의이상을평가할때에는관상면상에서의만곡만이 아니라시상면상의균형을 3 차원적으로평가하여야하는데, 흉 부의후만곡과요부의전만곡을정상적인상태로유지하는것 은매우중요하다. Doherty 4) 가 Harrington 신연기기를이용하여 척추측만증수술후요추의전만곡소실로인하여발생하는체 간이앞으로숙여지고무릎을굽히지않고는직립보행을할수 없는자세이상과요통이생긴다고보고한이후관상면상에서 의정렬뿐만아니라시상면상에서의정렬에대해서많은연구 가이루어지게되었고, Moe 와 Denis 14) 는이를편평배부증후군 (flatback syndrome) 이라고정의하였다. 하지만 Takemitsu 등 5) 은동양에서발생하는편평배부의원인 은서양에서주로발생하는의인성이아니라장시간구부린자 Table 2. Average values of radiologic parameters in initial and last follow-up Initial Last follow-up p-value LL ( )* 6.2(-15.6~24.9) -5.4(-20.3~8.4) TK ( ) 8.1(1.3~13.4) 8.4(1.2~22) TLK ( ) 15.9(1.4~31.6) 19.5(2.3~37.8) <0.001 SVA (cm) 8.5(5.5~24.3) 17.0(5.8~45.8) PI ( ) 57.5(36.3~85) 59.8(38.3~80.9) SS ( ) 18.4(1.1~28.4) 19.4(2.1~32.7) PT ( )** 39.2(22.5~65.2) 40.4(29.6~60.8) PI-LL ( ) 51.1(35.4~76.1) 67.4(39.7~101) <0.001 *LL: lumbar lordosis angle, TK: thoracic kyphosis angle, TLK: thoracolumbar kyphosis angle, SVA: sagittal vertical axis, PI: pelvic incidence, SS: sacral slope, **PT: pelvic tilt, : Statistically significant. 세에서일을한중, 장년에서추간판의퇴행에따른추간판간격 의감소와척추체의퇴행성변화에따른높이의감소, 그리고배 부신전근의약화에의한시상면불균형을퇴행성요추후만증 (Degenerative lumbar kyphosis) 이라명명하였다. 이후퇴행성 요추후만증은척추변형의중요한원인이며유병율또한상당 히높다는것이밝혀졌으며, 여성에서호발하며좌식문화권인 일본이나한국에서주로보고되고있다. 퇴행성요추후만증은특이한임상양상을가지는질환이다. 몸이앞으로굽어지면서생기는보행장애, 몸앞으로무거운물 건을들기가어렵고, 주방일을할때나세수할때팔꿈치를싱크 대나세면대에고여야하며, 언덕길을올라가기힘든증상등의 네가지특징적인증상 (Four Cardinal symptoms) 으로요약할수 있다. 이러한증상들로인하여환자들은일상생활에서어려움 을호소하고있다. Takemitsu 등 5) 은수술적치료의적응증으로, 65 세이하의노동이가능한사람, 보존적인치료에반응이없을 때, 골다공증이심하지않은경우, 환자가치료에대한의지가 강한경우등을언급하였으나이는평균수명이증가하였고, 환 자들의주관적인증상에따라적응증또한달라지므로정확한 수술적치료의적응증이될수없다고사료된다. 최근고령인구의증가, 삶의질에대한욕구의증가및수술 술기의발달로성인척추변형 (Adult spinal deformity) 에대한 수술적치료는점차증가하는추세이며이에대한많은연구들 이보고되고있다. 성인척추변형에서수술적치료가비수술적 치료에비해임상적결과가양호하고, 15) 10 년간의장기간추시 Clinical parameters VAS ODI Sagittal modifers SVA Statistical significance (-) (p>0.05) Fig. 3. Schematic diagram relating the clinical and radiological parameters at the initial and final follow-up visits. PT PI-LL Table 3. P-values after statistical analysis between clinical and radiological parameters in initial and last follow-up Initial Last follow-up SVA PT PI -LL SVA PT PI-LL VAS* ODI *VAS: visual analogue scale, ODI: Oswestry disability index, SVA: sagittal vertical axis, PT: pelvic tilt, PI: pelvic incidence, LL: lumbar lordosis angle. 27

6 Whoan Jeang Kim et al Volume 24 Number 1 March 2017 B A C D Fig. 4. Differential diagnosis of sagittal imbalance. (A) Initial radiograph of a 65-year-old man shows L3-on-L4 spondylolisthesis with severe pain and disability. (B) Magnetic resonance imaging shows L3-L4 spinal stenosis. (C) The patient underwent L4 nerve root block. (D) Two months later, the pain subsided and follow-up radiography revealed no sagittal imbalance. 관찰에서수술적치료가비수술적치료에비하여좀더비용효율 (cost-effective) 이좋으며, 16) 또한 75세이상의척추변형환자들을대상으로수술적인치료를한군과비수술적인치료를한군을비교한결과수술적인치료를받은환자들에서통증및장애정도에서더좋은결과를얻었다고보고되었다. 17) 하지만동양에서발생하는성인척추변형환자들은서양에서발생하는성인척추변형환자들과는질병군이다르고, 좌식문화등의생활습관이서양과는달라수술적치료가더좋은경과를얻을수있는지의심스럽다. 퇴행성요추부후만증의경우저자들은몸이앞으로굽는증상과방사선학적소견과다른양상으로나타나는동적인시상면불균형 (dynamic sagittal imbalance) 상태라고보고하였고, 18) 또한방사선학적검사에서는시상수직축이 5 cm 미만으로시상면균형을이루는것처럼보이지만실제로는불균형상태인숨겨진시상면불균형 (hidden sagittal imbalance) 이나타나기도한다. 19) 이를간과하여단분절감압술및유합술을시행하게되면수술후몸이앞으로다시굽고심한통증및일상생활에장애가발생하여재수술로이어질수있다. 이와는반대로실제로는시상면균형상태이나심한통증으로인하여시상면불균형상태로나타날수있는경우도있기때문에퇴행성요추부후만증환자들의경우에는진단및수술결정에있어서매우신중해야 한다 (Fig. 4). 일반적인퇴행성요추질환인퇴행성척추관협착증에대한자연경과는잘알려져있고, 20) 성인척추변형중의하나인퇴행성요추측만증의경우수술적치료및비수술적치료의적응증, 만곡의진행여부, 통증및장애의진행여부등의자연경과에대한많은연구가이루어지고있지만, 21-23) 퇴행성요추부후만증환자들의경우정확한자연경과및병태생리에대하여아직보고된바가없다. 퇴행성요추부후만증은앞서말한데로정확한기전이밝혀지지않았고, 확실하게정해진수술방법이존재하지않으며, 수술적치료에대한정확한적응증또한없고, 수술후의만족도역시다양하게보고되고 24-27) 있는실정이기때문에저자들은이것들에대한고민에서시작하여본연구를진행하게되었다. 본연구의퇴행성요추부후만증환자 31예에서보존적치료를시행한결과처음내원시와최종추시시간의방사선학적지표값은진행하였지만임상적증상은크게차이가없는것으로나타났다 (Fig. 5, 6). Schwab 등 13) 은성인척추변형환자들의건강관련삶의질 (HRQOL, Health-related quality of life) 지표인 ODI, SRS-22, Short Form-36 들과시상면조절인자들 (sagittal modifiers) 인시상수직축 (SVA), 골반경사각 (PT), 골반입사각과요추전만각 28

(B) Sagittal imbalance developed 97 months after conservative treatment was initiated, and her ODI score (40%) slightly decreased. 의차이값 (PI-LL) 들간에각각모두가유의한차이가있으며이지표들의교정이수술적치료에서중요한요소로작용한다고하였다.

7 Journal of Korean Society of Spine Surgery Natural History of Lumbar Degenerative Kyphosis with Conservative Treatment A B Fig. 5. A 64-year-old woman with lumbar degenerative kyphosis with sagittal imbalance. (A) Initial radiograph showing sagittal imbalance and an Oswestry disability index (ODI) score of 42%. (B) Sagittal imbalance developed 97 months after conservative treatment was initiated, and her ODI score (40%) slightly decreased. 의차이값 (PI-LL) 들간에각각모두가유의한차이가있으며이지표들의교정이수술적치료에서중요한요소로작용한다고하였다. 하지만본연구결과에서는처음내원시와최종추시시모두에서 Schwab 이제시한시상면조절인자들 (sagittal modifiers) 과 13) 환자들의임상적지표간의통계적인유의성은없는것으로나타났다. 이는퇴행성요추부후만증의정확한병태생리가잘알려져있지않으며, 또한요추부근육이관련되어있어이러한현상이나타나는것으로추정되나, 아직좀더많은연구가필요할것으로사료된다. 본연구에는몇가지제한점이있다. 첫째, 연구의대상환자대부분이보상기전이이미무너진척추시상불균형이있는환자들이며, 정상적인보상기전을갖는환자들과의비교분석연구가아니라는점이다. 둘째, 연구의대상에서수술적치료를시행받았던환자는제외되었으며, 이는비교적증상이수술적치료를시행한경우보다경미한환자들대상으로하였다는점이다. 셋째, 후향적연구라는점이다. 아직까지도퇴행성요추부후만증환자들에대한수술적치료및비수술적치료에대한정확한결론은없으며수술적치료에대한적응증역시정확하지못하고, 자연경과에대해서도잘알려져있지않으며, 이에대하여추후다기관전향적연구를통한연구가필요할것으로사료된다. 결론 퇴행성요추부후만증환자의수술적치료가증가하고이로인해수술후발생하는문제점들역시많이발생하고있다. 하지만퇴행성요추부후만증환자들에대한수술적치료및비수술적치료의적응증은여전히불분명하며그자연경과역시정확히밝혀진것이없는실정이다. 본연구에서는퇴행성요추부후만증환자들에게보존적치료를시행한결과임상적지표들은진행하지않았고, 비록방사선학적지표들은진행되었으나그진행정도와환자가느끼는임상증상간의유의한차이는없었다. 퇴행성요추부후만증환자의치료결정에있어변형의정도를나타내는방사선학적지표들로결정하면안되며, 환자의임상증상및장애정도에따라매우신중히결정해야할것으로사료된다. A Fig. 6. An 84-year-old woman with lumbar degenerative kyphosis with sagittal imbalance. (A) Initial radiograph showing sagittal imbalance and an Oswestry disability score (ODI) of 30%. (B) Sagittal imbalance had not developed 60 months after conservative treatment, but the ODI score (32%) slightly increased. B REFERENCES 1. Lee C-S, Kim Y-T, Kim E. Clinical study of lumbar degenerative kyphosis. J Korean Soc Spine Surg. 1997;4:

8 Whoan Jeang Kim et al Volume 24 Number 1 March Lee CS, Lee CK, Kim YT, et al. Dynamic sagittal imbalance of the spine in degenerative flat back: significance of pelvic tilt in surgical treatment. Spine (Phila Pa 1976). 2001;26: Lee CS, Chung SS, Chung KH, et al. Significance of pelvic incidence in the development of abnormal sagittal alignment. J Korean Orthop Assoc. 2006;41: Doherty J. Complications of fusion in lumbar scoliosis. J Bone Joint Surg Am. 1973;55: Takemitsu Y, Harada Y, Iwahara T, et al. Lumbar degenerative kyphosis. Clinical, radiological and epidemiological studies. Spine (Phila Pa 1976). 1988;13: Kim E-H, Han S-K, Kim H-J. A clinical analysis of surgical treatment of lumbar degenerative kyphosis. J Korean Soc Spine Surg. 2001;8: Carlsson AM. Assessment of chronic pain. I. Aspects of the reliability and validity of the visual analogue scale. Pain. 1983;16: Fairbank JC, Pynsent PB. The Oswestry disability index. Spine (Phila Pa 1976). 2000;25: O Brien M, Kuklo T, Blanke K, et al. Radiographic Measurement Manual. Spinal Deformity Study Group (SDSG) Medtronic Sofamor Danek USA, Inc: Kim MS, Chung SW, Hwang C, et al. A radiographic analysis of sagittal spinal alignment for the standardization of standing lateral position. J Korean Orthop Assoc. 2005;40: Kim WJ. Optimal standing radiographic positioning in patients with sagittal imbalance. J Korean Orthop Assoc. 2010;17: Jackson RP, McManus AC. Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study. Spine (Phila Pa 1976). 1994;19: Schwab F, Ungar B, Blondel B, et al. Scoliosis research society Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976). 2012;37: Moe J, Denis F. The iatrogenic loss of lumbar lordosis. Orthop Trans. 1977;1: Smith JS, Lafage V, Shaffrey CI, et al. Outcomes of operative and nonoperative treatment for adult spinal deformity: a prospective, multicenter, propensity-matched cohort assessment with minimum 2-year follow-up. Neurosurgery. 2016;78: McCarthy I, O Brien M, Ames C, et al. Incremental costeffectiveness of adult spinal deformity surgery: observed quality-adjusted life years with surgery compared with predicted quality-adjusted life years without surgery. Neurosurg Focus. 2014;36:E Sciubba DM, Scheer JK, Yurter A, et al. Patients with spinal deformity over the age of 75: a retrospective analysis of operative versus non-operative management. Eur Spine J. 2015; Kim W-J, Kang J-W, Kim H-Y, et al. Change of pelvic tilt before and after gait in patients with lumbar degenerative kyphosis. J Korean Soc Spine Surg. 2009;16: Garbossa D, Pejrona M, Damilano M, et al. Pelvic parameters and global spine balance for spine degenerative disease: the importance of containing for the well being of content. Eur Spine J. 2014;23: Benoist M. The natural history of lumbar degenerative spinal stenosis. Joint Bone Spine. 2002;69: Marty-Poumarat C, Scattin L, Marpeau M, et al. Natural history of progressive adult scoliosis. Spine (Phila Pa 1976). 2007;32: Silva FE, Lenke LG. Adult degenerative scoliosis: evaluation and management. Neurosurg Focus. 2010;28:E Benoist M. Natural history of the aging spine. Eur Spine J. 2003;12(Suppl): Kim WJ, Song DG, Lee JW, et al. Proximal junctional problems in surgical treatment of lumbar degenerative sagittal imbalance patients and relevant risk factors. J Korean Soc Spine Surg. 2013;20: Lee JC, Soh J-W, Jo J-H, et al. Comparative analysis of surgical options in the treatment of lumbar degenerative kyphosis. J Korean Soc Spine Surg. 2009;16: Kim K-T, Lee SH, Suk K-S, et al. Loss of sagittal balance and clinical outcomes following corrective osteotomy for lumbar degenerative kyphosis. J Korean Orthop Assoc. 2009;44: Kim WJ, Kang JW, Kang SI, et al. Factors affecting clinical results after corrective osteotomy for lumbar degenerative kyphosis. Asian Spine J. 2010;4:

9 Original Article J Korean Soc Spine Surg Mar;24(1): 퇴행성요추후만증의보존적치료시자연경과 김환정 장선호 이규상 김용호 박건영 박경훈 최원식을지대학교의과대학정형외과학교실연구계획 : 후향적연구목적 : 수술적치료를시행하지않은퇴행성요추후만증환자들에서자연경과에대하여분석하고자한다. 선행문헌의요약 : 일반적인성인척추변형환자에서의임상적증상과방사선학적지표들간의연관성은많이알려져있다. 하지만주로동양사람들에게발생하는퇴행성요추후만증은특징적으로보행시동적인시상면불균형이나타나기때문에이것의병인및자연경과는다른성인척추변형과다르게잘알려져있지않아치료방법에대한논란의여지가많다. 우리는퇴행성요추후만증의자연경과를밝히기위하여처음내원시와최종추시시의임상적결과및방사선학적결과를분석하였고, 임상적결과및방사선학적결과간의연관성을분석하였다. 대상및방법 : 2006년 6월부터 2014년 1월까지퇴행성요추후만증으로진단받은모든환자중보존적치료를받은총 31명의환자를대상으로하였다. 환자들의평균나이는 72.5세, 평균추시기간은 59.2개월이었다. 모든례에서처음내원했을때와최종추시시의방사선학적및임상적평가를하였다. 최소 24개월이상의추시기간을가졌으며, 임상적평가는 visual analogue scale (VAS) 와 Oswestry disability index (ODI) 를이용하여평가하였고, 방사선학적평가는척추및골반지표들을이용하여측정하였다. 결과 : 퇴행성요추후만증환자들에서비수술적치료시의임상적결과는 VAS, ODI 모두처음내원시와최종추시시간에통계적으로유의한차이는없었다. 방사선학적지표들중시상수직축, 흉요추후만각, 요추전만각, 골반지수와요추전만각의차이값은통계적으로유의하였으나골반경사각은통계적으로차이가없었다. 또한환자들이처음내원시와최종추시시에호소하는임상증상과방사선학적인지표값들간의유의한차이는없었다. 결론 : 퇴행성요추후만증환자에서추시시방사선학적지표들은진행되었으나그진행정도와환자가느끼는임상증상간의유의한차이는없었다. 퇴행성요추후만증환자의치료결정은변형의정도를나타내는방사선학적지표들로결정하면안되며, 환자의임상증상및장애정도에따라신중히결정해야한다. 색인단어 : 퇴행성요추후만증, 자연경과, 보존적치료 약칭제목 : 퇴행성요추후만증의보존적치료시자연경과 접수일 : 2016년 12월 26일 수정일 : 2017년 1월 2일 게재확정일 : 2017년 2월 2일 교신저자 : 장선호 대전광역시서구둔산서로 95 을지대학교의과대학정형외과학교실 TEL: FAX: smartguy1000@hotmail.com Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn 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. 31

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar