203 Symposium J Korean Orthop Assoc 2019; 54: Minimal Invasive Surgery for Lumbar Spin

Size: px

Start display at page:

Download "203 Symposium J Korean Orthop Assoc 2019; 54: Minimal Invasive Surgery for Lumbar Spin"

성민 고
5 years ago
Views:

1 203 Symposium J Korean Orthop Assoc 2019; 54: Minimal Invasive Surgery for Lumbar Spine Problems pissn : , eissn : 최소침습적외측요추간유합술 : 적응증, 결과, 합병증 소재완 이재철 * 순천향대학교부속천안병원정형외과, * 순천향대학교부속서울병원정형외과, 척추센터 Minimally Invasive Lateral Lumbar Interbody Fusion: Indications, Outcomes and Complications Jaewan Soh, M.D. and Jae Chul Lee, M.D.* Department of Orthopedic Surgery, Soonchunhyang University Cheonan Hospital, Cheonan, *Department of Orthopedic Surgery and Spine Center, Soonchunhyang University Seoul Hospital, Seoul, Korea The aim of this review was to evaluate minimally invasive lateral lumbar interbody fusion on the latest update. Lumbar interbody fusion was introduced recently. This study performed, a literature review of the indications, clinical outcomes, fusion rate, and complications regarding recently highlighted minimally invasive lateral lumbar interbody fusion. The indications of lateral lumbar interbody fusion are similar to the conventional anterior and posterior interbody fusion in degenerative lumbar diseases. In particular, lateral lumbar interbody fusion is an effective minimally invasive surgery in spinal stenosis, degenerative spondylolisthesis, degenerative adult deformity, degenerative disc disease and adjacent segment disease. In addition, the clinical outcomes and fusion rates of lateral lumbar interbody fusion are similar compared to conventional lumbar fusion. On the other hand, non-specific complications including hip flexor weakness, nerve injury, vascular injury, visceral injury, cage subsidence and pseudohernia have been reported. Lateral lumbar interbody fusion is a very useful minimally invasive surgery because it has advantages over conventional anterior and posterior interbody fusion without many of the disadvantages. Nevertheless, nonspecific complications during lateral lumbar interbody fusion procedure remain a challenge to be improved. Key words: lumbar, degenerative lumbar disease, lateral lumbar interbody fusion 서론 퇴행성요추부질환의수술적치료에추체간유합술은유용한수 술법이다. 추체간유합술의방법중외측요추체간유합술 (lateral lumbar interbody fusion) 은옆구리를통해복막뒤쪽으로접근 하고요근을통과하여추체의외측으로전방추체간유합술을 할수있는최소침습적수술법이다. 개발한기구회사의상품명 Received August 29, 2018 Revised October 4, 2018 Accepted October 15, 2018 Correspondence to: Jae Chul Lee, M.D. Department of Orthopedic Surgery and Spine Center, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea TEL: FAX: jlee@schmc.ac.kr ORCID: 에따라극외측추체간유합술 (extreme Lateral Interbody Fusion [XLIF]; NuVasive Inc., San Diego, CA, USA) 또는직접외측추체간유합술 (direct lateral interbody fusion [DLIF]; Medtronic, Memphis, TN, USA) 로도불린다. 이는 2003년 Bertagnoli와 Vazquez 1) 가전외측경요근접근법 (anterolateal transpsoas approach) 이라는신기술을발표한이후지속적으로발전하여 2006년 Ozgur 등 2) 이요추전방유합술의새로운수술방법으로극외측추체간유합술을발표하면서최소침습적외측요추체간유합술이주목을받기시작했다. 현재외측요추체간유합술을위한최소침습적수술기구들이다양하게개발되었으나국내에는의료보험의저수가로인해 DLIF 체계 (DLIF system; Medtronic) 만도입되어있다. 외측요추체간유합술은최소침습적수술이기때문에연부조직손상이적고, 수술중출혈량이적으며, 회복이빨라재원기 The Journal of the Korean Orthopaedic Association Volume 54 Number Copyright 2019 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.

2 204 Jaewan Soh and Jae Chul Lee 간의단축및재활기간이짧은장점이있다. 또한후관절, 척추주위근육등해부학적으로중요한후방구조물을보존할수있다. 2,3) 그리고고식적전방추체간유합술시발생할수있는합병증의가능성이적으며, 후방추체간유합술에비해외측요추간유합술에사용하는케이지 (cage) 가더커서추간판높이를효과적으로복원하여신경관을간접적으로감압시킬수있고, 접촉하는면적이넓어서유합도효과적이다. 3) 또한요추부퇴행성변형에서시상면과관상면의균형을효과적으로교정할수있다. 4) 초기에외측요추체간유합술의적응증은퇴행성추간판질환정도로제한적이었으나현재는발전을거듭하여그적응증이확대되었고, 그임상결과에대해서도고식적수술방법과비교하여많은결과가소개되고있다. 하지만이수술법에대한합병증들도보고되고있어외측요추체간유합술에대한평가는진행되고있는중이다. 적응증및금기증 외측요추체간유합술은기본적으로기존의추체간유합술과그적응증이동일하나그범위는제1 요추부터제5 요추까지로제한되어있다. 수술할부위가제2-3 요추부보다상위일경우늑골이, 제4-5 요추부보다하위일경우장골능이접근에방해가되기때문이다. 외측요추체간유합술의적응증으로는척추관협착증, 척추전방전위증, 팽윤형추간판탈출증, 퇴행성척추측만증, 척추후만증, 퇴행성추간판질환, 인접분절퇴행성질환, 불유합으로인한가관절증등이있다. 4) 그러나골절이나악성종양등종판의손상이있어케이지나이식골을위한적절한지지대역할을하지못하는경우, 심한골다공증환자, 감염, 게실염 (diverticulitis) 등후복막염증또는질환이있는경우, 이전에후복막수술을했던경우는적응이되지않는다. 5) 또한외측접근법으로신경관에대한직접감압이나탈출된추간판조각의제거를할수없기때문에탈출형혹은유리형 (sequestrated) 추간판탈출증에서도적응이되지않는다 (Table 1). 1. 척추관협착증중심성및추간공척추관협착증에서외측요추체간유합술을시행하면추간판높이를상승시키면서추간공 (neural foramen) 을증가시키고황색인대를신장시켜중심신경관 (central canal) 이상대적으로넓어지면서신경을간접적으로감압하는효과가있다 (Fig. 1). 2) Oliveira 등 3) 은외측요추간유합술을시행하면추간판높이가 42%, 추간공높이가 14%, 추간공면적이 25%, 척추관직경이 33% 증가한다고하였다. 하지만 Yang 등 6) 은척추관협착증환자에서외측요추간유합술을시행한후수술과정에서척수조영술을시행하여그결과 를평가하였는데대다수는외측요추간유합술을시행하고만족 스러운간접감압 (indirect decompression) 을얻었으나일부는만 족스러운간접감압을얻지못하여후방에서감압술을시행하였 다고하였다. 이는황색인대가과도하게비후되어있었거나삽 입된케이지의크기가작아서추간판높이회복이만족스럽지못 한경우였다고분석하였다. 2. 퇴행성척추전방전위증 척추전방전위증중에서퇴행성척추전방전위증은추간판또 는후관절의퇴행성변화로인하여불안정성이초래되면서발생 한다. 추체가전방으로전위되면서추간판높이는감소하고척추 관및추간공이좁아지며후관절이신경을압박하는것이병리이 다. 따라서수술의목적은압박된신경을감압해주고감소된추 간판높이를회복해주며해당분절을정렬하여안정적으로유지 해주는것이다. 고식적으로는후방에서감압술을시행하고추체 간유합술을시행했다. Pawar 등 7) 은고식적인후방추체간유합 술과최소침습적외측요추체간유합술을임상적, 방사선적으로 비교하였는데추간판높이회복은최소침습적외측요추체간유 합술이고식적인후방추체간유합술보다더결과가좋았고시상 정렬및최종임상결과는두군간에큰차이는없었다고하였다. 또한 Goyal 등 8) 은퇴행성척추전방전위증을외측요추체간유 합술로치료한결과에대해서메타분석을시행하였는데방사선 적결과, 유합률, 임상결과모두유용하다고하였다. 3. 퇴행성척추변형 퇴행성척추변형의수술적치료에있어서신경관감압과변형 교정을위해장분절고정을시행해야하는데대부분이고령이고 수술범위가크다보니장시간마취로인한대량출혈및내과적 Table 1. Indications and Contra-Indications for Lateral Lumbar Interbody Fusion Indications Spinal stenosis central, foraminal Degenerative spondylolisthesis Degenerative adult deformity Degenerative disc disease Adjacent segment disease Contraindications Endplate fracture Severe osteoporosis Active infection Past history of retroperitoneal infection or surgery Sequestrated herniated intervertebral disc

205 Recent Updates for Lateral Lumbar Interbody Fusion A B C D Figure 1.

narrowing of the disc height on L3 4 (arrow).

sagittal image shows widening of foramen due to restoration of disc height on L3 4 (arrow).

(D) After lateral lumbar interbody fusion and posterior percutaneous screw fixation, the T2-weighted MR

decompression. Cobb's angle: 20 Cobb's angle: 7 PT: 51 LL: 21 SS: 18 PT: 31 LL: 45 SS: 32 A B Figure 2.

scoliosis on lumbar spine was corrected.

kyphosis on lumbar spine had been corrected. LL, lumbar lordosis; SS, sacral slope; PT, pelvic tilt.

3 205 Recent Updates for Lateral Lumbar Interbody Fusion A B C D Figure 1. (A) Preoperative T2-weighted magnetic resonance (MR) sagittal image shows spinal foraminal stenosis due to a narrowing of the disc height on L3 4 (arrow). (B) Preoperative T2-weighted MR sagittal image shows spinal central stenosis due to hypertrophy of ligament flavum on L3 4 (arrow). (C) After lateral lumbar interbody fusion and posterior percutaneous screw fixation, the T2-weighted MR sagittal image shows widening of foramen due to restoration of disc height on L3 4 (arrow). This shows indirect foraminal decompression. (D) After lateral lumbar interbody fusion and posterior percutaneous screw fixation, the T2-weighted MR sagittal image shows widening of the neural canal due to distraction of ligament flavum on L3 4 (arrow). This shows indirect central decompression. Cobb's angle: 20 Cobb's angle: 7 PT: 51 LL: 21 SS: 18 PT: 31 LL: 45 SS: 32 A B Figure 2. (A) Preoperative and postoperative whole spine anterolateral standing plain X-rays show degenerative scoliosis on lumbar spine was corrected. (B) Preoperative and postoperative whole spine lateral standing plain X-rays show that the degenerative kyphosis on lumbar spine had been corrected. LL, lumbar lordosis; SS, sacral slope; PT, pelvic tilt. 합병증등으로수술적치료가위험한경우가많다. 이러한위험성에, 외측요추체간유합술은최소침습적수술로서척추변형을교정할수있다 (Fig. 2). Dakwar 등 9) 은퇴행성척추측만증의치료로외측요추체간유합술을시행하여방사선적, 임상적으로만족할만한결과를얻었다고하였다. Acosta 등 10) 도직접측방경요근접근법 (direct lateral transpsoas approach) 으로수술한퇴행성측만증환자들을대상으로관상면과시상면재정렬에대한분석을하였는데, 관상면교정은통계적의의가있었으 나시상면회복은통계적유의성이없다고하였다. 하지만 Pawar 등 4) 은관상면변형교정뿐만아니라시상면변형교정에도좋은결과를얻었다고하였고, Park 등 11) 도퇴행성척추변형환자에서고식적인후방수술과외측요추체간유합술시행후후방고정을시행한군과의비교하였고시상면교정및임상결과가큰차이가없어외측요추체간유합술이시상면교정에효과적이라고하였다. 그러나최소침습적수술방법으로이러한관상면과시상면을

4 206 Jaewan Soh and Jae Chul Lee 모두만족스럽게교정하는것에는한계가있다. 이에 Mummaneni 등 12) 은퇴행성척추변형의최소침습적치료를적용할수있는지침을만들고자환자의변형정도에따라수술적치료방법접근의순서도 (algorithm) 를제시하였다. 방사선적으로환자의시상축 (sagittal vertical axis) 이 6 cm 이내, 골반경사 (pelvic tilt) 25도이내, 골반부각과요추전만각차이 (pelvic incidence-lumbar lordosis mismatch) 가 30도이내이고, 또는흉추부후만각이 60도이내일때최소침습적수술로시상면교정을해도효과적이라고하였다. 4. 퇴행성추간판질환요추부퇴행성추간판질환은요추부의병적운동성, 부정렬, 진행하는변형, 그리고척추관협착증등과관련된만성요통의흔한원인이다. 또한심한추간판퇴행성변화는분절운동의악화와관련이있다. 치료는보존적또는수술적치료를시행하는데, 치료의목적은비정상적인분절불안정성과통증을경감시키는데있다. 보존적치료로통증이호전되지않는심한퇴행성추간판질환에서는요추부유합술을시행하는데, 특히추체간유합술은후외측유합술보다병인을제거하는효과가있고유합률이높아서수술적치료방법으로적합하다. 추체간유합술중에서전방추체간유합술은접근과정에서혈관손상, 장기손상, 교감신경절의손상등의합병증이발생할수있고수술후장폐색이잘발생한다는단점이있다. 또한후방추체간유합술은접근과정에서위험구조는없지만척추주위근육을박리하면서근육및근육으로가는신경이손상될수있고신경감압및기구삽입과정에서경막파열또는신경근손상이발생할수있다는단점이있다. 외측요추체간유합술은이러한단점들을보완한최소침습적수술법으로서추체간유합술을시행할수있다. 5. 인접분절퇴행성질환요추부퇴행성질환의수술적치료로요추부유합술이많이시행되고있다. 요추부유합술로견고한유합술이이루어진후에는가동분절수의감소로인해인접분절의과도한운동부하와응력의집중이초래되고유합인접분절의퇴행성변화가가속화되어결국인접분절퇴행성질환이초래된다. 이러한인접분절퇴행성질환이발생하면수술적치료로서일반적으로후방에서감압술을시행하고기존의기기에연장을해서기기고정을시행한다. 하지만수술과정에서최초수술로인한반흔조직때문에수술부위의접근이어렵고, 출혈량이증가하며경막손상, 수술부위감염, 그리고척추주위근육의위축및기능부전까지초래하게된다. 이에 Louie 등 13) 은인접분절퇴행성질환이발생한환자에서최소침습수술로서외측요추체간유합술을시행하여케이지단독삽입만으로도만족스러운결과를얻었다고하였다. 또한 Metzger 등 14) 은사체를이용한생역학 적실험에서외측요추체간유합술을시행하여케이지단독고정만으로도충분한안정성과고정력이있다고하였는데그이유는외측요추체간유합술에이용하는케이지가접촉면이넓고요추부의전, 후방인대를모두보존할수있기때문이라고하였다. 결과 1. 임상결과외측요추체간유합술의수술적목적은추간판높이를회복시켜서추간공을확장시키고구부러진황색인대를펴서신경관의간접적인감압을얻는것에있다. Rodgers 등 15) 은퇴행성요추부질환환자 600명을대상으로외측요추체간유합술을시행하였는데임상적으로 visual analogue scale (VAS) 점수는수술직후 65% 에서호전되었고 1년이상추시상 86.7% 에서호전되었다고하였다. 또한 Kotwal 등 16) 도퇴행성요추부질환으로외측요추체간유합술을시행받은 118명의환자를대상으로수술전과비교하여수술직후 VAS는 53%, Oswestry Disability Index (ODI) 는 43%, 12-Item Short Form Survey (SF-12) 는 41% 호전되었다고하였다. Malham 등 17) 은퇴행성요추부질환에서전방요추체간유합술과외측요추체간유합술을시행한환자의임상결과를후향적으로비교분석하였다. 전방요추체유합술을시행한군에서는수술전에비해수술직후요통과하지방사통의 VAS 점수는각각 64%, 65% 향상되었고, ODI는 60% 향상되었으며, SF-36은신체적부분이 44%, 정신적부분이 26% 향상되었다. 외측요추체간유합술을시행한군에서는요통과하지방사통에대한 VAS 점수는각각 56%, 57% 향상되었고, ODI는 52% 향상되었으며, SF-36 은신체적부분이 48%, 정신적부분이 12% 향상되었다고하였다. 두군은모두임상결과는유의하게향상되었으나, 두군간에통계적으로유의한차이는없다고하였다. Keorochana 등 18) 은퇴행성요추부질환에서최소침습적경추간공요추체간유합술과외측요추체간유합술을시행한환자들의임상결과를메타분석하였는데, 경추간공요추체간유합술이외측요추체간유합술보다요통과하지방사통에대한 VAS 점수와 ODI에서보다향상된결과를보였으나두군간에통계적으로유의한차이는없었다고하였다. 2. 유합률요추유합술을시행하면, 불유합이발생할수있다. Bono와 Lee 19) 는전방유합술, 후외측유합술, 후방추체간유합술등의수술방식에따라, 그리고자가골, 동종골, 골대체제등이식물에따라그유합률을분석하였는데최저 85% 에서최고 91% 라고하였다. 외측요추체간유합술의유합률에대하여, Berjano 등 20) 은퇴행성요추부질환에서자가골, 골대체제등을사용하여수술하였던

5 207 Recent Updates for Lateral Lumbar Interbody Fusion 78 분절에대해추시 1년째에 68 분절 (87.1%) 에서완전유합을보였다고하였으며, Marchi 등 21) 은케이지단독삽입만시행하였어도추시 1년째에유합률은 91% 라고하였다. 그리고외측요추체간유합술에케이지삽입후부가적인기기고정의필요성에대해서 Cappuccino 등 22) 은사체를이용한생역학적실험을시행하였다. 케이지단독삽입했을경우가동범위가 31.6% 였는데척추경나사못고정을부가적으로시행하니가동범위가 13.0% 로줄어서부가적인고정을하는것이안정적이라고하였다. 또한 Pawar 등 4) 도견고한요추유합을위해서는부가적인고정술을하는것이좋다고하였다. Malham 등 17) 은전방요추체간유합술과외측요추체간유합술간유합률을비교하였는데전방요추체간유합술은수술후 6개월에 66%, 12개월에 96%, 24개월에 100% 의유합률을보였고외측요추체간유합술은수술후 6개월에 45%, 12개월에 85%, 24개월에 95% 의유합률을보였으나두군간통계적차이는없다고하였다. Keorochana 등 18) 은최소침습적추간공간유합술과외측요추체간유합술간유합률을비교하였는데두수술간유합률에차이는없다고하였다. 합병증 외측요추체간유합술도고식적인요추부유합수술로발생할수있는수술전, 수술중, 수술후합병증이모두발생할수있다. 하지만수술방법의차이때문에외측요추체간유합술만의수술후발생할수있는합병증은다음과같다. 1. 고관절굴곡근약화 (hip flexor weakness) 외측요추체간유합술시행후많이발생하는합병증으로일시적고관절굴곡근약화가있다. 이는직접신경손상때문이아니라수술과정에서요근의박리로인한손상때문에발생하는일시적약화이다. Tohmeh 등 23) 은제3-4 요추부와제4-5 요추부에외측요추체간유합술을시행하면서실시간근전도감시를하였는데 27.5% 에서수술직후근력등급 4등급의고관절굴곡근약화가왔지만대부분 2주이내에회복되었다고하였다. 또한 Lee 등 24) 도동력계 (dynamometer) 를이용하여고관절굴곡근력을측정하였는데수술직후에는고관절굴곡근력이약화되어있었지만수술후 2주째에수술전기저수준 (baseline) 으로회복되었고 3개월째에는완전히회복되었다고하였다. 2. 신경학적손상 (neurologic injury) 외측요추체간유합술시행후가장흔하게발생하는합병증으로서혜부및대퇴부전방통증또는감각저하와고관절굴곡근약화등의신경손상이있다. 이는수술중신경감시를시행하 더라도발생할수있는데그이유는수술과정에서견인기가요근을박리하면서요천추신경얼기 (lumbosacral plexus) 가견인되고이로인해생기는압력에의해허혈성신경차단 (neurapraxia) 이발생하기때문이다. 하지만신경손상으로인한근력약화인지수술과정에서요근박리로인한손상때문에발생하는일시적약화인지구분을하기가어려운데 Lykissas 등 25) 은수술직후근력등급 3등급이하이거나 4등급의근력약화가 6개월이상회복이되지않는다면신경손상이라고언급을하였다. Hijji 등 26) 은외측요추체간유합술후발생하는합병증에대해서계통적고찰을하였는데가장많이발생하는합병증으로일시적신경손상이 36.07% 에서발생하였다고하였고, 이중지속적신경손상은 3.98% 에서발생하였다고하였다. 또한 Lykissas 등 25) 도외측요추체간유합술직후서혜부및대퇴부전방통증이 38.5%, 감각저하가 38.0%, 근력저하가 23.9% 에서발생하였다고했으나최소 18 개월까지추시관찰한결과감각저하는 9.6% 에서, 근력저하는 2.3% 에서남아있었다고하였다. 3. 혈관손상 (vascular injury) 외측요추체간유합술의장점중하나는전방요추체간유합술의장점을유지하면서접근과정에서발생할수있는혈관손상, 장기손상등의합병증을방지할수있다는점이다. 외측요추체간유합술은접근과정에서대혈관을견인하지만않는다면수술도달과정에서손상을초래하지는않는다. 비록발생가능성이드물긴하지만기기가파손되면서또는케이지삽입을잘못하면서대혈관이손상되기도한다. Kueper 등 27) 은외측요추체간유합술시행시혈관손상발생가능성을환자당 0.056%, 분절당 0.029% 의확률이있다고하였다. 4. 장기손상 (visceral injury) 외측요추체간유합술의시행에서장기손상은매우드물지만발생하면생명에위협을주는합병증이다. 이러한손상을방지하기위해서는접근과정에서후복막공간을안전하게확보하고수술을진행해야한다. 이런장기손상과는별개로수술후장폐색 (ileus) 은상대적으로잘발생한다. Al Maaieh 등 28) 은외측요추체간유합술후발생하는장폐색의위험인자에대해서분석하였는데수술후장폐색의발생률은약 7.0% 였으며, 위-식도역류성질환이있는경우, 후방기기고정술을시행한경우, 제1-2 요추체간수술을시행한경우장폐색이잘발생한다고하였다. 5. 케이지침강 (cage subsidence) 케이지침강은추체간유합술을시행한후나타나는현상으로그원인은명확하지않으나생리학적부하때문에발생한다고추측되고있다. 케이지침강이심하면전방주보강이소실되면서불유합, 회복되었던추간판높이소실, 시상면불균형등이초래된다.

6 208 Jaewan Soh and Jae Chul Lee Le 등 29) 은외측요추체간유합술을시행하였던 140명의환자, 238 분절을대상으로폭이 18 mm, 22 mm로다른두개의케이지에대하여 1년간임상적, 방사선적추시를하여비교하였는데전체케이지침강률은 14.3% 였다. 3 분절이상의장분절유합일경우케이지침강률이유의하게높았고, 18 mm 폭의케이지는 14.1% 의침강률을보였으나 22 mm 폭의케이지는 1.9% 의침강률을보여폭이넓은케이지의침강률이유의하게낮았다고하였다. 그리고유합분절및부가적인고정여부에따른침강률차이는없다고하였다. 하지만전체 14.3% 의침강된환자중에서임상적으로증상이발생한경우는 2.1% 였고, 전체케이지침강중 70% 가위측종판으로침강되었다. 수술과정에서추간판및종판의연골을조심스럽게제거하여종판을손상하지않는것이중요하며골다공증이있는환자에서는후방고정을부가적으로시행하는것이케이지침강을줄일수있다. 6. 위탈장 (pseudohernia) 외측요추체간유합술접근과정에서전복벽의근육을지배하는늑골하신경 (subcostal nerve), 장골하복신경 (iliohypogastric nerve), 장골서혜신경 (ilioinguinal nerve) 등의손상으로인하여복직근 (rectus abdominis muscle), 외복사근 (external oblique muscle), 내복사근 (internal oblique muscle), 횡근근막 (transverse abdominis fascia) 등이불완전마비가되면서근육이돌출되어나온모습이탈장처럼보인다고해서이를 위탈장 이라고한다. Dakwar 등 30) 은외측요추체간유합술후발생한복벽의불완전마비에대하여발표하였는데그발생률은약 1.8% 였다. 대부분수술후 2-6주사이에발견되고복부컴퓨터단층촬영 (computed tomography) 상에서탈장이없음을확인하여진단된다고하였으며장기추시에서후유증은없다고하였다. 결론 외측요추체간유합술은고식적전방요추체간유합술과후방요추체간유합술의장점을취합하고단점을보완한최소침습수술법이다. 또한추간판높이회복으로추간공과신경관의간접감압을효과적으로할수있으며척추변형의교정에도효과적이다. 이러한장점들때문에최근적응증도확대되어퇴행성요추부질환에많이사용되고있고임상결과나유합률도만족스러운결과들이보고되고있다. 하지만접근과정에서발생하는신경손상은비록요천추신경얼기의해부학적구조를이해하고신경감시를시행하더라도아직중요하게고려할점으로남아있다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Bertagnoli R, Vazquez RJ. The Anterolateral TransPsoatic Approach (ALPA): a new technique for implanting prosthetic disc-nucleus devices. J Spinal Disord Tech. 2003;16: Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J. 2006;6: Oliveira L, Marchi L, Coutinho E, Pimenta L. A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements. Spine (Phila Pa 1976). 2010;35:S Pawar A, Hughes A, Girardi F, Sama A, Lebl D, Cammisa F. Lateral lumbar interbody fusion. Asian Spine J. 2015;9: Salzmann SN, Shue J, Hughes AP. Lateral lumbar interbody fusion-outcomes and complications. Curr Rev Musculoskelet Med. 2017;10: Yang Y, Zhang L, Dong J, et al. Intraoperative myelography in transpsoas lateral lumbar interbody fusion for degenerative lumbar spinal stenosis: a preliminary prospective study. Biomed Res Int. 2017;2017: Pawar AY, Hughes AP, Sama AA, Girardi FP, Lebl DR, Cammisa FP. A comparative study of lateral lumbar interbody fusion and posterior lumbar interbody fusion in degenerative lumbar spondylolisthesis. Asian Spine J. 2015;9: Goyal A, Kerezoudis P, Alvi MA, Goncalves S, Bydon M. Outcomes following minimally invasive lateral transpsoas interbody fusion for degenerative low grade lumbar spondylolisthesis: a systematic review. Clin Neurol Neurosurg. 2018;167: Dakwar E, Cardona RF, Smith DA, Uribe JS. Early outcomes and safety of the minimally invasive, lateral retroperitoneal transpsoas approach for adult degenerative scoliosis. Neurosurg Focus. 2010;28:E Acosta FL, Liu J, Slimack N, Moller D, Fessler R, Koski T. Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar disease in adults: a radiographic study. J Neurosurg Spine. 2011;15:92-6.

7 209 Recent Updates for Lateral Lumbar Interbody Fusion 11. Park HY, Ha KY, Kim YH, et al. Minimally invasive lateral lumbar interbody fusion for adult spinal deformity: clinical and radiological efficacy with minimum two years follow-up. Spine (Phila Pa 1976). 2018;43:E Mummaneni PV, Shaffrey CI, Lenke LG, et al. The minimally invasive spinal deformity surgery algorithm: a reproducible rational framework for decision making in minimally invasive spinal deformity surgery. Neurosurg Focus. 2014;36:E Louie PK, Varthi AG, Narain AS, et al. Stand-alone lateral lumbar interbody fusion for the treatment of symptomatic adjacent segment degeneration following previous lumbar fusion. Spine J. 2018;18: Metzger MF, Robinson ST, Maldonado RC, Rawlinson J, Liu J, Acosta FL. Biomechanical analysis of lateral interbody fusion strategies for adjacent segment degeneration in the lumbar spine. Spine J. 2017;17: Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976). 2011;36: Kotwal S, Kawaguchi S, Lebl D, et al. Minimally invasive lateral lumbar interbody fusion: clinical and radiographic outcome at a minimum 2-year follow-up. J Spinal Disord Tech. 2015;28: Malham GM, Parker RM, Blecher CM, Chow FY, Seex KA. Choice of approach does not affect clinical and radiologic outcomes: a comparative cohort of patients having anterior lumbar interbody fusion and patients having lateral lumbar interbody fusion at 24 months. Global Spine J. 2016;6: Keorochana G, Setrkraising K, Woratanarat P, Arirachakaran A, Kongtharvonskul J. Clinical outcomes after minimally invasive transforaminal lumbar interbody fusion and lateral lumbar interbody fusion for treatment of degenerative lumbar disease: a systematic review and meta-analysis. Neurosurg Rev. 2018;41: Bono CM, Lee CK. Critical analysis of trends in fusion for degenerative disc disease over the past 20 years: influence of technique on fusion rate and clinical outcome. Spine (Phila Pa 1976). 2004;29: Berjano P, Langella F, Damilano M, et al. Fusion rate following extreme lateral lumbar interbody fusion. Eur Spine J. 2015;24 Suppl 3: Marchi L, Abdala N, Oliveira L, Amaral R, Coutinho E, Pimenta L. Radiographic and clinical evaluation of cage subsidence after stand-alone lateral interbody fusion. J Neurosurg Spine. 2013;19: Cappuccino A, Cornwall GB, Turner AW, et al. Biomechanical analysis and review of lateral lumbar fusion constructs. Spine (Phila Pa 1976). 2010;35:S Tohmeh AG, Rodgers WB, Peterson MD. Dynamically evoked, discrete-threshold electromyography in the extreme lateral interbody fusion approach. J Neurosurg Spine. 2011;14: Lee YP, Regev GJ, Chan J, et al. Evaluation of hip flexion strength following lateral lumbar interbody fusion. Spine J. 2013;13: Lykissas MG, Aichmair A, Hughes AP, et al. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014;14: Hijji FY, Narain AS, Bohl DD, et al. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J. 2017;17: Kueper J, Fantini GA, Walker BR, Aichmair A, Hughes AP. Incidence of vascular complications during lateral lumbar interbody fusion: an examination of the mini-open access technique. Eur Spine J. 2015;24: Al Maaieh MA, Du JY, Aichmair A, et al. Multivariate analysis on risk factors for postoperative ileus after lateral lumbar interbody fusion. Spine (Phila Pa 1976). 2014;39: Le TV, Baaj AA, Dakwar E, et al. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine (Phila Pa 1976). 2012;37: Dakwar E, Le TV, Baaj AA, et al. Abdominal wall paresis as a complication of minimally invasive lateral transpsoas interbody fusion. Neurosurg Focus. 2011;31:E18.

8 210 pissn : , eissn : Symposium J Korean Orthop Assoc 2019; 54: 최소침습적요추수술 최소침습적외측요추간유합술 : 적응증, 결과, 합병증 소재완 이재철 * 순천향대학교부속천안병원정형외과, * 순천향대학교부속서울병원정형외과, 척추센터 최소침습적외측요추체간유합술의최신지견에대하여알아보고자하였다. 아직도입된지얼마되지않았으나근래에각광받고있는최소침습적외측요추체간유합술에대한적응증및임상결과와유합률, 그리고합병증에대하여문헌고찰을하였다. 외측요추간유합술의적응증은퇴행성요추부질환에서고식적인전방, 후방추체간유합술의적응증과거의유사하다. 특히척추관협착증및퇴행성척추전방전위증, 퇴행성척추변형, 퇴행성추간판질환, 인접분절퇴행성질환에서최소침습적수술로서효과적이다. 또한고식적요추부유합술과비교하여임상적결과및유합률이대등한것으로보고되고있다. 하지만수술접근및과정에서발생하는수술후고관절굴곡근약화및신경손상, 혈관손상, 장기손상, 케이지침강, 위탈장등의비특이적합병증들이보고되고있다. 외측추체간유합술은고식적인전방또는후방추체간유합술의장점을취합하고단점을보완한수술이며그임상결과나유합률에도큰차이가없어퇴행성요추부질환의치료에최소침습수술로서유용한치료법이다. 하지만수술과정에서발생하는비특이적합병증들을개선해야하는것이향후과제이다. 색인단어 : 요추부, 퇴행성요추부질환, 외측요추체간유합술 접수일 2018 년 8 월 29 일수정일 2018 년 10 월 4 일게재확정일 2018 년 10 월 15 일책임저자이재철 04401, 서울시용산구대사관로 59, 순천향대학교부속서울병원정형외과, 척추센터 TEL , FAX , jlee@schmc.ac.kr, ORCID 대한정형외과학회지 : 제 54 권제 3 호 2019 Copyright 2019 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.

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