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1 대한골절학회지제24권, 제2호, 2011년 4월 Journal of the Korean Fracture Society Vol. 24, No. 2, April, 2011 종설 흉추골절 (Thoracic Spine Fractures) 김영우ㆍ김영석ㆍ변재철ㆍ박용복 한림대학교의과대학한강성심병원정형외과학교실 서 흉추골절치료의가장중요한목표는환자의생명을유지하고신경기능을보호하며, 척추의올바른정렬과안정성을얻게하여, 빠른시일내에재활과정을거쳐사회로복귀시키는것이다. 흉추와요추는척추에서골절이가장흔하게발생하는부위이며, 대부분의흉요추부골절은교통사고나낙상과같은고에너지손상으로발생하고남자에게호발한다 8,9). 척추측만증연구회 (Scoliosis Research Society) 에서 1,000 명이상의환자를대상으로시행한다기관연구에의하면 16% 의손상이제 1 흉추와제 10 흉추사이에서발생하고, 52% 는제 11 흉추와제 1 요추사이에서발생하며, 32% 는제 1 요추와제 5 요추사이에서발생하는것으로알려져있다 8,9). 흉추는늑골로구성된흉곽과척추주위근육이척수를보호하고있으며, 흉골과흉곽이흉추의운동범위를제한하고있다 1). 또한흉추에서는후관절이관상면상의배열을하고있어굴곡과신전을제한하지만, 염전력에는별제한을받지않는다 6). 흉추의생리적인후만은추체의쐐기모양에의하여형성된다. 이러한흉추의후만은흉추를수직압박손상에약하게만들고, 외상으로인하여후방구조물이파열되거나수술로후궁절제술을시행한경우후만변형을심하게만드는역할을한다 4). 흉추에서는튼튼한골인대복합조직이척수를보호하고있으나, 척추관의내경이요추보다좁기때문에외상시에신경조직을보호하기위한여유공간이좁다. 제 2 흉추에서제 10 흉추까지가척수의직경에비하여척추관의내경이가장좁다. 이러한이유로흉추골절환자는흔히심한신경학적손상이동반하게되며, 고에너지손상의경우 6 대 1 의비율로완전마비 론 가불완전마비보다흔하게발생한다 15). 흉요추부위는비가동적인흉추에서가동적인요추로이행하는부위이다. 이부위에서는흉곽이더이상척추를보호하거나지지해주지못한다. 또한이부위의추체가요추만큼크지않기때문에가해지는외력에저항하지못하고쉽게손상을받게되며, 방출성골절이가장흔하게발생하는부위가된다 14). 초기검사및치료 모든외상환자들에대한초기의조치는 ABC (airway, breathing, circulation) 부터시작하여야하며, 그후에척추에대한압통, 함몰, 부종, 변형및열상등의유무를관찰한다. 약 50% 의환자에서초기의이학적검사상척추손상을놓치게되며, 이를진단하는데평균 50 일이상소요되는것으로밝혀져있다. 또한 25% 의환자에서는부적절한고정으로인하여신경학적손상이악화되는것으로알려져있다 15). 신경학적검사로는근력검사, 감각검사, 건반사등을확인한다 (Table 1). 척수성쇽 은척수기능의이상으로나타나는이완성마비를말하는것으로흔히척수손상부위이하에서나타나며운동기능, 감각기능및모든반사가없어진다. 따라서정확한신경손상정도를파악하기위해서는척수성쇽으로부터회복된이후에검사하여야하며, 약 99% 이상의환자에서 48 시간이내에회복된다. 척수성쇽으로부터의회복은손상부위이하에서척수매개성반사의유무로판정하는데, 구해면체반사가가장먼저돌아오게된다 15). 완전마비란척수성쇽에서회복된상태에서손상부위 통신저자 : 김영우서울시영등포구영등포동 7 가 한림대학교의과대학한강성심병원정형외과학교실 Tel: ㆍ Fax: ywkimmd@hallym.ac.kr Address reprint requests to:young-woo Kim, M.D., Ph.D. Department of Orthopaedic Surgery, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Yeongdeungpo-dong 7-ga, Yeongdeungpo-gu, Seoul , Korea Tel: ㆍ Fax: ywkimmd@hallym.ac.kr 195

196 김영우, 김영석, 변재철, 박용복 이하로운동및감각기능이완전히소실된것을말하고, 불완전마비란손상부위이하에서일부의기능이남아있는상태를말한다. 불완전마비의증상을이해하기위해서는흉추척수의해부학을숙지하고있어야하며 (Fig. 1), 대부분의불완전마비는다음 4 가지중하나의형태로나타나게된다 (Fig. 2).

전방척수증후군 (anterior cord syndrome) 은운동기능과심부통증및온도감각의완전한소실을나타내지만, 후주 (dorsal column) 는보존되기때문에가벼운촉각, 위치및진동감각은남아있게된다. 기능적회복은매우불량하 여약 10% 의환자에서만의미있는기능회복을기대할수있다.

Extensor hallucis longus, Gluteus maximus, Gluteus minimus Soleus Flexor hallucis longus, Flexor hallucis brevis Intrinsic muscles of foot Fig. 1.

2 196 김영우, 김영석, 변재철, 박용복 이하로운동및감각기능이완전히소실된것을말하고, 불완전마비란손상부위이하에서일부의기능이남아있는상태를말한다. 불완전마비의증상을이해하기위해서는흉추척수의해부학을숙지하고있어야하며 (Fig. 1), 대부분의불완전마비는다음 4 가지중하나의형태로나타나게된다 (Fig. 2). 가장흔한것은중심성척수증후군 (central cord syndrome) 으로, 하지보다상지의기능이심하게손상되며천수의운동기능은비교적잘보존된다. 약 75% 의환자에서기능적운동회복을기대할수있다. 전방척수증후군 (anterior cord syndrome) 은운동기능과심부통증및온도감각의완전한소실을나타내지만, 후주 (dorsal column) 는보존되기때문에가벼운촉각, 위치및진동감각은남아있게된다. 기능적회복은매우불량하 여약 10% 의환자에서만의미있는기능회복을기대할수있다. 후방척수증후군 (posterior cord syndrome) 은매우드물며, 후주가손상되기때문에고유수용감각과가벼운촉각은소실되나운동기능은남아있게된다. Brown-Sequard 증후군은흔하지않은척수손상으로동측의운동기능, 가벼운촉각, 진동감각및고유수용감각의소실과반대측의심부통각및온도감각의소실을나타낸다. 예후는좋아서 90% 이상의환자에서기능적운동 Table 1. Nerve innervation of leg muscles Roots L1 L2 L3 L4 L5 S1 S2 S3 Muscles Iliopsoas, Flexors of hip Sartorius Quadriceps, Adductor longus, Adductor brevis Tibialis anterior Extensor hallucis longus, Gluteus maximus, Gluteus minimus Soleus Flexor hallucis longus, Flexor hallucis brevis Intrinsic muscles of foot Fig. 1. Schematic drawing of a transverse section of the spinal cord at the thoracic level, showing the anatomic organization of the corticospinal tract and posterior column (L: lumbar, S: sacral, T: thoracic). Fig. 2. Types of spinal cord injury (shaded zones) that produce the four main incomplete injury patterns seen clinically. (A) Central cord syndrome. (B) Anterior cord syndrome. (C) Brown-Sequard syndrome. (D) Posterior cord syndrome.

흉추골절 197 회복을기대할수있다. 손상된척수에대한초기내과적치료는부종과허혈에의한 2 차적손상을막거나최소화하는데있다.

다른약물치료제로는 monosialotetrahexosyl ganglioside (GM1), thyrotropin-releasing hormone

입원기간중에는심부정맥혈전증을예방하기위하여공기를이용한간헐적외부압박기 (intermittent external pneumatic compression

Denis three-column model of spinal stability which involves anterior (anterior 1/2

vertebra/disc and posterior longitudinal ligament), and posterior (posterior

$These fractures may involve both endplates (A, type A), the superior endplate only$ $Denis classification of thoracolumbar burst fractures.$

3 흉추골절 197 회복을기대할수있다. 손상된척수에대한초기내과적치료는부종과허혈에의한 2 차적손상을막거나최소화하는데있다. 수상후 8 시간이내에도착하였을경우고용량의 methylprednisolone 을정맥주사한다 (30 mg/kg 1 회투여, 추가로 5.4 mg/kg/hr 를 시간동안정맥투여 ). 수상후 3 시간이내에투여하였을경우에는 24 시간동안지속하고, 수상후 3 8 시간사이에투여하였을경우에는 48 시간동안유지한다. 다른약물치료제로는 monosialotetrahexosyl ganglioside (GM1), thyrotropin-releasing hormone (TRH), mannitol, nimodipine 등이연구되고있다 7). 입원기간중에는심부정맥혈전증을예방하기위하여공기를이용한간헐적외부압박기 (intermittent external pneumatic compression device) 나압박스타킹을착용시키며, 일부고위험환자에게는헤파린이나 low-molecular-weight heparin 을사용하기도한다. Fig. 3. Denis three-column model of spinal stability which involves anterior (anterior 1/2 of vertebra/disc and anterior longitudinal ligament), middle (posterior 1/2 of vertebra/disc and posterior longitudinal ligament), and posterior (posterior elements including the pedicles and facet joints and the remaining ligaments) columns. According to this paradigm, any injury extending into the middle column is largely considered to be unstable. Fig. 4. Denis classification of thoracolumbar compression injuries. These fractures may involve both endplates (A, type A), the superior endplate only (B, type B), the inferior endplate only (C, type C), or a buckling of the anterior cortex with both endplates intact (D, type D). Fig. 5. Denis classification of thoracolumbar burst fractures. (A C) Types A, B, and C represent fractures of both endplates, the superior endplate, and the inferior endplate, respectively. (D) Type D is a combination of a type A burst fracture with rotation, which is best appreciated on an anteroposterior radiograph. The superior or inferior endplate, or both, may be involved with this fracture. (E) Type E is eccentrically loaded type A fracture.

These may occur at one level through the bone (A), at one level through the

through the bone (C), or at two levels with the middle column injured

$Denis classification of fracture-dislocations.$ through the bone or at two levels with the middle column injuried through

이것에의하면해부학적인척추는 3 부위로나뉘는데, 전주 (anterior column) 는전방종인대, 추체와추간판의전방 1/2 이포함되며,

후주 (posterior column) 는골성신경궁 (osseous neural arch), 극상및극간인대, 황색인대가포함된다.

Minor 손상은골절의 15% 정도를차지하는데, 극상돌기및횡돌기골절, 추공판협부골절, 후관절골절등이포함된다.

$fracture), 안정방출성골절 (stable burst fracture), 불안정방출성골절 (unstable burst$ $fracture), Chance 골절, 굴곡 - 신연손상 (flexion- distraction injury), 전이성골절$ Ferguson 과 Allen 은 7 가지손상형태를포함하는기계학적분류를제시하였는데, 수술적혹은비수술적치료계획을세우는데유용하다고하였다.

Ferguson 과 Allen 은 7 가지손상형태를포함하는기계학적분류를제시하였는데, 수술적혹은비수술적치료계획을세우는데유용하다고하였다.

4 198 김영우, 김영석, 변재철, 박용복 Fig. 6. Denis classification of flexion-distraction injuries. These may occur at one level through the bone (A), at one level through the ligaments and disc (B), at two levels, with the middle column injured through the bone (C), or at two levels with the middle column injured through the ligament and disc (D). 골절의분류 Fig. 7. Denis classification of fracture-dislocations. These may occur at one level through the bone (A), at one level through the ligaments and disc (B), or at two levels, with the middle column injuried through the bone or at two levels with the middle column injuried through the ligament and disc (C). Denis 는 3 주설에근간을두고골절을분류하여널리사용되게하였다 (Fig. 3) 4). 이것에의하면해부학적인척추는 3 부위로나뉘는데, 전주 (anterior column) 는전방종인대, 추체와추간판의전방 1/2 이포함되며, 중주 (middle column) 는추체와추간판의후방 1/2 과후방종인대가포함된다. 후주 (posterior column) 는골성신경궁 (osseous neural arch), 극상및극간인대, 황색인대가포함된다. 또한그는흉요추골절을 minor 와 major 손상으로분류하였다. Minor 손상은골절의 15% 정도를차지하는데, 극상돌기및횡돌기골절, 추공판협부골절, 후관절골절등이포함된다. Major 손상은압박골절, 방출성골절, 굴골 - 신연손상, 골절 - 탈구등이포함된다 (Fig. 4 7). McAfee 는 CT 소견을근간으로하여중주의손상기전에따라 6 가지로분류하였는데, 설상압박골절 (wedge compression fracture), 안정방출성골절 (stable burst fracture), 불안정방출성골절 (unstable burst fracture), Chance 골절, 굴곡 - 신연손상 (flexion- distraction injury), 전이성골절 (translational fracture) 로분류하였다 (Table 2) 10). Ferguson 과 Allen 은 7 가지손상형태를포함하는기계학적분류를제시하였는데, 수술적혹은비수술적치료계획을세우는데유용하다고하였다. 7 가지손상형태로는압박굴곡손상 (compressive flexion injury), 신연굴곡손상 (distractive flexion injury), 측굴곡손상 (lateral flexion injury), 전이성손상 (translational injury), 염전굴곡손상 (torsional flexion injury), 수직압박손상 (vertical compression injury), 신연신전손상 (distractive extension injury) 이있다 (Table 3) 6).

5 흉추골절 199 Table 2. The McAfee classification system Type of fracture Columns Anterior Middle Posterior Mechanism Wedge compression Stable burst Unstable burst Chance Flexion-distraction Translational, lateral lexion, rotation Forward flexion Compressive load, lateral flexion, rotation Horizontal avulsion Flexion-distraction Table 3. The Ferguson and Allen classification system for spinal fractures Type of fracture Columns Anterior Middle Posterior Compressive flexion Type I Type II Type III Distractive flexion Lateral flexion Type I Type II Translational Torsional flexion Vertical compression Distractive extension Unilateral compression Unilateral compression /rotation Blown out* Unilateral compression Unilateral compression Disrupted Bony compression Ipsilateral compression/ contralateral tension /rotation Bony involvement *Blown out: Evidence of middle column bone rotated into the neural canal between pedicles. McCormack 등 11) 은부하분담분류 (load sharing classification) 를개발하였는데, 추체의분쇄정도, 골편의전위정도, 술후후만각교정정도에따라 1, 2, 3 점으로환산하여, 총점이 7 점이상인경우단분절고정시후방기기실패나불유합의확률이높으므로전방도달법으로전방추체보강술을시행하는것이좋다고하였다 (Fig. 8). 수술적치료의결정및수술시기 수술적치료는골절부의안정성과정렬상태, 신경학적손상정도, 환자의전신상태등에의하여결정된다. White 와 Panjabi 18) 는임상적불안정성에대하여정의하기를생리적인하중을받는상태에서척수나신경근에손상이나자극을주지않고심한통증이나기형을유발하지않으면서상하척추체간에정상적인관계를유지할수없는상태라고하였다. Denis 4) 는불안정성에대하여정의하기를 3 주 (column) 중에 2 주이상의파괴가있을때라고하였으며, 불안정성을기계적 (mechanical), 신경학적 (neurologic), 복합적 (combined) 불안정성등의 3 종류로분류하였다. 흉추손상에서수술치료의목적은입원기간을줄이고, 기능을최대한보존하고, 환자간호를쉽게하고, 기형이나불안정성통증을예방하기위함이다. 일반적으로수술은불안정한골절을안정화시키고정상적인배열로만들기위하여시행되거나, 신경학적결손이있는상황에서신경조직을감압시키거나, 혹은두가지모두를위하여시행한다. 흉추골절에서응급수술의적응증은심한척수의압박이있는불안정성골절환자에서신경학적결손이진행할때이다. 하지만보고된연구에의하면흉추에서척수의압박이지속되고있을경우늦게라도신경감압을하면신경기능의회복에도움이되는것으로알려져있다 3).

$The load sharing classification system for thoracolumbar fractures identifies injuries that$ may be appropriately treated with shortsegment posterior instrumentation constructs by

may be appropriately treated with shortsegment posterior instrumentation constructs by

fragments, and the degree of focal kyphosis. 수술도달법 수술시도달법의선택은수상부위, 척추관침범정도, 술자의경험에의하여결정된다.

전방도달법은골절된추체나추간판의후방전위에의한척추관침범이발생하였을때추체제거술과함께사용한다.

후외방도달법은각각의추체의척추경을통하여척수신경에도달할수있다. 후외방도달법의장점은전방도달법을같이시행하지않아도된다는것이다.

후방도달법은분절간척추기구삽입후신연력과신전력을이용하여척수신경을간접적으로감압하는데사용될수있다.

전방위 (circumferential) 도달법이필요한흉추골절도있는데, 척추강의침범이있고심한불안정성을동반한 3 주 (column)

$압박골절 (compression fracture) 설상압박골절에서후만변형이 20 30 도이상이거나, 전방추체높이의감소가 50% 이상일때수술적치료의대상이된다.$

6 200 김영우, 김영석, 변재철, 박용복 Fig. 8. The load sharing classification system for thoracolumbar fractures identifies injuries that may be appropriately treated with shortsegment posterior instrumentation constructs by assigning points based on the extent of vertebral body comminution, apposition of the body fragments, and the degree of focal kyphosis. 수술도달법 수술시도달법의선택은수상부위, 척추관침범정도, 술자의경험에의하여결정된다. 척수신경을감압하기위한도달법은전방, 후방, 후외측도달법을기본으로다양한방법이존재한다. 전방도달법은골절된추체나추간판의후방전위에의한척추관침범이발생하였을때추체제거술과함께사용한다. 척수신경이있는부위에서는전방도달법이압박된신경조직을관찰하는데가장직접적이고확실한방법이다. 직접신경을보며수술하기때문에신경조직에손상을주지않으면서신경을감압하고척추를재건할수있다. 후외방도달법은각각의추체의척추경을통하여척수신경에도달할수있다. 후외방도달법의장점은전방도달법을같이시행하지않아도된다는것이다. 하지만전방의경막을직접관찰할수없기때문에전주 (anterior column) 를재건하는것은기술적으로쉽지않고간혹수술중신경조직을건드려서의인성신경손상을일으킬가능성이있다. 후방도달법은분절간척추기구삽입후신연력과신전력을이용하여척수신경을간접적으로감압하는데사용될수있다. 기구를이용한신연술은수상후 2 일이내에사용될경우척추강내로후방전위된골절편을정복하는데매우효과적인것으로밝혀져있다 15). 전방위 (circumferential) 도달법이필요한흉추골절도있는데, 척추강의침범이있고심한불안정성을동반한 3 주 (column) 손상의경우후방도달법으로척추를안정화시킨다음전방도달법으로척수신경을감압하는것이효과적이다. 골절의형태에따른치료방법 1. 압박골절 (compression fracture) 설상압박골절에서후만변형이 도이상이거나, 전방추체높이의감소가 50% 이상일때수술적치료의대상이된다. Ferguson-Allen 압박성굴곡손상 (compressive flexion injury) 3 형에서불완전신경마비증상을보일경우전방도달법을이용하여척추관을감압한후전주 (anterior column) 를보강해주어야하고후방손상정도에따라후방유합술을추가한다 16). 증상이있는아급성및만성의골감소증성골절의경우경피적척추보강술 (percutaneous vertebral augmentation) 로골절부위를안정화시킬수있으며, 그적응증과임상결과에대하여연구중에있다 17). 2. 방출성골절 (burst fracture) 흉추의방출성골절에서후주 (posterior column) 의손상이없는경우, 즉후만각이 20 도이하이고전방추체높이의감소가 50% 이하이며후관절의아탈구가없고척추경간거리의증가가없는경우에는신전형 TLSO 를 주

명에대한전향적연구에서모든환자들이최종추시상만족할만한통증점수를보였고, 후만의진행은 4.6 도, 전방추체높이의감소는 6.

신경학적이상은없으나심한후방골인대조직에손상이있는경우즉, 초기후만각이 20 도이상이고전방추체높이가 50%

골절의정복방법은신연 (distraction) 과신전혹은전만화 (lordosing) 방법을사용하는데, Oda 등

불완전마비를보이는급성방출성골절환자에서방사선검사상심한신경압박소견이있을때수술적감압이 Fig. 9.

$unstable bursting fracture at T12 and L1 (A, B).$ The preoperative MRI (C), and CT (D) showed the cord compressed

He underwent indirect reduction by ligamentotaxis using

7 흉추골절 201 간착용하고조기보행시키는보존적치료가가능하다. Reid 등 13) 은 Denis type A 와 type B 의방출성골절환자 21 명에대한전향적연구에서모든환자들이최종추시상만족할만한통증점수를보였고, 후만의진행은 4.6 도, 전방추체높이의감소는 6.1% 증가하였다고보고하였다. 신경학적이상은없으나심한후방골인대조직에손상이있는경우즉, 초기후만각이 20 도이상이고전방추체높이가 50% 이상감소하였으며후관절의아탈구가있고 척추경간거리가증가된환자들은수술적치료로정상적인정렬을회복하고안정화시키는것이중요하다. 골절의정복방법은신연 (distraction) 과신전혹은전만화 (lordosing) 방법을사용하는데, Oda 등 12) 은알맞은해부학적정복을얻기위하여 5 mm 의신연과 6 도의신전이동시에필요하다고하였다 (Fig. 9). 불완전마비를보이는급성방출성골절환자에서방사선검사상심한신경압박소견이있을때수술적감압이 Fig. 9. A 36-year old man got injured by a fall from height, who was diagnosed with complete paraplegia due to the cord injury with unstable bursting fracture at T12 and L1 (A, B). The preoperative MRI (C), and CT (D) showed the cord compressed by the retropulsed bony fragments. He underwent indirect reduction by ligamentotaxis using segmental pedicle screw instrumentation from T11 to L2 with distraction (E, F). Postoperative CT (G) and MRI (H) shows the cord decompressed after the operation, but the patient has not recovered from the complete paraplegia.

굴곡 - 신연손상 (flexion-distraction injuries) 성인환자에서극간인대, 후종인대,

신연손상이있을때는회복의속도가느리고치료결과를예측할수없기때문에수술적으로고정및유합술을시행하여야한다 8).

$골절 - 탈구 (fracture-dislocation) 어떠한골절이라도후관절의골절 - 탈구가있거나, 회전불안정성$ injury) 이있으면서신경학적결손이없을때에는전방감압및고정술을시행하기전에후방분절간정복술및고정술을먼저시행하여야한다

$bursting fracture at other hospital.$ When she visited our spine center 15 months later from the

numbness on her both lower extremities with thoracolumbar

She couldn't lie flat on her back due to aggravating back pain

Preoperative x-ray showed thoracolumbar kyphosis and pull out of

8 202 김영우, 김영석, 변재철, 박용복 필요하다는것에대한이견은없으나, 척수압박에대하여즉각적인감압을하지않고후기감압을하더라도신경학적회복을기대할수있다 (Fig. 10) 2). 3. 굴곡 - 신연손상 (flexion-distraction injuries) 성인환자에서극간인대, 후종인대, 추간판의파열이동반된굴곡 - 신연손상이있을때는회복의속도가느리고치료결과를예측할수없기때문에수술적으로고정및유합술을시행하여야한다 8). 수술시에는후방도달법으로 손상부위의상하한분절씩만고정하여도충분한안정을얻을수있다 (Fig. 11, 12). 4. 골절 - 탈구 (fracture-dislocation) 어떠한골절이라도후관절의골절 - 탈구가있거나, 회전불안정성 (rotational instability) 이있거나, 전이성전단손상 (translational shear injury) 이있으면서신경학적결손이없을때에는전방감압및고정술을시행하기전에후방분절간정복술및고정술을먼저시행하여야한다 5). Fig. 10. A 53-year old lady was operated on her back to fix the T12 bursting fracture at other hospital. When she visited our spine center 15 months later from the initial operation, she complained of severe back pain and numbness on her both lower extremities with thoracolumbar kyphosis. She couldn't lie flat on her back due to aggravating back pain and leg numbness. Preoperative x-ray showed thoracolumbar kyphosis and pull out of both L1 pedicle screws (A C). In the CT and MRI findings, the spinal cord compressed slightly by the sharp margin of T12 body (D, E). The spinal cord decompressed by modified PSO and the spinal column realigned normally (F H). At 5 months postoperatively, the operation site was fused solidly without loss of correction (I, J). And the leg symptoms were resolved completely.

$fracture at T12 by a fall (A, B).$ $The fracture was reduced by cantilever$ method using USS universal spine system

$and L1 and compression fracture of L4$ which involving both end plates by a fall

The 28-year old man got 60% flame burn on

The spinal operation was delayed for 4 and

The preoperative x-ray shows kyphosis at

bilateral facet dislocation of T12 and L1

The patient complained paraparesis at both

dislodged posterosuperior coner of L1 body

9 흉추 골절 203 Fig. 11. A 68-year old man sustained a bony chance fracture at T12 by a fall (A, B). Preoperative CT showed clear fracture line at the T12 body and lamina (C). The fracture was reduced by cantilever method using USS universal spine system (D, E). Fig. 12. A flexion-distraction type injury at T12 and L1 and compression fracture of L4 which involving both end plates by a fall from height. The 28-year old man got 60% flame burn on his both lower extremities and the trunk. The spinal operation was delayed for 4 and half months to care the burn wound. The preoperative x-ray shows kyphosis at the thoracolumbar junction with wedging of L1 body (A, B). Preoperative parasagittal CT shows bilateral facet dislocation of T12 and L1 (C, E). The patient complained paraparesis at both lower extremities and the CT shows the dislodged posterosuperior coner of L1 body was compressing the spinal cord (D). The spinal cord decompressed by modified pedicle subtraction osteotomy at L1, and the spinal alignment normalized very nicely. The patient's neurologic symptoms were subsided after the operation (F H).

10 204 김영우, 김영석, 변재철, 박용복 5. 신전 - 신연손상 (extension-distraction injuries) 신전 - 신연손상은드물고강직성척추염이나미만성특발성골격과골화증 (diffuse idiopathic skeletal hyperostosis) 이동반된환자에게서주로발생한다. 이손상은심하게불안정하여견인하거나보조기를착용하여도신경손상이진행하므로빨리수상전시상면상의만곡으로복원해주어야한다. 일단정복이되었으면분절간고정술과유합술을시행한다. 요 흉추내부의척수는중추신경으로한번손상이되면회복되지않고많은합병증을유발하게된다. 따라서수상직후부터정확한진단과치료가필수적인데, 그동안마취기술과척추삽입물에대한발전이있어왔음에도불구하고흉추골절의치료에대한논란은계속되고있다. 어떠한골절에대하여수술적치료를할것인가? 만약수술이필요하다면언제시행할것인가? 또어떠한도달법을선택해야할것인가? 등이논란의대상이되고있다. 그러므로흉추골절의치료방법은획일화및단순화될수없고각각의특정한골절형태와환자의전신상태에맞추어개별적으로적절하게치료해야한다. 비록수술의필요성과수술시기에대한논란은있지만적극적인치료과정을통하여환자를조기에움직일수있게하는것이전반적인기능회복에도움이된다. 신경학적결손을동반하지않은안정한형태의흉추골절은비수술적방법으로성공적으로치료될수있다. 하지만신경학적결손유무와관계없이불안정한흉추골절은수술적으로치료하는것이신속한환자의거동과기능회복을가능하게하여조기에사회로복귀할수있게해준다. 흉추골절치료의궁극적인목표는신경기능의회복을극대화하고척추를신속하게안정화하여조기재활을가능하게함으로써생산적인활동을하는일상생활로빨리복귀할수있도록도와주는것이다. 약 참고문헌 1) Andriacchi T, Schultz A, Belytschko T, Galante J: A model for studies of mechanical interactions between the human spine and rib cage. J Biomech, 7: , ) Bohlman HH, Kirkpatrick JS, Delamarter RB, Leventhal M: Anterior decompression for late pain and paralysis after fractures of the thoracolumbar spine. Clin Orthop Relat Res, 300: 24-29, ) Bradford DS, McBride GG: Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop Relat Res, 218: , ) Denis F: The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976), 8: , ) Denis F, Burkus JK: fracture-dislocations of the thoracic and lumbar spine associated with forceful hyperextension (lumberjack paraplegia). Spine (Phila Pa 1976), 17: , ) Ferguson RL, Allen BL Jr: A mechanistic classification of thoracolumbar spine fractures. Clin Orthop Relat Res, 189: 77-88, ) Geisler FH, Dorsey FC, Coleman WP: Recovery of motor function after spinal-cord injury--a randomized, placebo-controlled trial with GM-1 ganglioside. N Engl J Med, 324: , ) Gertzbein SD: Fractures of the thoracic and lumbar spine. Baltimore, Williams & Wilkins: ) Gertzbein SD: Scoliosis Research Society. Multicenter spine fracture study. Spine (Phila Pa 1976), 17: , ) McAfee PC, Yuan HA, Fredrickson BE, Lubicky JP: The value of computed tomography in thoracolumbar fractures. An analysis of one hundred consecutive cases and a new classification. J Bone Joint Surg Am, 65: , ) McCormack T, Karaikovic E, Gaines RW: The load sharing classification of spine fractures. Spine (Phila Pa 1976), 19: , ) Oda T, Panjabi MM, Kato Y: The effects of pedicle screw adjustments on the anatomical reduction of thoracolumbar burst fractures. Eur Spine J, 10: , ) Reid DC, Hu R, Davis LA: The nonsurgical treatment of burst fractures. In: Floman Y, Farcy JP, Argenson C eds. Thoracolumbar spine fractures. New York, Raven: , ) Saboe LA, Reid DC, Davis LA, Warren SA, Grace MG: Spine trauma and associated injuries. J Trauma, 31: 43-48, ) Singh K, Kim D, Vaccaro AR: Thoracic and lumbar spinal injuries. In: Herkowitz HN, Garfin SR, Eismont FJ, Bell GR, Balderston RA eds. The spine. 5th ed. Philadelphia, Saunders: , ) Vaccaro AR: Combined anterior and posterior surgery for

11 흉추골절 205 fractures of the thoracolumbar spine. Instr Course Lect, 48: , ) Verlaan JJ, van Helden WH, Oner FC, Verbout AJ, Dhert WJ: Balloon vertebroplasty with calcium phosphate cement augmentation for direct restoration of traumatic thoracolumbar vertebral fractures. Spine (Phila Pa 1976), 27: , ) White AA, Panjabi MM: Clinical Biomechanics of the Spine. Philadelphia, JB Lippincott: 1978.

Original Article pissn eissn J Korean Soc Spine Surg Jun;19(2): Is It Nece

Original Article pissn eissn J Korean Soc Spine Surg Jun;19(2): Is It Nece Journal of Korean Society of Spine Surgery Is It Necessary to Add Anterior Decompression after Posterior Decompression for Thoracolumbar and Lumbar Fractures with Neurologic Deficit? Jae-Won You, M.D.,