Original Article pissn eissn J Korean Soc Spine Surg Dec;20(4): Proxima

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Journal of Korean Society of Spine Surgery Proximal Junctional Problems in Surgical Treatment of Lumbar Degenerative Sagittal Imbalance Patients and Relevant Risk Factors Whoan Jeang Kim, M.D., Dae Geon Song, M.

Originally published online December 31, 2013; http://dx.doi.org/10.4184/jkss.2013.20.4.156 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST.

1 Journal of Korean Society of Spine Surgery Proximal Junctional Problems in Surgical Treatment of Lumbar Degenerative Sagittal Imbalance Patients and Relevant Risk Factors Whoan Jeang Kim, M.D., Dae Geon Song, M.D., Jae Won Lee, M.D., Jong Won Kang, M.D., Kun Young Park, M.D., Je Yun Koo, M.D., Won Cho Kwon, M.D., Won Sik Choy, M.D. J Korean Soc Spine Surg 2013 Dec;20(4): Originally published online December 31, 2013; Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, , Korea Tel: Fax: Copyright 2013 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/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Original Article pissn eissn J Korean Soc Spine Surg Dec;20(4): Proximal Junctional Problems in Surgical Treatment of Lumbar Degenerative Sagittal Imbalance Patients and Relevant Risk Factors Whoan Jeang Kim, M.D., Dae Geon Song, M.D., Jae Won Lee, M.D., Jong Won Kang, M.D., Kun Young Park, M.D., Je Yun Koo, M.D., Won Cho Kwon, M.D., Won Sik Choy, M.D. Department of Orthopedic Surgery, Eulji University School of Medicine, Daejeon, Korea Study Design: Retrospective study. Objectives: As we analyze the incidence and the risk factor for proximal junctional problem after surgical treatment of lumbar degenerative sagittal imbalance, we want to contribute to reducing the junctional problem of surgical treatment of lumbar degenerative sagittal imbalance. Summary of Literature Review: Surgical treatment of degenerative spinal deformity has increased. Rigid fixation was a risk factor for degenerative change of adjacent segment and failure, and it remains a big challenge for the junctional problem of surgical treatment. However, research on the correlation with risk factors is rare. Materials and Methods: Forty four patients (mean age 66.5; range, 50-74) who had surgery due to lumbar degenerative sagittal imbalance were evaluated by the risk factor associated with junctional problems from January, 2005 to December, The risk factors were analyzed by surgical factor (proximal fusion level, using iliac screw, correction or undercorrection of lumbar lordosis compared with pelvic incidence) and patient factor (age, bone marrow density, body mass index). Results: Junctional problems occurred in 18 patients (41%) out of 44 patients. Among these problems, there were 10 cases of fractures, 8 cases of junctional kyphosis, and 4 cases of proximal screw pull out.. Among the risk factors, only the correction or undercorrection of lumbar lordosis compared with pelvic incidence in surgical factor was statistically significant. Other surgical factors and patient factors were not statistically significant. Conclusions: Junctional problems after a surgical treatment of lumbar degenerative sagittal imbalance were common. However, we could not know the exact risk factor of junctional problems except the degree of correction of lumbar lordosis compared with pelvic incidence, because most of the risk factors were not statistically significant. So, further evaluations of the risk factor of lumbar degenerative sagittal imbalance are required. Key Words: Lumbar degenerative sagittal imbalance, Surgical treatment, Junctional problem 서론 척추시상면의만곡은경추전만, 흉추후만, 요추전만의곡선을이루어척추에가해지는하중과충격을완화하는역할을하여척추근육이효과적으로작용할수있도록하며그중에서도특히요추부의전만곡이중요하다. 요추부의전만곡이소실되면이에대한보상기전이작용하게되며이로인해쉽게피로하고활동시동통을야기하게된다. 1) 이러한변형에대한수술적치료는 1946 년 La, Chapelle 의시도로 2) 시작되어 1985 년 Thomasen 의 vertebral wedge osteotomy 까지발달하였고 3) 이후로도발전하여현재에이르고있다. 일부에서는퇴행성척추변 Received: June 25, 2013 Revised: July 11, 2013 Accepted: December 6, 2013 Published Online: December 31, 2013 Corresponding author: Jae Won Lee, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, 1306, Dunsan-dong, Seo-gu, Daejeon , Korea TEL: , FAX: jwlee@eulji.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 156 Copyright 2013 Korean Society of Spine Surgery

3 Journal of Korean Society of Spine Surgery Proximal Junctional Problems and Relevant Risk Factors 형의유병율을 54세에서약 29% 이며 70대에서는 68% 까지증가한다고보고하고있다. 4,5) 최근고령인구의퇴행성척추변형에대한수술이증가하고있고퇴행성척추변형에대한유합술은다른척추수술에비해기기실패, 자가골채취부합병증, 신경손상, 감염, 가성관절증등많은합병증과관련되어있다. 유합술을실패하게하는이러한합병증들은견고한분절유합기기를사용함으로써줄일수있다. 6) 그렇지만, 성공적인유합술은인접분절의퇴행성변화와실패의위험인자가되며후방유합술후발생하는인접분절의문제는저자에따라 5.6% 에서 39% 까지다양하게보고하고있으며 7-10) 수술적치료후발생하는인접분절의문제는가장큰해결과제로남아있다. 이러한인접분절에서의문제들로는근위분절후만, 골절 ( 인접분절골절, 근위고정분절골절 ), 근위및원위나사의이완등이있다. 인접분절문제의발생은특별한증상을유발하지않는경우도있고통증, 신경학적증상, 퇴행성변화의진행등을발생시켜재수술을하게되는경우도있다. 인접분절문제의발생원인은아직도불분명하지만많은저자들이고정분절과가동분절사이의부하의증가, 추간판의퇴행성변화의진행, 후관절및인대조직의비후, 척추주변근육의지방변성, 후방인대복합체의약화등이영향을주는것에동의하고있다. 또한, 생역학연구에서유합술시행후척추에서하중분산의변화가양종단척추체와인접분제의부하를증가시키는것이알려져있다. 11,12) 앞선연구들에서는일부퇴행성변형수술후발생하는인접분절후만혹은척추체의골절에대하여빈도나위험요소에대하여보고하고있으며인접분절문제전반의발생빈도와위험요소와의연관성에대한연구는부족한실정이다. 따라서본연구의목적은요추부퇴행성시상면불균형으로수술후발생하는인접분절문제의종류와그에따른발생빈도, 인접분절문제발생에영향을주는연관된위험인자를분석하여요추부퇴행성시상면불균형환자의수술적치료에서발생하는근위인접분절의합병증을줄이는데기여하고자한다. 상에서제외하였다. 총 44 예의환자를대상으로하였으며연령 분포는평균 65.8 세 (50~74 세 ), 남녀비율은각각 4 명대 40 명이 었으며, 추시기간은평균 25.4 개월 (12~64 개월 ) 이었다. 대상및방법 1. 연구대상본연구는본원에서 2005 년 1월부터 2012 년 2월까지요추부퇴행성시상면불균형중퇴행성후만증을동반하여수술을시행받은환자중 1년이상추시가능한경우를대상으로하여후향적으로시행하였다. 모든환자에서보행분석검사를시행하였고골반신전근육이정상기능을하여골반후방회전을통한보상기전이유지되고있는환자에서수술적치료를시행하였다. 퇴행성측만증혹은수술후편평배부증후군환자들은대 Fig. 1. The schema displays he cobb s method of thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, and sagittal vertical axis. Pelvic parameter (pelvic tilt, sacral slope, and pelvic incidence) is also on lateral whole spine. TK, thoracic kyphosis; TLK, thoracolumbar kyphosis; LL, lumbar lordosis; SS, sacral slope; PT, pelvic tilt; PI, pelvic incidence; SVA, sagittal vertical axis 157

Whoan Jeang Kim et al Volume 20 Number 4 December 2013 2. 수술적치료의고려사항수술은한명의술자에의해시행되었으며모든환자에대하여제 3 요추부에서척추경을통한쐐기형절골술을시행하였다.

4 Whoan Jeang Kim et al Volume 20 Number 4 December 수술적치료의고려사항수술은한명의술자에의해시행되었으며모든환자에대하여제 3 요추부에서척추경을통한쐐기형절골술을시행하였다. 근위유합부위는흉요추후만정도에따라결정하였으며김 26) 등연구에의하면흉요추후만각이 10도이상인경우에는근위부고정부위를제 10흉추까지시행하는것이술후교정소실이적게발생하고, 10도미만인경우에는제 11 흉추혹은제 12 흉추까지만시행하여도근위부에서의교정소실이적게발생하였다. 이에따라흉요추후만각이 10도이상인경우제 10 흉추까지, 흉요추후만각이 10도미만인경우제 11 흉추혹은제 12 흉추까지유합술을시행하였다. 원위유합부위는모든환자에있어천추까지시행하였으며장골나사의사용유무는환자의변형교정정도, 골상태등을고려하여술자의판단에의해결정되었다. 3. 방사선적계측및인접분절문제방사선적계측은술전, 술후, 최종추시시에각각시상수직축 (Sagittal vertical axis), 흉추후만각 (thoracic kyphosis angle), 흉요추후만각 (thoracolumbar kyphosis angle), 요추전 만각 (lumbar lordosis angle), 골반지표 (pelvic parameter): 천추경사 (sacral slope), 골반경사 (pelvic tilt), 골반입사각 (pelvic incidence) 을측정하였다. 각각의전, 후만각은기립상전척추측면방사선사진에서 Cobb 의방법 13) 을사용하였으며, 시상수직축은제 7 경추체중심에서내린수선 (C7 plumb line) 에서제 1 천추후상연까지의거리 (cm) 로측정하였고흉추후만각은제 3 흉추혹은제 5 흉추에서제 12 흉추, 흉요추부후만각은제 10 흉추에서제 2 요추, 요추전만각은제 1 요추에서제 1 천추사이로하였다. 천추경사각은제 1 천추의상연과수평선과의각을측정하고골반경사각은제 1 천추상연의중심에서고관절축을잇는선과고관절중심을지나는수직선과의각으로측정하며골반입사각은천추경사와골반경사의합으로정하였다 (Fig. 1). 인접분절후만각은상위기기고정분절의하단과상위인접척추체상단의 Cobb 각으로정하였고인접분절후만각이 10도이상증가할경우인접분절후만으로정의하였고기기고정분절외가동분절의골절을인접분절골절로근위기기고정분절척추체의골절을근위고정분절골절로정하였다. 근위나사의이완은수술 6개월후골유합이어느정도진행된후에도나 Fig. 2. (A) A 64-year-old woman has lumbar degenerative sagittal imbalance with kyphosis. (B) She underwent an operation of L3 TPV, T12-S1 PLF. The whole spine lateral radiograph shows restored sagittal balance immediate postoperative period. (C) Junctional kyphosis with proximal screw loosening had been developed 76 months after surgery. (D) The patient had revision surgery of T10-12 PF with rod change and lumbosacral fixation with iliac screw. 158

5 Journal of Korean Society of Spine Surgery Proximal Junctional Problems and Relevant Risk Factors Table 1. Average results of radiographic index for perioperative period PJP(+) PJP(-) TK TLK LL SS PT PI TK TLK LL SS PT PI Preoperative Postoperative PJP: proximal junctional problem, TK: thoracic kyphosis angle, TLK: thoracolumbar kyphosis angle, LL: lumbar lordosis angle, SS: sacral slope, PT: pelvic tilt, PI: pelvic incidence 사의이완이진행되는경우로정의하였고원위나사의이완은연구대상에서제외하였다. 4. 인접분절문제발생의위험요소인접분절문제발생에관여할것으로생각되는위험요소를분석하였다. 위험요소는수술적요인과환자요인으로나누어분석하였다. 수술적요인으로근위유합부위, 장골나사의사용유무, 골반입사각대비요추전만각교정여부가있으며환자요인으로는나이, 골밀도, 체질량지수가있다. 근위유합부위은제 10 흉추까지유합술을시행한경우와그렇지않은경우에대하여분석하였으며골반입사각대비요추전만각교정여부는수술후요추전만각이골반입사각 ± 9 보다작은경우교정부족으로하였다. 5. 통계학적분석연속변수인나이, 골밀도, 체질량지수에대하여 independent t-test 를사용하였고근위유합부위, 장골나사의사용유무, 골반입사각대비요추전만각교정정도에대하여 Chi-square test를사용하였다. 통계학적으로 SPSS v20.0을이용하였으며 P-value 가 0.05 미만인경우통계적으로유의한것으로간주하였다. 결과 전체대상환자 44명의수술전후방사선학적계측결과를다음과같은표에정리하였다 (Table 1). 총 44예의환자중 18명의환자 (41%) 에서인접분절문제가발생하였다. 인접분절문제중골절이 10예로가장많았으며그중인접분절골절 7예, 근위고정분절골절 3예였으며분절후만 8예, 근위나사이완 4예가발생하였다. 인접분절문제가발생한환자 18명중 4예에서두가지인접분절문제가동반되어발생하였고이들을대상으로 4 예의재수술을시행하였다 (Fig. 2). 수술적요인에서근위유합부위가제 10 흉추인경우는 20 예로그중 7예 ( 골절 4예, 분절후만 3예, 근위나사이완 1예 ) 에 서인접분절문제가발생하였고근위유합부위가제 11 혹은 12 흉추인경우 24예중 11예 ( 골절 6예, 분절후만 5예, 근위나사이완 3예 ) 에서인접분절문제가발생하였다. 원위천추유합시장골나사사용유무에따라장골나사를사용한환자 27예중 11예 ( 골절 7예, 분절후만 4예, 근위나사이완 3예 ), 사용하지않은환자 17예중 7예 ( 골절 3예, 분절후만 4예, 근위나사이완 1예 ) 에서인접분절문제가발생하였다. 골반입사각대비요추전만각교정정도는요추전만각이교정된 17예중 4예 ( 골절 2 예, 분절후만 3예, 근위나사이완 0예 ), 부족교정된 27예중 14 예 ( 골절 8예, 분절후만 5예, 근위나사이완 4예 ) 에서인접분절문제가발생하였다. 수술적요인중골반입사각대비요추전만각교정여부만인접분절문제발생과통계적으로유의한차이를보였다 (Table 2). 환자요인에서인접분절문제가발생하지않은환자의나이는평균 66.1 세, 평균골밀도 -2.5, 평균체질량지수 26.3kg/m 2 이었으며인접분절문제가발생한환자의나이는평균 65.3 세, 평균골밀도 -2.51, 평균체질량지수 26.8kg/ m 2 였다. 인접분절문제가발생한환자군에서골절의경우, 평균나이 65.1 세, 평균골밀도 -2.48, 평균체질량지수 26.8kg/m 2 였고, 분절후만의경우평균나이 64.8 세, 평균골밀도 -2.47, 평균체질량지수 27.0kg/m 2 였으며근위나사이완의경우평균나이 68.0 세, 평균골밀도 -2.80, 평균체질량지수 26.6kg/m 2 였다. 환자요인과인접분절문제발생간에통계적으로유의한차이는없었다 (Table 3). 고찰 수명이길어지고삶의질을높이기위한여러노력들이시도되면서퇴행성척추변형에대한수술적치료에대한요구도증가하고있다. 수술적치료가증가함에따라수술후발생하는인접분절문제의발생또한중요한쟁점이되고있다. 앞선많은연구에서인접분절문제발생의유병률과원인에대하여 5.6% 에서 39% 까지다양하게보고하고있다. 7-10) Etebar 와 Cahill 14) 은 14% 의인접분절문제발생률을보고하면서폐경기여성의위험성을제시하였고주위험요소로고령, 골다공증, 흉추혹 159

6 Whoan Jeang Kim et al Volume 20 Number 4 December 2013 Table 2. Assessment of surgical factors as a related factor for proximal junctional problem Patient PJP (-) PJP P-value Proximal fusion level T T11 or T Iliac screw (+) (-) Correction or undercorrection of lumbar lordosis compared with PI Correction * Undercorrection PJP: proximal junctional problem, PI: pelvic incidence *: Statistically significant Table 3. Assessment of patient factors as a related factor for proximal junctional problem 은천추에고정되지않은유합술, 척추불균형을제시하였다. Watanabe 등 15) 은척추변형교정수술후인접분절의골절이 생긴그룹과아탈구가일어난그룹을비교하여나이, 골다공증, 수술전건강상태, 심한시상면불균형환자들에서수술후인 접분절골절이잘발생함을보고하였으며 Toyone 등 16) 은골밀 도와관련하여폐경기여성이퇴행성요추부유합술후척추체 골절에많음을보고하였다. PJP (-) PJP (Fx/JK/PSP) P-value Age (yr) (65.1/64.8/68.0) BMD (-2.48/-2.47/-2.80) BMI (kg/m 2 ) (26.8/27.0/26.6) PJP: proximal junctional problem, Fx: fracture, JK: junctional kyphosis, PSP: proximal screw pull out, BMD: bone marrow density, BMI: body mass index 본연구에서는흔히발생하는인접분절문제들과위험요소 들간의관련성을찾고자하였으며그결과골반입사각대비교 정정도와인접분절문제발생의통계적유의성을확인하였다. Kumar 등 17) 도술후방사선사진상정상제 7 경추체중심수선 (C7 plumb line) 과천추경사를보이는환자에서인접분절의변 화가최소였음을보고하였다. 단순하게골유합을얻는것만으 로척추의안정성을유지할수없고시상면불균형을충분히교 정하여시상면의균형이정상적으로유지될때척추의안정성이 유지되고이상적인하중분산이이루어져골유합을잘얻고수 술적치료의유지가잘될수있다. 이는척추수술의안정성을 유지하기위해시상면균형의중요성을시사하는것이다. 척추 변형교정수술에서요추전만각의교정정도에대한여러주장이제시되고있으나최근 schwab 등 18) 의연구에따라골반입사각 ± 9 를기준으로하는것이좋은임상적결과를보인다고보고하였다. 유합술후인접분절의후관절에서비가역적인퇴행성변화와추간판구성의변화가보고되었으며 19,20) 고정분절의경직성증가가인접가동분절의보상성움직임을증가시키고후방조직의하중을증가시킨다. 21) Etebar 등 14) 은견고한고정이인접분절문제발생에영향을준다고보고하였고 Watanabe 등 15) 도천추를포함하는견고한고정술이상위고정분절척추체에하중을집중시킨다고보고하였으나본연구결과근위유합부위, 장골나사의사용유무와인접분절문제발생의연관성을발견하지못하였다. 생역학연구에서나사이완과골밀도감소와의직접적인연관성을보였으나 22,23) Meredith 등 24) 은골밀도와골절의연관성을확인하지못하였으며본연구에서도나이, 골밀도, 체질량지수와의관련성을확인할수없었다. 그렇지만이것은통계적인유의성을의미하는것으로이러한요소들이인접분절의문제발생과무관한것은아니다. 비록통계적유의성을확인하지는못하였지만근위유합부위가짧을경우인접분절후만이나근위나사이완이더많이생기는경향이있었고특히인접분절골절이나근위기기고정분절골절의발생이장골나사를사용한경우 25.9% 인반면사용하지않은경우 17.6% 로차이가있었다. 본연구에서인접분절문제의발생률은 41% 였다. 다른연구에비해높은발생률을보이는데이는다른연구 7-10) 에비해전체환자의평균나이 65.8 세의고령을대상으로하였으며이로인해동반질환이많거나포괄적인요추부퇴행성시상면불균형이진행된경우가많았기때문으로생각된다. 15) Arlet 와 Aebi 25) 은방사선적인인접분절문제발생이실제임상적증상을일으 160

7 Journal of Korean Society of Spine Surgery Proximal Junctional Problems and Relevant Risk Factors 키는경우는적다고하였고 Hostin 등 9) 은약 5.6% 의재수술률을보고하였지만본연구에서재수술을시행한경우는 4예였으며이는전체인접분절문제발생의 22% 에해당한다. 이렇게인접분절문제의발생환자가재수술을받는경우도큰비율을차지하고있기때문에인접분절문제의발생은퇴행성척추변형환자의수술적치료에있어서아주중요한문제라고할수있겠다. 본연구에는몇가지제한점이있다. 첫째, 연구의대상이된환자들은대부분은폐경기여성이었다. 이는성별에따른영향분석을할수없고골밀도검사상정상이라고할지라도폐경후의호르몬불균형에따른영향을배제할수없다. 둘째, 환자들의생활패턴에대한고려를하지못하였다. 문화적특성상구부리는자세나바닥생활을하는경우가많아이로인한하중변화가있을수있고이점이인접분절문제발생에영향을줄수있다. 셋째, 후향적연구라는점이다. 인접분절문제발생의원인에정확한결론이내려져있지않으며이에대한여러연구가있으나결과가조금씩차이를보이고있다. 인접분절문제발생에관여하는위험인자의정확한확인을위해서다기관전향적연구를통한연구가필요할것으로생각된다. 결론 요추부퇴행성척추변형환자의수술적치료가증가하고이로인해수술후발생하는인접분절문제발생이중요한쟁점이되고있지만아직도그원인과위험인자에대한연구는부족한실정이다. 본연구를통해골반입사각대비요추전만각교정이인접분절문제발생을줄이는데중요한요소임을확인할수있었으나다른수술적요인과환자요인의수술후인접분절문제발생과의통계적유의성을확인하지는못하였다. 따라서추후요추부퇴행성시상면불균형환자의수술적치료에서충분한요추전만각교정을이루는것이중요하며인접분절문제발생에관여하는다른위험인자에대한추가연구가필요할것으로생각된다. REFERENCES 1. During J, Goudfrooij H, Keessen W, Beeker TW, Crowe A. Toward standards for posture. Postural characteristics of the lower back system in normal and pathologic conditions. Spine (Phila Pa 1976). 1985;10: La CE. Osteotomy of the lumbar spine for correction of kyphosis in a case of ankylosing spondylarthritis. J Bone Joint Surg Am. 1946;28: Thomasen E. Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis. Clin Orthop Relat Res. 1985; Jimbo S, Kobayashi T, Aono K, Atsuta Y, Matsuno T. Epidemiology of degenerative lumbar scoliosis: a communitybased cohort study. Spine (Phila Pa 1976). 2012;37: Schwab F, Dubey A, Gamez L, et al. Adult scoliosis: prevalence, SF-36, and nutritional parameters in an elderly volunteer population. Spine (Phila Pa 1976). 2005;30: West JL, 3rd, Bradford DS, Ogilvie JW. Results of spinal arthrodesis with pedicle screw-plate fixation. J Bone Joint Surg Am. 1991;73: Glattes RC, Bridwell KH, Lenke LG, Kim YJ, Rinella A, Edwards C 2nd. Proximal junctional kyphosis in adult spinal deformity following long instrumented posterior spinal fusion: incidence, outcomes, and risk factor analysis. Spine (Phila Pa 1976). 2005;30: Kim YJ, Bridwell KH, Lenke LG, Glattes CR, Rhim S, Cheh G. Proximal junctional kyphosis in adult spinal deformity after segmental posterior spinal instrumentation and fusion: minimum five-year follow-up. Spine (Phila Pa 1976). 2008;33: Hostin R, McCarthy I, O Brien M, et al. Incidence, Mode, and Location of Acute Proximal Junctional Failures Following Surgical Treatment for Adult Spinal Deformity. Spine (Phila Pa 1976). 2013;38: Yagi M, Akilah KB, Boachie-Adjei O. Incidence, risk factors and classification of proximal junctional kyphosis: surgical outcomes review of adult idiopathic scoliosis. Spine (Phila Pa 1976). 2011;36:E Wood KB, Schendel MJ, Ogilvie JW, Braun J, Major MC, Malcom JR. Effect of sacral and iliac instrumentation on strains in the pelvis. A biomechanical study. Spine (Phila Pa 1976). 1996;21: Erickson MA, Oliver T, Baldini T, Bach J. Biomechanical assessment of conventional unit rod fixation versus a unit rod pedicle screw construct: a human cadaver study. Spine (Phila Pa 1976). 2004;29: 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 161

8 Whoan Jeang Kim et al Volume 20 Number 4 December 2013 size. A prospective controlled clinical study. Spine (Phila Pa 1976). 1994;19: Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg. 1999;90: Watanabe K, Lenke LG, Bridwell KH, Kim YJ, Koester L, Hensley M. Proximal junctional vertebral fracture in adults after spinal deformity surgery using pedicle screw constructs: analysis of morphological features. Spine (Phila Pa 1976). 2010;35: Toyone T, Ozawa T, Kamikawa K, et al. Subsequent vertebral fractures following spinal fusion surgery for degenerative lumbar disease: a mean ten-year follow-up. Spine (Phila Pa 1976). 2010;35: Kumar MN, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J. 2001;10: Schwab F, Lafage V, Patel A, Farcy JP. Sagittal plane considerations and the pelvis in the adult patient. Spine (Phila Pa 1976). 2009;34: Cole TC, Burkhardt D, Ghosh P, Ryan M, Taylor T. Effects of spinal fusion on the proteoglycans of the canine intervertebral disc. J Orthop Res. 1985;3: Kahanovitz N, Arnoczky SP, Levine DB, Otis JP. The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage. Spine (Phila Pa 1976). 1984;9: Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976). 1984;9: Zindrick MR, Wiltse LL, Widell EH, et al. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop Relat Res. 1986; Halvorson TL, Kelley LA, Thomas KA, Whitecloud TS 3rd, Cook SD. Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976). 1994;19: Meredith DS, Schreiber JJ, Taher F, Cammisa FP Jr., Girardi FP. Lower preoperative hounsfield unit measurements are associated with adjacent segment fracture after spinal fusion. Spine (Phila Pa 1976). 2013;38: Arlet V, Aebi M. Junctional spinal disorders in operated adult spinal deformities: present understanding and future perspectives. Eur Spine J. 2013;22 Suppl:S Kim WJ, Kang JW, Yang DS, et al. Radiologic analysis of postoperative sagittal plane correction in lumbar degenerative kyphosis (LDK). J Korean Spine Surg. 2009;16: 요추부퇴행성시상면불균형환자에서의수술적치료후근위인접분절의문제와연관된위험인자 김환정 송대건 이재원 강종원 박건영 구제윤 권원조 최원식을지대학교의과대학정형외과학교실 연구계획 : 후향적연구 목적 : 요추부퇴행성시상면불균형으로수술후발생하는인접분절문제의발생빈도, 인접분절문제발생에영향을주는위험요소와연관성을분석 하여요추부퇴행성시상면불균형환자의수술적치료에서발생하는근위인접분절의합병증을줄이는데기여하고자한다. 선행문헌의요약 : 요추부퇴행성척추변형에대한수술이증가하고있다. 성공적인유합술은인접분절의퇴행성변화와실패의위험인자가되며수술 적치료후발생하는인접분절에서의문제들은가장큰과제로남아있으나그위험요소에대한분석은부족한실정이다. 대상및방법 : 2005 년 1 월부터 2011 년 12 월까지요추부퇴행성시상면불균형으로수술을시행받은 44 명의환자를대상 ( 평균 65.8 세, 범위 50~74 세 ) 으로하여인접분절의문제에대하여각각위험요소와의관련성을분석하였다. 위험요소는수술적요인 ( 근위유합부위, 장골나사의사용유무, 골반 입사각대비요추전만각교정여부 ) 와환자요인 ( 나이, 골밀도, 체질량지수 ) 로나누어분석하였다. 결과 : 총 44 예의환자중 18 명의환자 (41%) 에서인접분절문제가발생하였다. 인접분절문제중골절 10 예, 분절후만 8 예, 근위나사이완 4 예였으며 위험요소로서수술적요인중골반입사각대비요추전만각교정여부는통계적유의성을보였으나다른수술적요인과환자요인에서는통계적인유 의성이없었다. 결론 : 요추부퇴행성시상면불균형환자의수술적치료시근위인접분절문제가비교적흔하게발생하였으나분석요인들중골반입사각대비요추 전만각교정여부를제외하고는대부분통계적유의성을보이지않아근위인접분절문제의정확한위험요소를알기는힘들었으며이에대한추가적 인연구가필요할것으로생각된다. 색인단어 : 요추부퇴행성시상면불균형, 수술적치료, 인접분절의문제 약칭제목 : 근위인접분절문제와연관된위험인자 162

05-김환정/

05-김환정/ 요부변성후만증환자에서의술후시상면교정에대한방사선학적분석 대한척추외과학회지제 16 권제 3 호 Journal of Korean Spine Surgery Vol. 16, No. 3, pp 177~185, 2009 DOI:10.4184/jkss.2009.16.3.177 김환정 강종원 양대석 강성일 박건영 # 박재국 $ 성환일 최원식 을지대학교의과대학정형외과학교실,