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1 요부변성후만증환자에서의술후시상면교정에대한방사선학적분석 대한척추외과학회지제 16 권제 3 호 Journal of Korean Spine Surgery Vol. 16, No. 3, pp 177~185, 2009 DOI: /jkss 김환정 강종원 양대석 강성일 박건영 # 박재국 $ 성환일 최원식 을지대학교의과대학정형외과학교실, 대전보훈병원 #, 홍성의료원 $, 김천제일병원 Radiologic Analysis of Postoperative Sagittal Plane Correction in Lumbar Degenerative Kyphosis (LDK) Whoan Jeang Kim, M.D., Jong Won Kang, M.D., Dae Suk Yang, M.D., Sung Il Kang, M.D., Kun Young Park, M.D. #, Jae Guk Park, M.D. $,Hwan Il Sung, M.D., Won Sik Choy, M.D. Department of Orthopaedic Surgery, Eulji University School of Medicine, Daejeon Veterans Hospital #, Hongseong Medical Center $, Gimcheon Jeil Hospital Abstract Study Design: This is a retrospective study Objectives: We radiologically analyzed the correction of the sagittal imbalance and the proximal fusion level to prevent correction loss and the usefulness of iliac screws in LDK. Summary of the Literature Review: Complications can be encountered during fixation and fusion as most of the LDK patients are aged, and the osteoporosis that causes fixation loss is known to affect the loss of correction. Materials and Methods: We analyzed the cause of correction loss among 35 patients who underwent surgery and who were followed up for at least 1 year. All the patients had performed gait analysis before operation. The operative techniques were pedicle subtraction osteotomy and fixation to S1. For analyzing causes of correction loss, we analyzed the degrees of lumbar lordosis for the sagittal correction and the degrees of the preoperative thoracolumbar kyphosis for the proximal fusion range. For analyzing the usefulness of iliac screws, the subjects were divided into two groups: 1) the -iliac screw (23cases) group for the patients who were fixed without iliac screws and 2) the +iliac screw (12cases) group for the patients who were fixed with iliac screws. Results: There were no patients who had marked anterior pelvic tilt. It is important to correct the lumbar lordosis over 20 compared with the preoperative thoracic kyphosis. There are 10 cases of preoperative thoracolumbar kyphosis 10 and 25 cases of preoperative thoracolumbar kyphosis < 10 of the total 35 cases. Among 10 cases of preoperative thoracolumbar kyphosis 10, 4 cases that were fixed to T10 had no sagittal correction loss, and 2 of the 6 cases that were fixed to T11 or T12 had sagittal correction loss. For the 25 cases of preoperative thoracolumbar kyphosis < 10, 5 cases that were fixed to T10 had no sagittal correction loss and 1 of the 20 cases that were Address reprint requests to Jong Won Kang, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, 1306, Dunsan-dong, Seo-gu Daejon, , Korea Tel: , Fax: , jwkang@eulji.ac.kr Received: Accepted: * 본논문의요지는 2008년제 25 차대한척추외과학회추계학술대회에서구연되었음

2 대한척추외과학회지 Vol. 16, No. 3, 2009 fixed to T11 or T12 had sagittal correction loss (p<0.05). 6 cases (26%) in the -iliac screw group (23 cases total) and 1 case (8%) in the +iliac screw (12 cases total) showed sagittal correction loss (p<0.05). Conclusions: It is important to make the postoperative lumbar lordosis over 20 compared with the preoperative thoracic kyphosis for correcting sagittal imbalance, to decide on the proximal fixation level according to the preoperative thoracolumbar kyphosis and to fix with iliac screws. Key words: Lumbar degenerative kyphosis, Iliac screw, Sagittal plane correction loss 서 론 척추의정상적인기능을위하여시상면에서척추의정상적인만곡을유지하는것이중요하다. 이는각척추체를시상면상에정위시킴으로써추간판이나후관절에비정상적인하중을감소시켜척추근육의효율성을증대시키고, 시상면상균형유지를위한근육의피로도를감소시키기때문이다 1). 요부변성후만증의시상면불균형교정에대한수술적치료로는단순후방교정술, 전후방교정술, 후방교정술및후방추체간고정술, 척추경절골술등이있다. 이러한수술적치료후발생할수있는합병증으로는여러가지가있을수있으나, 가장문제가되는것은몸이앞으로굽는증상이다시발생하는것을들수있다. 이런증상이다시발생하는원인으로는크게세가지로나눌수있는데, 첫째불충분한교정, 둘째골다공증에의한고정력상실에의한교정소실, 셋째골반신전근의보상작용의부전등이있다. 시상면불균형의진단과교정의정도를정하는데있어시상수직축 (sagittal vertical axis) 을많이이용하고있지만, 요부변성후만증환자는잘알려져있듯이동적인시상면불균형때문에 2) 시상수직축이변하는문제가있어수술시시상면교정정도를정하는데쉽지않다. 또한, 고령으로인한수술의위험성때문에유합범위를결정하기어려우며, 골다공증에의한고정력유지에어려움이있다. 이에저자들은요부변성후만증으로진단받고척추경을통한절골술및유합술을시행받은환자에대하여수술시적절한시상면균형을얻기위한요추전만교정정도, 술전흉요추부후만각과술후시상면교정소실을통해근위부의유합범위의선택및장골나사의사용으로인한시상면교정유지의효과에대하여방사선학적측면에서분석하고자한다. 대상및방법 2004 년 2 월부터 2007 년 10 월까지본원정형외과에내 원하여임상및방사선소견상요부변성후만증으로진단받은모든환자를대상으로술전보행분석검사를시행하여현저한전방골반경사를보이는환자를제외한나머지환자에서척추경을통한절골술및후방유합술을시행하였고, 그중다발성압박골절이있거나, 척추수술을받은과거력이있는경우, 슬관절이나고관절의퇴행성질환으로수술을받은경우를제외하고 1 년이상추시가능하였던 35 례를대상으로후향적으로분석하였다. 연령분포는평균 65.4 세 (51~74 세 ), 추시기간은평균 21.4 개월 (12~48 개월 ) 이었다. 모든환자에서단순방사선사진은 36 인치필름을사용하여견관절을 90 굴곡, 고관절과슬관절신전상태에서경추와고관절을포함한기립상전척추측면방사선촬영을각각시행하였다 3). 방사선학적계측은술전, 술후, 최종추시시에각각시상수직축, 흉추후만각 (T5~T12), 흉요추부후만각 (T10~L2), 요추전만각 (T12~S1) 을측정하였으며, 시상수직축은제 7 경추체중심에서내린수선 (C7 plumb line) 에서제 1 천추후상연까지의거리 ( cm ) 로측정하였고술전및술후추시상시상면교정소실은제 7 경추체중심에서내린수선이고관절중심부전방에위치한경우로하였다. 수술방법은모든환자에서제 3 요추에서척추경을통한절골술과후방유합술을시행하였으며특히제 1 천추나사못은삽입시탐침 (probe) 을이용하여양면피질에천공이되었는지확인후나사못을삽입하였다. 적절한시상면교정을얻기위한교정정도를분석하고자술전및술후흉추후만각과요추전만각를측정하여술전흉추후만각보다 20 이하로요추전만각교정 ( 술후요추전만각 술전흉추후만각 +20 ) 을시행한경우 (A group, 7 례 ) 와술전흉추후만각보다최소한 20 이상요추전만각교정 ( 술후요추전만각 술전흉추후만각 +20 ) 을시행한경우 (B group, 28 례 ) 를비교분석하였다. 장골나사의병용유무와관계없이근위부유합부위에따라제 10 흉추까지시행한환자 (9 례 ) 와제 11 흉추또는제 12 흉추까지시행한환자 (26 례 ) 로나누어비교분석하였다. 또한제 1 천추까지유합한군 (- iliac screw, 23 례 ) 과제 1 천추까지유합하고장골나사를

3 요부변성후만증환자에서의술후시상면교정에대한방사선학적분석 김환정외 병용한군 (+iliac screw, 12 례 ) 으로나누어장골나사의유용성에대한분석을하였다. 통계학적으로 SPSS v13.0 을이용하였으며, student T- test 와 Chi-square test 를사용하였다. 결 과 술전흉추후만각보다약 20 이상요추전만각교정 을시행한 28 례의경우수술직후시상수직축이평균 2.3 cm으로적절한시상면균형을얻을수있었지만, 그렇지못한 7 례의경우시상수직축이평균 10.3 cm으로써제 7 경추체중심에서내린수선이고관절중심부전방에위치하여수술직후시상면균형을얻지못하였다 (P<0.05) (Table 1). 근위부유합범위에따라술전흉요추부후만각이 10 이상이었던총 10 례중근위부고정부위를제 10 흉추까지시행한 4 례는근위부시상면균형이유지되었으 Table 1. Radiologic analysis of patients according to lumbar lordosis correction A group(7cases) B group(28cases) Preop. Postop. Preop. Postop. p-value T-Kyphosis( ) L-Lordosis( ) SVA( cm ) Preop., Preoperative angle; Postop., Postoperative angle T-kyphosis, thoracic kyphosis; L-lordosis, lumbar lordosis; SVA, sagittal vertical axis Table 2. No. of proximal junctional problem Proximal fusion level T-L kyphosis 10 T-L kyphosis<10 T10 T11 or T12 T10 T11 or T12 No. of total case No. of proximal junctional problem No., number; T-L, thoracolumbar (p=0.01) Table 3. Demographics and preoperative radiologic measurement of patients with or without iliac screw -iliac screw (23cases) +iliac screw (12cases) p-value Age (year) No. of levels fused F/U (month) T-kyphosis( ) T-L kyphosis( ) L-lordosis( ) Radiologic Pelvic tilt( ) Pelvic tilt in Gait analysis( ) No., number; F/U, follow up; T-kyphosis, Thoracic kyphosis T-L kyphosis, Thoracolumbar kyphosis Table 4. Postoperative & F/U measurement of patients with or without iliac screw -Iliac screw (23cases) +Iliac screw (12cases) p-value SVA (cm) Postop Last F/U No. of correction loss 6(26%) 1(8.3%) 0.01 SVA, Sagittal vertical axis; Postop., Postoperative; F/U, follow up; No., number

4 대한척추외과학회지 Vol. 16, No. 3, 2009 나, 근위부고정부위를제 11 흉추또는제 12 흉추까지시행한 6 례중 2 례에서근위부문제가발생하였으며, 술전흉요추부후만각이 10 미만이었던총 25 례중근위부고정부위를제 11 흉추또는제 12 흉추까지시행한 20 례중 1 례에서근위부문제가발생하여, 술전흉요추부후만각이 10 이상인경우근위부고정부위를제 11 흉추또는제 12 흉추까지만시행할경우근위부문제의발생이많으며, 제 10 흉추까지시행한경우근위부고정부위가잘유지되었다 (p<0.05) (Table 2). 제 1 천추까지유합한군 (-Iliac screw, 23 례 ) 과제 1 천추까지유합하고장골나사를병용한군 (+iliac screw, 12 례 ) 은술전방사선학적측정에서두군간에유의한차이는없었다 (Table 3). 술후두군에서방사선학적측정을비교한결과 -iliac screw 군에서는시상수직축이술후 3.5 cm에서최종추시시 7.5 cm이었으며, +iliac screw 군에서는술후 1.2 cm에서최종추시시 5.3 cm으로나타났다. 또한, 시상수직축이고관절중심의전면에위치하여시상면상교정소실을보인경우는총 35 례중 7 례 (20%) 였으며, -iliac screw 군은총 23 례중 6 례 (26%), +iliac screw 군은총 12 례중 1 례 (8.3%) 에서시상면교정소실을보여 +iliac screw 군에서시상면소실이더적은것으로나타났다 (P<0.05) (Table 4). 시상면교정소실을보인환자들중 -iliac screw 군에서는근위부에서 2 례, 원위부에서 3 례, 근위부와원위부동시에교정소실이일어난경우 1 례있었으며, +iliac screw 군에서는근위부에서만 1 례의교정소실이일어났으며, 원위부교정소실은없었다. +iliac screw 군중근위부에서교정소실이일어난 1 례는최상부유합척추체의상부척추골단골절에의한것이었다 (Table 5). 또한두그룹의수술후시상면교정소실이발생한시점은 -iliac screw 군에서는평균 2.2 개월 (2.5~4.3 개월 ), +iliac screw 군에서는 1 례에서 4.7 Table 5. Site of occurring correction loss in both group (-Iliac screw and +Iliac screw) -Iliac screw (6cases) +Iliac screw (1case) Proximal junction 2 1 Distal junction 3 0 Both 1 0 No., number; Both, Proximal junction + Distal junction 개월에교정소실이일어났으며, 그이후에는교정소실이일어난경우가없어술후 5 개월이후에는시상면교정소실이없었다 (Table 6). 그외의합병증으로강봉의파괴가 -iliac screw 군에서 2 례, +iliac screw 군에서 1 례등총 3 례가있었으나, 굴곡 / 신전방사선사진상에서움직임은없었으며시상면균형이유지되었다. 고 찰 요부변성후만증환자의수술적방법에는여러가지가있지만, 단순후방교정술, 전후방교정술, 후방교정술및후방추체간고정술에서는불충분한교정에따른시상면교정소실에의한좋지않은결과가보고되고있기때문에최근에는대부분척추경절골술을시행하고있다. 척추경절골술은척추의전주는변화가없으며, 중주는폐쇄되고, 후주는단축되어분절당 30~35 의교정을얻을수있다고알려져있다 4). 이에저자들은모든환자들에대해서척추경절골술을시행하였다. 동적인시상면불균형인요부변성후만증환자에서이와김등 2,5) 이언급한보행시몸이앞으로굽는증상은술전시상면균형판단의기준인시상수직축이상황에따라변할수있어술전시상면균형을얻기위한교정각결정에어려움이있다. 김등 3) 은정상성인에서의흉추후만각은평균 24, 요추전만각은 -47 로흉추후만각과요추전만각간에평균 20 도의차이를보였으며, 시상면불균형환자에서적절한시상면균형을얻기위하여술후기립상단순방사선에서흉추부후만각과요추전만각의합의절대값이 20 이상으로유지되어야한다고하였다 6). 저자들의경우에서도술전및술후흉추부후만각과요추부전만각을비교분석하여, 술전흉추후만각보다최소한약 20 보다크게요추부전만각을교정을시행하였을경우술후시상수직축이정상시상면정렬에가깝게교정되는것을알수있었다. 요부변성후만증의환자들은고령이고대부분골다공증을동반하고있어고정력에대한문제가발생할수있기때문에유합범위를결정하는데있어많은어려움이따르고있으며특히성인척추변형환자에서의근위 Table 6. Duration of correction loss of both group (-Iliac screw and +Iliac screw) < Pod 1m < Pod 6m < Pod 1y Average -Iliac screw months +Iliac screw months Pod, postoperative day; m, month; y, year

5 요부변성후만증환자에서의술후시상면교정에대한방사선학적분석 김환정외 부유합범위에대한많은논란이지속되고있다. 몇몇저자들은제 1 요추와제 2 요추에서부터의유합은근위부인접분절문제의발생빈도가아주높아성인에서제 5 요추또는제 1 천추까지의장분절유합시근위부유합범위를제 1 요추또는제 2 요추에서시행하는것은피하라고하였으며 7,8), 다른저자들은성인에서의장분절유합시근위부유합범위에대하여제 9 흉추까지시행한경우와제 11 흉추또는제 1 요추까지시행한두군간의임상적및방사선학적으로큰차이가없다고하였으나 9), 일반적으로진성늑골이있는제 10 흉추이상고정하는것이인접분절후만증등과같은합병증을줄일수있다고보고되고있다. 그러나노인환자에서장분절유합술시큰수술에따른여러합병증이발생할수있기때문에적절한근위부고정범위를결정하는데어려움이있다. 저자들의경우에서는절골술시일반적으로상, 하부에같은모멘트암 (moment arm) 을유지하도록고정해야할것을권고하고있어제 3 요추에서절골술을시행하고근위부유합범위를제 12 흉추까지하 는것을원칙으로하였으나, 흉요추부 Cobb 씨각이후만을보이는경우는제 10 흉추까지근위부를유합하였다. 김과이등 4,10) 에의하면흉요추부후만각을제 11 흉추에서제 2 요추까지로정하여정상성인은 -5 에서 +5 에속한다고하였으며, Bernhard 등 11) 에의하면각척추체의분절각에서제 10 흉추의분절각을평균 3 라고하였다. 이에따라저자들은흉요추부후만각 (T10~L2 Cobb 씨각 ) 을평균 10 를기준으로근위부에서의교정소실발생과흉요추부후만각에따른근위부유합범위의상관관계를후향적으로분석한결과술전흉요추부후만각이 10 이상인경우에는근위부고정부위를제 10 흉추까지시행하는것이술후교정소실이적게발생하고, 10 미만인경우에는제 11 또는 12 흉추까지만시행하여도근위부에서의교정소실이적게발생한다는것을알수있었다 (Fig. 1,2). 성인에서의장분절유합술시원위부유합을제 5 요추까지시행하는것과제 1 천추까지시행하는것은각각장단점이있지만제 5 요추까지만시행하였을경우 Fig. 1. A 66-year old woman with Lumbar degenerative kyphosis. (A) Preoperative thoracolumbar kyphosis 25 (B) Postoperative sagittal balance after spinal fusion from T12 to S1 and L3 PSO (C) Sagittal balance loss due to proximal screw loosening after postoperative 4 years later. PSO, Pedicle subtraction osteotomy

대한척추외과학회지 Vol. 16, No. 3, 2009 제 5 요추와제 1 천추사이에퇴행성변화를초래할수있으며, 요통, 신경근병증, 요천추전만의상실, 전체적인균형이전방이동이일어날수있다고하였으며 12), 저자들은요추변성후만증환자에서술후추시과정에서기기고정범위내의하부분절에전방굴곡력이집중되어교정각소실이발생한다고하여제 1 천추까지유합하였다.

6 대한척추외과학회지 Vol. 16, No. 3, 2009 제 5 요추와제 1 천추사이에퇴행성변화를초래할수있으며, 요통, 신경근병증, 요천추전만의상실, 전체적인균형이전방이동이일어날수있다고하였으며 12), 저자들은요추변성후만증환자에서술후추시과정에서기기고정범위내의하부분절에전방굴곡력이집중되어교정각소실이발생한다고하여제 1 천추까지유합하였다. 하지만제 1 천추까지의유합시제 5 요추 - 제 1 천추에서의제 1 천추척추경나사만을사용한후가관절증의발생율이 22%~89% 까지다양하게보고되고있다 13,14,15,16). 제 1 천추척추경나사못의실패로인한합병증을줄이기위해다양한방법이시도되었는데, 김등 17) 은척추시상면불균형환자에서척추경을통한절골술시교정각소실은가동분절이있는추간판에서일어나 고특히, 절골술상부고정범위보다하부고정범위에서유의하게증가하므로절골술하부고정범위를모두전방지지하는것이교정각소실을줄일수있다고하였으며, 또다른여러저자들은제 1 천추나사못의양면피질고정과전방또는후방요추체간유합술시제 1 천추나사못의실패를줄일수있다고하였다. 또한제 5 요추 - 제 1 천추간전방주지지를시행하지않거나양측의장골고정을시행하지못한경우에가관절증이일어날확률이 34% 에이르지만, 양측의장골나사못, 양면피질제 1 천추척추경나사및제 4-5 요추간, 제 5 요추 - 제 1 천추간에전방주지지를시행하여완벽한천골반고정을시행한경우에가관절증이발생할확률이 17% 로감소하였다고보고하였으며 18), Tsuchiya 등 19) 은양측 Fig. 2. A 62-year old woman with Lumbar degenerative kyphosis. (A) Preoperative thoracic kyphosis 25, thoracolumbar kyphosis 25 (B) Proper sagittal balance after spinal fusion from T10 to S1 and L3 PSO. Postoperative lumbar lordosis -45 (C) Maintain proper sagittal balance after 2 years later operation. PSO, Pedicle subtraction osteotomy

7 요부변성후만증환자에서의술후시상면교정에대한방사선학적분석 김환정외 Fig. 3. A 73-year old woman with Lumbar degenerative kyphosis. (A) Preoperative thoracic kyphosis 16, thoracolumbar kyphosis 14, lumbar lordosis -7 (B) Proper sagittal balance after spinal fusion from T10 to S1 with iliac screw and L3 PSO. Postoperative lumbar lordosis -45 (C) Maintain proper sagittal balance after 2 years later operation. PSO, Pedicle subtraction osteotomy 의천추척추경나사와장골나사를이용하여더좋은결과를얻었다고보고하였다. 이제저자들은절골술하부고정범위에서가동분절이있는추간판에대하여전방지지를시행하고제 1 천추나사못의양면피질고정을확인했지만원위부나사못의이완으로인한고정력의실패로시상면교정소실이일어나는경우가발생하여장골나사를사용하게되었다. 본저자들의연구에서 -iliac screw 군총 23 례중에서술후시상면교정소실이나타난환자는 6 례로약 26% 였으며, +iliac screw 군총 12 례중에서술후시상면교정소실이나타난환자는 1 례로 8.3% 에서일어남으로써장골나사를사용했을때시상면교정을유지하는데있어강한고정력으로교정소실이적게나타나 (Fig. 3) 통계학적인의의를나타내었다 (p<0.05). 하지만 Emami 등 20) 은장골나사의강한고정력에도불구하고정상인천장골관절을통과함으로인해서통증을호소할수있으며, 장골나사의돌출등으로인해이차적인수술이필요할수있으며이를방지하기위해서는장골나사를후상장골극에깊이삽입하는게중요하다고하였다. 저자들의경우에는장골나사를사용하는경우수술시간이길어진다는단점과장골나사의돌출로인해누웠을때통증과미용상의문제가발생하는경우는있었으나, 장골나사를제거할정도로심한통증을호소하는환자는없었다. 그러나의인성편평배부증후군, 외상후후만증, 강 직성척추염등의시상불균형은일차적인골성변형 (bony deformity) 이므로충분한시상면교정및고정력의증가로술후다시몸이앞으로굽는증상을방지할수있지만, 요부변성후만증은충분한교정및고정력을얻더라도몸이앞으로다시굽는증상이발생할수있어이에대한추가적인연구가필요하리라사료된다. 결 론 요부변성후만증에서술후불충분한시상면교정및고정력상실에의한다시몸이앞으로굽는증상을예방하기위해흉추후만각보다 20 이상의충분한요추전만각을만들어주는것이중요하며, 술전방사선상흉요추부후만각의정도에따라근위부유합범위를결정하고장골나사를병용하는것이요부변성후만증의적절한수술방법으로사료된다. 참고문헌 01) Lee CS, Kim YT, Kim E: Clinical Study of Lumbar Degenerative Kyphosis. J Korean Spine Surg 1997; 4: ) Lee CS, Lee CK, Kim YT, Hong YM, Yoo JH: Dynamic

8 대한척추외과학회지 Vol. 16, No. 3, 2009 Sagittal Imbalance of the Spine in Degenerative Flat Back. Spine 2001; 26: ) Kim HJ, Kang JW, Yeom JS, et al.: A Comparative Analysis of Sagittal Spinal Balance in 100 Asymptomatic Young and Older Aged Volunteers. J Korean Spine Surg 2003; 4: ) Noun Z, Lapresle P, Missenard G: Posterior lumbar osteotomy for flat back in adults. J spinal Disord 2001; 14: ) Kim HJ, Kang JW, Kim HY, et al.: Change of Pelvic Tilt before and after Gait in Patients with Lumbar Degenerative Kyphosis. J Korean Spine Surg 2009; 16: ) Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G: An Analysis of Sagittal Spinal Alignment Following Long Adult Lumbar Instrumentation and Fusion to L5 or S1 : can we predict ideal lumbar lordosis? Spine 2006; 31: ) Swank ML: Adjacent segment failure above lumbosacral fusions instrumented to L1 or L2. Podium presentation at the Scoliosis Research Society 37th annual meeting, September 18-21, 2002, Seattle, WA, USA. 08) Suk SI, Kim JH, Lee SM, et al.: Incidence of proximal adjacent failure in adult lumbar deformity correction. Podium presentation at the Scoliosis Research Society 38th annual meeting, September 10-13, 2003, Quebec City, Canada. 09) Kim YJ, Bridwell KH, Lenke LG, Rhim S, Kim YW: Is the T9, T11, or L1 the more reliable proximal level after adult lumbar or lumbosacral instrumented fusion to L5 or S1? Spine 2007; 32: ) Lee CS, Oh WH, Chung SS, Lee SG, Lee JY: Analysis of the Sagittal Alignment of Normal Spines. J of Korean Ortho 1999; 34; ) Bernhardt M, Bridwell KH: Segmental Analysis of the Sagittal Plane Alignment of the Normal Thoracic and Lumbar Spines and Thoracolumbar Junction. Spine 1989; 14; ) Edwards CC 2nd, Bridwell KH, Patel A, Rinella AS, Berra A, Lenke LG: Long Adult Deformity Fusions to L5 and the Sacrum A Matched Cohort Analysis. Spine 2004; 29; ) Bernhardr M, Swartz DE, Clothiaux PL, et al.: Posterolateral lumbar and lumbosacral fusion with without pedicle screw internal fixation. Clin Orthop Rela Res 1992; 284: ) Horowitch A, Peek RD, Thomas JC Jr, et al.: The Wiltse pedicle screw fixation system. Early clinical results. Spine 1989; 14: ) Molinari RW, Bridwell KH, Lenke LG, Unqacta FF, Riew KD: Complications in the surgical treatment of pediatric high-grade isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches. Spine 1999; 24: ) Rechtine GR, Sutterlin CE, Wood GW, Boyd RJ, Mansfield FL: The efficacy of pedicle screw/plate fixation on lumbar/lumbosacral autogenous bone graft fusion in adult patients with degenerative spondylolisthesis. J Spinal Disord 1996; 9: ) Kim HJ, Kang JW, Kim KH, et al.: Analysis of Correctiom Loss aster Pedicle subtraction Osteotomy in patients with Sagittal Imbalance? Radiologic Aspects-. J Korean Spine Surg 2004; 39: ) Kim YJ, Bridwell KH, Lenke LG, Rhim S, Cheh G: Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases. Spine 2006; 31: ) Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C: Minimum 5-Year Analysis of L5-S1 Fusion Using Sacropelvic fixation(bilateral S1 and Iliac screws) for Spinal Deformity. Spine 2006; 31: ) Emami A, Deviren V, Berven S, Smith JA, Hu SS, Bradford DS: Outcome and Complications of long fusions to the Sacrum in Adult Spine Deformity : Luque- Galveston, Combined Iliac and Sacral Screws, and Sacral Fixation. Spine 2002; 27:

9 요부변성후만증환자에서의술후시상면교정에대한방사선학적분석 김환정외 국문초록 연구계획 : 후향적연구연구목적 : 요부변성후만증에서의척추경을통한절골술및유합술시적절한시상면균형을얻기위한요추전만교정정도, 술전흉요추부후만각과술후시상면교정소실을통해근위부의유합범위의선택및장골나사의사용으로인한시상면교정유지의효과에대하여방사선학적측면에서분석하고자한다. 대상및방법 : 요부변성후만증으로진단받고술전보행분석검사를시행하여현저한전방골반경사를보이는환자를제외한나머지환자에서척추경을통한절골술및후방유합술을시행한환자중 1년이상추시된 35례를대상으로후향적으로분석하였다. 수술직후충분한시상면교정을얻기위한요추부전만각의교정정도를분석하였고, 술전흉요추부후만각과술후시상면교정소실을통해근위부의유합범위를결정하였으며, 장골나사를병용하지않은군과장골나사를병용한군으로분류하여장골나사의유용성을확인하였다. 결과 : 술전흉추후만각보다 20 이상요추전만각교정을시행한 28례의경우수술직후시상수직축이평균 2.3 cm으로적절한시상면균형을얻을수있었지만, 그렇지못한 7례의경우시상수직축이평균 10.3 cm으로써제 7 경추체중심에서내린수선이고관절중심부전방에위치하여수술직후시상면균형을얻지못하였다 (p<0.05). 술전흉요추부후만각이 10 이상이 10례, 10 미만이 25례였으며, 이중흉요추부후만각이 10 이상이었던 10례중근위부유합범위를제 10 흉추까지시행한 4례는근위부시상면균형이유지되었으나, 근위부유합범위를제 11 흉추또는제 12 흉추까지시행한 6례는 2례에서시상면교정소실이발생하였고, 10 미만이었던총 25례중근위부고정부위를제11 흉추또는제 12 흉추까지시행한 20례는 1례에서근위부문제가발생하였다 (p<0.05). -iliac screw군 (23례) 의 6례 (26%), +iliac screw군 (12례) 의 1례 (8%) 에서시상면상교정소실을보였다 (p<0.05). 결론 : 요부변성후만증에서술후불충분한시상면교정및고정력상실에의한다시몸이앞으로굽는증상을예방하기위해흉추후만각보다 20 이상의충분한요추전만각을만들어주는것이중요하며, 술전방사선상흉요추부후만각의정도에따라근위부유합범위를결정하고, 장골나사를병용하는것이요부변성후만증의적절한수술방법으로사료된다. 색인단어 : 요부변성후만증, 장골나사, 시상면상교정소실 통신저자 : 강종원대전광역시서구둔산동 1306 을지대학교의과대학정형외과학교실 Tel: Fax: jwkang@eulji.ac.kr

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

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