Anesth Pain Med 2018;13:363-371 https://doi.org/10.17085/apm.2018.13.4.363 pissn 1975-5171 ㆍ eissn 2383-7977 종설 척추수술후만성통증의치료 박양효ㆍ최은주 분당서울대학교병원마취통증의학과 Received October 11, 2018 Revised October 19, 2018 Accepted October 22, 2018 Current strategy for chronic pain after spinal surgery Yang Hyo Park and Eun Joo Choi Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea Corresponding author Eun Joo Choi, M.D. Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Korea Tel: 82-31-787-7499 Fax: 82-31-787-4063 E-mail: ejchoi@snubh.org ORCID http://orcid.org/0000-0002-7002-3932 Failed back surgery syndrome was recently renamed, as chronic pain after spinal surgery (CPSS) by international classification of disease-11. CPSS is a challenging clinical condition. It has a variety of causes associated with preoperative, intraoperative and postoperative periods. Also, psychosocial factors should be considered. Diagnostic tools must be used differently, for each patient. Imaging and interventional nerve block for diagnosis, should be used properly. Strategy of management requires a multidisciplinary approach. The effect of conservative management (medication, interventional management) and invasive procedure (spinal cord stimulator, intrathecal drug delivery system) has been studied by many researchers. However, an evidence-based guide on management of CPSS, remains necessary, and further research is needed. This review focuses on understanding and clinical approaches for CPSS. Keywords: Failed back surgery syndrome; Nerve block; Pain management; Spinal cord stimulation. 서 론 최신의효과적인치료에대하여소개하고자한다. 척추수술후요통증후군 (Failed back surgery syndrome) 의정의는 1회이상의척추수술이후에도요통이지속되고하지방사통은존재하거나그렇지않은상태 로정의되는것이일반적이다 [1]. 그러나질환명에서드러나는부정적인암시로인해명칭에대한논란이있어동시에여러명칭을가진질환이기도하다. 수술을시행한척추외과의나통증치료를담당해야하는통증의사모두에게치료가어려운질환이며이는원인, 진단, 치료, 예후에대해각보고마다차이가있어높은의학적근거를가지는치료방법이아직명확하지않기때문이기도하다. 이에본문은국내현황에맞추어척추수술후요통증후군에대해고찰하고 명칭과정의 척추수술후요통증후군이포함하는수술실패라는의도하지않은암시로인해다른정의와명칭들이존재한다. 그중, 임상상황에적절한기능적정의는척추수술의결과가수술전기대한바와다를때, 집도의와환자가각각기대한바가일치하지않는상황이적합할것이다 [2]. 수술실패라는의미를암시하지않는척추후궁절제술후증후군 (post laminectomy syndrome), 척추수술후증후군 (post spinal surgery syndrome), 요추수술후증후군 (post lumbar surgery syndrome) 등의명칭이있지 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://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. Copyright c the Korean Society of Anesthesiologists, 2018 363
Anesth Pain Med Vol. 13 No. 4 Table 1. Diagnostic Criteria of Chronic Pain after Spinal Surgery in ICD- 11, 2018 Condition A to E are fulfilled A. Chronic pain (persistent or recurrent for > 3 months) B. The pain began or recurred after the spinal surgery C. 1 1. The pain presents with higher intensity than the preoperative pain 2. The pain has different characteristics than the preoperative pain D. The pain is located in the area of the surgery (back) or referred into the limb (s) E. Not better accounted for by an infection, a malignancy, a preexisting pain condition or any other alternative cause ICD: International classification of disease. 만세계보건기구 (World Health Organization) 에서 2018년 6월에발표한국제질병분류 (international classification of disease)-11에따르면척추수술후만성통증 (chronic pain after spinal surgery) 으로명명된것을알수있다 [3]. 정의는수술후발생한만성요통이나하지통증이 3개월이상지속되거나재발한경우이다. 5가지진단기준 (Table 1) 도함께제시하였는데만성통증이지속되거나재발한경우 3개월이상일것, 통증이척추수술후시작하거나재발한경우, 수술전보다더높은강도로통증이발생하거나혹은수술전과다른양상의통증이있을때, 통증이수술부위에해당하는등에있거나하지방사통일때, 감염, 악성질환, 이전부터존재하던통증, 어떤다른원인으로설명되지않는통증이그것이다. 이에본문에서는척추수술후만성통증으로명명하기로한다. 발생률 외국의보고에서척추수술후만성통증의발생률은척추유합술시행여부와관계없이척추후궁절제술을시행한환자중 10 40% 로 [1,4,5] 보고된바있다. 그러나이보고는약 20년전자료이며집단특성이다른환자군에서조사하였을뿐아니라평가방법도통일되지않았으므로참고만하는것이바람직할것이다. 최근연구에서는전체인구의 0.02 2% 로보고된바도있다 [6]. 수술종류에따른발생률보고도존재하는데미세현미경디스크절제술 (microdiscectomy) 은척추수술후만성통증의발생률이낮을것으로예상되며단일코호트연구에서전체환자의 8.4% 로보고되었다 [7]. 다른보고에서는수술후 8주시점의수술성공률은 81% 이며이는추후 2년까지도지속되었다고하였다 [8]. 그러나 1년후같은저자가발표한바에따르면, 수술후단기성공률은수술을시행한환자군이보존적인치료방법을시행한환자군에비해높으나, 수술후 2년시점에두그룹간의차이가없다고도하였다 [9]. 척추수술후만성통증으로재수술을거듭할수록성공률은감소하게된다는보고는익히알려져있다. Nachemson [10] 은첫번째수술시행시 50%, 두번째수술시행시 30%, 세번째수술시행시 15%, 네번째수술시행시 5% 의성공률을보고하였다. 또한, 치료과정중에척추수술이좀더일찍논의될수록, 척추수술후만성통증의환자수는증가하였다는보고들도있었다 [11 13]. 건강보험공단에서 2016년발표한주요수술통계연보에따르면주요 33개수술중, 일반척추수술건수는 4위를기록하였다. 2016년에대한민국인구 10만명당, 323명이일반척추수술을시행받았고이는 2011년과비교시연평균 1.2% 정도증가하였다. 또한, 총수술비용이 5,807억원으로진료비상위 7개수술중 1위를차지하였다. 현재, 국내척추수술후요통증후군의발생률은정확히알려진바없으나이와같은일반척추수술건수를감안할때, 적지않은환자가존재함을짐작해볼수있다. 또한, 척추수술건수가증가할수록척추수술후만성통증의발생률은높아질것으로예상할수있다. 반면에, 척추수술의술기와장비가발전하여도수십년전에비해척추수술후만성통증의발생률은크게변하지않았다는보고도있는데결국, 다른종류의수술, 각척추외과의의술기, 환자의소인과처해있는임상상황등이이질환의발생에영향을미친다고사료된다. 추후이러한인자를포함한국내척추수술후만성통증의발생률에대한조사가필요할것으로생각된다. 원인 척추수술후만성통증의원인은단한가지로정의하기어렵다. 각보고들이지적하는원인은모두같지않지만, 통증발생의원인은여러가지요인이복합적으로관여한다는것에는일치점을보인다. 수술전, 수술중인자수술전인자로는환자에게소인이있는경우와척추외과의에게원인이있는경우로나뉜다. 환자의소인중에가장주요한인자로지적되는것은정신사회적 (psychosocial) 요소이다 [14 17]. 수술전 magnetic resonance imaging (MRI) 에서관찰되는구조적이상보다정신사회학적인자가수술결과를예측할수있는강력한인자라는보고 [14] 와우울증, 불안장애, 신체화장애, 건강염려증등이척추수술의예후에나쁜영향을끼친다는것이내용이다 [15 17]. 또한, 정신사회적요소와상해로인한법적문제에연루되어있을경우에도마찬가지로수술결과에악영향을끼친다는보고도있다 [18]. 그러나이러한소인을가지고있는환자가척추수술적응증일경우, 수술을시행하지 364 www.anesth-pain-med.org
척추수술후만성통증 않을수없으므로환자의정신사회학적요인을파악하고적절한술전준비를시행하는것이더욱바람직하며수술후통증교육, 필요시정신건강의학과의협진요청등을적극적으로시행해야한다. 심리학적설문점수가낮은환자에게조기에척추수술을시행한것이더나은예후를보였다는보고도있다. 저자들은조기에수술을시행함으로써장기적인스트레스와통증을차단한것이효과적이었다고분석하였다. 즉, 술전환자의정신사회학적소인을정확하게파악하여그에맞는치료계획을세우는것이가장중요하다고할수있다 [19]. 이는통증의사에게도중요한데척추수술후만성통증을호소하는환자에게술전정신사회적소인이존재하였는지파악하는것이치료에도움이되며, 만성통증으로인해역으로정신과적질병이발생할수있으므로면밀히환자를관찰하여야할것이다. 척추외과의의요인으로는재수술의횟수가증가할수록낮은성공률을보이는것 [10] 과더불어수술적응증의부적절한선택 [20], 부적절한수술술기가있다 [2,21,22]. 부적절한수술술기란척추신경이압박된외측함요부 (lateral recess), 추간공 (neural foramen) 이덜감압된경우가가장흔하다 [21]. 부정확한수술의빈도는대략 2.1 2.7% 로보고된다 [2]. 통증센터에척추수술후만성통증환자가내원시완전하지않은수술로인한요인이있는지확인하는것도매우중요하다. 수술자체가완전하게이루어지지않은상황에서는여타의치료방법이효과적이지않을수있기때문이다. 수술후인자 North 등 [1] 은척추수술후만성통증의흔한원인으로는경추간공협착 (25 29%), 디스크성통증 (20 22%), 추간판탈출증의재발 (7 12%), 신경병증성통증 (10%), 후관절증 (3%), 천장관절통 (2%) 을보고하였다. 경추간공협착이나추간판탈출증의재발은기존질환의악화나불완전한수술의결과혹은수술주변구조물의변화가원인일수있다. 수술위, 아래의인접부위 (adjacent segment) 의역동성증가로척추전위증 (spondylolisthesis), 척추협착증자체가빠르게진행되는경우도있다 [23,24]. 이는척추의불안정성으로이어지기도한다 [25]. 수술후인접부위의질환은 6 27% 의빈도로발생하며재수술로이어지는흔한원인이기도하다 [25 27]. 척추수술후만성통증의원인중하나인경막외유착 (epidural fibrosis) 은경막외공간에서척추수술을시행하게되면일어나는섬유화에서기인한다. 경막외유착으로인해척추수술후통증이발생하는빈도는전체환자중 20 36% 라는보고가있다 [2]. 그러나척추수술시불가피하게거의모든환자에게섬유화가일어나는데이현상이반드시통증과연결되는지, 환자마다다른예후를보이는이유에대한논란이지속적으로있어왔다 [28,29]. 경막외유착자체가원인이되는것이아닌, 유착으로인한척추신경의당김, 허혈, 신경주변의영양을공급해주는뇌척수액흐름의방해가직, 간접적인원인이된다고볼수있다 [2]. 척추와골반사이의불균형, 수술부위주변의근긴장으로인한근막통증증후군, 수술중출혈혹은과도한신경견인으로술후하지방사통의원인이되는 Battered root syndrome도확인이필요하다 [2]. 진 단 척추수술후만성통증의진단에있어환자의현통증이다른심각한원인에의한것은아닌지확인하여야하며이는치료계획을수립하기위해필수적이다. 척추수술후만성통증의원인이다양한만큼통증의원인을다각도로추정해보는것이중요하다. 또한, 응급상황인지아닌지판단하는것도중요한데자세한병력청취와이학적검사및적절한영상진단이도움이된다. 병력 통증의특성과수술전통증양상과의비교 Red flag sign의확인 수술명과수술후의치료 통증치료시도여부와효과확인 정신사회학적소인의평가 여타내과적질환의존재유무 Red flag sign이란생명을위협할수있어응급을요하는징후로써특별히요통과연관된징후는 Table 2와같다 [20]. 영상진단및진단을위한신경차단술 단순방사선촬영은척추의굴곡 (flexion) 과신전 (extension) 을포함한전후, 측면영상이도움이된다. 수술위치, 척추의배열, 척추의불균형, 불안정성그리고퇴행성변화가존재하는지확 Table 2. Red Flag Signs in the Evaluation of Low Back Pain Age < 18 year or > 50 year Previous history of cancer (e.g., pancreatic cancer) Unexplained weight loss Persistent pain at night Fever, chills, night sweats Infection (e.g., psoas abscess) Immunosuppressed status Thoracic pain (e.g., aortic aneurysm) Neurologic impairment Bladder or bowel dysfunction www.anesth-pain-med.org 365
Anesth Pain Med Vol. 13 No. 4 인할수있다. 단순방사선영상의장점은척추의역동적인상황을관찰할수있다는것이다 [30]. 단점은연부조직을관찰할수없으므로척추협착증유무및정도를진단하기어렵고연부조직과관련된병변은진단할수없다. Computed tomography (CT) 의경우 MRI에비해척추의기구가삽입되어있을때좀더정확하게주변부를관찰할수있는장점이있다. 수술인접부위의퇴행성변화, 전방전위증의악화, 후관절의퇴행성변화를확인하는데용이하다. 또한, 심박동기삽입혹은뇌동맥류결찰술을시행받은환자의경우 MRI를대체하기도한다. 컴퓨터단층촬영척추조영술 (CT Myelogram) 은뼈구조물에의해척추신경이압박되는부위를좀더잘밝혀낼수있다. MRI는연부조직, 감염, 경막외유착등을관찰하는데유용하다. 척추수술후만성통증환자에게후관절, 천장관절, 디스크는통증의원인일수있어검사가필요하며축성통증 (axial pain) 의원인으로분류된다. 후관절은만성요통의원인중 15 40% 를차지하며 [2], 반복적인요추수술을받은환자 16% 에서후관절로인한통증이관찰된다 [31]. 그러나여타의영상검사가후관절의이상을밝혀내긴어렵다고알려져있으며진단을위한후관절차단, 내측지신경차단이유용할수있다. 또한, 최근골단일광자단층촬영 (bone single photon emission computed tomography) 을이용하여후관절의병변을밝혀내기위한노력이계속되고있다 [32 34]. 천장관절증은척추수술후만성통증환자에게서약 2% 에서일어난다고추정된다 [35,36]. 병력과이학적검사로진단하기어려우며진단을위한천장관절차단이유용할수있다 [37]. 디스크로인한척추수술후통증은이전두연구에서각 17.5%, 21.5% 의빈도로보고되었다 [35,36]. 그러나영상검사에서디스크의이상이관찰된다고해서임상증상과반드시연결되는것은아니라는이견도있다. 왜냐하면통증이없는일반인구에서도영상검사에서디스크의이상이발견되는경우가흔하기때문이다 [38,39]. 그러므로요추디스크조영술 (lumbar discography) 을통해통증을유발시키는방법이제안되는데증상이없는경우에도 40% 에서통증이유발되어위양성가능성이높다 [40]. 최근여러디스크조영술에관한논문을분석한결과, 디스크조영술시유발되는통증은전체환자의 16.9 26% 까지보이며이환자들중실제디스크의파열은 16.9 42% 에서관찰되어특히, 요추의디스크조영술이진단적가치를지닌다고보고되기도하였다 [41]. 디스크조영술이후에 CT 촬영을실시하여디스크의섬유륜파열여부를확인하고통증의원인을찾게되며파열정도에따라등급 (grade) 을나누게된다. 1987년 Dallas discogram description으로제안 [42] 되어현재는 Modified Dallas Discogram을주로사용한다 [43]. 그러나디스크조영술과섬유륜파열의확인만으로디스크성통증 (discogenic pain), 디스크내장증 (inernal derangement of disc) 을진단하기에는제한점이있으며환자의임상증상과이학적검사등을종합하여판단해야할것이다. 척추수술후만성통증환자중하지방사통만을혹은축성통증과하지방사통을함께호소하는경우도흔하다. 하지방사통의원인은이학적검사와 MRI를통해척추신경이압박되는부위를확인하는것이중요하며추간공경막외강신경차단술 (transforaminal epidural nerve block) 이진단및치료에도움을줄수있다. 이는추궁간 (interlaminar) 혹은미추 (caudal) 경막외강신경차단술에비해특정척추신경에집중적으로국소마취제및스테로이드주입을시행하여증상완화여부를통해진단에도움을줄수있다 [44,45]. 치료 척추수술후만성통증의치료는다양하며단일치료가아닌다학제적치료가이루어져야한다는것은각연구가일치점을보인다. 또한, 척추외과의, 통증의사, 재활의학과및정신건강의학과등의협진이요구되기도한다. 보존적치료 (conservative management) 약물치료제1차약제로는비스테로이드성항염증제 (nonsteroidal anti-inflamma tory drug, NSAID) 가추천되며만성요통에효과를보인다고알려져있으나하지방사통에는효과가없다는보고도있다 [46,47]. 또한, 뇌졸중, 위장관계출혈, 신부전등의합병증을유발할수있어주의를요한다. Paracetamol은요통에효과가없다는보고도 [48] 있으나 Tramadol과함께사용시처방이권장되기도한다 [49]. 마약성진통제는 tramadol, codeine 등약한작용제 (weak agonist) 의경우, 통증과기능을개선시키며소염진통제의원치않는부작용을줄인다고알려져있으나추가적인연구가필요하다 [50]. 강한작용제 (strong opioid) 인 morphine, oxycodone 등은요구될경우가있으나의존성으로인해처방에주의하여야한다. 또한, 척추수술후만성통증환자에게마약성진통제의처방기간제한, 약제의장기투여시위험성에대해명확히알려져있지않으므로처방이권장되지는않는다 [51]. 항우울제와항전간제는척추수술후만성통증환자를위한처방권고가마련되어있지않으며신경병증성통증에준하여처방한다. 2010년에개정된 European Federation Neurological Society의신경병증성통증가이드라인에따르면삼차신경통을제외하고항우울제중 TCA, 항전간제중 Gabapentin, Pregabalin을제1차약제로추천한다 [52]. 경구약물의단독투여로는증상이완전히호전되기는어려우며효과가있는다른 366 www.anesth-pain-med.org
척추수술후만성통증 치료와병행하는것이바람직하다. 중재적치료 (interventional management) 경막외강스테로이드주입 (epidural steroid injection): 경막외강은해부학적으로경, 흉, 요추로나뉘며접근법에따라후궁간 (inerlaminar), 경추간공 (transforaminal), 미추 (caudal) 경막외강신경차단으로분류된다. 경막외강스테로이드주입은염증이존재하는압박된신경주변에서일어나통증과기능을개선시킬수있는데주로요통환자를대상으로연구가이루어져왔다. Abdi 등 [53] 에따르면경추부위의후궁간경막외강스테로이드주입은장기간의통증감소를가져오나요추에서는근거가부족하며경추간공접근법의경우두부위모두에서중등도 (moderate) 이상의근거를가진다. 또다른연구들은경추간공접근법이하지방사통에효과가있으며강한 (strong) 의학적근거를가진다고주장하였다 [54,55]. 그러나위연구들은척추수술후만성통증환자에게만이루어진것이아니며수술후해부학적변화, 기구가삽입된상태, 경막외강유착으로인해환자에따라서는각시술이용이하지않을수있다는단점이있다. Manchikanti 등 [56] 은척추수술후 6개월이상의요추및, 혹은하지방사통을호소하는환자들에게미추경막외강신경차단시, 60 70% 환자가스테로이드여부에관계없이효과를보인다고하였다. 그러나후관절이원인이될경우미추경막외강신경차단은효과가없었다. 경막외강스테로이드주입은환자의증상에따라적절한접근법을선택하여척추수술후만성통증의진단및치료계획수립을위해시행해볼수있겠다. 후관절차단술 (facet joint block), 내측지신경차단술 (medial branch block) 및고주파열응고술 (radiofrequency thermocoagulation): 척추수술후만성통증환자가축성통증을주로호소하거나경막외강신경차단에반응이없을경우후관절에통증의원인이있다고의심해야한다. 이경우후관절신경차단이나내측지신경차단술이진단및치료에도움을줄수있다. 진단적차단술을통해후관절성통증이진단되면내측지신경의고주파열응고술을시도해볼수있다. 요통환자를대상으로내측지신경차단에통증감소가관찰되어고주파열응고술을시행할경우, 83% 의환자에게 10.5개월이상의통증감소를보였다 [57]. 이전척추수술의과거력이있는환자들을대상으로같은연구를시행시이전수술력이결과에영향을미치지않았다 [58]. 천장관절증이통증의원인일경우천장관절차단을시행하여진단및치료를시행하고장기적인효과를위해고주파열응고술혹은고주파냉각술이시도된다. 천장관절은여러개의신경분지에의해지배를받고제4, 5 요추의후지, 제1 3 천추의외측지가고주파의목표구조물이다 [59]. 최근리뷰논문에서천장관절내스테로이드주사, 고주파열응고술보다고주파냉각술의의학적근거가더높다고하였으나 [60] 추가적인연구가필요 하다. 경피적경막외강유착용해술 (percutaneous epidural adhesiolysis, PEA): 경막외유착 (epidural fibrosis) 은경막외공간에서척추수술을시행하게되면일어나는섬유화이다. 거의모든환자에게발생하는경막외유착이통증의원인인지에대하여오랜기간이견이있어왔다. MRI에서관찰되는경막외유착의범위가넓을수록수술후통증이심하였다는보고가있는데이는경막외유착자체가통증의원인이아니라경막외유착으로인한주변조직의허혈및만성염증이원인이라고지적할수있다. 120명의척추수술후만성통증환자에게미추경막외신경차단과 PEA의결과를비교하였을때 PEA를시행받은환자의 73% 가 1년간통증과기능의개선을보였다 [61]. 그이후연구에서단기간혹은장기간통증과기능의개선을보였고 [62,63] 기존의경막외강신경차단에비해우월한효과가있음을보고하기도하였다 [64,65]. PEA는여타보존적치료방법에불응할경우, 특히하지방사통이주요증상일때시도해볼수있다고생각된다. 내시경적경막외강유착용해술 (endoscopic epidural adhesiolysis, EEA): EEA는 PEA에비해경막외강내를직접눈으로관찰하며치료할수있다는장점이있다. 경막외강신경차단이나 PEA에치료효과가미미할경우시행한내시경에서유착용해술을시행한그룹과아닌그룹을비교시, 시행한환자의 57% 가 6개월시점까지유의한통증감소를보였다 [66] 고하였는데같은저자가보고한후향적논문에서는 PEA가통증감소와비용효과면에서더우월하다고하여이견이있다 [67]. 또한, 경막외강신경차단과 EEA를비교시통증감소면에서큰차이를보이지않았다는결과도존재한다 [68]. EEA는더많은척추수술후만성통증환자를대상으로추가적인전향적연구가필요하다고생각된다. Intradiscal electrothermal therapy (IDET), Nucleoplasty: 척추수술후만성통증의원인이디스크조영술과 CT를통해디스크의섬유륜파열로확인될경우디스크내감압을위해 IDET 혹은 Nucleoplasty가시행될수있다. 이시술들은디스크성통증을장기간효과적으로낮추며하지방사통이동반된경우에도효과적이라는보고 [69,70] 가있는반면, 다른보존적치료와비교시큰차이가없었다는보고도있어이견이있다 [71]. 척수자극기 (spinal cord stimulator) 와척수강내약물주입펌프 (intrathecal drug delivery system) 척수자극기삽입은척추수술후만성통증환자의치료방법중하나로제안된다. Kumar 등 [72] 은디스크제거수술이후에도하지방사통을호소하는 100명의환자를약물치료만하는군과척수자극기삽입을병행한군으로나누어관찰하였을때 12개 www.anesth-pain-med.org 367
Anesth Pain Med Vol. 13 No. 4 Assessment History (Table 1) Imaging: X-ray, CT, MRI, Bone SPECT Discography Axial back pain FJ pain SI joint pain IDD FJ block MBB RF Thermocoagulation SI joint block Cooled RF Discography IDET Neucleoplasty Radiculopathy ESI, TFESI PEA or EEA SCS ITDDS Surgical or psychological referral Fig. 1. Proposed algorithm for chronic pain after spinal surgery. CT: computed tomography, MRI: magnetic resonance imaging, SPECT: single photon emission computed tomography, FJ: facet joint, SI: sacroiliac joint, IDD: internal derangement of disc, ESI: epidural steroid injection, TFESI: transforaminal epidural steroid injection, MBB: medial branch block, PEA: percutaneous epidural adhesiolysis, EEA: endoscopic epidural adhesiolysis, RF: radiofrequency, IDET: intradiscal electrothermal treatment, SCS: spinal cord stimulator, ITDDS: intrathecal drug delivery system. 월시점에서병행군이통증과기능의감소를보이는것을확인하였다. 2년뒤, 병행군의환자 42명을추적시효과가지속되는것을확인하였으나 45% 환자에게서척수자극기삽입관련부작용이발견되어이를교정할필요가있다고주장하였다 [73]. 비용효과를조사한연구에서척수자극기삽입이더우수함을증명하기도하였다 [74,75]. 척수자극기는척추수술후만성통증환자중난치성하지방사통을호소하는경우적용해볼수있지만, 기존의보존적치료에효과가없는경우고려해야할것이며삽입이후합병증과관리의문제가존재하므로시술을결정시신중하게고려해야한다. 척추수술후만성통증환자에게적용된척수강내약물주입펌프의효과는아직정립되지않았다. Hamza 등 [76] 의연구에서전체 58명의환자중, 35명이척추수술후통증환자, 그외요통, 복합부위통증증후군, 복통, 골반통환자에게척수강내약물펌프삽입을적용하였다. 3년추적관찰시전체 70% 의환자가 50% 이상의통증개선, 30% 의환자가기능개선을보였다 [76]. 척수강내약물펌프의경우경구용마약성진통제를과량복용할경우, 이를척수강내주입으로전환함으로써소량의마약성진통제로도통증을조절이가능하다. 91명의비암성통증환자에게펌프삽입이후마약성진통제를효과적으로중단할수있었다는보고도있다 [77]. 그러나척추수술후만성통증환자에게전향적, 장기추적관찰연구가부족한점, 국내에서사용할수있는펌프삽입약제가제한적인점, 기계와연관된합병증가능성등으로신중하게고려하여야할것이다. 또한척수자극기와효과를비교한연구가아직없고두치료방법의원리가다르므로각환자의상황에맞춘선택이요구된다. 2018년도부터국내에서는척수강내약물펌프의전체급여화가실시되어그사용이증가할것으로예상된다. 이에보다활발한연구가뒷받침되어할것이다. Fig. 1에서는통증센터에환자가내원시, 진단과 치료의알고리즘을간단하게도식화하였다. 결론 척추수술후만성통증은척추수술이시행되는한, 지속적으로발생할수밖에없다. 발생시재수술을결정하는경우는드물고수술의횟수가거듭될수록수술성공률이낮아지므로비수술적요법으로환자의증상을조절하려는경향이두드러진다. 이에통증센터에서는환자의수술전상황부터시작하여통증의원인을면밀히찾아낸후, 이에맞는영상진단과진단을위한신경차단등을적극적으로시행해야한다. 또한, 적합한비수술적치료를시행하여통증을완치하거나감소시켜삶의질을향상시키는데초점을두어야한다. REFERENCES 1. North RB, Campbell JN, James CS, Conover-Walker MK, Wang H, Piantadosi S, et al. Failed back surgery syndrome: 5-year followup in 102 patients undergoing repeated operation. Neurosurgery 1991; 28: 685-90. 2. Chan CW, Peng P. Failed back surgery syndrome. Pain Med 2011; 12: 577-606. 3. World Health Organization. ICD-11 for mortality and morbidity statistics (ICD-11 MMS) 2018 version. World Health Organization [serial on the Internet]. 2018 [2018 Sep 1]. Available from https://icd.who.int/browse11/l-m/en. 4. Law JD, Lehman RA, Kirsch WM. Reoperation after lumbar intervertebral disc surgery. J Neurosurg 1978; 48: 259-63. 5. Lehmann TR, LaRocca HS. Repeat lumbar surgery. A review of patients with failure from previous lumbar surgery treated by 368 www.anesth-pain-med.org
척추수술후만성통증 spinal canal exploration and lumbar spinal fusion. Spine (Phila Pa 1976) 1981; 6: 615-9. 6. Lee J, Shin JS, Lee YJ, Kim MR, Choi A, Lee JH, et al. Long-term Course of Failed Back Surgery Syndrome (FBSS) patients receiving integrative Korean medicine treatment: a 1 year prospective observational multicenter study. PLoS One 2017; 12: e0170972. 7. Shamim MS, Parekh MA, Bari ME, Enam SA, Khursheed F. Microdiscectomy for lumbosacral disc herniation and frequency of failed disc surgery. World Neurosurg 2010; 74: 611-6. 8. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007; 356: 2245-56. 9. Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 2008; 336: 1355-8. 10. Nachemson AL. Evaluation of results in lumbar spine surgery. Acta Orthop Scand Suppl 1993; 251: 130-3. 11. Burton CV. Failed back surgery patients: the alarm bells are ringing. Surg Neurol 2006; 65: 5-6. 12. Mark VH. Instrumented fusions: a need for guidelines and research. Surg Neurol 2004; 61: 318-9. 13. Talbot L. Failed back surgery syndrome. BMJ 2003; 327: 985-6. 14. Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J 2005; 5: 24-35. 15. Celestin J, Edwards RR, Jamison RN. Pretreatment psychosocial variables as predictors of outcomes following lumbar surgery and spinal cord stimulation: a systematic review and literature synthesis. Pain Med 2009; 10: 639-53. 16. Mannion AF, Elfering A. Predictors of surgical outcome and their assessment. Eur Spine J 2006; 15 Suppl 1: S93-108. 17. Spengler DM, Freeman C, Westbrook R, Miller JW. Low-back pain following multiple lumbar spine procedures. Failure of initial selection? Spine (Phila Pa 1976) 1980; 5: 356-60. 18. Voorhies RM, Jiang X, Thomas N. Predicting outcome in the surgical treatment of lumbar radiculopathy using the pain drawing score, McGill Short Form Pain Questionnaire, and risk factors including psychosocial issues and axial joint pain. Spine J 2007; 7: 516-24. 19. Carragee EJ. Psychological screening in the surgical treatment of lumbar disc herniation. Clin J Pain 2001; 17: 215-9. 20. Guyer RD, Patterson M, Ohnmeiss DD. Failed back surgery syndrome: diagnostic evaluation. J Am Acad Orthop Surg 2006; 14: 534-43. 21. Phillips FM, Cunningham B. Managing chronic pain of spinal origin after lumbar surgery: the role of decompressive surgery. Spine (Phila Pa 1976) 2002; 27: 2547-53. 22. Slipman C. Posterior joints of the lumbar spine as a potential cause of low back pain. Pain Med 2004; 5: 287-8. 23. Carroll SE, Wiesel SW. Neurologic complications and lumbar laminectomy. A standardized approach to the multiply-operated lumbar spine. Clin Orthop Relat Res 1992; (284): 14-23. 24. Schaeren S, Broger I, Jeanneret B. Minimum four-year followup of spinal stenosis with degenerative spondylolisthesis treated with decompression and dynamic stabilization. Spine (Phila Pa 1976) 2008; 33: E636-42. 25. Harrop JS, Youssef JA, Maltenfort M, Vorwald P, Jabbour P, Bono CM, et al. Lumbar adjacent segment degeneration and disease after arthrodesis and total disc arthroplasty. Spine (Phila Pa 1976) 2008; 33: 1701-7. 26. Hong X, Liu L, Bao J, Shi R, Fan Y, Wu X. Characterization and risk factor analysis for reoperation after microendoscopic diskectomy. Orthopedics 2015; 38: e490-6. 27. Parker SL, Mendenhall SK, Godil SS, Sivasubramanian P, Cahill K, Ziewacz J, et al. Incidence of low back pain after lumbar discectomy for herniated disc and its effect on patient-reported outcomes. Clin Orthop Relat Res 2015; 473: 1988-99. 28. Manchikanti L, Manchikanti KN, Gharibo CG, Kaye AD. Efficacy of percutaneous adhesiolysis in the treatment of lumbar post surgery syndrome. Anesth Pain Med 2016; 6: e26172. 29. Jamison DE, Hsu E, Cohen SP. Epidural adhesiolysis: an evidence-based review. J Neurosurg Sci 2014; 58: 65-76. 30. Kizilkilic O, Yalcin O, Sen O, Aydin MV, Yildirim T, Hurcan C. The role of standing flexion-extension radiographs for spondylolisthesis following single level disk surgery. Neurol Res 2007; 29: 540-3. 31. Manchikanti L, Manchukonda R, Pampati V, Damron KS, McManus CD. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil 2007; 88: 449-55. 32. Al-Riyami K, Vöö S, Gnanasegaran G, Pressney I, Meir A, Casey A, et al. The role of bone SPECT/CT in patients with persistent or recurrent lumbar pain following lumbar spine stabilization surgery. Eur J Nucl Med Mol Imaging 2018. Advance Access published on Sep 6 2018. doi: 10.1007/s00259-018-4141-x. 33. Russo VM, Dhawan RT, Baudracco I, Dharmarajah N, Lazzarino AI, Casey AT. Hybrid bone SPECT/CT imaging in evaluation of chronic low back pain: correlation with facet joint arthropathy. World Neurosurg 2017; 107: 732-8. 34. Van de Kelft E, Verleye G, Van de Kelft AS, Melis K, Van Goethem J. Validation of topographic hybrid single-photon emission computerized tomography with computerized tomography scan in www.anesth-pain-med.org 369
Anesth Pain Med Vol. 13 No. 4 patients with and without nonspecific chronic low back pain. A prospective comparative study. Spine J 2017; 17: 1457-63. 35. Waguespack A, Schofferman J, Slosar P, Reynolds J. Etiology of long-term failures of lumbar spine surgery. Pain Med 2002; 3: 18-22. 36. Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, et al. Etiologies of failed back surgery syndrome. Pain Med 2002; 3: 200-14. 37. Thawrani DP, Agabegi SS, Asghar F. Diagnosing sacroiliac joint pain. J Am Acad Orthop Surg 2018. Advance Access published on Oct 1 2018. doi: 10.5435/JAAOS-D-17-00132. 38. Horton WC, Daftari TK. Which disc as visualized by magnetic resonance imaging is actually a source of pain? A correlation between magnetic resonance imaging and discography. Spine (Phila Pa 1976) 1992; 17(6 Suppl): S164-71. 39. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994; 331: 69-73. 40. Carragee EJ, Chen Y, Tanner CM, Truong T, Lau E, Brito JL. Provocative discography in patients after limited lumbar discectomy: a controlled, randomized study of pain response in symptomatic and asymptomatic subjects. Spine (Phila Pa 1976) 2000; 25: 3065-71. 41. Manchikanti L, Soin A, Benyamin RM, Singh V, Falco FJ, Calodney AK, et al. An update of the systematic appraisal of the accuracy and utility of discography in chronic spinal pain. Pain Physician 2018; 21: 91-110. 42. Sachs BL, Vanharanta H, Spivey MA, Guyer RD, Videman T, Rashbaum RF, et al. Dallas discogram description. A new classification of CT/discography in low-back disorders. Spine (Phila Pa 1976) 1987; 12: 287-94. 43. Schellhas KP, Pollei SR, Gundry CR, Heithoff KB. Lumbar disc high-intensity zone. Correlation of magnetic resonance imaging and discography. Spine (Phila Pa 1976) 1996; 21: 79-86. 44. Lee JH, Shin KH, Park SJ, Lee GJ, Lee CH, Kim DH, et al. Comparison of clinical efficacy between transforaminal and interlaminar epidural injections in lumbosacral disc herniation: a systematic review and meta-analysis. Pain Physician 2018; 21: 433-48. 45. Eckel TS, Bartynski WS. Epidural steroid injections and selective nerve root blocks. Tech Vasc Interv Radiol 2009; 12: 11-21. 46. Wong JJ, Côté P, Ameis A, Varatharajan S, Varatharajan T, Shearer HM, et al. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Eur Spine J 2016; 25: 34-61. 47. Roelofs PD, Deyo RA, Koes BW, Scholten RJ, van Tulder MW. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev 2008; (1): CD000396. 48. Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015; 350: h1225. 49. Tetsunaga T, Tetsunaga T, Tanaka M, Ozaki T. Efficacy of tramadol-acetaminophen tablets in low back pain patients with depression. J Orthop Sci 2015; 20: 281-6. 50. Imamura T. Significant efficacy of Tramadol/Acetaminophen in elderly patients with chronic low back pain uncontrolled by NSAIDs: an observational study. Open Orthop J 2015; 9: 120-5. 51. Hussain A, Erdek M. Interventional pain management for failed back surgery syndrome. Pain Pract 2014; 14: 64-78. 52. Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, et al.; European Federation of Neurological Societies. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol 2010; 17: 1113-e88. 53. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 2007; 10: 185-212. 54. Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: a comprehensive literature review. J Back Musculoskelet Rehabil 2011; 24: 67-76. 55. Parr AT, Diwan S, Abdi S. Lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain: a systematic review. Pain Physician 2009; 12: 163-88. 56. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: part 3--post surgery syndrome. Pain Physician 2008; 11: 817-31. 57. Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for lumbar facet pain. Spine (Phila Pa 1976) 2004; 29: 2471-3. 58. Cohen SP, Hurley RW, Christo PJ, Winkley J, Mohiuddin MM, Stojanovic MP. Clinical predictors of success and failure for lumbar facet radiofrequency denervation. Clin J Pain 2007; 23: 45-52. 59. Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A. Randomized placebo-controlled study evaluating lateral branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology 2008; 109: 279-88. 60. Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician 2012; 15: E247-78. 370 www.anesth-pain-med.org
척추수술후만성통증 61. Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syndrome: a randomized, equivalence controlled trial. Pain Physician 2009; 12: E355-68. 62. Yousef AA, EL-Deen AS, Al-Deeb AE. The role of adding hyaluronidase to fluoroscopically guided caudal steroid and hypertonic saline injection in patients with failed back surgery syndrome: a prospective, double-blinded, randomized study. Pain Pract 2010; 10: 548-53. 63. Kim SB, Lee KW, Lee JH, Kim MA, An BW. The effect of hyaluronidase in interlaminar lumbar epidural injection for failed back surgery syndrome. Ann Rehabil Med 2012; 36: 466-73. 64. Lee F, Jamison DE, Hurley RW, Cohen SP. Epidural lysis of adhesions. Korean J Pain 2014; 27: 3-15. 65. Kim SH, Choi SS. Epidural neuroplasty/epidural adhesiolysis. Anesth Pain Med 2016; 11: 14-22. 66. Manchikanti L, Rivera JJ, Pampati V, Damron KS, Beyer CD, Brandon DE, et al. Spinal endoscopic adhesiolysis in the management of chronic low back pain: a preliminary report of a randomized, double-blind trial. Pain Physician 2003; 6: 259-67. 67. Manchikanti L, Pampati V, Bakhit CE, Pakanati RR. Non-endoscopic and endoscopic adhesiolysis in post-lumbar laminectomy syndrome: a one-year outcome study and cost effectiveness analysis. Pain Physician 1999; 2: 52-8. 68. Dashfield AK, Taylor MB, Cleaver JS, Farrow D. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial. Br J Anaesth 2005; 94: 514-9. 69. Helm Ii S, Simopoulos TT, Stojanovic M, Abdi S, El Terany MA. Effectiveness of thermal annular procedures in treating discogenic low back pain. Pain Physician 2017; 20: 447-70. 70. Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low back pain: prospective outcome study with a minimum 2-year follow-up. Spine (Phila Pa 1976) 2002; 27: 966-73. 71. Cohen SP, Williams S, Kurihara C, Griffith S, Larkin TM. Nucleoplasty with or without intradiscal electrothermal therapy (IDET) as a treatment for lumbar herniated disc. J Spinal Disord Tech 2005; 18 Suppl: S119-24. 72. Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain 2007; 132: 179-88. 73. Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery 2008; 63: 762-70. 74. Manca A, Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, et al. Quality of life, resource consumption and costs of spinal cord stimulation versus conventional medical management in neuropathic pain patients with failed back surgery syndrome (PROCESS trial). Eur J Pain 2008; 12: 1047-58. 75. North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery 2007; 61: 361-8. 76. Hamza M, Doleys D, Wells M, Weisbein J, Hoff J, Martin M, et al. Prospective study of 3-year follow-up of low-dose intrathecal opioids in the management of chronic nonmalignant pain. Pain Med 2012; 13: 1304-13. 77. Caraway D, Walker V, Becker L, Hinnenthal J. Successful Discontinuation of systemic opioids after implantation of an intrathecal drug delivery system. Neuromodulation 2015; 18: 508-15. www.anesth-pain-med.org 371