Journal of Korean Society of Spine Surgery Does Preoperative Cervical Sagittal Alignment And Range of Motion Affect Adjacent Segment Degeneration After Anterior Arthrodesis In Degenerative Cervical Spinal Disorders? Midterm Follow up Study - Kyung-Jin Song, M.D., Kwang-Bok Lee, M.D., and Jong-Han Yim, M.D. J Korean Soc Spine Surg 2014 Mar;21(1):1-7. Originally published online March 31, 2014; http://dx.doi.org/10.4184/jkss.2014.21.1.1 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2014 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.krspine.org/doix.php?id=10.4184/jkss.2014.21.1.1 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// 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. www.krspine.org
Original Article pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2014 Mar;21(1):1-7. http://dx.doi.org/10.4184/jkss.2014.21.1.1 Does Preoperative Cervical Sagittal Alignment And Range of Motion Affect Adjacent Segment Degeneration After Anterior Arthrodesis In Degenerative Cervical Spinal Disorders? Midterm Follow up Study - Kyung-Jin Song, M.D., Kwang-Bok Lee, M.D., and Jong-Han Yim, M.D. Departments of Orthopedic Surgery, Chonbuk National University Medical School, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Jeonju, Korea Study Design: Retrospective study. Objectives: The purpose of this study was to investigate whether preoperative sagittal alignment and range of motion (ROM) affect adjacent segment degeneration (ASD) and disease after anterior arthrodesis in degenerative cervical spinal disorders. Summary of Literature Review:There is no study about the relationship between preoperative ROM and sagittal alignment and the development of ASD yet. Materials and Methods: We took a retrospective approach to study 136 patients who underwent an anterior arthodesis for less than 2 segments with PEEK cage and plate construct method for degenerative cervical diseases and who have a minimum of 3 years of followup. We analyzed ASD and cervical ROM, such as less than 40 (group A) and more than 40 (group B) and sagittal alignment, such as lordosis or kyphosis with less than 10 (group a), 10 ~30 (group b) and more than 30 (group c). Adjacent segment degeneration was graded according to Park s classification and Hillibrand method. Results: There was no statistically significant difference between group A(1.35±0.48) and group B (1.44±0.50) in the correlation between the cervical ROM and the variation of disc height(p=0.07). Concerning the relationship between the ROM and osteophyte formation on adjacent segment, no statistically significant difference has been found between group A(1.64±0.88) and group B(1.43±0.67) (p=0.06). The disc height change at the final follow up after cervical sagittal alignment showed no statistically significant difference among the groups: Group A presented with 1.53±0.50, group B with 1.30±0.46 and group C with 1.40±0.50.(p=0.08) Regarding sagittal alignment and osteophyte change, there was no statistically significant difference among the groups as group A showed an average of 1.33±0.48, group Ban average of 1.56±0.88 and group Can average of 1.60±0.82(p=0.07). Conclusion: Although the preoperative sagittal alignment and ROM did not significantly affect adjacent segment degeneration and diseases in a mid-term follow-up evaluation after anterior arthrodesis with PEEK cage and plate in degenerative cervical spinal disorders, we think a future study is required with a sufficient number of patients and a long term follow-up because there were borderline statistical significances shown in the present study. Key Words: Degenerative cervical disorder, Anterior cervical fusion, Sagittal alignment, Range of motion, Adjacent segment degeneration Received: November 16, 2011 Revised: June 10, 2013 Accepted: April 12, 2012 Published Online: March 31, 2014 Corresponding author: Kwang-Bok Lee, M.D Department of Orthopedic Surgery, Chonbuk University Hospital 634-18, Keum Am-dong, Dukjin-gu, Jeonju, Chonbuk, 561-712, Korea TEL: 82-63-250-1760, FAX: 82-63-271-6538 E-mail: osdr2815@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://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. Copyright 2014 Korean Society of Spine Surgery www.krspine.org 1
Kyung-Jin Song et al Volume 21 Number 1 March 2014 서론 경추전방유합술은 1950 년대에 Smith 와 Robinson 1) 에의해소개된이후로경추퇴행성질환의효과적인수술적치료법으로시행되고있다. 그러나유합부인접분절의문제는최근경추수술분야에서가장큰논쟁거리가되고있으며, 여러생역학적, 임상적연구에서유합되지않은인접분절에과도한부하를야기하여, 경추유합술후 25-89% 의인접분절의새로운퇴행성변화를보고하고있다. 2-5) 인접분절의퇴행성변화에영향을주는인자로여러저자들은유합분절의수, 위치, 나이및동반된기저질환등에대하여보고하였으며, 수술후인접분절의퇴행성변화와동반하여새롭게발생한방사통및척수병증의인접분절질환의연관성에대하여보고하고있다. 6-8) 경추시상면상후만일경우축성부하가경추의앞쪽에위치하므로이것이더욱후만을조장하게되므로, 경추각분절에스트레스가더증가하게되며, 이는인접분절의퇴행성변화를조장할가능성이있다. 9) 그래서운동역학상경추의전만각유지는경추운동시부하의흡수등에중요한인자임에도불구하고경추의시상면정렬과운동범위와인접분절질환의연관성에대한보고가없었다. 수술전자기공명영상 (MRI) 이나단수방사선사진상수술할분절의인접분절의퇴행성많이진행되어있으면, 수술이후에인접분절질환이빨리발생할것이라고예측할수있다. 그러나수술전방사선사진상보이는퇴행성변화를제외한알려지지않은다른위험인자도있을것으로생각되며, 술전경추의시상면부정정렬과운동범위가큰환자에서인접분절의미세한 퇴행성변화가더많이진행되어있지않을까라는의문을갖게되었다. 이에저자들은퇴행성경추질환에서수술전시상면정렬과운동범위가전방유합술후인접분절퇴행성변화에미치는영향에대하여알아보고자하였다. 대상및방법 1. 연구대상 2004 년 3월부터 2007 년 3월까지경추퇴행성질환에대하여 PEEK 케이지를이용한 2분절이하의전방유합술및금속판이용한전방고정술을시행한 343명의환자중, 3년이상추시가가능하였던 236명의환자중경추부전후방, 측면, 굴곡, 신전측면사진모두갖춰진 136명의환자를대상으로후향적연구를하였다. 평균연령은 57.2 세 (43-67 세 ) 이며, 평균추시관찰은 46 개월 (40-72 개월 ), 남자 70명, 여자 66명이었다. 1분절전방유합술을시행한환자는총 76명이었으며, 제 5-6경추한분절을시행한환자가 26명으로가장많았으며, 제 6-7 경추유합술을시행한환자는 22명, 제 4-5경추부는 15명, 제 3-4경추부는 10명, 제 2-3 경추부는 3명이었습니다. 2분절유합술을시행한환자는총 60명이었고, 제 4-5-6 경추유합술을시행한환자가 23명, 제 5-6-7 경추부는 21명, 제 3-4-5 경추부는 15명, 제 2-3-4 경추부는 1명이었다. 2. 방법경추의굴신운동범위는굴곡측면사진과신전측면사진에 A B C Fig. 1. (A) neutral, (B) flexion, (C) extension. Histogram demonstrate Gore angle(c2-7) that determined from the tangent of the posterior body line of C2 and C7. 2 www.krspine.org
Journal of Korean Society of Spine Surgery Preoperative sagittal alignment and range of motion 서 C2과 C7 추체의후연이이루는 Gore 각 (Gore angle) 을측정하여그차이로하였다. 40도미만의굴신운동범위를갖는 A군과 40도이상의큰굴신운동범위를갖는 B군으로구분하여비교하였다. 경추의측면정렬의측정은환자가자연스러운자세를취하게하고촬영한측면사진상에서 C2과 C7 추체의후연이이루는 Cobb 각 (Cobb s angle) 으로하였다 (Fig. 1). 이러한경추측면정렬의전만정도가 10도미만이거나후만이있는 a군, 10~30 도의측면정렬을보이는 b군, 그리고 30도초과의측면정렬을보이는 c군으로구분하여비교하였다 (Table 1). 모든환자에대하여트로카를이용하여자가장골을채취하여충전한 PEEK 케이지 (Stryker spine, South Allendale, NJ, USA) 을이용한전방유합술과 Maxima 금속판 (U&I corporation, Seoul, Korea) 을이용한전방고정술을시행하였다. 경추부전후방, 측면, 굴곡, 신전측면단순방사선사진을술전, 술후, 술후 6주, 3, 6, 9, 12개월, 이후 1년단위로최종추시시까지검사하였고, 술후새롭게발생한방사통및척수병증에대 하여자기공명영상을이용한검사를추가로시행하였다. 경추운동범위 (ROM of whole cervical spine) 에대해서는단순방사선촬영에서 C2과 C7간의 Gore 각 (Gore s angle) 을이용하여측정하여굴곡상과신전상의차이를비교하였다. 22) 인접분절의퇴행성변화에대하여골극형성및추간판공간변화를단순방사선사진상측정을하여, Park 등 10) 이보고한인접분절의골극형성에대하여인접상, 하분절의골극형성이되지않은경우를 1단계, 추간판높이의 50% 미만으로확장된경우를 2단계, 50% 이상확장된 3단계, 골극이유합분절까지연장되어완전히가교가형성된경우를 4단계로하였으며, 이를이용하여인접분절골극형성을평가하였다. Hilibrand 등 6) 의방법을변형하여단순방사선사진상추간판가장전방과후방에서높이를측정하여그평균값을추간판의높이로정하였고, 추간판높이변화가없는 1단계, 수술전에비해 50% 이하의감소가보이며, 후방골극이형성된 2단계, 50% 이상 75% 미만과후방골극이형성된 3단계, 75% 이상의감소와후방골극이보이는 4 단계로하였다 (Table 2). Table 1. Demographic Data of Each groups Group A (ROM <40) Group B (ROM >40) Group a Sag. Align.<10 Group b 10< alignment <30 Group c Sag. Align.>30 N 66 70 30 86 20 성별 (M:F) 34 : 32 36 : 34 16 : 14 44 : 42 10 : 10 평균나이 56.8 (44~67) 57.5 (43~67) 58.5 (43~66) 57.1 (44~67) 56.3 (45~65) 평균추시기간 ( 분포 )(ms) 46.1 (40~71) 45.9 (40~72) 48.1 (40~71) 44.3 (40~68) 45.9 (42~72) 수술 level C2-3 (3) 1 2 1 2 0 C3-4 (10) 5 5 2 6 2 C4-5 (15) 7 8 4 8 3 C5-6 (26) 12 14 6 16 4 C6-7 (22) 11 11 5 14 3 C2-3-4 (1) 0 1 0 1 0 C3-4-5 (15) 7 8 3 10 2 C4-5-6 (23) 12 11 5 15 3 C5-6-7 (21) 11 10 4 14 3 Table 2. Radiographic Grading of Degenerative Changes at Adjacent Level Grade Body spur Disc space narrowing Points I No ossification Normal 1 II Ossification extendion across <50% of the adjacent disc space <50% of normal disc height 2 III Extending > 50% of the adjacent disc space 50%< and <75% of narrowing 3 IV Complete bring of the adjacent disc space >75% 4 Park s bony spur grading: Development of adjacent-level ossification in patients with an anterior cervical plate. J Bone Joint Surg Am 2005; Modified Hilibrand s adjacent segmetal degeneration: Radiculopathy and myelopathy at segments adjacent to the site of previous anterior cervical arthrodesis. J Bone Joint Surg Am 1999. www.krspine.org 3
Kyung-Jin Song et al Volume 21 Number 1 March 2014 상, 하분절모두에퇴행성변화가발생된경우에는양측분절중퇴행성변화가심한분절의등급을표시하였다. 추시관찰동안인접분절퇴행성변화에대하여정확한비교분석을위해수술전유합부위상, 하인접분절에골극형성과추간판공간높이감소가 2단계이상이었던 18예는제외하였으며, 수술전과비교하여단계에따라점수화하여 1단계를 1점으로각단계에 1점을더하여점수화하였으며최종추시관찰시퇴행성변화에대한비교분석을하였다. 골극형성및추간판감소의정도를계측시관찰자내, 관찰자간오차를줄이기위하여척추전임의과정을마친정형외과전문의 3명이한증례에대하여 3차례이상측정하여평균화하였다. 퇴행성변화에각군의점수화에따른비교는 Chi-square test 를사용하였으며, 인접분절질환발생률에대해서는 One way ANOVA test 를사용하였다. P value 는 0.05 미만일때, α value 는 0.017 미만일때통계학적유의성을보이는것으로하였다. 결과 136명의환자중 40도미만의굴신운동범위를갖는 A군은총 66명, 40도이상의큰굴신운동범위를갖는 B군은 70명이었다. 경추측면정렬의전만정도가 10도미만이거나후만이있는 a군은 30예, 10~30 도의측면정렬을보이는 b군은 86예, 30도초과의측면정렬을보이는 c군은 20예였다. 평균 1.40±0.50 점으로, 통계학적으로각군간의의미있는차이는보이지않았다 (p =0.08). 최종추시경추측면사진상인접분절의골극형성은 a군에서 1단계 20명, 2단계 10명, 3단계와 4단계모두 0 명이었고, 평균은 1.33±0.48, b군에서 1단계 56명, 2단계 16명, 3단계 10명, 4 단계 4명이었고, 평균 1.56±0.88, c군에서 1단계 12명, 2단계 4 명, 3단계 4명, 4단계 0명이었고, 평균 1.60±0.82 로, 통계학적으로각군간의의미있는차이는보이지않았다 (p =0.07). 3. 인접분절질환의발생률수술후외래추시관찰중새롭게발생한인접분절과관계된방사통및척수병증은자기공명영상과컴퓨터단층촬영으로병변을확인하였다. 136명의환자중수술후 1년에 1 예, 2 년에 2 예, 3년에 2 예, 4년에 1 예가새롭게발생하였으며, 총 6 예 (4.41%) 에서발생하였다. 해마다발생하는인접질환발생율은 1년째에 0.7 %, 2년째에 1.47 %, 3년째에 1.47 %, 4년째에 0.7 % 를보였으며, A군에서 4명으로발생률은 6.1%, B군은 2명으로 2.9% 의발생률을보여, 두군간에통계학적으로의미있는차이는보이지않았다 (P=0.09). 또 a군 2명 (6.6%), b군 4명 (4.6%) 의발생률을보였으며, 통계학적차이는보이지않았다 (P=0.10). 발생위치로는경추 3-4번에서 1예, 경추 4-5번에서 2예, 경추 5-6번에서 1예, 경추 6-7번에서 1예였으며, 증상을보이는환자에대하여약물및보조기치료로 6명모두에서증상의호전을보였다. 1. 경추운동범위와인접분절의골극형성및추간판높이의변화추간판높이의변화에따른퇴행성정도는 A군에서 1단계 43 명, 2단계 23명, 3단계 0명, 4단계 0명으로각단계별로점수화하여평균 1.35±0.48 점이며, B군에서 1단계 39명, 2단계 31명, 3단계 0명, 4단계 0명, 평균 1.44±0.50 점으로 A군과 B군의통계학적차이는보이지않았다 (p=0.07). 인접분절의퇴행성변화중최종추시경추측면사진상인접분절의골극형성이 A군에서 1단계 39명, 2단계 15명, 3단계 9 명, 4단계 3명이었으며, 평균 1.64±0.88 점이며, B군에서 1단계 47명, 2단계 16명, 3단계 7명, 4단계 0명평균 1.43±0.67 점으로통계학적으로 A군과 B군의차이는보이지않았다 (p=0.06). 2. 시상면정렬과인접분절의골극형성및추간판높이의변화각군별추간판높이의변화에다른퇴행성정도는 a군에서 1 단계 14명, 2단계 16명, 3단계 0명, 4단계 0명으로각단계별로점수화하여평균 1.53±0.50 점이며, b군에서 1단계 60명, 2단계 26명, 3단계 0명, 4단계 0명이었고, 평균 1.30±0.46 점이었다. c 군에서는 1단계 12명, 2단계 8명, 3단계 0명, 4단계 0명이었고, 고찰 인접분절퇴행성병변은유합된인접분절에방사선학적으로퇴행성변화를보이는경우를말하며, 인접분절질환은해당인접분절의퇴행성변화에신경근증이나척수병증의신경증상이발생할때를의미한다. 6,11) 전방유합술이퇴행성경추질환을치료하는데효과적으로알려져있지만, 장기간추적관찰시에약 7~15% 에서인접한분절에증상을유발하는퇴행성변화가나타난다고알려져있다. 21,22) 경추유합은인접분절의생역학적조건을변화시켜퇴행성변화및인접분절질환의발생에영향을주며, 인접분절에과도한부하, 과도한운동과인접분절추간판내압력상승을야기한다고여러연구에서보고하고있다. 12-15) Park 등 16)) 은사체생역학실험으로경추유합술을시행후경추 3번에부하제공시인접분절에추간판내압력상승및운동범위증가하며, 한분절보다두분절유합시추간판압력을더욱상승시킨다고보고하였다. 또한 Rao 등 17) 도사체생역학적연구를통하여경추유합인접분절에과도한부하와추간판내압력상승이인접분절의퇴행성변화에영향을주는인자라고보 4 www.krspine.org
Journal of Korean Society of Spine Surgery Preoperative sagittal alignment and range of motion 고하였다. 그러나사체생역학적연구와달리여러임상적인연구에서는유합인접분절의퇴행성변화에영향을주는여러가지인자에대하여보고하고있으며, Goffin 등 18) 은 180명의 100 개월이상장기간추시경추전방유합술의연구에있어환자의연령, 유합분절수는인접분절의퇴행성변화와연관성이없으며, 수술후추시관찰기간이인접관절퇴행성변화와연관성이있다고보고하여인접분절에발생한퇴행성변화는자연적인경과에의한다고보고하였다. Elsawaf 등 19) 은 20명의평균 28개월추시경추유합술시행후인접분절의운동범위가보상적으로증가하게되고이로인해인접분절의퇴행성변화를유발하는중요한인자라고하였다. 그러나현재까지수술전경추운동범위와경추후만정렬이인접분절의퇴행성변화를유발하는관련인자라고보고한연구는없었으며, 저자들의연구결과를보면케이지와전방금속판을이용한유합술에있어수술전경추시상면정렬의변화와경추운동범위정도가인접분절의퇴행성변화를촉진시키는데에기여한다고생각할어떤근거도발견하지못하였다. 유합인접분절질환에대하여여전히여러연구에서논쟁거리가되고있으나유합후단순방사선사진상나타나는인접분절의퇴행성병변은반드시방사통및척수병증의증상을나타내지는않으며, 이는골극형성및추간판감소의퇴행성변화가인접분절의질환과는연관성이없다는것이여러연구의일반적인견해이다. 20) Hilibrand 등 6) 은퇴행성경추질환에대해전방금속판고정없이자가골이식유합술을시행한환자에있어인접분절질환의연간발생률을 2.9% 로보고하며, 생존분석상수술후 10년이내약 25% 이상의유병률을보고하였으며, 경추 5-6번또는경추 6-7번유합술이인접분절질환의위험인자이며, 다분절유합술보다단분절유합술시인접분절질환의위험인자로보고하였다. 본연구에서수술후추시기간이평균 46 개월 (40-62 개월 ) 로기존연구에비해비교적단기간이라는제한점이있어서, 수술전경추시상면정렬과운동범위가인접분절의골극형성및추간판간격감소등의퇴행성변화에영향을주는인자가아니라고결론을내리기는힘들지만, 일단중 장기추시에서는영향을미치지않는것으로생각된다. 이는퇴행성변화이외에다른여러인자가복합적으로작용하여인접분절질환에영향을준다고생각하며, 또한일정부분자연경과가인접분절질환을유발한다고생각한다. 본연구에서는연구대상이충분하지않고, 추시기간이길지않다는제한점이있으며, 수술후의생활습관과경추의운동범위및시상면정렬의정도를고려하지않았다는한계점이존재한다. 실제로본연구에서수술후 50도미만의운동범위를갖는군은 108예에서 132예로증가였고, 이는수술후운동범위 의감소를의미한다. Katsuura 등 8) 은 42명의평균 9.8년의장기간추시퇴행성경추질환에대해금속판고정술없이자가장골이식에의한전방유합술을시행한환자들에서수술후경추후만정렬이인접분절의퇴행성변화를유발하는중요한인자라고하였다. 본연구에서는시상면정렬에서전만정도가 10도미만이거나후만이있는군은 30 예에서 10예로감소되었으며, 이또한수술전의시상면부정정렬이많이교정되었음을의미한다. 본연구의연간인접질환평균발생율은 1.1 % 로 Hilibrand 등이보고한 2.9 % 보다작았으며, 이러한결과는수술후시상면정렬의교정이인접분절질환의발생감소에영향을주었을것으로사료된다. 또한이연구에서보여준통계적결과가 0.06 에서 0.08 정도를보여의미없는통계적수치이기는하나의미있는수치인 0.05 에근접하므로증례수나추시기간, 통계적처리방법등연구의변수가바뀌게되면의미있는수치로변할수있으므로이에대한해석의주의가필요하리라생각한다. 또한저자들의경우에케이지를이용하므로기존의자가장골유합시필연적으로발생하는점진대치 (creeping substitution) 에의해발생될수있는이식골의침강을줄이려고노력하였고, 금속판을이용하므로인해시상면의전만정렬을유지할수있어술후및추시관찰상시상면정렬이잘유지될수있어기존의연구에비해인접질환의연간발생률이비교적적은결과를얻을수있었다고생각한다. 또한기존연구들이전방금속판고정술없이자가장골만을이용한유합술후의인접질환발생에대한연구이기때문에전방유합술및금속판이용한전방고정술이술후인접분절의퇴행성변화나퇴행성질환의발생에어떤영향을줄수있을지에대해서는좀더전향적이고장기적인연구가필요할것으로생각된다. 결론퇴행성경추질환에서케이지와전방금속판을이용한유합술후중기추시관찰상수술전시상면정렬과운동범위가전방유합술후인접분절퇴행성변화와인접분절질환에대한발생에영향을미치지않았다. REFERENCES 1. SMITH GW, ROBINSON RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am. 1958;40:607-24. 2. Baba H, Furusawa N, Imura S, Kawahara N, Tsuchiya H, Tomita K. Late radiographic findings after anterior cervical www.krspine.org 5
Kyung-Jin Song et al Volume 21 Number 1 March 2014 fusion for spondyloticmyeloradiculopathy. Spine (Phila Pa 1976). 1993;18:2167-73. 3. Goffin J, van Loon J, Van Calenbergh F, Plets C. Longterm results after anterior cervical fusion and osteosynthetic stabilization for fractures and/or dislocations of the cervical spine. J Spinal Disord. 1995;8:500-8. 4. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Statist Assoc. 1958;53:457-81. 5. McGrory BJ, Klassen RA. Arthrodesis of the cervical spine for fractures and dislocations in children and adolescents. A long-term follow-up study. J Bone Joint Surg Am. 1994;76:1606-16. 6. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999;81:519-28. 7. Döhler JR, Kahn MR, Hughes SP. Instability of the cervical spine after anterior interbody fusion. A study on its incidence and clinical significance in 21 patients. Arch Orthop Trauma Surg. 1985;104:247-50. 8. Katsuura A, Hukuda S, Saruhashi Y, Mori K. Kyphoticmalalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J. 2001;10:320-4. 9. Song KJ, Johnson JS, Choi BR, Wang JC, Lee KB. Anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. J Bone Joint Surg Br. 2010;92:1548-52. 10. Park JB, Cho YS, Riew KD. Development of adjacent-level ossification in patients with an anterior cervical plate. J Bone Joint Surg Am. 2005;87:558-63. 11. Rhin JA, Lawrence J, Gates C, Harris E, Hilibrand AS. Adjacent segment disease after cervical spine fusion. Instr Course Lect. 2009;58:747-56. 12. Buckwalter JA. Aging and degeneration of the human intevertebral disc. Spine (Phila Pa 1976) 1995;20:1307-14. 13. Schwab JS, Diangelo DJ, Foley KT. Motion compension associated with single-level cervical fusion: where does the lost motion go? Spine (Phila Pa 1976). 2006;31:2439-48. 14. Ragab AA, Escarcega AJ, Zdeblick TA. A quantitative analysis of strain at adjacent segment after segmental immobilization of the cervical spine. J Spinal Disord Tech. 2006;19:407-10. 15. Maiman DJ, Kumaresan S, Yoganandan N, Pintar FA. Biomechanical effect of anterior cervical spine fusion on adjacent segment. Biomed Mater Eng. 1999;9:27-38. 16. Park DH, Ramakrishnan P, Cho TH, et al. Effect of lower two-level anterior cervical fusion on the superior adjacent level. J Neurosurg Spine. 2007;7:336-40. 17. Rao RD, Wang M, McGrady LM, Perlewitz TJ, David KS. Dose anterior plating of the cervical spine predispose to adjacent segment changes? Spine (Phila Pa 1976). 2005;30:2788-92. 18. Goffin J, Geusens E, Vantomme N, et al. Long-term followup after interbody fusion of the cervical spine. J Spinal Disord Tech. 2004;17:79-85. 19. Elsawaf A, Mastronardi L, Roperto R, Bozzao A, Caroli M, Ferrante L. Effect of cervical dynamics on adjacent segment degeneration after anterior cervical fusion with cages. Neurosurg Rev. 2009;32:215-24. 20. Yue WM, Brodner W, Highland TR. Long-term results after anterior cervical discectomy and fusion with allograft and plating: a 5- to 11- year radiologic and clinical follow-up study. Spine (Phila Pa 1976). 2005;30:2138-44. 21. Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am. 1993;75:1298-307. 22. Gore DR, Sepic SB. Anterior cervical fusion for degenerated or protruded discs. A review of one hundred forty-six patients. Spine(Phila Pa 1976). 1984;9:667-71. 6 www.krspine.org
Journal of Korean Society of Spine Surgery Preoperative sagittal alignment and range of motion 술전경추시상면정렬과운동범위가전방경추유합술후의인접관절퇴행성변화에대해영향을미치는가? - 중기추시연구 - 송경진 이광복 임종한전북대학교의학전문대학원정형외과학교실 연구계획 : 후향적연구목적 : 퇴행성경추질환에서전방유합술후수술전경추시상면정렬과운동범위가인접분절의퇴행성변화와인접분절질환에대한영향에대하여알아보고자하였다. 선행문헌의요약 : 현재까지술전시상면정렬과운동범위와인접분절퇴행성변화에대한연구가없었다. 대상및방법 : 퇴행성경추질환에대하여 PEEK 케이지및금속판이용한 2분절이하의전방유합술을시행후, 3 년이상추시가가능했던 136명의환자를대상으로후향적연구를시행하였다. 경추의운동범위를 40도미만 (A군), 40도이상 (B군) 으로, 경추시상면정렬은후만또는전만 10도이하 (a군), 10-30 도전만 (b군), 30도이상 (c군) 으로구분하여인접분절퇴행성변화와인접분절질환발생과의연관성에대하여Chi-square test 를이용하여비교분석하였다. 결과 : 경추의운동범위와디스크높이의변화의관계는 A군에서 1.35±0.48 점, B군 1.44±0.50 점으로통계적으로유의한차이를보이지않았다 (p= 0.07). 운동범위와인접분절의골극형성의관계는 A군에서평균 1.64±0.88 점이며, B 군에서평균 1.43±0.67 점으로통계학적으로차이는보이지않았다 (p=0.06). 경추의시상면정렬에따른최종추시시디스크높이의변화는 a군에서 1.53±0.50 점, b군 1.30±0.46 점, c군에서 1.40±0.50 점으로통계적으로유의한차이를보이지않았다 (p = 0.08). 시상면정렬과골극변화의관계에서 a군평균은 1.33±0.48, b군평균은 1.56±0.88, c군평균은 1.60 ±0.82 로, 통계학적으로각군간의의미있는차이는보이지않았다 (p =0.07). 결론 : 비록퇴행성경추질환에서전방유합술후중중기추시상수술전시상면정렬과운동범위가인접분절퇴행성변화와인접분절질환발생에영향을미치지않았다. 색인단어 : 퇴행성경추질환, 경추전방유합, 경추시상면정렬, 경추운동범위, 인접분절퇴행성변화 약칭제목 : 경추시상면정렬과운동범위 www.krspine.org 7