Journal of Korean Society of Spine Surgery Effectiveness of Selective Nerve Root Block for the Treatment of Single-Segment Lumbar Spinal Stenosis and

Journal of Korean Society of Spine Surgery Effectiveness of Selective Nerve Root Block for the Treatment of Single-Segment Lumbar Spinal Stenosis and Disc Herniation Tae Kyun Kim, M.D., Chang Su Kim, M.D., Young Chae Choi, M.D., Dae Moo Shim, M.D. J Korean Soc Spine Surg 2017 Mar;24(1):32-38. Originally published online March 31, 2017; https://doi.org/10.4184/jkss.2017.24.1.32 Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: 82-2-2019-5410 Fax: 82-2-573-5393 Copyright 2017 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.2017.24.32.1 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.krspine.org

Original Article J Korean Soc Spine Surg. 2017 Mar;24(1):32-38. https://doi.org/10.4184/jkss.2017.24.1.32 Effectiveness of Selective Nerve Root Block for the Treatment of Single-Segment Lumbar Spinal Stenosis and Disc Herniation Tae Kyun Kim, M.D., Chang Su Kim, M.D.*, Young Chae Choi, M.D., Dae Moo Shim, M.D. Department of Orthopedic Surgery, School of Medicine, Wonkwang University Hospital, Iksan, Korea Department of Orthopedic Surgery, Kosin University College of Medicine, Busan, Korea* Study design: Retrospective clinical study. Objectives: To determine and compare the therapeutic effectiveness of selective nerve root block performed for single-segment spinal stenosis and disc herniation. Summary of Literature Review: The usefulness of selective nerve root block has been reported in several previous studies, but those results were aggregated across many diseases, making it difficult to estimate its effectiveness for each disease. Materials and Methods: From January 2008 to January 2013, among patients who had undergone selective nerve root block, those who were diagnosed with single-segment spinal stenosis or disc herniation were enrolled in this study. Among a total of 103 patients, 47 spinal stenosis patients were classified as group 1, and 56 disc herniation patients as group 2. Visual analog scale (VAS) scores and Kim s criteria were used to compare the reductions in radiating pain in each group. Results: In group 1, the VAS scores improved from 7.6 before the procedure to 2.6 and 3.3 at 1-month and 6-month follow-up visits, respectively. Kim s criteria also improved from a mean of 1.6 before the procedure to 2.9 at the 6-month follow-up. In group 2, the VAS scores improved from 7.8 before the procedure to 2.1 and 2.7 at 1-month and 6-month follow-up visits, respectively. Kim s criteria also improved from a mean of 1.8 before the procedure to 3.2 at the 6-month follow-up. Conclusions: Radiating pain in the lower limb due to spinal stenosis or disc herniation limited to a single segment was effectively controlled by selective nerve root block. Key words: Spinal stenosis, Disc herniation, Selective root block 서론 요통, 하지방사통및파행을유발하는요추의퇴행성질환으로는척추관협착증과추간판탈출증이있으며, 이중척추관의중심성협착증을제외하면비교적양호한자연경과를가지는것으로알려져있다. 1,2) 하요추부의신경근증으로인한통증에대한초기치료로대부분의경우보존적인치료를시행하며, 이중많게는 90% 까지호전되었다는보고도있다. 3) 그러나증상의초기발현시심한통증과불편감의호소로자연경과에따른증상호전을기다리지못하고수술적치료를시행하는경우가많으며, 이는수술로인한각종합병증및높은수술빈도로사회경제적인문제를야기하고있다. 4) 따라서신경근증증상의급성기에적절한보존적치료로통증을감소할후있다면, 수술의필요성을감소하는데효과적일것이다. Mcnab 5) 에의해처음소개된선택적신경근차단술은저자들 의이전의연구를통해신경근증환자에대한보존적치료로서 효과적이라는결론을얻을수있었으며, 6-8) 다수의저자들도그 유용성에대하여보고하였다. 9-15) 하지만기존의연구들은원인 질환에대한분류없이다양한질환군을대상으로분석하였기 때문에선택적신경근차단술이각각의질환에대하여어느정도 의효과를보이는지판단하기어려운점이있었다. 이에저자들 Received: March 23, 2015 Revised: September 6, 2016 Accepted: February 13, 2017 Published Online: March 31, 2017 Corresponding author: Tae Kyun Kim, M.D. Department of Orthopedic Surgery, School of Medicine, Wonkwang University, 344-2 Shinyong-dong, Iksan, Chunbuk, Korea TEL: +82-63-859-1360, FAX: +82-63-852-9329 E-mail: osktg@wonkwang.ac.kr *This paper was supported by wonkwang university in 2017. 32 Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 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.

Journal of Korean Society of Spine Surgery Comparison of Therapeutic Effect of Selective Nerve Root Block Fig.1. Grade of nerve root compression. 은단분절에국한된척추관협착증과추간판탈출증에서선택적신경근차단술시행후질환및분류에따른치료효과의차이및유용성에대해알아보고자하였다. 대상및방법 1. 대상 2008 년 1월부터 2013 년 1월까지 5년동안본원에서선택적신경근차단술을시행받았던환자중최소 6개월이상추시가가능했던환자중단분절척추관협착증및추간판탈출증으로진단받았던환자를대상으로하였다. 척추관협착증의경우다발성으로발생하는경우가많으나, 본연구에서는단일분절협착증에한하여추시관찰을시행하였으며, 중심성협착증에서는경막낭의단면적이 100 mm 2 이하인경우, 16-17) 외측함요부협착은 Ciric 등 18) 에의한외측함요부의높이가 2 mm 이하인경우, 신경관협착의경우 Wildermuth 19) 의분류상 Grade II (marked foraminal stenosis) 와 Grade III (Advanced foraminal stenosis) 의소견을보이는경우만포함하였다. 임상양상이영상학적검사와일치하지않는환자는연구에서제외하였다. 추간판탈출증의경우팽윤이나단순한돌출은제외하였고 Choi 등 20) 에의한신경근압박정도의분류법에따라파열형추간판탈출증이상인 Grade III (entrapment) 를기준으로분석하였다 (Fig. 1). 영상학적분류는 Infinitt PACS system 의 free line ROI calculator 를이용해자기공명 T2 강조영상에서병변의부위를측정하였다 (Fig. 2). 방사통수준의평가는자기공명영상검사와환자의이학적검사 ( 방사통의위치, 감각의소실정도, 반사항진및감소 ) 에따른양상비교를통해구분하였다. 예를들어자기공명영상검사상에서 L4/5 에단일수준추간판탈출증을보이며, 이학적검사에서제 5요추신경근통증인하퇴부의바깥쪽, 발등, 엄지발가락의저리고땡기는통증이있는경우를제 5요추신경근의 Fig.2. Measurements were performed on a picture archiving and communication system where the herniation was visualized. 단일수준방사통으로구분하였다. 선정의제외기준으로기존요추부수술력이있는경우, 외상 이나마미증후군, 진행성의신경손실이나운동손실을보이는 경우, 두개이상의신경근이침범된경우, 척추분리증이나척 추전방전위증, 분절불안정성이동반된경우등은연구결과에 영향을줄수있으므로그대상에서제외하였다. 연구기준을만족하는대상자는총 103 명이었으며, 척추관협 착증환자 47 명을 1 군, 추간판탈출증환자 56 명을 2 군으로분 류하였다. 1 군중남자는 22 명, 여자는 25 명이었고, 평균연령 은 61 (50~72) 세, 증상발현후신경근차단술까지의기간은평 균 14.3(4~31) 주였으며, 평균추시기간은 21.2(13~42) 개월이 었다. 2 군의경우남자는 31 명, 여자는 25 명이었고, 평균연령은 42.3(21~57) 세, 증상발현후신경근차단술까지의기간은평 균 12.7(2~26) 주였으며, 평균추시기간은 18.6(10~38) 개월이 었다 (Table 1). 신경근차단술은입원상태에서 3~6( 평균 4) 차례 시행하였다. 요천추신경근의차단방법은, 환자를투시진단테이블에눕 히고 Potadine swap 을이용해소독하고원하는부위의극돌기 www.krspine.org 33

Tae kyun Kim et al Volume 24 Number 1 March 2017 Table 1. Group I (Spinal stenosis) Group II (HIVD) Total cases 47 56 Sex (Male:Female) 22:25 31:25 Age (year) 61(50~72) 42.3(21~57) Duration of symptom (week) 18.3(8~62) 12.7(2~51) Average follow-up (month) 21.2(13~42) 18.6(12~38) Table 2. Criteria or clinical results (Kim, 1986) Excellent Good Fair Poor * Complete relief of pain in back and lower limbs * No limitation of physical activity * Analgesics not used at all * Able to squat on floor * Relief of most of pain in back and lower limbs * Able to return to accunstomsed employment * Physical activities sightly limited * Analgesics used only infrequently * Able to squat on the floor * Partial relief of pain in back and lower limbs * Able to return to accustomed employment with limityation or return to lighter work * Physical activities definitely limited * Mild analgesic medication used frequently * Mild limitation to squat on the floor * Little or no relief of pain in back and lower limbs * Physical activities greatly ; limited * Unable to return toaccustomed employment * Analgesic medication used regularly * Unable to squat on the floor 부터외측으로 4~5 cm 가량떨어진곳을바늘삽입점으로하였 다. 투시진단화상을보면서횡돌기의하연과척추체의외측면이 만나는부위로척추바늘을비스듬하게삽입하였다. 신경근근 처에다다르면 0.5 ml 의 radiopaque dye (pamiray 370) 를주입 하고방사선촬영하고, 이후 dexamethasone 과 lidocaine 을각각 0.5 ml 씩섞어서주입하였다. 2. 결과의판정방법 각군에서하지방사통의감소정도에대해 VAS score 와 Kim s criteria (Table 2) 이용하여비교하였고, 각군에서병변부의 level, 병변부의위치및척수압박정도, 증상발현후신경근차단술까지의기간에따른치료효과도비교하여보았다. 통계학적처리및분석은 SPSS (Ver 17.0) 을이용하였으며시술전, 후평가는 Paired T-test 를이용하였고, 각군의아형별호전정도파악을위해서는 ANOVA 분산분석을이용하였습니다. I군과 II 군의치료효과비교는 Student T-test 를통해시행하였다. 결과 1군에대한추시관찰상 47명, 2군은 56명이었으며 VAS 와 Kim s criteria 모두에서신경근차단전에는두군간의차이를보이지않았다. 하지만신경근차단후 6개월째에는유의한차이를보였고 2군에서더좋은예후를보였다 ()(Table 3). 1 군에대한추시관찰상 VAS 는시술전평균 7.6점에서추시 1개월 2.6점, 추시 6개월 3.3점으로호전되었고, Kim s criteria 는시술전평균 1.6점에서추시 6개월 2.9로호전되었다. 이환된분절의분포는 L3/4 2명 (4%), L4/5가 28명 (60%), L5/S1 이 17명 (36%) 이었고, L4/5 에서더좋은예후를보였으나통계적으로유의성은없었다 (p=0.235). 아형별분류로중심성협착증이 22 명, 외측함요부협착증이 2명, 추간공협착증이 23명이었으며, 추간공협착증일경우양호한예후를보였다 (). 증상발현후 3개월이내로치료를시작한경우치료효과가좋았고이는통계적으로도유의하였다 ()(Table 4). 2군의경우 VAS 는시술전평균 7.8점에서추시 1개월 2.1점, 추시 6개월 2.7점으로호전되었고, Kim s criteria 는시술전평균 1.8점에서추시 6개월 3.2점으로호전되었다 (). 이환된신경근의분포는 Table 3. Comparison of group I (Spinal stenosis) and Group II (HIVD) VAS Kim s criteria Pre injection Post 6months Pre injection Post 6months Group I (47) 7.6 3.3 1.6 2.9 Group II (56) 7.8 2.7 1.8 3.2 34 www.krspine.org

Journal of Korean Society of Spine Surgery Comparison of Therapeutic Effect of Selective Nerve Root Block Table 4. Result of group I (Spinal stenosis) Group I VAS Kim s criteria Pre injection Post 6months (Paired T test) Pre injection Post 6months (Paired T test) Total (47) 7.6 3.3 1.6 2.9 Level involved (cases) L3/4 (2) L4/5 (28) L5/S1 (17) Type (cases) central stenosis (22) lateral recess stenosis (2) foramen stenosis (23) Symptom duration (cases) <3 months (19) >3 months (28) 8.0 7.5 7.7 7.8 7.5 7.4 7.4 7.9 3.5 3.1 3.3 p=0.314 3.6 3.5 2.9. 2.8 3.7 1.5 1.7 1.5 1.5 1.7 1.8 1.9 1.4 3.0 2.8 3.2 p=0.235 2.6 3.0 3.4 3.3 2.4 Table 5. Result of group II (HIVD) Group II Pre injection VAS Post 6months (Paired T test) Pre injection Kim s criteria Post 6months (Paired T test) Total (56) 7.8 2.7 1.8 3.2 Root involved (cases) L3 (1) L4 (17) L5 (23) S1 (15) Type (cases) central (39) far lateral (17) P-value Symptom duration (cases) <3 months (32) >3 months (24) 7.0 7.6 8.1 7.9 7.6 8.0 7.5 7.9 3.0 2.9 2.4 2.8 3.1 2.2 2.3 2.9 2.0 1.7 1.9 1.8 1.7 1.9 2.1 1.6 3.0 2.8 3.3 3.1 2.9 3.4 3.4 2.9 3요추신경근 1명 (2%), 4요추신경근 17명 (30%), 5요추신경근 23명 (41%), 천추 1 신경근 15명 (27%) 이었고, 5요추신경근이병변일경우우수한치료효과를보였다 (). 아형별로중심성탈출증 39명, 후외측탈출증 17명이었으며, 후외측탈출증일경우더좋은예후를보였다. 2군에서도 1군과마찬가지로이환기간이 3개월이내로짧을수록치료효과는우수하였다 () (Table 5). 시술후증상이악화되어수술을시행한환자는 1군의경우 4예, 2군의경우 7예였다. 고찰 1971년 Mcnab 5) 이선택적신경근차단술을발표한이래로, 많은저자들에의해 21) 진단및치료의목적의신경근차단술의유용성이기술되어왔다. 선택적척추신경근차단술의시술상의장점은수기의간편함과경제성을들수있으며, 수술전수술후예후평가에도유용하다. Amundsen 등 22) 및 Atlas 등 23) 은척추관협착증환자들에서도증상의호전과악화가반복되고, 수술을시행할경우에도수술직후에만환자의만족도가높다는것을결과를발표하였고, 1992 년 Derby 등 24) 은신경근증상을동 www.krspine.org 35

Tae kyun Kim et al Volume 24 Number 1 March 2017 반한요통의치료에있어하부요통보다신경근증상이더심하면서증상의지속시간이 1년이넘지않은환자나 1년을넘었더라도척추신경근차단검사에반응이좋은환자는수술후에신경근증상이소실될확률이 95% 이상이라하였다. 최근에는선택적신경근차단술의진단적가치에대해서도연구되고있는데, Beynon 등 25) 은선택적신경근차단술이민감도 93%, 특이도 26% 를보여낮은특이도로인해확진검사로는부적절하나수술에앞서이환된신경근을밝혀내는데비용효율이높은술식이라고발표하였다. 하지만, 여러저자들은환자의선택에있어서신중해야한다고보고하고있다. Krempen 등 26) 은선택적척추신경근차단술의적응증으로첫째로방사통을가진환자로연관통과는감별해야하며, 둘째는정신적, 기능적인요인에의해발생된방사통의병력을가진환자, 셋째는방사선적검사로신경근압박의원인에대한정확한진단이안되는경우, 넷째는방사통을가진환자로임상적증상과병변부위가일치하지않는경우, 다섯째는 iodine 의알러지가있는환자를적응으로하였다. White 등 27) 은경막외스테로이드및국소마취제의주입으로 2주이내의단기적증상감소는 73% 에서 87% 까지효과적이었으나 2주이후로는효과가감소되었으며주사바늘의잘못된위치선정이평균 25% 에이른다고보고하였다. Ridley 등 28) 은추간판탈출증환자에서선택적신경근차단술을시행한경우 2주내에는통증조절에유효한결과를가져왔으나장기추시결과에서는대조군과크게차이가없었다고보고하였으며 Carette 등 29) 도유사한결과를보고하였다. 저자들의이전의연구에서도수술이예정된하지방사통환자를대상으로수술준비기간동안에신경근차단술을시행하여 5년이상의장기추시결과 24.6% 에서다른치료가필요치않은결과를보였다. 30) 이처럼선택적신경근차단술의유용성은대규모의연구를통해서입증되고있으나, 특정한질환에서시행후양호한효과를보이는지에대해서는비교적논의가이루어지지않았다. 이에본연구에서는단분절에국한된환자군에대한분석을통해선택적신경근차단술의특수성에대하여고찰한바, 추간판탈출증환자군에서보다양호한예후를보이는것으로사료된다. 두군간의성별, 나이에서는두군간의치료효과에영향을줄만한차이는찾아볼수없었다. 척추관협착증에서는기계적인압박이서서히진행하며정맥울혈 (venous congestion) 과허헐 (ischemia) 를초래하고신경근의압박이국소적인염증을일으키는것으로생각된다. 31,32) 저자들은추간판탈출증에서는정맥울혈에의한파행보다는염증이신경근이주원인이되어스테로이드를사용한신경근차단술에더좋은효과를보인것으로생각된다. 하지만이러한임상적결과를나타내는기전에대하 여조직학적연구를포함한다각적인추가적연구가필요할것으로보인다. 또한, 본연구는 6개월추시관찰로일반적인자연경과와비교하여보다장기적인관찰이필요할것으로사료되며이는이번연구의제한점으로사료된다. 결론 선택적신경근차단술후추시상추간판탈출증환자군에서임상적결과가좋았다. 또한 5요추신경근에이환되었을때치료효과가우수하였다. 척추관협착증환자중에서는추간공협착증환자에서치료후좋은예후를보였으며, 추간판탈출증중에서는후외측탈출증환자에서좋은예후를보였다. 두군모두증상발현후조기치료를시작한경우에서더좋은임상결과를보였다. 이에단분절에국한된척추관협착증또는추간판탈출증으로인해발생한하지방사통은선택적신경근차단술을통해효과적으로조절될수있으며, 조기에적극적인보존적치료를시행하여불필요한수술을줄일수있을것으로사료된다. REFERENCES 1. Tadokoro K, Miyamoto H, Sumi M, et al. The prognosis of conservative treatments for lumbar spinal stenosis: analysis of patients over 70 years of age. Spine (Phila Pa 1976). 2005;30:2458-63. 2. Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine (Phila Pa 1976). 2005;30:857-62. 3. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine(Phila Pa 1976). 1989;14:431-7. 4. Guigui P, Devyver B, Rillardon L, et al. Intraoperative and early postoperative complications of lumbar and lumbosacral fusion: prospective analysis of 872 patients. Rev Chir Orthop Reparatrice Appar Mot. 2004;90:5-15. 5. Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am. 1971;53:891-903. 6. Shim DM, Kim TK, Song HH, et al. The usefulness of selective spinal nerve root block. J Korean Soc Spine Surg. 2004;11:48-54. 7. Shim DM, Park JY, Yang JH, et al. Effectiveness of selective 36 www.krspine.org

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Original Article J Korean Soc Spine Surg. 2017 Mar;24(1):32-38. https://doi.org/10.4184/jkss.2017.24.1.38 단분절에국한된요추척추관협착증과추간판탈출증환자에서선택적신경근차단술의치료효과비교 김태균 김창수 최영채 심대무원광대학교의과대학정형외과학교실연구계획 : 후향적임상연구목적 : 단분절에국한된척추관협착증과추간판탈출증에서선택적신경근차단술시행후질환및분류에따른치료효과의차이및유용성에대해알아보았다. 선행문헌의요약 : 선택적신경근차단술은다수의연구를통해그유용성이보고되었으나다양한질환군을대상으로분석하였기때문에각각의질환에대하여어느정도의효과를보이는지판단하기어려운점이있었다. 대상및방법 : 2008년 1월부터 2013년 1월까지 5년동안본원에서선택적신경근차단술을시행받았던환자중단분절척추관협착증및추간판탈출증으로진단받았던환자를대상으로하였다. 103명의환자를대상으로하였고, 척추관협착증환자 47명을 1군, 추간판탈출증환자 56명을 2군으로분류하였다. 각군에서하지방사통의감소정도에대해 VAS score와 Kim s criteria 이용하여비교하였다. 결과 : 1군의경우시술전 VAS 평균 7.6점에서추시 1개월 2.6점, 6개월 3.3점으로호전되었으며시술전 Kim s criteria 평균 1.6점에서추시 6개월 2.9로호전되었다. 2군의경우시술전 VAS 평균 7.8점에서추시 1개월 2.1점, 추시 6개월 2.7점으로호전되었으며시술전 Kim s criteria 는평균 1.8점에서추시 6개월 3.2점으로호전되었다. 결론 : 단분절에국한된척추관협착증또는추간판탈출증으로인해발생한하지방사통은선택적신경근차단술을통해효과적으로조절될수있을것으로사료된다. 색인단어 : 척추관협착증, 추간판탈출증, 선택적신경근차단술 약칭제목 : 선택적신경근차단술의효과비교 접수일 : 2015년 3월 23일 수정일 : 2016년 9월 6일 게재확정일 : 2017년 2월 13일 교신저자 : 김태균 전라북도익산시신용동 344-2 번지원광대학교의과대학정형외과학교실 TEL: 063-859-1360 FAX: 063-852-9329 E-mail: osktg@wonkwang.ac.kr 38 Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 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.