Journal of Korean Society of Spine Surgery Clinical Efficacy and Safety of Radiofrequency Ablation Therapy with Cement Augmentation for a Metastatic Spine Tumor Chang Su Kim, M.D., Young Ho Kwon, M.D., So Hak Chung, M.D., Samuel Baek, M.D. J Korean Soc Spine Surg 2016 Dec;23(4):207-215. Originally published online December 31, 2016; https://doi.org/10.4184/jkss.2016.23.4.207 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: 82-2-2019-3413 Fax: 82-2-573-5393 Copyright 2016 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.2016.23.4.207 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. 2016 Dec;23(4):207-215. https://doi.org/10.4184/jkss.2016.23.4.207 Clinical Efficacy and Safety of Radiofrequency Ablation Therapy with Cement Augmentation for a Metastatic Spine Tumor Chang Su Kim, M.D., Young Ho Kwon, M.D., So Hak Chung, M.D., Samuel Baek, M.D. Department of Orthopedic Surgery, Kosin University Gospel Hospital, Busan, Korea Study Design: Retrospective study. Objectives: To evaluate the clinical efficacy and safety of radiofrequency (RF) ablation therapy followed by a bone cement augmentation procedure in treating and managing pain among metastatic spine tumor patients. Summary of Literature Review: As a metastatic spine tumor is unresectable, this procedure was performed. Results showed an increase in the necrosis rate, and a decrease in local recurrence and secondary vertebral stability. Materials and Methods: From March 2007 to April 2016, 26 patients who were treated with RF ablation with a bone cement augmentation procedure and the same number of patients treated with radiotherapy for metastatic spine lesions were included in this study. Pain relief and functional quality of life were evaluated using a visual analogue scale (VAS) and Roland Morris Questionnaire (RMQ). Results: VAS scores preoperatively and at 1, 4, and 12 weeks follow-up were 7.45, 3.01, 3.78, and 2.97 in the procedure group, and 7.04, 6.65, 5.87, and 3.03 in the radiotherapy group. The procedure group had significantly better average outcomes than the radiotherapy group for pain relief at 4 weeks but showed no difference at 12 weeks. The RMQ score improved from 13.92 to 7.21 in the procedure group, and from 15.33 to 9.75 in the radiotherapy group. Two patients who had a metastatic tumor near the vertebral body posterior cortex showed cement leakage into the disc space, that is, intraforaminal and intracanal space; therefore, operations were performed (7.69% nerve injury). Conclusions: RF ablation therapy with cement augmentation in treatment of metastatic spine tumor shows effectiveness in early pain relief and brings immediate vertebral stability, helping patients return to normal life. However, it carries a risk of nerve injury due to cement leakage. Key words: Radiofrequency ablation, Cement augmentation, Spinal metastases, Pain relief, Cement leakage 서론 전이성골종양은골종양중가장흔한종양으로악성종양에대한여러가지치료방법의발달로환자의생존기간이연장되면서그빈도가증가하고있다. 1) 전이되는골격부위로는척추가가장높은비율을차지하고있으며, 이전이성척추종양은주로척추체에전이되며, 짧은여명기간과통증으로인한삶의질적저하를특징으로한다. 2) 치료는단독혹은인접한두개의추체전이의경우에수술기법의발달로인해수술적치료가시행되고있다. 척추종양에의한통증은감소시키고, 추가적인추체붕괴및신경손상을방지하며생존율을증가시킬수있지만적응증이협소하며풍부한경험을가진시술자가아니면시행할수없어대부분의전이성척추종양은방사선치료에의존할수 밖에없었다. 그러나방사선단독치료는통증의감소효과가늦 고, 추가적인추체의붕괴를방지할수없으며방사선에저항성 이있는종양에는적용하기어렵다. 이에반하여고주파열용해 술후척추시멘트충전술 ( 성형술 ) 은전이종양의직접적인괴사 Received: May 25, 2016 Revised: June 1, 2016 Accepted: September 12, 2016 Published Online: December 31, 2016 Corresponding author: Chang Su Kim, M.D. Department of Orthopedic Surgery, Kosin University Gospel Hospital, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea TEL: +82-51-990-6467, FAX: +82-51-243-0181 E-mail: mewha98@naver.com * 본논문의요지는 2015 년도대한정형외과학회추계학술대회에서발표되었음. Copyright 2016 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. 207
Chang Su Kim et al Volume 23 Number 4 December 2016 를가져오며골시멘트주입을통한추가적인척추안정성을도모할수있어시술후즉각적인통증의완화와함께일상적인생활이가능한이점이있어제한적으로증가하고있는고식적인치료이다. 3) 2011 년본원에서전이성척추종양환자에대한고주파열용해술후척추성형술의유용성에대해방사선요법을시행한환자와비교하여연구한바있어 3) 본연구는고주파열용해술후척추성형술을시행받은환자의장기추적관찰결과를통한고주파열용해술후척추성형술의임상적효용성와척추체후벽피질골과인접한전이종양에서발생한신경손상을보고하고자한다. 대상및방법 연구대상 2007 년 3월부터 2016 년 4월까지본원에서진단된전이성척추종양환자중요통을주소로정형외과에문의된 65명중원발암에대한항암화학요법혹은수술적치료만받았거나, 치료를중단한경우, 치료도중타병원으로전원한경우등을제외하고치료를받은이후 1년이상경과관찰이가능하였던 52명을대상으로하였다. 이중환자동의하에고주파열용해술후척추성형술을시행한 26명과방사선요법을시행한 26명을후향적비교연구하였으며각 26명중 17명은 2011 년본원에서대한정형외과학회지 3) 에보고한전이성척추종양환자를 (34명) 지속적으로추적관찰하였다. 연구방법 1. 시술방법시술전환자의자기공명영상사진의축면영상을이용하여척추전체의면적과병변 (tumor lesion) 의면적을표시한후 Eclipse TPS (Treatment Planning System) 을이용하여 3차원으로구성한후척추전체의부피와종양이침범한부위의부피및투관침의삽입위치를정하였다. 시술은환자를복와위로눕히고시술부위에국소마취를하였으며, 영상증폭장치를이용하여치료할병변추체를확인하였다. 양측척추경도달법으로첫번째척추성형술바늘을병변부위에삽입한후투관침을제거하였다. 병변의크기와맞게노출된전극을피복덮개 (sheath) 를통하여병변에삽입하고피복덮개를후퇴하여노출전극과전극후방 1 cm 지점에부착된첫번째온도센서가병변과추체내에위치하게하였다. 두번째바늘을통하여두번째온도센서를추체의후방피질골전면이나추경부에위치하고, 20 cm 이상긴천자바늘을통한후외방도달법으로병변에인접한추간공에세번째센서를위치하였다. 병변이추체중앙부후면에위치한경우측방도달법으로추 간공을통하여네번째온도센서를전경막강에위치하였다. 고주파발생기의저항과온도, 식염수관류기를통한식염수주입량을조절하면서평균온도 65 이상평균시술시간은 15분이상가열하였다. 추체당시술시간은 10-30 분, 온도는 55-92, 골시멘트주입량은 3-10 ml였다. 병변의부위가 3 cm 이상인경우 3-5회정도부위를달리하여시술하고, 전극을제거한후피복덮개를통하여병변의크기보다 1-2 ml 많은골시멘트를주입하였다. 환자는시술후 1시간침상안정후거동시켰으며, 시술전과시술당일, 2일간정맥항생제를사용하였고, 시술다음날퇴원하였다. 전이성척추종양의괴사율을높이기위하여시술전 Eclipse TPS(Treatment Planning System) 을이용해종양이침범한부위의부피및위치를파악하여, 투관침의삽입위치를정하였고시술중에는영상증폭장치를이용하였다. 또한신경손상과관련된합병증을최소화하기위하여추체내, 후방피질골전면, 추간공에각각의온도센서를설치하여감시하였다. 2. 방사선치료방법방사선치료는하루 300 cgy 씩 2주에걸쳐 10일동안총 3,000 cgy를사용하는국소방사선치료를시행하였으며, 인접하지않았거나진단시기가다른척추분절에대해서는같은방법으로반복시술하였다. 3. 방사선학적평가시술후단순방사선촬영을통하여삽입된골시멘트의분포와누출여부를확인하였으며, 단순방사선촬영은지속적으로추시하였다. 시술후시행한자기공명영상에서조영증강부위가사라지는것을통해종양의괴사여부및괴사부위를확인할수있었다. 4. 임상적평가치료전, 후의통증경감정도를파악하기위하여고주파열용해술후척추성형술을시행한군에서는시술전, 시술후 1 주, 4주및 12주후의 VAS (Visual Analog Scale) 점수를확인하였고, 방사선요법을시행한군에서는척추전이암부위방사선치료전, 치료후 1주, 4주, 12주후의 VAS 점수를확인하여비교하였다. 요통으로인한실질적인생활능력수준을비교하기위하여시술전과시술후또는방사선치료전과치료후의 RMQ (Roland Morris Questionnaire) 점수를비교하였다. 통계학적분석은 SPSS Window Ver 15.0 을이용하여, 두군간의 VAS 점수와 RMQ 점수는 t-test 로검정하였으며, 통계적유의수준은 0.05 이하로하였다. 208 www.krspine.org
Journal of Korean Society of Spine Surgery Radiofrequency Ablation Therapy with Cement Augmentation in Spinal Metastases 결과 1. 원발암의종류및빈도전이성골종양의성별분포는남자가 34명 (65.4%), 여자가 18 명 (34.6%) 였으며, 평균연령은 53.5 세 (20-79 세 ) 였는데남자가평균 51.3 세, 여자가평균 56.7 세였다. 원발암의종류로는총 52 명중폐암 14예, 위장관암 10예, 유방암 8예, 신장암 4예, 간세포암 3예, 갑상선암 3예, 골육종 2예, 췌장암 2예였으며, 그외에전립선암, 자궁경부암, 연골육종, 요로상피암, 간담도암, 다발성 골수종이각각 1예씩관찰되었다. 전이성척추종양환자 26명에서 65개의척추에고주파열용해술후척추성형술을시행하였으며방사선사진상골형성성종양은 3명 (11개척추 ), 골파괴성종양은 23명 (54 개척추 ) 이었다 (Table 1, 2). 2. 방사선학적결과고주파열용해술후척추성형술을시행한군의전이성척추종양의위치는경추 2예, 흉추 23예, 요추 34예, 천추 6예였으며 Eclipse TPS (Treatment Planning System) 을이용하여측정한 Table 1. Demographic chart of the RF* ablation with cement augmentation group No Age/Sex Tumor origin Cell type Spine Meta Location Frequency of operation Expire 1 57/M Breast Ductal ca. L1, L2, L3, T7 2 0 2 55/M Breast Ductal ca. T9, T10, T11 1 0 3 28/M OSA Osteoblastic L3, L5 1 0 4 57/M Esophageal Small cell ca. T3, T10, T11, S1 1 0 5 71/M Lung NSCLC (adeno ca.) T9, L3 2 0 6 54/M Rectal Adeno ca. L4, L5 1 7 57/M Lung NSCLC (adeno ca.) L5 1 0 8 47/M Liver HCC T5 1 0 9 67/M Lung NSCLC (adeno ca.) L1, L2, L4 1 0 10 66/F Uterine Squamous cell ca. T12, L5, S1 1 11 78/M Prostate L3 1 12 77/F Thyroid Papillary ca. T11, L1 1 13 55/M Liver HCC T12 1 14 58/F Lung SCLC (atypical) C3, T1, T4, T10, T11, L2, L3, L4, L5 1 15 57/M Pancreatic Adeno ca. C5, T10, L4, L5 1 16 62/M Rectal Adeno ca. L2 1 17 52/F Stomach Adeno ca. T7 1 0 18 68/M Renal Adeno ca. L1, L2, S1 1 0 19 52/M Rectal Adeno ca. L4 1 20 67/M Rectal Adeno ca. T6, L3 1 21 57/M Rectal Adeno ca. T10, L1 1 22 63/M Lung NSCLC (adeno ca.) L3 1 0 23 34/M Chondrosarcoma Mesenchymal L2, L3, S2, S3 1 0 24 57/F Thyroid Papillary ca. T3, T10, L3 1 25 73/M Renal Adeno ca. S2 1 0 26 72/F Urothelial cell carcinoma Squamous ca. T12, L2, L3, L5 1 *RF: radiofrequency, NSCLC: non small cell lung cancer, HCC: hepatocellular carcinoma, SCLC: small cell lung cancer, OSA: osteosarcoma. www.krspine.org 209
Chang Su Kim et al Volume 23 Number 4 December 2016 Table 2. Demographic chart of the radiotherapy group No Age/Sex Tumor origin Cell type Spine Meta Location Frequency of RTx. Expire 1 60/M Liver HCC T10, T11, T12 10 0 2 65/F Myeloma Multiple myeloma C5, C6, C7 10 3 57/M Lung NSCLC* (SQLC) T9, L3 20 0 4 53/F Breast Ductal ca. T9, L1, L5 30 5 62/F Breast Ductal ca. L2, L3, L4 10 6 71/F Rectum Adeno ca. L2 10 7 52/F Breast Ductal ca. L2, T1 20 8 71/F Lung NSCLC (adeno ca.) L4, S1 10 0 9 59/M Lung NSCLC (adeno ca.) L3, L4, L5 30 10 83/F Lung NSCLC T12, L1, L2 10 11 52/F Lung NSCLC (adeno ca.) L3, L5 20 0 12 36/M Pancrease Adeno ca. L2 10 0 13 57/M Lung NSCLC (adeno ca.) T3, T6, T10, T12, L3, L4, L5 20 14 47/M Lung NSCLC (adeno ca.) T11, T12, L1, L4 30 15 57/M Stomach Adeno ca. T9 10 16 60/M Renal RCC (papillary type) T1, T2, T3, T4, T7, T8, T9, T12, L2, L3 10 0 17 55/M Lung SCLC T9, T11, L1 10 0 18 33/F OSA Fibroblastic L1, L2 10 19 47/M Rectal Adeno ca. L5 10 0 20 25/M Renal RCC (papillary type) T12, L4 20 0 21 74/M Thyroid Papillary ca. T4, T5, T6 10 22 53/F Breast Ductal ca. L3, S3 30 0 23 59/M liver Ductal ca. L2, L3, S2, S3 20 0 24 62/F Breast Ductal ca. T4, T11, T12 10 25 73/F Breast Ductal ca. S1, S2, S3 10 0 26 64/M Lung NSCLC (adeno ca.) T12, L3, L5 20 *NSCLC: non small cell lung cancer, HCC: hepatocellular carcinoma, SCLC: small cell lung cancer, RCC: renal cell carcinoma. 척추내종양의부피는 1.3-67.4 cm 3 ( 평균, 13.34±9.42 cm 3 ) 였다. 시술후시행한자기공명영상에서조영증강부위가사라지는것을종양의괴사로보았고, 종양의부피에대한괴사의정도는 31-100%( 평균, 64.4±24.7%) 로관찰되었다. 전이종양이후방척추체에위치한 8예중 6예에서최대 8년까지의추시단순방사선영상에서골침하 (Bone subsidence) 는있으나, 골시멘트누출과같은합병증은관찰되지않았으나, 1예에서 ( 간엽성연골육종, 골파괴성종양 ) 시술 28일후 1예 ( 요로상피암, 골형성성종양 ) 에서시술직후 (Fig. 3) 골시멘트의척추체간공간, 신경공과 신경관내누출이있었다. 방사선치료후종양괴사정도에대한평가는시행하지않았다 (Fig. 1-3). 3. 임상적결과고주파열용해술후척추성형술을시행한군은총 26예중 13명이사망하였으며, 방사선치료를시행한군은총 26예중 12명이사망하였다. 두군에서치료전, 후의통증경감정도를파악하기위하여고주파열용해술후척추성형술을시행한군에서는시술전, 210 www.krspine.org
Journal of Korean Society of Spine Surgery Radiofrequency Ablation Therapy with Cement Augmentation in Spinal Metastases A B C D Fig. 1. Postoperative anteroposterior (A) and lateral (B) radiographs of a 66-year-old female treated with radiofrequency ablation with vertebroplasty for uterine cancer spine bone metastasis at T6, L5, and S1. Her last follow-up anteroposterior (C) and lateral (D) radiographs 8 years later show some bone subsidence. A B C D Fig. 2. Preoperative (A, B) and postoperative (C, D) anteroposterior (A) and lateral (B, C, D) radiographs of a 34-year-old male treated with radiofrequency ablation with vertebroplasty for mesenchymal chondrosarcoma spine bone metastasis at L2, L3, S2,and S3 with an osteoclastic lesion. Leakage of bone cement into the intracanal and intraforaminal space (C) irritated the L2 and L3 nerves and induced back pain, so an L2/L3 partial laminectomy for decompression (D) was performed 28 days later. 시술후 1주, 4주및시술후 12주후의 VAS 점수를확인하였으며, 각각평균 7.45, 3.01, 3.78, 2.97 로통계학적으로의미있는통증의경감을보였다 (p <0.001). 시술을시행하지않은군에서는척추전이암부위의방사선치료전, 치료후 1주, 4주그리고 12주후의 VAS 점수를확인하였으며, 각각평균 7.04, 6.65, 5.87, 3.03 로역시통계학적으로의미있는통증의경감을보였다 (p <0.001). 그러나시술을시행한군의점수가방사선치료를시행한군에비해통계적으로유의하게초기에는더많은감소를보이나 12주후에는두군간의차이가없었다 (Table 3)(p for interaction 0.004). 요통으로인한실질적인생활능력수준을비교하기위해 RMQ (Roland Morris Questionnaire) Score 를이용하였다. 고 주파열용해술후척추성형술을시행한군에서는시술전과시술후 RMQ 점수가평균 13.92 에서 7.21 로변화하였으며 (p <0.001), 방사선치료를시행한군에서는치료전과치료후의 RMQ 점수가평균 15.33 에서 9.75 로변화하여 (p<0.001), 두군모두통계학적으로의미있는변화를보였으나고주파열용해술후척추성형술을시행한군의점수가방사선치료를시행한군에비해통계적으로더유의하게많은감소를보였다 (Table 4)(p for interaction 0.024). 고찰 전이성골종양은악성골종양중에서가장흔한종양으로그 www.krspine.org 211
Chang Su Kim et al Volume 23 Number 4 December 2016 A B C D Fig. 3. Preoperative (A, B) and postoperative (C, D) anteroposterior (A) and lateral (B, C, D) radiographs of a 72-year-old female treated by radiofrequency ablation with vertebroplasty for urothelial cell carcinoma spine bone metastasis at T12, L2, L3, and L5 with an osteoblastic lesion. Leakage of bone cement into the intracanal and intraforaminal space (C, D) was noted, so T12/L1 partial laminectomy for decompression was performed just after the procedure. Table 3. Pain Relief compared with both groups by VAS score VAS Pre-OP POD 1 week POD 4 weeks POD 12 weeks p-value p for interaction Group A 7.45 3.01 3.78 2.97 <0.001 Group B 7.04 6.65 5.87 3.03 <0.001 0.004 *VAS: visual analog scale, Group A: radiofrequency ablation with vertebroplasty, Group B: radiotherapy, p-values by repeated measure t-test. Table 4. Comparison of both groups by RMQ score RMQ Pre-OP POD 12 weeks p-value p for interaction Group A 13.92 7.21 <0.001 Group B 15.33 9.75 <0.001 0.024 *RMQ: roland moris questionnaire, Group A: radiofrequency ablation with vertebroplasty, Group B: radiotherapy, p-values by repeated measure t- test. 원발암으로는유방암, 전립선암, 폐암, 신장암, 갑상선암, 간암 등이주를이루며전이되는골격부위로는척추가가장높은비 율을차지하고있다. 4,5) 전이성척추종양에서치료의임상적목 표는통증의감소와신경학적손상의회복에있다. 통증은말기 의환자에서주로보이며, 신경학적증상은전이성척추종양환 자의약 10% 에서나타난다. 적용가능한치료법으로는수술적 치료법, 냉동치료법, 호르몬치료법, 항암화학요법, 방사선동 위원소를이용한항암약물요법, 방사선치료법, 비스포스포네 이트치료법, 고주파열용해술, 척추성형술및통증에대한약 물치료법등이있으며기대여명이길지않고근치적인치료가 불가능하다는이유로이들중가장많이적용되는방법은방사선치료및통증약물치료이다. 방사선치료는전체의 60% 을차지하며많은환자에게효과적이기도하지만방사선치료에저항성이있는흑색종, 육종, 신장암에서는사용할수없으며, 이미척추의파괴가진행된경우에척추의안정성을제공할수없어실질적인생활능력수준의향상을기대할수없다. 3) 또한통증의재발이자주발생하고, 6) 통증의감소효과가 10~14 일이후에서가능하며최대치료효과는 12~20 주에나타나므로통증완화반응이느리며, 신경손상의회복률도 50% 미만으로보고되고있다. 7) 따라서즉각적인통증의감소효과와척추의안정성이있어생활능력수준의향상을얻을수있는치료가필요하게되었다. 후방도달법을이용한전척추절제술후다분절고정술 8) 등의발전된수술기법으로수술적치료를통해척추종양에의한통증은감소시키고추가적인추체붕괴및신경손상을방지하며생존율의증가를얻을수있어점진적으로증가하는추세에있으나수술에견딜수없는고령이나동반된합병증이있는경우, 다분절침범과같은적응증이아닌경우등제한점이있어비수술적치료가요구되고있다. 3) 전이성척추종양에대한고주파열용해술후척추성형술의 212 www.krspine.org
Journal of Korean Society of Spine Surgery Radiofrequency Ablation Therapy with Cement Augmentation in Spinal Metastases 병용치료법은척추체의병변부위에경피적으로고주파열에너지를가하여골종양세포를괴사시킨후, 골시멘트를삽입하여통증을감소시키고척추의안정성을얻는비수술적치료이다. 적응증은고령, 병발된합병증및인접하지않은 2분절혹은 3분절이상의다발성병변, 기대여명이 1년이하, 종양의크기가 5-6 cm 이하이거나수술적절제가불가능할경우, 2주이상의방사선치료나약물치료법으로조절되지않는통증, 방사선치료에저항성이있는흑색종, 육종, 신장암으로부터의전이성척추종양, Spinal Instability Neoplastic Score (SINS) 7점이상의이차적인척추불안정성이예상될경우이다. 금기증은신경근증상이있거나, 척수신경손상, 경막외종양형성과같이신경관에 1cm 이내로접근하여있는종양및병변부위에동반된감염, 혈액응고장애등의내과적질환이병발되어있는경우이다. Grönemeyer 등 9) 은골시멘트온도가 80~90 까지상승하여괴사효과가있다고하였으나, Nakatsuka 등 10) 은종양세포괴사에관하여시술후평균 71% 의괴사율을보인다하였고종양의크기가 5 cm 이상인경우에서 5 cm 이하의경우보다유의하게국소종양이재발하는것으로보아종양의괴사는골시멘트주입효과보다고주파열용해술의효율성과관계한다고보고하였다. Padina 등 11) 은사체연구를통하여고주파열용해술단독요법과척추성형술병용요법을비교하여고주파열용해술은시술후공동 (cavity) 을만들어척추체후벽의생역학적안정성을감소시킬수있으나척추성형술을같이하였을경우축성압박력에대하여안정성이증가함을보고하였다. 따라서용해술을이용한전이종양에대한직접적인괴사및골시멘트삽입을통한추가적인척추안정성을얻을수있어시술이후즉각적인통증의완화와함께일상적인생활이가능하다. Grönemeyer 등 9) 와 Nakatsuka 등, 10) Padina 등 11) 의연구에따르면고주파열용해술의효율성은종양세포의괴사뿐만아니라, 이후골시멘트삽입시골시멘트분포를통한척추체의생역학적안정성까지관계한다고보고하였다. 본연구에서는전이척추종양의정확한위치및크기를파악하기위하여 Eclipse TPS (Treatment Planning System) 을이용하여 3차원으로구성한후척추전체의부피와종양이침범한부위의부피를파악하여투관침의삽입위치를정한후시술시영상증폭장치를통하여위치를확인하였다. 또한노출된전극길이의 90~100% 직경의원모양으로조직이가열되므로, 직경 1 cm 크기의종양에는 1 cm 길이의전극을사용하였고 3 cm 이상의큰직경을가진종양에는 3~5회정도부위를달리하여시술하여종양괴사율을최대화하였다. 마지막으로종양괴사로인한골결손부위에양측척추경도달법으로골시멘트를주입하여즉각적인척추의안정성을확보하였다. 시술과관련된가장심각한합병증은신경손상이며, 이는고 주파열과골시멘트누출로인해발생한다. 신경증상이있는척추전이환자를대상으로한 Huang 등 12) 의보고에서는고주파열용해술후척추성형술, 고주파열용해술단독과척추성형술단독군을비교, 시술후각각 28.6%, 18.2%, 11.1% 의사지무감각 (limb numbness) 의호전을보였다하나신경관내의온도감시를하지않았던 Nakatsuka 등 10) 의보고에서는 24% 의신경손상을보여신경관근처, 후궁, 추경부의종양에서는적용하지않는것이좋겠다하였으며, Eren 등 13) 은 0.5% 의척추체간공간 (disc space) 의골시멘트의누출이있었으나신경증상이없었다하였다. 저자의경우신경관내, 신경공및추체후방부에온도센서를삽입하여엄격히감시하여신경손상없이병변부위의온도를 92 까지올릴수있었다. 척추체후벽피질골과인접한전이종양 8예중 1예에서시술직후, 1예에서시술 28일후골시멘트의척추체간공간, 신경공과신경관내누출과함께요추제 2, 3번신경자극증상및심한요통으로수술적치료를시행하였다. 따라서고주파열보다골시멘트의누출로인한신경손상을주의해야함을알수있었다. 본연구의제한점으로대상자수가적으며, 생존결과와삶의질에가장영향을미치는원발암에대한차이를방사선사진비교외에는시행하지못하였으며, 고주파열용해술후척추성형술또한전극의위치설정과골시멘트주입양조절등에숙련된술기가필요하여시술자변경에따라결과에차이가있다는것이다. 이러한시술자의존도는골조직의절연성과종양내혹은주위조직의혈관의열대류현상에의한열감소효과, 인접조직의열손상을고려하여최근보고된나선형코일전극 (helical coil electrode), 14) 양극-냉각성고주파열기구 (bipolarcooled radiofrequency device) 15) 등시술에필요한기구의발달로인해보완될것으로생각되나추가적인연구가필요한상태이다. 결론 수술적치료가불가능한전이성척추종양에서고주파열용해술후척추성형술은즉각적인초기통증감소와추체안정성을얻을수있어일상적인생활을가능하게한다. 상호보완적으로종양의괴사율을높여국소재발을줄이며, 방사선저항성이있는종양에효과적으로적용할수있으나, 척추체후벽피질골과인접한전이종양에서골시멘트누출로인한신경손상의가능성이있다. www.krspine.org 213
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Original Article J Korean Soc Spine Surg. 2016 Dec;23(4):207-215. https://doi.org/10.4184/jkss.2016.23.4.215 전이성척추종양환자에서고주파열용해술후척추시멘트충전술의임상적효용성과안정성 김창수 권영호 정소학 백사무엘고신대학교복음병원정형외과학교실연구계획 : 후향적연구목적 : 전이성척추종양환자의치료와통증의관리에있어고주파열용해술후척추시멘트충전술의유용성과안전성에대하여알아본다. 선행연구문헌의요약 : 수술적절제가불가능한전이성척추종양에서고주파열용해술과척추시멘트충전술의병용치료법은종양의괴사율을높여국소재발을줄이고이차적인추체의안정효과를얻을수있다. 대상및방법 : 2007년 3월 ~2016년 4월까지본원에서치료한전이성척추종양환자를대상으로, 시술을시행한 26명과방사선치료를시행한 26명에대하여비교하였다. 두군간의통증의경감은 VAS (Visual analog scale) 를, 생활능력의수준은 RMQ (Roland Moris Questionnaire-korean version) 을이용하여평가하였다. 결과 : 통증경감의정도는시술군의술전, 술후 1주, 4주및 12주의 VAS 점수는 7.45, 3.01, 3.78 그리고 2.97, 방사선치료군은 7.04, 6.65, 5.87 그리고 3.03로술후 4주이전통증의경감에서시술군이방사선치료군보다통계학적으로유의하게나은결과를보였으나, 술후 12주추시상유의한차이는없었다. RMQ 점수는시술군에서 13.92에서 7.21로, 방사선치료군에서 15.33에서 9.75로두군모두에서개선되었다. 척추체후벽피질골과인접한전이종양을가진 2명에서골시멘트의척추체간공간, 신경공과신경관내누출로수술적치료를시행하여 7.69% 의신경손상을보였다결론 : 고주파열용해술후척추시멘트충전술은전이성척추종양환자의치료에서초기통증경감에효과적이며즉각적인추체안정성을얻을수있어일상적인생활을가능하게한다. 그러나전이성척추종양에서골시멘트누출로인한신경손상의가능성이있다. 색인단어 : 고주파열용해술, 척추시멘트충전술, 전이성척추종양, 통증경감, 골시멘트누출 약칭제목 : 고주파열용해후척추시멘트충전술 접수일 : 2016년 5월 25일 수정일 : 2016년 6월 1일 게재확정일 : 2016년 9월 12일 교신저자 : 김창수 부산광역시서구감천로 262 고신대학교복음병원정형외과학교실 TEL: 051-990-6467 FAX: 051-243-0181 E-mail: mewha98@naver.com Copyright 2016 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. 215