KISEP Clinical Article J Korean Neurosurg Soc 33454-459, 2003 요추협착증에서미세수술적감압술과기구고정술을병행한요추간골유합술과의임상적비교 이국진 이정청 김근수 Clinical Comparison between Microsurgical Decompression and Lumbar Interbody Fusion with Instrumentation for Lumbar Stenosis Kuk-Jin Lee, M.D., Jung-Chung Lee, M.D., Keun-Su Kim, M.D. Department of Neurosurgery, Research Institute for Clinical Medicine, Chonbuk National University Medical School Hospital, Jeonju, Korea Objective:We report clinical results of the patients who received microsurgical decompression procedure (bilateral partial laminectomy and medial facetectomy:group A) compared with lumbar interbody fusion with instrumentation(total laminectomy, interbody fusion and pedicle screw fixation:group B). Methods:From March 1996 to December 2000, twenty patients with symptomatic lumbar stenosis underwent microsurgical decompression and twenty-five patients underwent lumbar interbody fusion by two operators. Two groups of patients were compared retrospectively in respect to the mechanical back pain, leg pain, motor weakness, sensory hypesthesia(numbness) and clinical outcomes. The mean follow-up period was 30 months. Results:In Group A, mechanical back pain, leg pain, motor weakness, and sensory hypesthesia were improved in 72.2%, 69%, 80%, 44.4% and 70%, 71%, 83.3%, 50% respectively in Group B. Clinical outcomes was excellent or good in 80% in Group A and 84% in Group B and no differences in clinical parameters between Groups were demonstrated Conclusion:We recommend microsurgical decompression for the patients suffering from symptomatic lumbar stenosis with stable spine because microsurgical decompression provided a satisfactory clinical results equivalent to lumbar interbody fusion with instrumentation. KEY WORDS:Lumbar stenosis Microsurgical decompression Lumbar interbody fusion. 서 론 ReceivedNovember 21, 2002 AcceptedFebruary 4, 2003 Address for reprintsjung-chung Lee, M.D., Department of Neurosurgery, Research Institute for Clinical Medicine, Chonbuk National University Medical School Hospital, 634-18 Geumam-dong, Deokjin-gu, Jeonju 561-712, Korea Tel063 250-1871, Fax063 277-3273 E-mailnsljc@hanmail.net 454 J Korean Neurosurg SocVolume 33May, 2003
KJ Lee, et al. 대상 및 방법 추간 골유합술은(B군) 환자를 전신마취 하에서 복와위로 하 고 피부를 정중절개한 후, 후방접근법으로 완전 후궁절제술 1996년 3월부터 2000년 12월까지 본원 신경외과에서 을 시행하고 경우에 따라 추간반제거술, 관절면 내측절제술 증상이 있는 요추 협착증으로 진단 받고 수술적 치료 후 퇴원 (medial facetectomy), 또는 추간공확대술(foraminotomy) 한 환자 중에서 추적조사가 가능하였던 환자 45명을 대상 을 시행하여 신경근을 감압 시켰으며 동시에 carbon cage와 으로 하였으며 수술 후 평균 추적기간은 약 30개월이었다. transpedicular screw를 이용하여 요추간 골융합술을 시행 환자는 양측성 부분 후궁절제술 및 관절면 내측절제술을 통 하였다(Fig. 2). 한 미세수술적 감압술을 받은 환자를 A군으로, 완전 후궁절 제술로 감압술을 시행한 후 척추 불안정성이 예상되어 기구 고정술을 병행한 요추간 골유합술을 시행 받은 환자를 B군 으로 분류하였으며, A군과 B군의 수술은 각각 서로 다른 두 명의 수술자에 의해 시행되었다. 그리고 각 군의 환자 특성 (연령 및 성별분포, 임상증상 및 기간)과 수술성적에 대하여 그 결과를 후향적으로 비교 검토하였다. 모든 환자는 수술 전 요추부 자기공명영상을 촬영하여 협 착증의 부위 및 복합 병변 유무를 확인하였으며, 단순 방사 선 촬영을 통해 전체적인 요추 상태 및 불안정성 여부를 조 사하였고, 불안정성이 있는 경우와 척추전방전위증 및 척추 분리증이 있는 경우는 제외하였다. 수술 후 모든 환자는 단 A B Fig. 2. A preoperative transaxial L4-5 magnetic resonance T1WI shows hypertrophied ligamentum flavum and facet joints. B Postoperative transaxial L4-5 computed tomography scan shows total laminectomy, medial facetectomy and pedicle screw. 순 방사선 촬영으로 수술부위를 확인하였고 일부 환자들의 경우 요추부 전산화 단층 촬영을 시행하였다. 수술방법으로 미세감압술은(A군) 환자를 전신마취 하에 수술 후 임상적으로 두 군사이의 요통, 다리의 방산통, 운 동증상, 이상감각(numbness)의 호전정도를 비교하였다. 서 복와위로 하고 피부를 정중 절개한 후 척추 측방 근육을 치료 결과는 편의상 Table 2와 같이 신경인성 간헐적 파 극상돌기, 후궁 및 후추관절로부터 박리하여 수술시야를 확 행의 정도, 요통의 정도, 하지 방산통의 정도, 보행의 능력, 일 보한 후 수술 현미경 하에서 고속드릴을 사용하여 극상돌기 상생활의 제한정도, 진통제의 사용정도 등의 6개 항목의 총 아래쪽 양측 후궁을 일부 갈아낸 후 후궁하단의 일부와 관절 합계에 따라 excellent(11~12점), good(8~10점), fair 면의 내측을 갈아내고 황색인대를 제거하여 경막과 신경근을 (6~7점) 그리고 poor(0~5점)의 4등급으로 구분하여 두 노출시켰다. 경우에 따라 Kerrison punch 등을 이용하여 추 군을 비교하였다. 그리고 각 비교 대상을 SAS 통계 프로그 간공 확대술을 시행한 후 요추간반 탈출증이 있는 경우에는 램 중 chi-square test의 통계적 방법으로 두 군을 비교 분 신경근을 가능한 지속적으로 견인하지 않으면서 추간반제거 석하였다. 술을 시행하였다. 반대측 신경근 감압을 위하여 같은 방식으 로 접근하였다(Fig. 1). 감압술 후 기구고정술을 병행한 요 Table 1. Profile of patients(n=45) Group A(n=20) Group B(n=25) Sex Men(n=16) 7 9 Women(n=29) 13 16 Mean(range) 60.9(40-71) 53(36-66) 32(14-43) 28(13-46) 17 23 Age Followup(months) A Mean(range) B Site Fig. 1. A Preoperative transaxial L4-5 magnetic resonance T1WI shows hypertrophied ligamentum flavum and facet joints. B Postoperative transaxial L4-5 computed tomography scan shows bilateral partial hemilaminectomy and medial facetectomy. J Korean Neurosurg Soc/ Volume 33/ May, 2003 L4-5 L5S1 3 2 Group A microsurgical decompression, Group B lumbar interbody fusion with instrumentation after decompression 455
Table 2. Criteria for estimation of clinical results Point NIC Back pain Leg pain Walking ability Restrict of ADL Use of analgesics 2 500m Mild or none Mild or none Complete None None 1 100500m Tolerable Tolerable Intolerable Mild Frequent 0 100m Intolerable Intolerable Disable Severe Regular NICNeurogenic intermittent claudication, ADLAverage daily life Table 3. Comparison of clinical and neurological symptoms Back pain Leg pain Motor weakness Hypesthesia Group A B A B A B A B Improved 1372.2% 1470% 969% 1571% 880% 1083.3% 444.4% 650% Not-improved 5 6 4 6 2 2 5 6 Total 18 20 13 21 10 12 9 12 Group Amicrosurgical decompression, Group Blumbar interbody fusion with instrumentation after decompression 결과 대상 임상증상및신경학적증상 불안정성 (Instability) 치료결과 (Clinical results) Table 4. Comparison of clinical results Group A% B% Excellent 735 1248 Good 945 0936 Fair 420 0416 Poor 0 00 Group A : microsurgical decompression, Group B : lumbar interbody fusion with instrumentation after decompression 456 J Korean Neurosurg SocVolume 33May, 2003
고 찰 - J Korean Neurosurg SocVolume 33May, 2003 457
- 결론 458 References 1. Caputy AJ, Luessenhop AJ:Long-term evaluation of decompressive surgery for degenerative lumbar stenosis. J Neurosurg 77:669-676, 1992 2. Caspar W, Campbell B, Barbier DD, Kretschmmer R, Gotfried Y: The caspar microsurgical discectomy and comparison with a conventional standard lumbar disc procedure. Neurosurgery 28:78-87, 1991 3. Dipierro CG, Helm GA, Shaffrey CI, Chadduck JB, Henson SL, Malik JM, et al:treatment of lumbar spinal stenosis by extensive unilateral decompression and contralateral autologous bone fusion: Operative technique and results. J Neurosurg 84:166-173, 1996 4. Esses SI, Huler RJ:Indications for lumbar spine fusion in the adult. Clin Orthop 279:87-100, 1992 5. Fast A, Robin GC, Floman Y:Surgical treatment of lumbar spinal stenosis in the elderly. Arch Phys Med Rehabil 66:149-151, 1985 6. Gartland JJ:The future of spinal fusions, in Cotler JM, Cotler HB (eds):spinal Fusion:Science and Technique. New York:Springer- Verlag, 1990, pp391-395 7. Hopp E, Tsou PM:Postdecompression lumbar instability. Clin Orthop 227:143-151, 1988 8. Johnsson K-E, Redlund-Johnell I, Uden A, Willner S:Preoperative and postoperative instability in lumbar spinal stenosis. Spine 14: 591-593, 1989 9. Johnsson K-E, Rosn I, Udn A:The natural course of lumbar spinal stenosis. Clin Orthop 279:82-86, 1992 10. Kalbarczyk A, Seiler RW:Surgical treatment of lumbar stenosis in the elderly. Acta Neurochir(Wien) 140:637-641, 1998 11. Katz JN, Lipson SJ, Larson MG, Mcinnes JM, Fossel AH, Liang MH, et al:the outcome of decompressive laminectomy for degenerative lumbar stenosis. J Bone Joint Surg 73A:809-816, 1991 12. Lim SJ, Kim YT, Ha HG:Microsurgical decompression of lumbar stenosis:technical innovations and early experience of 20 cases. J Korean Neurosurg Soc 26:780-786, 1997 13. Mackay DC, Wheelwright EF:Unilateral fenestration in the treatment of lumbar spinal stenosis. Br J Neurosurg 12:556-558, 1998 14. Nasca RJ:Rationale for spinal fusion in lumbar spinal stenosis. Spine 14:451-454, 1989 15. Nasca RJ:Surgical management of lumbar spinal stenosis. Spine 12: 809-816, 1987 16. Niggemeyer O, Strauss JM, Schulitz KP:Comparison of surgical procedures for degenerative lumbar spinal stenosis:a meta-analysis of the literature from 1975 to 1995. Eur Spine J 6:423-429, 1997 17. Nystrom B:Experience of microsurgical compared with conventional technique in lumbar disc operations. Acta Neurol Scand 76:129-141, 1987 18. Postacchini F:Surgical management of lumbar spinal stenosis. Spine 24:1043-1047, 1999 19. Silvers HR, Lewis PJ, Asch HL:Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg 78:695-701, 1993 20. Shim YJ, Ha HG, Lee JS, Kim YS, Park MS, Kim JS:Microsurgical decompression for lumbar stenosis via unilateral laminotomy. J Korean Neurosurg Soc 29:1505-1513, 2000 J Korean Neurosurg SocVolume 33May, 2003
21. Spetzger U, Bertalanffy H, Naujokat C, Keyserlingk DGV, Gilsbach JM:Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis. Part I:Anatomical and surgical considerations. Acta Neurochir(Wien) 139:392-396, 1997 22. Spetzger U, Bertalanffy H, Reinges MHT, Gilsbach JM:Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis. Part II:Clinical experiences. Acta Neurochir(Wien) 139:397-403, 1997 23. Watanabe R, Parke WW:Vascular and neural pathology of lumbosacral spinal stenosis. J Neurosurg 64:64-70, 1986 24. Weiner BK, Walker M, Brower RS, McCulloch JA:Microdecompression for lumbar spinal canal stenosis. Spine 24:2268-2272, 1999 25. West JL III, Ogilvie JW, Bradford DS:Complications of the variable screw plate pedicle screw fixation. Spine 16:576-579, 1991 26. Wiltse LL, Kirkald-Willis WH, Mclvor DWD:The treatment of spinal stenosis. Clin Orthop 115:83-91, 1976 27. Yasargil MG:Microsurgical operation of herniated lumbar disc. Adv Neurosurg 4:81-81, 1977 28. Young S, Veerapen R, O Laoire SA:Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy:preliminary report. Neurosurgery 23:628-633, 1988 J Korean Neurosurg SocVolume 33May, 2003 459