대한정형외과학회지 : 제 43 권제 6 호 2008 J Korean Orthop Assoc 2008; 43: 791-798 신경학적결손을동반한골다공증성후만증의후방수술 - 후외측감압술및금속그물망을이용한전방지지 - 이정희ㆍ김기택ㆍ석경수ㆍ이상훈ㆍ황대우 * ㆍ김진수 신재흥 * ㆍ홍우성 * ㆍ어재형ㆍ곽윤호 경희대학교의과대학정형외과학교실, 국립의료원정형외과 * Posterior Surgery of Neurologically Compromised Osteoporotic Kyphosis - Posterolateral Decompression and Stabilization using Titanium Mesh - Jung-Hee Lee, M.D., Ki-Tack Kim, M.D., Kyung-Soo Suk, M.D., Sang-Hun Lee, M.D., Dae-Woo Hwang, M.D.*, Jin-Soo Kim, M.D., Jae-Heung Shin, M.D.*, Woo-Sung Hong, M.D.*, Jae-Hyung Eoh, M.D., and Yoon-Ho Kwak, M.D. Department of Orthopedic Surgery, School of Medicine, Kyung Hee University, Department of Orthopedic Surgery, National Medical Center*, Seoul, Korea Purpose: Several treatment options have been reported for post-traumatic kyphosis (PTK) and neurologically compromised osteoporotic fractures. However, there is no ideal surgical procedure. This study evaluated the effectiveness of posterolateral decompression and anterior support with a titanium mesh in PTK by posterior surgery. Materials and Methods: Seventeen patients with PTK and neurologically compromised osteoporotic fractures underwent a single posterior approach. During posterior decompression, a titanium mesh was inserted through the posterior approach after a transpedicular intracorporeal corpectomy. Complications, operating time and blood loss were noted, and radiographic studies and neurological status were evaluated before surgery, after surgery, and at final follow-up. Results: The mean kyphosis was 35±9.7 o (range; 17-58 o ) before surgery, 3.2±1.8 o after surgery (correction; 90.5%) and 5.5±3.2 o at the final follow-up (correction; 85.5%). There was 29.6 o correction of the kyphosis with a 6% loss of correction. Postoperative neurological improvement using the Frankel classification was demonstrated in all patients. There was no new onset or progressive neurological deterioration, additional surgery or extrusion of mesh. Three complications were encountered: one care each of pneumonia, prolonged ventilator support and distal adjacent vertebral fracture. Conclusion: The posterior insertion of a titanium mesh for anterior support appears to maintain the length of the anterior column, stabilize the injured vertebra and facilitate spinal fusion. Posterolateral decompression allows as direct a decompression as the anterior approach. Key Words: Osteoporosis, Posttraumatic kyphosis, Neurologic compromise, Posteiror approach, Pedicle screw, Titanium mesh 서론고령의골다공증환자에서흔히발생하는압박골절은 비교적안정골절로보조기등을이용한보존적치료또는 PMMA 등을이용한척추성형술로대개의경우양호한 통신저자 : 이정희서울시동대문구회기동 1 경희대학교의과대학정형외과학교실 TEL: 02-958-8357 ㆍ FAX: 02-964-3865 E-mail: ljhos@khmc.or.kr * 본논문의요지는 2007 년도대한정형외과학회추계학술대회에서발표되었음. Address reprint requests to Jung-Hee Lee, M.D. Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, 1, Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea Tel: +82.2-958-8357, Fax: +82.2-964-3865 E-mail: ljhos@khmc.or.kr 791
792 이정희ㆍ김기택ㆍ석경수외 7 인 결과를얻을수있다 16,25). 그러나드물지않게추체압박과후만변형이진행하여신경학적결손이발생할수있으며, 이러한신경학적결손을동반한외상후후만변형이발생하였을경우에는수술적치료가필요하다 2,10,18,33,34). 수술적치료는감압을통한신경학적결손의회복, 후만변형의교정및척주의안정화를목표로한다 7,15,16,31,35). 수술적치료는전방감압술및유합술, 전방감압술및후방기기고정술, 또는후방도달을통한감압및기기고정술이소개되고있고, 골다공증을동반한고령의환자에서어떤방법이가장적절한지에대하여는아직도논란이되고있다 32). Suk 등은후방도달법만을이용한수술적치료가전, 후방도달법을이용한치료결과와비교시신경학적결손의개선은동일하며, 변형의교정에서는더우수하다고보고하였으나수술적어려움이있다 32). 저자들은이러한우수한결과를바탕으로후방도달법만으로감압을용이하게하고자후외측감압술로이환된추체를제거하는후방척주절제술 (posterior vertebral column resection) 을시행하고골다공증환자에서발생할수있는척추경나사의고정상실등의문제를예방하고자전주에금속그물망 (titanium mesh) 을삽입하여전주를복원하 는방법을시행하고이에대한임상및방사선학적결과에따른유용성을분석하였다. 대상및방법 1. 연구대상골다공증과신경학적결손을동반한외상후후만증환자로수술적치료를시행받고 1년이상추시가가능하였던 17예를대상으로하였다 (Table 1). 평균연령 66.6± 9세 ( 범위 ; 52-80세 ), 남자 6예, 여자 11예이었고, 평균추시 26.4±12.5개월 ( 범위 ; 12-43개월 ) 이었다. 이환된추체는제1요추 9예및제12흉추 5예등이며, 수술전 MRI 소견에서전예에서무혈성괴사증과중주의붕괴로인한신경압박소견이관찰되었다 (Fig. 1). 수상기전을기억한경우는 11예로미끄러짐 9예, 낙상 2예이었다. 배부통이발생한기간은평균 6.1±5.8개월 ( 범위 ; 2-24 개월 ) 이었고, 신경학적결손이발생한기간은평균 3.1± 2.9개월 ( 범위 ; 0.5-12 개월 ) 이었다. 수술전신경학적결손은 Frankel 분류 4) B 1예, C 5예, D 11예다. 수술전후단순방사선사진으로수술전국소후만각, 수술후교정, 불유합및고정상실등을분석하였다. 국소후만은골절된추체보다상부추체의상부종판및하부추체의 Table 1. Clinical Data on All Patients Duration* Angle Neurologic deficit Injured Case Age/sex BMD vertebra Neurologic Preop Postop Correction Back pain Preop F/U deficit (degree) (degree) (percent) 1 77 / F 12 2 L1 4.9 31 2 29 B E 2 63 / F 2 2 T12 2.1 33 3 30 D3 E 3 77 / M 3 0.5 L1 3.7 32 2 30 C E 4 80 / M 4 3 L1 1.7 26 1 25 D3 E 5 67 / M 12 12 L1 5.1 32 3 29 D3 E 6 71 / F 24 1 T12 3.3 31 4 27 C D3 7 57 / F 12 8 T12 3.3 43 8 35 D3 E 8 71 / F 6 5 T12 3.9 30 4 26 C E 9 72 / M 3 3 L1 2.9 33 2 31 D2 E 10 54 / M 3 3 L1 2.7 32 2 30 D2 E 11 65 / F 4 3 L1 2.8 33 3 30 C D3 12 64 / F 3 1 L1 4.3 34 5 29 D1 E 13 56 / F 2 2 T11 3.0 54 1 53 D2 E 14 52 / M 2 1 T11 3.0 35 3 32 D3 E 15 73 / F 6 3 L1 4.6 58 6 52 D2 E 16 56 / F 3 3 T12 2.9 42 3 39 D3 E 17 78 / F 3 1 T10 4.2 17 3 14 C D3 *Months; Bone Mineral Densitometry (T-score); Modified Frankel grades; Preop, Preoperative; Postop, Postoperative; F/U, Follow up.
신경학적결손을동반한골다공증성후만증의후방수술 793 Fig. 1. 77-year-old female sustained a L1 compression fracture 1 year earlier. She presented with post-traumatic kyphosis and neurological compromise that had developed 3 months earlier. (A) Preoperative radiographs show a burst out and kyphotic deformity on the standing radiographs and a vacuum cleft of L1 on the recumbent radiograph. Preoperative neurological deficit was Frankel grade C. (B) T2-weighted sagittal MR image shows retropulsed bony fragments into the spinal canal and avascular necrosis on the T12 and L1 body. (C) The axial MR image shows compression of the spinal cord at the L1 level. Fig. 2. (A) Postoperative radiographs show that the kyphosis was corrected to 0 o. (B) The postoperative radiographs taken three years after surgery show that the reconstructed portion of the spine is stable with the correction of kyphosis being maintained. 하부종판을기준으로 Cobb 의방법으로계측하였다 1). 수술후추시상척추경나사주변의골흡수음영, 척추경나사의뽑힘, 척추경나사의고정장치의파단이관찰되는경우고정상실로판정하였다. 의무기록을검토하여평균실혈양, 수술시간, 수술후합병증을분석하였다. 2. 수술방법전예에서후방도달법만으로감압술및안정화술식을시행하였다 (Fig. 2). 척추경나사고정술은이환된추체의상방 2개및하방 2개의추체에시행하였다. 감압술은이환된추체의후궁및상부추체후궁의일부를제거하여후방유합술을용이하게하였다. 이환된추체의양측척추경을제거하고추체내의해면골과상하추체종판을
794 이정희ㆍ김기택ㆍ석경수외 7 인 Fig. 3. 64-year-old female was injured by slip down and sustained a L1 compression fracture 2 months before presentation. Before presentation at our facility, she was treated with kyphoplasty and presented to our institution with severe back pain and paraparesis that developed one month after kyphoplasty. (A) Post-trauma lateral radiograph. (B) Radiograph taken 2 weeks after the injury shows a collapse of the vertebral body. (C) Immediate lateral radiograph after kyphoplasty. (D) Preoperative lateral radiograph shows the collapsed vertebral body at L1 with 32 o of kyphosis. The patient had Frankel grade D before surgery. (E) The preoperative MR images show the avascular necrosis of the L1 body, retropulsed bony fragments into the spinal canal and neural compression at the level of L1. 골정 (osteotome) 과큐렛을이용하여제거하였다. 상하종판을제거하고상하추간판을추간공및제거된이환된추체의빈공간을이용하여제거하였다. 추간판을제거하는과정에서상부추체의하부종판과하부추체의상부종판은골다공증으로손상되기쉬우며만일손상되면이후삽입될금속그물망이추체내로감입될수있고견고한전방지지를얻기어려우므로이에대한세심한주의를기울였다. 이환된추체상하척주가분리되었음을확인하고신경관으로돌출된골편을전방으로함몰시켜신경의견인등의과정없이전방감압을완성하였다. 이때상하척주의분리로불안정한상태에이르게되므로임시로강봉을척추경나사에고정하여신경손상을예방하였다. 추체의외측피질골만을보존하여수술과정에서발생할수있는분절동맥의손상을예방하여출혈량의최소화하였고, 전방과후방으로 360 o 감압을완성하 고전방의길이를측정하고파쇄동종골을다져넣고파쇄동종골을채운금속그물망을척추경을제거한공간으로삽입하여전방지주를재건하였다. 척추경나사에강봉을삽입하여압박력을가하여고정하고후방유합술을시행하였다. 후방유합술은 17예중 7예에서후궁보존술을시행하였고, 10예서는인접추체에서채취한극돌기의중앙을분리시켜후궁결손부에덮은후에후방유합술을시행하였다 (Fig. 3, 4). 결과수술전국소후만변형 35±9.7 o ( 범위 ; 17-58 o ) 는수술직후 3.2±1.8 o 로교정되어교정각 31.8±9.3 o ( 범위 ; 14-53 o ) 로 90.5% 교정되었다. 최종추시에서 5.2± 3.4 o 로유지되어 85% 교정되었고교정소실은 2.2±2.6 o ( 범위 ; -1-9 o ) 및 6% 이었다 (Table 1).
신경학적결손을동반한골다공증성후만증의후방수술 795 Fig. 4. (A) Intraoperative findings; working space made by pedicle subtraction (empty arrow), extraction of cement mass through the space (short arrow), covering of interlaminar defect with splitted interspinous process following transpedicular intracoporeal corpectomy and rods fixation (long arrow) and posterior fusion (dotted arrow). (B) Cement mass from vertebral body. (C) 3D-reconstruction CT sacns show the reconstructed portion of the spine is stable and the correction of kyphosis is well maintained. (D) Postoperative radiographs tatken sixteen months after the surgery show that kyphosis was corrected to 0 o. 수술전배부통이발생한기간은 6.1±5.8개월 ( 범위 ; 2-24개월 ) 이었고신경학적증상이나타난기간은 3.1± 2.9개월 ( 범위 ;0.5-12 개월 ) 이었다. 신경학적증상은수술전 (B 1예, C 5예, D 11예 ) Frankel 등급은수술후 (D 3예, E 14예 ) 전예에서호전되었다. 최종추시결과척추경나사의고정상실또는금속그물망의탈위는관찰되지않았다. 후방에서삽입된금속그물망은 4예에서인접추체로함입되었으나모두수술중추체종판의손상으로발생된경우였고, 함입은수술후초기에진행되었으나이후안정화되었고교정소실또는척추경나사의이완등에영향을주지않았다. 수술시간은평균 231.5±42.3 분 ( 범위 ; 180-315분 ) 이었고출혈량 (Estimated Blood loss) 은 1058.8± 500.1 ml ( 범위 ; 500-2,000 ml) 이었다. 수술후호흡기합병증은 2예에서발생하였으나폐렴 1예및수술후 2일 까지인공호흡기의지지가필요했던 1예로결과에영향을미치지않았다. 새로운압박골절이원위인접추체에서 1예발생하여보존적치료로보조기착용을 3개월시행하였다. 고찰골다공증에의한척추골절은주로척추의전주높이만소실을보이며대부분추체의후벽이보존되어신경증상이발생하지않는안정골절로고려되고, 보존적치료로양호한결과를얻을수있다 24). 그러나 Kümmell 은경미한외상후지연성척추체붕괴 (delayed vertebral collapse) 를보고하였고, 또한척추체의붕괴와후만변형의증가로신경학적결손이발생할수있음이보고되고있다 18,25,28,33). 골다공증성압박골절에속발하는외상후척추체붕괴
796 이정희ㆍ김기택ㆍ석경수외 7 인 는손상받은추체의전방에위치하는시상면무게중심이국소후만으로전방으로이동하게되어압박응력이굴곡응력으로작용하여손상된추체의전방지주에압박응력이증가하는생역학적결과로발생한다 20,25,28). 이러한후만변형은흉요추이행부위에서후방의불안정보다는추체의괴사및붕괴로발생하며 20), 손상된추체의미세혈액순환장애와반복적인미세한움직임으로불유합과허혈성골괴사가발생하여추체가붕괴하고신경학적결손을야기한다 12,17,18). 본연구에서도 18예모두에서수술전 MRI 소견에서손상된추체의무혈성괴사소견이관찰되었고수술전이학적소견에서신경학적결손이관찰되었다. 신경학적결손을동반한외상후후만변형의수술적치료는신경증상의호전을위한감압과척주의안정을유합술및변형의교정을목적으로한다 7). Gertzbein 과 Harris 7) 는신경학적결손이동반된경우는전방도달법으로감압술을시행하고그외의경우는전방또는후방도달법을시도하였으나논란의여지가있다. 전방도달법이우수하다고주장하는저자들은병변이전방에위치하여감압술이용이하고전방지지가가능할뿐만아니라전방기기고정술로유합분절을단축할수있어전방으로수술을시행되어야한다고주장하였다 12,16). 후방도달법을이용한후외측감압술은후궁절제술후에척수에손상주지않고전방을감압할수없으며후방구조물에손상되어후만변형이악화되며척수를더욱손상시킬수있어금기증으로주장되었다 3,5,9,26). 그러나 Royle 27) 은반척추를후외측도달로, Capener 5) 는외측늑횡돌기절제술 (rhachotomy) 로, Heinig 8) 는 eggshell 술식으로후방도달법의가능성을제시하였다. 이후 Shikata 등 29) 은후방단축술을, Gertzbein 과 Harris 7) 는손상된추체에폐쇄형쐐기절골술 (closing wedge osteotomy) 을, Wu 등 36) 은폐쇄형쐐기절골술과후궁보존술을병행하여골유합을도모하는술식을소개하는등여러저자들에의해후방도달법만을시행한우수한결과들이보고되었다 11,13,14,19,23,28,30,32,35). Streitz 등 31) 은전방도달법을시행하였으나변형의교정보다도골유합이임상적결과에더욱중요하다고주장하였다. Malcolm 등 21) 은전방유합술만을시행한경우 50% 에서고정상실이관찰되어부가적인후방유합술이필요하다고주장하였고 Roberson 과 Whitesides 25) 도전 방유합술만시행한 18예중 17예에서견고한골유합을얻었으나후만변형의진행이관찰되었다고보고하였다. 따라서전방도달법과후방기기고정술을병행하여우수한결과를보고하며견고한골유합의중요성이강조되고있다 6,21,22,25). 후방도달법만을이용한경우에서 Lehmer 등 19) 은 Steffee 술식으로치료한흉요추부후만변형에서 (n=38) 수술후 2예서후방기기의파손으로추가적인수술이필요하였다고보고하였고, Suk 등 32) 은전후방도달법을시행한경우 (n=11) 와후방도달법만을시행한경우 (n=15) 에서각각 2예의척추경나사의이완이관찰되어추가적인보존적치료가필요하였다고보고하였다. 후만증환자의수술적치료에서발생하는이러한문제는전방지지가전방압박응력과후방인장응력을감소시키는생역학적기초에서비롯된다 16). 또한후방기기술은전방을압박하여골유합을증진시킬수있는장점이보고되었다 6,36). 따라서저자들의경우 Suk 등 32) 의후방도달법의장점을계승발전시키고감압을보다용이하게할수있으며금속그물망을삽입하여전방지지를가능케하는후방척주절제술 (posterior vertebral column resection) 을시행하였다. 최종추시결과척추경나사의고정상실또는금속그물망의탈위는관찰되지않았으며후방에서삽입된금속그물망은 4예에서인접추체로함입되었으나함입은수술후초기에진행되었으나이후안정화되었고교정소실또는척추경나사의이완등에영향을주지않았다. 골다공증환자에서시행된장분절고정술로새로운압박골절이원위인접추체에서 1예발생하였으나보존적치료로양호한결과를얻을수있었다. 결론골다공증과신경학적결손을동반한외상후후만증환자의수술적치료에서후방도달법만을이용한후외측감압술및후방척주절제술은감압이용이할뿐만아니라금속그물망을이용하여전방지지가가능케하여견고한내고정을얻을수있었다. 참고문헌 1. Alanay A, Pekmezci M, Karaeminogullari O, et al: Radiographic measurement of the sagittal plane deformity in patients with osteoporotic spinal fractures evaluation of intrinsic error. Eur Spine J, 16: 2126-2132, 2007.
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