대한척추외과학회지제 15 권제 3 호 Journal of Korean Spine Surg. Vol. 15, No. 3, pp 174~182, 2008 요추부후외방유합술후발생하는인접분절질환에관여하는위험인자 이규열 손성근 이명진 왕왕립 동아대학교의과대학정형외과학교실 Risk Factors for Adjacent Segment Disease after Posterolateral Lumbar Fusion Kyu Yeol Lee, M.D., Sung Keun Sohn, M.D., Myung Jin Lee, M.D., Lih Wang, M.D. Department of Orthopaedic Surgery, College of Medicine, Dong-A University, Busan, Korea Abstract Study Design: This is a retrospective study. Objective: We wanted to analyze the treatment outcome and the risk factors for adjacent segment disease after lumbar fusion. Summary of Literature Review: Biomechanical alterations likely play a primary role in causing adjacent segment disease. Radiographically apparent, asymptomatic adjacent segment disease is common after lumbar fusion, but this does not correlate with the functional outcomes. Materials and Methods: We reviewed 544 patients who underwent lumbar fusion at a minimum of 5-year follow-up between March 1993 and August 2006. Risk factors analysis was performed for 48 of 544 patients with adjacent segment disease and who were needed a second operation, and the treatment outcomes were assessed for 46 patients with a minimum 1-year follow-up after the second operation. The average interval to the second operation was 4.5 years, and the average follow-up after the second operation was 34.5 months. The treatment outcome was assessed by using the modified Brodsky criteria and the reoperation rate was assessed in relation to several risk factors. Results: Excellent and good operative results were obtained in 29 cases (63%) and bony fusion was achieved in 41 cases (89%). Of the risk factors we examined, multi-level fusion, a high grade of initial radiographic degeneration, the loss of physiologic lumbar lordosis and the involvement of degenerative scoliosis were associated with a high reoperation rate, with statistical significance. Age, gender, the initial diagnosis, the upper placement of the proximal screws and the extent to the sacrum were not correlated with the reoperation rate. Conclusion: The treatment outcome was relatively satisfactory; however, the factors influencing the treatment outcome of the second operation still need to be considered. The fusion level, the initial radiographic degeneration, the preservation of lumbar lordosis and the involvement of degenerative scoliosis are considered to be risk factors for the failure of lumbar fusion. Key Words: Adjacent segment, Lumbar fusion, Treatment outcome, Risk factor Address reprint requests to Kyu Yeol Lee, M.D. Department of Orthopedic Surgery, College of Medicine, Dong-A University, 3-1 Dongdaesin-Dong, Seo-Gu, Busan, 602-715, Korea Tel: 82-51-240-2867, Fax: 82-51-243-9764, E-mail: gylee@dau.ac.kr - 174 -
인접분절질환의위험인자 이규열외 서 론 요추질환의수술적치료방법으로서의유합술은가장많이사용되는방법으로최근여러가지의고정기기의발전으로높은유합성공율을얻고있다. 그러나요추부유합술의합병증인인접분절질환은골유합으로인한운동성소실과인접분절에과도한운동부하로퇴행성변화가더욱촉진될수있으며, 이로인한요통으로수술적치료가필요한환자가적지않다 1,2,3,4,5,6,7,8,9,10). 이러한인접분절질환은시간의존적이어서유합술후시간이경과함에따라그발생율이증가하는것으로알려져있으며, 그밖에유합시의연령, 기기고정의유무등이발생율과관계된다고보고되고있다 1,11,12,13,14). 또한, 인접분절질환의발생이반드시임상증세와의관련성이있는지에대하여는아직논란이있다 10,11,12,15,16,17,18). 그러나아직까지는인접분절질환에대한치료는보존적치료가우선이며, 수술적치료는신경학적증상이있거나보존적치료가실패한경우에시행한다. 최근들어요추부유합술후인접분절질환으로수술적치료를시행한경우가많아지면서위험인자및치료결과에대한연구도많이보고되고있다. 저자들은요추부유합술후인접분절에척추협착증및불안정성으로수술을시행받았던환자의치료결과를평가하고, 수술적치료를요하는인접분절질환의위험인자들을분석하여문헌고찰과함께보고하고자한다. 연구대상및방법 1993 년 3 월부터 2006 년 8 월까지본원에서요추부유합술을시행한환자 1100 명중 5 년이상장기추시가가능하였던 544 명환자중에서인접분절질환으로 2 차수술을시행한환자 48 명을대상으로인접분절질환에관여하는위험인자들에대해분석하였고, 이중 1 년이상추시가가능하였던 46 명을대상으로수술적치료결과를평가하였다. 연구대상인 48 예중남자 20 예, 여자 28 예였고, 2 차수술시평균연령은 64.9 세 (46~79 세 ) 였으며, 2 차수술까지의평균기간은 4.5 년 (3~12 년 ) 이었다. 2 차수술후 1 년이상추시가가능하였던 46 예의평균추 시기간은 34.5 개월 (15~45 개월 ) 이었다. 2 차수술전방사선영상촬영을시행하여인접분절의퇴행성변화및불안정성으로인한척추관협착증의소견이확인되었으며, 인접분절의척추관협착증증세로신경학적파행이동반된예에서최소 3 개월이상의보존적치료이후에도지속되는요통, 파행및신경학적이상이있는경우에수술을시행하였고, 임상적또는방사선학적으로인접분절의증상과일치하지않는경우에는수술적치료를시행하지않았다. 1 차수술에있어서유합방법은최초진단명과관계없이모두후궁절제술, 후방기기고정및후외방골이식술을시행하였고, 2 차수술에있어서도전예에서인접분절의불안정성및척추협착증을치료하기위해광범위후궁절제술, 후방기기고정및후외방유합술을병변분절에대해서만연장시행하였고퇴행성요추측만증을고려한수술범위의추가연장은시행하지않았다. 수술적치료를요하는인접분절질환에대한위험인자분석에있어서전체 544 명환자중인접분절질환으로 2 차수술을시행한 48 예에대한재수술율 (reoperation rate) 을통해위험인자들에대해분석하였다. 위험인자들은 1 차수술에대한술전및술후요인으로나누었고, 술전요인으로성별, 연령 (50 세이상또는이하 ), 최초진단명 ( 척추관협착증, 퇴행성척추전방전위증, 척추불안정성및재발성추간판탈출증 ), 퇴행성요추측만증동반유무, 단순방사선사진상 Kellgren 분류에의한인접분절의퇴행성변화정도 (III 이상또는 II 이하 ) 등이있으며, 술후요인으로 1 차수술후사진상요추전만각정도 (35 도이상또는이하 ), 장분절유합유무 (3 개이상또는 2 개이하 ), 유합범위중제 1 천추가포함유무, 최상위척추경나사못의상부위치유무등이있다. 1. 방사선학적평가 위험인자분석을위해 1 차수술전시행한단순촬영 (plain radiographs) 에서 Kellgren 의분류를이용하여인접분절의퇴행성변화정도를분석하였다 (Table 1). 2 차수술전인접분절에대한방사선학적평가는단순촬영을통해인접분절의퇴행성변화를확인하였고, 1 차수술전상태와비교하였으며, 인접분절의불안정성평가는 Table 1. Radiologic grading of adjacent segment degeneration (prior to primary surgery) Kellgren Grade 1: Minimal osteophytosis only 2: Definite osteophytosis with some sclerosis of anterior part of vertebral plates 3: Marked osteophytosis and sclerosis of vertebral plates with slight narrowing of disc space 4: Large osteophytosis, marked sclerosis of vertebral plates and marked narrowing of disc space - 175 -
대한척추외과학회지 Vol. 15, No. 3, 2008 동적검사 (dynamic radiographs) 에서시상면에서의굴곡 - 신전각도차이가 10 도이상, 전위가 4 mm 이상이면분절불안정성이있다고정의하였다 19,20). 그리고컴퓨터단층촬영또는자기공명영상촬영을실시하여퇴행성변화및불안정성으로인한척추관협착증의소견을확인하고인접분절의상태를보다정확하게파악하였고. 2 차수술후, 마지막추시단순촬영을통해골유합정도 Table 2. Modified Brodsky's criteria 를확인하였다. 2. 임상적평가 2 차수술에대한치료결과는 modified Brodsky s 분류를이용하였으며평가기준을우수, 양호, 보통, 불량으로정하였고 (Table 2), 재수술에의한합병증에대해서도조사하였다. Designation Excellent Good Fair Poor Criterion Table 3. Cause and location of adjacent segmental disease at second operation 3. 통계학적평가 재수술율을이용하여인접분절질환에영향을미치는위험인자들에대해단변량분석을하였고, 통계학적검증을위해 SPSS 15.0 통계프로그램의 Chi-square test 를이용하였으며유의수준은 p<0.05 로정하였다. 결 과 요추부유합술를시행받은 544 명환자중 2 차수술을시행한환자는 48 명이었으며 8.8% 의재수술율을보였 Cause Nubmer (n) Percentage (%) Stenosis 27 56.3 Instability 09 18.7 Stenosis and instability 11 22.9 Far lateral HNP* 01 02.1 Location Number (n) Percentage (%) Upper segment 37 77.1 Lower segment 08 16.7 Upper and lower segment 03 06.2 * HNP; herniated nucleus purposus No pain Occasional back or leg pain No change of work No change of leisure activity Frequent back or leg pain Some change of work Some change of leisure activity Disabling pain Long-term medication Unable to work Fig. 1. Posterolateral fusion with instrumentation at L3-4-5 in a 62 year-old male patient. (A) Postoperative 2 years, plain radiographs show both upper and lower adjacent degenerative changes. (B) Extended posterior decompression and instrumented posterolateral fusion were performed. At the last follow-up, clinical result was good according to the modified Brodsky s criteria. - 176 -
인접분절질환의위험인자 이규열외 Fig. 2. Posterolateral fusion with instrumentation at L4-5-S1 in a 69 year-old female patient. (A) Postoperative 10 years, plain radiographs show degenerative lumbar scoliotic change about 13 degrees at AP view and adjacent degenerative changes at saggital view. S1 pedicle screw was broken. (B) T2-weight axial MR images show central and lateral recess type stenosis at L2-3 and L3-4. (C) Dynamic radiographs show L3-4 adjacent instability. (D) Metal removal and posterior decompression and instrumented posterolateral fusion were performed. At the last follow-up, clinical result was excellent according to the modified Brodsky s criteria. Table 4. Clinical result of second operation for adjacent segment disease Modified Brodsky s criteria Excellent Good Poor Fair Number (n) 10 19 11 06 Percentage (%) 22 41 24 13 다. 2 차수술의원인으로척추관협착증이가장많은빈도를차지하였고, 인접분절질환의위치를보면상위분절에가장많았고, 3 예에서는상위, 하위분절모두에서인접분절질환을보였다 (Table 3) (Fig. 1). 2 분절이상의인접분절질환을보인경우가 13 예였고, 모두상위분절에척추협착증및분절불안정성이동시에존재하였다 (Fig. 2). 인접분절질환에대한수술적치료결과를보면, Brodsky 분류를이용한임상적결과는 29 예 (63%) 에서우수및양호의치료결과를보였으며 (Table 4) 방사선학적결과는 41 예 (89%) 에서후외방골유합소견을보였다. 2 차수술의합병증으로는경막파열이 5 예, 술후감 염이 3 예가있었으나마미증후군과같은신경학적후유증은없었다. 불량의임상결과를보인 6 예중 1 예는술후감염으로인해수차례변연절제및세척술을시행한경우였고, 나머지예는모두불유합이발생한경우였다. 인접분절질환의위험인자에대한분석에있어서남성인경우, 50 세이하인경우, 최초진단명이퇴행성척추전방전위증인경우, 유합범위중제 1 천추가포함되지않는경우그리고최상위척추경나사못의위치가상부에위치한경우에상대적으로높은재수술율을나타냈으나통계학적유의성은보이지않았다 (p>0.05) (Table 5). 3 분절을포함한장분절유합은재수술율과유의한상관관계를보였으며 (p<0.001), 최초단순방사선 - 177 -
대한척추외과학회지 Vol. 15, No. 3, 2008 Table 5. Rate of reoperation related to risk factors Risk factors Rate of reoperation Number (n) Percentage (%) P Sex Female 28/342 8.2 Male 20/202 9.9 0.496 Age <50 years 13/132 9.8 0.633 50 years 35/412 8.5 Initial diagnosis Spinal stenosis 38/432 8.8 Degenerative spondylolisthesis 8/83 9.4 1.000 Dynamic instability 2/23 8.7 Recurred HNP* 0/4 0.0 Adjacent segment degeneration** Kellgren grade < II 18/502 3.6 Kellgren grade III 30/42 71.40 <0.001< Number of fusion segment <2 segments 10/378 2.6 3 segments 38/166 22.90 <0.001< Preservation of lumbar lordosis*** 35 degree 30/224 13.40 0.002 <35 degree 18/320 5.6 Type of fusion Floating fusion 34/364 9.3 0.545 Extended to sacrum 14/180 7.8 Upper placement of proximal screw 5/40 12.50 0.564 Associated with lumbar scoliosis 10/15 66.70 <0.001< *HNP; herniated nucleus purposus **; Prior to primary surgery ***; Posterior to primary surgery 사진상인접분절의퇴행성변화가 Kellgren 분류 grade III 이상인경우 (p<0.001), 최초수술후사진상요추전만각이 35 도이상인경우 (p=0.002) 그리고퇴행성요추측만증이동반된경우 (p<0.001) 에높은재수술율을보였으며통계학적으로도의미가있었다 (Table 5). 증 례 64 세여자환자로하부요통및양측하지방사통을주소로내원하여시행한방사선학적검사상제 3-4-5 요추간척추관협착증및퇴행성요추측만증으로진단되어요추 3-4-5 번에대해광범위감압술, 후방기기고정및후외방유합술을시행받았다. 술후 3 년째하부요통및양측하지방사통이재발하여내원하였고시행한방사선학적검사상제 1-2-3 요추간퇴행성척추관협착증이발견되어감압술, 후방기기고정및후외방유합술을연장하였다. 2 차수술시행후 6 개월에골유합이되었으 며, 술후 2 년추시에서임상성적은양호로평가되었다 (Fig. 3). 고 찰 요추부유합술후인접분절의퇴행성변화의발생은많은보고가있으며, 이에대한생역학적연구도많이이루어져있다 14,15,21). 이러한인접분절의퇴행성변화의발생율에있어서는저자마다다르나대체로 24~49% 로보고되고있다 1,4,16,17,22,23). 하지만이러한방사선학적퇴행성변화와임상증세와의관련성에대하여역시많은논란이있다. 많은보고들이이러한인접분절의퇴행성변화가임상증세와의연관성은적다고보고하고있으나 8,15), 8~17% 에서는 2 차수술이필요하였다고보고하고있다 9,10,11,15). 이러한유합술후 2 차수술의결과에있어서는만족할만한결과를얻기가힘들다는것을쉽게예상할수있으며, 실제보고에서도만족할만한결과를 70~80% 로 - 178 -
인접분절질환의위험인자 이규열외 Fig. 3. A 64 year-old female radiographs. (A) Initial radiographs show multiple osteophytes and disc space narrowing with mild scoliotic change at L3-4-5. (B) Posterior decompression and instrumented posterolateral fusion were performed. Kellgren grade II degeneration and joint space widening were noted at L2-3 on immediate postoperative radiographs. (C) At postoperative 3 years, severe endplate degeneration, disc collapse and advanced scoliosis were noted at L2-3. (D) Computerized axial tomography images show central and lateral recess type stenosis at L1-2-3. (E) Extended posterior decompression and instrumented posterolateral fusion were performed. (F) At the last follow-up, radiographs show bone union and the clinical result was good according to the modified Brodsky s criteria. 보고하고있다 10,11,12,18,24). 따라서요추부의유합술에있어서발생할수있는인접분절질환에대하여이들의발생과관련이있는요소를파악하는것은중요하다할수있다. 최근까지보고에의하면, 환자의연령, 성별, 질환, 유합범위, 기기이용유무, 척추전방유합및요추부의시상면상균형의복원등이관련된다고보고하고있다 1,4,6,7,9,11,13). Lehmann 등 8) 은고정기구를사용하지않는요추유합술후평균 33 년을추시하여 45% 에서상위인접분절의불안정이관찰되었으며이는전산화단층촬영검사상의척추관협착정도와상관관계가있었으나임상증상과는무관한것으로보고하였다. Hsu 등 25) 은요추의기구를사용한고정술과사용하지않은군을장기간비교하여인접분절의변화에의한퇴화가기구사용군에서조기에일어나임상적만족도가감소한다고하였고 Schlegel 등 10) 도기구사용군이인접분절의변화가월등히조기에발생한다고하였으면 Shahin 등 26) 은기기를사용한요추유합술에서인접분절의증상이나타나기까지기간이평균 26.8 개월로매우짧고이는기구고정술을시행하지않는경우는유합골괴가성숙하면서부하의전이가일어나나기구고정을시행한경우는처음부터부하의전이가발생하기때문인것으로설명하였 다. 이처럼여러저자들의보고는척추의유합술이인접분절질환을가속화시킬수있으며이러한변화는기기고정술을시행한군에서보다많이그리고조기에발생하는것으로보고되는경향이었다. 그러나최근척추유합술은골유합을위해대부분기기고정술을이용하는경향이라서척추유합술에서기기고정유무에따른인접분절질환에대한비교문헌은찾아보기가힘들며본연구에서도유합술과함께기기고정술을시행한환자를대상으로연구하였으므로위험인자인기기고정술시행유무는본연구에서제외되었다. 유합범위에따른인접분절의변화에있어서는여러분절을고정할수록인접분절에응력이더욱많이집중된다는보고도있으나 1), Kettler 등 27) 은유합범위와인접분절의변화의발생과는연관성이없다고보고하였고, Rohlman 등 28) 의보고처럼장분절유합에서인접분절의보상성운동의증가는기계적인요소보다시상또는관상면상의부정정렬에더큰영향을받는다는것을알수있었다. 그러므로요추전만각및척추의시상면, 관상면의균형은이러한인접분절의변화에영향을주는인자로알려져있으며 7,10,13), Cho 등 29) 의연구에서도요추전만각이생리적범위를벗어난경우에인접분절의변화가많이관찰되었다. 본연구에서는유합분절의범위 - 179 -
대한척추외과학회지 Vol. 15, No. 3, 2008 가 3 분절이상시에높은재수술율을보였고통계학적의미를보였다. 그리고수술후시상면상의요추전만각이 35 도이상일경우상대적으로높은재수술율을보였으며통계학적의미를보였다. 그러므로장분절유합및기기고정으로인접분절의응력및보상성운동증가에의해속발적으로생기는퇴행성변화를줄이기위해장분절유합술시행할때보다섬세한술기가요구되고유합부위분절간전만각을생리적범위로유지하는것이중요하다고생각되고향후보다많은연구가필요할것으로사료된다. 하등 30) 은최초수술시단순방사선사진및컴퓨터단층사진상의인접분절의퇴행성변화는 2 차수술이필요하였던기간과유의한상관관계가있었으며, 퇴행성측만증이동반된예에서는다른질환보다조기에 2 차수술이필요하였다. 그러나 Gillet 31) 의연구에서는수술당시이미퇴행성변화가있는분절을유합범위에포함하지않아도장기적인결과에차이가없어장분절의퇴행성변화에서도신경증상과관계있는분절만유합범위에포함시킬것을권장하였다. 본연구에서는최초수술시단순방사선사진상의인접분절의퇴행성변화가 Kellgren 분류상 grade III 이상인경우에높은재수술율을보였고통계학적으로도의미가있었다. 그리고요추부의퇴행성측만증이동반된경우에있어서통계학적으로의미있게빠른시간에진행이되었으며, 수술적치료가필요하였다. 그러므로인접분절의퇴행성변화가이미존재할때는그정도에따라미리유합술에포함시킬필요가있는지에대한고려가필요할것으로사료되고, 퇴행성요추측만증이동반된경우유합부위의결정에있어서좀더신중을기해야할것으로생각되며, 동반된측만각이큰경우, 또는퇴행성변화가동반된경우에서는흉추까지의유합및기기고정의연장도고려해볼필요가있을것으로생각된다. 인접분절질환에대한수술적치료의결과는만족스럽지못하게보고되고있으며 10,11,12,18), 가관절의발생이나, 요추전만의소실등이나쁜결과와관련이있다고보고되고있다 12,18,24). 본연구에서도 37% 에서보통이하의임상결과를나타내었는데불량의임상결과를보인 6 예중 1 예는술후감염으로인해수차례변연절제및세척술을시행한경우였고, 나머지예는모두불유합이발생한경우였다. 이미유합된분절로인하여새로유합할인접분절에부하가더많이집중되기때문에유합이쉽지않을것이므로효과적인유합을위해서는후방추체간유합술의추가시행이필요할것으로생각되고, 골이식을더잘하여야할것이다. 그러나보통의결과를보인 11 예에서는방사선학적으로모두후외방골유합을얻었으나임상적결과가좋지못한점에대해향후 2 차수술의치료결과에영향을미치는인자, 예를들면 2 차수술방법간의차이, 2 차수술까지의기간, 2 차수술전인접분절의단순방사선또는자기공명영상에서의퇴행성정도및이전과의변화등에대한추가연구가필요할것으로생각된다. 결 론 광범위감압술, 후방기기고정및후외방유합술을통한인접분절질환의수술적치료는비교적만족스러운결과를얻었으나, 보다좋은결과를얻기위해서는향후 2 차수술의치료결과에영향을미치는인자에대한연구가필요할것으로생각된다. 요추부유합술시행에있어서유합분절의범위, 술전단순방사선상인접분절의퇴행성변화및술후전만각의생리적범위로의유지그리고퇴행성측만증의동반유무는신중히검토해야할위험요소라고생각되고, 장분절유합술시행할때보다섬세한술기가요구되고유합부위분절간전만각을생리적범위로유지하는것이중요하며퇴행성측만증이동반되거나또는인접분절의퇴행성변화가이미존재할때는그정도에따라미리유합술에포함시키거나연장유합이필요할것으로생각된다. 참고문헌 01) Aota Y, Kumano K, Hirabayashi S: Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord 1995; 8: 464-473. 02) Fritsch EW, Heisel J, Rupp S: The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments. Spine 1996; 21: 626-633. 03) Frymoyer JW, Hanley E, Howe J, Kuhlmann D, Matteri R: A comparison of radiolographic findings in fusion and non-fusion patients ten or more years following lumbar disc surgery. Spine 1979; 4: 435-440. 04) Guigui P, Lambert P, Lassale B, Deburge A: Long-term outcome at adjacent levels of lumbar arthrodesis. Rev Chir Orthop Reparatrice Appar Mot 1997; 83:685-696. 05) Ha KY, Sung TP: Changes of the adjacent mobile segment after cat spine fixation. J Kor Orthop Surg 1997; 32: 1808-1816. 06) Ha KY, Moon MS, Paek SY: Effect of Instumental stabilization and fusion of degenerative lumbar scoliosis on? - 180 -
인접분절질환의위험인자 이규열외 unfused adjacent segment. J Kor Spine Surg 1995; 2: 270-278. 07) Kumar MN, Jacquot F, Hall H: Long-term follow up of functional outcomes and radiographic changes at adjacent levels following lumbar spine fusion for degenerative disc disease. Eur Spine J 2001; 10: 309-313. 08) Lehmann TR, Spratt KF, Tozzi JE, et al: Long-term follow-up of lower lumbar fusion patients. Spine 1987; 12: 97-104. 09) Rahm MD, Hall BB: Adjacent-segment degeneration after lumbar fusion with instrumentation: A retrospective study. J Spinal Disord 1996; 9: 392-400. 10) Schlegel JD, Smith JA, Schleusener RL: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Spine 1996; 21:970-981. 11) Etebar S, Cahill DW: Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg 1999; 90: 163-169. 12) Kim SS, Michelsen CB: Revision surgery for failed back surgery syndrome. Spine 1992; 17: 957-960. 13) Kumar MN, Baklanov A, Chopin D: Correlation between saggital plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 2001; 10: 314-319. 14) Lee CK, Langrana NA: Lumbosacral spinal fusion. A biomechanical study. Spine 1984; 9:574-581. 15) Bastian L, Lange U, Knop C, Tusch G, Blauth M: Evaluation of the mobility of adjacent segments after posterior thoracolumbar fixation: A biomechanical study. Eur Spine J 2001; 10: 295-300. 16) Frymoyer JW, Hanley E, Howe J, Kuhlmann D, Matteri R: Disc excision and spine fusion in the management of lumbar disc disease. A minimum 10 year follow up. Spine 1978; 13: 1-6. 17) Hambly MF, Wiltse LL, Raghavan N, Schneiderman G, Koenig C: The transition zone above a lumbosacral fusion. Spine 1998; 23: 1785-1792. 18) Whitecloud TS, Davis JM, Olive PM: Operative treatment of the degenerated segment adjacent to a lumbar fusion. Spine 1994; 19: 531-536. 19) Morgan FP, King T: Primary instability of lumbar vertebrae as a common cause of low back pain. J Bone Joint Surg 1957; 39: 6-22. 20) Dupuis PR, Yong-Hing K, Cassidy JD, Kirkaldy-Willis WH: Radiologic diagnosis of degenerative lumbar spinal instability. Spine 1985; 10: 262-276. 21) Ha KY, Schendel MJ, Lewis JL, Ogilvie JW: Effect of immobilization and configuration on lumbar adjacent segment biomechanics. J Spinal Disord 1993; 6: 99-105. 22) Brunet JA, Wiley JJ: Acquired spondylolysis after spinal fusion. J Bone and Joint Surg 1984; 66: 720-724. 23) Ha KY, Kim KY, Park SJ, Lee YH: Changes of the adjacent-unfused mobile segment after instrumental lumbar fusion. More than 5 years follow-up. J Kor Spine Surg 1998; 5: 205-214. 24) Chen WJ, Lai PL, Niu CC, Chen LH, Fu TS, Wong CB: Surgical treatment of adjacent instability after lumbar spine fusion. Spine 2001; 26: 519-524. 25) Hue KY, Zucherman J, White A, et al: Deterioration of motion segments adjacent to lumbar fusions. Annual meeting of North American Spine Society, Colorado Springs, Colorado, 1998. 26) Shahin E, David W: Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg 1999; 90: 163-169. 27) Kettler A, Wilke HJ, Haid C, Claes L: Effects of specimen length on the monosegmental motion behaviour of the lumbar spine. Spine 2000; 25: 543-550. 28) Rohlman A, Neller S, Bergmann G, Graichen F, Claes L, Wilke HJ: Effect of an internal fixator and a bone graft on intersegmental spinal motion and intradiscal pressure in the adjacent regions. Eur Spine J 2001; 10: 301-308. 29) Cho JL, Park YS, Han JH, Lee CH, Roh WI: The changes of adjacent segments after spinal fusion. J Korean Spine Surg 1998; 5: 239-246. 30) Ha KY, Kim YH, Kang KS: Surgery for adjacent segment changes after lumbosacral fusion. J Kor Spine Surg 2002; 9:332-340. 31) Gillet P: The fate of the adjacent motion segment after lumbar fusion. J Spinal Disord Tech 2003; 16: 338-345. - 181 -
대한척추외과학회지 Vol. 15, No. 3, 2008 국문초록 연구계획 : 인접분절질환의위험인자에대한후향적연구. 연구목적 : 요추부유합술후발생하는인접분절질환에대해수술적치료를요하는위험인자들을분석하였고, 이에따른치료결과를보고하고자한다. 대상및방법 : 1993년 3월부터 2006년 8월까지본원에서요추부유합술시행받고최소 5년이상추시가가능하였던 544명환자중인접분절질환으로수술을시행하였던 48명 (8.8%) 을대상으로위험인자분석을시행하였고, 그중1 년이상추시가가능하였던 46명을대상으로수술적치료결과를평가하였다. 2차수술까지의기간은평균 4.5년 (3~12년) 이었고 2차수술후평균추시기간은 34.5개월 (15~45개월) 이었다. 치료결과는 modified Brodsky's 분류를통해평가하였고인접분절질환에영향을미치는위험인자들에대해서는재수술율 (reoperation rate) 을평가하여위험인자와의관계를분석하였다. 결과 : 치료결과에있어서 2차수술후29예 (63%) 에서양호이상의결과를보였으며 41예 (89%) 에서단순방사선상골유합을얻었다. 위험인자중장분절유합, 최초수술시단순방사선사진상 Kellgren 분류 III 이상인경우, 최초수술후전만각이 35도이상인경우그리고퇴행성측만증이동반된경우재수술율이높았으며통계학적으로의미가있었다. 그러나성별, 나이, 최초진단명, 최상위척추경나사못의상부위치및제1천추의포함유무와는유의성을보이지않았다. 결론 : 광범위감압술, 후방기기고정및후외방유합술을통한수술적치료는비교적만족스러운결과를얻었으나, 향후 2차수술의치료결과에영향을미치는인자에대한연구가필요할것으로생각된다. 요추부유합술시행에있어서유합분절의범위, 술전단순방사선상인접분절의퇴행성변화, 전만각의생리적범위로의유지그리고퇴행성측만증의동반유무는신중히검토해야할위험요소라고생각된다. 색인단어 : 인접분절, 요추부유합술, 치료결과, 위험인자 통신저자 : 이규열부산광역시서구동대신동 3가 1 동아대학교의과대학정형외과학교실 Tel: 82-51-240-2867 Fax: 82-51-243-9764 E-mail: gylee@dau.ac.kr - 182 -