Journal of Korean Society of Spine Surgery Conservative Treatment of Osteoporotic Spinal Fractures Jae Hyup Lee, M.D., Ph.D., Yuanzhe Jin, M.D., Ji-Ho Lee, M.D., Ph.D. J Korean Soc Spine Surg 2015 Dec;22(4):186-191. Originally published online December 31, 2015; http://dx.doi.org/10.4184/jkss.2015.22.4.186 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 2015 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:///doix.php?id=10.4184/jkss.2015.22.4.186 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Review Article pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2015 Dec;22(4):186-191. http://dx.doi.org/10.4184/jkss.2015.22.4.186 Conservative Treatment of Osteoporotic Spinal Fractures Jae Hyup Lee, M.D., Ph.D., Yuanzhe Jin, M.D., Ji-Ho Lee, M.D., Ph.D. Department of Orthopedic Surgery, Seoul National University, College of Medicine Study Design: Literature review. Objectives: To present updated information on the conservative treatment of osteoporotic spinal fractures (OSFs). Summary of Literature Review: The treatments of osteoporotic spinal fractures are bed rest, pain medication, bracing, exercise and rehabilitation, and osteoporosis medication. However, there is disagreement about the outcomes of these treatments. Materials and Methods: Review of the relevant literature. Results: In the case of osteoporotic spinal fractures, analgesic administration, bracing, physical therapy, and exercise should be conducted. In order to prevent secondary fractures, bisphosphonates, selective estrogen receptor modulators, strontium ranelate, or parathyroid hormone, which has proven efficacy with respect to the prevention of secondary fractures, should be prescribed. Conclusions: We should actively prevent the occurrence of secondary fractures with fracture healing by implementing a proven effective treatment for osteoporotic spinal fractures. Key Words: Osteoporosis, Spinal fractures, Treatment, Conservative 서론 골다공증은골량의감소와골의미세구조의변화로골질의약화및골이쉽게부서지는상황이초래되고결국골절을유발한다. 전세계적으로도고령인구가증가하면서해마다골다공증환자및골다공증성골절환자가증가하고있으며, 우리나라도고령화의속도가매우빠르기때문에골다공증성골절환자의수도다른나라보다더빠른속도로급증하고있다. 골다공증성골절중대표적인것은척추골절, 고관절, 손목골절등이며이외에도상완골골절, 쇄골골절, 늑골골절, 발목골절도골다공증과연관되어발생한다. 고관절골절은골절후사망률이높기때문에대부분수술적치료를시행하며, 손목골절의경우는도수정복후석고고정을하든지수술적치료를시행한다. 그러나, 척추골절은증상이별로없는경우부터심한통증이유발되는경우, 그리고근력약화등의신경학적이상이발생하는경우등임상양상이매우다양하다. 따라서, 척추골절에대해서는통증조절에대한약물치료만시행하는경우도있고, 보조기치료, 골시멘트보강수술, 기기고정술및유합술을시행하기도한다. 그러나, 기기고정술및유합술은골질이약하기때문에기기이완이나수술실패의가능성이있고, 재수술이쉽지않으며유합을얻기도어렵기때문에심한변형이나불안정증혹은마비 가발생하지않는한잘시행하기않는다. 따라서, 대부분의골 다공증성척추골절환자는다양한방법으로보존적치료를시 행하고있다. 치료효과에대한근거수준과권고등급은 Scottish Intercollegiate Guideline Network (SIGN) 의정의가많이이용 된다. SIGN 에서는메타분석, 체계적문헌고찰, 무작위대조연구 를바탕으로근거수준을 1++, 1+, 1- 를포함해서 4 까지정의하 고있으며 (Table 1), 이를바탕으로목표대상에적용가능여부 와근거수준에따른일관성등을바탕으로권고등급을 A 부터 D 까지정의하고있다 (Table 2). 1) 이에골다공증성척추골절에대 한보존적치료중투약, 보조기치료, 운동치료, 도수치료를문 헌고찰을통해치료효과가있는지알아보고자한다. Received: October 22, 2015 Revised: October 26, 2015 Accepted: November 18, 2015 Published Online: December 31, 2015 Corresponding author: Jae Hyup Lee, M.D., Ph.D. Professor of Department of Orthopaedic Surgery, Seoul National University, College of Medicine, SMG-SNU Boramae Medical Center, Boramae-gil, 5-ro, Dongjak-gu, Seoul 156-707, Korea TEL: +82-2-870-2314, FAX: +82-2-870-3863 E-mail: spinelee@snu.ac.kr 186 Copyright 2015 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Conservative Treatment of OSFs Table 1. Levels of Evidence. 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias 1- Meta-analyses, systematic reviews or RCTs, or RCTs with a high risk of bias 2++ 2+ High quality systematic reviews of case-control or cohort studies or High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal Well conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal 2- Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion Table 2. Grades of Recommendations. A B C At least one meta-analysis, systematic review, or RCT rated as 1++ and directly applicable to the target population or a systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results or extrapolated evidence from studies rated as 1++ or 1+ A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results or extrapolated evidence from studies rated as 2++ D Evidence level 3 or 4 or extrapolated evidence from studies rated as 2+ 본론 1. 투약골다공증성척추골절은심한통증을유발하는경우가많으며이로인해거동제한이나보행장해가발생할수있다. 따라서, 적극적인투약을통해통증을조절하는것이필요하다. 또한, 골다공증성척추골절이발생하게되면이차골절의가능성이높아지고고관절골절의위험도증가하기때문에추가적인골절을예방하기위해골다공증치료약을투약해야한다. 1.1. 통증조절을위한약제통증조절을위해사용할수있는약제로우선적으로아세트아미노펜을처방하며, 비스테로이드소염제나 Cox-2 선택적길항제를사용할수있다. 그러나, 비스테로이드소염제는위장관계부작용, 신부전과심혈관계부작용의위험때문에고령의환자에게주의를요한다. 2) 중등도통증에는트라마돌이나코데인등약한아편양진통제를처방할수있으며, 증상이심할경우모르핀, 옥시코돈등의아편양진통제를처방할수있다. 3) 그러나, 아편양진통제는소화기계운동저하, 배뇨장애, 호흡기능저하, 인지기능저하, 우울증, 평형감각저하에의한낙상위험성증가등의부작용이있기때문 에처방에주의를요한다. 4) 기타약제로는근육이완제를수상후 1-2주정도사용하는것이척추주변근육의강직호전에도움이된다. 5) 그러나, 나른함, 어지러움, 남용등의부작용이발생할수있기때문에장기간사용시에는효능대비부작용을고려할때지속적으로처방하는것은권고되지않는다. 6) 골다공증치료제중비스포스포네이트와부갑상선호르몬이골다공증성척추골절의통증조절에도움이된다는보고가있다. 비스포스포네이트중졸레드론산은 3년간주사한경우골절후요통을호소하는기간, 요통에의한일상생활장해정도및침상안정기간을플라세보군에비해유의하게감소시킨다고알려져있다. 7) 따라서, 졸레드론산은 Level I 근거수준으로골다공증성척추골절의통증조절에효과가있어서 Class 1 수준으로통증조절에추천된다. 클로드로네이드와파미드로네이트도골다공증척추골절환자의급성통증에효과가있다고보고되고있다. 8-10) 그러나, 골다공증골절예방효과가다른비스포스포네이트에비해떨어지기때문에골절예방과통증치료효과를동시에고려할때처방되는것은권고되지않는다. 1.2. 이차골절예방을위한약제골절예방을위해사용되는현재골다공증치료제는비스포스포네이트, 선택적여성호르몬수용체길항제, 여성호르몬, 칼시 187
Jae Hyup Lee et al Volume 22 Number 4 December 2015 토닌, 스트론튬라넬레이트, 데노수맙, 부갑성선호르몬등이있다. 이약제들의이차골절예방의효과는다음과같다. 알렌드로네이트는 Fracture Intervention Trial 에서플라세보군에비해한개이상의이차골다공증성척추골절을 47% 감소시켰고임상적으로의미있는이차골다공증성척추골절도유의하게감소시켰으나비척추골절은유의하게감소시키지못했다고보고되고있다. 11) 또한, Wells 등이보고한메타분석에서, 알렌드로네이트를 1년이상복용할경우이차골다공증성척추골절의상대위험감소 (relative risk reduction) 는 45% (RR 0.55, 95% CI 0.43-0.69) 이고절대위험감소 (absolute risk reduction) 는 6% 라고보고하였다. 12) 이연구에서비척추골절에대한이차예방의상대위험감소는 23% (RR 0.77, 95% CI 0.64 0.92) 이고절대위험감소는 2% 라고보고하였다. 12) 또한, 이차고관절골절의상대위험감소는 53% (RR 0.50, 95% CI 0.34-0.73) 이고절대위험감소는 2% 라고보고하였다. 12) 리세드로네이트는 Vertebral Efficacy with Risedronate Therapy North American Society (VERT-NA) 연구에서 2개이상의척추골절을가진환자가 3년간복약시플라세보군에비해이차골다공증성척추골절의누적발생률을 49%, 비척추골절의누적발생률을 33% 감소시켰다고보고하고있다. 13) 이연구에서는이차골다공증성척추골절위험은 1년내에 61% 감소한다고보고하였다. 13) Wells 등의메타분석에서 1년이상리세드로네이트를복약시이차골다공증성척추골절의상대위험감소는 39% (RR 0.61, 95% CI 0.50-0.76) 이고절대위험감소는 5% 라고보고하였다. 14) 이연구에서비척추골절에대한이차예방의상대위험감소는 20% (RR 0.74, 95% CI 0.59 0.94) 이고절대위험감소는 1% 라고보고하였다. 14) 이반드로네이트는요추 T값이 -2.0 이하면서 1개에서 4개이하의흉요추골절을가진환자를대상으로한 oral ibandronate Osteoporosis Vertebral Fracture Trial in North America and Europe (BONE) 연구에서 2년간복약시플라세보군에비해이차방사선사진상의골다공증성척추골절의발생률을 62% 감소시켰고, 15) 증상을유발하는이차골다공증성척추골절도 49% 감소시켜통계적으로유의하였다고보고하였다. 그러나, 비척추골절은유의하게감소시키지못하였는데, 대퇴경부골밀도 T- 값이 -3.0 미만인군에서는경구용제제를매일복약한군에서비척추골절의위험을 69% 감소시켜서통계적으로유의한감소가있었다고보고되고있다. 16) 랄록시펜은 Multiple Outcomes of Raloxifene Evaluation (MORE) 연구에서이차골다공증성척추골절의상대위험감소는 30% (RR 0.7, 95% CI 0.6-0.9) 라고보고되고있다. 17) 그러나, 비척추골절의위험감소에대한효과는입증하지못하였다. 바제독시펜은척추골절이있는환자에서추가적인척추골절 발생률을 45% (RR 0.55, 95% CI 0.32-0.94) 감소시켰다고보고되고있다. 18) 이연구에서, 바제독시펜은대퇴경부 T-값이 -3.0 이하이거나, 중등도혹은심한척추골절이있거나다수의경도척추골절이있는고위험환자에서는비척추골절의위험을플라세보에비해서는 50%, 랄록시펜에비해서는 42% 감소시켰다고보고하였다. 18) 스트론튬라넬레이트는 Spinal Osteoporosis Therapeutic Intervention (SOTI) 연구에서이차골다공증성척추골절의상대위험감소는 41% (RR 0.59, 95% CI 0.48-0.73) 라고보고되고있다. 19) 칼시토닌은 Prevent Recurrence of Osteoporotic Fractures (PROOF) 연구에서칼시토닌을 200IU 로투여한환자의이차골다공증성척추골절의상대위험감소는 33% (RR 0.67, 95% CI 0.47-0.97) 라고보고되고있다. 20) 그러나, 비척추골절이나고관절골절에대한감소효과는입증되지않았다. 그리고, 칼시토닌은메타분석에서급성척추골절에의한통증을초기수주동안의투약으로호전시키는것으로알려져있으나장기적인사용은발암의위험과연관된다는보고가있으면서살카토닌은 FDA와국내에서처방이금지되었다. 부갑상선호르몬은이전에골다공증성척추골절이있는환자에대해시행한 Fracture Prevention Trial (FPT) 연구에서이차골다공증성척추골절의상대위험감소는 65% (RR 0.35, 95% CI 0.22-0.55) 라고보고되고있다. 21) 또한, 비척추골절의발생을 53% (RR 0.47, 95% CI 0.25-0.88) 감소시켰다고보고되었다. 21) 이와같은부갑상선호르몬의이차골절예방효과는 9-12 개월치료하였을때명확해진다고알려져있다. 22) 그러나, 부갑상선호르몬은고칼슘혈증을유발할수있기때문에 23) 약제사용전에혈중칼슘수치를측정하여고칼슘혈증이있는지확인하여야하며, 부갑상선기능항진증이나파젯병, 골격악성종양이있는경우에는투여할수없다. 2. 보조기보조기는골절된추체를안정화시키고후만변형이나추체압박등의변형을방지하며, 통증을경감시키면서조기에보행을시키는목적이있다. 그러나, 보조기착용은근육위축, 피부자극및호흡제한, 비용발생등의부작용이있다. 이상적인보조기는가볍고, 착용이간편하고, 순응도를높일수있도록편리하고, 호흡기능억제를최소화해야한다. 골다공증척추골절에서사용할수있는보조기로는, 불안정골절의경우 body jackets brace나 thoracolumbosacral orthoses (TLSO) brace 를사용할수있으며, 흉추골절에대해서는 thoracolumbar orthoses (TLO) 가사용된다. 또한, Jewett brace나 cruciform anterior spinal hyperextension (CASH) brace 등과신전보조기 188
Journal of Korean Society of Spine Surgery Conservative Treatment of OSFs 가많이사용된다. 골다공증성척추골절에서보조기착용의효과를비교한연구가많지않는데, 김등은 24) 단분절골다공증성척추골절환자를보조기를하지않은군, 연성보조기를착용한군, 경성보조기를착용한군으로나누어서 Oswestry Disability Index score, 통증, 전방추체압박률을비교한결과세군간에유의한차이가없었다고보고하였다. 그러나, 메타분석에서보조기를착용한경우가보조기를착용하지않은경우보다중기간의통증감소와장애감소에유의한효과를보인다고보고하였고, 25) 일상생활에서의장애의감소정도도보조기를착용한경우가착용하지않은경우보다유의하게크다고보고하였다. 25) 또한, 일부연구에서는후만각교정에도보조기를착용한경우가착용하지않은경우보다효과가있다고보고하고있다. 따라서, 골다공증성척추골절환자에게증상호전과장애호전을위해선택적으로보조기착용을권유할수있다고판단된다. 3. 운동치료골다공증성골절이발생하면단기간의침상안정후에환자를재활과운동을통해조기에움직이도록해야한다. 운동치료는골다공증환자에서골밀도를증가시키고 26) 낙상이나골절을예방하며 27) 임상결과를향상시킨다고알려져있다. 27) 따라서, 골다공증환자에서척추주변근육강화운동과 28) 매일체중부하운동을하고, 밸런스향상을위한운동을함께하는것이권장되고있다. 운동치료로척추신전근운동, 다양한체중부하운동, 밸런스운동, 스트레칭, 상하지및체간근력강화운동등이추천되나어느운동이다른운동에비해우수한결과를가져왔다는근거는없다. 골다공증척추골절이있는환자에서운동치료에대한연구는부족하다. 골다공증척추골절의병력이있는여성에대한연구에서, circuit exercise 는운동성과건강관련삶의질지표를향상시키고, 29) 운동이체간신전근력과심리증상을호전시키며, 30) 또한운동이삶의질과밸런스를향상시키지만 timed up and go test, sickness impact profile, 골밀도는향상시키지못했다고보고되었다. 31) 그러나, 골다공증척추골절환자에서운동치료에대한통합분석에서는 timed up and go test 는운동에의해유의하게향상된다고알려져있다. 28) 따라서, 골다공증척추골절환자에서운동치료는 Class 1 수준으로추천된다. 4. 도수치료고령의골다공증성척추골절환자에서배부통에대한수기치료는일부무작위배정임상시험에서배부통과기능평가에서효과적이었고특별한부작용은없었다는보고가있으나연구대상 자수가적고추시기간이짧아서치료법으로추천하기에는근거가부족하다. 골다공증성척추골절환자에대해운동치료와수기치료를병행한결과통증과기능상에서호전을가져왔다는연구가있으나역시연구대상자수가적고도수치료단독효과를입증하기어려워치료법으로추천하기에근거가부족하다. 32) 결론 골다공증성척추골절이발생하면단기간의침상안정과함께진통제등의처방을통해적극적인통증조절을시행해야하며, 환자의상태가가능하다면보조기를착용해서보행및운동을시행해야한다. 또한, 척추주변근육강화운동과재활운동을시행하는것이임상결과를호전시키는데도움이된다. 이차골절을예방하기위해서는알렌드로네이트, 리세드로네이트, 이반드로네이트, 졸레드로네이트등의비스포스포네이트와, 랄록시펜, 바제독시펜등의선택적여성호르몬수용체조절제, 스트론튬라넬레이트, 부갑상선호르몬등이차골절예방이입증된골다공증치료제를적극적으로투여해야한다. REFERENCES 1. Robin H, Juliet M. A new system for grading recommendations in evidence based guidelines. BMJ. 2001;323:334-6. 2. Gerdhem P. Osteoporosis and fragility fractures: Vertebral fractures. Best Pract Res Clin Rheumatol. 2013;7:743-55. 3. Cherubiono P, Sarzi-Puttini P, Zuccaro SM, et al. The management of chronic pain in important patient subgroups. Clin Drug Investig. 2012;32:35-44. 4. Cherasse A, Muller G, Ornetti P, et al. Tolerability of opioids in patients with acute pain due to nonmalignant musculoskeletal disease. A hospital-based observational study. Joint Bone Spine. 2004;71:572-6. 5. Longo UG, Loppini M, Denaro L, et al. Osteoporotic vertebral fractures: current concepts of conservative care. Br Med bull 2012;102:171-89. 6. van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low back pain. Cochrane Database Syst Rev. 2003;2:CD004252. 7. Cauley JA, Black D, Boonen S, et al. Once-yearly zoledronic acid and days of disability, bed rest, and back pain: randomized, controlled HORIZON Pivotal Fracture Trial. J Bone Miner Res. 2011;26:984-92. 189
Jae Hyup Lee et al Volume 22 Number 4 December 2015 8. Rovetta G, Maggiani G, Molfetta L, et al. One-month follow-up of patients treated by intravenous clodronate for acute pain induced by osteoporotic vertebral fracture. Drugs Exp Clin Res. 2001;27:77-81. 9. Rovetta G, Monteforte P, Balestra V. Intravenous clodronate for acute pain induced by osteoporotic vertebral fracture. Drugs Exp Clin Res. 2000;26:25-30. 10. Armingeat T, Brondino R, Pham T, et al. Intravenous pamidronate for pain relief in recent osteoporotic vertebral compression fracture: a randomized double-blind controlled study. Osteoporos Int. 2006;17:1659-65. 11. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 1996;348:1535-41. 12. Wells GA, Cranney A, Peterson J, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;1:CD001155. 13. Reginster J, Minne HW, Sorensen OH, et al. Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. Osteoporos Int. 2000;11:83-91. 14. Wells G, Cranney A, Peterson J, et al. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008;1:CD004523. 15. Delmas PD, Recker RR, Chesnut CH 3rd, et al. Daily and intermittent oral ibandronate normalize bone turnover and provide significant reduction in vertebral fracture risk: results from the BONE study. Osteoporos Int. 2004;15:792-8. 16. Chesnut CH 3rd, Skag A, Christiansen C, et al. Effects of oral ibandronate administered daily or intermittently on fracture risk in postmenopausal osteoporosis. J Bone Miner Res. 2004;19:1241-9. 17. Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. Multiple Outcomes of Raloxifene Evaluation (MORE) Investigators. JAMA. 1999;282:637-45. 18. Silverman SL, Christiansen C, Genant HK, et al. Efficacy of bazedoxifene in reducing new vertebral fracture risk in postmenopausal women with osteoporosis: results from a 3-year, randomized, placebo-, and active-controlled clinical trial. J Bone Miner Res. 2008;23:1923-34. 19. Meunier PJ, Roux C, Seeman E, et al. The effects of strontium ranelate on the risk of vertebral fracture in women with postmenopausal osteoporosis. N Engl J Med. 2004; 350:459-68. 20. Chesnut CH 3rd, Silverman S, Andriano K, et al. A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporotic fractures study. PROOF Study Group. Am J Med. 2000;109:267-76. 21. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001;344:1434-41. 22. Cheng MH, Chen JF, Fuh JL, et al. Osteoporosis treatment in postmenopausal women with pre-existing fracture. Taiwan J Obstet Gynecol. 2012;51:153-66. 23. Eastell R, Nickelsen T, Marin F, et al. Sequential treatment of severe postmenopausal osteoporosis after teriparatide: final results of the randomized, controlled European Study of Forsteo (EUROFORS). J Bone Miner Res. 2009;24:726-36. 24. Kim HJ, Yi JM, Cho HG, et al. Comparative study of the treatment outcomes of osteoporotic compression fractures without neurologic injury using a rigid brace, a soft brace, and no brace: a prospective randomized controlled noninferiority trial. J Bone Joint Surg Am. 2014;96:1959-66. 25. Rzewuska M, Ferreira M, McLachlan AJ, et al. The efficacy of conservative treatment of osteoporotic compression fractures on acute pain relief: a systematic review with metaanalysis. Eur Spine J. 2015;24:702-14. 26. Howe TE, Howe TE, Rochester L, et al. Exercise for improving balance in older people. Cochrane Database Syst Rev. 2011;11:CD000333. 27. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146. 28. Giangregorio LM, Macintyre NJ, Thabane L, et al. Exercise for improving outcomes after osteoporotic vertebral frac- 190
Journal of Korean Society of Spine Surgery Conservative Treatment of OSFs ture. Cochrane Database Syst Rev. 2013;1:CD008618. 29. Bergland A, Thorsen H, Kåresen R. Effect of exercise on mobility, balance, and health-related quality of life in osteoporotic women with a history of vertebral fracture: a randomized, controlled trial. Osteoporos Int. 2011;22:1863-71. 30. Gold DT, Shipp KM, Pieper CF, et al. Group treatment improves trunk strength and psychological status in older women with vertebral fractures: results of a randomized, clinical trial. J Am Geriatr Soc. 2004;52:1471-8. 31. Papaioannou A, Adachi JD, Winegard K, et al. Efficacy of home-based exercise for improving quality of life among elderly women with symptomatic osteoporosis-related vertebral fractures. Osteoporos Int. 2003;14:677-82. 32. Bennell KL, Matthews B, Greig A, et al. Effects of an exercise and manual therapy program on physical impairments, function and quality-of-life in people with osteoporotic vertebral fracture: a randomised, single-blind controlled pilot trial. BMC Musculoskelet Disord. 2010;11:36. Available from: http://www.biomedcentral.com/1471-2474/11/36. 골다공증성척추골절의보존적치료 이재협 김원철 이지호 서울대학교의과대학정형외과학교실 연구계획 : 문헌고찰목적 : 골다공증성척추골절의보존적치료의최신지견을제시하고자한다. 선행문헌의요약 : 골다공증성척추골절의치료는침상안정, 진통제투약, 보조기착용, 운동및재활, 골다공증치료제투약등이있으나치료의효과에대해서는이견이있다. 대상및방법 : 문헌고찰. 결과 : 골다공증성척추골절이발생하면적극적인진통제투여, 보조기착용, 운동및재활치료를시행해야한다. 이차골절을예방하기위해서는비스포스포네이트와선택적여성호르몬수용체조절제, 스트론튬라넬레이트, 부갑상선호르몬등이차골절예방이입증된골다공증치료제를적극적으로투여해야한다. 결론 : 골다공증성척추골절환자에게효과가입증된치료를시행함으로써골절치료와함께적극적으로이차골절을예방해야한다. 색인단어 : 골다공증, 척추골절, 치료, 보존적 약칭제목 : 골다공증성척추골절의보존적치료 191