Original Article pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2012 Dec;19(4):123-130. http://dx.doi.org/10.4184/jkss.2012.19.4.123 Comparison of Cage and Allograft Mixed Bone Marrow for Monosegmental Instrumented Posterior Lumbar Interbody Fusion Chae Hyun Lim, M.D., Dae Hee Kim, M.D., Sang Ho Ahn, M.D. Yong Soo Choi, M.D. Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea Study Design: A retrospective study. Objectives: To compare the radiological and clinical results between cage and cancellous allograft mixed with bone marrow for monosegmental instrumented posterior lumbar interbody fusion (PLIF). Summary of the Literature Review: Allograft has potential problems, such as delayed union. Autologous bone marrow provides for improving the capability of bone induction with allograft. There are rare reports on PLIF using allograft mixed with autologous bone marrow. Materials and Methods: Monosegmental instrumented PLIF was performed on 51 patients who had lumbar degenerative disease, cage for 28 patients (cage group) and allograft mixed with bone marrow for 23 patients (allograft group). The clinical and radiological results in each group were compared. Results: The mean follow-up was 45 (30-111) months. At the final follow up, there was no significant difference between the cage group and the allograft group in the Korean Version Oswestry Disability Index (p=0.72) and Visual Analogue Score for back pain (p=0.54) and radiating pain to the leg (p=0.26). The radiological fusion rate was 92.8% in the cage group, and 82.6% in the allograft group (p=0.02). At the last follow up, disc height was decreased to 1.5±0.8 mm of the cage group, and 3.0±1.5 mm of the allograft group (p=0.0001). Conclusions: PLIF using cancellous allograft mixed bone marrow has low fusion rate contrast to good clinical results. It is necessary to take a careful selection of the allograft mixed bone marrow for PLIF. Key Words: Lumbar spine, Posterior lumbar interbody fusion, Cage, Cancellous allograft 서론 퇴행성요추질환의치료방법으로후방추체간유합술에사용되는추체간이식물의종류는다양하며자가장골, 국소자가골, 금속이나비금속 cage 와같은인공구조물, 동종골등이있다. 그중에서자가장골을이용하는방법이골유합등에서우수한결과를보이나이식공여부동통과출혈등단점이있어, 1-3) 자가골의대체물로동종골, 인공삽입물에이식골을채워넣는방법등많은방법들이여러저자들에의해소개되었다. 4) 공여부문제를해결하기위해후방감압시획득한국소조각골을추체간과 cage 내부에충전하여이식하는방법은성공적인결과를보여주고있으며 5,6) cage 를이용한후방추체간유합술과척추경나사못고정술은퇴행성요추질환치료에널리사용되고있다. 동종골효과에대해서는많은저자들이다양한견해를보고하고있다. 동종골의부정적인결과보고, 7-9) 와긍정적인결과들이있다. 10-13) Malloy 와 Hilibrand 14) 은동종골이유합율은낮으나공 여부장애가적기때문에이식골의선택에있어서이런문제를 함께고려해야한다고하였다. 종합해보면동종골의근본적인 문제는유합기간이지연되고역학적인안정성이약화될수있 Received: March 13, 2012 Revised: August 16, 2012 Accepted: November 15, 2012 Published Online: December 31, 2012 Corresponding author: Yong Soo Choi, M.D. Department of Orthopedic Surgery, 264 Yangrim-dong Nam-gu Gwangju, Kwangju Christian Hospital, Kwangju, Korea TEL: 82-62-650-5064, FAX: 82-62-650-5066 E-mail: stemcellchoi@yahoo.co.kr 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. Copyright 2012 Korean Society of Spine Surgery www.krspine.org 123
Chae Hyun Lim et al Volume 19 Number 4 December 2012 다는것이다. 자가골수이식은임상적으로신생골형성에우수한것으로알려져있고 15-17) 채취로인한합병증이없으나골수그자체로는골전도능력이제한되고, 골수내의골형성세포의수또한제한된양만존재하여단독으로적용하기에는한계가있다. 18,19) 저자들은후방요추체간유합술을위한방법중해면동종골의단점을보완하기위해상용화한해면동종골에자가골수를혼합하였고, 해면동종골의역학적강화를위해수술수기상고관절인공관절의골결손부를재건할때적용하는압박골이식수기를적용하여후방요추체간유합술을시행하였다. 본연구의목적은퇴행성요추질환에서단분절추체간유합술을위해자가골수혼합해면동종골삽입술의방사선학적및임상결과를 cage 내고정술과비교분석하여해면동종골의유용성을알아보고자하였다. 측에서시행하여추간판공간을충분히채운후내측후관절골편을케이지모양으로만들어입구에삽입하여파쇄해면동종골의탈출을막고추체간지지를유지하고자하였다 (Fig. 2). 3. 연구방법임상적결과는한국어판장애지수 (Korean Version Oswestry Disability Index; KODI) 20) 와요통에대한시각통증점수 (Visual Analogue Score) 를이용하여평가하였고, 측면방사선사진을이용하여유합율, 추체간간격의변화를측정하여각각비교하였다. 유합의판정은 Brantigan & Steffee 분류법 21) 을이용하여 A, B, C 단계를불유합으로, D, E 단계를유합으로판정하였으며 대상및방법 1. 연구대상 2002 년 9월부터 2008 년 6월까지본원에서퇴행성요추질환으로단분절추체간유합술을시행하였던 51예를대상으로하였다. Cage 를이용하여후방추체간유합술및감압술, 척추경나사못고정술을시행한환자중 2년이상추시가능한 28명을 cage 군으로분류하였고, cage 없이파쇄해면동종골과자가골수를혼합하여후방요추체간유합술을시행한 23명을동종골군으로분류하였다. Cage 군의평균연령은 59.5 세였으며, 남자 7명, 여자 21명이었다. 척추관협착증이 11명, 척추전방전위증이 17명이었다. L3-4 가 2명, L4-5 가 23명, L5-S1 이 3명이었다. 동종골군의평균연령은 61.3 세였으며, 남자 7명, 여자 16명이었다. 척추관협착증이 19명, 척추전방전위증이 4명이었다. L3-4 가 3명, L4-5 가 20명이었다. 추시기간은평균 45(30 ~ 111) 개월이었다. Fig. 1. Case of cage group. A 63 year old female patient who had spondylolisthesis L4 on L5 was undergone posterior lumbar interbody fusion with cage and local bone. 2. 수술방법 Cage 군에서는후방감압술후절제된추궁판과내측후방관절에서획득한국소골을 2~3mm로조각내어 cage(ogival interbody cage, Stryker) 에충진하고, 나머지국소조각골은척추체사이에충진한후 cage 를삽입하고척추경나사못과강봉을사용하여단단히압박고정을하였다 (Fig. 1). 동종골군에서는후방추체간유합술을위해추간판을철저히제거하고종판을노출시킨후상용화된해면동종골을자가장골골수와혼합하여준비된깔대기를통해압박골이식술을양 Fig. 2. Case of allograft group. Photograph of the allograft and bone block (A), this bone block (arrow) that was harvested from facet joint could be provided not only mechanical stability of the disc space as a cage but also prevention from extrusion of mosellized graft. Postoperative lateral radiograph (B). 124 www.krspine.org
Journal of Korean Society of Spine Surgery PLIF using cages or BM mixed allografts Table 1. Brantigan and Steffee classification for radiologic union Classification Description A: obvious Pseudoarthrosis, collapse of construct, loss of disc height, vertebral slip, broken screw, displacement of the carbon cage, resorption of bone graft B: probable pseudoarthrosis Significant resorption of the bone graft, major lucency or gap visible in fusion area(2>mm around the entire periphery of graft) C: uncertain(here nonunion) Bone graft visible in the fusion area at approximately the density originally achieved at surgery; a small lucency or gap may be visible involving just a portion of the fusion area at least half of graft area showing no lucency between graft bone & vertebral bone D: probable fusion Bone bridge entire fusion area at surgery; there should be no lucency beween the donor bone & vertebral bone E: fusion Bone in the fusion area is radiographically adhesive at surgery; optimally, there is no interface between the donor bone & the vertebral bone, although a sclerotic line between graft & vertebral bone indicates fusion; other sign of solid fusion include the fusion area, resorption of anterior traction spur, anterior progression of the graft within disc space, fusion of facet joint Table 2. The Clinical Results and Radiological Fusion Rate between two Groups KODI score VAS score (back pain) VAS score (radiating pain) Radiological fusion rate (B-S classification) Cage group 16.1±4.3 2.7±1.9 1.8±1.8 92.8% Allograft group 15.7±5.8 2.4±1.6 2.4±2.2 82.6% P value 0.72 0.54 0.26 0.02 KODI, Korean Version Oswestry Disability Index, VAS, Visual Analogue Score, B-S classification, Brantigan and Steffee classification (Table 1), 특히케이지군의유합판정은전후면방사선사진에 서케이지내부이식골과추체간그리고케이지주위추체간골 성연결을준용하여적용하였다. 추체간간격은상위척추체종 판의중심점에서수직선을그어하위척추체의종판과만나는 거리로정하였다 (Fig. 3). 한국어판장애지수와 VAS 를이용한요통과하지방사통은각 각 Fisher s exact 검정으로비교분석하였고, 방사선학적골유합 은 X 2 검정으로분석하였으며, 추체간높이의변화는 T 검정을 Fig. 3. The disc height was measured at the preoperative, postoperative and follow-up lateral radiograph. 이용하여분석하였다. 자료의통계학적인분석을위하여 SPSS 12.0 for Windows(SPSS, Chicago, IL, USA) 프로그램을사용하였고, 통계학적인유의수준은 0.05 로하였다. 결과 1. 임상적결과최종추시상한국어판장애지수는 Cage 군에서수술전 33.3 ±6.7 에서수술후최종추시상 16.1±4.3 으로호전되었고, 동종골군에서수술전 32.2±8.5 에서수술후최종추시상 15.7±5.8 로호전되었다. 요통의시각통증점수는 Cage 군에서수술전 6.6±2.7 에서수술후최종추시상 2.7±1.9 로호전되었고, 동종골군에서수술전 4.9±2.5 에서수술후최종추시상 2.4±1.6 으로호전되었다. 하지방사통의시각통증점수는 Cage 군에서수술전 5.0±3.3 에서수술후 1.8±1.8 로호전되었고동종골군에서수술전 7.0±1.9 에서수술후최종추시상 2.4±2.2 로호전되었다. 한국어판장애지수 (p=0.72), 요통 (p=0.54) 과하지방사통 (p=0.26) 의시각통증점수에서각각두군간에유의한차이는없었다 (Table 2). www.krspine.org 125
Chae Hyun Lim et al Volume 19 Number 4 December 2012 Fig. 4. Revision for one case of allograft group. At 6-months follow-up, radiograph shows loss of disc height and absorption of the allograft (B). Histological finding reveals inflammation around dead allograft (C). After radical curettages, two cages filled with autograft were inserted (D) and at 40-months follow-up, computed tomographs show well bony fusion and loss of disc height (E). 126 www.krspine.org
Journal of Korean Society of Spine Surgery PLIF using cages or BM mixed allografts Table 3. The Changes of Disc Height on Lateral Radiograph Preoperative Postoperative Last follow up Cage group 8.6±2.4mm 13.3±1.3mm 11.8±1.2mm Allograft group 9.3±2.4mm 14.2±2.4mm 11.2±2.1mm P value 0.47 0.0001 2. 방사선학적결과방사선학적으로추체간유합은 Cage 군 28 예중에서 26예 (92.8%) 에서유합, 동종골군에서 23 예중에서 19 예 (82.6%) 의유합을얻었다. 동종골군의유합률이낮았다 (p=0.02). 추간판간격의변화는 Cage 군에서평균수술전 8.6±2.4mm 에서수술직후 13.3±1.3mm 로회복되어최종추시상 11.8±1.2mm 로감소하였다. 동종골군에서평균수술전 9.3±2.4mm 에서수술직후 14.2±2.4mm 로회복되어, 최종추시상 11.2±2.1mm 로감소하였다. 수술직후추간판높이의회복정도는 Cage 군에서평균 4.6±2.6mm, 동종골군에서 5.1±2.4mm 로양군간차이가없었으나 (p=0.47) 최종추시상 Cage 군평균 1.5±0.8mm, 동종골군평균 3.0±1.5mm 소실되어 Cage 군이추체간높이유지에양호한결과를얻었다 (p=0.0001)(table 3). 방사선학적으로 Cage 군 2 예, 동종골군 4 예에서불유합의결과를얻었으나 Cage 군 2 예와동종골군 3예는임상증상이양호하여추적관찰하였으며, 동종골군 1예에서이식골의흡수및추체간격감소와요통으로수술후 6개월째 cage 고정및척추경나사못의재삽입술을시행하였다 (Fig. 4). 3. 합병증수술의합병증으로감압술중에발생한경막손상이 cage 군에서 2예있었으며신경근증상의합병증없이치료되었다. 고찰 요추의추체간유합술을위한이식골로자가장골은잘알려진바와같이숙련된수술자가시행하더라도이식공여부동통, 심부감염, 이식공여부의골절등의단점이있고, 1-3) 다분절유합이나불유합에따른재수술시제한된양으로인한문제가있어현재다양한골이식대체물에대한연구및개발이진행되고있다. Cage 를이용한추체간유합술과후방기기고정술은최근가장널리쓰이는수술방법으로 cage 내에수술시제거된국소골을 cage 내부에삽입하여사용함으로써이식골의역학적기능을 cage 가수행하여높은안정성과요추전만도회복에유용한술식이다. Okuyama 등 5) 의보고에의하면 93.5% 높은유합율과비교적높은임상적만족도를보여주고있다. 저자들의 cage 군도유합율 92.8%, 임상적결과가양호하여유사한결과를얻었다. 자가골의대체물로동종골은자가골사용의단점인채취에따른문제점이없고, 인공삽입물과달리생물학적인유합이가능하며그리고생역학적으로도추체와물성이비슷한장점이있다. 하지만동종골이식술은몇가지약점이있다. 먼저골유합율면에서 An 등 9) 은자가골과동종골을이용하여척추의후외측유합율을시행함에있어서자가골은 80% 의유합율을보이나동종골은 45% 의유합율을얻었다고보고하였고, Brantigan 등 21) 은동종골을이용한요추추체간유합술후 56% Fig. 5. At 36 months follow-up, radiograph (A) and MRI (B) didn t achieved bony fusion of the allograft exactly. But at 54 months follow-up, radiograph revealed well bony fusion and maintenance of the disc height. www.krspine.org 127
Chae Hyun Lim et al Volume 19 Number 4 December 2012 골유합성공율을보고하여동종골의골유합율의성적이자가골과비교할때좋지않았다. 최근골유합을향상시키기위해동종골에 BMP를혼합하여우수한유합결과가보고되고있으나, 22) Vaidya 등 23) 은동종골의골유도능을위해재조합 BMP를혼합하여골유합율은크게향상시켰으나이식골의침강이 50% 이상에서발생하여더이상혼합사용을권하지않는다보고하였다. 자가골수는 1986 년 Connolly 와 Shindell 24) 이발표한경골의불유합을치료하기위해자가골수의경피적주입으로치료한결과를보고한이후골형성능력이있는세포를쉽게얻을수있는방법으로임상에서사용되어지고있다. 그러나자가골수는그자체로는골전도능력이제한되어파쇄동종골과혼합사용한경우우수한임상결과의보고가점차늘고있다. 17,25) Curylo 등 26) 은후외방유합술토끼모델에서탈무기질동종골과자가골수혼합의결과가방사선학적유합율 76.5%, 탈무기질단독사용의 52.3% 보다높은결과로자가골수의척추후외방유합술모델에서자가골수의역할을보여주었다. 따라서자가골수와해면동종골혼합이식은이론적으로동종골이가지고있는골전도성과제한적이지만자가골수의골유도성과골형성세포를활용할수있는좋은방법으로사료된다. 저자들의결과에서 82.6% 의방사선학적골유합의결과를얻어이전의동종골을이용한유합술의연구보다유합율이향상된결과를얻었으나케이지고정보다낮은유합의결과를얻었다. 또한저자들이초기불유합으로판정한해면동종골이식환자의 36개월추시방사선및자기공명검사에서해면동종골이자가골로완전치환되지않았으나 54개월추적방사선사진에서완전골유합을이루어 (Fig. 5), 해면동종골의추적관찰에서골유합을얻을가능성을시사하였다. 또하나의약점으로역학적으로안정성이뛰어난특성을가진자가피질골과달리해면동종골은안정성이떨어져동종골이식후이식골의추체내로침강또는붕괴가일어날수있다는것이다. 27) 해면동종골의압박골이식수기가인공고관절치환술의골결손을재건이나대퇴골두무혈성괴사에서핵심감압술후압박골이식술의임상적적용의양호한결과가보고되고있어, 28) 해면동종골의역학적취약점을보완하는방법으로저자들은파쇄해면동종골의압박골이식술을시행하였고추가적으로감압으로채취된내측후관절골편을케이지처럼지지골로사용하였다. 그러나압박골이식술과내측후관절골편의지지대사용에도추체간높이유지에한계가있었다. 본논문이환자의흡연이나질환등특성조사가되지않았고, 대상환자수가적을뿐아니라대상환자의적응증의차이, 후향적조사의제한점이있으나, 요추후방추체간유합술을위한자가골수혼합해면동종골의압박골이식수기의적용은기존 에보고된동종골이식술보다는골유합을향상시킨결과를고려할때자가골이식의대체방법의하나로선택될수있으리라사료되며, 향후많은환자를대상으로불유합위험군연구등동종골이식의금기증연구가필요하리라사료된다. 결론 요추후방추체간유합술에서자가골수혼합해면동종골은임상적으로양호한결과를얻었으나방사선학적으로추체간유합에불량한결과로자가골수혼합해면동종골이식술의요추후방추체간유합술적용에신중한선택이필요하리라사료된다. REFERENCES 1. Enker P, Steffee AD. Interbody fusion and instrumentation. Clin Orthop Relat Res. 1994;300:90-101. 2. Lin PM. Posterior lumbar interbody fusion technique: complications and pitfalls. Clin Orthop Relat Res. 1985;193:90-102. 3. Verlooy J, De Smedt K, Selosse P. Failure of a modified posterior lumbar interbody fusion technique to produce adequate pain relief in isthmic spondylolytic grade 1 spondylolisthesis patients: A prospective study of 20 patients. Spine (Phila Pa 1976). 1993;18:1491-5. 4. Brantigan JW, Steffe AD, Geiger JM. A carbon fiber implant to aid interbody lumbar fusion. Mechanical testing. Spine (Phila Pa 1976). 1991;16(6 Suppl):S277-82. 5. Okuyama K, Kido T, Unoki E, Chiba M. PLIF with a titanium cage and excised facet joint bone for degenerative spondylolisthesis in augmentation with a pedicle screw. J Spinal Disord Tech. 2007;20:53-9. 6. Miura Y, Imagama S, Yoda M, Mitsuguchi H, Kachi H. Is local bone viable as a source of bone graft in posterior lumbar interbody fusion? Spine (Phila Pa 1976). 2003;28:2386-9. 7. Jorgenson SS, Lowe TG, France J, Sabin J. A prospective analysis of autograft versus allograft in posterolateral lumbar fusion in the same patients: A minimum of 1-year followup in 144patients. Spine (Phila Pa 1976). 1994;19:2048-53. 8. Aurori BF, Weierman RJ, Lowell HA, Nadell Cl, Parsons JR. Pseudoarthrosis after spinal fusion for scoliosis: A com- 128 www.krspine.org
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Chae Hyun Lim et al Volume 19 Number 4 December 2012 단분절후방요추체간유합술에서 Cage 내고정군과자가골수혼합동종골군의 방사선학적및임상결과비교 임채현 김대희 안상호 최용수광주기독병원정형외과 연구계획 : 후향적연구 목적 : 퇴행성요추질환에서단분절추체간유합술을위해 cage 내고정술과자가골수혼합해면동종골삽입술의방사선학적및임상결과를비교하 였다. 선행문헌의요약 : 동종골의문제로유합기간지연이지적되고있다. 자가골수이식은신생골형성에우수한것으로알려져있어요추질환에서추체간 유합술을위해자가골수혼합동종골삽입술결과보고는드물다. 대상및방법 : 퇴행성요추질환으로단분절추체간유합술을시행하였던 51 예를대상으로하였다. Cage 를이용한 28 예를 Cage 군으로, cage 없이해 면동종골과자가골수를혼합하여후방요추체간유합술을시행받은 23 예를동종골군으로분류하였다. 두군간의임상적및방사선학적결과를비교 분석하였다. 결과 : 45(30-111) 개월추적조사되었다. 최종추시상한국어판장애지수 (p=0.72), 요통 (p=0.54) 과하지방사통 (p=0.26) 의시각통증지수에서 Cage 군과동종골군간차이를보이지않았다. 방사선학적추체간유합율은 Cage 군 92.8%, 동종골군이 82.6% 로동종골군의유합률이낮았다 (p=0.02). 최종추시상추체간높이가 Cage 군평균 1.5±0.8mm, 동종골군평균 3.0±1.5mm 소실되어 Cage 군이추체간높이유지에양호한결과를얻었다 (p=0.0001). 결론 : 요추후방추체간유합술에서자가골수혼합해면동종골은임상적으로양호한결과를얻었으나방사선학적으로추체간유합에불량한결과로 자가골수혼합해면동종골이식술의요추후방추체간유합술적용에신중한선택이필요하리라사료된다. 색인단어 : 요추, 후방추체간유합술, Cage, 해면동종골 약칭제목 : 케이지또는해면동종골을이용한요추유합술 130 www.krspine.org