Journal of Korean Society of Spine Surgery Unilateral Biportal Endoscopy as a Treatment for Acute Radiculopathy after Osteoporotic Lumbar Compression Fracture - A Case Report - Hyoung Bok Kim, M.D., Hoon-Jae Chung, M.D. J Korean Soc Spine Surg 2019 Mar;26(1):21-25. Originally published online March 31, 2019; https://doi.org/10.4184/jkss.2019.26.1.21 Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: +82-2-483-3413 Fax: +82-2-483-3414 Copyright 2017 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://www.krspine.org/doix.php?id=10.4184/jkss.2019.26.1.21 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.krspine.org
Case Report J Korean Soc Spine Surg. 2019 Mar;26(1):21-25. https://doi.org/10.4184/jkss.2019.26.1.21 Unilateral Biportal Endoscopy as a Treatment for Acute Radiculopathy after Osteoporotic Lumbar Compression Fracture - A Case Report - Hyoung Bok Kim, M.D., Hoon-Jae Chung, M.D. Department of Orthopedic Surgery, Bumin Hospital, Seoul, Korea Study Design: Case report. Objectives: To document unilateral biportal endoscopy (UBE) as a treatment for acute radiculopathy after osteoporotic vertebral fracture. Summary of Literature Review: Acute radiculopathy after osteoporotic vertebral fracture leads to claudication. Treatment of osteoporotic vertebral fractures with accompanying radiating pain is challenging. Materials and Methods: A 74-year-old woman was diagnosed with an osteoporotic vertebral fracture at L3 after slipping and falling. Vertebroplasty was performed for the osteoporotic vertebral fracture at L3. She still complained of right lower extremity radiating pain. UBE was performed to treat acute radiculopathy. Results: Foraminal decompression using UBE was performed at the L3-4 right foraminal area. Her symptoms resolved after surgery. Conclusions: UBE is a useful treatment method for acute radiculopathy after osteoporotic vertebral fracture. Key Words: Unilateral biportal endoscopy, Osteoporotic vertebral fracture 골다공증성척추골절은폐경한 60세이상의여성에서미미한외상혹은자연적으로발생할수있다고알려져있다. 1) 대게골절부위주변에축성통증을호소하며, 대부분은 3~6주내로증상이호전되나, 심한통증의경우에는수개월까지지속될수있다고알려져있다. 골다공증성척추골절은우선침상안정, 보조기및약물치료를통한보존적치료로충분한증상호전을볼수있으나, 보존적치료에반응하지않는경우에있어서척추성형술이증상호전에도움이된다. 2,3) 하지만, 주증상이축성통증이아니라하지의방사통인경우가있는데, 이는골다공증성척추골절로인해추간공공간이좁아지면서추간공을지나는신경근의자극에의해발생한다고알려져있으며, 단순축성통증보다는치료가까다롭다고알려져있다. 4) 본저자들은골다공증성척추골절로급성방사통이발생하여보존적치료를시행하였지만, 증상호전이없던환자에게편측양방향척추내시경을이용해치료한증례를보고하고자한다. 증례보고 74세여자환자는본원내원 2주전낙상이후발생한 VAS 8 점의요통과우측하지방사통을주소로타병원에서약물및 물리치료등의보존적치료를받았으나증상호전이없고, 오 히려악화되어본원응급실에내원하였다. 내원당시움직임에 따라요통을호소하였고, 우측하지방사통으로인해파행이발 생하여서서걷기가어려운상태였다. 본원에서시행한신체검 사상요추부위에동통이외에다른신경학적증상은관찰되지 않았다. 시행한방사선검사상퇴행성측만증및요추제 3 번의압 박변형이관찰되었다 (Fig. 1). 정밀진단을위해 MRI 를시행 하였으며, 요추제 3 번의척추골절이관찰되었다 (Fig. 2A). 골 절선은척추체하부쪽에위치하였으며, 골절편이척수강중심 부위로약간뒤로밀린양상관찰되고있었다 (Fig. 2B). 또한요 Received: September 16, 2018 Revised: October 16, 2018 Accepted: December 22, 2018 Published Online: March 31, 2019 Corresponding author: Hyoung Bok Kim, M.D. ORCID ID: Hyoung Bok Kim: https://orcid.org/0000-0001-6798-6386 Department of Orthopaedic Surgery, Bumin Hospital, 389, Gonghang-daero, Gangseo-gu, Seoul, Korea TEL: +82-2-2620-0003, FAX: +82-2-2620-0100 E-mail: esshappy@daum.net Copyright 2019 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 21
Hyoung Bok Kim et al Volume 26 Number 1 March 31 2019 Fig. 1. An X-ray showing degenerative scoliosis and compression deformity at L3. Fig. 3. The patient underwent percutaneous vertebroplasty at L3. A B C Fig. 2. Magnetic resonance imaging (MRI) findings. (A) MRI shows an acute compression fracture at L3 with a fracture line (arrow) in the inferior part (1/3) of the vertebral body. (B) A fracture fragment extending to the spinal canal was noted. (C) Severe foraminal stenosis was noted at the L3-4 right foraminal area (arrow head). A B 추제 3-4번의우측추간공부위에심한협착소견이관찰되었다 (Fig. 2C). 골밀도검사상 T-score 는 -3.8로골다공증성척추골절을동반한심한골다공증으로확인되었다. 보존적치료를먼저계획하였고, 침상안정, 보조기착용및약물을이용한통증조절을시행하였다. Teriparatide 제재치료도고려하였으나, 환자분의경우보험조건을충족시키지않았으며, 경제적인이유로비급여치료는부담되어보류하기로하였다. 하지방사통에대해서는요추제 3번신경근에대한신경차단술을시행하였다. 2주간의보존적치료에도불구하고환자분이증상을지속적으로호소하여, 우선골절부위의안정화를위해척추성형술을계획하고시행하였다 (Fig. 3). 척추성형술시행한이후요통은 VAS 2점으로호전되었으나, 우측하지의방사통은 VAS 8점으로지속되었다. 이에신경차단술을총 3차례 1~2주간격으로시행하였으며, 신경차단술을시행하고 1~2 일은증상호전보이나, 이후에는다시악화되었다. 본원에서 6 C Fig. 4. Unilateral biportal endoscopy was performed. (A) Three-dimensional computed tomography scan for preoperative planning, showing the L3-4 right foraminal area (arrow). (B) The endoscopic view of the foraminal area was the same as in the 3-dimensional image, with this view of the superior articular process of L4 (*). (C) Bony decompression was done. (D) Full decompression was seen at the foraminal area. 주이상의보존적치료에도불구하고, 우측하지의방사통에의 한파행은호전되지않아요추제 3-4 번의우측추간공협착에 대한수술을계획하였다. 고령의환자분으로최소침습치료를 고려하였고, 편측양방향척추내시경을이용한추간공확장술 을시행하기로하였다. 수술전요추 3D CT 를촬영하여추간공 D 22 www.krspine.org
Journal of Korean Society of Spine Surgery Unilateral Biportal Endoscopy for Osteoporotic Vertebral Fracture A Fig. 5. Comparison of magnetic resonance imaging findings between the preoperative (A) and postoperative (B) foraminal area. 부위에감압할위치를확인하고, 0 도내시경을이용해수술을 진행하였다. 내시경시야에서추간공이충분히감압된소견이 관찰되었으며, 수술중특이사항은발생하지않았다 (Fig 4). 수술이후우측하지의방사통은 VAS 1 점으로호전되었으며, 수술후촬영한 MRI 상추간공부위가감압된소견이관찰되 었다 (Fig. 5). 환자는수술후 3 일째퇴원하였으며, 현재외래추 시중이며, 추시중특이사항은관찰되지않았다. 본논문은본원 IRB 승인 (201809-BM-004) 을받은이후진 행되었다. 고찰 골다공증성척추골절이후발생한급성방사통은요추부위 에척추골절이발생하였을때나타나며, 요추제 3 번에서제 5 번으로갈수록빈도가높아지는것으로알려져있다. 척추체골 절선이하위 1/3 에위치하고있을때호발되는것으로나타나 는데, 이는골절로인해추간공의높이가직접적으로낮아짐으 로인해신경근이지나가는추간공이좁아져방사통이발생한 다는보고가있다. 4) 본증례에서도요추제 3 번의척추골절이 발생하였으며, 척추체골절선이하위 1/3 에위치하고있었다. 또한, 골다공증성척추골절환자는보조기를착용하게되는데, 보조기가요추부의신전을유지함으로인해, 요추부의추간공 이더욱좁아져추간공증상이더심해진다고알려져있다. 4) Doo 등은척추체높이의감소로인해추간공이좁아짐으로 써신경근후측분지를자극하게되고이로인해방사통혹은 체성통증이발생한다고보고하였다. 5) 추간공협착에대한치 료로써관혈적감압술및유합술을시행할수있는데, 이러한 골다공증환자들은고령으로수술의위험성이높고, 기기고정 B 술을시행했을경우약한골질때문에기기고정실패가일어날확률이높다고하였다. 6) 이러한문제들때문에방사통이있는골다공증성척추골절환자에있어서척추성형술을시행하여, 좋은결과가있었다는보고가있는데, 이는시멘트삽입으로인해골절부위에안정성을주어추간공내의신경근충돌을완화하여증상을호전시킬수있다고보고하였다. 4) 하지만, 척추성형술에도불구하고통증이지속되고, 보존적치료에실패하였을경우수술적치료를고려할수있다. 수술적치료를고려할때는보존적치료기간을지키는것이중요한데, 고령의골다공증성척추골절환자는 8주까지골절된척추의압박이진행될수있어서, 적어도수상이후 8주이상의보존적치료를유지하는것이중요할것으로생각된다. 신경학적증상이발생하거나, 통증조절이되지않아수상이후 8주가되기전에미리수술을시행하는경우에는골절된척추의압박진행을고려하여충분한감압이필요할수있으며, 수술후골절된척추의추후압박에따라증상이재발될수있음을주의해야하겠다. 하지만, 적절한보존적치료기간에대해서는추가적인연구가필요할것으로생각된다. 최근최소침습적인치료법으로알려진편측양방향척추내시경은 0도혹은 30도내시경만있다면, 다른기구를추가로구매하지않고관혈적수술에사용하였던기구를사용해수술을진행할수있다는장점이있다. 또한, 관혈적수술경험이많은사람이라면다른척추내시경수술에비해숙련되기까지의시간이많이소요되지않아많은이들이시도하고있으며, 수술에대한임상결과도관혈적수술과비슷하다는보고가있다. 7,8) 본증례는척추성형술을포함한충분한보존적치료를수상이후타병원과본원포함하여 8주간시행하였음에도불구하고, 방사통이지속되었던환자의치료로편측양방향척추내시경을이용한추간공확장술을시행하여증상호전이관찰된증례였다. 따라서, 척추성형술을포함한충분한보존적치료에도불구하고, 지속적인급성방사통을호소하는고령의골다공증성척추골절환자에있어서편측양방향척추내시경은유용한치료법중의하나가될수있을것으로생각된다. REFERENCES 1. Tamayo-Orozco J, Arzac-Palumbo P, Peon-Vidales H, et al. Vertebral fractures associated with osteoporosis: patient management. Am J Med. 1997 Aug;103(2 Suppl):44 50. DOI: 10.1016/S0002-9343(97)90026-7. 2. Belkoff SM, Mathis JM, Jasper LE, et al. The biomechanics of vertebroplasty: the effect of cement volume on mechanical behavior. Spine (Phila Pa 1976). 2001 Jul ;26(14):1537- www.krspine.org 23
Hyoung Bok Kim et al Volume 26 Number 1 March 31 2019 41. 3. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009 Aug;361(6):557-68. DOI: 10.1056/NEJMoa0900429. 4. Kim DE, Kim HS, Kim SW, et al. Clinical Analysis of Acute Radiculopathy after Osteoporotic Lumbar Compression Fracture. J Korean Neurosurg Soc. 2015 Jan;57(1):32-5. DOI: 10.3340/jkns.2015.57.1.32. 5. Doo TH, Shin DA, Kim HI, et al. Clinical relevance of pain patterns in osteoporotic vertebral compression fractures. J Korean Med Sci. 2008 Dec;23(6):1005-10. DOI: 10.3346/ jkms.2008.23.6.1005. 6. Miller JD, Nader R. Treatment of combined osteoporotic compression fractures and spinal stenosis : use of vertebral augumentation and interspinous process spacer. Spine (Phila Pa 1976). 2008 Sep;33(19):E717-20. DOI: 10.1097/ BRS.0b013e31817f8d40. 7. Eum JH, Heo DH, Son SK, et al. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine. 2016 Apr;24(4):602-7. DOI: 10.3171/2015.7.SPINE15304. 8. Choi DJ, Kim JE, Jung JT, et al. Biportal Endoscopic Spine Surgery for Various Foraminal Lesions at the Lumbosacral Lesion. Asian Spine J. 2018 Jun;12(3):569-73. DOI: 10.4184/asj.2018.12.3.569. 24 www.krspine.org
Case Report J Korean Soc Spine Surg. 2019 Mar;26(1):21-25. https://doi.org/10.4184/jkss.2019.26.1.25 편측양방향척추내시경을이용한골다공증요추압박골절로인해발생한급성방사통의치료 - 증례보고 - 김형복 정훈재서울부민병원정형외과연구계획 : 증례보고목적 : 골다공증성척추골절이후발생한급성방사통에대한치료로서편측양방향척추내시경을보고하고자한다. 선행연구문헌의요약 : 골다공증성척추골절이후발생한급성방사통은파행의원인이될수있으며, 그에대한치료는상당히까다롭다고알려져있다. 대상및방법 : 74세여자환자는낙상이후시행한검사상요추제 3번골다공증성척추골절을진단받았다. 골다공증성척추골절로인한증상이지속되어척추성형술을시행한이후요통은호전되었으나, 우측하지의방사통은지속되었다. 이에급성방사통을치료하기위해편측양방향척추내시경을시행하였다. 결과 : 우측요추제 3-4번추간공부위에편측양방향척추내시경을이용해추간공확장술을시행하였으며, 이후환자의방사통은호전되었다. 결론 : 양방향척추내시경은골다공증성척추골절이후발생한급성방사통에대한유용한치료법으로생각된다. 색인단어 : 편측양방향척추내시경, 골다공증성척추골절 약칭제목 : 골다공증성척추골절에서의양방향척추내시경 접수일 : 2018년 9월 16일 수정일 : 2018년 10월 16일 게재확정일 : 2018년 12월 22일 교신저자 : 김형복 서울특별시강서구공항대로 389 서울부민병원 TEL: 02-2620-0003 FAX: 02-2620-0100 E-mail: esshappy@daum.net Copyright 2019 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 25