대한척추외과학회지제 15 권제 3 호 Journal of Korean Spine Surg. Vol. 15, No. 3, pp 140~148, 2008 전방유합술을이용한단분절경추간판탈출증의치료 - 금속판고정술과케이지의비교 - 박희전 심영준 양재형 연세대학교원주의과대학정형외과학교실 Anterior Decompression and Fusion in the Treatment of Single-level Cervical Disc Herniation - Plate Fixation vs Cage - Heui-Jeon Park, M.D., Young-Jun Shim, M.D., Jae-Hyung Yang, M.D. Department of Orthopaedic Surgery Yonsei University, Wonju College of Medicine, Wonju, Korea. Abstract Study Design: This is a retrospective study. Objectives: We analyzed the radiological and clinical results to verify the efficacy of anterior interbody fusion with using cages gradually increases in the treatment of cervical radiculopathy. Summary of the Literature Review: Anterior cervical decompression and fusion is well accepted treatments for cervical radiculopathy. Performing anterior interbody fusion using cages has recently gradually increased to minimize the extent of surgery. While there are numerous reports on the primary stabilizing effects of the cervical cages, little is known about the subsidence behavior of such cages in vivo. Materials and Methods: We retrospectively analyzed 38 patients with cervical disc herniation who underwent anterior decompression and interbody fusion with autoiliac bone graft and plate fixation (Group I, 21 patients) or who underwent with standalone cage (Group II, 17 patients). We statistically analyzed the changes of the cervical lordosis, the segmental lordosis, the vertebral body height, the fusion rate on the plain x-ray and the clinical results with using a pain visual analogue scale. Results: All the cases were fused by 11.2±2.7 weeks after operation. The changes of the cervical lordosis and segmental lordosis show no statistically significant difference between the two groups (p=0.07, 0.66). The anterior and posterior vertebral heights of the fused segments of group II were more decreased than those of group I, but there was no statistically difference between the two groups (p=0.06, 0.30). The clinical results were not statistically difference between the two groups (p=0.64, 0.45). Conclusions: Implantation of autoiliac cancellous bone impacted stand-alone cages or on a tricortical iliac crest autograft after anterior decompression was safe and reliable options for the treatment of cervical disc herniation that causes single level radiculopathy. Both procedures produced equally satisfying clinical and radiological results, leading to a high fusion rate and they maintained the intervertebral height. Address reprint requests to Heui-Jeon Park, M.D. Department of Orthopaedic Surgery, Wonju College of Medicine, Yonsei University 162 Ilsan-dong, Wonju, Kangwon-do, Korea Tel: 82-33-741-1352, Fax: 82-33-746-7326, E-mail: par73@yonsei.ac.kr 본논문은 AOSpine Korea 의연구비지원기금의일부를지원받았음. - 140 -
전방유합술을이용한경추간판탈출증의치료 박희전외 Key Words: Cervical radiculopathy, Anterior interbody fusion, Cage 서 론 경추간판탈출로인한단분절신경병증의수술적치료는여러가지방법이있으나전방감압후유합술을시행하는방법이많이이용되고있다. 전방감압을위한추간판제거후추간판을대체할삽입물이필요하며지난 50 여년동안자가장골이가장많이이용되어왔다. 전방유합술은추간공의유지, 빠른안정성의회복, 경추의생리적전만을유지시킬수있는장점이있는반면수술시간이길고, 삽입물의탈출, 자가장골이식에따른골공여부의동통, 동종골사용에따른합병증등이있다. 이러한골이식의단점, 삽입물의붕괴및전위등의문제점을극복하기위해새로운추체간삽입물이개발, 발전되어왔으며지난수년간추체간케이지의사용이증가하고있다. 추체간케이지의삽입은골공여부의합병증을줄일수있는방법이기는하나불유합의증가, 케이지의침하 (subsidence) 로인한동통및신경증상재발등의문제점이있다. 또한추체간유합술은인접분절의퇴행성병변을가속화시킨다고하여최근에는추간판치환술이시행되고있으나전방유합술보다우월한결과가보고되지는않고있다. 본연구는경추간판탈출로인한단분절경추신경근병증이있는환자에서전방감압후자가장골이식과금속판고정술을시행또는자가장골을충전한케이지를단독으로사용하여유합술을시행하고 1 년이상추시결과를분석하여유합방법에따른임상적, 방사선학적차이를알아보고자한다. 연구대상및방법 2001년 1월부터 2006년 12월까지본원에서단분절의경추간판탈출로인한경추신경근병증이있는환자에서전방감압및유합술을시행하고 1년이상추시가능하였던환자 38명을대상으로하였으며추시기간은평균 16.2개월 (14~70개월) 이었다. 수술의적응증은 3개월이상의보존적치료를시행하였으나퇴행성병변에의한신경근병증소견이지속되고자기공명영상과일치되는소견을보인환자를대상으로하였으며척수병증, 정신과적문제가있는환자, 약물남용및전에수술을받았던환자는제외하였다. 자가장골이식과금속판고정술 (I군) 은 2001년 1월부터 2004년 2월까지, 케이지를이용한유합술 (II군) 은 2004년 3월부터 2006년 12월까지시행하였으며나이, 성별, 증상기간, 흡연여부, 추시기간이두군간에차이를보이지않았다 (Table 1). 수술부위는제 4-5경추간 10례, 5-6경추간 19례, 6-7경추간 9례이었으며자가장골이식및금속판고정은 21 례에서 (Fig. 1), 케이지를이용한유합술은 17례에서시행하였다 (Fig. 2). 수술은동일집도의에의해 Smith-Robinson 1) 술식에의한전방도달법을이용하여추간판, 후종인대, 골극, 구상돌기의후면을제거하고종판연골을소파기 (curette), 골도, 연마기 (burr) 를이용하여추체간종판에출혈이될때까지제거하였으며삽입물에대한체중부하면 (weight bearing surface) 의기능을할수있도록종판피질골이보존되도록하였다. 21례에서는추간판제거후자가장골삼중피질골이식후금속판 (Cevical Spine Locking Plate, Synthes, Davos, Switzerland) 고정을시행하였고, 나머지 17례에서는 PEEK 케이지 (Solis, Stryker, South Allendale, NJ, U.S.A.) 를자가장골능에서특수고안된원통형절단기 (dowel cutter) 를이용하여채취한해면골을충전한후삽 Table 1. Demography of sampling errors Plate group (n=21) Cage group (n=17) P-value Age (years) 46.4±5.2 47.2±6.8 0.833 Sex (M/F) 12/9 10/7 0.498 Smoking 6 5 0.531 Follow-up (months) 16.4±5.6 15.9±1.9 0.273 C4-5 5 4 Fusion level C5-6 11 9 0.841 C6-7 5 4-141 -
대한척추외과학회지 Vol. 15, No. 3, 2008 Fig. 1. 36-years-old female with cervical disc herniation on C3-4. (A) Preoperative lateral roentgenogram. (B)Lateral radiograph, immediately after surgery, shows anterior cervical fusion with autogenous iliac bone and cervical locking plate. (C) Lateral radiograph, 6years after surgery, shows the solid union of grafted bone. (D) Lateral roentgenogram of flexion/extention view that shows no motion at fused level. (E) Sagittal MRI, 6years after surgery, shows the solid union at fused level. Fig. 2. 43-years-old female with cervical disc herniation on C4-5. (A) Preoperative lateral roentgenogram. (B), (C) T1 weighted sagittal and axial MRI image show a C4-5 disc herniation. (D) Lateral radiograph, immediately after surgery, show anterior cervical fusion with Solis PEEK cage that packed with cancellous iliac bone. (E) Lateral radiograph, 16 months after surgery, shows the solid union at fused level but disc height is decreased slightly than after surgery. 입하였다. 술후고정은전례에서골유합시까지 Miami J 보조기를착용하였다. 임상적결과는경부동통및방사통에대해통증강도 (pain visual analogue scale: VAS) 를이용하여평가하였으며, 방사선학적평가는이식물의전위및흡수, 고정의안정성등을알아보기위해수술후및최종추시에서측면방사선사진을이용하여경추전만각, 유합분절의 전만각, 유합분절의전후방높이변화를측정하였다. 경추전만각은제 2 경추하연에서제 7 경추상연이이루는각으로, 유합분절의전만각은유합된분절의상부추체상연과하부추체하연이이루는각으로하였다. 유합분절의높이변화는방사선촬영시확대비율에따른오차를줄이기위하여유합분절상부추체에대한비율로계산하여추체높이변화를백분율로표시하였으며, 전방 - 142 -
전방유합술을이용한경추간판탈출증의치료 박희전외 추체높이는유합분절상부추체전상연과하부추체전하연의길이, 후방추체높이는유합분절상부추체후상연과하부추체후하연의길이로하였다 (Fig. 3). 골유합의판단은측면굴신 (flexion-extension) 평면방사선사진에서극돌기의운동이없고, 이식골과추체종판간에방사선투과선이없고, 연속된골교의형성, 이식골과추체간에골소주가형성되어있는경우로하였으며, 불유합은이식골과추체사이에골교가형성되지않거나, 굴신측면방사선사진에서극돌기사이에운동이있거나, 이식골과추체사이에방사선투과선이보이는경우로하였다. 각각의결과를자가장골이식및금속판고정술을이용한유합술과케이지를이용한유합술의두가지유합방법에따라비교하였다. 통계학적분석은 SPSS Ver. 12.0 프로그램을이용하여두군간의경추전만각, 유합분절전만각, 추체높이의변화는 paired T-test 로, 성별, 흡연, 유합부위의양군간의비교는 Pearson Chi-square 로검정하였다. 결 과 1. 임상적결과 임상적결과는통증강도를이용하여평가하였으며, 경부통증은금속판을이용한고정군에서술전 68±13 mm, 마지막추시에서 23±19 mm 로, 방사통은 79±17 mm 에서 15±11 mm 로, 케이지군에서는경부통증은 71 ±12 mm 에서 22±11 mm 로, 방사통은 81±14 mm 에서 18±12 mm 로감소하여양군간에차이를보이지않았다 (p=0.64, 0.45). 2. 전만각의변화 경추전만각은금속판고정군에서술전 13.7±7.4 도, 술후 8.5±5.3 도, 최종추시 12.6±4.7 도, 케이지고정군에서는각각 12.5±8.0 도, 11.9±6.4 도, 12.7±6.4 도로양군간의차이는보이지않았다 (p=0.66, 0.09, 0.94). 유합분절의전만각은금속판고정군에서는술전 3.2±2.7 도, 술후 5.8±4.8 도, 최종추시 3.6±2.9 도, 케이지고정군에서는각각 4.1±3.3 도, 4.2±3.1 도, 2.7±3.6 도로양군간에통계학적차이를보이지않았다 (p=0.34, 0.26, 0.38). 최종추시에서술후에비해유합분절의전만각은금속판고정군에서는 2.1±3.8 도, 케이지군에서는 1.6 ±3.8 도감소하여양군간에차이를보이지않았다 (p=0.66, Table 2). 3. 유합분절높이의변화 방사선사진촬영에따른오차를최소화하기위해유합상부추체에대한백분율로표시하였으며, 유합분절의전방높이변화는금속판고정군에서는술후에비해최종추시에서 2.3±8.0% 감소, 케이지군에서 7.1±6.4% 감소, 후방높이는각각 1.3±9.2%, 4.4±7.0% 감소하여케이지삽입군에서유합분절의높이가더많이감소하는경향을보였으나통계학적차이는보이지않았다 (p=0.06, 0.30, Table 2). 4. 수술시간및술후경과 Fig. 3. Radiograph showing linear and angular measurement. 골유합은술후평균 11.2±2.7 주에전례에서얻을수있었으며, 금속판고정군에서평균 10.9±3.6 주에, 케이지군에서평균 12.2±2.2 주에이루어졌으며양군간의차이를보이지는않았다 (p=0.07). 수술시간은금속판고정군에서 110.7±28.6 분, 케이지사용군에서 100.4± 20.0 분으로양군간에통계학적차이를보이지않았다 - 143 -
대한척추외과학회지 Vol. 15, No. 3, 2008 (p=0.25). 술후합병증으로는 7 례에서연하곤란 (dysphagia) 이있었으나특별한치료없이 3-5 일후에증상소실되었으며, 골공여부의동통은금속판고정군에서는술후 3 개월에 4 명 (19%) 에서, 1 년후에는 2 명 (10%) 에서골공여부에동통을호소하였으며, 케이지군에서는술후 3 개월에 1 명 (6%) 에서동통을호소하였고 6 개월후에는특별히골공여부에동통을호소하는사람은없었다. 고 찰 경추의추체간전방유합술은 1958 년 Robinson 과 Smith 1), Cloward 2) 에의해소개된이래지난 50 여년동안퇴행성경추질환의치료에많이이용되고발전되어왔다. 전방유합술의기본적인개념은수술적치료를시행한분절에서골유합이이루어질때까지추간판간격의유지와이식골의붕괴가일어나지않도록안정성이유지되도록하는데있다. 경추간판탈출증의치료로 1977 년 Wilson 과 Campbell 3) 이단독으로추간판제거만을시행하여좋은결과를보고한이래전방추간판제거술단독으로치료한보고도있으나경부동통의증가, 추간공간격감소, 경추전만감소등의합병증있어 4,5), 대부분의척추외과의사들은경추의전방감압과유합술을선호 한다. 그러나유합을위해삽입한이식골의전위, 붕괴, 흡수로인해신경의압박, 불안정성, 불유합등이발생될수있으며이를방지하기위해전방금속판고정을병행하여사용하는것이일반적이나인접분절의퇴행성병변을가속시킨다는단점이있다. 자가장골이식을이용한전방유합술은경추의퇴행성병변뿐만아니라골절 - 탈구의치료에도이용되어왔으며 6), 높은골유합율, 추간판간격의유지, 국소전만유지와저렴한비용등의장점이있다. 그러나이식골채취로인한골공여부의출혈, 동통, 골절, 혈종, 마비성대퇴신경통 (meralgia paresthetica) 등의합병증이생길수있어 7) 동종골을사용하기도하나, 이는유합율이낮고골공여자의질환에이환 (disease transmission) 될위험이있다. 이러한자가골또는동종골이식의단점들때문에추체간케이지의사용이증가하고있는추세이고, 또한최근에는분절운동을보존하고인접분절에생길수있는합병증을예방하는방법으로인공추간판치환술이이용되고있으나장기추시에서전방감압및유합술보다우월한결과가보고되지않고있다 8). 케이지를이용한유합술은 1979 년 Bagby 9) 에의해말의경추병변치료에처음으로사용되었으며, 임상적으로는 1990 년대요추에서원통형혹은사각형모양의케이지를이용한유합술이시작되었다 10,11,12). 그후작은모 Table 2. Radiological comparison between two groups Plate group (n=21) Cage group (n=17) P-value Lordotic angle ( ) Preoperation 13.7±7.4 12.5±8.0 0.658 Postoperation 8.5±5.3 11.9±6.4 0.090 Last Follow-up 12.6±4.7 12.7±6.4 0.935 Δ(Last f/u-post op) 4.1±5.4 0.9±4.7 0.073 Disc angle ( ) Preoperation 3.2±2.7 4.1±3.3 0.344 Postoperation 5.8±4.3 4.2±3.1 0.256 Last Follow-up 3.6±2.9 2.7±3.6 0.384 Δ(Last f/u-post op) -2.1±3.8-1.6±3.8 0.658 Anterior body height (ABH*, %) Preoperation 259.6±61.2 234.5±47.8 0.221 Postoperation 284.9±59.9 256.8±48.9 0.148 Last Follow-up 277.2±55.9 236.9±36.6 0.022* Δ(Last f/u-post op) -2.3±8.0-7.1±6.4 0.064 Posterior body height (PBH*, %) Preoperation 260.9±62.5 231.6±48.4 0.143 Postoperation 275.0±57.6 247.4±44.3 0.134 Last Follow-up 270.4±56.7 235.5±37.5 0.048* Δ(Last f/u-post op) -1.3±9.2-4.4±7.0 0.297 *ABH= Anteriorvertebral height (A) 100, Control height (C) *PBH= Posteriorvertebral height (P) 100 Control height (C) Δ(LastF/U-Post op.) ABH (%) = Last F/U ABH-Post op ABH 100, Post op. ABH Δ(LastF/U-Post op.) PBH (%) = Last F/U PBH-Post op PBH 100 Post op. PBH - 144 -
전방유합술을이용한경추간판탈출증의치료 박희전외 양의케이지를제작하여경추의전방유합술에이용되었고현재는 WING 케이지, BAK 케이지, Solis PEEK (polyetheretherketone) 케이지등이사용되고있다. Wilke 등 13) 은경추유합케이지와골시멘트의안정성과함몰에대한실험에서주기적부하 (cyclic loading) 에대해모든케이지는골시멘트를삽입하였을때와같이모든방향에안정성을보이고특히측굴곡에강한안정성을보인다고하였으며, 케이지와추체종판과의접촉면이적으면함몰의위험성은증가하는반면이식골과종판과의접촉면이증가하여많은골이식이가능하고골유합율을높일수있다는장점이있다하였다. Furderer 등 14) 은추체종판의박리는케이지의함몰을증가시키고, 종판이완전하게남아있는경우에는사각형모양의케이지나측면날개가있는원통형의몸통을가진케이지가축성압박력에강하다고하였으며종판이제거되었을때는원통형케이지가함몰이가장많이일어난다고하였다. 따라서케이지를삽입할때에는종판의피질골이손상받지않도록주의를기울여야하고사각형모양의케이지를사용하는것이함몰의위험을줄일수있다. Vavruch 등 15) 은 Cloward 방법과탄소섬유케이지의비교에서임상적인결과는비슷하였으나해부학적인정렬은케이지를사용하였을때더욱좋았고골유합율은 Cloward 방법 (86%) 이케이지를사용한경우 (62%) 보다우월하였다고하였다. Gercek 등 16) 은해면골을충전한단독케이지를이용한유합술에서 9 분절의유합중 5 분절에서방사선학적으로케이지의함몰이발생한것을보고하면서함몰을예방하기위해서는추가적인전방금속판의고정이필요하다고하였으며, 실험적연구에서도단독케이지의함몰에대한위험성은이미지적된바있다 17,18). 이러한케이지함몰의원인은여러가지로추간판절제로인한불안정성의증가, 술후경추의운동, 케이지의모양, 추체종판의조작, 골밀도등 19,20,21,22) 에의해일어날수있으나케이지의함몰, 불유합이항상임상결과와일치하지는않는다. 또한케이지를삽입한경우에자가장골이식과금속판고정을병행한술식에서보다낮은골유합율이보고되고있으나불유합의원인은잘알려지지않고, 이는단독케이지삽입으로인한불안정성의증가, 추체와이식골사이의접촉면감소, 케이지에의한응력차단 (stress shielding) 에의한것으로생각할수있다. 골성장은응력 (stress) 에따른반응으로기계적자극이없으면골흡수가일어난다. 이식물질과추체사이의탄성의차이가크면응력차단이일어나서종판의피질골이얇아지게되는데해면골의탄성계수 (elastic modulus) 는 0.1 GPa, 티타늄은 110 GPa, 탄소 PEEK 는 13 Gpa, PEEK 는 3.6 GPa 를보여 PEEK 케이지가티타늄케이지보다해면골의탄성계수와좀더가까워보다나은골유합이일어날수있는기계적자극을제공할가능성이높다고생각된다. 본연구에서는 1 례에서약 3 mm 의케이지함몰을보였으나술후 12 주에유합되었고신경증상의악화나발현은없었다. 이식골을충전하지않은빈탄소섬유케이지만을삽입하여술후 12 개월에 96% 의골유합과삽입물의파손이나전위가없고삼중피질자가장골을이용한유합술과비교하여임상적으로나방사선학적으로차이가없다고보고한경우도있다 23). 그러나일반적으로골유합을위해서케이지에자가장골또는해면골을채워사용하는데 24,25), 이로인한이차적인피부절개가필요하고골공여부의합병증이발생할수있다. 이러한골공여부의합병증을방지하기위해동종골 26), 탈무기골기질 (demineralized bone matrix), 수산화인회석 (hydroxyapatite) 27,28), 골형성단백 (bone morphogenic protein) 29) 등이이용되기도한다. 그러나수산화인회석을사용하였을때는감염의위험이증가하고, 골형성단백을사용하였을때는골유합율을높일수있으나인두후부종등으로인한높은합병율이보고되고있어사용에신중을기하여야한다. 또한골공여부의합병증을피하기위한방법으로골시멘트를이용하여유합을시행하여유합율은약 60% 로낮았으나임상적으로는좋은결과를보고하기도하였다 30). 본연구에서는두군모두에서자가장골을이용하였으나케이지군에서는장골능에서원통형절단기를이용하여해면골을채취하여골공여부의합병증을줄일수있었으며술후 6 개월후에는골공여부에특별한동통을호소하는사람은없었다. 골유합의판단은평면방사선사진에서이식골과추체간의골소주의형성으로판단할수있으나 WING 케이지나 BAK 케이지와같이방사선비투과성의티타늄소재를사용한경우에는유합여부의판단이어려워자기공명영상을이용하거나측면굴신방사선사진에서운동이없는것으로판단할수있다. Solis PEEK 케이지는중합체 (polymer) 재질로만들어져완전한방사선투과성때문에골소주의형성이나골교형성을평면방사선사진으로판단할수있다. 그러나케이지의삽입위치를판단할수있도록금속핀을삽입하였는데이로인해자기공명영상에서인공음영을형성하는단점이있다. 본연구에서는평면방사선측면및굴신사진을이용하여극돌기간운동여부, 이식골과추체의골교형성여부와이식물질과추체사이의방사선투과선 (radiolucent line) 여부로결정하였다. 술후합병증으로는 7 례에서연하곤란이있었으나특별한치료없이 3~5 일후에증상소실되었으며, 골공여 - 145 -
대한척추외과학회지 Vol. 15, No. 3, 2008 부의동통은금속판고정군에서는술후 3 개월에 4 명 (19%) 에서, 1 년후에는 2 명 (10%) 에서골공여부에동통을호소하였으며, 케이지군에서는술후 3 개월에 1 명 (6%) 에서동통을호소하였고 6 개월후에는특별히골공여부에동통을호소하는사람은없었다. 결 론 경추간판탈출에의한단분절의신경근병증환자에서자가장골이식과금속판고정을이용한유합술또는단독케이지를이용한전방유합술모두에서임상적또는방사선학적결과에서유의한차이를보이지않았다. 케이지를사용한군에서골공여부에대한동통이없었으나추체높이가더많이감소하는경향을보였다. Solis PEEK 케이지를이용한유합술은임상적으로나방사선학적으로자가장골이식을이용한유합술과같이만족할만한결과를보여단분절의신경근병증치료에자가장골이식과금속판고정을대체할수있는방법으로사료된다. 참고문헌 01) Robinson R, Smith G: Anterolateral cervical disc removal and interbody fusion for cervical disc herniation. Bull Johns Hopkins Hosp 1955; 96: 223-224. 02) Cloward R: The anterior approach for removal of ruptured cervical discs. J Neurosurg 1958; 15: 602-617. 03) Wilson DH, Campbell DD: Anterior cervical discectomy without bone graft. Report 71 cases. J Neurosurg 1977; 47: 551-555. 04) Savolainen S, Rinne J, Hernesniemi J: A prospective randomized study of anterior single-level cervical disc operations with long-term follow-up: surgical fusion is necessary. Neurosurgery 1998; 43: 51-55. 05) Barlocher C, Barth A, Krauss JK, Binggeli R, Seiler RW: Comparative evaluation of microdiscectomy only, autograft fusion, polymethylmethacrylate interposition, and threaded titanium cage fusion for treatment of singlelevel cervical disease: a prospective randomized study in 125 patients. Neurosurg Focus 2002; 12: E4. 06) Park HJ, Shim YJ: Treatment of distractive flexion injury in lower cervical spine using anterior cervical fusion. J Korean Soc Spine Surg 2007; 14: 221-228. 07) Schnee C, Freese, A, Weil RJ, Marcotte PJ: Analysis of harvest morbidity and radiographic outcome using autograft for anterior cervical fusion. Spine 1997; 22: 2222-2227. 08) Goffin J, Van Calenbergh F, van Loon J, et al: Intermediate follow-up after treatment of degenerative disc disease with the Bryan Cervical Disc Prosthesis: single-level. Spine 2003; 28: 2673-2678. 09) Bagby GW: Arthrodesis by the distraction-compression method using a stainless steel implant. Orhtopaedics 1988; 11: 931-934. 10) Ray CD: Threaded titanium cages for lumbar interbody fusions. Spine 1997; 22: 667-679. 11) Kuslich SD, Ulstrom CL, Griffith SL, Ahern JW, Dowdle JD: The Bagby and Kuslich method of lumbar interbody fusion. History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial. Spine 1998; 23: 1267-1279. 12) Brantigan JW, Steffee AD: A carbon fiber implant to aid interbody lumbar fusion. Two-year clinical results in the first 26 patients. Spine 1993; 18: 2106-2107. 13) Wilke HJ, Kettler A, Claes L: Stabilizing effect and sintering tendency of 3 different cages and bone cement for fusion of cervical vertebrae segments Orthopade 2002; 31: 472-480. 14) Furderer S, Schollhuber F, Rompe JD, Eysel P: Effect of design and implantation technique on risk of progressive sintering of various cervial vertebrae cages. Orthopade 2002; 31: 466-471. 15) Vavruch L, Hedlund R, Javid D, Leszniewski W, Shalabi A: A prospective randomized comparison between the Cloward procedure and a carbon fiber cage in the cervical spine. A clinical and radiologic study. Spine 2002; 27: 1694-1701. 16) Gercek E, Arlet V, Delisle J, Marchesi D: Subsidence of stand-alone cervical cages in anterior interbody fusion: warning. Eur Spine J 2003; 12: 513-516. 17) Shimamoto N, Cunningham BW, Dmitriev AE, Minami A, MaAfee PC: Biomechamical evaluation of standalone interbody fusion cages in the cervical spine. Spine 2001; 26: 432-436. 18) Shono Y, McAfee PC, Cunningham BW, Brantigan JW: A biomechanical analysis of decompression and reconstruction methods in the cervical spine. Emphasis on a carbon-fiber-composite cages. J Bone Joint Surg 1993; 75: 1674-1684. 19) Curylo LJ, Lindsey RW, Doherty BJ, LeBlanc A: Segmental variations of bone mineral density in the cervical - 146 -
전방유합술을이용한경추간판탈출증의치료 박희전외 spine. Spine 1996; 21: 319-322. 20) Hollowell JP, Vollmer DG, Wilson CR, Pintar FA, Yoganandan N: Biomechanical analysis of thoracolumbar interbody constructs: how important is the endplate? Spine 1996; 21: 1032-1036. 21) Kettler A, Wilke HJ, Claes L: Effects of neck movements on stability and subsidence in cervical interbody fusion: an in vitro study. J Neurosurg 2001; 94: 97-107. 22) Wilke HJ, Kettler A, Goetz C, Claes L: Subsidence resulting from simulated postoperative neck movements: an in vitro investigation with a new cervical fusion cage. Spine 2000; 25: 2762-2770. 23) Frederic S, benedict R, Payer M: Implantation of an empty carbon fiber cage or a tricortical iliac crest autograft after cervical discectomy for single-level disc herniation: a prospective comparative study. J Neurosurg Spine 2006; 4: 292-299. 24) Bartels R, Donk R, Azn R: Height of cervical foramina after anterior discectomy and implantation of carbon fiber cage. J Neurosurg 2001; 95: 40-42. 25) Samandouras G, Shafafy M, Hamlyn PJ: A new anterior cervical instrumentation system combining an intradiscal cage with integrated plate: an early technical report. Spine 2001; 26: 1188-1192. 26) Hacker RJ, Cauthen JC, Gilbert TJ, Griffith SL: A prospective randomized multicenter clinical evaluation of an anterior cervical fusion cage. Spine 2000; 25: 2646-2655. 27) Agrillo U, Mastronardi L, Puzzilli F: Anterior cervical fusion with carbon cage containing coralline hydroxyapatite: preliminary observations in 45 consecutive cases of soft-disc herniation. J Neurosurg 2002; 96: 273-276. 28) van Limbeek J, Jacobs WC, Anderson PG, Pavlov PW: A systematic literature review to identify the best method for a single level anterior cervical interbody fusion. Eur Spine J 2000; 9: 129-136. 29) Boakye M, Mummaneni PV, Garrett M, Haid R: Anterior cervical discectomy and fusion involving a polyetheretherketone spacer and bone moerphogenetic protein. J Neurosurg Spine 2005; 2: 521-525. 30) Hamburger C, Festenberg F, Uhl E: Ventral discectomy with pmma interbody fusion for cervical disc disease: long-term results in 249 patients. Spine 2001; 26: 249-255. - 147 -
대한척추외과학회지 Vol. 15, No. 3, 2008 국문초록 연구계획 : 후향적연구연구목적 : 단분절경추간판탈출증환자에서전방감압후자가장골또는케이지를이용한전방유합술을시행하고 1 년이상추시결과를분석하여유합방법에따른임상적, 방사선학적차이를알아보고자한다. 대상및방법 : 단분절의경추간판탈출증으로전방감압및유합을시행하고 1년이상추시가능한환자 38명을대상으로하였으며, 21명에서는자가장골이식및금속판고정술 (I군) 을시행하였고, 나머지 17명에서는케이지를이용한유합술 (II군) 을시행하였다. 임상적결과는경부동통및방사통에대해통증강도를이용하여평가하였으며, 방사선적결과는경추전만각, 유합분절의전만각및전후방상대높이의변화를측정하였으며, 유합여부를관찰하였다. 각각의결과를자가장골이식및금속판고정술을이용한유합술과케이지를이용한유합술의두가지유합방법에따라비교하였다. 결과 : 전례에서술후 11.2±2.7주에유합되었으며, 경추전만과국소전만은양군에서차이가없었다 (p=0.07, 0.66). 전방과후방추체높이는 I군보다II군에서많은감소를보였으나통계학적유의성은보이지않았고 (p=0.06, 0.30), 임상적결과에서도양군간에차이를보이지않았다 (p=0.64, 0.45). 결론 : 경추간판탈출에의한단분절의신경병증환자에서자가장골이식과금속판고정을이용한유합술과단독케이지를이용한전방유합술은임상적또는방사선학적결과모두에서유의한차이를보이지않았다. 케이지를사용한군에서추간판간격이더많이감소하는경향을보였다. 케이지를이용한유합술은임상적으로나방사선학적으로자가장골이식과금속판고정을이용한유합술과같이만족할만한결과를보여단분절의신경병증치료에자가장골이식과금속판고정을대체할수있는방법으로사료된다. 색인단어 : 경추간판탈출증, 전방유합술, 금속판고정, 케이지 통신저자 : 박희전강원도원주시일산동 162 연세대학교원주의과대학정형외과학교실 Tel: 82-33-741-1352 Fax: 82-33-746-7326 E-mail: par73@yonsei.ac.kr - 148 -