219 Symposium J Korean Orthop Assoc 2019; 54: 219-226 https://doi.org/10.4055/jkoa.2019.54.3.219 www.jkoa.org Minimal Invasive Surgery for Lumbar Spine Problems 요추척추관협착증환자의양방향경피적내시경을이용한척추수술 강태욱 이순혁 박시영 고려대학교의과대학고려대학교안암병원정형외과학교실 pissn : 1226-2102, eissn : 2005-8918 Biportal Percutaneous Endoscopic Spinal Surgery for Lumbar Spinal Stenosis Taewook Kang, M.D., Soon Hyuck Lee, M.D., Ph.D., and Si Young Park, M.D., Ph.D. Department of Orthopaedic Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea Lumbar decompressive surgery is a standard surgery for lumbar spinal stenosis. Many surgical techniques have been introduced, ranging from open surgery to percutaneous procedures. Minimally invasive techniques are preferred because of the less postoperative pain and shorter hospital stay. Uniportal percutaneous endoscopic decompression has technical difficulties due to the narrow field. Biportal percutaneous endoscopic decompression is a satisfactory technique that can compensate for the shortcomings and provide sufficient decompression. Key words: spinal stenosis, endoscopy, minimally invasive surgery 서론 요추척추관협착증 (lumbar spinal stenosis) 은어떠한원인에의해 중앙의척추관, 신경근관또는추간공이좁아져서요통과간헐 적파행등의여러복합적신경증상을일으키는질환으로정의 된다. 1) 척추관협착증은퇴행성변화로인한것이더흔한것으로 알려져있으며, 퇴행성요추척추관협착증은추간판의변화로부 터주로시작되고추간판의탈수와팽윤등의퇴행성변화로인 해추간판높이가감소하게된다. 이에충격흡수능력이감소되 고후관절에비정상적으로증가된힘을가하게되어후관절연골 Received March 12, 2018 Revised April 16, 2018 Accepted July 5, 2018 Correspondence to: Si Young Park, M.D., Ph.D. Department of Orthopaedic Surgery, Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul 02841, Korea TEL: +82-2-920-5925 FAX: +82-2-924-5271 E-mail: drspine90@kumc.or.kr ORCID: https://orcid.org/0000-0002-1216-901x 의퇴화와골극의형성을촉진한다. 2) 이러한추간판과후관절의퇴행성변화는중앙부, 후외측함요부의협착과함께척추분절의불안정을가져와전방혹은후방으로척추체의전위를일으킬수있다. 3) 후관절비후, 황색인대의섬유화와비후, 추간판팽윤, 골극형성에의한협착은신경에압박을초래하여요통, 하지통증, 감각의변화, 하지근력약화와간헐적파행등의증상을일으킬수있으며이러한증상은활동으로인해악화되는양상을보인다. 요추척추관협착증의유병률은 20%-25% 이며 50세이상에서증가한다고알려져있다. 요추척추관협착증의자연경과는보존적치료에대한전향적연구가드물기때문에자세히알려져있지않지만일부연구에서보존적치료를시행한결과증상의뚜렷한호전이나악화는보이지않았다. Johnsson 등 4) 은 32명의치료받지않은요추척추관협착증환자들을 49개월간관찰한결과, 간헐적파행의증상이 22명 (68.8%) 은변화가없었고, 5명 (15.6%) 은호전, 5명 (15.6%) 은악화를보였다고하였으며증상의 The Journal of the Korean Orthopaedic Association Volume 54 Number 3 2019 Copyright 2019 by The Korean Orthopaedic Association 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.
220 Taewook Kang, et al. 심각한악화를보인환자는없었다. 노년층인구가증가함에따라요추척추관협착증에대한수술적치료의빈도가높아지면서다양한수술방법에대한관심이증가하고있다. 요추척추관협착증은감압술이기본적인수술법이며고식적인수술법으로는후방도달후궁절제술 (laminectomy) 이시행되어왔다. 이러한수술은해당부위에큰절개선을가하고후궁을노출시키기위하여척추주위근을극돌기로부터박리하여벌리게되는데, 여러연구에서이러한고식적수술법의침습성에대하여우려를표현하고있다. 5) 작은절개선을통해정상구조물에손상을최소화하고연부조직박리를적게하기위한최소침습적수술법이다양한기구들의발전과함께여러분야에서시행되고있다. 최소침습적수술법은의인성합병증과수술후통증을줄이고, 빠른회복과입원기간을줄일수있는장점을가진다. 6) 현미경을이용한최소침습적수술이척추에서시행되어왔으며최근요추추간판탈출증및척추관협착증에서내시경을이용한수술이시행되고있다. 양방향 (biportal) 내시경수술은선명하고넓은시야와기구를자유롭게쓸수있다는장점을가지는수술방법이다. 7) 저자들은이종설에서요추척추관협착증환자에서시행할수있는다양한수술법의장단점을비교하고, 최근도입되어효과적으로시행할수있는양방향내시경을통한감압술을소개하고자한다. 수술적치료 요추척추관협착증에서마미증후군등과같이응급수술이필요한심각한신경장애를보이는경우는드물고주로보행및일상생활의장애를일으키는경우가많기때문에통증완화와기능의향상을위한보존적치료가우선이된다. 보존적치료로는약물치료, 물리치료, 보조기, 경막외부신피질호르몬주입등의치료를시행할수있다. 극심한통증을호소하는경우, 진행하는신경학적증상이있는경우, 보존적치료에반응하지않는경우에수술적치료를고려하게된다. Amundsen 등, 8) Malmivaara 등, 9) Weinstein 등 10) 에의한연구에의하면요추척추관협착증환자에서비수술적치료와수술적치료의결과를비교하였을때, 감압술을시행하였을경우비수술적치료를한환자들에비해통증경감과기능향상효과를가져올수있다고보고하고있다. 1. 고식적감압술 1954년 Verbiest 11) 가광범위한후궁절제술에의한내측후관절의하부절제를통한감압술을시행한이래이방법이척추관협착증의수술적치료의근간이되어왔다. 감압술은경막과신경근을압박하는골성및연부조직을제거하는수술법으로대부분 의요추척추관협착증의경우적절한감압술만으로도충분하며 64%-95% 에서만족할만한결과가보고되고있다. 12) 수술의목적은신경의감압에있으며협착의위치와특성에따라수술의종류와범위를정하게된다. 고식적감압술시행후 2.0%-10.5% 에서감염, 경막파열, 결막외혈종, 불안정성등의합병증을보였다. 대부분후방도달법으로접근하며충분한감압을위해시행하는후궁절제술은후궁을노출시키기위해극돌기로부터척추주위근을박리하여벌리게되는데, 이는척추주위근의혈액공급감소와이로인한근육의위축을초래하며수술후에만성요통의원인이된다. 13) 또한요추의극돌기와그주위인대를모두제거하므로요추굴곡시에안정성을제공하는후방구조물이소실되어수술후불안정성을야기할수있고큰사공간 (dead space) 을만들어수술부위의창상감염의가능성을높이며, 이공간이반흔조직으로치유되어공간은경막이나신경근을압박하여재수술이필요할수있다. 14) 감압술을시행할때충분한감압과동시에분절간안정성유지를위해후관절의외측 1/2-2/3는보존해야한다. Abumi 등 15) 에의하면양쪽요추후관절의내측 1/3-1/2까지제거한경우는불안정이초래되지않으나일측이라도후관절을전절제하면불안정이초래된다고하였다. 따라서수술중후관절이과도하게절제되었거나과도한절제가필요한경우는골유합술을시행하여야한다. 이러한광범위한감압술및유합술은긴수술시간, 많은출혈량, 술후감염, 오랜입원기간, 술후심한요추부통증, 유합으로인한척추관절운동장애등의상당한합병증이남을수있다. 16) 요추부의척추관협착증은대부분퇴행성질환이므로수술적치료가필요한환자는고령일경우가많으며, 고령의환자들은내과적문제를수반하는경우가많아이러한합병증의발병이더높다고알려져있다. 17) 2. 최소침습적감압술고식적인척추관감압술및유합술의합병증인정상적인후방구조의손상이나수술후반흔조직에의한신경근의유착및압박등을최소화하기위해최근다양한최소침습적수술방법들이시도되고있다. 최소침습적수술방법의기본개념은정상조직의손상을최소화하며병변을치료하는것으로, 이는의인성합병증을줄이고후방요추부근육및인대손상의최소화하여수술후통증을줄이고빠른회복을기대할수있다는장점이있다. 다열근 (multifidus) 은척추를안정화하고운동기능을갖는매우중요한근육이기때문에다열근을지배하는척추신경의내측분지의신경절제는안정화와조화기능소실을야기한다. 따라서이러한장점을극대화하고근육손상의단점을보완하면서척추관을감압시키는최소침습적척추수술방법들이많이시행되고
221 Biportal Percutaneous Endoscopic Spinal Surgery for Lumbar Spinal Stenosis 있다. 14) 최소침습적수술방법은광학, 확대등의기술과수술기구들의발달로비약적인발전을하였으며, 이에따라최소침습적척추수술의적응증이다양해졌다. 관혈적추간공감압술, 추간판제거술, 후궁절제술이관형견인기와현미경, 내시경을이용한추간공감압술, 추간판제거술, 후궁절제술로대체되고있다. 6) 1) 현미경을이용한감압술 ( 관형견인기 ) 1975년 Hijikata에의해후외측접근법을통한경피적추간판제거술이처음시행되었다. 18) Kambin과 Sampson 19) 은후외측접근법을통해추간판에도달할때안전하게작업할수있는공간을 Kambin 삼각 (Kambin triangle) 으로정의하였다. 직각삼각형의빗변은 exiting nerve root, 밑변은아래측척추체의상연, 높이는상후관절돌기 (superior articular facet) 로구성된다 (Fig. 1). 이접근법을통하면경막외정맥의조작을줄여만성신경부종, 경막외출혈, 경막외반흔을줄일수있는장점이있다. 20) 하지만이런후외측접근법은 bony surgery를시행할수없어추간공감압을할수없다는단점을가진다. 1997년 Foley와 Smith가현미경을이용한미세추간판절제술 (microendoscopic discectomy) 을시행하였고, 이후 2003년 METRx system (Medtronic, Inc., Minneapolis, MN, USA) 관형견인기가도입되면서현미경을이용한척추수술이더욱널리시행되고있다. 관형견인기및현미경을이용한수술은작은직경부터큰직경의확장기를순차적으로삽입하므로근육을박리하지않고네방향으로분리하여근육의손상을최소화시켜수술후수술부위의통증을최소화시킬수있다는장점을가지고있다. 16-20 mm 크기의관형견인기를이용한하나의통로로수술을시행하며, 추가적인절개없이삽입각의조절로내외측및상하부위를도달할수있고, 고전적관혈적인접근법보다수술부위의밝은조명과현미경을통한확대된영상을볼수있다는장점이있다. 21) 요추척추관협착증환자에서임상결과를향상시키기위하여현미경을이용한다양한최소침습적감압술이시행되어왔다. 최근가장널리시행되는단측후궁절제술을통한양측감압술 (unilateral laminectomy for bilateral decompression) 은중심성척추관협착증환자에서 Guiot 등 22) 이설명한단측접근법을통하여양측함요부와중심부를모두감압한다. 황색인대를모두제거하고외측함요부의감압은부분후관절절제술를통해시행하며후관절를최대한보존하기위해고속절삭기 (high speed burr) 와 Kerrison rongeur를사용하여후관절을 undercut한다. 이후내시경을중심부와반대측함요부로옮겨같은작업을반복하게된다. 그외에도 Watanabe 등 23) 의극돌기분리감압술 (spinous process splitting decompression), port-hole 감압술등의현미경을이용한최소침습적감압술이시행되고있다. `관형견인기및현미경을사용한수술은작은절개로도확대된시야와밝은조명하에서후방구조물을최대한보존하면서충분한감압을할수있기때문에수술후발생할수있는분절간불안정성을예방할수있을뿐만아니라조기보행과빠른재활로입원기간과이환율을줄여서일상생활과작업으로복귀도빠른것으로여겨지고있다. 24) 또한내시경수술에비해현미경을이용하여 3차원적시야를얻을수있어보다안전하고지혈에용이하다는장점이있다. 반면에피부절개는작지만통로역시좁아서수술시야가제한적이며기구조작이어렵고술기획득에비교적오랜시간이필요하다는단점이있다. 또한관혈적수술법에비해신경근손상, 경막파열, 재발성탈출증이더많다는보고도있다. 25) Exiting root Superior end plate Superior articular facet Figure 1. Kambin s triangle: the exiting root is the hypotenuse, the superior border of the lower vertebral body is the base, and the height is the superior articular facet. 2) 단방향내시경수술 1990년대부터광학기술, 고해상도카메라, 광원 (light source), 고속절삭기, 관류펌프 (irrigation pump) 등의급격한발달로추간판탈출증에서만사용되던내시경을척추관협착증등다양한척추수술에서시행할수있게되었다. 척추관협착증과추간공협착증에서다양한도달법을통한단방향 (uniportal) 내시경수술이시행되어왔으며, 부분후궁절제술을통한후궁간도달법을이용한수술이가장널리사용되고있다. 1997년 Yeung이 YESS (Yeung Endoscopic Spine System) 내시경을고안한뒤로 26) 현재의내시경은카메라, 관류, 작업통로등의여러통로를가진내시경기구로발전되어사용되고있다. 단방향내시경을이용한수술의결과는고식적인수술의결과와견줄만하며주변조직을보호할수있는장점이있지만제한적인적응증을가지고충분한감압을시행하기에기술적인어려움이있다. 27) 한개의통로를이용하는구조적인한계를가져시
222 Taewook Kang, et al. 야가좁고특정한부분만제거할수있으며또한작업공간이작고기구사용과내시경적관찰이동일통로를통하여이루어지기때문에여러기구를같이사용하기가제한되어있다 (Fig. 2). 작업관삽입시신경손상의가능성이있으며퇴행성병변에의해발생하는골극에의한신경압박이나협착증에의한증상이발현될경우사용할수없다. 28) 이러한기술적인어려움이있기때문에요추척추관협착증에서단방향내시경을이용한경피적감압술은숙련된관절경수술자에게도쉽지않은수술법이다. 요추척추관협착증환자에서단방향내시경을통한감압술시행결과, 70% 의환자에서임상증상호전을보였고 86% 의환자에서만족할만한결과를보였으며, 이는고식적인감압술과차이를보이지않았다. 29) 3) 양방향내시경수술관형견인기를이용한수술은좁은통로를통한작업공간으로 인해수술시야가제한적이고술기가어렵다는단점이있으며단방향내시경수술은병변에내시경을거치하여수술하기때문에기구사용에제한이있고퇴행성병변에의해발생하는골극의신경압박이나협착증의증상에는사용할수없다는단점이있다. 양방향내시경수술은두개의입구를통하여기구들이자유롭게움직일수있어이러한단점을해결할수있으며카메라를다양한각도로볼수있어시야가좋고충분한감압을안전하게시행할수있다는장점이있기때문에양방향내시경수술이척추관협착증수술에도입되고있다. 30) 양방향내시경수술을시행하는경우, 내시경안에다른기구가없고내시경을자유롭게움직일수있기때문에렌즈를병변바로앞에위치시킬수있으며근육과인대를보호하면서반대편까지관찰할수있다. 25) 일반적인관절경기구와기존의척추수술기구들을자유롭게사용할수있으며, 이를통해고식적인수술법만큼충분한감압술을시행할수있다. 30) 두개의삽입구를 Figure 2. Uniportal endoscopic surgery has restricted vision and technical difficulties because all the instruments use a single portal. Cephalad Viewing portal Working portal Figure 3. Portal placement of the biportal arthroscopic approach: two separate 1 cm vertical incisions were made obliquely. Arrows: disc protrusion.
223 Biportal Percutaneous Endoscopic Spinal Surgery for Lumbar Spinal Stenosis 이용하여내시경삽입구와기구삽입구가각각다른피부절개를 통해후궁에접근하게되어내시경과수술기구들이서로충돌 하지않게되어기술적인어려움을해결하였으며, 한쪽삽입구 를통해신경조직을젖혀다른삽입구를통해쉽고안전하게조 작을할수있다. 7) 또한지속적으로생리식염수가흐르면서경막 외정수압과추간판내압력의증가를막을수있고, 열손상을예 방할수있으며, 시야를좋게하고지혈기능도할수있다. 31) 하지 만척추는슬관절, 견관절과다르게빈공간이아니기때문에식 염수의관류에도불구하고수술기구와조직의내시경하시야가 제한적이기때문에후궁절제술을시행하기전에빈공간을만들 어주는것이필요하다. 경막손상, 신경근손상, 경막외혈종등이발생할수있는합 병증이나그빈도는흔하지않은것으로알려져있다. 32) 확대된 시야및지속적인식염수관류로인한경막의압박으로인해경 Figure 4. One portal is used for arthroscopic viewing and continuous irrigation, and the other is used for the insertion and manipulation of instruments. Saline inflow through cranial viewing portal, and outflow through the caudal working portal allows continuous irrigation. 막손상은다른수술법에비해오히려적게발생한다. 요추척추관협착증에서양방향내시경수술을통한감압술후시각통증척도 (visual analogue scale), Oswestry disability index, Macnab criteria를통한임상결과를여러논문에서보고하고있다. Eun 등 7) 은 58명의환자중 81% 에서좋은임상결과를보고하였고, 2명의환자에서경막손상, 2명의환자에서일시적감각저하를보였다. Torudom과 Dilokhuttakarn 31) 은 30명의환자중 83% 에서좋은임상결과를보고하였으며, 2명의환자에서일시적감각저하를보였다. Lee 등 30) 은 17명의환자모두에서좋은임상결과를보고하였으며, 2명의환자에서경막파열과경막외혈종의합병증을보였다. 하지만아직연구결과가부족하여향후장기추시결과를포함한추가적인연구가필요할것으로생각한다. 수술부위소독이전에 C-arm 영상을통해해부학적지표확인후추간판을기준으로각각 1 cm 상방과하방에 2개의삽입구를비스듬히만든다 (Fig. 3). 한개의삽입구는식염수의지속적인관류와내시경카메라가들어가며, 다른삽입구는감압술을위한기구를위한삽입구이다. 머리쪽삽입구에식염수관류펌프를연결한작업관을삽입하고 0도내시경을삽입한다. 머리쪽삽입구를내측으로옮길수록척추관을더넓은시야로관찰할수있다는장점이있으며, 두개의삽입구를비스듬히만들어수술기구들의충돌을막을수있다. 과도한경막외압력상승, 열손상을막고효과적인지혈을위해지속적으로식염수가체외로유출되도록유지하여지속적인식염수의관류가필수적이다 (Fig. 4). 7) 후궁간접근법을통하여감압술을시행하며, 수술기구는일반적인관절경장비와 Kerrison rongeur, pituitary forceps, 큐렛 (curette), 고속절삭기등의고식적척추수술기구를사용한다 (Fig. 5). Shaver, pituitary forceps, 고주파열을이용하여연부조직을제거하고하부후궁과황색인대를완벽히노출시킨후절삭기를이용하여동측에부분후궁절제술을시행한다. 황색인대의제거는신경근의외측연이자유롭게움직일수있을때까지시행 Figure 5. Intraoperative arthroscopic view: standard arthroscopic instruments and conventional spinal instruments are used, such as Kerrison rongeur, high speed burr, pituitary forceps, and curette.
224 Taewook Kang, et al. 한다. 경막외출혈은물압력조절과고주파열을이용하여지혈한다. 결론 양방향내시경을이용한감압술은고식적감압술과비견할만한임상결과를보이며, 최소침습적수술로선명하고넓은시야와자유로운기구사용의장점이있어요추척추관협착증에서안전하고충분한감압술을시행할수있는이상적인수술법이다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Arnoldi CC, Brodsky AE, Cauchoix J, et al. Lumbar spinal stenosis and nerve root entrapment syndromes. Definition and classification. Clin Orthop Relat Res. 1976;115:4-5. 2. Buckwalter JA. Aging and degeneration of the human intervertebral disc. Spine (Phila Pa 1976). 1995;20:1307-14. 3. Epstein JA, Epstein BS, Lavine LS, Carras R, Rosenthal AD, Sumner P. Lumbar nerve root compression at the intervertebral foramina caused by arthritis of the posterior facets. J Neurosurg. 1973;39:362-9. 4. Johnsson KE, Rosén I, Udén A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res. 1992;279:82-6. 5. Hu ZJ, Fang XQ, Zhou ZJ, Wang JY, Zhao FD, Fan SW. Effect and possible mechanism of muscle-splitting approach on multifidus muscle injury and atrophy after posterior lumbar spine surgery. J Bone Joint Surg Am. 2013;95:e192(1-9). 6. Thongtrangan I, Le H, Park J, Kim DH. Minimally invasive spinal surgery: a historical perspective. Neurosurg Focus. 2004;16:E13. 7. Eun SS, Eum JH, Lee SH, Sabal LA. Biportal endoscopic lumbar decompression for lumbar disk herniation and spinal canal stenosis: a technical note. J Neurol Surg A Cent Eur Neurosurg. 2017;78:390-6. 8. Amundsen T, Weber H, Nordal HJ, Magnaes B, Abdelnoor M, Lilleâs F. Lumbar spinal stenosis: conservative or surgical management?: a prospective 10-year study. Spine (Phila Pa 1976). 2000;25:1424-35; discussion 1435-6. 9. Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). 2007;32:1-8. 10. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the spine patient outcomes research trial. Spine (Phila Pa 1976). 2010;35:1329-38. 11. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br. 1954;36:230-7. 12. Getty CJ. Lumbar spinal stenosis: the clinical spectrum and the results of operation. J Bone Joint Surg Br. 1980;62:481-5. 13. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine (Phila Pa 1976). 1996;21:2763-9. 14. Weiner BK, Fraser RD, Peterson M. Spinous process osteotomies to facilitate lumbar decompressive surgery. Spine (Phila Pa 1976). 1999;24:62-6. 15. Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976). 1990;15:1142-7. 16. Carreon LY, Puno RM, Dimar JR 2nd, Glassman SD, Johnson JR. Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am. 2003;85:2089-92. 17. Cassinelli EH, Eubanks J, Vogt M, Furey C, Yoo J, Bohlman HH. Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine (Phila Pa 1976). 2007;32:230-5. 18. Kambin P, Gellman H. Percutaneous lateral discectomy of the lumbar spine a preliminary report. Clin Orthop Relat Res. 1983;174:127-32. 19. Kambin P, Sampson S. Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res. 1986;207:37-43. 20. Kambin P. Arthroscopic microdiskectomy. Mt Sinai J Med. 1991;58:159-64. 21. Ki SC, Choi YS, Kim KS, Kuk WJ. Lumbar discectomy using tubular retractor and microendoscopy. J Korean Soc Spine Surg. 2008;15:265-71. 22. Guiot BH, Khoo LT, Fessler RG. A minimally invasive technique for decompression of the lumbar spine. Spine (Phila Pa 1976). 2002;27:432-8. 23. Watanabe K, Hosoya T, Shiraishi T, Matsumoto M, Chiba K,
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226 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Assoc 2019; 54: 219-226 https://doi.org/10.4055/jkoa.2019.54.3.219 www.jkoa.org 최소침습적요추수술 요추척추관협착증환자의양방향경피적내시경을이용한척추수술 강태욱 이순혁 박시영 고려대학교의과대학고려대학교안암병원정형외과학교실 요추척추관협착증에서다양한방법으로감압술을시행하고있으며, 최근들어고식적인척추관감압술의여러합병증을최소화하기위하여최소침습적척추수술이시행되고있다. 단방향내시경을이용한감압술은구조적으로한계가있어그사용이제한적이기때문에양방향내시경을이용한감압술을시행하고있다. 요추척추관협착증에서양방향내시경을이용한감압술은안전하게충분한감압술을시행할수있는만족스러운수술법이다. 색인단어 : 척추관협착증, 내시경, 최소침습적수술 접수일 2018 년 3 월 12 일수정일 2018 년 4 월 16 일게재확정일 2018 년 7 월 5 일책임저자박시영 02841, 서울시성북구고려대로 73, 고려대학교의과대학정형외과학교실 TEL 02-920-5925, FAX 02-924-5271, E-mail drspine90@kumc.or.kr, ORCID https://orcid.org/0000-0002-1216-901x 대한정형외과학회지 : 제 54 권제 3 호 2019 Copyright 2019 by The Korean Orthopaedic Association 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.