Journal of Korean Society of Spine Surgery Usefulness of Minimally Invasive Posterior Foraminotomy using Tubular Retractor for Lumbar Spinal Stenosis with Foraminal Stenosis Hun-Kyu Shin, M.D., Jae-Yeol Choi, M.D., Hwa-Jae Jeong, M.D., Eugene Kim, M.D., Se-Jin Park, M.D., Seung-Hee Lee, M.D., Dong-seok, Seo, M.D. J Korean Soc Spine Surg 2014 Mar;21(1):15-23. Originally published online March 31, 2014; http://dx.doi.org/10.4184/jkss.2014.21.1.15 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2014 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.2014.21.1.15 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. www.krspine.org
Original Article pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2014 Mar;21(1):15-23. http://dx.doi.org/10.4184/jkss.2014.21.1.15 Usefulness of Minimally Invasive Posterior Foraminotomy using Tubular Retractor for Lumbar Spinal Stenosis with Foraminal Stenosis Hun-Kyu Shin, M.D., Jae-Yeol Choi, M.D., Hwa-Jae Jeong, M.D., Eugene Kim, M.D., Se-Jin Park, M.D., Seung-Hee Lee, M.D., Dong-seok, Seo, M.D. Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea Study Design: Retrospective study. Objectives: The aim of this study was to report the usefulness of lumbar posterior foraminotomy and central decompression using tubular retractor with minimally invasive technique. Summary of Literature Review: Posterior decompression and arthrodesis for the treatment of lumbar spinal stenosis with foraminal stenosis is a classical surgical method. It is inappropriate for patients who have rejection to arthrodesis or medical problems, because it may have several complications. Materials and Methods: Clinical results were obtained from 12 patients who underwent posterior foraminotomy and central decompression from January 2009 to April 2011 and were assessed using a Visual analogue scale, Oswestry disability index and the Prolo outcome scale. Results: Six Of 12 patients showed immediate relief of radiculopathy. Postoperative posterior lumbar pain and spasm were negligible, and no surgically related complication was noted. During the follow-up period, the Oswestry disability index decreased from 24.25±2.89(pre-op) to 19.33±3.02(Last F/U)(p=0.28, paired t-test) in 8 of 12 patients. Conclusions: A minimally invasive posterior foraminotomy and central decompression could be an alternative surgical option for the treatment of lumbar spinal stenosis with foraminal stenosis, especially in subjects with old age, having medical problems and refusal of arthrodesis. Key Words: Lumbar spine, Spinal stenosis, Foraminotomy, Minimally invasive surgery 서론 보존적치료에반응하지않는요추부추간공및척추관협착증환자에대한치료의목적은요통과하지방사통및신경인성파행증상을완화시키는것에있다. 척추관협착증은해부학적위치에따라중심성과측부형으로나눌수있으며, 이에대한많은연구가진행되어왔다. 1-4) 그중, 추간공의중간부에서신경근이빠져나가는부위의압박을추간공협착증이라하는데, 척추관협착증환자에서이러한추간공협착증이종종동반되고 3) 술전진단이어려운경우가많으며, 진단이되더라도이에대한적절한수술법에대해서는논란이있는상태이다. 추간공근방의후근신경절은 substace P의높은농도와외부압력에대한감수성으로인해통증유발부위로생각되어지는데, 4-7) 추간공부와외측부의협착증이이러한구조물의압박으로인해요통및하지방사통을유발할수있다. 특히, 제 5요추- Received: May 31, 2012 Revised: October 12, 2012 Accepted: November 8, 2013 Published Online: March 31, 2014 Corresponding author: Jae-Yeol Choi, M.D., 108, Pyeong-dong, Jongno-gu, Seoul, Korea, Kangbuk Samsung Hospital TEL: 82-2-2001-2168, FAX: 82-2-2001-2176 E-mail: ch5420.choi@samsung.com 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. * 본논문의요지는 2012 년도대한척추외과학회춘계학술대회에서발표되었음 Copyright 2014 Korean Society of Spine Surgery www.krspine.org 15
Hun-Kyu Shin et al Volume 21 Number 1 March 2014 제 1천추부위에서는 Wiltse 등 8) 에의하면제 5요추의횡돌기와천장골비익부사이에서신경근이압박될수있다고하였으며, 이를 far-out syndrome 이라명명하였다. Nathan 등 9) 은제 5 요추의척추체및 lumbosacral ligament, sacral ala로구성된소위 lumbosacral tunnel 을발견하였으며, 이안에서제 5요추신경근이압박될수있다고하였다. Burton 등 10) 은요추부수술실패의가장흔한원인은술전추간공협착에대한불충분한인지로인한불충분한감압이라고하였다. 대부분의퇴행성척추관협착증에서신경성파행증상을치료하기위해서는고정술없이단순한감압으로충분하다고하나, 유합술을동반하지않은단순감압술을시행할경우에는요통의호전을보이기가어렵다. 많은환자에서, 특히추간공협착증이동반된경우에서는적절한감압술을위해관절면절제술이필요하고, 이에따른불안정성으로인해광범위한감압술후에추가적인유합술이필요한경우가발생한다. 이러한광범위한감압술및유합술은긴수술시간, 많은출혈량, 술후감염, 오랜입원기간, 술후심한요추부통증, 유합으로인한척추관절운동장애등의상당한합병증이남을수있다. 11,12) 특히, 요추부의척추관협착증은퇴행성질환이므로수술적치료가필요한환자는고령일경우가많으며, 고령의환자들은내과적문제를수반하는경우가많다. 이러한환자군에서는앞서기술한합병증의발병이더높다는보고도있다. 13,14) 퇴행성척추관협착증의수술적치료에는몇가지방법 15-20) 이있지만, 고령의내과적기저질환이많은환자에서는의학적인필요에의해서고식적인감압술및유합술이좋지않은선택이될수있고, 젊은환자군에서도개인적성향에따라큰수술을원치않을경우다른수술술기를선택해야할때가있다. 그중, Foley 와 Smith 21) 가요추추간판절제술에관상형견인기 (tubular retractor) 를사용한근육분리법 (muscle splitting method) 을사용한이후로이접근법이최소침습적감압술에도이용되어왔다. 이술기는후방요추부근육및인대손상의최소화를통한수술후요추부통증의최소화와빠른사회복귀를기대할수있는장점이있다. 이에저자들은고식적인감압술및유합술을시행할수없는경우에대안적수술방법으로제시될수있는관상형견인기를이용한최소침습적감압술을시행한환자의수술기법과그유용성에대하여살펴보고자하였다. 대상및방법 1. 대상 2009 년 1월부터 2011 년 4월까지요추부추간공협착증을동반한척추관협착증으로내원한환자중최소침습적후방추간공확장술 (posterior foraminotomy) 및척추관감압술을시행한 12명의환자를대상으로임상적결과를후향적으로분석하였다. A B Fig. 1. Imaging studies is obtained in a 56-year-old woman who presented with severe back & radicular pain on left lower extremity. Preoperative sagittal (A) and axial (B) T2 weighted MR image demonstrates a left L5-S1 foraminal stenosis (arrow). 16 www.krspine.org
Journal of Korean Society of Spine Surgery Minimally Invasive Foraminotomy using Tubular Retractor 진단은증상과이학적검사및수술전요추단순방사선촬영, 컴퓨터단층촬영 (CT), 자기공명영상 (MRI) 등의방사선학적검사를토대로이루어졌으며, 투약, 물리치료, 선택적신경차단술등의보존적치료를 6주이상시행하였으나, 신경증상이호전되지않은환자들중유합술을시행할수없는환자를대상으로하였다. 수술의적응증은요추간공협착증으로요추신경근병증이저명한환자를대상으로유합술을하기에는너무고령이거나내과적질환이심한경우, 또는유합술을원하지않는경우에시행하였으며 (Fig. 1), 척추불안정증, 척추전방전위증, 골절, 감염, 종양등이발견된환자는제외하였고, 이전에수술을시행받았던환자 2명을포함하였다. 2. 방법수술방법은 Park 등 22) 이발표한최소침습적방법을참고하였으며, 환자를전신마취하에복와위자세를취하고통상적인방법으로수술부위를소독하였다. 방사선영상투시기 (fluoroscopy) 를이용하여수술을시행할부위를정하고, 수술부위의중심선에서약 2 cm 외측에약 3 cm 가량피부를절개하고요추근막의일부를절개하였다. 확장기를단계별로삽입하여수술할부위의근육을연속적으로확장시킨후직경 20 또는 22 mm의관상형견인기 ( 길이 50 또는 60 mm) 를확장기에삽입하고유연성이있는고정장치 (flexible arm assembly) 를이용하여수술침대에고정시켰다. 관상형견인기가수술을시행할부위에정확하게위치하였는지방사선영상투시기를이용하여확인한후이를통해수술할부위의정중선과동측후관절의위치를인식하고수술을시행하였다. 수술시현미경을사용하여밝고선명한수술시야를볼수있었다. 관상형견인기를통하여후궁부위와횡돌기를확인한후척추궁과후관절면의연부조직을제거하고, 상부척추체척추경의하면일부와횡돌기의일부및하부척추체의상관절돌기일부를제거하여신경공을적절히감압하였다. 동측의신경공을감안한후에중심성척추관협착증을동반한경우견인기를척추관내측으로향하고드릴, Kerrison 펀치와큐렛을이용하여척추관감압술을시행하였다. 특히, 제 5요추-제 1천추간의추간공협착증이있는경우에는 Kunogi와 Hasue23) 가처음소개한척추경내척추경부분절제술 (intrapedicular partial pediculectomy, IPPP) 및천장골비익절제술 (sacral alar resection) 을시행하였다. 수술중에척추관협착부에서경막낭과신경근이압박되지않으면척추관이충분히감압된것으로간주하고수술부위를지혈한후에관상형견인기를제거하였다. 수술부위에배액관을삽입하고, 일반적인방법으로근육과피부를봉합하였다. 최소침습적감압술을시행한환자에서수술전, 후의임상증상의변화와방사선촬영결과를이용하여임상결과를후향적으로평가하였다. 최소한 10개월이상임상적, 방사선학적으로추적관찰이가능한환자들을대상으로분석하였다. 환자들의성별, 나이, 동반된내과적질환, 증상의이환기간을조사하였으며, 수술전후의통증정도는 Visual Analogue Scale (VAS) score를이용하여평가하였다. 임상결과는전화상담과외래방문시이루어졌으며, 통증에의한기능장애의정도를고려한 Oswestry Disability Index (ODI) 24) 와, 기능적인상태와경제적인상태를모두고려한 Prolo Outcome Scale (POS) 25) (Table 1) 로평가하였다. ODI는 10개부분의점수를합하여총점 (50점 ) 으로나눈값을 % 로평가하는데, 0~20% 는경증장해 (minimal Table 1. Prolo Functional Economic Outcome Scale Score Economic status Criteria 1 Complete disability 2 No gainful occupation but can do housework or some retirement activities 3 Able to work, but not as previous occupation 4 Able to work at previous occupation but w/ restrictions or limited status 5 Able to perform previous occupation w/o restrictions Functional status 1 Total incapacity (worse than before operation) 2 Mild to moderate level of low-back pain &/or sciatica (able to perform tasks of daily living) 3 Low level of pain & able to do everything except sports 4 No pain, but has had >1 recurrence of low-back pain or sciatica 5 Complete recovery w/o recurrent pain, no activity restriction www.krspine.org 17
Hun-Kyu Shin et al Volume 21 Number 1 March 2014 Table 2. Baseline Characteristics of Study Subjects Case No. Sex/Age Underlying disease Side Level Duration (month) F/U(month) 1 F/62 Cerebral infarct Angina Lt. L4-S1 5 22 2 M/73 HTN* ASO Lt. L4-S1 120 11 3 F/83 HTN Rt. L4-S1 24 34 4 F/56 HTN Lt. L3-S1 6 10 5 F/79 HTN Both L4-L5 36 14 6 F/56 HTN Lt. L4-S1 8 15 7 M/76 HTN DM Lt. L4-S1 7 10 8 M/48 (-) Rt. L4-S1 120 27 9 M/58 HTN Rt. L4-L5 5 11 10 F/67 HTN DM Rt. L1-S1 6 15 11 M/41 (-) Lt. L4-L5 5 13 12 F/76 (-) Lt. L4-S1 9 11 *HTN; hypertension, ASO; artherosclerosis, DM; diabetes mellitus. Table 3. Change of Clinical Course using VAS, ODI, POS Case No. VAS*score ODI (%) POS pre-op last f/u pre-op last f/u pre-op last f/u 1 9 6 29 23 2 3 2 7 5 23 20 5 7 3 8 8 20 20 6 6 4 6 8 21 14 5 7 5 3 6 28 36 4 2 6 9 2 39 19 3 7 7 6 4 20 14 7 8 8 7 3 17 1 6 10 9 10 6 45 15 2 7 10 8 9 7 33 8 2 11 8 3 21 6 4 7 12 8 3 21 31 7 4 *VAS; visual analogue scale, ODI; oswestry disability index, POS; prolo outcome scale disability), 21~40% 는중등도 (moderate) 장해, 41~60% 는중증 (severe) 장해, 60% 이상은고도장해 (severely disabled life) 로구분하였다. POS는 5점이하를 poor outcome, 6~7점을 moderate outcome, 그리고 8점이상을 good outcome 으로정의하였다. 24) 통계적분석은 IBM SPSS Statistics 19.0(IBM, Armonk, NY, USA) 을이용하였으며, 수술전, 후통증의변화와기능장애의정도를대응표본 t 검정 (Paired t-test) 으로분석하여 p 값이 0.05 미만인경우를유의수준으로정하였다. 결과 전체환자중남자는 5명, 여자는 7명이었으며, 41세에서 83세까지평균나이는 64.6 세였다. 전체환자중 8명이기저질환으로고혈압을앓고있었으며, 그중 2명은당뇨병도동반되어있었다 (Table 2). 수술전의이환기간은 5개월에서 10년까지다양하게분포되어있었으며, 주요증상은하지방사통, 요통, 저림등으로나타났다. 이학적검사상피부분절 (dermatome) 에지각 18 www.krspine.org
Journal of Korean Society of Spine Surgery Minimally Invasive Foraminotomy using Tubular Retractor A B C Fig. 2. Postoperative image is obtained in Case 2. (A, B) Axial CT images show laminoforaminotomy site. (C) 3D-CT images depicteforaminotomy site. A B Fig. 3. Radiographic studies. (A) Preoperative anteroposterior plain radiograph is obtained in a 73-year-old man with a left-sided L5 radiculopathy and an L5-S1 extraforaminal stenosis. A large accessory process and laterally projecting osteophytes are present. (B) Postoperative radiograph demonstrate that the osseous boundary of the extraforaminal exit is decompressed. Note the changes (arrow heads) in the respective pedicle and trasverse processes on the left side of L5. 이상이 12예에서관찰되었으며, 근력저하는보이지않았다. 수술전 MRI는전예에서시행되었으며, 발생부위는제 4-5 요추간이 12예, 제 5요추제 1천추간이 9예로나타났으며, 병소의방향은좌측이 7예로더호발하였다. CT는 8예에서시행되었으며추간공협착증을평가하는데에유용하였다. 모든환자에서 tubular retractor 를이용한최소침습적추간공확장술과척추관감압술을시행하였으며, 3예에서 1분절감압술, 7예에서 2분절감압술, 1예에서 3분절감압술, 1예에서 4분절감압술을시행하였다. 수술직후 6예에서즉각적인하지방사통의소실을보였으며, 술후요통은거의없거나미미하였다. 수술후시행한 dynamic (flexion-extension) 단순방사선상불안정성은관찰되지않았으며, 단순방사선과전산화단층촬영상확장된추간공의소견을관찰할수있었다 (Fig. 2, 3). 임상결과는 VAS 통증지수와 ODI, POS를이용하여평가하였으며, 12예의환자에대한정보수집시일괄적으로전화를통해측정하였고기간은수술후 1-2년째로나타났다 (Table 3). VAS 지수는수술전평균 7.42±0.53 에서수술후최종추시결과시 www.krspine.org 19
Hun-Kyu Shin et al Volume 21 Number 1 March 2014 평균 5.25±0.66 로감소되고 (p=0.03, paired t-test), ODI는수술전평균 24.25±2.89 에서수술후최종추시결과시평균 19.33 ±3.02 으로감소하였다 (p=0.28, paired t-test). POS는수술전평균 4.92±0.57 에서수술후최종추시결과시평균 5.75±0.71 로증가하였다 (p=0.39, paired t-test). 수술전, 후 VAS 통증지수를비교한결과통계학적으로유의하게통증이감소하고, ODI 와 POS를비교한결과통계학적인유의성은없었으나, 기능장해가호전되는양상을보였다. 수술로인한신경손상이나감염등의주요합병증은발생되지않았고, 수술로인한신경반응악화소견은없었다. 술후 10 개월에서 34개월의추적관찰기간중 12명중 4명 (33%) 에서 poor outcome 을보이고있었으며, 8명 (67%) 에서 moderate to good outcome 을보이고있었다. 술후 12명중 6명 (50%) 에서증상의호전이불만족스러워추가적인신경근차단술을시행받은후 2명은호전을보였으며, 4명은호전을보이지않았다. 또한수술과관련한요추부의만성통증이나운동장애등은나타나지않았다. 단, 유합술후인접관절의퇴행성변화로인한추간공협착증이발생한환자에서신경공확장술을시행한경우좋은결과를보이지않았다 (case 3, 8). 고찰 신경관의협착에의한증상의발현은압박받는해부학적위치에따라신경구조물이다르며, 이에대한분류는치료법의선택과수술의방법및범위등의결정에매우중요하다. 일반적으로척추관협착증에대한수술은광범위한후궁절제술로내측후관절의하부를절제하고, 추간공확장술을시행하는방법으로 64~95% 에서만족할만한결과가보고된다. Getty26) 에의하면감압술에서가장흔하게행해지는오류는불충분한감압이기때문에신경에대해적절하고충분한감압술을하기위해과도한골성구조를파괴하여감압분절의불안정성을초래하게되어골유합술을병행해야하는경우가있다고하였다. 광범위한후방감압술을시행한후발생할수있는불안정성을방지하기위해감압술과동시에기기고정술및골유합술을시행하지만수술이복잡하고, 대량출혈, 수술시간의연장, 감염율증가, 유합부위의인접분절조기퇴행성변화등여러가지부작용이발생할수있다. Okuyama 등 27) 에의하면골다공증이동반된환자에서후궁절제술과기기고정술을시행하면나사못이완과같은문제가발생되어척추고정이실패하거나불유합이발생될위험이있으며, 이러한합병증은 0.6~11% 정도보고되고있다. Niggemeyer 등 28) 은퇴행성척추전방전위증을제외한퇴행성 요추척추관협착증의수술결과를비교하면서감압술만시행한경우가성공률이가장높았으며그다음이감압술과기기술을병행한유합술을한경우이고감압술과기기술없이유합술을시행한경우가가장불량한결과를나타냈다고보고하였다. 다른보고에서도골유합술을병행하는경우더우수한결과를얻을수있다는증거는없으며오히려골유합술에따른합병증의빈도만증가할뿐이라고하였다. 척추관협착증의감압술에고식적으로사용된방법인척추후궁절제술은척추후방근육을양측으로박리하고극돌기, 극상인대및극간인대를절제하는방법이다. 이는, 병변뿐아니라정상부위까지제거되는데이러한구조물들은요추의안정성에중요한요소들이어서술후불안정성이나요통을유발할수있다. 또한구조물들이제거된부위는 dead space 으로남게되어감염을포함한국소적인창상부위합병증의가능성을높이고이부위는반흔조직으로치유되어마미나신경근을압박할수있고, 재수술이필요한경우주위조직과의유착으로수술이어려운단점이있다. 이러한이유로요추극돌기와주변인대, 후관절등의구조물들을가능한한보존하는것이좋다. Hejazi 등 29) 은요추부신경공협착증에서후관절을 50% 미만으로절제하는부분적인후관절절제술을시행하면수술후척추불안정증이발생하지않는다고보고하였고, 다른보고에서도감압술후척추불안정증이없고후관절의안정성이보장된다면척추고정술은필요없으며, 편측혹은양측후관절의내측부분절제술은추체의안정에영향을주지않는다고하였다. You 등 30) 은후방구조물을보존하는술식으로양측성척추후궁절개술, 극돌기절골술후척추후궁절개술, 척추후궁성형술의감압술방법에따른결과비교에서척추고정술이필요없고, 큰합병증을보이지않으며증상의호전을보일수있다고보고하였다. Foley 와 Smith 21) 가추간판탈출증수술을위하여내시경적미세추간판절제술 (microendoscopic discectomy, MED) 을도입한이후이와같은후방접근법으로요추부척추관협착증에서수술현미경과 tubular retractor system 을이용하여밝은조명과확대된수술시야에서피부절개와조직손상을최소화하고, 척추후방조직을보존하는최소침습적척추관감압술이시행되어왔다. 이수술법은관혈적인현미경적감압술과수술적접근방식이비슷하고, 수술시해부학적구조가익숙하여어렵지않게감압술을시행할수있었고, 익숙해질때까지오랜시간이필요하지는않았다. 또한, 본증례에서는척추불안정성을줄이기위하여가능하다면증상이심한한쪽으로만접근해서신경공감압술을시행하려고하였으며, 술후불안정성의요인을제거하려고하였다. 본연구에서는척추관및추간공협착증환자 12례에서수술 20 www.krspine.org
Journal of Korean Society of Spine Surgery Minimally Invasive Foraminotomy using Tubular Retractor 현미경과 tubular retractor system 을이용한척추관감압술을시행한후 VAS 지수는수술전평균 7.42±0.53 에서수술후평균 5.25±0.66 로감소되어의미있는증상의호전을관찰할수있었다. ODI는수술전평균 24.25±2.89 에서수술후평균 19.33± 3.02 으로감소하였고, POS는수술전평균 4.92±0.57 에서수술후평균 5.75±0.71 로증가하여수술후기능이호전되는임상결과를얻을수있었다. 단, 방사선학적으로수술전불안정성이있는경우는연구대상에서제외하였으며, 전례에서평균 16.1 개월의추적관찰기간중방사선학적으로술후불안정성이있는경우는없었다. 술후 12명중 6명 (50%) 에서증상의불충분한호전으로인한 3차례의추가적인신경근차단술을시행받았으며, 이중 4명은신경근차단술후에도증상이지속되었다. 또한수술과관련한요추부의만성통증이나운동장애등은나타나지않았다. 본연구에서수술과관련된합병증은보이지않았고, 최종추시시성공률이 67% 로높지는않았으나감압술의목표인방사통이나간헐적파행의호전에서양호한결과를얻었다. 이는기존의보고보다는더나쁜결과이지만추시기간이짧고환자군이적어더많은환자를대상으로한장기추시연구가필요하다. 본증례에서는내과적질환이많고당뇨병성신경염등이있는환자들이많아서결과가더안좋게나타났을것으로판단된다. 또한, 수술후증상이재발하는경우는술후발생할수있는불안정성을막기위해충분한감압술이시행되지못하였거나, 퇴행성변화가진행하면서추간공이다시좁아지면서생길수있다고판단된다. 따라서, 술전방사선검사상불안정성이있다고판단되는환자에서는이수술이적합하지않다고할수있겠다. 제 5요추-제 1천추간에서는척추관협착증을동반하지않는추간공협착증만있는경우가전체 12예중 4예 (33%) 로나타났고, 감압술을시행할때척추경내척추경부분절제술 (intrapedicular partial pediculectomy, IPPP) 및천장골비익절제술 (sacral alar resection) 을시행하였다. 수술술기가약간복잡하긴하지만불충분한감압술이수술실패와연관되어있음을볼때꼭필요한술기라고하겠다. 최소침습적감압술은수술후척추불안정증을유발하지않고척추고정술이필요하지않아고령과골다공증이있는요추부척추관협착증환자들에서선택할수있는수술법이될수있다. 또한, 유합술에거부감이있는환자에있어서도권유할만한수술적방법중한가지로생각된다. 결론 최소침습적후방추간공확장술을시행한경우에서는합병증이적으면서 75% 에서는방사통이나간헐적파행등의증상의 호전을보였으나, 약절반가량에서술후추가적인신경근차단술을필요로하였다. 수술의효과만을따졌을때에는고식적인후방감압술및유합술이우수하나최소침습추간공확장술은조기보행이가능하고, 척추고정술을필요치않으며실혈량을최소화할수있는등의장점이있어고령의기저질환이많은환자나유합술을원하지않는환자에서대안적수술법으로선택적으로사용할수있을것으로사료된다. REFERENCES 1. Crock HV. Normal and pathological anatomy of the lumbar spinal nerve root canals. J Bone Joint Surg Br. 1981;63:487-90. 2. Hasegawa T, An HS, Haughton VM. Imaging anatomy of the lateral lumbar spinal canal. Semin Ultrasound CT MR. 1993;14:404 13. 3. Kunogi J, Hasue M. Diagnosis, operative treatment of intraforaminal and extraforaminal nerve root compression. Spine (Phila Pa 1976). 1991;16:1312 30. 4. Cohen MS, Wall EJ, Brown RA, et al. 1990 AcroMed Award in basic science. Cauda equina anatomy. II: Extrathecal nerve roots and dorsal root ganglia. Spine. 1990;15:1248 51. 5. Hasue M, Kunogi J, Konno S, et al. Classification by position of dorsal root ganglia in the lumbosacral region. Spine (Phila Pa 1976). 1989;14:1261 4. 6. Vanderlinden RG. Subarticular entrapment of the dorsal root ganglion as a cause of sciatic pain. Spine (Phila Pa 1976). 1984;9:19 22. 7. Weinstein J. Report of the 1985 ISSLS Traveling Fellowship. Mechanisms of spinal pain. The dorsal root ganglion and its role as a mediator of low-back pain. Spine (Phila Pa 1976). 1986;11:999 1001. 8. Wiltse LL, Guyer RD, Spencer CW, Glenn WV, Porter IS. Alar transverse process impingement of the L5 spinal nerve: the farout syndrome. Spine (Phila Pa 1976). 1984;9:31 41. 9. Nathan H, Weizenbluth M, Halperin N. The lumbosacral ligament(lsl) with special emphasis on the lumbosacral tunnel and the entrapment of the 5th lumbar nerve. Int Orthop. 1982;6:197 202. 10. Burton CV, Kirkaldy-Willis WH, Yong-Hing K, et al. Cause of failure of surgery on the lumbar spine. Clin Orthop Relat Res. 1981;157:191 9. www.krspine.org 21
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Journal of Korean Society of Spine Surgery Minimally Invasive Foraminotomy using Tubular Retractor 요추부추간공협착증을동반한척추관협착증환자에서관상형견인기를이용한 최소침습적감압술의유용성 신헌규 최재열 정화재 김유진 박세진 이승희 서동석성균관대학교의과대학강북삼성병원정형외과 연구계획 : 최소침습적후방추간공확장술을시행한 12명의요추부추간공부협착증을동반한척추관협착증환자의임상및수술결과에대해후향적분석을시행하였다. 목적 : 요추부의추간공협착증을동반한척추관협착증환자에서최소침습적요추부후방추간공확장술및척추관감압술의유용성에대하여살펴보고자하였다. 선행문헌의요약 : 요추부의추간공협착증을동반한척추관협착증환자에서흔히사용되는수술법은고식적인후방감압술및유합술이다. 이는수술시간이길고, 오랜입원기간, 술후요추부통증, 유합술로인한인접척추분절장애등이남을수있어고령의기저질환이많은환자에서는위험할수있고, 큰수술을원치않는환자군에서는적절치못한수술법이다. 대상및방법 : 2009 년 1월부터 2011 년 4월까지후방추간공확장술및척추관감압술을시행한 12명의환자를대상으로하였으며통증정도는 VAS score 를이용하였다. 술후예후는 Oswestry Disability Index (ODI) 와 Prolo Outcome Scale (POS) 로평가하였다. 결과 : 12명중 6명에서수술후하지방사통의즉각적인호전이관찰되었다. 수술후요추부통증은미미한정도였으며, 수술과관련된합병증은관찰되지않았다. 관찰기간동안 8명에서 ODI는수술전평균 24.25±2.89 에서수술후최종추시결과평균 19.33±3.02 으로감소하였다 (p=0.28, paired t-test). 결론 : 최소침습적후방추간공확장술은고령의기저질환이많은환자나유합술을원하지않는환자에대안적수술법으로선택적으로사용할수있을것으로사료된다. 색인단어 : 요추, 척추관협착증, 추간공확장술, 최소침습수술 약칭제목 : 추간공협착증에서최소침습적감압술 www.krspine.org 23