Journal of Korean Society of Spine Surgery Change of Lumbar Isometric Extensor Strengths after Posterior Lumbar Interbody Fusion in Patients with Lumbar Degenerative Disease Yong Gon Seo, M.S., Chong Suh Lee, M.D., Ph.D., Kyung Chung Kang, M.D., Won Hah Park, M.D., Ph.D. J Korean Soc Spine Surg 2014 Dec;21(4):160-166. Originally published online December 31, 2014; http://dx.doi.org/10.4184/jkss.2014.21.4.160 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:///doix.php?id=10.4184/jkss.2014.21.4.160 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.
Original Article pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2014 Dec;21(4):160-166. http://dx.doi.org/10.4184/jkss.2014.21.4.160 Change of Lumbar Isometric Extensor Strengths after Posterior Lumbar Interbody Fusion in Patients with Lumbar Degenerative Disease Yong Gon Seo, M.S.*, Chong Suh Lee, M.D., Ph.D., Kyung Chung Kang, M.D., Won Hah Park, M.D., Ph.D.* Division of Sports Medicine, Department of Physical Medicine & Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea* Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Department of Orthopedic Surgery, College of Medicine, Kyung Hee University Medical Center Study Design: Prospective cohort study. Objectives: This study was undertaken to examine changes in lumbar isometric extensor strength after posterior lumbar interbody fusion (PLIF) surgery. Summary of Literature Review: In most reports, the patients that have undergone PLIF surgery have been shown to have muscle weakness and atrophy. However, the research conducted regarding the changes in muscle strength throughout a follow up period is insufficient. Materials and Methods: Forty-nine patients (mean age, 65 years (range, 45 to 77)), scheduled for posterior lumbar interbody fusion due to symptomatic degenerative diseases, were enrolled. Preoperatively and 3, 6, and 12 month after surgery, lumbar isometric extensor strength was assessed using a MedX instrument in 7 angular positions (0-72 ). The mean isometric strength and rate of increase were calculated. Isometric strengths were compared according to patients age (<60, 60-70, and 70 years) and fusion level (short: <3; and long: 3) and the respective relationships were analyzed. Results: The mean isometric strength changed from 89.0 preoperatively to 85.3, 110.4, and 120.8 ft-lb at each follow-up, respectively. The rate of increase of strength was significantly greater at 0 (36.1 %) than at 72 (24.2 %) (p=0.019). Preoperative isometric strengths were similar in each age and fusion level group, but isometric strengths at the final follow-up were significantly lower in older patients and in the long level fusion group (p=0.002 and 0.043, respectively). Mean isometric strength at the last follow-up showed significant associations with age and fusion level (r=-0.431 and -0.317, p=0.002 and 0.030, respectively). Conclusion: After lumbar fusion surgery, back muscle strength slightly decreased until 3 months and then significantly increased. However, postoperative strength increases were lower in older patients and those in the long level (>3) fusion group. These results could be basic data for a rehabilitation program after lumbar fusion. Key Words: Lumbar degenerative disease, Posterior lumbar interbody fusion, Lumbar isometric extensor strength 서론 퇴행성변화로인한척추관협착증이나척추전방전위증으로보행이어렵거나통증이심할때노인환자의경우수술적치료를고려하게된다. 수술적치료로척추유합술을실시하며원인질환은협부또는퇴행성척추전방전위증, 퇴행성디스크질환과척추관협착증이다. 1) 척추유합술의접근방법중퇴행성변화가일어난부위를후방에서접근하여감압술후경막과신경근을견인하여추간판을제거한후에그안에단독적으로 cage 를삽입하거나자가골이식을실시하여척추의불안정성을치료하는후방요추체간유 Received: May 13, 2014 Revised: July 1, 2014 Accepted: December 4, 2014 Published Online: December 31, 2014 Corresponding author: Won Hah Park, M.D., Ph.D. Won Hah Park, Division of Sports Medicine, Department of Physical Medicine & Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea TEL: +82-2-3410-3847, FAX: +82-2-3410-6689 E-mail: wonhah.park@samsung.com 160 Copyright 2014 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Change of Lumbar Muscle Strengths After Posterior Lumbar Interbody Fusion 합술 (PLIF) 이가장보편적으로시행되고있다. 2,3) 하지만수술시수술부위의광범위한척추근육박리로인한주위근육의신경손상및근위축, 장시간의과도한견인으로인한통증발생이근력약화를초래하기도한다. 4,5) 이전의몇몇연구에서요통이나기능적장애를가진환자재활시근력은하나의중요한매개변수라고보고하였다. 6,7) Keller 등 8) 의연구에서는단순한감압술후요부근력의기능적향상을보고하였으며또한 Choi 등 9) 은요추부디스크절제술후신전근강화운동이요부근력향상에긍정적효과를나타낸다고보고하였다. 이처럼단순한감압술및미세디스크절제술후요부신전근력의변화를보는연구들은이루어지고있으나후방요추체간유합술환자를대상으로실시한근력변화에대한국내연구는그리많지않다. 몇몇연구에서후방요추체간유합술 3개월이후실시한척추안정화운동이요부의통증, 근력, 관절가동범위를향상시키고 10) 전만각도회복과근력향상에도도움을주어빠른일상생활복귀에도움을줄수있다고보고하였다. 11) 하지만연구들은수술후운동요법을적용했을때환자들의예후가어떻게변화되는지를검증하는것에그목적을두고있으며다른선행연구들은 12,13) 수술적기법이수술의결과에어떠한영향을미치는지에대해서만추시결과를보고하였다. 이에저자들은후방요추체간유합술후등척성요부신전근력의변화를비교분석하여기간별임상적기초자료를제공하고자한다. 대상및방법 1. 대상서울소재 S병원의스포츠의학센터에서 2007 년부터 2009 년동안요추부퇴행성질환을가진환자를대상으로 6개월이상보존적치료를했음에도불구하고증상의호전이없어후방요추체간유합술 (PLIF) 을시행한 140명으로하였다. 이들중수술전연구에동의하지않은 70명, 추시기간에근력검사를시행하지못한 15명과나이제한 (<40 또는 80) 으로 6명이연구제외되었으며 49명이최종연구대상이다. 대상자들의평균나이는 65세이다 ( 범위 45-77)(Table 1). 평균등척성요부신전근력은환자의나이 (<60(n=9), 60-70(n=27), 70(n=13) 와유합정도 (fusion level) 에따라 ( 단분절 : <3(n=28), 장분절 : 3(n=21)) 비교하였다. Analogue Scale: VAS) 설문지와요부의기능적평가를위해오스웨스트리장애지수 (Oswestry Disability Index: ODI) 설문지를작성하였다. 요부신전근력측정요부신전근력검사는등척성 (isometric) 원리를이용하여제작된요부신전운동기기 (MedX lumbar extension, MedX, USA) 을이용하여수술전, 수술후 3개월, 6개월, 12개월에걸쳐총 4 회실시하였다. 각검사는요부의관절가동범위인 72 내에서 12 간격으로모두일곱가지각도 (72, 60, 48, 36, 24, 12, 0 ) 에서측정하였다. 모든환자는검사전검사에대한충분한설명을듣고검사시요부의급성좌상 (strain) 을예방하기위해요부의충분한준비운동을실시하도록하였다. 피검자의자세는장비의프로토콜에맞추어대퇴와골반부위를고정시키고검사시최대근력을발현하기시키기위해 3초간등뒤에있는저항패드에힘을주도록한다 (Fig. 1). 정점에서 1초를버티고 3초간천천히저항을없애는방법으로실시한다. 각각도별휴식시간은요부의근피로를줄이기위해서 10초동안실시하였다. 최대요부신전근력발현을위해서검사간피검자에게모니터를보게하여피드백을주었으며검사자는구두로환자에게동기부여를주었다. 검사의신뢰성을위해서모든검사는한명의운동처방사가실시하였다. 설문조사본연구에서요부통증정도를알아보기위해서시각사상척도 (VAS, 0-10) 을이용하였으며 VAS 는눈금이표시되어있지않는막대위에환자가느끼고있는통증의강도를표시하게한후시작점에서표시점까지의거리를측정하여점수화하는방법으 12 24 36 48 0 60 72 2. 방법본연구는수술전, 수술후 3, 6, 12개월이경과하는시점에서 MedX 장비를이용하여각도별요부신전근력을측정하였다. 주관적통증정도를알아보기위해시각적사상척도 (Visual Fig. 1. Restraining mechanism of the Medx lumbar extension machine. 161
Yong Gon Seo et al Volume 21 Number 4 December 2014 로 0점에서 10점까지이며, 통증이없는상태를 0으로하였고, 참을수없는통증의정도를 10으로정의하였다. 또한요통으로인한장애정도를측정하기위해한국어로된오스웨스트리장애지수 (ODI) 를이용하였다. ODI는환자에의해작성되는선다형설문으로일상생활시각각의동작과관련된 10개의항목으로구성되어있고각항목에서는일상생활의장애를 0-5점으로 6 가지단계로기술한다. 각각의항목에서가장심한장애를모두합하면 50점으로 100% 의장애가되고, 장애가전혀없다면 0점으로 0% 의장애가있다는것이다. 자료처리본연구에서얻어진자료는 SAS version 9.1(SAS Institute Inc., Cary, NC, USA) 을사용하였으며모든변인에대한평균과표준편차를제시하였다. 집단간의차이를비교분석을위해 the t-test, Mann-Whitney U-test, paired t-test, Wilcoxon signedrank test, 1-way ANOVA, Kruskal-Wallis test를실시하였다. 또한상관분석을위해서 Pearson s product moment correlation 과 Spearman s rank correlation rho을실시하였다. 통계적유의수준은 p<0.05 로설정하였다. 나타났으며 (p<0.05) 수술후 3개월에는약간의감소를나타냈다. 이러한근력의증가는오직수술후 3개월과 6개월사이에서유의적인변화를나타냈으며 (p<0.001), 수술전과수술후 3개월또는 6개월과 12개월에사이에서는나타나지않았다 (p>0.05) (Fig. 2). 수술후 12개월에서근력의향상은굴곡보다는신전각도에서더크게나타났다. 등척성요부신전근력은수술전과수술후 12개월에서모든각도에서 0 (36.1%), 12 (28.2%), 24 (26.5%), 36 (27.7%), 48 (27.2%), 60 (25.9%), 70 (24.2%) 증가하였다. 0 에서근력의증가율은 72 에서보다더크게나타났다 (p=0.019). 허리를굴곡과신전할때발생하는신전근력 결과 1. 등척성요부신전근력의변화평균등척성요부신전근력은수술전 89.0±23.6 ft-ibs 에서수술후 3, 6, 12개월에서각각 85.3±31.0, 110.4±28.8, 120.8± 27.2 ft-ibs 으로나타났다. 근력은요부의굴곡각도에서더크게 Fig. 2. After lumbar fusion surgery, the isometric strengths were maintained or slightly decreased without significance until 3 months and then increased until 12 months. In particular, significant increases were obseved between at postoperative 3 and 6 months* (p<0.001). The isometric strengths were stronger in higer flexion angular positions. Fig. 3. After lumbar fusion surgery, the mean isometric extension strength increased significantly and the mean ratio of 72 /0 isometric strength decreased significantly, particularly between postoperative 3 and 6 months* (p<0.001 and 0.007, respectively). The mean isometric strength showed a significant negative association with the ratio of 72 /0 isometric strength (r=-0.371, p<0.001). 162
Journal of Korean Society of Spine Surgery Change of Lumbar Muscle Strengths After Posterior Lumbar Interbody Fusion 의비율을나타내는 72 /0 의평균비율은수술전 3.23±1.81 에서수술후 3, 6, 12개월에서각각 3.36±2.23, 2.70±1.25, 2.71± 1.11 으로수술후점차적으로감소하는것으로나타났다. 평균등척성요부신전근력은 72 /0 평균비율과음의상관관계가있었다 (r=-0.371, p<0.001) (Fig. 3). 즉, 72 /0 평균비율이증가할수록각각도에서측정한평균값의요부신전근력은낮게나타났다. 연령에따른평균등척성근력의비교에있어서는수술전에는의미적인차이가없지만나이가증가할수록 70세이상의환 Table 1. Baseline demographic and clinical data Variable Data Age, mean (Range) 65 (45-77) <60 9 60-70 27 70 13 Diagnosis group, n Spinal stenosis 30 Degenerative spondylolisthesis 14 Spondylolytic spondylolisthesis 5 Funsion level, n 1 level 13 2 level 13 3 level 15 4 level 8 자군은수술후 3, 6, 12 개월에서 60 세이하의환자군에비해서 그증가비율이낮게나타났다 ( 각각 p=0.011, 0.041, 0.002). 또한유합분절간평균등척성요부신전근력을살펴보면단 분절과장분절유합술환자간에차이는없지만 (p=0.446), 장분절 유합술환자의근력은수술후 3, 6, 12 개월에서단분절유합술 환자보다의미적으로낮게나타났다 ( 각각 0.036, 0.043)(Fig. 4). 상관분석에서평균등척성요부신전근력은수술후 12 개월에 서환자의나이, 유합정도와음적관련성을나타냈다 (Table 2). 2. 추시기간에따른통증과장애지수의변화 평균 VAS 는수술전 55.0±32.6 에서수술후 3, 6, 12 개월에 각각 32.4±16.7, 25.7±12.4, 23.3±11.8 나타났으며추시기간 동안감소하는양상을보였다. 평균 ODI 는수술전 48.7±13.2 에서수술후 3, 6, 12 개월에각각 36.9±18.0, 26.8±12.2, 25.1 ±14.9 로감소하였다. 수술전과수술후 3 개월사이에서 ODI 와 VAS 의의미있는감소가나타났다 (p=0.045 와 0.022) (Fig. 5). Table 2. Correlations between the mean isometric strength and other p rameters at postoperative 12 months Correlation coefficient (r) Age Fusion length ODI Mean isometric strength - 0.431-0.317-0.270 (p-value) 0.002* 0.030* 0.080 Pearson s product moment correlation and Spearman s rank correlation rho. * p-value < 0.05. Fig. 4. In comparisons of the mean isometric strength according to patients age and fusion level groups, preoperative isometric strengths were not significantly different, but the increases of isometric strengths were lower in older patients and long level fusion group (*p<0.05). 163
Yong Gon Seo et al Volume 21 Number 4 December 2014 Fig. 5. After lumbar fusion sugery, the ODI and VAS for back decreased gradually until postoperative 12 months and significant decreases were obseved between preoperative and at postoperative 3 months* (p=0.045 and 0.022, respectively). 고찰 이연구는요추체간유합술 (PLIF) 후등척성요부신전근력 의변화를본것으로서근력은수술후 3 개월시점에서약간감 소되는변화를보이지만그이후 6 개월까지는의미있는증가를 나타냈다. 수술후근력의증가는모든각도에서나타났으며그 증가율은굴곡보다는신전각도에서더크게나타났다. 병변을 제거함에도불구하고수술후 3 개월시점에서근력이감소된것 은수술중발생되는요부근육의신경제거와손상으로근위축 5), 수술후 3 개월동안보조기를착용으로인한요부의움직임제 한그리고삽입물 (instrumentation) 에대한수동적인경직이그 원인인것으로사료된다. 또한수술 3 개월이후에근력이의미있 는증가를보이는것은보조기없이활동하는시간과개인차에 따라다를수있지만신체활동의증가가영향을미쳤을것으로 판단되며이에대한추후연구가이루어져야할것으로생각된 다. 수술전과비교해볼때 1 년후의등척성요부신전근력은향 상된변화를나타내고있으며 Keller 등 8) 보고한수술후 1 년시 점에서약 20% 가량요부신전근력의감소를보였다는연구내 용과는상반되는결과이다. 이는요부신전근력의평가방법에 있어서측정자세, 힘발현방법이달랐으며연구집단의차이도 영향을미쳤을것으로생각된다. 본연구에서는앉은자세에서 골반을고정하고검사를실시하였으나이전연구에서는선자세 로실시하였다. 또한힘발현방법에있어서도자발적으로 3 초 간최대로힘을주어평가를실시한본연구의방법과는달리장 비의정해진저항 (25% 와 50%) 에대해서최대로버티는힘을평 가하였다. 연구집단에서도후방척추체간유합술환자를대상 으로한이번연구와달리이전연구는척추관협착증환자가대상이므로이에대한결과적차이도있을것이라고생각한다. 아직까지이전연구들에서유합술후 1년시점에서의요부근력의변화에대한의견은다양한것이현실이다. 많은연구에서 14-16) 증상을가진퇴행성질환자의경우요부근력의약화나병소에퇴행성변화를보인다고보고하였기때문에장분절의요부퇴행성질환자가수술전신전근력이더약할것이라고생각했지만단분절과장분절을비교해볼때수술전등척성요부신전근력은의미있는차이를보이지않았다. 하지만, 수술후 12개월에서는장분절과 70세이상환자군에서근력이낮게나타났다. 등척성요부신전근력은환자의나이와유합정도에상관없이증가하지만그증가율은장분절과 70세이상환자군이단분절과 60세이하환자군보다더낮게나타났다. 즉, 환자의나이가많거나유합술을시행한정도가심할수록 1년후근력은낮은것으로나타났다. 이러한결과로볼때수술후요부근력강화운동은단분절과장분절환자모두에게서필요하며특히, 장분절환자에게는수술후통증과기능적회복을위해요부근력강화운동이더욱중요하다고판단된다. 이연구에서는등척성요부신전근력의 72 /0 의비율을분석하였다. 이비율은허리를굴곡과신전시발생하는신전근력의비율을나타내는지수로많은연구에서는건강한사람보다요통을가진환자에게있어그비율이높다고보고하였다. 17,18) 연구결과평균등척성요부신전근력의 72 /0 의비율은 3.23 이며이것은건강한사람을대상으로실시한연구 (2.0-2.3) 18) 와요통을가진환자들 19.20) 보다더높게나타났다 (2.3-2.9). 즉, 후방요추체간유합술을실시한환자의경우건강한사람과요통환자와비교할때허리의굴곡과신전각도에서발생하는신전근력간의근력차이는더심하다고볼수있다. 이러한비정상적인요부신전근력의 72 /0 간차이는요통및근육의좌상을일으키는하나의요인이될수있으므로이를예방하기위해서몸통근육의근력강화운동이병행되어야한다는것의저자의의견이다. 게다가유합술후요부의굴곡각도보다는신전각도에서증가율이더크기때문에 72 /0 의비율은수술후 12개월에서감소한다. 또한 72 /0 의평균비율은등척성요부신전근력과의미있는상관관계를가진다. 이연구에서는평균 ODI와 VAS 를통해수술후환자의통증과기능적상태를살펴보았다. 수술후 3개월의평균 ODI와 VAS 는의미있는감소를보였으며 12개월까지점진적으로감소하는양상을보였다. 이러한결과는유합술시행후통증및기능장애가수술후 1년까지조금씩더호전되는양상 ( 수술전 56.5%~ 수술 1년 20.1%) 을보인다고보고한 Cho 등 13) 와같은결과를나타냈다. 수술후감소한 ODI와 VAS 는통증을일으키 164
Journal of Korean Society of Spine Surgery Change of Lumbar Muscle Strengths After Posterior Lumbar Interbody Fusion 는병소 (pathologic lesion) 을직접적으로제거함으로써개선된것으로사료된다. 또한 3개월이후의 ODI와 VAS 의의미있는감소는요부신전근력의향상에의한것으로판단되며, 등척성요부신전근력의증가가기능적장애를감소시킨다는 Tarnanen 등 21) 의연구와같은결과를나타낸것이다. 이연구는몇가지제한점을가지고있다. 첫째로, 이연구에서는연구대상자와비교할건강한성인의통제그룹이없다는것이다. 통제그룹과의비교는수술후재활이나요부근력운동에있어서기준을제시하는데도움이되었을것이다. 두번째로, 이연구의 49명의환자는다양한기초적인질환과다른수술을실시하였다. 비록환자의나이와유합정도를비교하였지만이러한차이는수술후결과에영향을미칠것으로사료된다. 세번째로, 연구대상자가모두여성이라는것이다. 이는성별의차이에따른 1년간의추시적결과를볼수없다는것이아쉬운점이다. 이로인해이연구의결과를남성에게도적용시키는것은제한이있다고볼수있다. 마지막으로등척성요부신전근력검사에대한신뢰성연구가이루어지지않았다. 이전의연구에서는요통환자를대상으로실시한등척성근력평가에대한신뢰성보고는있지만후방요추체간유합술을실시한환자를대상으로실시한신뢰성연구는거의없다. 하지만, 연구자는본연구전 20 명을대상으로실시한신뢰성검사에대해서높은신뢰성을확인하였다 (Intraclass correlation coefficient : 0.839). 결론 등척성요부신전근력은수술후 3개월시점에서약간의감소를보이지만수술후 1년까지는점진적증가를보이며요부신전각도에서더의미있게증가한다. 하지만, 수술후근력의증가는나이가많거나장분절환자에게서낮게나타났다. 이연구의결과는후방요추체간유합술후통증감소및기능적향상을요하는환자의요부신전근력과기능적상태를파악하는데기초자료가될것이며근력강화운동을위한재활프로그램을계획하는데있어추시적결과를비교분석하는데도움을줄것으로판단된다. REFERENCES 1. Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976). 2005;30:1441-5. 2. Suk SI, Lee CK, Kim WJ, Lee JH, Cho KJ, Kim HG. Adding posterior lumbar interbody fusion to pedicle screw fixation and posterolateral fusion after decompression in spondylolytic spondylolisthesis. Spine (Phila Pa 1976). 1997;22:210-9. 3. Suk SI. Text of spinal surgery. 1sted. Newmed Co: 2004.119-20. 4. Matsui H, Kitagawa H, Kawaguchi Y, Tsuji H. Physiologic changes of nerve root during posterior lumbar discetomy. Spine (Phila Pa 1976). 1995;20:654-9. 5. Kawaguch Y, Mastsui H, Tsuji H. Back muscle injury after posterior lumbar spine surgery. Part 2: Histologic and histochemical analyses in humans. Spine (Phila Pa 1976). 1994;19:2598-602. 6. Hirsch G, Beach G, Cooke C, Menard M, Locke S. Relationship between performance on lumbar dynamometry and Waddell score in a population with low-back pain. Spine (Phila Pa 1976). 1991;16:1039-43. 7. Keller A, Hellesnes J, Brox JI. Reliability of the isokinetic trunk extensor test, Biering-Sorensen test, and Astrand bicycle test: assessment of intraclass correlation coefficient and critical difference in patients with chronic low back pain and healthy individuals. Spine (Phila Pa 1976). 2001;26:771-7. 8. Keller TS, Szpalski M, Gunzburg R, Spratt KF. Assessment of trunk function in single and multi-level spinal stenosis: a prospective clinical trial. Clin Biomech (Bristol, Avon). 2003;18:173-81. 9. Choi G, Raiturker PP, Kim MJ, Chung DJ, Chae YS, Lee SH. The effect of early isolated lumbar extension exercise program for patients with herniated disc undergoing lumbar discetomy. Neurosurgery. 2005;57:764-72. 10. Moon HK, Yoon JY, Han GS. Effects of spinal exercise program in the elderly patients after posterior lumbar interbody fusion surgery. J Kor Sports Med. 2008;26:19-26. 11. Cho JH, Lee WY. Effects of lumbar stabilization exercise on lordosis angle and muscular strength in posterior lumbar interbody fusion surgery patients. J Korean Soc Living Environ Sys. 2010;17:667-74. 12. Watanabe K, Yamazaki A, Morita O, Sano A, Katsumi K, Ohashi M. Clinical outcomes of posterior lumbar interbody fusion for lumbar foraminal stenosis: Preoperative diagnosis and surgical strategy. J Spinal Disord Tech. 2011;24:137-41. 13. Cho KJ, Moon KH, Kim MK, et al. Change of clinical outcomes after decompression and fusion for spinal stenosis 165
Yong Gon Seo et al Volume 21 Number 4 December 2014 during 2-year follow-up periods. Journal of Korean Spine Surg. 2003;10:113-8. 14. Kang CH, Shin MJ, Kim SM, Lee SH, Lee CS. MRI of paraspianl muscles in lumbar degenerative kyphosis patients and control patients with chronic low back pain. Clin Radiol. 2007;62:479-86. 15. Lee JC, Cha JG, Kim Y, Kim YI, Shin BJ. Guantitiative analysis of back muscle degeneration in the patients with the degenerative lumbar flat back using a digital image analysis: comparision with the normal controls. Spine (Phila Pa 1976). 2008;33:318-25. 16. Takemitsu Y, Harada Y, Iwahara T, Miyamoto M, Miyatake Y. Lumbar degenerative kyphosis. Clinical, radiological and epidemiological studies. Spine (Phila Pa 1976). 1988;13:1317-26. 17. Carpenter DM, Graves JE, Pollock ML, et al. Effect of 12 and 20 weeks of resistanced training on lumbar extension torque production. Phys Ther. 1991;71:580-8. 18. Tucci JT, Carpenter DM, Pollock ML, Graves JE, Leggett SH. Effect of reduceted frequency of training and detraining on lumbar extension strength. Spine (Phila Pa 1976). 1992;17:1479-501. 19. Risch SV, Norvell NK, Pollock ML, et al. Lumbar strengthening in chronic low back pain patients. Physiologic and psychological benefits. Spine (Phila pa 1976). 1993;18:232-8. 20. Robinson ME, Greene AF, O Connor P, Graves JE, MacMillan M. Reliability of lumbar isometric torque in patients with chronic low back pain. Phys Ther. 1992;72:186-90. 21. Tarnanen S, Neva MH, Kautiainen H, et al. The early change in trunk muscle strength and disability following lumbar spine fusion. Disabil Rehabil. 2013;35:134-9. 퇴행성요추부질환을가진환자의후방요추체간유합술후등척성요부신전근력의변화 서용곤 * 이종서 강경중 박원하 * 성균관대학교의과대학삼성서울병원재활의학과스포츠의학실 * 성균관대학교의과대학삼성서울병원정형외과, 경희대학교의과대학경희대학병원정형외과 연구계획 : 전향적코호트연구목적 : 후방요추체간유합술후요부의등척성신전근력의변화를알아보기위한것이다. 선행문헌의요약 : 대부분의연구에서, 후방요추체간유합술을실시한환자는근력의약화와위축이나타난다. 하지만추시기간에따른근력의변화에대해수행된연구는부족하다. 대상및방법 : 증상이있는퇴행성질환으로인해후방요추체간유합술을실시한 49명의환자를대상으로하였다. 수술전그리고수술후 3, 6, 12개월에 Medx 장비 ( 요부신전장비 ) 로굴곡에서신전까지일곱가지각도 (72, 60, 48, 36, 24, 12, 0) 에대한최대근력을측정하였다. 평균등척성근력과근력증가율을평가하였다. 등척성근력은나이 (<60, 60-70, 70세 ) 와수술분절 ( 단분절 : <3 그리고장분절 : 3) 에따라비교분석하였다. 결과 : 평균등척성근력은수술전 89.0 에서수술후 3, 6, 12개월에각각 85.3, 110.4 그리고 120.8 로변화되었다. 근력의증가율은 72도 (24.2%) 보다 0 도 (36.1%) 에서더크게나타났다 (p=0.019). 수술전등척성근력은각나이와수술분절에서비슷했지만수술후근력은나이가많은환자와장분절환자에게서의미적으로낮게나타났다 (p=0.002 과 0.043, 각각 ). 마지막추시의평균등척성근력은나이와수술분절과의미있게관련이있는것으로나타났다 (r=-0.431 과 -0.317, p=0.002 과 0.030, 각각 ). 결론 : 요부유합술후허리근력은 3개월시점에서약간감소하지만이후에의미있게증가한다. 하지만, 수술의근력의증가는나이가많거나장분절환자에게서더낮게나타났다. 이러한결과는요부유합술후재활프로그램을위한기초적인자료가될것이다. 색인단어 : 퇴행성요추부질환, 후방요추체간유합술, 등척성요부신전근력 약칭제목 : 후방요추체간유합술후요부근력의변화 166