Journal of Korean Society of Spine Surgery Old and New Fashion: Minimally Invasive Spine Surgery for Adjacent Segmental Spinal Stenosis after Luque Sublaminar Wiring and Posterolateral Fusion - Case Report - Seung-Pyo Suh, M.D.*, Jaewon Lee, M.D., Chang-Nam Kang, M.D., Ph.D. J Korean Soc Spine Surg 2014 Dec;21(4):179-182. Originally published online December 31, 2014; http://dx.doi.org/10.4184/jkss.2014.21.4.179 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.2014.21.4.179 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.
Case Report pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2014 Dec;21(4):179-182. http://dx.doi.org/10.4184/jkss.2014.21.4.179 Old and New Fashion: Minimally Invasive Spine Surgery for Adjacent Segmental Spinal Stenosis after Luque Sublaminar Wiring and Posterolateral Fusion - Case Report - Seung-Pyo Suh, M.D.*, Jaewon Lee, M.D., Chang-Nam Kang, M.D., Ph.D. Department of Orthopedic Surgery, Sung-Ae Hospital, Seoul, Republic of Korea* Department of Orthopedic Surgery, College of Medicine, Hanyang University, Seoul, Republic of Korea Study Design: A case report. Objectives: To report a rare case of minimally invasive spine surgery after sublaminar wiring fixation with Luque rods. Summary of Literature Review: In the past, sublaminar wiring fixation with Luque rods was believed to be an effective fixation method; however, the development of transpedicular fixation resulted in the discontinuation of this method. Currently, instead of classical surgery using a broad incision, minimally invasive spine surgery is performed, which has a multitude of advantages. Material and Methods: Initially, the patient underwent Luque sublaminar wiring and posterolateral fusion. After 25 years, minimally invasive TLIF and percutaneous transpedicular fixation were performed for the adjacent segmental spinal stenosis. Results: A good bone union is developing with an excellent clinical outcome, 14 months after the surgery. Conclusions: We report a very rare case of a patient who underwent Luque sublaminar wiring and then, 25 years later, had spine surgery with minimally invasive techniques. Key Words: Luque sublaminar wiring, Adjacent segmental spinal stenosis, Minimally invasive spine surgery 척추유합술은척추분절간기능또는형태의이상, 불안정등을해결하기위하여발전하여왔다. 척추유합술시견고한골유합이필요로하며현재까지분절간고정술을위하여다양한방법들이고안되었다. 본격적인고정기구로는해링턴지지대 (Harrington rod), 루끼강선결박술 (Luque sublaminar wiring), 추궁고리시스템, 척추경나사못고정술로발전되었다. 현재는척추경나사못고정술이기존의다른방법에비하여고정력이우수하기때문에주로사용되고있다. 접근법에대하여최근에는고전적인수술적접근법대신에비침습적, 최소침습적인방법이소개되고있으며수술중또는수술후생길수있는합병증을줄이기위해노력하고있다. 이증례는루끼강선결박술및후외방유합술을시행후 15년후에발생한상위인접분절의척추관협착증에대하여 10년동안고식적가료를시행하였으나임상증상이악화되어처음수술후 25년뒤에최소침습법으로치료하였던증례를경험하였기에문헌고찰과함께보고하는바이다. 증례보고 당시 45 세의여자환자는지속되는요통으로 1987 년본원정 형외과에내원하였으며제 5 요추의척추전방전위증을진단받 았고제 4 요추부터제 1 천추까지루끼강선결박술과자가장골 을이용한후외방유합술을시행받았다. 수술후환자는간헐적 인요통이있을때만외래내원하며추시관찰되었다. 환자는수 술후 12 년째, 1999 년에마지막으로외래내원하여단순방사선 Received: April 5, 2014 Revised: May 21, 2014 Accepted: August 18, 2014 Published Online: December 31, 2014 Corresponding author: Chang-Nam Kang, M.D., Ph.D. Department of Orthopedic Surgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong- gu, Seoul 133-791, Republic of Korea TEL: +82-2-2290-8485, FAX: +82-2-2299-3774 E-mail: cnkang65@hanyang.ac.kr Copyright 2014 Korean Society of Spine Surgery 179
Jaewon Lee et al Volume 21 Number 4 December 2014 영상검사시행하였고, 환자는추시관찰되지않았던기간동안에통증없이일상생활을수행하였다고한다. 환자는수술로부터 15년후, 2002 년에요통을주소로다시내원하였으며동반된하지의방사통은없었고하지근력검사상정상소견관찰되었다. 수술후인접분절의문제에대하여평가하기위하여환자동의하에단순방사선영상검사및자기공명영상검사를시행하였으며검사상특히제 3요추의상부종판에서골극이관찰되며제 2요추-제 3요추간추간판의변성, 미만성추간판팽윤의소견과함께후관절및황색인대의비후로인한상위인접분절의척추관협착증소견을보였다. 요통에대하여보존적으로약물치료를시행하였고이후 1년간호전과 악화를반복하는요통이지속되었다. 수술적치료권고하였으나환자는처음수술시시간이많이걸리고출혈이많아서고생을하였다고호소하며수술적치료를거절하였다. 처음수술로부터 25년후, 2012년에환자는내원한달전부터심해지요통 (VAS 9) 과함께양측하지의방사통 (VAS 7), 저린감, 이상감각및 5분미만의간헐적파행을호소하였다. 하지근력저하소견은보이지않았고그외신경학적이상소견은관찰되지않았다. 단순방사선검사 (Fig. 1A, B) 및자기공명영상검사 (Fig. 1C, D) 를시행하였으며제 2요추-제 3요추간척추관협착증이 2002년에비하여악화되었다. 임상증세및영상학적소견이모두악화되었기에수술적치료를시행하 A B C D Fig. 1. Lumbar spine anteroposterior (A) and lateral (B) radiographs taken at 25 years after operation. There are endplate sclerosis and traction spurs at proximal L2-L3 level. T2 sagittal (C) and axial (D) MRI taken at 25 yeaers after operation show severe spinal stenosis of L2-L3 level and more aggravated than 10 years ago. A B C D Fig. 2. Lumbar spine anteroposterior (A) and lateral (B) radiographs after minimally invasive TLIF and percutaneous transpedicular fixation were performed. Good bone union without loosening of screws is shown on sagittal (C) and axial (D) CT scan after 14 months of last surgery. 180
Journal of Korean Society of Spine Surgery Old and New Fashion of Spinal Surgery 기로하였다. 제 3요추-제 4요추간추간판은추간판변성이 Pfirrmann 씨 1) 등급 II에해당되며척추관협착증의병변이관찰되지않았고, 제 2요추-제 3요추간척추관협착증에대하여만최소침습법으로경추간공을통하여추간판을제거한후탈무기질화골기질 (Demineralized Bone Matrix) 과국소자가골을충전한 PEEK 케이지를이용하여요추추체간유합술및경피적척추경나사못고정술을시행하였다. 수술후부터환자는요통과양측하지의이상감각, 저린감및통증이모두사라졌으며, 수술후 14개월에촬영한단순방사선검사 (Fig. 2A, B) 에서척추경나사못의이완등의소견은관찰되지않았고컴퓨터단층촬영 (Fig. 2C, D) 에서골유합이양호하게진행되고있는소견을확인하였으며주관적인증상없이현재외래추시관찰중이다. 고찰 척추수술기구의시작은해링턴 (Harrington) 시스템으로부터처음소개되었으며척추변형수술의새시대를열게되었다. 측만각을교정하고척추를안정화시키기위하여당시에는수개월동안침상안정이필요하였고단계적으로캐스트 (cast) 또는보조기를착용하고보행을시작하였었다. 이후분절간척추수술기구가개발되었는데이는척추와기구간의힘의스트레스를여러분절에분산시킴으로써변형교정이더용이해졌으며수술후보조기를통한고정이필요없어졌다. 이런분절간척추수술기구의원형이바로루끼 (Luque) 에의해소개되었다. 2) 루끼강선결박술은 Luque 와 Cordosa 3) 가척추측만증의분절교정의방법으로처음소개되었다. Luque 4) 는청소년기특발성척추측만증환자에서평균 72% 의교정효과를보고하고부작용은 65명중감염이 2예, 가관절증이 2예만을보고하며루끼강선결박술은매우만족할만한수술법이라고주장하였다. 하지만효과적인고정은가능하였지만철사삽입또는제거중경막손상의가능성이제기되었다. Zdeblick 등 5) 은기구삽입없이골이식을시행한경우, 척추경나사못을이용한고정술과추궁하철사고정술시의중등도이상의신경병리학적이상소견이나타나는정도를비교하였으며, 각각 21%, 18%, 64% 를보이며추궁하철사고정술시신경병리학적이상소견이가장많이나타난다고주장하였다. 이에대한해결책으로추궁하철사고정술시철사대신케이블을이용하여경막손상을줄일수있다고보고하기도하였다. 6,7) 그러나루끼강선결박술은척추경나사못고정술에비하여고정능력이떨어짐으로인해현재는거의사용되지않는수술방법이되었다. 척추경나사못시스템은이론적으로는후방인대복합체를보존할수있으며, 척추의 3주 (3 column) 를모두고정할수있기에척추유합술에서큰인기 를끌게되었다. 척추경나사못은고리를이용한기구보다강도 (strength) 및강성 (stiffness) 이뛰어났으며 8) 또한관상면, 시상면, 회전이상의교정에서모두뛰어난결과를보였고교정의실패율도이전의다른기구들보다적었다. 이번증례에서는과거루끼강선결박술시와이번최소침습적척추수술후출혈량과입원기간, 수술후통증정도를비교하고자하였으나안타깝게도과거의자료가남아있지않아객관적인비교는불가하였다. 하지만환자의수술후만족도조사시수술후컨디션과통증정도, 입원기간등에대하여과거에비하여매우만족하는것으로나타났다. 최소침습적수술법과기존의수술법들을비교한연구들을보면, 고전적인경추간공요추추체간유합술은현재가장많이쓰이는척추유합술술식중의광범위한근육박리와연부조직의과도한뒷당김 (retraction) 으로인한부작용들이보고되고있으며이로인한입원기간의연장, 비용증가를보고하였고 9) 최근에는수술적치료에있어서비침습적, 최소침습적인방법을도모하며활발히시행되고있다. 많은저자들은최소침습적척추수술이고전적인광범위절개후접근법보다출혈의감소, 입원기간감소, 수술부위감염률감소, 수술후진통제사용감소, 수술후일상생활로의빠른복귀등의장점을보이며이를통하여비용절감의효과까지있다고보고하였다. 10,11) 인접분절퇴행성변화는추간판의퇴행성변화가가장흔하며이와동반하여척추전방전위증, 불안정성, 척추관협착증, 후관절비후, 골극형성등이일어난다. 인접분절퇴행성변화가일어나는기전은아직까지밝혀지지않았지만생역학적스트레스의변화와환자의노화로인한자연적인퇴행성변화가주요인으로생각되고있다. 이환율은방사선학적기준만가지고분석할경우 8% 에서 100% 까지다양하게나타났고, 방사선학적기준과증상의발현을같이고려할경우 5.2% 에서 18.5% 까지보고되고있으며 12) 또한척추유합술을시행한분절이많을수록유병률이높아진다고보고되었다. 13,14) 본증례의환자는루끼강선결박술및자가장골을이용한후외방유합술후 25년간견고하게유합되어있었으며인접분절의척추관협착증으로추가적인수술이필요하였던환자로서현재는루끼강선결박술이거의시행되지않아서거의볼수없는증례이며, 인접분절의척추관협착증에대하여최소침습법을이용한수술적치료의결과가우수하여문헌고찰과함께보고하는바이다. REFERENCES 1. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. Magnetic resonance classification of lumbar intervertebral 181
Jaewon Lee et al Volume 21 Number 4 December 2014 disc degeneration. Spine (Phila Pa 1976). 2001;26:1873-8. 2. Foster MR. A functional classification of spinal instrumentation. Spine J. 2005;5:682-94. 3. Luque ER, Cordosa A. Segmental correction of scoliosis with rigid internal fixation: preliminary report. Orthop Trans. 1977;1:136-7. 4. Luque ER. Segmental spinal instrumentation for the correction of scoliosis. Clin Orthop Relat Res.1982;163:192 8. 5. Zdeblick TA, Becker PS, McAfee PC, Sutterlin CE, Coe JD, Gurr KR. Neuropathologic changes with experimental spinal instrumentation: transpedicular versus sublaminar fixation. J Spinal Disord. 1991;4:221-8. 6. Parsons JR, Chokshi BV, Lee CK, Gundlapalli RV, Stamer D. The biomechanical analysis of sublaminar wires and cables using luque segmental spinal instrumentation. Spine (Phila Pa 1976). 1997;22:267-73. 7. Songer MN, Spencer DL, Meyer PR Jr, Jayaraman G. The use of sublaminar cables to replace Luque wires. Spine (Phila Pa 1976). 1991;(Suppl):S418-21. 8. Zindrick MR, Wiltse LL, Widell EH, Thomas JC, Holland WR, Field BT, Spencer CW. A biomechanical study of intrapeduncular screw fixation in the lumbosacral spine. Clin Orthop. 1986;203:99 112. 9. Park Y, Ha JW. Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach. Spine (Phila Pa 1976). 2007;32:537-43. 10. Tian NF, Wu YS, Zhang XL, Xu HZ, Chi YL, Mao FM. Minimally invasive versus open transforaminal lumbar interbody fusion: a meta-analysis based on the current evidence. Eur Spine J. 2013;22:1741-9. 11. Chung HT, Na CO, Ha SH, Shin DR. Minimally invasive transforaminal lumbar interbody fusion. J Korean Soc Spine Surg. 2009;16:24-9. 12. Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976). 2004;20:1938-44. 13. Yang JY, Lee JK, Song HS, Kim TH, Yeon KW. Correlation between clinical result and adjacent segment degeneration after lumbar spinal fusion. J Korean Soc Spine Surg. 2008;15:38-43. 14. Cho JL, Park YS, Han JH, Lee CH, Roh WI. The change of adjacent segments after spinal fusion: Follow-up more than three years after spinal fusion. J Korean Soc Spine Surg. 1998;5:239-46. Old and New Fashion: Luque 지지대와추궁하철사고정술및후외방유합술후상위인접분절척추관협착증의최소침습법을이용한수술적치료 서승표 * 이재원 강창남성애병원정형외과 *, 한양대학교의과대학정형외과학교실 연구계획 : 증례보고목적 : 루끼강선결박술후최소침습적인척추수술을시행한증례를보고하는바이다. 선행문헌의요약 : 과거에루끼강선결박술은효과적인고정이라는장점으로많이이용되었지만척추경나사못고정술의발달로현재는거의이용되지않는다. 최근에는광범위절개가아닌최소침습적인방법으로척추수술을하려는노력들이활발히시도되고있으며이를통해다양한장점들을기대하고있다. 대상및방법 : 이증례는척추전방전위증으로루끼강선결박술및자가장골을이용한후외방유합술을시행하였으며 25년후, 인접분절의퇴행성척추관협착증에대하여최소침습적척추수술을시행하였다. 결과 : 수술후 14개월에골유합이양호하게진행되고있으며우수한임상경과를얻었다. 결론 : Luque 지지대를이용한추궁하철사고정술은최근에매우보기힘든드문증례로인접분절의최소침습적고정술을시행한사례를보고한다. 색인단어 : 루끼강선결박술, 인접분절척추관협착증, 최소침습법 약칭제목 : 척추수술의과거와현재경향 182