대한척추외과학회지제 16 권제 3 호 Journal of Korean Spine Surgery Vol. 16, No. 3, pp 160~166, 2009 DOI:10.4184/jkss.2009.16.3.160 흉요추부골절에서후방고정술식에따른설상각교정이후만의진행에미치는영향 김석곤 * 김명호 이성철 민상혁 이진원 단국대학교의과대학정형외과학교실, 단국대학교의과대학마취통증의학과교실 * The Effect of Vertebral Wedge Angle to the Change of Kyphotic Angle by the Posterior Instrumentation Method in Thoracolumbar Spine Fracture Seok-Kon Kim, M.D*., Myung-Ho Kim, M.D., Sung-Churl Lee, M.D., Sang-Hyuk Min, M.D., Jin-Won Lee, M.D. Department of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, Korea Department of Anesthesiology & Pain Medicine, Dankook University College of Medicine, Cheonan, Korea* Abstract Study design: Retrospective study Objectives: To examine the effect of transpedicular screw fixation on fractured vertebrae about the vertebral wedge angle (VWA) after posterior instrumentation of the thoracolumbar fracture, determine the effect of reduced VWA on the change in the Kyphotic angle (KA), and minimize loss of reduction of KA. Summary of the literature review: Maintenance of the KA of a thoracolumbar fracture after surgery is important for the radiologic and functional outcome. Materials and methods: Forty patients, who had undergone posterior instrumentation in a thoracolumbar fracture between February 2006 and February 2008 and followed-up for more than one year, were enrolled in this study. The patients were divided into two groups according to transpedicular screw fixation (Group A) or not (Group B) including fractured vertebrae. The evaluation was performed by measuring the changes in the KA and VWA taken after the injury, immediate after surgery and 1 year after surgery. Results: There was correlation between groups A (transpedicular screw fixation on fractured vertebrae) and B (no transpedicular screw fixation on the fractured vertebrae) regarding the correction of the VWA and the loss of correction KA, (p<0.05). Conclusions: Reduction of the VWA is an important factor for preventing reduction loss of the KA, and transpedicular screw fixation including fractured vertebrae would help reduce the VWA. Therefore, the operator must pay attention to the increase in VWA to maintain the KA through short segment transpedicular screw fixation including fractured vertebrae. Key Words: Thoracolumbar spine, Fracture, Transpedicular screw fixation, Vertebral wedge angle, Kyphotic angle Address reprint requests to Sang-Hyuk Min, M.D. Department of Orthopaedic Surgery, College of Medicine, Dankook University 16-5 Anseo-dong, Cheonan, Chungnam, 330-715, Korea Tel: 82-41-550-3953, Fax: 82-41-556-3238, E-mail: osmin71@naver.com Received: 2008. 10. 28. Accepted: 2009. 8. 25. - 160 -
흉요추부골절에서설상각교정 김석곤외 서 론 흉요추부골절은외상에의한척추골절중가장흔하게발생하며신경마비나후만변형등의많은합병증을일으킨다. 현재흉요추부골절의치료는크게보존적인치료에서부터많은종류의수술적치료까지다양하며, 각각의적응증역시치료자에따라다양하게적용된다 1,2,3,4). 수술적인치료는골절부의해부학적정복및견고한내고정을함으로써신경손상의회복및조기거동과재활을도모하는데있고특히손상구조의정확한정복으로신경관의충분한감압과정상후만각을복원시키며, 견고한내고정으로교정상태를유지함으로써기능및신경학적회복을최대화하고후유변형을방지하는데목적이있다 5,6,7). 이중후방도달법에의한기기고정술은주로인대신연을통한간접정복으로전방도달법에의한직접정복에비해추체자체의변형에대한교정효과가부족하며, 척추불안정성에저항할수있는충분한강도의고정력을갖기어려워변형의재발또는정복의상실이나타날수있는문제점이있다 8). 이에저자들은한개의흉요추부척추체에발생한골절에서후방기기고정술시골절추체부를포함한척추경나사못고정유무에따른설상각교정이후만각의변화에어떠한영향을미치는지알아보고자하였다. 연구대상및방법 1. 연구대상 2006 년 2 월부터 2008 년 2 월까지흉요추부골절이발생하여본원에서단분절후방기기고정술을시행한 59 례중술후 1 년이상추시가가능하였던 40 례를대상으로하였다. 평균추시기간은 14.2 개월 (12~29 개월 ) 이었으며골절추체부를포함한척추경나사못고정을시행한경우 (A 군 ) 는 32 례 (80.0%) 였고시행하지않은경우 (B 군 ) 는 8 례 (20.0%) 였다. 수술의적응증으로설정하였던술전단순방사선측면사진상골절된척추체전방주의압박률이 50% 이상이거나시상지수가 25 도이상또는골편의척추관침범이 30~50% 이상인골절환자들을대상으로후향적연구를하였다. 신경학적증상으로인해전방도달법을이용하여수술한경우및골다공증성골절환자는제외하였다. 2. 연구방법 후방기기고정술은수상후평균 2.2 일 (0~6 일 ) 에시행하였으며모든예에서 6 일이내에수술을시행하였다. 골절의정복은전신마취후복와위에서후방도달법으로시행하였으며후방고정기기를이용하여골절된추체를포함혹은포함하지않고단분절척추경나사못고정을시행하였으며정상척추만곡과일치하게미리굴곡시킨금속봉을적용하였다. 이어 C 형투시장치유도하에골절부위를가로지르는인대신연을통한간접정복을시행하였다. 본연구에서는조직손상의복원력이우수할것으로기대되는 40 세이하, 신경학적손상이없어감압술이필요치않은경우, 후관절의관절면손상이없는경우, 심한추간판손상이없는경우에는골이식술을시행하지않았으며본연구에포함된총 40 례중 25 례 (62.5%) 는후방에서골이식술을시행하여골유합을유도하였으나나머지 15 례 (37.5%) 에서는골이식술을시행하지않았다 9). 술후평균 1.3 일 (1~3 일 ) 후부터보조기착용후보행을시작하였으며외래추시상골유합혹은골절추체안정소견을확인한후술후평균 12.2 주 (11.3~12.7 주 ) 에보조기를제거하였다. 수술전, 수술직후및수술후최소 1 년이상추시시의단순방사선측면사진을이용하여척추체후만각 (Kyphotic Angle, 이하 KA) 과척추체설상각 (Vertebral Wedge Angle, 이하 VWA) 및상부추간각 (Upper Intervertebral angle, 이하 UIVA), 하부추간각 (Lower Intervertebral angle, 이하 LIVA) 을각각측정하였다. 후만각은골절척추체에대한한마디상부의척추체상연을잇는선과골절된척추체의한마디하부의척추체하연을잇는선이이루는각도인 Cobb s angle 을측정하였고설상각은골절된추체의상부종판과하부종판이이루는각도를측정하였 Fig. 1. Schematic diagram of geometric parameters measured on a lateral radiograph. KA: Kyphotic angle, VWA: Vertebral wedge angle, UIVA: Upper intervertebral angle, LIVA: Lower intervertebral angle - 161 -
대한척추외과학회지 Vol. 16, No. 3, 2009 Table 1. The changes in radiologic parameters over time preop. Immpo. (reduction) 1yr (loss) Presence of screw or not Yes-Group A (32) KA( ) 6.88 1.92(4.94) 6.27(4.34) (Screw-Yes) VWA 17.89 6.73(11.19) 7.30(0.56) UIVA( ) 3.84 6.63(2.80) 4.78(-1.87) LIVA( ) 9.38 9.83(0.44) 8.18(-1.63) No-Group B (8) KA( ) 5.25 4.75(0.5) 13.5(8.75) (Screw-No) VWA 13.88 6.50(7.38) 9.88(3.38) UIVA( ) 2.88 6.77(3.90) 5.18(-1.58) LIVA( ) 7.25 9.88(2.63) 7.74(-2.13) preop.; preoperative, Immpo.; parameters of immdiate postoperative, (reduction) ; average of amount of reduction, 1yr ; parameters after 1 year at least, (loss) ; average of amount of reduction loss, KA; Kyphotic angle, VWA; Vertebral wedge angle, UIVA; Upper Intervertebral angle, LIVA; Lower Intervertebral angle Table 2. The p-value and standard deviation between A,B two groups on study 으며상부추간각은골절된척추체의상연과한마디상부의척추체하연을잇는선이이루는각도, 하부추간각은골절된척추체의하연과한마디하부의척추체상연을잇는선이이루는각도를측정하였다 10) (Fig. 1). 골절된추체의척추경나사못고정유무에따라골절된추체에척추경나사못을고정한군은 A 군, 고정하지않은군은 B 군으로분류하여설상각, 후만각의교정및교정소실과상, 하부추간각의변화를분석하였으며군간의비교는 SPSS software version 12.0 독립표본 T- 검정을이용하였다. 결 과 p-value Standard deviation A group B group Reduction of VWA 0.047 3.46 6.80 Reduction loss of VWA 0.023 1.95 3.29 Reduction loss of KA 0.038 2.61 5.20 VWA; Vertebral wedge angle, KA; Kyphotic angle 손상원인으로추락에의한손상이 23 례 (57.5%) 로가장많았으며다음으로교통사고가 10 례 (25.0%), 직접적인외상이 6 례 (15.0%), 넘어져수상한경우가 1 례 (2.5%) 였다. 남자가 30 명 (75.0%), 여자가 10 명 (25.0%) 이었으며평균연령은 43.9 세 (19-69 세 ) 였다. 골절위치는제 1 요추가 13 례 (32.5%) 로가장많았고제 2 요추가 10 례 (25.0%), 제 12 흉추가 8 례 (20.0%), 제 11 흉추가 2 례 (5.0%) 등흉요추부이행부위가 33 례 (82.5%) 로대부분이었으며이외의흉요추부는제 3 요추 5 례 (12.5%) 와제 4 요추 2 례 (5%) 로총 7 례 (17.5%) 였다. 골절추체부에척추경나사못고정을시행한군 (A 군 ) 이시행하지않은군 (B 군 ) 보다수술직후설상각교정에유의한차이 (A 군 11.19, B 군 7.38 ) 를보였으며 (p<0.05), 최종추시상설상각및후만각의교정소실또한 (A 군 - 설상각 0.56, 후만각 4.34, B 군 - 설상각 3.38, 후만각 8.75 ) A 군에서 B 군보다통계학적으로유의하게작았다 (p<0.05)(table 1, 2). 추간각의추이를관찰한결과 A, B 군모두에서수술직후상부 (UIVA) 및하부추간각 (LIVA) 의증가 (A 군 ; UIVA 2.80, LIVA 0.44, B 군 ; UIVA 3.90, LIVA 2.63 ) 가관찰되었고최종추시시상부및하부추간각의감소 (A 군 ; UIVA -1.87, LIVA -1.63, B 군 ; UIVA -1.58, LIVA - 2.13 ) 가관찰되었으며 A, B 군간통계학적유의성은없었다 (p>0.05)(table 1). 흉요추이행부 33 례 ( 흉추 11 번 - 요추 2 번 ) 와이외의흉요추부 7 례를비교분석한결과골절위치에따른설상각과후만각의교정및교정소실에있어통계적인차이가없었다 (p>0.05). 골이식술을시행한군과시행하지않은군에대한비교분석결과골이식술여부에따른설상각과후만각의교정및교정소실에있어통계적인차이는없었다 (p>0.05). 골절추체부를포함하는척추경나사못고정을시행함으로써골편의이동으로인한신경학적증상이발생한예는없었으며, 술후전산화단층촬영을시행한 9 례에서도술전과비교하여골편의정복이방해되거나골편이후방으로전위된경우는없었으며나사못이추체내에유지되어있는것을확인할수있었다. 고 찰 흉요추부골절의치료방법중수술적치료는골절부 - 162 -
흉요추부골절에서설상각교정 김석곤외 의해부학적정복에의한신경관의충분한감압과정상시상만곡의복원, 견고한내고정을통한교정상태의 유지, 신경손상의최대한의회복, 그리고조기보행및재활, 후유방지등에목적이있다 5,6,7,11,12,13). 수술적방법 Fig. 2. Change of KA & VWA over time (screw fixation including a fractured vertebra) The patient was 24 years old female. Fracture type was Flexion-Distraction. Spinous process of L2 spine was bisected. Transpedicular fixation including a fractured vertebra was done. KA and VWA was initial 7, 16 and immediate post-operation -22, 2, last follow-up -20, 2, After implant removal -19, 2. Initial reduction of VWA was 14. So, reduction loss of KA and VWA (2, 0 ) was minimal. Reduction loss KA and VWA (3, 0 ) after implant removal was minimal, too. (A) Preoperative lateral radiography (B) immediate postoperative lateral radiography (C) Follow-up lateral radiography after 15 months (D) Follow-up lateral radiography after implant removal. Fig. 3. Change of KA & VWA over time (screw fixation not including a fractured vertebra) The patient was 54 years old male. Fracture type was Flexion-Distraction. Transpedicular fixation not including a fractured vertebra was done. KA and VWA was initial 34, 27 and immediate post-operation 15, 7, last follow-up 20, 17. Initial reduction of VWA was 20. Reduction loss of KA and VWA (5, 10 ) was progressed. (A) Preoperative lateral radiography (B) immediate postoperative lateral radiography (C) Followup lateral radiography after 27 months. - 163 -
대한척추외과학회지 Vol. 16, No. 3, 2009 은후방도달법과전방도달법의크게두가지로분류되며척추골절의수술적치료시전방도달법과후방도달법의선택에대한논란의대상은신경의감압효과와고정범위에초점이맞춰진다. 수술방법의선택으로인한수술적위험부담률을최소화하면서충분한신경의감압효과를얻고, 고정범위를짧게하여척주의운동범위를최대화하는것이가장이상적인수술방법이다 14). 골절척추체에척추경나사못을고정하는것이추가적인고정점을제공하여물리적으로특히종축의염전력에대하여안정적이며골절정복과후만각교정에좋은결과를발표한사체실험연구가있으며 15), 임상적인연구에서또한골절추체부나사못고정이골절추체부의만곡각교정과이후교정소실을방지하는데도움이된다고하였다 16). 이를바탕으로, 저자들은골절추체부를포함한척추경나사못고정시견고한고정력외에어떠한변수가후만각의변화에영향을미치는지의문점을가지게되었다. Wang 등 10) 은후방고정술을시행했을경우추시상추간판간격의감소는피할수없기때문에수술시술자는후만각교정및교정소실을방지하기위하여설상각교정에중점을두어야하고만약설상각교정이충분히이루어지지않았다면추가적인전방고정 술이필요할수도있다고주장하였다. 본연구에서또한골절된추체부에척추경나사못을고정한군 (A 군 ) 에서고정하지않은군 (B 군 ) 보다설상각교정의정도가컸으며술후후만진행에밀접한관계가있었다 (p<0.05). 술후설상각이최대한교정되었던예에서최종추시상후만각교정소실정도가작았으며, 골절된추체부를포함하는척추경나사못고정을시행한예에서설상각교정및후만각의교정소실방지에우수한결과를보였다 (Fig. 2, 3). 이는골절된척추체의상, 하부척추체에고정된나사못을이용하여간접적인정복을시도함과동시에골절척추체의나사못이척추체를정복할경우도수조작시지렛대로작용할수있어설상각을증가시키는데용이하였다고생각한다. 그러나골절추체부를포함하는척추경나사못고정을시행한예에서설상각교정이만족할만큼이루어지지않아추시상설상각및후만각변형이진행된 2 례가있었다 (Fig. 4). 따라서척추경나사못고정시술후후만진행의방지를위해견고한고정력이선행되어야하며이때설상각교정이중요한변수로작용한것으로생각된다. 각군의상, 하부추간각의변화를분석한결과각군간에통계학적으로유의한차이는없었으며대부분의 Fig. 4. Change of KA & VWA over time (screw fixation including a fractured vertebra) The patient was 69 years old male. Fracture type was Flexion-Distraction. Transpedicular fixation including a fractured vertebra was done. KA and VWA was initial 32, 26 and immediate post-operation 21, 20, last follow-up 30, 25. Initial reduction of VWA was 6. So, reduction loss of KA and VWA (9, 5 ) was progressed. (A) Preoperative lateral radiography (B) immediate postoperative lateral radiography (C) Follow-up lateral radiography after 23 months. - 164 -
흉요추부골절에서설상각교정 김석곤외 예에서수술직후에는추간각의증가소견을보였고최종추시상수술직후보다추간각이감소되는소견을보였다 (p>0.05). 즉, 수술시설상각의증가가아닌추간각의증가로인하여후만각의교정이이루어졌다면추시상추간각의감소와함께후만변형이진행될수있음을의미한다. 따라서수술시만족할만한후만각의교정이이루어졌다하여도추시관찰상골절추체부상, 하부추간각의감소는피할수없으므로설상각교정이충분히이루어지지않는경우후만변형은진행될것으로생각된다. 즉, 설상각교정이술후후만진행에직접적인영향을미칠수있으며골절추체부를포함하는척추경나사못고정을시행한군에서후만변형이적은것은설상각교정이더욱많이이루어졌기때문으로생각한다. 본연구는각소그룹의개체수가적어통계적인유의성을일반화하는것에다소한계점이있을수있으며술후추시기간이평균 14.2 개월로서보다장기적인추시가필요할것으로생각된다. 결 론 흉요추부골절에서후방고정술시후만변형의진행을방지하는데있어설상각교정이중요한변수로작용하며, 골절추체부를포함하는척추경나사못고정이설상각교정에도움을주고후만변형방지에도움이될것으로생각된다. 참고문헌 01) Siebenga J, Leferink VJ, Segers MJ, et al.: Treatment of traumatic thoracolumbar spine fractures: a multicenter prospective randomized study of operative versus nonsurgical treatment. Spine 2006; 31: 2881-2890. 02) Reinhold M, Knop C, Lange U, Bastian L, Blauth M: Non-operative treatment of thoracolumbar spinal fractures. Long-term clinical results over 16 years. Unfallchirurg 2003; 106: 566-576. 03) Stadhouder A, Buskens E, de Klerk LW, et al.: Traumatic thoracic and lumbar spinal fractures: operative or nonoperative treatment: comparison of two treatment strategies by means of surgeon equipoise. Spine 2008; 33: 1006-1017. 04) Vaccaro AR, Kim DH, Brodke DS, et al.: Diagnosis and management of thoracolumbar spine fractures. Instr Course Lect 2004; 53: 359-373. 05) Yue JJ, Sossan A, Selgrath C, et al.: The treatment of unstable thoracic spine fractures with transpedicular screw instrumentation: a 3-year consecutive series. Spine 2002; 27: 2782-2787. 06) Shen WJ, Liu TJ, Shen YS: Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 2001; 26: 1038-1045 07) Mikles MR, Stchur RP, Graziano GP: Posterior instrumentation for thoracolumbar fractures. J Am Acad Orthop Surg 2004; 12: 424-435 08) Ahn JS, Lee JK, Hwang DS, Kim YM, Kim WJ, Byun KH: The change of kyphotic angle and anterior vertebral height after posterior or posterolateral fusion with transpedicular screws for thoracolumbar bursting fractures. J Korean Fracture Soc. 2003; 2: 379-387 09) Kim YM, Kim DS, Choi ES: Results of non-fusion method in thoracolumbar and lumbar spinal fractures. J Korean Soc Spine Surg 2005; 12: 132-139 10) Wang XY, Dai LY, Xu HZ, Chi YL: Kyphosis recurrence after posterior short-segment fixation in thoracolumbar burst fracture. J Neurosurg Spine 2008; 8: 246-254 11) Scholl BM, Theiss SM, Kirkpatrick JS: Short segment fixation of thoracolumbar burst fractures. Orthopedics 2006; 29: 703-708 12) Dai LY, Jiang SD, Wang XY, Jiang LS: A review of the management of thoracolumbar burst fractures. Surg Neurol 2007; 67: 221-231 13) Inamasu J, Guiot BH, Nakatsukasa M: Posterior instrumentation surgery for thoracolumbar junction injury causing neurologic deficit. Neurol Med Chir (Tokyo) 2008; 48: 15-21 14) Lee JY, Kim GL: Posterior instrumentation of thoracolumbar fracture. J Korean Soc Spine Surg 2001; 8: 423-427 15) Mahar A, Kim C, Wedemeyer M et al.: Short segment fixation of lumbar burst fractures using pedicle fixation at the level of the fracture. Spine 2007; 32: 1503-1507 16) Min HJ, Kim KW, Kim YH, Yoon US, Hwang JS: The comparison of loss of reduction at the thoracolumbar fracture according to insertion of screw including fractured vertebra or not in short segment posterolateral fusion. J Korean Soc Spine Surg 2002; 9: 19-26 - 165 -
대한척추외과학회지 Vol. 16, No. 3, 2009 국문초록 연구계획 : 후향적연구연구목적 : 흉요추부골절에서후방기기고정술시골절추체부를포함한척추경나사못고정이설상각교정에미치는영향을찾고교정된설상각의유지가척추후만의진행에미치는영향을분석하여교정소실을최소화하고자하였다. 대상및방법 : 2006년 2월부터 2008년 2월까지흉요추부골절환자중단분절후방기기고정술을시행하고최소 1 년이상추시가가능했던 40례를대상으로하였고이중골절추체부의척추경나사못고정여부에따라두군 (A, B 군 ) 으로분류하였으며수술전의설상각과수술직후설상각의회복정도및최소 1년추시상설상각과후만각의교정소실정도를측정하였다. 결과 : 골절추체부를포함한척추경나사못고정을시행한군 (A군) 이시행하지않은군 (B군) 보다설상각의교정정도가통계적으로유의하게컸으며 (p<0.05) 술후추시상 B군보다 A군에서후만각의교정소실정도또한유의하게작았다 (p<0.05). 결론 : 흉요추부골절에서후방고정술시후만변형의진행을방지하는데있어설상각교정이중요한변수로작용하며, 골절추체부를포함하는척추경나사못고정이설상각교정에도움을주고후만변형방지에도움이될것으로생각된다. 색인단어 : 흉요추부, 골절, 척추경나사못고정, 설상각, 후만각 통신저자 : 민상혁충청남도천안시안서동산 16-5 단국대학교의과대학정형외과학교실 TEL: 82-41-550-3953, FAX: 82-41-556-3238, E-mail: osmin71@naver.com - 166 -