Journal of Korean Society of Spine Surgery Influence of Gonarthrosis on Sagittal Spinal Alignment Kyu-Bok Kang, M.D., Young-Bae Kim, M.D., Young-Rok Ko, M.D., Ji-Young Cheong, M.D. J Korean Soc Spine Surg 2017 Sep;24(3):169-175. Originally published online September 30, 2017; https://doi.org/10.4184/jkss.2017.24.3.169 Korean Society of Spine Surgery Asan Medical Center 88, Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: +82-2-483-3413 Fax: +82-2-483-3414 Copyright 2017 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.2017.24.3.169 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. www.krspine.org
Original Article J Korean Soc Spine Surg. 2017 Sep;24(3):169-175. https://doi.org/10.4184/jkss.2017.24.3.169 Influence of Gonarthrosis on Sagittal Spinal Alignment Kyu-Bok Kang, M.D., Young-Bae Kim, M.D., Young-Rok Ko, M.D., Ji-Young Cheong, M.D. Department of Orthopedic Surgery, Veterans Health Service Medical Center, Korea Study Design: Research using radiographic findings. Objectives: To compare spinopelvic parameters in detail between normal subjects and those who had bilateral gonarthrosis with or without spondylosis. Summary of Literature Review: The relationship between knee joint flexion contracture and hypolordosis in the lumbar spine has been well established. However, spinopelvic parameters in subjects with gonarthrosis without flexion contracture have not been well described in the literature. Materials and Methods: Fifty-seven male subjects in their 60s with bilateral gonarthrosis over Kellgren-Lawrence grade III were included. They were subdivided into the KS group (with spinal osteoarthritis, n=32) and the KN group (without spinal osteoarthritis, n=25). Normal asymptomatic subjects without disease in their back or leg were analyzed as the control group (NN; n=84). The following spinopelvic parameters were measured and compared; C7 plumbline (C7PL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Results: In the KS group, the C7PL was significantly anteriorly displaced compared to the KN group (1.7±4.5 cm vs. 0.6±2.9 cm, p=0.031) and the NN group (1.7±4.5 cm vs. 0.5±2.9 cm, p=0.014). TK in the KN group was significantly smaller than in the NN group (25.4±8.8 vs. 30.1±8.3, p=0.041). The KS group had the smallest value of LL, while the NN group had the largest value of LL ( 23.2±48.7 vs. 44.9±33.8 vs. 57.3±8.5, p<0.001). No significant difference was observed in PI, SS, or PT among the 3 groups. A strong correlation was found between LL and SS in the NN group (R= 0.776, p<0.01), while this correlation was moderate in the KN group (R= 0.355, p<0.01). Conclusions: Overall balance was maintained in the subjects who had gonarthrosis without spinal osteoarthritis. Subjects with gonarthrosis showed less LL, especially if they had spinal osteoarthritis. Further studies are needed to characterize the differences in these pelvic parameters, and to evaluate changes in individuals with knee joint flexion contracture. Key words: Knee, Spine, Osteoarthritis, Sagittal alignment. 서론 고령의환자들에게슬관절과척추의퇴행성질환은흔히동반되며이에대한상관관계는잘알려져있다. 1-3) 병적후만으로척추의시상면상의불균형이심하여척추내상하인접분절의보상성전만으로정상적균형을회복하지못하면, 골반경사값이증가하고, 이차적으로슬관절의보상성굴곡이발행한다고알려져있다. 4,5) 이와반대로여러저자들은슬관절에질환이있어굴곡이있는경우척추의시상면상의이상을보인다고하였다. 6-8) 슬관절관절염환자들의척추시상면상변화의특징을알기위하여 Wang 등 9) 은이들을요추의통증유무로두군으로분류한후, 요추전만과골반변수를비교하여양군에서유의한차이가없다고발표하였다. Received: October 31, 2016 Revised: June 21, 2017 Accepted: August 17, 2017 Published Online: September 30, 2017 Corresponding author: Young-Bae Kim, M.D ORCID ID: Young-Bae Kim: https://orcid.org/0000-0003-6966-0949 Kyu-Bok Kang: https://orcid.org/0000-0001-7974-7438 Young-Rok Ko: https://orcid.org/0000-0002-5208-8599 Ji-Young Cheong: https://orcid.org/0000-0002-6214-6035 Veterans Health Service Medical Center 53, Jinhwangdo-ro 61-gil, Gangdonggu, Seoul, 05368 Korea TEL: +82-2-2225-1352, FAX: +82-2-2225-1910 E-mail: drortho@korea.com Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 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. 169
Kyu-Bok Kang et al Volume 24 Number 3 September 2017 그러나이들은대부분굴곡변형이있는슬관절관절염환자들에게서골반과요추의변형에대한연구들이었으며, 아직굴곡변형이진행되지않은경우에서흉추를포함하는척추와골반의시상면상변수들의변화와상관관계및, 척추의보상기전이남아있는경우와, 이미척추질환이있어서보상기전이없는경우의시상면상변화의차이에대하여는잘알려져있지않다. 이에저자들은슬관절관절염으로치료받고있는 60대의남성환자들만을대상으로흉추를포함하는척추와골반의시상면상변수들을측정하였으며, 이들을척추의질환이있는군과없는군으로세분하여척추의시상면상보상기전의차이를알아보고자하였다. 또한슬관절을포함하는하지와척추양측에질환이없는 60대의남성정상인들을대조군으로선정하여이들과의차이도알아보고자하였다. 대상및방법 본원에서진료를받은환자들과신체검사를시행받은사람들중에서지원자들을대상으로하였다. 본원의임상연구윤리위원회 (IRB, institutional review board) 심의를거친후 2015년 5월부터 2016년 2월까지연구대상자모집및측정을시행하였다 (IRB No. 2015-03-008). 대상자들은본원에서슬관절인공관절치환술을시행받기위하여입원한환자들중에서 61세이상 70세이하의남성들로하였다. 이들중 Kellgren-Lawrence 기준으로양슬관절에서 IV 등급이거나, 편측슬관절이 IV 등급이며반대측슬관절이 III 등급인자들을대상으로하였다. 10) 슬관절통증이외의고관절이나족관절등의하지의다른부위에통증이있는경우는제외하였다. 모집한대상자들을다시슬관절에는관절염이있으나척추의이상이관찰되지않는 KN군과, 슬관절과척추에모두관절염이있는 KS군으로세분하여정의하였다. KN군은설문지검사에서척추에통증이나수술, 염증, 종양의과거력이없으며, 촬영한방사선사진상관상면상에서 10도이상의코브스씨각을가지고있는측만증, 양측협부결손, 척추이분증, 한분절또는두분절의국소적추간판간격의협소, 압박골절등이없는슬관절관절염환자들을대상자들로하였다. KS 군은임상증상으로슬관절통증으로치료를받고있는환자들중척추의통증을가지고있는환자들을대상으로하였다. 이들중, 영상의학적검사를시행하여국소적또는광범위한추간판간격의협소등의퇴행성변화를보이는환자들을대상으로하였다. 11) 척추에수술적치료를시행하였거나, 염증이나종양의과거력이있는경우, 또는압박골절의소견이보이는경우는제외하였다. NN군은슬관절과척추양측에모두이상이없는자들을대상으로시행한척추의시상면상정렬에대한연구에 서, 61 세이상 70 세이하의남자들의자료들을추출하여사용 하였다. 12) 이후이들을대상으로신장, 체중, 체질량지수 (Body Mass Index, BMI) 등의인구통계학적자료들을수집하였다. 방사선학적검사는하지의경우슬관절의전후면상과기립 하지전장측면상을촬영하였고, 척추의경우전신기립전후면 및측면의전체척추를촬영하였다. 하지전장촬영의경우고관 절과슬관절을최대한신전하여기립자세를취한후, 상지는 허리높이에파지하고촬영하였다. 이후 KS 군과 KN 군간의슬 관절의굴곡정도를측정하여비교하였다. 척추의경우전신기 립전후면및측면의전체척추촬영을시행하였다. 측면촬영 은 spinal deformity study group 의방법에따라고관절과슬관 절을신전하여기립자세를취한후, 상지는주관절을굴곡하 고수부를쇄골위에위치한후촬영하였다. 13) 영상자료의촬 영및보관은 Maroview (Marotech, Seoul, Korea) 의 PACS (picture archiving and communication system) 을이용하여 DICOM (Digital Imaging and Communications in Medicine) 양식으로저장하였다. 슬관절굴곡의측정은대상자의양슬관절중굴곡의정도 가더심한관절을선택하여시행하였으며, 그값은대퇴골두 로부터 Blumensaat 선까지이은선을대퇴의역학적축과, 경 A Fig. 1. Sagittal spinal angular parameters. (A) Group KN. (B) Group KS. TK: thoracic kyphosis (T5 UEP-T12 LEP), TLK: thoracolumbar kyphosis (T10 UEP-L2 LEP), LL: lumbar lordosis (T12 LEP-S1 UEP), SS: sacral slope, and PI: pelvic incidence. (UEP: upper end plate, LEP: low end plate). B 170 www.krspine.org
Journal of Korean Society of Spine Surgery Gonarthrosis and Spinal Sagittal Alignment 골의해부학적축을측정한후이들이이루는각도로하였다. 14) 세군들의척추시상면변수들의측정은 Surgimap software (Nemaris Inc., New York, NY) 를사용하였다. 15) 척추의시상면상지표들로흉추후만각 ( 제 5흉추상단-제 12흉추하단 ), 흉요추후만각 ( 제 10흉추상단-제 2요추하단 ), 및요추전만각 ( 제 12흉추하단-천추경사 ) 등을구하였다. 후만의경우양의값으로, 전만의경우음의값으로표시하였다. 시상면거리지표 (C7 plumbline, C7PL) 는제 7경추수선과천추후상단과의거리를측정하였다. 수선이천추후상단보다전방에위치하는경우양의값으로후방에위치하는경우음의값으로표시하였다. 골반지표로는골반입사각, 천추경사및골반경사를측정하였다 (Fig. 1). 세군의평균치의비교는 ANOVA test를이용하였고사후검정으로 Tukey 의방법을이용하였다. KS군과 KN군간의지표들을비교할때연속변수의경우는 t-test 를, 연관된인자분석에는카이제곱검정 (χ 2 test) 을이용하였다. 각지표들간의상관관계는 Pearson 상관성검사를이용하여분석하였다. p값이 0.05 이하에서유의한것으로보았다. 유의한상관관계를보이는결과들중상관계수의절대값이 0.7 이상은고도, 0.7 이하 0.3 이상은중등도, 0.3 이하 0.1 이상의경우경도의상관관계를보인다고하였다. 통계의분석은 SPSS ver. 10.1(SPSS Inc., Chicago, IL, USA) 한글판소프트웨어를이용하여시행하였다. 결과 슬관절관절염이있는대상자들은 57예로전례에서 61세이상 70세이하의남성이었다. 이들중슬관절과척추에모두관절염이있는 KS군이 32예, 슬관절에는관절염이있으나척추의이상이관찰되지않는 KN군이 25예이었다. 대조군인 NN군은 61세이상 70세이하의남성 84예이었다. NN군에서신장은 KS군에비하여유의하게컸고, 체중은 KN군에비하여낮았으 며, BMI는양군에비하여유의하게낮았다 (Table 1). KS군과 KN군의슬관절관절염의정도는 Kellgren- Lawrence 기준에따라양측슬관절모두 IV 단계인대상자들이 33명 (KS군 19명, KN군 14명 ), 편측슬관절이 IV 등급이며반대측슬관절이 III 등급인대상자들이 24명 (KS군 13명, KN 군 11명 ) 등이었으며, 양군에서구성인원에대한차이는통계학적으로유의하지않았다 (p=0.798). 대상자들의슬관절의굴곡의정도는평균 6.3±6.1 도이었으며, 양군에서유의한차이를보이지않았다 (6.7±7.2 도 vs. 5.8±4.5 도, p=0.585). 척추시상면상지표들의비교에서, 제 7경추수선과천추후상단과의거리는 KS군에서 KN군 (1.7±4.5 cm vs. -0.6± 2.9 cm, p=0.031) 및 NN군 (1.7±4.5 cm vs. -0.5±2.9 cm, p=0.014) 에비하여유의하게전방으로전이되어있었다. 5 cm 이상전방으로전이된대상자들의수는모두 8명이었으며, KS 군에서 32명중 4명, KN군에서 25명중 1명, NN군에서 84명중 3명으로, 각군간의통계학적으로유의한차이는보이지않았다 (p=0.164). 흉추후만의경우 KN군이 NN군에비하여유의하게작은값을보였다 (25.4±8.8 도 vs. 30.1±8.3 도, p=0.041). 흉요추후만의경우세군에서유의한차이를보이지않았다 (12.3±10.1 도 vs. 9.3±6.4 도 vs. 10.1±8.5 도, p=0.435). 요추전만의절대값은 KS군에서가장작은값을보였고, KN군에이어 NN군에서가장큰값을보였다 (-23.2±48.7 도 vs. -44.9±33.8 도 vs. -57.3±8.5 도 ). KN군과 KS군사이에서는유의한차이를보였고 (p=0.009), NN군과 KN군사이에서는통계적으로주변차이를보였다 (p=0.055). 골반지표의경우천추경사 (33.3±8.6 도 vs. 36.3±7.5 도 vs. 37.0±6.5 도, p=0.101), 골반경사 (13.9± 6.6도 vs. 13.2±10.3 도 vs. 10.6±5.7 도, p=0.069), 및골반입사각 (45.8±10.4 도 vs. 48.1±10.8 도 vs. 47.6±7.9 도, p=0.646) 의모든지표에서세군에서유의한차이를보이지않았다 (Table 2). Table 1. Demographic data Variable Group KS* Group KN Group NN p-values No. of cases 32 25 84 KS-KN KS-NN KN-NN Height (cm) 163.0±5.1 165.1±5.9 166.3±5.6 0.376 0.044 0.558 Weight (kg) 68.8±8.2 73.0±8.0 66.8±9.6 0.240 0.626 0.004 BMI (kg/mm 2 ) 30.8±3.0 31.8±2.8 24.4±3.2 0.583 0.000 0.000 Values are presented as mean±standard deviation. *Group KS: subjects with osteoarthritis in both knee and spine. Group KN: subjects with osteoarthritis in knee and normal asymptomatic spine. Group NN: subjects with normal asymptomatic knee and spine. www.krspine.org 171
Kyu-Bok Kang et al Volume 24 Number 3 September 2017 Table 2. Spinopelvic parameters ( ) among three groups Group KS (n=32) Group KN (n=25) Group NN (n=84) p-values KS-KN KS-NN KN-NN C7 plumbline (cm) 1.7±4.5-0.6±2.9-0.5±2.9 0.031 0.014 0.992 Thoracic kyphosis 26.4±13.3 25.4±8.8 30.1±8.3 0.914 0.240 0.041 Thoracolumbar kyphosis 12.3±10.1 9.3±6.4 10.1±8.5 0.415 0.538 0.888 Lumbar lordosis -23.2±48.7-44.9±33.8-57.3±8.5 0.009 <0.001 0.055 Sacral slope 33.3±8.6 36.3±7.5 37.0±6.5 0.287 0.082 0.876 Pelvic tilt 13.9±6.6 13.2±10.3 10.6±5.7 0.929 0.140 0.191 Pelvic incidence 45.8±10.4 48.1±10.8 47.6±7.9 0.644 0.692 0.966 A 시상면상의지표들간의상관관계는 NN 군에서는골반입 사각과천추경사사이 (R=0.793, p<0.01) 및천추경사와요 추전만사이 (R=-0.776, p<0.01) 에서고도의상관관계를, 골 반입사각과요추전만사이 (R=-0.558, p<0.01) 및요추전만 과흉추후만사이 (R=-0.373, p<0.01) 에서중등도의상관관 계를보였다 (Fig. 2A). KN 군에서골반입사각과천추경사사 이 (R=0.550, p<0.01), 천추경사와요추전만사이 (R=-0.355, p<0.01) 및골반입사각과요추전만사이 (R=-0.360, p<0.01) 에서중등도의상관관계를보였다. KS 군에서는골반입사각과 천추경사사이에서만중등도의상관관계를보였다 (R=0.698, p<0.01) (Fig. 2B). 고찰 B Fig. 2. Chains of correlations. (A) Group NN: subjects with normal asymptomatic knee and spine. (B) Group KN: subjects with osteoarthritis in knee and normal asymptomatic spine. Group KS: subjects with osteoarthritis in both knee and spine. 퇴행성슬관절관절염과척추의관절염이동반된경우, 슬관 절질환이우선적인영향을미칠가능성이있는지여부와그병 리기전을알기위하여본연구를시행하였다. 두질환이동반되 는경우, 척추의통증과시상면변화에대하여는여러가지연구 들이시행되어왔다. 1,2,6,9,16,17) 이들중슬관절의굴곡변형을보이는경우척추의시상면변화에대한연구에서는, 10도이상의슬관절굴곡구축을기준으로연구가시행되어왔다. 9,18,19) 본연구에서는 Kellgren-Lawrence 기준으로양슬관절에서 IV 등급이거나, 편측슬관절이 IV 등급이며반대측슬관절이 III 등급인진행된관절염을가진환자들을대상으로하였으나, 이들의슬관절굴곡의정도는평균 6.3±6.1 도로기존의연구들의기준에미치지못하였다. 그러나슬관절의굴곡변형이영향을미치지못하는각도의상태에서도척추의시상면상의변화를관찰할수있었던점이유의한결과로사료된다. 슬관절관절염환자의전신시상면상균형에대하여 Wang 등 9) 은슬관절의굴곡구축여부에상관없이정상대조군에비하여유의하게전방으로전위되었다고보고하였다. 본연구에서는슬관절관절염이있더라도척추의보상작용이남아있는 KN군에서는, 척추관절염이있는 KS군과달리, 정상인 NN군과유의한차이를보이지않았다. 또한제 7경추수선이 5 cm 이상전방으로전위되는뚜렷한시상면상불균형을보이는대상자들의수도각군간에서유의한차이를보이지않았다. 20) 그러나본연구의자료만으로는슬관절의굴곡변형이심한경우에척추의보상작용의한계를알수없기에추가적인연구가필요할것으로사료된다. 흉추후만은요추전만과상호만곡을형성하면서시상면상정렬을유지하며, 골반지표들과함께요추만곡의정도를결정하는중요인자이다. 12,21,22) 또한요추전만의변화에따라그후만의정도가감소하거나회복되기도한다. 23,24) 본연구에서도요추전만이다른군과비교하여가장큰 NN군에서가장큰흉추후만을보였고, KN군과유의한차이를보였다. 요추전만과의상관관계에대하여는중등도의상관관계를보인 NN군과달리 KS군및 KN군에서는유의한상관관계를보이지않아서, 슬관절관절염이있는환자들의경우흉추후만이요추전만의 172 www.krspine.org
Journal of Korean Society of Spine Surgery Gonarthrosis and Spinal Sagittal Alignment 형성에미치는영향력을확인할수없었다. 이의원인을파악하 기위하여는향후지속적인연구가필요할것으로사료된다. 시상면상의균형을결정하는핵심지표인요추의전만의이 상에대하여흉추나골반에서충분한보상이이루어지지못하 는경우슬관절이굴곡된다고하였다. 4,25) 또한슬관절의굴곡은 정상인의모의굴곡실험 18) 및슬관절굴곡구축을보이는관절 염환자에서모두요추전만의감소를보인다고보고하였다. 6-9) 이와같이요추전만과가장상관관계가높은슬관절굴곡구축 이외에도내반변형이있는환자의경우에서도수술전후의요 추전만의변화에대하여보고되었다. 17) 본연구에서는슬관절 의유의한굴곡구축을보이지않았던대상자들사이에서세군 간의요추전만이모두유의한차이를보였고, 슬관절관절염이 있는 KS 및 KN 군에서정상인 NN 군에비하여작은값을보여 서, 슬관절의관절염과요추의전만감소와의상관관계를보여 주었다. 골반입사각은성인이된후개인의일생동안변하지않는 값으로알려져있다. 26) 본연구에서는세군간유의한차이를 보이지않았는데, 이는골반입사각이완성된후에척추나슬관 절의퇴행성변화가발생하며, 골반입사각의크기와관절염의 발생과는관련이없기때문이라고사료된다. 천추경사와골반 경사는흉추후만및요추전만과다양한상관관계를보이면서 시상면상균형을이루는데기여한다. 4,6,9,18,25,27) 대상자들에서 세군간의유의한차이를보이지않았는데, 슬관절염이진행하 여굴곡구축을보이는경우에는여러저자들과같이상이한결 과가나올것으로사료된다. 요추전만과천추경사사이는대 조군인 NN 군에서는고도의상관관계를보였으나, KN 군에서 중등도의상관관계를보였고, KS 군에서는상관관계를보이지 않았다. 이를통하여슬관절의관절염이있는군에서는골반지 표들로부터의영향력이떨어지는것을보여주었다. 이연구는대상자의숫자가적어서각군들을다양한조건으 로세분하여비교하지못하였다는점, 대상자들의슬관절굴곡 구축의정도에따른분류를하지못한점, 인구통계학적지표 와단순방사선학적지표만으로결론을유도하여퇴행성질환 을가진환자들의 MRI 상의근위축여부등을반영하지못하였 다는점등에서제한점이있다. 그러나동일성별, 및유사한연 령대를대상으로연구를시행하여, 굴곡구축이심하지않은슬관절관절염환자에서척추의시상면상정렬작용하는영향을관찰할수있었다. 이는향후두질환의상관관계와, 더나아가서선행원인질환을밝히는데도움이되는중요한자 료가될것으로사료된다. 결론 슬관절관절염을가진환자들중에서척추에병변이없는환자들은척추의정상적인시상면상균형을유지할수있었다. 슬관절관절염환자들은정상인에비하여요추전만이감소하였으며, 척추의관절염이동반된경우더욱감소하였다. 골반지표들은세군에서유의한차이가없었으나, 이에대하여는향후슬관절의굴곡이심한관절염환자들을대상으로추가의연구가이루어져야할것이다. REFERENCES 1. Murata Y, Takahashi K, Yamagata M, et al. The kneespine syndrome. Association between lumbar lordosis and extension of the knee. J Bone Joint Surg Br. 2003;85:95-9. 2. Tsuji T, Matsuyama Y, Goto M, et al. Knee-spine syndrome: correlation between sacral inclination and patellofemoral joint pain. J Orthop Sci. 2002;7:519-23. 3. Chang CB, Park KW, Kang YG, et al. Coexisting lumbar spondylosis in patients undergoing TKA: how common and how serious? Clin Orthop Relat Res. 2014;472:710-7. 4. Roussouly P, Pinheiro-Franco JL. Biomechanical analysis of the spino-pelvic organization and adaptation in pathology. Eur Spine J. 2011;20(Suppl):609-18. 5. Diebo BG, Ferrero E, Lafage R, et al. Recruitment of compensatory mechanisms in sagittal spinal malalignment is age and regional deformity dependent: a full-standing axis analysis of key radiographical parameters. Spine (Phila Pa 1976). 2015;40:642-9. 6. Obeid I, Hauger O, Aunoble S, et al. Global analysis of sagittal spinal alignment in major deformities: correlation between lack of lumbar lordosis and flexion of the knee. Eur Spine J. 2011;20(Suppl):681-5. 7. Tauchi R, Imagama S, Muramoto A, et al. Influence of spinal imbalance on knee osteoarthritis in community-living elderly adults. Nagoya J Med Sci. 2015;77:329-37. 8. Obeid I, Boissiere L, Yilgor C, et al. Global tilt: a single parameter incorporating spinal and pelvic sagittal parameters and least affected by patient positioning. Eur Spine J. 2016;25:3644-9. 9. Wang WJ, Liu F, Zhu YW, et al. Sagittal alignment of the spine-pelvis-lower extremity axis in patients with severe knee osteoarthritis: A radiographic study. Bone Joint Res. www.krspine.org 173
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Original Article J Korean Soc Spine Surg. 2017 Sep;24(3):169-175. https://doi.org/10.4184/jkss.2017.24.3.175 슬관절퇴행성관절염환자에서척추시상면지표의변화 강규복 김영배 고영록 정지영중앙보훈병원정형외과학교실연구계획 : 방사선학적검사를이용한연구. 목적 : 슬관절염을가지고있는환자들과정상인의척추를비교하여방사선학적검사를통해시상면상척추와골반의세분화된지표들에대하여비교해보고자하였다. 선행연구문헌의요약 : 슬관절염환자의굴곡구축과요추의전만감소와의상관관계는잘알려져있지만, 어느쪽이원인질환인지는알려져있지않다. 굴곡변형이없는슬관절관절염환자의흉추를포함하는척추와골반의시상면상변수들의변화에대하여는잘알려져있지않다. 대상및방법 : 양측에 Kellgren-Lawrence grade III 이상의슬관절염을가진 60대의남성환자들 (n=57) 을대상으로척추의관절염이있는군 (KS, n=32) 과척추의이상이관찰되지않는군 (KN, n=25) 으로세분하여이를동일연령대의정상인대조군 (NN, n=84) 과비교하였다. 방사선학적검사로제 7경추수선 (C7 plumbline, C7PL), 흉추후만 (thoracic kyphosis, TK), 흉요추후만 (thoracolumbar kyphosis, TLK), 요추전만 (lumbar lordosis, LL), 천추경사 (sacral slope, SS), 골반경사 (pelvic tilt, PT), 골반입사각 (pelvic incidence, PI) 등을측정하여비교하였다. 결과 : C7PL은 KS에서 KN군 (1.7±4.5 cm vs. -0.6±2.9 cm, p=0.031) 및 NN군 (1.7±4.5 cm vs. -0.5±2.9 cm, p=0.014) 에비하여유의하게전방으로전이되어있었다. TK는 KN군이 NN군에비하여유의하게작은값을보였다 (25.4±8.8 도 vs. 30.1±8.3 도, p=0.041). LL은 KS군에서가장작은값을, NN 군에서가장큰값을보였다 (-23.2±48.7 도 vs. -44.9±33.8 도 vs. -57.3±8.5 도, p<0.001). 골반지표의경우 PI, SS, PT에서세군사이의유의한차이를보이지않았다. 요추전만과천추경사사이의상관관계는 NN군에서는고도의상관관계 (R=-0.776, p<0.01) 를, KN군에서는중등도의상관관계를보였다 (R=-0.355, p<0.01). 결론 : 슬관절관절염을가진환자들중에서척추에병변이없는환자들은정상적인시상면상균형을유지할수있었다. 환자들은정상인에비하여요추전만이감소하였으며, 척추의관절염이동반된경우더욱감소하였다. 골반지표들은세군에서유의한차이가없었으나, 이에대하여는향후슬관절의굴곡이심한관절염환자들을대상으로추가의연구가이루어져야할것이다. 색인단어 : 슬관절, 척추, 시상면, 관절염, 분류 약칭제목 : 슬관절염과척추시상면 접수일 : 2016년 10월 31일 수정일 : 2017년 6월 21일 게재확정일 : 2017년 8월 17일 교신저자 : 김영배 서울시강동구진황도로 61길 53 중앙보훈병원정형외과 TEL: 02-2225-1352 FAX: 02-2225-1910 E-mail: drortho@korea.com Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. www.krspine.org. pissn 2093-4378 eissn 2093-4386 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. 175