Journal of Korean Society of Spine Surgery The Role of Early or Late Pedicle Screw Fixation for Pyogeinc Spondylitis in the Duration of Intravenous Antibiotic Use and the Period of Hospitalization Ji-Ho Lee, M.D., Ph.D., Yong Sung Kim, M.D., Jae Hyup Lee, M.D., Ph.D. J Korean Soc Spine Surg 2016 Sep;23(3):154-159. Originally published online September 30, 2016; http://dx.doi.org/10.4184/jkss.2016.23.3.154 Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: 82-2-2019-3413 Fax: 82-2-573-5393 Copyright 2016 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.2016.23.3.154 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. 2016 Sep;23(3):154-159. http://dx.doi.org/10.4184/jkss.2016.23.3.154 The Role of Early or Late Pedicle Screw Fixation for Pyogeinc Spondylitis in the Duration of Intravenous Antibiotic Use and the Period of Hospitalization Ji-Ho Lee, M.D., Ph.D., Yong Sung Kim, M.D., Jae Hyup Lee, M.D., Ph.D. Department of Orthopedic Surgery, Seoul National University, College of Medicine Study Design: Retrospective study. Objectives: To evaluate how the timing of pedicle screw fixation (early or late) in pyogenic spondylitis relates to the period of hospitalization, duration of intravenous antibiotic use, and recurrence of infection and to confirm the efficacy of early pedicle screw fixation for pyogenic spondylitis. Summary of Literature Review: Intravenous antibiotics and surgery including debridement and fixation are used as a treatment option for pyogenic spondylitis. Materials and Methods: We retrospectively reviewed 31 patients who underwent posterior decompression and pedicle screw fixation with intravenous antibiotic treatment for pyogenic spondylitis from November 2005 to February 2015. We divided the study group into an early fixation group, whose instrumentation was inserted no later than 15 days after antibiotic therapy, and a late fixation group for cases who underwent the procedure 15 days or more after antibiotic therapy. We compared the period of hospitalization and intravenous antibiotic treatment, the rate and period of the prescription of oral antibiotics, and the rate of recurrence or reoperation. Results: The period of hospitalization and intravenous antibiotic treatment of the early fixation group (55 and 43.4 days) were significantly shorter than those of the late fixation group (85 and 67.1 days). The rate and period of the prescription of oral antibiotics were not significantly different between the two groups. There was no case of recurrence or reoperation in either group. Conclusions: Early fixation using pedicle screws for pyogenic spondylitis reduces the period of hospitalization and intravenous antibiotic treatment compared to late fixation. Key words: Spondylitis, Instruments, Antibiotics, Hospitalization 서론 화농성척추염은흔하지는않지만장기간의적극적인약물치료와함께수술적치료도필요한경우가있기때문에임상적으로중요하다. 보존적치료의원칙은정확한균주를진단해서감수성이있는항생제를충분한기간동안투여하면서보조기등으로척추를고정하는것이다. 1) 만약보존적치료에반응이없거나신경학적이상이명확하거나증가할때, 혹은농양이너무크거나패혈증상태인경우, 혹은불안정증이발생하거나변형이증가할경우, 또는통증이조절되지않는경우등에는수술적치료를시행해야한다. 그러나, 대규모임상연구에서는화농성척추염환자의 43% 에서 57% 까지수술이필요하다고보고되고있으며, 2,3) 적절한치료를하더라도재발률이 14% 이른다고알려져있다. 2,3) 화농성척추염의수술적치료원칙은추간판을포함한병소를제거하고골이식을통해추체간의전방지지를하면서기기고정 을통한유합술과함께원인균에맞는항생제치료를병행하는 것이다. 전통적으로많이사용되는수술은전방도달법및유합 술이지만 4) 기기고정술을통한강력한고정을하지않을경우불 유합이나시상면불균형등의문제가발생할수있다. 5) 기기고정 술중가장강력한것은척추경나사못을이용한후방고정술이 Received: March 15, 2016 Revised: March 18, 2016 Accepted: May 10, 2016 Published Online: September 30, 2016 Corresponding author: Jae Hyup Lee, M.D., Ph.D. Professor of Department of Orthopaedic Surgery, Seoul National University, College of Medicine, SMG-SNU Boramae Medical Center, Boramae-gil, 5-ro, Dongjak-gu, Seoul 156-707, Korea TEL: +82-2-870-2314, FAX: +82-2-870-3863 E-mail: spinelee@snu.ac.kr * 본연구는서울특별시보라매병원임상공동연구비지원에이해이루어졌다. 154 Copyright 2016 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.
Journal of Korean Society of Spine Surgery Effect of the Timing of the Pedicle Screw Fixation In Pyogenic Spondylitis 며, 화농성척추염에서의사용에대해이견이있지만점차그사용이증가하고있다. 정형외과영역에서일반적인화농성감염의치료원칙은감염부위의내고정물을제거하고감염이충분히조절된후에필요시재삽입하는것이다. 이는내고정물에의해감염이조절되지않을수있기때문이다. 따라서, 화농성척추염이완전히이조절되지않은상태에서금속내고정술을시행할경우금속내고정물에의해감염치료기간이증가하거나치료실패의원인이될수있다는우려가있다. 이에, 본연구에서는화농성척추염이조절되지않은상태에서조기에척추경나사못을이용한고정수술을시행한경우와항생제치료로어느정도화농성척추염을조절한후에척추경나사못고정술을시행한경우를비교하여입원기간, 항생제투여기간, 감염부위재발등의차이를확인하고조기척추경나사못고정술의유용성을확인하고자한다. 대상및방법 1. 연구대상 2005년 11월부터 2015년 2월까지본원정형외과에서요추부화농성척추염으로배농술및척추경나사못을이용한후방기기고정술, 정맥주사항생제치료를시행한 20세이상, 80세미만의환자중 1년이상추시가가능하였던경우를대상으로하였다. 연구대상자는전례에서진단을위해자기공명영상검사를시행하였고, 아래두종류의수술방법중한가지가시행되었는데, 2010 년 2월이전에는전방도달법을이용한배농술및추간판제거술, 그리고자가장골이식술을시행한후일정기간경과하여척추경나사못을이용한후방기기고정술을시행한경우다. 2010 년 3월이후에는처음부터후궁절제술과추간판제거술을통한배농술및자가장골을이용한추체간유합술을하면서척추경나사못을이용한후방기기고정술을동시에시행한경우다. 본연구의제외대상은, 척추수술후발생한감염, 결핵등비화농성감염, 척추경나사못을이용한기기고정술을시행하지않고단순배농술이나추간판제거술만시행한경우, 기존에기기고정술이되어있던환자에서발생한화농성척추염등이다. 본연구에서주사항생제의사용기간은혈액검사상 C-반응성단백검사와절대호중구수가정상화되고임상적으로발열, 통증, 발적, 화농등의감염소견이없을때까지사용하였다. 2. 연구방법연구대상자를정맥주사항생제를투여한지 15일이내에척추경나사못을이용한후방기기고정술을시행한군 ( 조기고정술군 ) 과 16일이상경과하여후방기기고정술을시행한군 ( 지연고 정술군 ) 으로나누어서후향적으로의무기록과영상자료를분석하였다. 양군간의표본의편중 (selection bias) 을평가하기위해서연령, 성별, 체질량지수를비교하였고, 기저질환으로간경화, 만성신부전, 당뇨, 심혈관질환, 악성종양의비율과원인균을비교하였다. 평가변수로는두군간의입원기간, 정맥주사항생제투약기간, 퇴원후경구항생제투약비율및투약기간, 척추염재발률및재수술비율의차이를비교하였다. 통계학적분석은두군간의차이를비모수적방법으로 Chisquare 를이용하였고모수적방법으로 t-test 를이용하여평가하였다. 통계학적유의성은 p값이0.05 미만으로정의하였다. 결과 1. 인구학적정보선정기준에포함된총환자수는 31명이며, 평균나이는 59.8(±13.6) 세였고, 남성이 21명, 여성이 10명이었다. 원인균으로는, 메티실린내성황색포도상구균 (methicillin-resistant Staphylococcus aureus, MRSA) 이 10예, 폐렴막대균 (Klebsiella pneumoniae) 3예, 코아귤라제음성포도상구균 (coagulase negative Staphylococci, CNS) 2예, 메티실린내성코아귤라제음성포도상구균 (methicillin negative coagulase negative Staphylococci, MRCNS) 2예, 녹농균 (Pseudomonas aeruginosa) 1예, 엔테로박터클로아카 (Enterobacter cloacae) 1예, 엔테로박터아스부리에 (Enterobacter asburiae) 1예, 엔테로코쿠스페칼리스 (Enterococcus faecalis) 1예, 그룹 B 연쇄구균 (Group B streptococcus) 1예, 원인미상균이 9예였다. 양군의나이, 성별, 체질량지수, 기저질환비율, 원인균에통계적차이는없었다 (Table 1). 2. 임상결과조기고정술군의항생제투여후기기고정술까지기간은평균 4(0-15 일, ±6) 일이었고, 이중 7예는수술전항생제치료없이기기고정술직후부터항생제를투여하였고 (Fig. 1) 4예는전방감압술및배농술후 2차적으로기기고정술을시행하였다. 지연고정술군의항생제투여후기기고정술까지기간은평균 39(17-89, ±20) 일이었고, 이중 7예는전방감압술및배농술을시행하고 2 차로후방기기고정술을시행하였다 (Fig. 2). 조기수술군의입원기간은 55(17-101, ±25) 일로지연수술군의입원기간인 85(51-219, ±45) 일보다유의하게짧았다 (p=0.0306). 조기수술군의정맥주사항생제투약기간은 43.3(±22.5) 일로지연수술군의입원기간인 67.1(±20.2) 일보다유의하게짧았다 www.krspine.org 155
Ji-Ho Lee et al Volume 23 Number 3 September 2016 Table 1. Demographic data. No significant differences were shown in age, sex, and pathogen between two groups Demographic variables Early operation group Delayed operation group p-value Number of patients 15 16 Age distribution (years) 61.1 ± 11.7 58.6 ±15.4 0.617 Sex (M:F) 11:4 10:6 0.704 BMI 21.9 ± 4.6 23.0 ± 3.4 0.453 Underline disease (#) Liver cirrhosis 1 0 0.484 Chronic kidney disease 2 2 1.00 Diabetic mellitus 8 8 1.00 Cardiovascular disease 5 8 0.475 Malignancy 0 1 1.00 Pathogen (#) MRSA* 4 6 0.704 MRCNS 1 0 0.484 K. pneumoniae 1 2 1.00 CNS 1 1 1.00 Enterobacter 1 1 1.00 MSSA 1 0 0.484 Enterococcus 1 0 0.484 GBS 1 0 0.484 P. aeruginosa 1 0 0.484 Unknown 3 6 0.433 #: numbers, *MRSA: methicillin-resistant Staphylococcus aureus, MRCNS: methicillin negative coagulase negative Staphylococci, K. pneumonia: Klebsiella pneumoniae, CNS: coagulase negative Staphylococci, GBS: group B streptococcus, P. aeruginosa: Pseudomonas aeruginosa. A B C D Fig. 1. Case of early fixation with pedicle screw and rod system on pyogenic spondylitis. Single-stage posterior decompression and posterior lumbar interbody fusion with pedicle screw and autograft was performed. (A) Sagittal enhanced MRI showing endplate destruction and high signal intensity centered on the disc space and epidural space. (B) Axial enhanced MRI showing high signal intensity on the psoas muscle, intervertebral disc, and epidural space. (C) Anteroposterior image after the operation. (D) Lateral image after the operation. 156 www.krspine.org
Journal of Korean Society of Spine Surgery Effect of the Timing of the Pedicle Screw Fixation In Pyogenic Spondylitis A B C D Fig. 2. Case of late fixation with a pedicle screw and rod system on pyogenic spondylitis. Anterior decompression and tricortical bone graft was performed. After that operation, a staged operation of posterior pedicle screw fixation was performed. (A) Sagittal enhanced MRI showing high signal intensity on the disc space and vertebral body. (B) Axial enhanced MRI showing high signal intensity on the psoas muscle, intervertebral disc, and epidural space. (C) Anteroposterior image after surgery. (D) Lateral image after surgery. (p=0.0042). 경구항생제의투약비율은양군간에유의한차이가없었고 ( 각각 6예씩 ), 경구항생제의투약기간은조기수술군이 27.7(±62.1) 일로지연수술군의 35.0(±92.0) 과유의한차이가없었다 (p=0.799). 양군간에척추염의재발로재입원이나재수술이필요한예는없었다. 고찰 화농성척추염의치료시원인균에대한정확한동정과함께감수성이있는항생제를장기간주사함으로써감염을조절하는것이원칙이다. 일반적으로원인균동정은컴퓨터단층촬영하에침생검을통한배양검사가선호되는데, 원인균동정률은약 60-70% 정도로알려져있다. 6,7) 그러나, 침생검으로동정이되지않을때는관혈적추간판생검을통해동정해서보다높은동정률을얻을수있다고알려져있다. 8) 본연구에서도전체적인동정률은 71% 였는데, 조기고정술군의동정률이통계적으로유의하지는않았지만 80% 로지연고정술군의 62.5% 보다높았다. 이는조기고정술군에서침생검을하지않고바로수술장검체를얻어서동정한경우가 7예가있었기때문으로해석된다. 추간판은혈관이없는조직이기때문에화농성감염이발생할경우항생제가도달하기어렵고다른조직에발생한화농성감염에비해항생제정맥주사기간이상대적으로길다. 따라서, 이론적으로수술적으로감염된추간판조직을제거해줄경우항생제의사용기간을줄일수있는장점이있다. 일반적으로수술은전방감압술을통해병소를직접제거하는것이감염치료에효과적이지만, 9) 추가적으로후방기기고정술을시행해야한다는단점 이있다. 10) 이를극복하기위한방법으로후방추체간유합술이나신경공경우요추추체간유합술을이용해서후방에서추간판의병소를제거하고추가수술없이 1회의수술로끝내는방법이있다. 11) 본연구의조기고정술군중 8예는이와같이후방에서제거술과고정술을동시에시행한례였다. 이와같이화농성척추염에서후방감압술과기기고정술을시행하는경우에경막외농양이동반되어있는경유효과적인감압을시행할수있다는장점이있다. 화농성척추염의원인균으로는황색포도상구균이가장흔하다고알려져있는데, 3,12) 외국에서보고된바와는달리본연구에서는메티실린내성황색포도상구균이가장많았다. 일단균동정이되면감수성검사를해서원인균에맞는주사항생제를사용해야하는데, 일반적으로약 6주정도의주사항생제를사용하고추가로경구항생제를사용한다. 6,13) 본연구에서는조기고정술군에서주사항생제사용기간이지연고정술군에비해유의하게짧았다. 이는조기고정술과함께조기배농술과추간판제거술을함께시행함으로써감염병소에대한효과적인치료가이루어진것으로해석할수있다. 즉, 수술적으로병소제거술을조기에시행한조기고정술군은지연고정술군에비해상대적으로남아있는감염조직이적기때문에감염치료가더조기에효과적으로진행됨으로써항생제사용기간을줄일수있었기때문에항생제사용기간이짧아졌다고판단된다. 화농성척추염환자는감염이외에도다른내과적문제가동반된경우가많기때문에장기적인침상안정과입원기간의증가는또다른합병증을유발할수있다. 이러한합병증을감소시키기위해서는수술로인한조직손상을최소화시키면서되도록조기에보행을할수있도록해야한다. 이런의미에서, 본연구에서처럼조기고정술군의입원기간이지연고정술군보다짧았던것은 www.krspine.org 157
Ji-Ho Lee et al Volume 23 Number 3 September 2016 내고정술을조기에시행한경우조기보행이가능해져서전신기능회복이빨라지고기타합병증의발생을줄여주는효과와재활기간의단축이있었기때문이라고판단된다. 본연구의한계는후향적연구로서무작위배정을하지않은상태에서인위적으로두군을나누어비교한것과, 연구대상자수가적다는점, 그리고, 전방감압술후 2차적으로후방기기고정술을시행한적응증이통일되지않고양군에다르게분포한점등이다. 그러나, 감염치료시문제가되는메티실린내성황색포도상구균은조기고정술군에 4예, 지연고정술군에 6예로유의한차이가없었다. 또한, 메티실린내성코아귤라제음성포도상구균은조기고정술군에 1예만있어서, 메티실린내성균은조기고정술군에 5예, 지연고정술군에 6예로양군에차이가없었기때문에무작위배정에서원인균에대한비뚤림은거의없었다고판단된다. 또한, 양군의체질량지수, 기저질환비율에서도양군에차이가없었다. 그리고, 전방감압술을하고 2차적으로후방기기고정술을시행한례는조기고정술군에서 4예, 지연고정술군에서 7예로유의한차이가없었다. 따라서, 본연구에서강조하고자하는결론인척추경나사못을이용한내고정술을감염이조절되지않은상태에서조기부터시행하여도감염을악화시키거나감염치료기간을증가시키지않는다는것을약화시키는요인은아니라도판단된다. 이와같이, 본연구의한계에도불구하고화농성척추염에서척추경나사못을이용한내고정술을조기에시행한군이오히려지연고정술군에비해전체적인입원기간과항생제사용기간이유의하게짧았다. 결론적으로, 화농성척추염환자에대해척추경나사못을이용한내고정술을감염초기에시행할경우지연성으로고정술을시행하는것보다입원기간과정맥주사항생제사용기간을유의하게감소시키기때문에조기감압술및척추경나사못을이용한조기고정술은화농성척추염의치료에고려해볼수있는수술방법이라고판단된다. REFERENCES 1. Skaf GS, Domloj NT, Fehlings MG, et al. Pyogenic spondylodiscitis: an overview. J Infect Public Health. 2010;3:5-16. 2. McHenry MC, Easley KA, Locker GA. Vertebral osteomyelitis: long-term outcome for 253 patients from 7 Cleveland-area hospitals. Clin Infect Dis. 2002;34:1342-50. 3. Hadjipavlou AG, Mader JT, Necessary JT, et al. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000;25:1668-79. 4. Kuklo TR, Potter BK, Bell RS, et al. Single-stage treatment of pyogenic spinal infection with titanium mesh cages. J Spinal Disord Tech. 2006;19:376-82. 5. Emery SE, Chan DP, Woodward HR. Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine (Phila Pa 1976). 1989;14:284-91. 6. Gasbarrini AL, Bertoldi E, Mazzetti M, et al. Clinical features, diagnostic and therapeutic approaches to haematogenous vertebral osteomyelitis. Eur Rev Med Pharmacol Sci. 2005;9:53-66. 7. Fouquet B, Goupille P, Gobert F, et al. Infectious discitis diagnostic contribution of laboratory tests and percutaneous discovertebral biopsy. Rev Rhum Engl Ed. 1996;63:24-9. 8. Friedman JA, Maher CO, Quast LM, et al. Spontaneous disc space infections in adults. Surg Neurol. 2002;57:81-6. 9. Lin TY, Tsai TT, Lu ML, et al. Comparison of two-stage open versus percutaneous pedicle screw fixation in treating pyogenic spondylodiscitis. BMC Musculoskelet Disord. 2014;15:443. 10. Dimar JR, Carreon LY, Glassman SD, et al. Treatment of pyogenic vertebral osteomyelitis with anterior debridement and fusion followed by delayed posterior spinal fusion. Spine (Phila Pa 1976). 2004;29:326-32. 11. Gonzalvo A, Abdulla I, Riazi A, et al. Single-level/singlestage debridement and posterior instrumented fusion in the treatment of spontaneous pyogenic osteomyelitis/discitis: long-term functional outcome and health-related quality of life. J Spinal Disord Tech. 2011;24:110-5. 12. Cottle L, Riordan T. Infectious spondylodiscitis. J Infect. 2008;56:401-12. 13. Govender S. Spinal infections. J BoneJoint Surg Br. 2005;87:1454-8. 158 www.krspine.org
Original Article J Korean Soc Spine Surg. 2016 Sep;23(3):154-159. http://dx.doi.org/10.4184/jkss.2016.23.3.159 화농성척추염에서척추경나사못을이용한조기고정술과지연고정술의입원기간및주사항생제사용기간비교 이지호 김용성 이재협서울대학교보라매병원정형외과학교실연구계획 : 후향적연구목적 : 화농성척추염에서조기에척추경나사못을이용한고정수술을시행한경우와기간이경과해서고정수술을시행한경우사이에입원기간, 항생제투여기간, 감염부위재발등의차이를확인하고조기척추경나사못고정술의유용성을확인하고자한다. 선행문헌의요약 : 화농성척추염의치료로주사항생제사용과함께병소제거술과기기고정술이사용되고있다. 대상및방법 : 2005년 11월부터 2015년 2월까지본원정형외과에서요추부화농성척추염으로배농술및척추경나사못을이용한후방기기고정술, 정맥주사항생제치료를시행한 20세이상, 80세미만의환자중 1년이상추시가가능하였던경우를대상으로하였다. 연구대상자를정맥주사항생제를투여한지 15일이내에척추경나사못을이용한후방기기고정술을시행한군 ( 조기고정술군 ) 과 16일이상경과하여후방기기고정술을시행한군 ( 지연고정술군 ) 으로나누어서두군간의입원기간, 정맥주사항생제투약기간, 퇴원후경구항생제투약비율및투약기간, 척추염재발률및재수술비율의차이를비교하였다. 결과 : 조기고정술군의항생제투여후기기고정술까지기간은평균 4일이었고, 지연고정술군은평균 39일이었다. 조기수술군의입원기간과정맥주사항생제투약기간은 55일과 43.3일, 지연수술군은 85일과 67.1일로조기수술군이지연수술군이에비해유의하게짧았다. 경구항생제의투약비율과투약기간은양군간에유의한차이가없었다. 양군간에척추염의재발로재입원이나재수술이필요한례는없었다. 결론 : 화농성척추염환자에서척추경나사못을이용한내고정술을감염초기에시행할경우지연성으로고정술을시행하는것보다입원기간과정맥주사항생제사용기간을유의하게감소시키기때문에조기감압술및척추경나사못을이용한조기고정술은화농성척추염의치료에고려해볼수있는수술방법이라고판단된다. 색인단어 : 척추염, 기기고정술, 항생제, 입원 약칭제목 : 화농성척추염에서척추경나사못을이용한조기기기고정술 접수일 : 2016년 3월 15일 수정일 : 2016년 3월 18일 게재확정일 : 2016년 5월 10일 교신저자 : 이재협 서울시동작구보라매로 5길서울대학교보라매병원정형외과학교실 TEL: 02-870-2314 FAX: 02-870-3863 E-mail: spinelee@snu.ac.kr Copyright 2016 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. 159