Journal of Korean Society of Spine Surgery Comparison of Short Segment and Long Segment Posterior nstrumentation of Thoracolumbar and Lumbar Bursting Fractures at Load Sharing Score or Above Hwa-Yeop Na, M.D., Young-Sang Lee, M.D., Joon-Cheol Choi, M.D., Woo-Seong Kim, M.D., Woo-Suk Song, M.D., Yu-Hun Jung, M.D., Tae-Hoon Park, M.D., Tae-Hwan Kim, M.D., Kang-Won Seo, M.D. J Korean Soc Spine Surg 20 Jun;20(2):44-50. Originally published online June 30, 20; http://dx.doi.org/10.414/jkss.20.20.2.44 Korean Society of Spine Surgery Department of Orthopedic Surgery, nha University School of Medicine #-206, 3rd ST. Sinheung-Dong, Jung-Gu, ncheon, 400-11, Korea Tel: 2-32--3044 Fax: 2-32--346 Copyright 20 Korean Society of Spine Surgery pssn 2093-43 essn 2093-436 The online version of this article, along with updated information and services, is located on the World Wide Web at: http:///dox.php?id=10.414/jkss.20.20.2.44 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 pssn 2093-43 essn 2093-436 J Korean Soc Spine Surg. 20 Jun;20(2):44-50. http://dx.doi.org/10.414/jkss.20.20.2.44 Comparison of Short Segment and Long Segment Posterior nstrumentation of Thoracolumbar and Lumbar Bursting Fractures at Load Sharing Score or Above Hwa-Yeop Na, M.D., Young-Sang Lee, M.D., Joon-Cheol Choi, M.D., Woo-Seong Kim, M.D., Woo-Suk Song, M.D., Yu-Hun Jung, M.D., Tae-Hoon Park, M.D., Tae-Hwan Kim, M.D., Kang-Won Seo, M.D. Department of Orthopedic Surgery, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Gyeonggi, Korea Study Design: A retrospective comparative analysis of the short-segment and long-segment posterior fixation in thoracolumbar burst fractures that are points or above in load-sharing score was performed. Objectives: The purpose of this study is to demonstrate the appropriate level of fixation by comparing the results of short-segment and long-segment posterior fixation. Summary of Literature Review: There is general consensus that short-segment fixation should be done in thoracolumbar burst fractures that are 6 points or less in load-sharing classification. There is some controversy regarding whether short-segment or longsegment fixation should be done in thoracolumbar burst fractures that are points or above in load-sharing classification Materials and Methods: From 199 through 200, 32 patients with thoracolumbar burst fractures above points in load-sharing classification had been operated with short-segment (1 segment above and 1 segment below: 23 patients) or long-segment (2 segments above and 1 segment below: 9 patients) transpedicular screw fixation at the author s institution. They were divided by two groups (group : short-segment fixation, group : long-segment fixation). The mean age of patients was 49.2 years old and the mean follow-up period was 2.4 years (1- years). n preoperative and postoperative simple radiographs, the bony unions, breakages or loosening of implants were assessed, and the losses of correction angle and anterior vertebral body height were measured. Results: n all cases, non-union or loosening of implants were not observed. There was 1 screw breakage in short-segment fixation group during the follow up period, but bony union was obtained at final follow-up. The mean score of load sharing classification was.3 in Group and.1 in Group, and there was no significant difference between two groups. (p>0.05) The mean anterior vertebral body height loss was 5.3% in Group and 3.6% in Group and the mean loss of correction angle were 4.2 in Group and 3.3 in Group. There was no significant difference between the two groups for both. (p>0.05) Conclusions: There was no significant difference in radiologic parameters between two groups. Short-segment fixation could be used successfully in selected cases of thoracolumbar burst fractures that are points or above in load-sharing classification. Key Words: Thoracolumbar, Burst fracture, Short segment posterior fixation, Posterior fusion, Load sharing classification 서론 흉요추부방출성골절에서후방도달법을통한척추경나사못고정술은골절부위의최소분절고정으로도견고한고정력을얻어가동운동분절을최대한남길수있을뿐만아니라간접적인감압의효과등의장점으로인하여주된수술적치료로인정되고있다. 그러나고정되는척추의분절수에대한논란은아직남아있다. 1-3) 특히 Parker 등 4) 은후방고정술이전방주를충분히지지할수없기때문에부하분담분류에의하여 점이상에서는전방고정을시행해야한다고하였고, Lee 등 5) 은 점이상에서골절된추체를포함하여상위 2개, 하위 1개의추체를고정하는것이좋다고보고한바있다. 이에본연구에서는부하분담 Received: September 22, 2011 Revised: December 12, 2011 Accepted: February 2, 20 Published Online: June 30, 20 Corresponding author: Young-Sang Lee, M.D. Department of Orthopedic Surgery, Jesang Hospital, 20, Seohyeon-ro 10beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea TEL: 2-31-9-015, FAX: 2-31-9-016 E-mail: yslee20@yahoo.com 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. 44 Copyright 20 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Short- or long-segment fusion in TL spine burst fractures Table 1. Load Sharing Classification of Spine Fracture Score Comminution / involvement(%) Apposition of fracture fragment(mm) Angle correction 1 <30 <1 <3 2 30-60 1-2 4-9 3 >60 >2 >10 분류 점이상의흉요추부방출성골절에대하여단분절과장분절후방고정술을시행한후방사선학적결과를후향적분석을통하여비교하고자한다. 대상및방법 199 년 1월부터 200 년 1월까지본원에부하분담분류 점이상의흉요추부방출성골절로내원하여척추경나사못을이용한후방고정술을시행받은환자중 1년이상연속추시가가능했던환자 32명 ( 단분절 :23명, 장분절 :9명) 을대상으로하였으며, 후향적으로연구하였다 (Table. 1). 골절-탈구혹은다분절골절로다분절고정술치료를받은 명, 골밀도가 -2.5 미만인골다공증성척추골절 명, 후방고정술만으로는추체높이나시 상면지수의회복이어려운심한분쇄골절이거나신경학적결손이있어전방및후방고정술을병행한 3명은대상에서제외하였다. 32례중남자가 16례, 여자가 16례였고, 추시기간은최소 1년에서최대 년으로평균 2.4년이었으며, 연령은 26세에서 6세까지로평균나이는 49.2세였다. 골절부위는제1요추 22 례, 제12흉추 6례, 제2요추 4례순이었다. 수술의적응증으로는전방추체의높이가정상의 40% 이상소실되어비수술적치료시추체의붕괴및후만곡이진행될가능성이높다고판단된경우, 50% 이상의척추관침범이있는경우, 혹은신경학적증상이진행하는경우등이었다. 장분절고정은골절된추체를제외하고상위 2개의추체와하위 1개의추체를고정하였고, 단분절고정은골절된추체를포함하여상위 1개와하위 1개의추체를고정하였다 (Figs. 1, 2). 1,3,5) 장분절및단분절고정수술방법의선택 Fig. 1. (A) 3-year-old woman, burst fracture, load sharing score is. (B) Short segment transpedicular fixation was done from T12 to L2. (C) Axial CT image shows comminution, canal encroachment. (D) Follow-up X-ray at 6 years shows minimal loss of correction. Fig. 2. (A) 52-year-old man, burst fracture, load sharing score is. (B) Long segment transpedicular fixation was done from T11 to L2. (C) Axial CT image shows comminution, canal encroachment. (D) Follow-up X-ray at 2 years shows minimal loss of correction. 45
Hwa-Yeop Na et al Volume 20 Number 2 June 20 Table 2. Data analysis of all patients Case Sex/Age (yrs) Group Level of injury Load-sharing score Duration of F/U (mos.) 1 M/45 15 2 F/4 2 3 M/52 14 4 F/60 12 5 M/64 3 6 M/60 L2 F/4 21 M/55 L2 12 9 M/44 L2 10 M/44 21 11 M/2 12 F/54 53 F/60 14 F/40 1 15 F/39 T12 15 16 M/4 4 Yrs : years F/U : follow-up mos : months Preop : preoperation Postop : postoperation F : female M : male Anterior vertebral height (%) Pre. Op Post. Op Last f/u 62 9 0 4 9 49 1 66 96 95 49 5 3 59 95 64 3 3 6 3 6 99 62 2 34 5 45 6 5 52 9 64 5 4 6 2 44 5 4 Segmental kyphotic angle (degree) Pre. Op Post. Op Last f/u.0 4..2. 4.5.6 20. 12. 16.3 11.9. 9.9 21.4 11.4 15.6 10.2.0 9.9 9. 6. 6.1 6.9 4.6 5. 23.2.5 16.5 21.3. 21.3 36.3 1.1 23.2 19.2 5.0 14.3 12.4 6.3 10.9 19.1 9.5.2 1.0 9. 16.1 19.1 10.9. 46
Journal of Korean Society of Spine Surgery Short- or long-segment fusion in TL spine burst fractures Table 2. Data analysis of all patients. Case Sex/Age (yrs) Group Level of injury Load-sharing score Duration of F/U (mos.) 1 F/3 2 1 F/59 29 19 F/6 T12 6 20 M/29 21 M/43 T12 1 22 M/51 0 23 F/60 24 F/54 19 25 M/52 22 26 F/61 15 2 M/32 L2 14 2 F/65 1 29 M/55 96 30 F/26 19 31 M/43 T12 1 32 F/52 24 Yrs : years F/U : follow-up mos : months Preop : preoperation Postop : postoperation F : female M : male Anterior vertebral height (%) Pre. Op Post. Op Last f/u 4 45 0 60 6 92 0 6 92 3 51 9 0 65 96 55 100 95 54 3 4 66 4 2 52 93 9 63 6 61 49 92 6 3 1 (Continued) Segmental kyphotic angle (degree) Pre. Op Post. Op Last f/u 21.5 4.2.1 11.1 4.3 9.5 24.2. 21.5 20.3 12.4 1.6 24.4 16. 1.4 19.2 10.1 15.3 12.5 2.5 10. 19.0. 10.4 14.1.. 25.6 9.. 15.2 5.0 10. 15.2 6.0 14..5..9 22.0 15.3 16.1 16.1. 9.2 21.3 5.1 15.2 4
Hwa-Yeop Na et al Volume 20 Number 2 June 20 Table 3. Data of Analysis Anterior vertebral height (%) Segmental kyphotic angle (degree) Group Patient Pre. Op Post. Op Last f/u Pre. Op Post. Op Last f/u 30 5..5 3.1 16.14.59 12.19 12 56.4 9. 6.6 1.93.1 11.34 P value 0.10 0.341 0.934 0.246 은무작위로배정하여수술을시행하였다. 골절된추체에나사못을삽입하는방법은다른추체에서의삽입과동일하게시행하였으며, 나사못고정후자가장골이식술을시행하였다. 또한후만곡교정및붕괴된추체의정복을위해골절된척추체의상방과하방에위치한정상추체에골단판과평행하게단일축척추경나사못 (monoaxial pedicle screw) 을삽입한후후만곡이교정될수있도록금속막대를휘어고정하였다. 모든환자에서술전단순방사선사진과전산화단층촬영을이용하여골절된추체의분쇄정도, 골편의전위정도, 술후후만각교정정도를측정하여부하분담분류에따른점수를계산하였다. 부하분담분류 점이상의환자에서단분절고정술을시행한 23명의환자와장분절고정술을시행한 9명의환자를각각 군과 군으로분류하였다. 환자들의술전단순방사선사진과컴퓨터단층촬영영상을이용하여측정한부하분담분류에따른평균점수는 군.3점, 군.1점으로통계학적으로의미있는차이는없었다. 각각의환자에대하여수술직후와최종추시시의방사선소견을비교하여방사선측면사진상전방추체높이의변화를측정하였고, 분절후만각의차이를통하여교정각의소실정도를평가하였다. 전방추체높이는인접상하추체높이의평균에대한전방주높이의비를백분율로계산하였으며, 교정각의소실정도는수술직후와최종추시시의분절후만각을측정하여그차이로평가하였다. 분절후만각은골절된추체의상위추체하연과하위추체하연이이루는각으로측정하였다 (Table 2). 6,) 결과값은항목별변화값에있어서두군사이의차이를 Mann-Whitney U test 로분석하였고모든분석에서유의확률은 0.05 미만으로하였으며, 분석에서 SPSS 12.0 Ver. 을이용하였다. 결과 전례에서불유합및기기의이완은관찰되지않았다. 단분절고정술을시행한 1례에서나사못의파손이관찰되었으나, 최종추시시양호한골유합소견을보였다. 1. 전방추체높이의변화 군에해당하는총 23명의환자에서의전방추체높이는술전평균 55.%, 수술직후 6.5%, 최종추시에는평균 1.2% 로나타났다. 군에해당하는총 9명의환자에서는술전평균 55.3%, 수술직후.3%, 최종추시에는평균 6.% 로나타났다. 전방추체높이의감소는 1군 5.3%, 2군 3.6% 이었고통계학적으로유의한차이는없었다 (P>0.05)(Table 3). 2. 분절후만각에따른교정각의소실 군에해당하는총 23명의환자에서의분절후만각은수술전에는평균 1.2 도였으며, 수술직후에는평균. 도, 최종추시에는평균.60 도였다. 군에해당하는총 9명의환자에서는수술전에는평균 1.5 도였으며, 수술직후에는평균.41 도, 최종추시에는평균 11.9 도였다. 교정각의소실은 1군 4.2, 2군 3.3 로통계학적으로유의한차이는없었다 (P>0.05)(Table 3). 고찰 1994 년 McCormack 등 ) 은척추골절의수술적치료방향결정에서추체의부하분담능력의평가의중요성을강조하였고, 이에관여하는인자로는추체의분쇄정도, 골편의전위정도및술후후만각교정정도라고하였다. 총점 점이상인경우에서추체의부하부담이부실하므로후방기기고정술로는실패확률이높다고하였으며, 이에따라단분절고정시전방추체보강을위한골지지술이필요하다고하였다. Parker 등 5) 은 6점이하에서는단분절후방유합술만으로도만족할만한결과를얻을수있다고하였으며, McLain 등 ) 은흉요추골절환자 19례를대상으로단분절척추경나사못고정술을시행한환자의 50% 가량에서조기금속파열등의문제점을제기하였다. 한편 load-sharing 분류총점 점이상에서의결과만판단하여볼때, Lee 등 9,10) 은단분절고정유합술은지양되어야하며골절된추체를포함한상위 2개, 하위 1개의추체를고정유합하는것이만족스러운결과를얻을수있다고보고하였으며, Kim 등 6) 또한 점이상인경 4
Journal of Korean Society of Spine Surgery Short- or long-segment fusion in TL spine burst fractures 우에는단분절고정유합술후후만각교정소실이장분절고정유합술시행보다유의하게차이가있어단분절고정유합술로만은불충분하다고보고하였다. Altay 등 11) 도부하분담능력 6점이하, Magerl type A3.3, 또는 점이하 Magerl type A3.1, A3.2 는단분절고정유합술, 그외는장분절고정유합술을제안하였다. load-sharing 분류가발표되기전 Chung 과 Rhym 등 12) 은상하인접척추체뿐아니라골절된척추체에도척추경을통한나사못삽입술을시행함으로써고정효과의향상과간접정복의용이함을보고하였으며, Jeong 등 1) 도골절추제에척추경나사못을삽입하는삼점고정에의한단분절고정술과장분절고정술과의비교에서전방추체높이변화와 sagittal index 의변화를비교하여두군간의유의한차이가없음을보고하였다. loadsharing 분류의개념이언급된이후단분절고정술의유용성에대하여 Lee등 5) 이발표한바있으며, Mahar 등 3) 역시골절추체에나사못삽입술을적절하게함으로써삼점고정에의한만족할만한결과를얻었다고보고하였다. 저자들은 load-sharing 분류 점이상에해당하는비교적분쇄정도가심한흉요추부골절에대하여복와위에서체위변경에따른정복을충분히한뒤골절추체와상하인접추체에척추경나사못을삽입하여삼점고정을통한단분절고정술을시행하였다. 척추경나사못을시상면상에서상하정상추체의골단판과평행하게삽입후단일축척추경나사못과금속막대가수직으로고정되면서발생하는신연력을이용하여간접적인추체의정복을얻은후고정하였고, 충분한 decortication 과자가장골이식술을시행하여조기골유합을얻음으로써안정성을비교적충분하게얻어, 기기의이완이나불유합및교정각의큰소실이없었던것으로사료된다. 결론 본연구에서는부하분담분류 점이상의비교적심한분쇄를보이는흉요추부및요추부방출성골절에대하여후방단분절및장분절고정술을시행하였고, 후향적으로연구한결과영상학적지표에유의한차이가없었다. 부하분담분류 점이상의비교적심한분쇄를보이는흉요추부및요추부방출성골절에대하여골절추체의척추경나사못고정, 적절한정복과견고한기기고정및자가장골이식술을통해단분절고정술을시행하여도불유합이나기기의이완및후만변형의진행을최소화하면서양호한골유합을도모할수있어, 후방단분절고정술이부하분담분류 점이상의흉요추부골절에서선택적으로사용될수있는유용한술식이라고사료된다. REFERENCES 1. Jeong ST, Cho SH, Song HR, Koo KH, Park HB, Chung UH. Comparison of Short and Long-Segment Fusion in Thoracic and Lumbar Fractures. J Korean Soc Spine Surg. 1999;6:3-0. 2. McLain RF. The biomechanics of long versus short fixation for thoracolumbar spine fractures. Spine (Phila Pa 196). 2006;31:S0-9. 3. 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 (Phila Pa 196). 200;32:1503. 4. Parker JW, Lane JR, Karaikoric EE, Gaines RW. Successful short-segment instrumentation and fusion for thoracolumber spine fractures: a consecutive 41/2-year series. Spine (Phila Pa 196). 2000;25:115-0. 5. Lee KY, Sohn SK, Kim CH, Song CK. Posterior Short- Segment nstrumentation of Thoracic and Lumbar Burst Fractures Retrospective study related with Load-Sharing classification. J Korean Soc Spine Surg. 2001;:49-503 6. Kim CH, Hwang JK, Choi YJ, Kim KH, Song JS, Kang JH. Treatment of Thoraco-Lumbar Burst Fractures According to Load-Sharing Classification. J Korean Fract Soc. 2005;1:69-5.. McCormack T, Karaikovic E, Gaines RW. The load-sharing classification of spine fractures. Spine (Phila Pa 196). 1994;19:141-4.. McLain RF, Sparling E, Benson DR. Early failure of short-segment pedicle instrumentation for thoracolumbar fractures. A preliminary report. J Bone Joint Surg Am. 1993;5:162-. 9. Lee CS, Chung SS, Jung HW, Kim ES. Decision of Posterior Fixation Level by Load-Sharing Classification in Thoracolumbar and Lumbar Burst Fracture. J Korean Soc Spine Surg. 2001;:2-3. 10. Scholl BM, Theiss SM, Kirkpatrick JS. Short segment fixation of thoracolumbar burst fractures. Orthopedics, 2006;29:03-. 11. Altay M, Ozkurt B, Aktekin CN, Ozturk AM, Dogan O, Tabak AY. Treatment of unstable thoracolumbar junction burst fractures with short- or long-segment posterior fixa- 49
Hwa-Yeop Na et al Volume 20 Number 2 June 20 tion in magerl type a fractures. Eur Spine J. 200;16:1145-55. 12. Chung JY, Rhym S. Short Segment Transpedicular Cotrel - Dubousset nstrumentation including nvolved Vertebra for Fractures of Thoracic and Lumbar Spine. Journal of Korean Orthopedics. 1994;29:940-.. Steib JP, Charles YP, Aoui M. n situ contouring technique in the treatment of thoracolumbar fractures. Eur Spine J. 2010;19(1 Suppl):S66-. 흉요추부불안정성방출성골절의단분절및장분절후방고정술의비교 - 부하분담분류 점이상 - 나화엽 이영상 최준철 김우성 송우석 정유훈 박태훈 김태환 서강원분당제생병원정형외과 연구계획 : 부하분담분류 점이상의흉요추부방출성골절에서단분절및장분절후방고정술의결과를후향적으로비교분석하였다. 목적 : 단분절및장분절후방고정술의결과를비교하여적절한유합범위를결정하는데도움을주고자한다. 선행문헌의요약 : 부하분담분류 6 점이하에서는후방단분절고정술을통한유합에대부분이동의하는바이며, 점이상에서는전방지지의필요성 및후방장분절및단분절고정술이논란이되고있다. 대상및방법 : 199 년부터 200 년까지흉요추부골절에대하여부하분담분류 점이상의환자에서단분절및장분절후방고정술을시행한 32 명 ( 단분 절 -1 군 : 골절된추체상하위 1 개의추체고정 :23 명, 장분절 -2 군 : 골절된추체상위 2 개, 하위 1 개의추체를고정 : 9 명 ) 의환자를대상으로하였으며, 환자 들의평균연령은 49.2 세였으며, 평균추시기간은 2.4 년 (1~ 년 ) 이었다. 수술전후단순방사선사진에서골유합및기기의파단과이완여부를평가하 였고, 전방추체높이의변화를측정하였으며, 국소후만각을 Cobb 씨방법으로측정하였다. 결과 : 전례에서불유합및기기의이완은관찰되지않았다. 단분절고정술을시행한군 1 례에서나사못의파손이관찰되었으나최종추시상양호한골 유합소견을보였다. 부하분담분류에의한점수의평균은 1 군.3, 2 군.1 로유의한차이가없었으며 (p>0.05), 술후전방추체높이의감소는 1 군 5.3%, 2 군 3.6% 이었고, 교정각의소실은 1 군 4.2, 2 군 3.3 로술후전방추체높이의감소및교정각의소실모두두군간에유의한차이가없었다. (p>0.05) 결론 : 단분절고정술은장분절고정술과비교하여방사선학적지표상유의한차이가없었다. 단분절고정술은잘선별된부하분담분류 점이상의흉 요추부방출성골절의수술적치료에있어서성공적인술식으로시행될수있을것으로사료된다. 색인단어 : 흉요추부, 방출성골절, 단분절후방고정유합술, 부하분담분류 약칭제목 : 흉요추부방출성골절의단분절및장분절후방유합술 50