The Clinical Correlations between Diabetes, Cigarette Smoking and Obesity on Intervertebral Degenerative Disc Disease of the Lumbar Spine

Ande M. Jakoi,Gurpal Pannu,Anthony D’Oro,Zorica Buser,Martin H. Pham,Neil N. Patel,Patrick C. Hsieh,John C. Liu,Frank L. Acosta,Raymond Hah,Jeffrey C. Wang 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.3

Study Design: Retrospective analysis of a nationwide private insurance database. Chi-square analysis and linear regression models were utilized for outcome measures. Purpose: The purpose of this study was to investigate any relationship between lumbar degenerative disc disease, diabetes, obesity and smoking tobacco. Overview of Literature: Diabetes, obesity, and smoking tobacco are comorbid conditions known to individually have effect on degenerative disc disease. Most studies have only been on a small populous scale. No study has yet to investigate the combination of these conditions within a large patient cohort nor have they reviewed the combination of these conditions on degenerative disc disease. Methods: A retrospective analysis of insurance billing codes within the nationwide Humana insurance database was performed, using PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA), to identify trends among patients diagnosed with lumbar disc degenerative disease with and without the associated comorbidities of obesity, diabetes, and/or smoking tobacco. Patients billed for a comorbidity diagnosis on the same patient record as the lumbar disc degenerative disease diagnosis were compared over time to patients billed for lumbar disc degenerative disease without a comorbidity. There were no sources of funding for this manuscript and no conflicts of interest. Results: The total number and prevalence of patients (per 10,000) within the database diagnosed with lumbar disc degenerative disease increased by 241.4% and 130.3%, respectively. The subsets of patients within this population who were concurrently diagnosed with either obesity, diabetes, tobacco use, or a combination thereof, was significantly higher than patients diagnosed with lumbar disc degenerative disease alone (p <0.05 for all). The number of patients diagnosed with lumbar disc degenerative disease and smoking rose significantly more than patients diagnosed with lumbar disc degenerative disease and either diabetes or obesity (p <0.05). The number of patients diagnosed with lumbar disc degenerative disease, smoking and obesity rose significantly more than the number of patients diagnosed with lumbar disc degenerative disease and any other comorbidity alone or combination of comorbidities (p <0.05). Conclusions: Diabetes, obesity and cigarette smoking each are significantly associated with an increased diagnosis of lumbar degenerative disc disease. The combination of smoking and obesity had a synergistic effect on increased rates of lumbar degenerative disc disease. Patient education and preventative care is a vital goal in prevention of degenerative disc disease within the general population.

퇴행성 요추부 질환에 대한 치료에서 척추 고정술과 동반된 인접부 극돌기간 기구 삽입술의 유용성에 대한 예비 보고

최우진,장상근,김동천 대한척추신경외과학회 2009 Neurospine Vol.6 No.3

Objective: Posterior lumbar or lumbosacral spinal fusion in degenerative lumbar disease has the problems of adjacent level disease as well as surgical complications. An interspinous device used for dynamic stabilization can also be applied to the adjacent segment for spinal fusion to reduce the severity of these problems. The authors reviewed the adjacent interspinous stabilization using an interspinous spacer (CoflexTM paradigm spine, Germany) combined with posterior lumbar or lumbosacral spinal fusion in degenerative lumbar disease. Method: From January 2007 to July 2008, ten patients with degenerative lumbar disease underwent posterior lumbar or lumbosacral spinal fusion with adjacent interspinous stabilization using CoflexTM. The indications for this type were adjacent segmental disc protrusion, adjacent segmental degenerative changes or high surgical risk groups, such as elderly patients or osteoporotic patients undergoing multiple leveled fusions. CoflexTM was inserted into the adjacent segmental interspinous space. The control group consisted of fifteen patients, who underwent posterior lumbar or lumbosacral spinal fusion without interspinous stabilization. The radiological parameters and clinical outcomes were compared. All patients were followed-up for more than twelve months. Results: The visual analogue scale (VAS) in both groups postoperatively and at the twelve month follow-up were improved. In the CoflexTM group, the postoperative and twelve month follow-up X-ray showed no significant change in posterior disc height, interpedicular height, segmental lordotic angle, flextion-extension angulation and translation and no significant segmental instability. The control group showed a higher level of segmental lordotic angle, translation and a lower posterior disc height, interpedicular height, flextion-extension angulation and three patients showed adjacent segmental instability. Conclusion: CoflexTM can be used to stabilize the adjacent segment of spinal fusion in degenerative lumbar disease and might be effective in preventing adjacent segmental degeneration. However, further study will be needed to confirm this observation. Objective: Posterior lumbar or lumbosacral spinal fusion in degenerative lumbar disease has the problems of adjacent level disease as well as surgical complications. An interspinous device used for dynamic stabilization can also be applied to the adjacent segment for spinal fusion to reduce the severity of these problems. The authors reviewed the adjacent interspinous stabilization using an interspinous spacer (CoflexTM paradigm spine, Germany) combined with posterior lumbar or lumbosacral spinal fusion in degenerative lumbar disease. Method: From January 2007 to July 2008, ten patients with degenerative lumbar disease underwent posterior lumbar or lumbosacral spinal fusion with adjacent interspinous stabilization using CoflexTM. The indications for this type were adjacent segmental disc protrusion, adjacent segmental degenerative changes or high surgical risk groups, such as elderly patients or osteoporotic patients undergoing multiple leveled fusions. CoflexTM was inserted into the adjacent segmental interspinous space. The control group consisted of fifteen patients, who underwent posterior lumbar or lumbosacral spinal fusion without interspinous stabilization. The radiological parameters and clinical outcomes were compared. All patients were followed-up for more than twelve months. Results: The visual analogue scale (VAS) in both groups postoperatively and at the twelve month follow-up were improved. In the CoflexTM group, the postoperative and twelve month follow-up X-ray showed no significant change in posterior disc height, interpedicular height, segmental lordotic angle, flextion-extension angulation and translation and no significant segmental instability. The control group showed a higher level of segmental lordotic angle, translation and a lower posterior disc height, interpedicular height, flextion-extension angulation and three patients showed adjacent segmental instability. Conclusion: CoflexTM can be used to stabilize the adjacent segment of spinal fusion in degenerative lumbar disease and might be effective in preventing adjacent segmental degeneration. However, further study will be needed to confirm this observation.

퇴행성 하요추부 질환에서 PEEK Cage와 척추경 나사못 고정을 통한 후방 추체간 유합술의 유용성 - 최소 3년 이상 추시 결과 -

송경진,이광복,함동훈 대한척추외과학회 2011 대한척추외과학회지 Vol.18 No.4

Study Design: A retrospective study. Objectives: To evaluate the three-plus year follow-up results of patients who underwent posterior lumbar interbody fusion with PEEK cage and pedicle screw fixation for lumbar degenerative disease. Summary of Literature Review: There are few previous reports addressing posterior lumbar interbody fusion using PEEK cage with mid-term follow up periods. Materials and Methods: 260 patients who underwent posterior lumbar interbody fusion with PEEK cage and pedicle screw fixation for lumbar degenerative disease were enrolled. We classified patients into three groups according to their fusion level: group A (n=151) had one-level fusion, and group B (n=91) had two-level fusion, and group C (n=18) had three-level fusion. Clinical outcomes were evaluated by pre- and post-operative Visual analogue scale (VAS) scores, the Oswestry Disability Index (ODI), and complication and reoperation rates. Radiologic outcomes were measured by the fusion rate, sagittal alignment, disc height and changes. Results: VAS (pre-operative to final follow-up) changed from 7.62±2.03 (5-10) to 3.19±1.94 (1-8) in group A, from 6.83±2.28(4-9)to 4.51±2.18(2-9) in group B and from 7.17±2.46 (5-10) to 4.63±1.97(1-9) in group C. Final follow-up ODI also decreased in group A (17.6±8.56%), group B (15.4±5.46%) and group C (24.7±7.46%). This corresponds to scores of 94.7% in group A, 92.3% in group B and 94.4% in group C. There were significant differences between preoperative, post-operative and final follow-up lumbar lordosis [p=0.042(group A), 0.036(group B), 0.045(group C)], segmental lordosis [p=0.036(group A), 0.039(group B), 0.047(group C)]. Reoperation was performed in patients 8 group A, 4 group B, and 1 group C, and there is no significant diffrence between groups. Adjacent segmental change was found in all reoperation patients, but showed no correlation with clinical results. Conclusions: Posterior lumbar interbody fusion with PEEK cage and pedicle screw fixation in lumbar degenerative disease showed excellent clinical results and fusion rates, regardless of patient fusion levels. 연구 계획: 후향적 연구목적: 하요추부 퇴행성 질환에서 PEEK cage와 척추경 나사못 고정으로 후방 추체간 유합술을 시행한 환자들의 3년 이상 추시 결과에 대해 알아보고자하였다. 선행문헌의 요약: PEEK cage를 이용한 후방 추체간 유합술의 중기 추적 관찰에 대한 연구가 거의 없다. 대상 및 방법: 퇴행성 요추부 질환으로 PEEK cage을 이용한 후방 추체간 유합술 및 척추경 나사못 고정술을 시행한 환자들 중 추시 가능 260명을 대상으로 하였다. 단분절에만 시행한 151명을 A군, 이분절에서 시행한 91명을 B군, 삼분절에서 시행한 18명을 C군으로 분류하였다. 임상적 결과 판정은 수술 전후의 Visual analogue scale(VAS), Oswestry Disability Index(ODI) 평가 기준을 통해 판정하였고, 방사선학적 분석을 통해 골 유합, 시상면 배열, 추간판 간격 및 인접분절의 변화를 평가하였다. 또한 합병증과 재수술 여부와 원인에 대해서 분석하였다. 결과: VAS는 수술전과 수술 후 3년에서 A군 7.62±2.03(5~10)점에서 3.19±1.94(1~8)점, B군 6.83±2.28(4~9)점에서 4.51±2.18(2~9)점,C군 7.17±2.46(5~10)점에서 4.63±1.97(1~9)점으로 감소되었으며, ODI에서는 3년 추시에서 A군 17.6±8.56%, B군 15.4±5.46%,C군 24.7±7.46%로 감소된소견을 확인하였다. A군 94.7%, B군 92.3%, C군 94.4%의 골 유합 소견을 보였다. 요추부 전만도(p=0.042(A군), 0.036(B군), 0.045(C군)), 분절간 전만도(p=0.036(A군), 0.039(B군), 0.047(C군)) 는 수술 후 술 전에 비해 의미있게 증가되었고, 최종 추시에서도 의의있게 증가되었다. 재수술은 A, B 군에서만 나타났고, 이들 모두에서 수술 후 인접분절 변화를 관찰할 수 있었지만 임상적 결과와의 연관성을 보이지 않았다. 결론: 퇴행성 요추 질환에서 PEEK 케이지를 이용한 후방 추체간 유합 및 나사못을 이용한 고정술은 중기간 추시에서 각 유합 분절 수에 따른 치료 결과와 상관없이 우수한 임상적 결과와 골유합을 얻을 수 있어 추천될 만한 수술 방법이라고 생각한다.

최소 침습적 외측 요추간 유합술: 적응증, 결과, 합병증

소재완(Jaewan Soh),이재철(Jae Chul Lee) 대한정형외과학회 2019 대한정형외과학회지 Vol.54 No.3

최소 침습적 외측 요추체간 유합술의 최신 지견에 대하여 알아보고자 하였다. 아직 도입된 지 얼마 되지 않았으나 근래에 각광받고 있는 최소 침습적 외측 요추체간 유합술에 대한 적응증 및 임상 결과와 유합률, 그리고 합병증에 대하여 문헌 고찰을 하였다. 외측 요추간 유합술의 적응증은 퇴행성 요추부 질환에서 고식적인 전방, 후방 추체간 유합술의 적응증과 거의 유사하다. 특히 척추관 협착증 및 퇴행성 척추 전방 전위증, 퇴행성 척추 변형, 퇴행성 추간판 질환, 인접 분절 퇴행성 질환에서 최소 침습적 수술로서 효과적이다. 또한 고식적 요추부 유합술과 비교하여 임상적 결과 및 유합률이 대등한 것으로 보고되고 있다. 하지만 수술 접근 및 과정에서 발생하는 수술 후 고관절 굴곡근 약화 및 신경 손상, 혈관 손상, 장기 손상, 케이지 침강, 위탈장 등의 비특이적 합병증들이 보고되고 있다. 외측 추체간 유합술은 고식적인 전방 또는 후방 추체간 유합술의 장점을 취합하고 단점을 보완한 수술이며 그 임상 결과나 유합률에도 큰 차이가 없어 퇴행성 요추부 질환의 치료에 최소 침습 수술로서 유용한 치료법이다. 하지만 수술 과정에서 발생하는 비특이적 합병증들을 개선해야 하는 것이 향후 과제이다. The aim of this review was to evaluate minimally invasive lateral lumbar interbody fusion on the latest update. Lumbar interbody fusion was introduced recently. This study performed, a literature review of the indications, clinical outcomes, fusion rate, and complications regarding recently highlighted minimally invasive lateral lumbar interbody fusion. The indications of lateral lumbar interbody fusion are similar to the conventional anterior and posterior interbody fusion in degenerative lumbar diseases. In particular, lateral lumbar interbody fusion is an effective minimally invasive surgery in spinal stenosis, degenerative spondylolisthesis, degenerative adult deformity, degenerative disc disease and adjacent segment disease. In addition, the clinical outcomes and fusion rates of lateral lumbar interbody fusion are similar compared to conventional lumbar fusion. On the other hand, non-specific complications including hip flexor weakness, nerve injury, vascular injury, visceral injury, cage subsidence and pseudohernia have been reported. Lateral lumbar interbody fusion is a very useful minimally invasive surgery because it has advantages over conventional anterior and posterior interbody fusion without many of the disadvantages. Nevertheless, nonspecific complications during lateral lumbar interbody fusion procedure remain a challenge to be improved.

퇴행성 요추 질환과 동반된 인접 분절 척추 골절의 치료

조재림,성일훈,백승욱,박예수 대한척추외과학회 2008 대한척추외과학회지 Vol.15 No.4

Study Design: Retrospective study Objective: To analyze the treatment results of vertebroplasty in patients who suffered osteoporotic compression fractures during conservative treatments for pre-existing degenerative lumbar disease. Summary and Literature Review: Whilst spinal fusion has shown satisfactory clinical results, solid fusion has been reported to accelerate the degenerative changes at the unfused adjacent levels. Therefore, the level of spinal fusion in patients with compression fractures and pre-existing degenerative lumbar disease is controversial. Few studies have evaluated the outcomes of spinal fusion and adjacent segment vertebroplasty. Materials and Methods: A retrospective review was carried out on 28 patients who suffered the osteoporotic compression fractures during conservative treatment for pre-existing degenerative lumbar disease. Posterolateral fusion and vertebroplasty were performed for degenerative disease and compression fractures. The average fusion level was 1.82. The mean compressed vertebral bodies were 1.68. The radiology results were evaluated to determine the progression of the compression rate and fractures in the adjacent segment. The clinical results were evaluated using the Denis pain scale for compression fractures and Katz satisfaction scale for degenerative lumbar disease. Results: The average compression rate was 30.2% preoperatively, 21.4% postoperatively, and 24.6% at the final follow-up. There was no fracture in the adjacent segment. Clinically, the preoperative Denis score was P3 and P4 in 8 and 20 patients, respectively. On the other hand, the postoperative Denis score was P1, P2 and P3 in 8, 19 and 1 patients, respectively. In regard to degenerative diseases, the overall satisfaction was 82.1%. Conclusion: The stability of fracture sites in vertebroplasty of patients with pre-existing lumbar disease was confirmed. However, further compression of the fractured vertebral body was observed after vertebroplasty in long fusion. Therefore, a followup study of more cases will be necessary to confirm the changes in the vertebroplasty site.

Cantilever Transforaminal Lumbar Interbody Fusion for Upper Lumbar Degenerative Diseases (Minimum 2 Years Follow Up)

Akira Hioki,Kei Miyamoto,Hideo Hosoe,Seiichi Sugiyama,Naoki Suzuki,Katsuji Shimizu 연세대학교의과대학 2011 Yonsei medical journal Vol.52 No.2

Purpose: To evaluate the clinical outcomes of cantilever transforaminal lumbar interbody fusion (c-TLIF) for upper lumbar diseases. Materials and Methods: Seventeen patients (11 males, 6 females; mean ± SD age: 62 ± 14 years) who underwent c-TLIF using kidney type spacers between 2002 and 2008 were retrospectively evaluated,at a mean follow-up of 44.1 ± 12.3 months (2 year minimum). The primary diseases studied were disc herniation, ossification of posterior longitudinal ligament (OPLL), degenerative scoliosis, lumbar spinal canal stenosis, spondylolisthesis, and degeneration of adjacent disc after operation. Fusion areas were L1-L2 (5 patients), L2-L3 (9 patients), L1-L3 (1 patient), and L2-L4 (2 patients). Operation time, blood loss, complications, Japanese Orthopaedic Association (JOA) score for back pain, bone union, sagittal alignment change of fusion level, and degeneration of adjacent disc were evaluated. Results: JOA score improved significantly after surgery, from 12 ± 2 to 23 ± 3 points (p < 0.01). We also observed significant improvement in sagittal alignment of the fusion levels, from - 1.0 ± 7.4 to 5.2 ± 6.1 degrees (p < 0.01). Bony fusion was obtained in all cases. One patient experienced a subcutaneous infection, which was cured by irrigation. At the final follow-up, three patients showed degenerative changes in adjacent discs, and one showed corrective loss of fusion level. Conclusion: c-TLIF is a safe procedure, providing satisfactory results for patients with upper lumbar degenerative diseases.

퇴행성 요추질환 환자에서 후방경유 요추체간 유합술과 360˚척추 고정술의 비교에 대한 임상연구

오성훈,김주헌,이형중,정진환,이우택 한양대학교 의과대학 2002 한양의대 학술지 Vol.22 No.1

The goal of surgical treatment for degenerative lumbar diseases is to relieve radiculopathy by decompression of neural canal and to resolve mechanical low back pain through spinal fusion, therefore rendering them prevent from further degeneration. Authors analyzed the surgical results between posterior lumbar interbody fusion(PLIF) and 360° spinal fixation to evaluate the proper treatment policy among the patients with spinal stenosis, the degenerative spondylolisthesis and the low-grade isthmic spondylolisthesis. The authors performed PLIF on 92 patients and 360°spinal fixation on 138 patients with spinal stenosis, degenerative spondylolisthesis or low-grade isthmic spondylolisthesis. We retrospectively investigated clinical outcomes by using Prolo's economic and functional outcome sclae and subjective satisfaction scales of these patients by using several criteria such as visual analog scale (VAS), analgesic prescription after operation and questionnaire for overall outcome (1. successful?, 2. repeat if similar condition?, 3. recommend to others?). 1. Excellent and good outcomes on Prolo's scale was 81.5% in PLIF group and 82.6% in 360° spinal fixation group. 2. Pre- and postoperative VAS on back pain and leg pain showed marked decrease in the intensity of pain from 6.52±1.03, 6.74±0.93 to 2.23±1.15, 2.44±1.03 in PLIF group and from 7.04±1.05, 7.23±1.26 to 2.52±1.05, 2.74±1.12 in 360°spinal fixation group respectively. 3. Analgesic prescription after operation decreased in both group (79.3% in PLIF group and 78.3% in 360°spinal fixation group). 4. Patients' self-reported overall success rate of their procedure showed 82% in PLIF group and 84% in 360° spinal fixation group. Both groups of PLIF and 360°spinal fixation showed good outcomes and biomechanically stable fusion in spinal stenosis, degenerative spondylolisthesis or low-grade isthmic spondylolisthesis. Therefore, unless extensive laminectomy and facetectomy was carried out, PLIF should provide similar success rate compared to the 360°spinal fixation procedure in the above mentioned degenerative lumbar diseases. In PLIF procedures, we sould achieve a more stable bone fusion with performing partial hemilaminectomy, preserving supraspinous/interspinous ligaments and grafting autogenous harvested bone into the cages.

요추 안정화 술식의 원칙

박종범,강기상,장한 대한척추외과학회 2001 대한척추외과학회지 Vol.8 No.3

Study Design : Review of the literatures. Objectives : To provide the principles of fusion and internal fixation for the degenerative lumbar disc diseases. Summary of Literature Review : Lumbar spine stabilization can be achieved with fusion that eliminates the motion of the lumbar motion segment. Materials and Methods : Fusion only or fusion with internal fixation, anterior or posterior approach, additional use of interbody fusion and cages as well as decompression have been used for the treatment of degenerative lumbar disc diseases. Results : Various radiological and clinical results, fusion rates and complications have been reported on each fusion techniques and internal fixation devices in the literatures. Conclusions : Stabilization is considerd to be useful therapeutic option for degenerative lumbar disc diseases but not absolute one. Therefore, careful consideration should be required for its applications of degenerative lumbar disc diseases.

요추질환의 비수술적 치료에 대한 근거

안동기,김학선,서형연,김창수,김명진 대한척추외과학회 2019 대한척추외과학회지 Vol.26 No.4

Study Design: Review article. Objectives: To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases. Summary of Literature Review: No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases. Methods: The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles. Results: No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%-66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise. Conclusions: Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence. Key words: Lumbar spine, Degenerative spinal disease, Nonoperative treatment 연구 계획: 종설목적: 퇴행성 요추질환들에 대해 비수술적 치료의 효과를 검증하고자 하였다. 선행 연구문헌의 요약: 수술전 비수술적 치료에 대한 근거를 제시한 연구는 없었다. 대상 및 방법: 각질환 별 비수술적 치료의 근거는 NASS의 지침을, 수술 대비 상대적 효과는 SPORTs를 참조하였고 중증도와 특수 상황에 대한 근거는 각각의 해당 문헌을 조사하였다. 결과: 모든 비수술적 치료의 수단은 퇴행성 척추질환의 진행에 근본적인 변화를 주지 못한다. 요추 추간판탈출증의 자연경과는 치료 여부에 관계없이 양호하다. 보편적 증례는 6주 이내에 70% 가 호전된다. 그러나 수술의 필요를 결정하는데 6주간의 관찰이 다 필요한 것은 아니다. 경추간공 경막외스테로이드주사가 단기간 통증조절에 유효하다는 것에는 A등급의 근거가 있다. 전반적인 비수술적 치료가 중장기적으로 효과가 있다는 것에 B등급의 근거가 있으나 자연경과 보다 더 좋은가 에 대해서는 근거가 없다. 근력약화가 동반된 경우는 수술여부에 관계없이 마비의 정도가 예후와 관계 있다. 그러나 마비의 기간이 수술 결과와 관계 있는 가는 근거가 불충분하다. 추간판탈출증으로 인해 발생하는 사회적 비용은 치료비 보다 환자의 생산성이 감소하는 것에서 발생하고 조기수술은 마비의 정도보다 통증 때문에 필요하게 된다. 척추관 협착증은 자연 경과 상 호전과 악화를 반복한다. 추간판탈출증과 달리 많은 호전이 없지만 급격한 악화도 없다. 약 15%는 호전되고 70%는 변화가 없으며 15%는 점차 심해진다. 비수술적 치료가 자연경과에 비해 우수한가 에 대한 연구는 없다. 중증 이상의 협착에 대해서는 비수술적 치료 효과에 근거가 없다. 경에서 중까지의 협착에는 경막외스테로이드주사가 증상 호전에 단기적인 효과가 있다. 신경근 압박에 의한 근력 약화가 있는 경우는 자연회복은 기대할 수 없고 조속한 수술이 필요하다. 퇴행성 척추전방전위증은 자연경과에 대한 연구는 없다. 비수술적 치료에 대한 효과는 별도의 연구가 없으며 전문가 의견은 협착에 의한 신경근 증상이 주 일 때에는 척추관협착증의 치료를 따르도록 권고하고 있다. 성인의 협부형 척추전방전위증은 자연 경과 상 양측성인 경우 40~66%가 증상을 유발하는 전방전위를 일으킨다. 물리치료와 운동치료에 불충분한 근거가 있는 것을 제외하고 비수술적 치료에 대한 연구가 없다. 결론: 비수술적 치료방법으로 단기간의 증상호전은 가능하나 근본적인 병의 진행에는 영향을 주지 못한다. 연구에서 제외된 조건들 즉, 이전 척추수술, 마미증후군, 진행성 신경증상, 조절되지 않는 통증, 불안정, 변형, 추체골절과 동반된 경우 등에 대해서는 비수술적 치료의 연구가 매우 제한적이어서 동일한 원칙을 적용할 근거가 부족하고 사례별의 고려가 필요할 것으로 생각된다. 또한 각 질환별 비수술적 치료의 방법들은 서로 차별화되지 못하고 추간판 탈출증에서의 방법이 타 영역까지 확대 적용되고 있다. 약칭 제목: 비수술적 치료의 근거

50세 이상의 퇴행성 요추 질환 환자에서 기립 전신 척추 측면 사진의 필요성- 앙와위 요추부 측면 사진과의 비교 -

김환정,박건영,성환일,구제윤,권원조,박창규,최원식 대한척추외과학회 2014 대한척추외과학회지 Vol.21 No.2

Study Design: Cross-sectional study. Objectives: Sagittal imbalance cannot be predicted depending on the degree of lumbar lordosis. Thus, we tried to evaluate thenecessity of whole spine standing lateral radiograph through comparison of the spinal and pelvic parameter between supine lumbarlateral radiograph and whole spine standing lateral radiograph. Summary of the Literature Review: No studies in the literature compare supine lumbar lateral radiograph and whole spine standinglateral radiograph. Materials and Methods: We randomly selected 50 males and 50 females among the patients over the age of 50 who visited ourhospital for outpatient due to degenerative lumbar disease. Lumbar lordosis (sLL/wLL), sacral slope (sSS/wSS), and pelvic tilt (sPT/wPT) were measured and compared respectively by supine lumbar lateral radiograph and whole spine standing lateral radiograph. Wecategorized as group AI (sLL<30˚) and group AII (sLL≥30˚) by supine lumbar lateral radiograph and analyzed them. We also categorized asgroup BI (SVA≤5 cm) and group BII (SVA>5 cm) by whole spine standing lateral radiograph and analyzed them. Results: There were no statistical difference in lumbar lordosis (sLL/wLL: 35.1˚/37.7˚) and pelvic parameter (sSS/wSS: 32˚/31.7˚, sPT/wPT: 24.3˚/24.2˚. sPI/wPI: 56.3˚/58.2˚) between supine lumbar lateral radiograph and whole spine standing lateral radiograph, and therewere also no statistical difference between two groups (group AI & AII) in SVA, lumbar lordosis and pelvic parameter. Pelvic parametercompared by supine lumbar lateral radiograph and whole spine standing lateral radiograph based on sagittal balance was no significantdifference, but lumbar lordosis appeared statistical difference. Conclusion: Sagittal imbalance appears quite a lot in patients with degenerative lumbar disease and supine lateral radiograph can’treflect the whole sagittal imbalance. So, whole spine standing lateral radiograph should be performed routinely to analyze the sagittalalignment. Key Words: Degenerative lumbar disease, Supine lumbar lateral radiograph, Whole spine standing lateral radiograph, Sagittal balance 연구 계획: 횡단 연구목적: 요추 전만각 정도에 따라 시상면 불균형을 예측할 수 없어, 앙와위 요추부 측면 사진과 기립 전신 척추 측면 사진에서의 척추 지표와 골반 지표를비교하여 기립 전신 척추 측면 사진의 필요성을 알아보고자 하였다. 선행문헌의 요약: 앙와위 요추부 측면 사진과 기립 전신 척추 측면 사진을 비교한 연구는 없었다. 대상 및 방법: 퇴행성 요추 질환으로 외래로 내원한 50세 이상 환자에서 남자 50명과 여자 50명을 무작위로 선정하였다. 앙와위 요추부 측면 사진과 기립 전신 척추 측면 사진에서 요추 전만각(sLL/wLL), 천추 경사(sSS/wSS), 골반 경사(sPT/wPT)를 각각 측정하여 비교 분석 하였다. 앙와위 요추부 측면사진 상에서 요추 전만각이 30도 미만인 Group AI과, 30도 이상인 Group AII으로 분류하여 비교분석 하였다. 또한 기립 전신 척추 측면 사진에서 시상수직축이 제 1천추의 후상연 모서리를 기준점으로 전방 5 cm 미만인 Group BI과 5 cm 이상인 Group BII으로 분류하여 비교 분석하였다. 결과: 왕와위 요추부 측면 사진과 기립 전신 척추 측면 사진에서 요추 전만각(sLL/wLL: 35.1도/37.7도) 및 골반 지표(sSS/wSS: 32도/31.7도, sPT/wPT:24.3도/24.2도. sPI/wPI: 56.3도/58.2도)는 통계적으로 유의하지 않았다. 또한, AI과 AII에서 시상 수직축 및 요추 전만각, 골반 지표는 모두 통계적으로유의한 차이는 없었다. 시상면 균형 여부에 따라 앙와위 측면 사진과 기립 전신 척추 측면 사진 상에서 비교한 골반 지표도 유의한 차이가 없었지만, 요추 전만각은 유의한 차이를 보였다. 결론: 퇴행성 요추 질환이 있는 환자에서 시상면 불균형이 적지 않게 나타나고 앙와위 요추부 측면 사진으로는 전체적인 시상면 불균형을 예측할 수 없기 때문에, 시상면 상태를 파악하기 위해서는 기립 전신 척추 측면 사진을 일괄적으로 촬영해야 할 것으로 사료된다. 색인 단어: 퇴행성 요추질환, 앙와위 요추부 측면 사진, 기립 전신 척추 측면 사진, 시상면 균형약칭 제목: 기립 전신 척추 측면 사진의 필요성