전방경유 경추체유합술에서 금속판 사용여부의 결과 비교

박춘근,박춘근,조경석,허필우,이일우,강준기 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.10

Although anterior cervical plates are thought to be good tools. their clinical results have not been compared with those of anterior cervical fusion without a plating system in the domestic scientific literature. As there are some advantages as well as shortcomings in these two surgical methods. it is imperative to know which one might be better in terms of the postoperative complications and management. Therefore the authors reviewed 80 patients undergoing anterior cervical fusion during the period of January 1992 to May 1994. Top plate placement was made in 25 and simple fusion without a plating system was applied in 55. The average follow-up period was 9.6 months. In the patients undergoing simple cervical fusion. thirty-two patients(58%) needed rigid braces such as halo braces and Minerva casts for 3 months postoperatively. Thirteen patients(24%) showed graft complications including graft extrusion. whereas patients undergoing plate placement needed only semi-rigid philadelphia braces for 4 to 8 weeks postoperatively. Two patients(8%) showed graft settling and screw breakage without any indication of reoperation. However there appeared no difference in the immediate postoperative course of clinical symptoms and the fusion rate(95 vs 96%) at the final follow-up day between the simple fusion and the plate placement patients. The authors conclude that a plating system in anterior cervical fusion may be safe in spite of more extensive operations. and is more likely to offer postoperative stability in the cervical spine and early ambulation and rehabiliation without rigid braces.

폴리메틸메타크리레이트를 사용한 경피적 척추성형술의 골다공증 척추체 압박골절에 대한 치료효과 : 예비보고

박춘근,이관성,최영근,류경식,박춘근,조경석,강준기,Park, Chun Kun,Lee, Kwan Sung,Choi, Yung Gun,Ryu, Kyung Sig,Park, Choon Keun,Cho, Kyung Suck,Kang, Joon Ki 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.3

Objectives : To describe a technique for percutaneous vertebroplasty of osteoporotic vertebral body compression fractures and to report preliminary results of its use. Methods : The technique was used over a 8-month period in 9 patients with 10 painful vertebral fractures. The technique involves percutaneous puncture of the involved vertebrae with a Jamshidi needle via a transpedicular approach followed by injection of polymethylmethacrylate(PMMA) into the vertebral body. Results : The procedure was technically successful in all patients, with an average injection amount of 5.9 cc per vertebral body. One patient complained of flank pain postoperatively in spite of improvement in back pain caused by the fractured vertebra. Remaining eight patients reported significant pain relief early after treatment. The patients were followed up for 3 to 15 months(average 7.2 months) and demonstrated no recurrence of pain or aggravation of deformity. Conclusion : Vertebroplasty appears to be a valuable tool in the treatment of painful osteoporotic vertebral fractures, providing acute pain relief and early mobilization in appropriate patients. However, it needs to have more extensive prospective clinical study to confirm its definitive role in the management of this condition.

Barrier Techniques for Spinal Cord Protection from Thermal Injury in Polymethylmethacrylate Reconstruction of Vertebral Body : Experimental and Theoretical Analyses

박춘근,지철,황장회,권성오,성재훈,최승진,이상원,박성찬,조경석,박춘근,강준기,Park, Choon Keun,Ji, Chul,Hwang, Jang Hoe,Kwun, Sung Oh,Sung, Jae Hoon,Choi, Seung Jin,Lee, Sang Won,Park, Sung Chan,Cho, Kyeung Suok,Park, Chun Kun,Yuan, Ha The Korean Neurosurgical Society 2001 Journal of Korean neurosurgical society Vol.30 No.3

Polymethylmethacrylate(PMMA)는 척추 전적출술후에 척추를 재건하기 위해 사용되지만 액체 형태의 PMMA가 응고하면서 발생되는 열은 척수 신경의 열 손상 가능성을 가지고 있다. 이 연구의 목적은 이미 응고된 PMMA sheet가 척수 신경을 보호하는 방어 벽으로서의 열 차단 역할을 할 수 있는지 또한 열손상으로부터 신경을 보호하기 위해 필요한 방어벽의 최소한의 두께를 탐구하는 데 있다. 실험실에서 제 12번째 흉추체 전 적출후의 상태와 동일한 크기와 모양의 정육면체의 용기를 제작하였다. 60ml의 액체형 PMMA를 용기 안에 주입하여 응고하는 PMMA중심부와 세 가지 다른 두께의(제 1 군 : 0mm, 제 2 군 : 5mm, 제 3 군 : 8mm) 이미 응고된 PMMA sheet의 하부(척수의 전면을 의미)에서 온도를 측정하였다. 또한 이 결과에 대한 위의 세 가지 군에 대해 열역학적 분석도 시행하였다. 응고하는 PMMA 덩이의 중심부에서의 온도는 18회의 실험 동안 매우 일정하여($106.8{\pm}3.9^{\circ}C$)이 실험 모델의 재현성을 보여주고 있었다. 방어 벽이 없는 군(제 1 군)에서 척수 신경 전면의 최고 온도가 $60.3^{\circ}C$이었으나 5mm군 (제 2 군)과 8mm군(제 3 군)에서는 각각 $47.3^{\circ}C$와 $43.3^{\circ}C$로 이미 응고된 PMMA는 통계적으로 유의한(p<0.00005) 온도 차단 효과를 보였다. 최고 온도에 도달하기까지의 계산된 시간은 실제 실험치 보다 35%이내의 오차를 보였으나 최고 온도에 대한 열역학적인 계산치는 실제 실험에서 나타난 수치의 1%이내의 오차를 보였다. 이상의 열역학적인 자료를 토대로 볼 때, PMMA를 이용한 척추의 재건술에서 PMMA 방어벽은 척수의 열손상을 방지하는 효과가 있으며, 이 실험에서 가정한 척수의 열손상 역치인 $39^{\circ}C$이하로 척수 온도를 유지하기 위해 필요한 PMMA방어벽의 두께는 10mm정도로 계산되었다. PMMA 방어벽의 임상 적용에 대해서는 추가적인 임상 실험이 필요하다고 사료된다. Objective : Polymethylmethacrylate(PMMA) is often used to reconstruct the spine after total corpectomy, but the exothermic curing of liquid PMMA poses a risk of thermal injury to the spinal cord. The purposes of this study are to analyze the heat blocking effect of pre-polymerized PMMA sheet in the corpectomy model and to establish the minimal thickness of PMMA sheet to protect the spinal cord from the thermal injury during PMMA cementation of vertebral body. Materials & Methods : An experimental fixture was fabricated with dimensions similar to those of a T12 corpectomy defect. Sixty milliliters of liquid PMMA were poured into the fixture, and temperature recordings were obtained at the center of the curing PMMA mass and on the undersurface(representing the spinal cord surface) of a prepolymerized PMMA sheet of variable thickness(group 1 : 0mm, group 2 : 5mm, or group 3 : 8mm). Six replicates were tested for each barrier thickness group. Results : Consistent temperatures($106.8{\pm}3.9^{\circ}C$) at center of the curing PMMA mass in eighteen experiments confirmed the reproducibility of the experimental fixture. Peak temperatures on the spinal cord surface were $47.3^{\circ}C$ in group 2, and $43.3^{\circ}C$ in group 3, compared with $60.0^{\circ}C$ in group 1(p<0.00005). So pre-polymerized PMMA provided statistically significant protection from heat transfer. The difference of peak temperature between theoretical and experimental value was less than 1%, while the predicted time was within 35% of experimental values. The data from the theoretical model indicate that a 10mm barrier of PMMA should protect the spinal cord from temperatures greater than $39^{\circ}C$(the threshold for thermal injury in the spinal cord). Conclusion : These results suggest that pre-polymerized PMMA sheet of 10mm thickness may protect the spinal cord from the thermal injury during PMMA reconstruction of vertebral body.

단일 나사형 Cage를 이용한 후방 요추체간 융합술과 두개의 나사형 Cage를 이용한 PLIF의 생체 역학적 비교

박춘근,황장회,지철,권성오,성재훈,최승진,이상원,김문규,박성찬,조경석,박춘근,강준기,Park, Choon Keun,Hwang, Jang Hoe,Ji, Chul,Kwun, Sung Oh,Sung, Jae Hoon,Choi, Seung Jin,Lee, Sang Won,Kim, Moon Kyu,Park, Sung Chan,Cho, Kyeung Suok,Park, 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.7

Objectives : An in vitro biomechanical study of posterior lumbar interbody fusion(PLIF) with threaded cage using two different approaches was performed on eighteen functional spinal units of bovine lumbar spines. The purpose of this study was to compare the segmental stiffnesses among PLIF with one long posterolateral cage, PLIF with one long posterolateral cage and simultaneous facet joint fixation, and PLIF with two posterior cages. Methods : Eighteen bovine lumbar functional spinal units were divided into three groups. All specimens were tested intact and with cage insertion. Group 1(n=12) had a long threaded cage($15{\times}36mm$) inserted posterolaterally and oriented counter anterolaterally on the left side by posterior approach with left unilateral facetectomy. Group 2(n=6) had two regular length cages($15{\times}24mm$) inserted posteriorly with bilateral facetectomy. Six specimens from group 1 were then retested after unilateral facet joint screw fixation in neutral(group 3). Likewise, the other six specimens from group 1 were retested after fixation with a facet joint screw in an extended position(group 4). Nondestructive tests were performed in pure compression, flexion, extension, lateral bending, and torsion. Results : PLIF with a single cage, group 1, had a significantly higher stiffnesses than PLIF with two cages, group 2, in left and right torsion(p<0.05). Group 1 showed higher stiffness values than group 2 in pure compression, flexion, left and right bending but were not significantly different. Group 3 showed a significant increase in stiffness in comparison to group 1 for pure compression, extension, left bending and right torsion(p<0.05). For group 4, the stiffness significantly increased in comparison to group 1 for extension, flexion and right torsion(p<0.05). Although there was no significant difference between groups 3 and 4, group 4 had increased stiffness in extension, flexion, right bending and torsion. Conclusion : Posterior lumbar interbody fusion with a single long threaded cage inserted posterolaterally with unilateral facetectomy enables sufficient decompression while maintaining a majority of the posterior elements. In combination with a facet joint screw fixation, adequate postoperative stability can be achieved. We suggest that posterolateral insertion of a long threaded cage is biomechanically an ideal alternative to PLIF.

Comparisons of Unicortical and Bicortical Lateral Mass Screws in the Cervical Spine : Safety vs Strength

박춘근,황장회,지철,이재언,성재훈,최승진,이상원,박성찬,조경석,박춘근,강준기,Park, Choon-Keun,Hwang, Jang-Hoe,Ji, Chul,Lee, Jae Un,Sung, Jae Hoon,Choi, Seung-Jin,Lee, Sang-Won,Seybold, Eric,Park, Sung-Chan,Cho, Kyung-Suok,Park, Chun-K The Korean Neurosurgical Society 2001 Journal of Korean neurosurgical society Vol.30 No.10

Introduction : The purpose of this study was to analyze the safety, pullout strength and radiographic characteristics of unicortical and bicortical screws of cervical facet within cadaveric specimens and evaluate the influence of level of training on the positioning of these screws. Methods : Twenty-one cadavers, mean 78.9 years of age, underwent bilateral placement of 3.5mm AO lateral mass screw from C3-C6(n=168) using a slight variation of the Magerl technique. Intraoperative imaging was not used. The right side(unicortical) utilized only 14mm screws(effective length of 11mm) while on the left side to determine the length of the screw after the ventral cortex had been drilled. Three spine surgeons(attending, fellow, chief resident) with varying levels of spine training performed the procedure on seven cadavers each. All spines were harvested and lateral radiographs were taken. Individual cervical vertebrae were carefully dissected and then axial radiographs were taken. The screws were evaluated clinically and radiographically for their safety. Screws were graded clinically for their safety with respect to the spinal cord, facet joint, nerve root and vertebral artery. The grades consisted of the following categories : "satisfactory", "at risk" and "direct injury". Each screw was also graded according to its zone placement. Screw position was quantified by measuring a sagittal angle from the lateral radiograph and an axial angle from the axial radiograph. Pull-out force was determined for all screws using a material testing machine. Results : Dissection revealed that fifteen screws on the left side actually had only unicortical and not bicortical purchase as intended. The majority of screws(92.8%) were satisfactory in terms of safety. There were no injuries to the spinal cord. On the right side(unicortical), 98.9% of the screws were "satisfactory" and on the left side(bicortical) 68.1% were "satisfactory". There was a 5.8% incidence of direct arterial injury and a 17.4% incidence of direct nerve root injury with the bicortical screws. There were no "direct injuries" with the unicortical screws for the nerve root or vertebral artery. The unicortical screws had a 21.4% incidence of direct injury of the facet joint, while the bicortical screws had a 21.7% incidence. The majority of "direct injury" of bicortical screws were placed by the surgeon with the least experience. The performance of the resident surgeon was significantly different from the attending or fellow(p<0.05) in terms of safety of the nerve root and vertebral artery. The attending's performance was significantly better than the resident or fellow(p<0.05) in terms of safety of the facet joint. There was no relationship between the safety of a screw and its zone placement. The axial deviation angle measured $23.5{\pm}6.6$ degrees and $19.8{\pm}7.9$ degrees for the unicortical and bicortical screws, respectively. The resident surgeon had a significantly lower angle than the attending or fellow(p<0.05). The sagittal angle measured $66.3{\pm}7.0$ degrees and $62.3{\pm}7.9$ degrees for the unicortical and bicortical screws, respectively. The attending had a significantly lower sagittal angle than the fellow or resident(p<0.05). Thirty-three screws that entered the facet joint were tested for pull-out strength but excluded from the data because they were not lateral mass screws per-se and had deviated substantially from the intended final trajectory. The mean pull-out force for all screws was $542.9{\pm}296.6N$. There was no statistically significant difference between the pull-out force for unicortical($519.9{\pm}286.9N$) and bicortical($565.2{\pm}306N$) screws. There was no significant difference in pull-out strengths with respect to zone placement. Conclusion : It is our belief that the risk associated with bicortical purchase mandates formal spine training if it is to be done safely and accur 서 론 : 후방 경유 경추 융합을 위한 후관절 금속판 고정술은 외상성 및 퇴행성 불안정성의 치료에 효과적인 방법이다. 후관절 금속판 고정의 안정성은 여러 가지 인자에 의해 결정된다. 이중 하나가 나사못의 삽입깊이이다. 이 방법이 처음 소개될 때에는 양피질골성 삽입이 이용되었다. 외과의사의 관심은 어떻게 안전하면서 생역학적으로 강력한 고정을 얻느냐에 있다. 목 적 : 이 연구의 목적은 사체에서 단피질성과 양피질성 나사못 삽입술을 시행한 후 안전성, pull-out 강도, 방사선학적 특성을 분석하고 나사못의 삽입에 대한 교육 훈련의 수준에 따른 영향을 평가하는데 있다. 방 법 : 평균 나이 78.9세인 21구의 사체에 대하여, Magerl의 기술을 변형하여 C3-C6(n=168)까지 3.5mm AO 나사못을 양쪽 후관절에 삽입하였다. 수술중 방사선 사진영상은 사용되지 않았다. 오른 쪽(단피질성 삽입)은 14mm 나사못(11mm의 유효 길이)을 이용하고, 왼쪽은 양피질성 삽입을 시도하였다. 각 사체는 3개의 군으로 나누어 척추 수술 수련의 수준이 다른 받은 3명의 척추 외과 의사들(전임 강사, 임상 강사, 수석 레지던트)이 수술을 시행했다. 수술 후 경추를 떼어내어 나사못의 위치를 육안적으로 확인하고 방사선학적으로 안정성과 삽입 위치 (1,2,3)를 평가하였다. 척수, 후관절, 신경근과 척추 동맥에 대한 나사못의 위치를"만족할 만한","위험한", 그리고"직접적인 손상"으로 구분하였다. material testing machine을 이용하여 모든 나사못에 대해서 Pull-out 강도를 측정하였다. 결 과 : 대다수의 나사못(92.9%)은 만족할 만한 상태였다. 전예에서 척수에 대한 위험성은 없다. 오른 편(단피질성 : 14mm) 나사못의 98.9%는"만족할 만한"에 속했다. 그리고 왼쪽 편(양피질성)의 68.1%는"만족할 만한"에 속했다. 양피질성 나사못 군에서 5.8%의 척추 동맥에 대한 직접적인 손상이 있었고 신경근의 직접적인 손상 발생율은 17.4%였다. 반면에 단피질성 나사못 군에서는 이들에 대한 직접적인 손상은 없었다. 양피질성 나사못에서 보인"직접 손상"의 거의 대부분은 외과 의사의 경험 부족으로 발생하였다. 나사못의 안정성과 삽입 위치 사이에는 특별한 관련이 없었다. 모든 나사못의 pull-out 강도는 $542.0{\pm}296.6N$였다. 단피질성에 있어서의 pull-out 강도($519.0{\pm}289.9N$)와 양피질성($565.2{\pm}306N$) 나사못에는 아무런 통계학적으로 의미있는 차이점을 발견할 수 없었다(p>0.05). 나사못 삽입위치와 pull-out 강도 사이에는 의미있는 차이가 없었다. 결 론 : 이번 연구는 경추 후관절 나사못 고정술시 단피질성과 양피질성 나사못의 안정성과 효능을 집중적으로 알아보았다. 명백한 것은 14mm의 나사못(효과적인 길이는 11mm)이 보다 긴 양피질성 나사못 보다 손상의 위험이 훨씬 낮고 거의 동등한 pull-out강도를 갖는다는 것이다. 또한, 수술시 방사선 영상을 사용할 수 없을 때, 훈련과 축적된 경험에 의해 나사못 삽입의 정확성과 안전성이 향상될 수 있다.

뇌종양과 유사한 혈전형성된 거대 후교통동맥류 수술적 치험 1예 : A Case Report

박춘근,김문찬,박춘근,김달수,강준기,송진언 대한신경외과학회 1988 Journal of Korean neurosurgical society Vol.17 No.3

A giant intracranial aneurysm(GIA) is an aneurysm greater than 2.5㎝ in size. GIA may simulate brain tumor on computed tomography scans. We report a case of giant thrombosed posterior communicationg artery aneurysm simulating brain tumor. To minimize brain retraction and achieve excellent exposure in the shortest possible distance during the operation, we used a new surgical technique, an orbitozygomatic infratemporal approach, with good results.

원발성 시상부 혈종의 분류에 따른 처치 및 예후 분석

박춘근,조태훈,김문찬,이재수,백민우,김달수,하영수,강준기,송진언 대한신경외과학회 1985 Journal of Korean neurosurgical society Vol.14 No.4

65 patients with spontaneous thalamic hemorrhage (TH) diagnosed by CT scan were treated in Catholic Medical Center. Of total 340 patients with spontaneous intracerebral hemorrhage from 1980 to 1983, TH occured in 19.1%. In order to analyse prognosis and guidline of management we classified TH into 4 types with the topographic involvement of thalamus : Type Ⅰ- the anteromedial TH in 3 cases (4.8%) showed no specific correlation between symptoms and site of hematoma. The prognosis was good with medical treatment alone. Type Ⅱ - the posterolateral TH in 23 cases (35.2 %), mainly spreaded into the internal capsule and the midbrain. Aphasia was one of the main clinical features and the prognosis was worse with both conservative and surgical treatment than those of type Ⅰ and Ⅲ. Type Ⅲ-the dorsal TH in 26 cases (40%), often extended to the lateral ventricle and were localizing in the thalamic area. Emotional change was more characteristic. The prognosis was better than those of type Ⅱ and Ⅳ. EVD was occasionally indicated. Type Ⅳ-the massive TH in 13 cases (20%), was extensively involved in the thalamus and spreaded to all direction. Symptoms and signs were various and surgery was not indicated because the prognosis was poor. Aphasia was noted in the left TH, but right - hemisphere cortical dysfunctions were found mainly in the right TH. The prognoses of the patients with aphasia and/or right hemisphere cortical dysfunction were poorer than those of the patients without. We consider that the patients in type Ⅱ or Ⅲ with aphasia and/or right-hemisphere cortical dysfunction should be managed with EVD or stereotaxic urokinase therapy for better neurological outcome.

Urokinase의 뇌정위적 혈종내 주입에 의한 자발성 두개강내 혈종의 치료 효과

박춘근,정철구,백민우,김문찬,김달수,하영수,강준기,송진언 대한신경외과학회 1985 Journal of Korean neurosurgical society Vol.14 No.2

Authors describe methods for evacuation of intracerebral and/or intrventricular hematomas with CT-aided stereotaxic infusion of urokinase into the hematoma and controlled drainage. In the past 6 months we performed the procedures in 21 cases during acute (within 3 days) or subacute (between 4 and 14 days) stage after the apoplectic attack. Three dimensional CT images were used to locate the hematoma sites, to assess its volume and to determine stereotaxic coordinates. Under local anesthesia a silicon tube was inserted into the hematoma through a burr hole and the hematoma was aspirated with syringe. And then urokinase (6,000 IU/5㎖ saline) was infused into the hematoma and the drain was clipped. Thereafter aspiration and administration were performed repeatedly every 6 hours until the hematoma was completely removed. In cases of intraventricular hematoma a drain was inserted into the ventricle having the main hematoma. As a first trial of hematoma removal, the ventricle was irrigated with urokinase (6,000 IU/100㎖ saline), and the drain was clipped after administration of urokinase (6,000 IU/5㎖ saline). Subequentry clipping of the drain for 4 hours and drainage of the CSF with the hematoma for 2 hours were repeated under the monitoring of intracranial pressure. Now we review serial changes of CT findings and results of 10 cases which were followed up for at least 4 months' and priliminarily conclude that this procedure may be as good as conventional cranitomy, and safer and less traumatic than any other management especially in cases of intraventricular or deep seated hematomas and elderly or high-risk patients.

내경동맥의 외상성 두개강내 폐색 : 증례보고 Case Report

박춘근,박성찬,김문찬,강준기,송진언 대한신경외과학회 1989 Journal of Korean neurosurgical society Vol.18 No.2

본 가틀릭의대 신경외과학 교실에서는 전두부 골절을 동반한 중증의 폐쇄성 두부외상 환자에서 두개강내 내경동맥폐쇄 및 후대뇌동책폐쇄로 인하여 한쪽 대뇌반구 전체에 뇌경색증을 보였던 1례를 보고하고 문헌고찰을 통해 두부외상에서 뇌혈관 합병증 조기진단의 의의와 중요성을 강조하였다. A case of traumatic intracranial occlusion of the right internal carotid artery is reported, and the mechanism and management of occlusion is reviewed to make realize the importance of vascular lesions in patients with head injury. Considering that CT became the principal diagnostic method in head injured patients, it is important to realize the possibility of vascular injury in patients with head injury who have unexplained neurological deficits and to pursue the evaluation of the patients with an angiography.

뇌실질내혈종 유발시 뇌혈류에 대한 Naloxone의 효과

박춘근,강준기,송진언,김대조 대한신경외과학회 1988 Journal of Korean neurosurgical society Vol.17 No.3

In an attempt to investigate the role of endogenous opiate in the changes of regional cerebral flow(rCBF) in intracerebral hematoma(ICH), an experimental model of ICH was induced in the cat. Fourty adult cats were devided into four groups, saline-treated normal control group(10 cats), saline-treated ICH group(10 cats) and naloxone-treated ICH group(10 cats) respectively. The ICH was induced in the right frontal region stereotactically with the autogenous arterial blood(1.5㎖). The rCBF measurements done by hydrogen clearance method were carried out in each cat immediately, 20 min, 40 min, 60 min, 80 min, 100 min, 120 min, 140 min, and 160 min following ICH induction, and naloxone(10 ㎎/㎏) was intravenously administered immediately, 60 min and 120 min after ICH induction. ICH induction resulted in increases of mean arterial blood pressure(MABP) and intracranial pressure(ICP) and decrease of rCBF of the ipsilateral hemisphere. Naloxone did not modify the pattern of MABP and ICP changes, however it transiently increased rCBF, every time the drug was administered in naloxone-treated control group and from 60min following ICH induction in naloxone-treated ICH group. The animals were sacrificed 180min after ICH induction and the brains were sliced and prepared with Evans Blue, which revealed no significant mass effect, midline shift or perifocal brain edema. It is concluded that the decrease of rCBF in ICH could be influenced by endogenous opiates and naloxone could improve decreased rCBF in ICH without increase of MABP or decrease of ICP.