요통 환자에서 입원 전 치료 양상에 대한 분석

심대무,김태균,송하헌,송재용,이동훈,이명실 대한척추외과학회 1999 대한척추외과학회지 Vol.6 No.1

연구계획 : 요통으로 대학 병원에 입원하여 수술 치료전까지 질환의 만성화와 과대한 의료비 지출을 보이는 경향 이 있어 의무 기록 및 간호사 면담을 통하여 조사하였다. 연구목적 : 본 연구는 요통으로 입원한 환자의 입원 전까지 치료 내용을 간호사가 환자 상담을 통하여 얻은 내원 동기, 진료비, 치료 과정, 치료 결과 등에 대하여 분석하여 우리 의료 환경 특성을 이해하고자 하는데 있다. 대상 및 방법 : 1997년 10월부터 1998년 3월까지 5개월간 본교 정형외과에 요통을 주소로 입원치료한 100명을 대상으로 하였다. 입원 후 간호력 조사시 오차를 줄이기 위하여 한 명의 간호사가 병력 일지 및 면담 후 작성하고 치료 기간, 내원 동기, 진료비, 치료 과정, 치료 결과 등에 대하여 조사하였다. 결과 : 다음과 같이 요약 할수 있다. 1. 입원 전의 진료는 발병 후 입원까지 기간이 6개월 이상이 72 %로 만성화를 보였으며, 한방 진료를 거쳐 내원한 경우가 80 %이였다. 2. 입원 전 진료비 지출은 1인 평균 100만원 이상의 고가의 진료비 지출을 보였고, 한방 진료 기관의 경우 1인당 평균 130만원의 진료비 지출이 있었으며, 1회 방문 당 진료비는 한의원이 의원에 비하여 7배이상의 지출로 제일 높았다. 3. 입원을 선택한 동기는 주위의 권유에 의한 경우가 89 %로 주종을 이루었고, 수술적 치료를 시행한 환자는 62명중 탁월 12명, 우수 35명, 양호 13명과 불량 2명을 보였다. 결론 : 환자의 장기화 및 고가의 진료비 지출과 한방 진료의 선호들을 보이고 있으며, 위 3가지 요소가 서로 관련 이 있음을 보여 주고 있다. Object : The Authors compaired the treatment interval, the motive of admission and costs of episodes of back pain care between different provide type in a population representation of the Korea. Material & Method : We reviewed 100 different patients undergone back pain care from October 1997 to March 1998 in Wonkwang Medical Center. This study was a prospective, nurse community based and observational design. Male were 42 and female were 58, mean age was 51(18-81)years. Patients with back pain had been treated with 62 patients operation and 38 patients conservative treatment. Results : The results were as follows 1. The from preadmmision treatment to admission treatment time is consume over 6 months, that makes chronic phase of back pain until 72%, more than 80% of the patients were admitted after the herb medical treatment. 2. The cost of preadmission treatment is average 1,000,000 won. In the cases of herb medicine are average 1,300,000won. The medical fee in the herb medicine is seven times as much as in the medical clinics for a visit. 3. The motive of admission is recommended by neighbour that major to 89%, 62 patients were operated that showed 12 excellent, 35 good, 13 fair and 2 poor results. Conclusion : There were correlations of three factors, that is high cost, patients chronicity and preference of the herb medicine.

수정기사

심대무,김태균,오성균,이석중,양희석 대한정형외과학회 2012 대한정형외과학회지 Vol.47 No.6

정형외과 영역에서 Sulperazon의 임상적 경험

심대무,나범수,김상수 최신의학사 1991 最新醫學 Vol.34 No.7

백서 좌골신경을 이용한 신경이식술후 혈류회복에 관한 연구

심대무,황병연,김상수,전철홍,이용옥 圓光大學校 醫科學硏究所 1991 圓光醫科學 Vol.7 No.1-2

Nerve graft is one of the procedures to be used to overcome a large gap of the peripheral nerve injury. The survival of the grafted nerve is the most important factor involved with good results. To investigate the sequential change of the blood supply to the grafted nerve, an experimental graft was performed on the sciatic nerve of the rats and change of the local vascularity was observed by microangiography with indian ink. Followings are the results. 1. The specimen of one week, only few vessels were appeared in the grafted nerve, but not avascular. Even in the mid portion, several endoneurial vessels were observed, which seemed to be important for the survival. 2. The vascular system of the epineurium was restored to a normal level at the one or two weeks after, and the perineurial and endoneurial vessels were normalized at three or four weeks after the graft. 3. The perineurial and endoneurial vessels were restored from the two anastomotic sites, but not from the surface of the nerve, and then proceeded to the mid portion. 4. Hypervascularity occurred in the perineurial and endoneurial systems to reach its peak at six weeks, thereafter gradually decreased to the normal level at eight or ten weeks. Transient vasodilatation was observed. 5. The restorated intraneural vascular system showed a diffuse distribution like branches of a tree, but not in parallel pattern as seen in normal nerve.

하 경추부 손상

심대무,김태균,송하헌,채수욱,하대호,김영진,조재득 圓光大學校 醫科學硏究所 2002 圓光醫科學 Vol.17 No.1

경추외상 환자의 진찰에서 모든 부위에 대한 손상가능성을 염두에 두고 면밀한 검사가 필요하다. 의인성 손상을 최소화하기 위하여 환자는 적절하게 후송되어야 하고 응급실에서 철저히 검사를 시행해야 한다. 면밀하게 구성된 치료 원칙으로 치료를 시행함으로서 양호한 결과를 얻을 수 있다. 환자의 상태가 확인되면 치료는 골절의 양상과 신경학적 상태에 따라서 결정한다. 치료의 원칙은 빠른 정복에 의해 더 이상의 신경 손상을 막고 신경 회복을 최대화하며, 변형과 동반된 골절과 탈구를 고정시키는 것이다. 수술시 사용되는 전방이나 후방 접근법은 적절하게 선택된 환자에서 시행된다면 만족할만한 결과를 얻을 수 있다. 수술 후 일정기간 동안 적절한 외고정의 중요성은 아무리 강조해도 지나치지 않다. 정확한 진단과 면밀하고 합리적인 치료를 실시함으로서 치료 후의 합병증을 최소화하고 만족할 만한 기능적 결과를 얻을 수 있다. Historically, injuries of lower cervical spine were associated with a poor prognosis and result in some type of neurologic deficit. But, the incidence of cervical spine injury is increasing because of motor vehicle accidents, followed by falls and diving activities, etc. Proper initial in-field management and early identification and institution of definitive treatmem are crucial to obtaining a favorable prognosis. The Allen and Ferguson classification system divided into six pathogenesis or categories; Compression flexion, vertical compression, distraction flexion, compression extension, distraction extension, and lateral flexion injuries. If allows for a convenient mechanistic description of the biomechanical deficiencies present after cervical injury. Distinguishing between complete and partial spinal cord injuries (SCIs) is important for determining a patient's overall functional prognosis as well as an acute in-hospital treatment plan. Early mismanagement may result in preventable neurologic compromise. The current recommendation for selection of imaging studies put forth by the American College of Radiology are predicated on patient's symptom and an overall suspicion of injury. Plain radiograph can be extremely effective in diagnosing cervical trauma. It consists of three or five-films cervical spine series. A magnetic resonance imaging (MRI) scan is recommended for patients with a neurologic deficit but negative plain radiographic findings. The goals of treatment are to maximize neurologic recovery, to maximize the degree of neurologic and medical comorbidities, to obtain spinal stability, to improve patient functionally, and to help the patient to cope psychologically. In cases of SCIs, high dose each type of fracture have a treatment option which included closed reduction, external stabilization device (cervical and cervicothoracic orthoses, halo vest), and corpectomy and plating or fusion.

수술용 현미경을 이용한 추간판 수술

심대무,박지영 圓光大學校 醫科學硏究所 2005 圓光醫科學 Vol.20 No.1

흰쥐에서 척수손상후 후지의 운동기능회복을 위한 좌골신경의 전기자극 효과

심대무,최정기,차상도,박병림 대한척추외과학회 1995 대한척추외과학회지 Vol.2 No.2

Spondylolisthesis has been recognized as one of the leading cause of the low back pain in orthopaedic field. Occasionally they may cause the neurological symptoms of the lower extremity. Most of the cases are successfully managed with conservative treatment, but operative treatment are indicated if conservative treatment fails. Operative treatment are categorized decompression, reduction and fusion, now a days posterior decompression and posterolateral fusion are most commonly used. In the methods of posterolateral fusion, there are some controversies between two methods 1) short segment fusion for saving of functioning segment, 2)extended fusion for more amount of reduction. We suggest short segment fusion with S-shaped VSP for satisfactory reduction with saving of functioning segment. Twenty one cases of spondylolisthesis treated operatively with S-shaped VSP from september,1991 to March, 1993 were reviewed. The results obtained were as follows; 1.According to the affected site, between L4 and L5 was 14cases, and between L5 and S1 was 7 cases. 2.13 cases were degenerative type and 8 cases were isthmic type. 3.Degree of olisthesis(by Meyerding method): Grade I was 16 cases(76.2%), Grade Ⅱ was 4 cases(19%), Grade Ⅲ was 1 case(4.8%) 4.Satisfactory reduction was obtained: 4.5% slippage by Taillard method postoperatively(21.5% preoperatively). 5.In the functional result, 91% was above good according to the Gill's criteria without any serious complications.

다발성 요추 척추관 협착증에 수술현미경을 이용하여 시행한 감압술

심대무,이현,김동철,송재용,김상수 대한척추외과학회 1995 대한척추외과학회지 Vol.2 No.1

There was a trend to perform the concomitant fusion and instrumentation in decompression of spinal stenosis, because of extensive decompression and instability. However, the introduction of the microscopy in spinal operation and the development of surgical technique make exquisite decompression possible, minimize the range of excision of posterior anatomic structures, reduce decompression levels in the multiple lesions, and minimize anterior slipage by mailtaining the stability of the spine without performing spinal fusion. The authors performed the spinal nerve root block and microscopic decompression in the treatment of 25 patients of lumbar spinal stenosis. The ages of patients were either above sixty-years-old or in their fifties who had osteoporosis with Saville's index 2 or higher. The patients were followed up at least twelve months(mean 17.6 months). Analysis of the overall results showed that excellent, good, fair, and poor grades were 16%, 56%, 16%, and 12%, respectively. We recommend the selective microscopic decompression is one of the effective method for the elderly patients or patients with osteoporosis in addition to multiple stenotic lesions.

다발성 손상을 동반한 관절내 종골골절에 유관나사를 이용한 비관혈적 수술치료

심대무,김태균,채수욱,권석현 대한골절학회 2002 대한골절학회지 Vol.15 No.4

목적 : 종골골절의 대부분을 차지하는 거골하 관절을 침범하는 관절내 골절 환자중 다발성 손상에 의한 장시간의 수술이 불가능한 경우나 자세변화를 할 수 없는 경우, 타과적 수술후 장시간의 상태관찰이 필요한 경우에 유관나사를 이용한 비관혈적 정복술을 시행하고 그 결과를 분석하고자 하였다. 대상 및 방법 : 1998년 6월부터 2001년 6월까지 종골의 관절내 골절 진단하에 본원에서 수술적 치료를 시행한 40명 48례중 순수한 유관나사를 이용한 비관혈적 정복술을 시행한 13명 15례(30-75세. 평균 48세. 남자 14례. 여자 1례)를 대상으로 하였다. 전 례에서 다발성 손상 및 타과적 손상을 동반하였으며, 체위변화 없이 수술을 시행하였고, 유관나사 이외의 고정틀은 사용하지 않았으며 추시 기간은 최소 12개월부터 27개월까지 평균 17개월이었다. 치료 결과에 대한 평가는 동통, 환자의 만족감, 보행능력, 보조기 사용여부에 따라 판정한 Salama 평가 기준에 의거하였으며, 수술전과 추시상의 방사선 소견에서 Bohler 각의 변화와 거골하 관절면의 상태 및 종골의 변형등을 관찰하였다. Sanders분류상 제 Ⅰ형이 2례(13%), 제 Ⅱ형이 9례(60%), 제 Ⅲ형이 4례(27%)로 제 Ⅱ형이 가장 많았다. 결과 : Salama 평가 기준에 의한 추시 결과 우수가 2례, 양호가 8례, 보통이 3례, 불량이 2례였으며, Bohler 각은 수술전 5 ˚에서 35 ˚사이였으며, 수술후에는 15 ˚에서 45 ˚사이로 호전되었고, 추시상에서는 15 ˚에서 40 ˚사이였다. 거골하 관절면의 관절염이 발생한 경우는 5례 였으며, 종골의 변형이 관찰된 경우는 4례였다. 결론 : 종골의 관절내 골절에서 여러 가지 이유에 의해 관혈적 정복 및 내고정술을 시행할수 없을 경우 수술시기를 지연하지 않고 체유변화 없이 수상 후 즉시 다발성 손상 수술시 유관나사를 이용하여 비관혈적 정복술이 시행할 만한 유용한 치료법으로 사료된다. Purpose : To evaluate the radiological and clinical results of closed reducation and cannulated screw percutaneous fixation of intraarticaluar calcaneal fractures combined with multiple injuries. Materials and Methods : We reviewed 15 caese of 13 patients intraarticular clacaneal fractures combined with multiple injuries which were treated with closed reducation and cannulated screw percutaneous fixation between June 1998 to June 2001 and minimum follow up period of 12 months(12-27 months). The results were based on the assessment criteria of Salama and the analysis of Bohler’s angle, states of subtalar joint and deformities of calcaneus. Based on the Sanders classification, there were 2 cases(13%) of type Ⅰ, 9 cases(60%) of type Ⅱ and 4 cases(27%) of type Ⅲ. Results : The preoperative Bohler’s angles were between 5 ˚ to 35 ˚, postoperative Bohler’s angles were between 15 ˚ to 45 ˚ and the last follow up Bohler;s angles were between 15 ˚ to 40 ˚. The postoperative complication of subtalar arthritis were developed in 5 cases and deformities of calcaneus were developed in 4 cases. Based on the assessment criteria of Salama, the functional results were excellent in 2 cases, good in 8 cases, fair in 3 cases, and poor in 2 caese. Conclusion : The closed reduction and cannulated screw percutaneous fixation of intraarticular calcaneal fractures combined with multiple injuries was thought to be a useful method of treatment at the state of not delayed operating time and not position changing.

척추 수술후 C-반응 단백 및 적혈구 침강 속도의 정량분석

심대무,김태균,송하헌,심용석,이성호,송진호 대한척추외과학회 1998 대한척추외과학회지 Vol.5 No.1

Objectives : In order to standardize the CRP, ESR and WBC count after three types of spinal surgery and get clinical usefulness from these laboratory datas after spinal surgery and clinical usefulness of laboratory datas. Material and Methods : Three groups of patients(microdisectomy, anterior and posterior fusion) were chosen for the study. CRP, ESR and WBC levels were prospectively determined before surgery and at days 1-5, 10, 14, 21 and 42 after surgery Results : In all patients, preoperative normal CRP level(<10㎎/L) increased, reaching peak levels on the second day after anterior fusion(84.6㎎/L), and at the third day after microdiscectomy(54.5㎎/L) and posterolateral intercorporal fu sion(152.2㎎/L), with normalization in 5-10 days. Preoperative normal ESR `level increased to peak level on the forth day after microdiscectomy(33.0㎜/hr), and increased double peak levels after anterior(postoperative days 2&5) and posterolateral intercorporal fusion(postoperative days 3&5). ESR followed by a slow and irregular decrease, and at 42 days after surgery often remained elevated. WBC increased to variable peak level within normal limit in all patients. Conclusions : The rapid decline in CRP will probably be interrupted by a second rise or persisting elevation if infection occurs. CRP is presumably a better test than ESR for early detection of postoperative infection.