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.

Bisphosphonate’s and Intermittent Parathyroid Hormone’s Effect on Human Spinal Fusion: A Systematic Review of the Literature

Michael A. Stone,Andre M. Jakoi,Justin A. Iorio,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

There has been a conscious effort to address osteoporosis in the aging population. As bisphosphonate and intermittent parathyroid hormone (PTH) therapy become more widely prescribed to treat osteoporosis, it is important to understand their effects on other physiologic processes, particularly the impact on spinal fusion. Despite early animal model studies and more recent clinical studies, the impact of these medications on spinal fusion is not fully understood. Previous animal studies suggest that bisphosphonate therapy resulted in inhibition of fusion mass with impeded maturity and an unknown effect on biomechanical strength. Prior animal studies demonstrate an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. The purpose of this study was to determine if bisphosphonates and intermittent PTH treatment have impact on human spinal fusion. A systematic review of the literature published between 1980 and 2015 was conducted using major electronic databases. Studies reporting outcomes of human subjects undergoing 1, 2, or 3-level spinal fusion while receiving bisphosphonates and/or intermittent PTH treatment were included. The results of relevant human studies were analyzed for consensus on the effects of these medications in regards to spinal fusion. There were nine human studies evaluating the impact of these medications on spinal fusion. Improved fusion rates were noted in patients receiving bisphosphonates compared to control groups, and greater fusion rates in patients receiving PTH compared to control groups. Prior studies involving animal models found an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. No significant complications were demonstrated in any study included in the analysis. Bisphosphonate use in humans may not be a deterrent to spinal fusion. Intermittent parathyroid use has shown early promise to increase fusion mass in both animal and human studies but further studies are needed to support routine use.

퇴행성 요추 질환환자에서 척추유합술 후 발생한 인접분절의 퇴행성 변화에 대한 수술적 치료

김영수,구성욱,조용은,진병호,윤영설,진동규 대한신경외과학회 2002 Journal of Korean neurosurgical society Vol.32 No.4

정형외과 연구의 동물모델: 척추유합술모델

이재협(Jae Hyup Lee),남윤진(Yunjin Nam),이지호(Ji-Ho Lee) 대한정형외과학회 2017 대한정형외과학회지 Vol.52 No.4

퇴행성 척추질환이나 외상 등의 증가로 인해 척추유합술이 증가하고 있으며, 다양한 내고정장치나 골이식재의 개발도 이에 동반해서 증가하고 있다. 척추유합술 동물모델은 새로운 척추 고정기기나 골이식재의 효능을 평가하는 데 매우 유용한 술식이다. 척추유합술 동물모델은 크게 후외방 유합술모델, 후방 유합술모델, 전방 유합술모델이 있으며 주로 이용되는 동물에는 마우스, 랫드, 가토와 같은 소동물부터 개, 돼지, 염소, 양 및 영장류 등 중, 대동물도 있다. 소동물모델은 자가골이나 골이식재를 이식한 후 내고정 없이 유합을 평가하는 것이 일반적이다. 그러나 중동물이나 대동물은 척추경 나사못을 이용한 내고정술을 추가로 이용할 수 있으며 케이지를 이용한 추체간 유합술을 시행할 수도 있다. 소동물모델은 크기가 작아 다루기 쉽지만 인체와 해부학적이나 생역학적인 반응이 다르다. 중동물이나 대동물모델은 인체와 유사한 특성을 갖고 있지만 다루기 힘들거나 윤리적 문제가 있다. 척추유합술에 대한 유합결과 평가는 도수 촉진이나 인스트론 등의 기계를 이용한 기계적 측정, 컴퓨터 단층촬영이나 마이크로 컴퓨터 단층촬영 등을 이용한 영상평가, 그리고 비탈석회화 조직슬라이드를 이용한 조직학적 평가가 있다. 골유합률이나 골유합에 소요되는 기간은 종이나 해부학적 위치에 따라 다르며 대부분의 척추유합술 동물모델에서 골이식재를 삽입하지 않을 경우 유합을 기대할 수 없다. 이에 본 종설에서는 대표적으로 이용되고 있는 척추유합술 동물모델의 특징과 차이점에 대해 기술하고자 한다. The incidence of spinal fusion surgery has increased due to an increase in the incidence of degenerative spinal disease or trauma. Moreover, the development of various kinds of implants and bone graft substitutes has also increased. The animal models of spinal fusion are useful methods in evaluating the effectiveness of the newly developed spinal implants or bone graft substitutes. The most widely used animal models of spinal fusion are posterolateral fusion model, posterior fusion model, and anterior interbody fusion model. Mice, rats, rabbits, dogs, pigs, goats, sheep, and primates are frequently used in animal models of spinal fusion. Small animals are implanted with a bone graft substitute without internal fixation; however middle- or large-sized animals are implanted with a bone graft substitute using pedicle screws or cages. Small animals are easy to handle due to their size, but have different anatomical or biomechanical reactions with the human body. Middle- or large-sized animals have characteristics like the human body, but they are difficult to handle or there is an ethical problem. The fusion status is evaluated by manual palpation, mechanical testing using Instron, and radiologic techniques such as computed tomography, micro-computed tomography or undecalcified histology. The fusion rate and duration required for successful fusion differ according to the species and anatomical site. We have identified and reviewed several typical animal models of spinal fusion.

The Effect of Zoledronic Acid on the Volume of the Fusion-Mass in Lumbar Spinal Fusion

박예수,김홍식,Seung-Wook Baek,Dong-Yi Kong,류정아 대한정형외과학회 2013 Clinics in Orthopedic Surgery Vol.5 No.4

Background: Few studies have explored the effects of bisphosphonates on bony healing in patients undergoing spinal fusion surgery. Most previous studies used animal models and found that bisphosphonate shows negative effects on spinal fusion consolidation. We intended to evaluate the effect of a single-dose of zoledronic acid on the volume of the fusion-mass in lumbar spinal fusion. Methods: A retrospective review was carried out on 44 patients with symptomatic degenerative lumbar spinal stenosis who underwent one or two-level posterolateral fusion from January 2008 and January 2011. They were divided into 4 groups: group 1, autograft and zoledronic acid; group 2, allograft and zoledronic acid; group 3, autograft alone; and group 4, allograft alone. Functional radiography and three-dimensional computed tomography scans were used to evaluate and quantify the volume of the fusion-mass. The visual analog scale (VAS), the Oswestry disability index (ODI), and the short form 36 (SF-36) were used to evaluate the clinical outcomes. Results: The mean volume of the fusion-mass per level was 8,814 mm3, 8,035 mm3, 8,383 mm3, and 7,550 mm3 in groups 1, 2, 3, and 4, respectively, but there were no significant differences between the groups (p = 0.829). There were no significant decreases in the volume of the fusion-mass (p = 0.533) in the zoledronic acid groups (groups 1 and 2). The VAS, the ODI, and the SF-36 at the 6-month follow-up after surgery were not significantly different (p > 0.05) among the 4 groups. The VAS, the ODI, and the SF-36 were not correlated with the volume of the fusion-mass (p = 0.120, 0.609, 0.642). Conclusions: A single dose of zoledronic acid does not decrease the volume of the fusion-mass in patients undergoing spinal fusion with osteoporosis. Therefore, we recommend that zoledronic acid may be used after spinal fusion in osteoporotic patients.

요추부 퇴행성 질환의 유합술 후 발생한 근위 인접 분절 질환- 한 분절 위와 두 분절 위에 발생한 경우의 비교 -

최성우,안중현,이재철,구형모,신병준 대한척추외과학회 2013 대한척추외과학회지 Vol.20 No.4

Study Design: Retrospective study. Objective: To compare patients who underwent spinal revision surgery of adjacent segment degeneration with above one and above two vertebral segment preceded by initial spinal fusion surgery. Summary of Literature Review: The adjacent segment disease(ASD) occurs more frequently at the more proximal segment of the spinal fusion. Also, the preexisting degenerative segments (with discs or facet joints) not included in the fusion procedure, fusion segmental sagittal angle, fixed appliances method, gender, and age, have been accepted as the causes. Materials and Methods: The patients were watched over a year after the spinal revision operation followed by initial spinal fusion of single or multiple segments; the subjects were limited to 41 patients. The average age, entity of diseases, average duration between the initial spinal fusion and the revision surgery, multiple clinical and radiographic parameters were evaluated and compared. Results: Using the UCLA grade of intervertebral disc degeneration, the average grade of 1 level upper segment was 2.2 in group A and 1.9in group B without statistical significance(p=0.426). However, the average grade of 2-level upper segment was 1.8 in group A and 2.4 in group B with significant difference(p=0.021). There was no statistical difference in other factors between the two groups. Conclusions: Patients with ASD of above two-vertebral segment after spinal fusion were more severe in disc degeneration than those with ASD of above one vertebral segment before initial spinal fusions. 연구 계획: 후향적 연구. 목적: 요추부 퇴행성 질환으로 시행한 요추 유합술 후 인접 분절 질환으로 인해 재수술을 시행했던 경우의 환자들을 대상으로 인접 분절 질환이 한 분절위와 두 분절 위에서 발생한 경우를 비교 하였다. 선행 문헌의 요약: 인접 분절 질환은 유합부의 근위일수록 잘 발생하고, 유합에 포함되지 않았던 분절에 존재하던 추간판 또는 후관절의 퇴행, 유합술후 요추 전만각과 유합 분절의 시상각, 기구 고정의 방법, 그리고 성별과 나이 등의 다양한 원인이 제기되고 있다. 대상 및 방법: 퇴행성 요추부 질환으로 한 분절 또는 두 분절에 유합술을 시행 받은 환자 중 인접 분절 질환이 발생하여 재수술을 시행한 41명을 대상으로, 한 분절 위에서 발생한 경우를 A군, 두 분절 위에서 발생한 경우를 B군으로 분류하였다. 각 군에 대하여 나이, 성별, 진단명, 내과적 동반 질환 등의기초 정보와 통증 지수, 방사선적 요소들을 측정하였고, 방사선적 요소들로는 요추부전만각, 유합부 시상각, 한 분절/두 분절 위의 추간판 퇴행, 후관절퇴행 등을 측정하여 비교하였다. 결과: 나이, 성별, 진단명, 요추부 전만각, 유합부 시상각, 유합 방법, 유합 분절, 후관절 퇴행 등은 두 군간에 통계적 유의성이 없었다.한 분절 위의 추간판의 퇴행은 A군 2.2, B군 1.9로 통계적 유의성은 없었으나(p=0.426), 두 분절 위의 추간판 퇴행은 A군 1.8, B군 2.4로 통계적으로 유의한 차이가 있었다(p=0.021). 결론: 요추부 유합술시 상위 인접 분절의 퇴행성 질환은 두 분절 위에서 발생한 경우 수술 전 이미 추간판 퇴행이 더 심하였던 경우가 많았다. 이는 인접분절 질환의 여러 요인 중에 기존의 퇴행이 가장 많은 영향을 주는 것으로 생각된다.

Activin A/BMP2 Chimera (AB204) Exhibits Better Spinal Bone Fusion Properties than rhBMP2

Ryu, Dalsung,Yoon, Byung-Hak,Oh, Chang-Hyun,Kim, Moon-Hang,Kim, Ji-Yong,Yoon, Seung Hwan,Choe, Senyon The Korean Neurosurgical Society 2018 Journal of Korean neurosurgical society Vol.61 No.6

Objective : To compare the spinal bone fusion properties of activin A/BMP2 chimera (AB204) with recombinant human bone morphogenetic protein (rhBMP2) using a rat posterolateral spinal fusion model. Methods : The study was designed to compare the effects and property at different dosages of AB204 and rhBMP2 on spinal bone fusion. Sixty-one male Sprague-Dawley rats underwent posterolateral lumbar spinal fusion using one of nine treatments during the study, that is, sham; osteon only; $3.0{\mu}g$, $6.0{\mu}g$, or $10.0{\mu}g$ of rhBMP2 with osteon; and $1.0{\mu}g$, $3.0{\mu}g$, $6.0{\mu}g$, or $10.0{\mu}g$ of AB204 with osteon. The effects and property on spinal bone fusion was calculated at 4 and 8 weeks after treatment using the scores of physical palpation, simple radiograph, micro-computed tomography, and immunohistochemistry. Results : Bone fusion scores were significantly higher for $10.0{\mu}g$ AB204 and $10.0{\mu}g$ rhBMP2 than for osteon only or $1.0{\mu}g$ AB204. AB204 exhibited more prolonged osteoblastic activity than rhBMP2. Bone fusion properties of AB204 were similar with the properties of rhBMP2 at doses of 6.0 and $10.0{\mu}g$, but, the properties of AB204 at doses of $3.0{\mu}g$ exhibited better than the properties of rhBMP2 at doses of $3.0{\mu}g$. Conclusion : AB204 chimeras could to be more potent for treating spinal bone fusion than rhBMP2 substitutes with increased osteoblastic activity for over a longer period.

Fixed and Variable Relationship Models to Define the Volume-Value Relationship in Spinal Fusion Surgery: A Macroeconomic Analysis Using Evidence-Based Thresholds

Sergio M. Navarro,William Case Frankel,Heather S. Haeberle,Prem N. Ramkumar 대한척추신경외과학회 2018 Neurospine Vol.15 No.3

Objective: Increased surgical volume has been associated with improved patient outcomes at the surgeon and hospital level. To date, clinically meaningful stratified volume benchmarks have yet to be defined for surgeons or hospitals in the context of spinal fusion surgery. The objective of this study was to establish evidence-based thresholds using outcomes and cost to stratify surgeons and hospitals performing spinal fusion surgery by volume. Methods: Using 155,788 patients undergoing spinal fusion surgery, we created and applied 4 models using stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve. This statistical approach was used to generate 4 sets of volume thresholds predictive of increased length of stay (LOS) and increased cost for surgeons and hospitals. Results: SSLR analysis of the 2 ROC curves by annual surgical volume produced 3 or 4 distinct volume categories. Analysis of LOS by annual surgeon spinal fusion volume produced 4 strata: low, medium, high, and very high. Analysis of LOS by annual hospital spinal fusion volume produced 3 strata: low, medium, and high. No relationship between volume and cost could be clearly defined based on the generation of ROC curves for surgeons or hospitals offering spinal fusion. Conclusion: This study used evidence-based thresholds to identify a direct, variable relationship model between volume and outcomes of spinal fusion surgery, using LOS as a surrogate, for both surgeons and hospitals. A fixed relationship model was identified between surgeon and hospital volume and cost, as no statistically meaningful relationship could be established.

사람 골 형성 단백질 Ex vivo 유전자 치료법을 이용한 척추 유합

김기범,김재룡,안면환,서재성 영남대학교 의과대학 2007 Yeungnam University Journal of Medicine Vol.24 No.2

AdBMP-2와 AdBMP-7을 형질도입 시킨 사람 섬유아세포와 사람 골수기질세포를 면역결핍 생쥐의 척추 옆 근육으로 주입하여 척추 유합을 유도한 결과, AdBMP-7/BMSC가 AdBMP-2/BMSC 또는 AdBMP-7/HuFb와 AdBMP-2/HuFb 보다 골 형성능이 우수하였으며, 척추 유합을 잘 유도하였음을 확인하였다. Purpose : Bone morphogenetic proteins (BMPs) play an important role in the formation of cartilage and bone, as well as regulating the growth of chondroblasts and osteoblasts. In this study, we investigated whether recombinant human BMP adenoviruses are available for ex vivo gene therauy, using human fibroblasts and human bone marrow stromal cells in an animal spinal fusion model. Materials and Methods : Human fibroblasts and human bone marrow stromal cells were transduced with recombinant BMP-2 adenovirus (AdBMP-2) or recombinant BMP-7 adenovirus (AdBMP-7), referred to as AdBMI-7/BMSC, AdBMP-2/BMSC, AdBMP-7/HuFb, and AdBMP-2/HuFb. We showed that each cell secreted active BMPs by alkaline phosphatase staining. Since AdBMP-2 or AdBMP-7 tranducing cells were injected into the paravertebral muscle of athymic nude mice, at 4 weeks and 7 weeks, we confirmed that new bone formation uccurred by induction of spinal fusion on radiographs and histochemical staining. Results : In the region where the AdBMP-7/BMSC was injected, new bone formation was observed in all cased and spinal fusion was induced in two of these. AdBMP-2/BMSC induced bone formation and spinal fusion occured among one of five. However, in the region where AdBMP/HuFb was injected, neither bone formation nor spinal fusion was observed. Conclusion : The osteoinductivity of AdBMP-7 was superior to that of AdBMP-2. In addition, The human bone marrow stromal cells were more efficient than the human fibroblasts for bone formation and spinal fusion. Therefore, the results of this study suggest that AdBMP-7/BMSC would be the most useful approach to ex vivo gene therapy for an animal spinal fusion model.

Fusion Rates of Instrumented Lumbar Spinal Arthrodesis according to Surgical Approach: A Systematic Review of Randomized Trials

Choon Sung Lee,Chang Ju Hwang,Dong-Ho Lee,Yung-Tae Kim,Hee Sang Lee 대한정형외과학회 2011 Clinics in Orthopedic Surgery Vol.3 No.1

Background: Lumbar spine fusion rates can vary according to the surgical technique. Although many studies on spinal fusionhave been conducted and reported, the heterogeneity of the study designs and data handling make it diffi cult to identify whichapproach yields the highest fusion rate. This paper reviews studies that compared the lumbosacral fusion rates achieved with differentsurgical techniques. Methods: Relevant randomized trials comparing the fusion rates of different surgical approaches for instrumented lumbosacralspinal fusion surgery were identifi ed through highly sensitive and targeted keyword search strategies. A methodological qualityassessment was performed according to the checklist suggested by the Cochrane Collaboration Back Review Group. Qualitativeanalysis was performed. Results: A literature search identifi ed six randomized controlled trials (RCTs) comparing the fusion rates of different surgical approaches. One trial compared anterior lumbar interbody fusion (ALIF) plus adjunctive posterior transpedicular instrumentation withcircumferential fusion and posterolateral fusion (PLF) with posterior lumbar interbody fusion (PLIF). Three studies compared PLFwith circumferential fusion. One study compared three fusion approaches: PLF, PLIF and circumferential fusion. Conclusions: One low quality RCT reported no difference in fusion rate between ALIF with posterior transpedicular instrumentationand circumferential fusion, and PLIF and circumferential fusion. There is moderate evidence suggesting no difference in fusionrate between PLF and PLIF. The evidence on the fusion rate of circumferential fusion compared to PLF from qualitative analysiswas confl icting. However, no general conclusion could be made due to the scarcity of data, heterogeneity of the trials included,and some methodological defects of the six studies reviewed.