골다공증성 척추 골절 환자의 수술적 치료 시 고려 사항: 외과적 적응증, 접근 방법, 고정 방법, 이식 재료의 선택 = Considerations for Surgical Treatment of Osteoporotic Spinal Fracture: Surgical Indication, Approach, Fixation, and Graft Material

다국어 초록 (Multilingual Abstract)

Study Design: A review of the literature.
Objectives: To review the current evidence on the development of a viable surgical strategy for successful treatment of patients with osteoporotic vertebral fractures.
Summary of Literature Review: Achieving rigid and stable spinal column reconstruction in elderly patients with osteoporosis is challenging because of the poor healing capacity and weak mechanical strength of their bones.
Materials and Methods: A literature search of clinical and biomechanical studies on the issues of surgical treatment of patients with osteoporotic vertebral collapse was performed and reviewed in terms of the surgical approach, fixation, graft material, and medical considerations. Illustrative cases of the authors’ experiences were presented and reflected upon.
Results: Posterior spinal fusion and vertebral augmentation showed shorter operating times, less bleeding, and fewer complications with comparable or superior clinical results than anterior corpectomy and fusion or a posterior closing wedge vertebral shortening procedure in multiple studies. Therefore, we recommend the former as a first-line surgical plan for patients with osteoporotic vertebral collapse. However, in some patients who suffer fixed kyphosis, or spinal cord compression by a retropulsed bony fragment or bone cement, or infected vertebroplasty, an anterior approach could be considered to remove the pertinent lesion and to restore anterior spinal column. For the enhancement of the purchasing strength of the screw in the osteoporotic vertebra (e), a technique of prefilled bone cement in the instrumented vertebra(e) or injection of bone cement through a fenestrated screw is useful. Further, preoperative assessment and correction of systemic and local factors that affect bone healing is required when spinal fusion surgery is considered in elderly osteoporotic patients. The selection of the graft material should be individualized according to the property among osteoconduction, osteoinduction, and ostegenesis, or structural support that is the most important for the successful bone healing of each patient.
Conclusions: Comprehensive geriatric assessment and management of elderly patients before surgery and careful and meticulous surgical planning with respect to the surgical approach, instrumentation, and the graft material are important to achieve the best outcome of the surgical treatment of patients with osteoporotic vertebral collapse.

국문 초록 (Abstract)

연구 계획: 종설.
목적: 본 연구에서는 골다공증성 척추 골절 환자에서 성공적인 수술적 치료를 위해 외과적 접근법, 기기 고정술, 이식 재료 선택 등에 있어 어떤 고려가 필요한지 살펴보겠다.
선행 문헌의 요약: 고령 환자에서 골다공증과 관련된 척추의 골절에 대한 수술적 치료는, 뼈의 기계적·물리적 강도가 약하고, 골 유합 능력이 저하되어 있어튼튼한 고정과 성공적인 골 유합을 얻는데 실패하는 경우가 많다.
대상 및 방법: 골다공성 척추 골절 이후 수술적 치료를 시행할 경우 고려해야 할 내과적, 일반적 사항 및 외과적 접근법, 기기고정술, 이식 재료의 선택에 관한연구 결과를 보고한 문헌을 검색하여 최신 지견을 정리하고 저자들의 경험에 비추어 고찰한다.
결과: 후방접근수술과 척추성형술을 함께 시행할 경우 할 경우 합병증 및 수술시간, 출혈량 등에 있어 장점이 있고, 많은 척추 외과의사에게 훨씬 익숙한 술식이라는 점에서 불유합된 골다공증성 척추 골절에서 수술적 치료를 요할 때 가장 일차적으로 고려할 만한 술식으로 권할 만 하다. 후만 변형이 복와위 체위에의해 교정되는 정도가 크지 않고, 척수를 압박하는 골편이나 시멘트가 있거나 감염된 시멘트 등 병소를 직접 제거해야 하는 경우 전방접근법을 고려할 수 있다. 골다공증성 척추의 나사못 고정술 시행 시 충분한 고정력을 얻을 수 없는 경우 시멘트 충전 이후 나사못 삽입방법을 이용할 수 있다. 아울러 고령 환자의생물학적 내과적 특성을 고려하여 영양상태 등 골유합에 영향을 미칠 수 있는 생물학적 변수들을 가능한 최적의 조건으로 맞추기 위한 노력이 필요하다.
결론: 고령의 골다공증성 척추 골절 환자의 수술적 치료 시, 포괄적 노인의학적 평가를 통하여 수술적 치료의 득과 실을 면밀히 살피고, 다양한 수술 방법과이식물의 장단점을 따져서 최선의 외과적 접근법, 기기고정술, 이식재료 등을 선택 하는 것이 성공적인 치료를 위하여 중요하다.

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