kyphoplasty 2014 정형외과 개원의 연수강좌
DESCRIPTION
Kyphoplasty, 척추후궁복원술TRANSCRIPT
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Kyphoplasty경피적 척추후굴풍선복원술
서울나은병원 원장 남기세
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Kyphoplasty Procedure
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Questions
Which procedure is best ?- Conservative, - Open ?- Vertebroplasty, - Kyphoplasty
심평원 심사기준- 기준에 따라서 치료 ?- 삭감되더라도 의학적 판단에 따라서 ?
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Age 50 Age 75
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Vertebral Body Compres-sion Fracture (VCF)
Normal Fractured
Wedge-shaped
Depressed endplate(s)
Spine shorter, tilted for-ward
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VCP Problem
사망률 : 100 명중 3 명 1 년 내 1 개 골절 : 정상에 가까움 2 개 이상 ( 여러 개 ) 골절 : 허리 통증 , 소화
불량 , 옆구리 통증 , 일상 생활이 어려움 , 꼬부랑 할머니
사회 활동 제약 , 자존심 상실 , 집안에서만 생활 재 골절의 위험도 : 5 – 10 배
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Expected and Observed Survival Rates after Vertebral, Hip Fracture
Cooper, et al., Am J Epidemiology, Vol 137, No. 9, 1993, 1001-1005
0%
20%
40%
60%
80%
100%
0 1 2 3 4 5
ExpectedObserved
0%
20%
40%
60%
80%
100%
0 1 2 3 4 5
ExpectedObserved
% S
urvi
val
Years After Fracture
Vertebral Hip
Expected
Observed
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Which procedure is best ?
Conservative Open ? Vertebroplasty Kyphoplasty
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Conventional management
Medical: rest, medication, braces- palliative care only
Shortcomings- rest actually increases bone loss- doesn’t provide long term functional improvement
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Open Surgical Treatment
Surgical- only if neurologic deficit - but this is rare- instrumented anterior or posterior
Shortcomings- invasive -generally an elderly popula-tion and they may not tolerate invasive procedure- Outcomes poor due to quality of bone
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Vertebroplasty, Kyphoplasty
Vertebroplasty, 1987 년 Galibert
Kyphoplasty, 1997 년 Reiley 에 의해 개발2001 년 Lieberman 에 의해보고
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Vertebroplasty
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Vertebroplasty
Designed to stabilize painful VCFs Shortcomings
- Risk of filler leaks- Uncontrolled fill- Freezes spinal deformity, Does not re-duce fracture
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Kyphoplasty
Restoration of anatomy 1
Early diagnosis and treatment for op-timal outcomes 2
Special care for geriatric patients
1 Colton, “The History of Fracture Treatment,” Skeletal Trauma, Ch. 1, Vol. 1, Pg. 25, ©1998 W.B. Saunders Company
2 Brakoniecki, “Anesthetic Management of the Trauma Patient with Skeletal Injuries,” Skeletal Trauma, Ch. 7, Vol. 1, Pg. 171-172, ©1998 W.B. Saunders Company
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Kyphoplasty
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(ClinicalTrials.gov number, NCT00068822)
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(Australian New Zealand Clinical Trials)
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To the editor
both trials, which included patients with a duration of pain of up to 12 months
- Internal fixation of healed fractures is clearly inappropriate.
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To the editor
Kallmes, - the protocol mandated 4 weeks of medical therapy before enrollment- difference in crossover rates between the treatment and control groups (12% vs. 43%) in the study. This difference suggests patient
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To the editor
Buchbinder et al., - the number of patients with pain for less than 6 weeks was far too small for a subgroup analysis.- The rates of eligible patients who de-clined to par participate were 64% in the trial reported
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Particular situations (VP > Conservative)
Very elderly patients suffering from both OVCFs in the thoracic spines and chronic lung diseases
Female gender, Back muscle fatigue or pain may be
more severe in patients with greater wedge angles than those with smaller wedge angles
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심평원 심사기준
기준에 따라서 치료 ?
삭감되더라도 의학적 판단에 따라서 ?
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개원의 ? 심사평가원 ? 남기세
서울나은병원 원장- 개업의 . 삭감에 매우 예민- 삭감률 : 서울지원에 제일 높음 ?
심평원 서울지원 척추분과 비상근위원- 마구잡이 시술은 조정해야 하는데 .
나는 골다공증성 척추압박골절 환자 치료를 어떻게 하지 ?
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Question
시골에서 올라온 4 주전에 주저 앉으면서 발생한 허리통증을 호소하는 79 세 할머니
동네의원에서 단순방사선 촬영으로 지방에서 단순요부 염좌 진단 , 약 , 물리치료
한의원 : 침치료 전문병원 : MRI 촬영결과 흉요추부 골다공증성
압박골절 신경성형술 , 인대강화술 치료 압박률 : 27%
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Answer
Kyphoplasty 시행 소견서 작성 ,
- 골절 유사진단 4 주전 , - 전문병원 비급여 시술한것 기술 ,- 가능한 서서 30 분 있고 , 방사선 촬영시 최대한 굴곡하여 30 도 각도를 측정
그래도 삭감 . 보존적 치료결과를 전산자료상 확인할 수가 없어서 .
심판청구 준비 -> 결국은 기준을 고쳐야…
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현재 상황
척추골 성형술 + 술후 MRI 검사 척추골 성형술 + FIMS 척추골 성형술 + 프롤로 치료 척추골 성형술 + 신경성형술 (Neurolysis)
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제안하는 기준
압박변형이 30-60% 이거나 , 나중에 후만변형이 30% 이상 발생될것으로 추정될 경우 ?
적극적인 보존적 치료에 시작지점은 객관적인 진단이 없더라도 의사의 골절 진단이라면 인정 ,
보존적 치료를 받지 못해도 진단이후 3 주면 척추골 성형술 인정 ?
환자가 3 주간의 보존적 치료를 원하지 않으면 즉시 시술 가능
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unenhanced area of VCF is a reliable sign predicting a solid distribution of the injected cement
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합병증
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감사합니다