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1 척추부지주막낭종 : Pars 절골술과 Recapping 추궁판성형술을통한수술적치료 - 5 례보고 - 대한척추외과학회지제 16 권제 3 호 Journal of Korean Spine Surgery Vol. 16, No. 3, pp 215~221, 2009 DOI: /jkss 박원욱 안성준 # 구자경 송무호 # 유성호 # 강석웅 # 부산고려병원척추센터, 부산대동병원정형외과학교실 # Spinal Arachnoid Cyst: Treated with Pars Osteotomy and Recapping Laminoplasty - Report of 5 Cases - Weon Wook Park, M.D., Seong Jun Ahn, M.D. #, Ja Gyung Ku, M.D., Moo Ho Song M.D. #, Seong Ho Yoo M.D. #, Suk Woong Kang M.D. # Spine Center, Korea Hospital, Pusan, Korea Department of Orthopaedic Surgery, Daedong Hospital, Pusan, Korea # Abstract Spinal arachnoid cysts are a rare disease with an unknown origin. Because of their broad base, a total laminectomy with or without fusion has been the treatment of the choice. We encountered 5 patients with a spinal arachnoid cyst who were treated by recapping laminoplasty after pars osteotomy. This procedure has not been reported in Korea. All patients showed neurological recovery with no recurrence of the cyst. The findings on the stressed plain film confirmed bony union and stability of the posterior element. No complications such as postoperative spinal canal stenosis, facet arthrosis or kyphosis were observed. Among the various surgical options for the extirpation of arachnoid cysts, recapping laminoplasty appears to be a good but technically demanding procedure. Key words: Arachnoid cyst, Pars osteotomy, Recapping laminoplasty. 척추부지주막낭종은척수를압박하여척수증을유발하는드문질환이다. 일반적으로알려진 Tarlov 낭종은천추부에호발하고증상이거의없는경우가많으나척추부지주막낭종은척추어느부위에나발생할수있으 며주로흉추부에서가장흔하게발견되고 1,2) 남자에게더흔하며주로 30대이전에발견된다 1,3). 낭종의발생원인을일부저자들은선천적인경막의작은결손이원인이라고주장하고다른저자들은선천적결손과함께염 Address reprint requests to Seong Jun Ahn, M.D. Department of Orthopaedic Surgery, Daedong Hospital, Myungyun 1-Dong, Dongrae-Gu, Pusan, Korea Tel : , Fax : , Received: Accepted:

2 대한척추외과학회지 Vol. 16, No. 3, 2009 증, 외상, 특발성원인등을주장하나질환의희귀성으로인하여아직명확하게밝혀지지는않았다. 대부분의척추부지주막낭종은증상을유발하지않으나낭종이점차커져서척수를압박하는환자들은그에따른증상을나타낸다. 이러한환자에서명확한치료는낭종을완전히제거하는것이다 4,5,6). 대부분의저자들은척추부지주막낭종의제거를위하여추궁판절제술을시행하였고 Doita 등 7) 은 recapping 추궁판성형술을이용하였다. 저자들은 pars 절골술과 recapping 추궁판성형술로치료한척추부지주막낭종 5 례의치험을국내보고가아직없기에보고하고자한다. 증례보고 2002 년에서 2005 년사이에수술적치료를시행한 5 례의척추부지주막낭종환자에대해고찰하였다. 1 례에서경미한외상의기왕력이외에나머지모두에서요추부천자를비롯한척추에침습적시술을받은병력은없었고다른외상이나감염등의증거는없었다. 5 례모두에서낭종의위치는척추관내에서후방혹은후외방에위치하였다. Nabor 분류 (Table 1) 에의하면 1 형이 3 례, 3 형이 2 례였다. 성별은남자가 1 례 (38 세 ) 와여자가 4 례이었으며 (43, 44, 57, 68 세 ) 로평균연령은 50 세였다 (Tabel 2). 증상의이환기간은 15 일에서 2 년이었으며평균추시관찰기간은 1 년에서 5 년사이로평균 31 개월이었다. 낭종의형성부위는흉요추부 3 례였고 2 례에서요추부였으며이환범위는평균 4.4 추체였다. 환자의주소는흉요추부낭종환자의경우척수증에따른증상이었고요추부낭종 Table 1. Nabor classification (1994) Type I Type II Type III cysts do not contain nerve fibers (extradural) cysts do not contain nerve fibers (extradural) intradural arachnoid cysts Table 2. Summary of the cases of the spinal arachnoid cyst 의경우하지방사통, 위약감, 이상감각등이었다. 내원당시시행한단순방사선사진에서는 5 례모두에서특별한이상을발견하지는못하였다. 자기공명영상검사에서경계가명확한얇은막을가진낭종은뇌척수액 (Cerebrospinal fluid) 와거의같은신호강도의수액을함유하였다. 그러나, 수술전자기공명영상에서경막의결손부위확진은어려웠다.(Fig. 1A, 2A). 5 례모두에서 recapping 추궁판성형술을이용한낭종의절제술 (radical resection) 을시행하였다. recapping 추궁판성형술은흉추부에서는협부부위를 Gigli saw 혹은절골도 (osteotome) 로절골술을시행한뒤관절낭을절개하여추궁판, 극돌기및하방관절돌기를거상하여척추관내의신경조직을노출시키고요추부에서는관절낭을절개하지않고추궁판의후관절가까이에서절골술을하여추궁판및극돌기를거상하여요추부경막을노출시키는방법이다. 추궁판성형술을위한절골술의시행을위하여저자들은척추부의후방접근법시행후 1 mm Kerrison punch 와절골도를이용하여추궁판협부부위를절단하였다. 극상및극간인대 (supra and interspinous ligaments) 는손상을받지않고보존될수있도록하였으며 2 례에서절골술을시행한제일아래부위의극상및극간인대도제거하지않고보존하여후방구조물을재위치시킬때좀더안정성을가질수있도록하였다 (Fig. 1B, 2B). 낭종을완전제거하고경막과낭종사이의연결을확인한후연결부위를폐쇄하였다. 연결부위가발견되지않는경우에는패쇄하지않았으며낭종이신경공을통해척추관외측으로연결된경우에는신경공부위까지만낭종을절제하였다. 낭종의제거후후방구조물을원래의해부학적위치에재위치시켰다. 재위치시킨후방구조물의고정을위하여절골술을시행한최상부와최하부의극돌기사이와절골술을시행하였던협부부위에금속강선혹은비흡수사를이용한고정을시행하였고 1 례에서는 pars screw 를이용한고정을추가하였다 (Fig. 1C). 절골술부위에는 Kerrison punch 로제거하였던골을이용한골이식을시행하였고후관절은봉합사로복원하였다. 각각 4 개에서 6 개의추궁판이 5 례의환자에서거상되 patient case Age sex Nabor classification lesion Symtom Treatment 1 38 M I T9-L1 myelopathy recapping laminoplasty, wire fixation 2 57 F I T12-L3 radiculopothy, lower leg weakness recapping laminoplasty, wire fixation 3 43 F III L2-L5 radiculopothy, lower leg weakness recapping laminoplasty, pars screw fixation 4 44 F I T9-L2 myelopathy recapping laminoplasty, wire fixation 5 68 F III L3-L5 Racliculopothy lower leg weakness recapping laminoplasty, wire fixation

3 Recapping 추궁판성형술 -5 례보고 - 박원욱외 Fig. 1. (A) Preoperative MRI and plain X-ray shows type III arachoid cyst from L2 to L5 in the 43-year-old female patient. (B) Intraoperative photograph. we try to remain distal supraspinous ligament attached distal part and complete removal of cyst 9cm in length. (C) Postoperative-6-month X-ray shows good union of pars after recapping and interosseous wiring and pars fixation using screw

4 대한척추외과학회지 Vol. 16, No. 3, 2009 었다. 모든수술에서충분한시야를확보할수있었으며경막손상이나골절등의합병증은발생하지않았다. 수술시간은평균 5.5 시간이소요되었고실혈량은무시할수있을정도로적어서수혈이필요한경우는없었다. 수술후혈종의형성으로인한일시적인근력저하를보인환자가 1 례있었으나혈종제거후완전한신경학적회복을보였으며나머지 4 례에서는수술후완전한신경학적회복을보였고술전에있었던신경학적증상역시소실되었다. 술후 3 일까지흡입배액관을이용한배액을시행하였고배액관제거후 TLSO 보조기착용후보행을시행하였다. 보조기의착용은환자의증상과골유합정도에따라서 2 개월에서 4 개월사이의기간동안시행하였다. 외래추시관찰시술후자기공명영상촬영을통하여낭종의재발여부를판단하였고 (Fig. 2C), 추시관찰기간동안낭종의재발이나합병증의발현은관찰되지않았다. 수술부위의굴곡신전단순방사선과전후방및측면단순방사선사진을촬영하여수술부의안정성과골유합을평가하였으며 3 례에서술후 3 개월에골유합을보였고 2 례에서술후 4 개월에골유합소견을보였다. 최종추시관찰시시행한측면굴곡신전단순방사선사진상 5 례모두에서후방구조물의안전성을확인할수있었고절골부위골흡수나붕괴, 재위치된추궁판절골면의경화상과같은무혈성괴사소견은보이지않았다 (Fig. 2D). 절골도에의해절골후재위치된추궁판의절골면은약간의갭이있었지만성공적인유합이가 Fig. 2. (A) Preoperative MRI shows type I arachnoid cyst from T9 to L2 in the 44-year-old female patient. (B) Intraoperative photograph shows remaing distal supraspinous ligament and wire fixation. (C) Postoperative MRI and X-ray shows complete removal of cyst. (D) Postoperative 3 year after recapping laminoplasty shows complete union at the osteotmy levels and shows no instability

5 Recapping 추궁판성형술 -5 례보고 - 박원욱외 능하였고절골부위의가골의과형성으로인한척추관협착이발생한경우는없었다. 고 찰 척추부지주막낭종은확장성병변으로척수를압박하여증상을유발하는드문질환이다. 흉추부에서호발하며, 30 세이하 10 대에서, 주로남성에서호발하며, 소아에비해성인에서 2 배정도호발하고소아에서발견되는경우는척수수막류, 척수이분증이나잠재이분척추와같은다른선천성척추이상이동반되는경우가많다 2). 본연구에서는오히려여성에서호발하였고, 중년나이에서발견되었으며신경관결손과같은선천성기형은동반되지않았다. 낭종은경막내부와외부에생길수있으며대부분이흉추에서발견되며, 주로척수의후외측에위치하나, 경추부에발생하는경우는척수의전방에서호발한다. 정확한발병기전과원인은아직확실하게밝혀진바가없으며논란의대상이되고있다. 일부저자들은경막외지주막낭종의경우선천성, 특발성, 유전성, 염증혹은외상으로인한발생등을원인으로생각하고있으나저자들의증례에서는 1 례의경미한외상의과거력외에 4 례에서는과거력상염증이나외상의병력은없었으며또한가족력상에서도특별한점을발견할수없었다. 이에저자들은 Cloward 나 Hatashita 등 8,9) 의주장처럼경막외낭종의발생은선천적인경막의결손부를통하여지주막의탈출로인하여발생한다고추측하였다. 실제로저자들의증례중 3 례에서수술중경막의결손부를발견할수있었고수술중에결손부의복원을시행하였다. 이러한경막의결손부위가밸브로작용하여뇌척 수액의순환을방해하고낭종내고삼투압에의해낭종이커지나, 대부분무증상으로지내다우연히발견되는경우가많다. 증상은대부분은무증상이나척수와신경근의압박정도에따라다양하다. 점진적인이완성, 혹은강직성마비가올수있고, 호전과악화를반복하며허리를신전하거나기침만해도악화되기도한다 3). 병력또한다양하여급성으로통증이나신경학적증상이발현할수있으며점진적인신경학적결손을보이기도한다. 특정자세에서밸브를통해뇌척수액의교통이되면환자의증상이호전되기도하지만낭종의크기가큰경우는자세에따른호전을기대할수없고수술적치료를요하게된다. 단순방사선소견상척추경간거리가증가한경우가있지만정확한진단을위해자기공명영상촬영이유용하다 3). 자기공명영상소견상에낭종내뇌척수액과동일한신호를보이는소견과, 격막을가진다발성낭종이보일수있으며역동학적영상에서낭종과경막외교통상태를알수있다 7). 치료는낭종내수액의흡인술은일시적인증상의호전을기대할수있을뿐이며, 낭종의외벽을절제한후주위조직과봉합하여폐쇄된낭종을열어두는술식인 marsupialization, 낭종막의부분혹은완전절제술등다양하게보고되었으나, 낭종의완전절제술후경막의결손부위를봉합하는것이치료의근간이다. 수술할경우경막의결손부위를봉합하지못하면재발하고재수술을요하게되는경우도있다. 일반적으로척추관내종양의제거를위해여러분절의척추관내병변을노출시키는방법은추궁판성형술외의다른수술방법은추궁판절제술이고식적으로시행되어왔다. 하지만낭종의완전절제를위해여러분절의추궁판을절제하는경우에는추궁판의소실, 불안정성, 지연성후만증이나후관절의아탈구등을초래할 Fig. 3. Schematic diagram of recapping laminoplasty

6 대한척추외과학회지 Vol. 16, No. 3, 2009 수있고, 많은출혈, 술후혈종에의한신경압박, 수술시간연장등의많은단점이있다. 추궁판절제술후생성된섬유막반흔이경막이나신경근과유착되거나, 나이가들어감에따라두꺼워지면서척주의안정성에기여할수도있는반면에척추관협착을유발할수있다. 또한척추후방주의보존은척추의생역학적안정성을유지하는데중요하므로기술적으로가능하다면보존하는것이좋다 년 Kondo 와 Yamada 는요추추간판탈출증의수술에서절골도를이용한감압술후추궁판의재건을보고한이후추궁판을보존하기위하여다양한추궁판성형술이보고되었다 년 Shimamua 등은척수종양의수술에서정중시상면분리추궁판성형술을보고하였고, 1999 년 Kawahara 등 10) 은 T-saw 를사용하여척수강내종양절제후척추후궁을원위치에복원하는 recapping 추궁판성형술을소개하였고술후과도한가골형성에의한척추관협착증이나불유합, 추궁판의무혈성괴사없이양호한임상결과를보고하였다. 흉추부절골술시지금까지 T-saw 나 Gigli saw 를사용하는방법이있었으나협부하방으로 saw 를통과시킬때신경근이손상될수있는단점이있었기때문에저자는절골도를주로사용하였다. 그러나절골도도잘못사용하면신경근, 경막혹은척수까지손상될수있기때문에세심한주의가필요하다. 이때제거되는골양은다시재위치시킬때무시해도될정도의양으로안정성에는영향이없었다. 경막외낭종의제거를위한수술시선택할수있는방법중에서 recapping 추궁판성형술은매우안전하고우수한결과를얻을수있는방법으로생각된다. Recapping 추궁판성형술은낭종의제거에매우효과적이며안전성을손상시키지않으며수술중수혈이필요하지않으며, 추궁판절제술보다덜침습적이다. 그러나, 황색인대골화증이나, 경막유착이있는환자에서시행하기어려우며이술식을시행할외과의는절골도의사용시신경손상의위험이있으므로숙련된기술이요구되 는단점이있다. 참고문헌 01) Dastur HM: The radiological appearances of spinal extradural arachnoid cysts. J Neurol Neurosurg Psychiarty 1963; 26: ) Rabb CH, McComb JG, Raffel C, Kennedy JG: Spinal arachnoid cysts in the pediatric age group: an association with neural tube defects. J Neurosurg 1992; 77: ) Rimmelin A, Clouet PL, Salatino S, et al.: Imaging of thoracic and lumbar spinal extradural arachnoid cysts: report of two cases. Neuroradiology 1997; 39: ) Kulkarin AG, Goel A, Thiruppathy SP, Desai K: Extradural arachnoid cysts: a study of seven cases. British Journal of Neurology 2004; 18: ) Krings T, Lukas R, Reul J, et al.: Diagnostic and Therapeutic management of spinal arachnoid cysts. Acta Neurochir 2001; 143: ) Choi JY, Kim SH, Lee WS, Sung KH: Spinal extradural arachnoid cyst. Acta Neurochir, 2006; 148: ) Doita M, Nishida K, Miura J, Takada T, Kurosaka M, Fujii M: Kinematic magnetic resonance imaging of a thoracic spinal extradural arachnoid cyst: an alternative suggestion for exacerbation of symptoms during straining. Spine 2003; 28: ) Cloward RB: Congenital spinal extradural cyst: case report with review of literiture. Ann Surg 1968; 168: ) Hatashita S, Kondo A, Shimizu T, Kurosu A, Ueno H: Spinal extradural arachnoid cyst. Case report. Neurol Med Chir (Tokyo) 2001; 41: ) Kawahara N, Tomita K, Shinya Y, et al.: Recapping T- saw laminoplasty for spinal cord tumors. 1999; 24:

7 Recapping 추궁판성형술 -5 례보고 - 박원욱외 국문초록 척추부지주막낭종은매우드물며그원인은잘알려져있지않다. 치료의근간은병변부위추궁판절제술후경우에따라유합술을병행할수있다. 저자들은 5례의척추부지주막낭종의치험에서낭종침범부위의 pars 절골술과 recapping 추궁판성형술후골간금속강선고정과추궁판나사고정을시행하였고모든증례에서신경학적증상은호전되었고최종추시상낭종의재발은없었다. 단순방사선소견상에서불유합으로인한불안정성은관찰되지않았고, 수술후척추관협착증, 후관절증, 후만증과같은합병증도없었다. 척추부지주막낭종의다양한수술방법중 pars 절골술과 recapping 추궁판성형술은후방구조물을복원함에있어의미있는술식으로사료되나기술적으로어려움을요한다. 색인단어 : 지주막낭종, pars 절골술, recapping 추궁판성형술 통신저자 : 안성준부산광역시동래구명륜1동 대동병원정형외과 Tel: Fax:

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