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1 Case Report J Korean Geriatr Soc 2009;13(2): 흉추부척추압박골절의지연된속발성압박골절 건국대학교의학전문대학원재활의학교실 김보람 이인식 고성은 김세원 김승범 김선유 Delayed Subsequent Refracture of a Thoracolumbar Vertebral Compression Fracture Bo Ram Kim, MD, In-Sik Lee, MD, Seong-Eun Koh, MD, Se-Won Kim, MD, Seung Beom Kim, MD, Seon Yu Kim, MD Department of Rehabilitation Medicine, Konkuk University Medical Center and School of Medicine, Seoul, Korea Most patients experiencing an osteoporotic vertebral compression fracture remain asymptomatic or minimally symptomatic. However, a notable number of these patients do experience significant pain at some time resulting in disability and decreased quality of life. A 77-year-old man was admitted to a hospital with severe thoracolumbar pain and functional disabilities even though, 12 months ago, he had received inpatient treatment for 6 months in another hospital with the diagnosis of T12 vertebral compression fracture. Although initial outside spine MRI revealed a stable T12 com pression fracture with a 27.6% compression rate, delayed subsequent re-fracture of the same vertebrae was found on simple X-ray and thoracolumbar CT scan with an 86.5% compression rate and retropulsion to the central spinal canal. He continued to have severe spinal pain and functional disabilities in spite of undergoing a first anterolateral fusion one year ago and a subsequent posterior fusion. We emphasize a proper clinical and radiologic examination at one-year follow-up after successful conservative treatment of vertebral compression fractures. Key Words: Compression fractures, Thoracolumbar, Subsequent refracture 서 론 척추압박골절은골다공증성골절의가장흔한형태중하나이다 1). 대부분의척추압박골절은궁극적으로무증상혹은최소한의잔여증상을남기게되지만, 많은수에서상당한통증을느끼면서일상생활의저해와장애를겪게 Received: Jun 5, 2009 Revised: Jun 11, 2009 Accepted: Jun 24, 2009 Address for correspondence: In-Sik Lee, MD, PhD Department of Rehabilitation, Konkuk University Medical Center, 4-12, Hwayang-dong Gwangjin-gu, Seoul , Korea Tel: , Fax: mdlis@nate.com 된다. 이들에대한전통적인보존적치료로는침상안정, 진통제투약, 보조기처방, 물리치료등을들수있으며 2,3), 1984년프랑스의 Galibert와 Deramond에의해악성혈관종에대한경피적척추성형술이소개되면서척추성형술 (vertebroplasty) 및후만성형술 (kyphoplasty) 이라는 2가지의최소침습적척추중재적치료법이전통적인보존적치료법에반응하지않는압박골절에대한새로운치료적방법으로최근들어널리사용되고있다 4,5). 기존의보존적치료와경피적척추성형술간의치료경과에대한비교연구들에서경피적척추성형술을시행했을경우빠른통증경감과더불어일상생활로의복귀를도와줄수있다는점이가장큰장점으로부각되고있다 6-9). 그러나경피적척추성형 J Korean Geriatr Soc 13(2) June

김보람외 : 흉추부척추압박골절의지연된속발성압박골절 술이후인접한척추의골절발생률이증가할수있어보존적치료를시행하는경우가아직까지많은것으로보고되고있으며 10), 우리나라의경우건강보험규정상만 80세이하에서는압박골절후 2주가지나야척추성형술이보험급여로인정되기때문에보존적치료는아직까지도가장널리사용되고있는실정이다.

2 김보람외 : 흉추부척추압박골절의지연된속발성압박골절 술이후인접한척추의골절발생률이증가할수있어보존적치료를시행하는경우가아직까지많은것으로보고되고있으며 10), 우리나라의경우건강보험규정상만 80세이하에서는압박골절후 2주가지나야척추성형술이보험급여로인정되기때문에보존적치료는아직까지도가장널리사용되고있는실정이다. 골다공증성척추압박골절은여성에서더흔하게발생하는것으로알려져있으며, 남성은 75세이상에서골다공증이발생하면서척추압박골절의위험도가증가할수있으나, 75세이하의남성에게서골다공증성척추압박골절이발생할경우, 종양이나내분비계이상유무를확인하라고권고되고있다 1). 또한, 척추압박골절후의합병증으로점진적인후만변형, 추가혹은속발성골절, 그리고신경학적이상등을들수있으나, 이들의발병률에대한정확한문헌보고는없는실정이다. 이에본저자들은보행자교통사고로인한낙상에준하는충격에의해발생한골다공증성척추압박골절환자에서보존적치료를시행한후 18개월이지난시점에서속발성재골절이발견되어뒤늦게수술적치료를받은환자 1 예를보고하고자한다. 증례 평소일상생활동작에문제가없던 78 세남자환자가본 원내원 18개월전발생한보행자교통사고로낙상을한후발생한흉요추부통증을주호소로타병원에서단순영상촬영및흉요추부자기공명영상촬영등의검사후에제 12번흉추부안정성압박골절로진단받은후입원하여 6 개월간침상안정, 약물치료및보조기착용, 그리고물리치료등의보존적치료를받고퇴원하여집에서지내던중점점악화되는흉요추부통증으로인해본원재활의학과외래로내원하였다. 본원내원당시에는사고후 18개월이지난시점임에도불구하고, 환자는의자차보행상태였으며, 스스로앉기및스스로서기가겨우가능할정도로심한흉요추부통증을호소하였으며, 보행도심한흉추부후만자세로 5m 정도만스스로가능한정도였다. 환자는과거력상전립선비대증으로약물복용중이었으나, 뚜렷한외상력, 악성종양, 고혈압및당뇨병등의병력은없었으며, 요통으로치료를받은병력도없었다. 흡연및음주는모두하지않는상태였다. 이학적검진상흉요추부의심한골성압통이존재하였으나, 도수근력검사상상-하지모두정상으로측정되었으며, 감각이상을호소하지는않았고심부건반사도정상소견이었다. 배변장애는동반되지않았으나, 배뇨곤란을호소하고있었다. 외부병원에서수상당시촬영한흉요추부척추자기공명영상소견상, 제12 흉추척추체의 27.6% 압박률을보이는급성안정성압박골절의소견을확인할수있었다 (Fig. 1). 병력청취및이학적검진상, 속발성재발성압박골절혹은인근부위의새 Fig. 1. Initial outside thoracolumbar spine MRI shows acute T12 ver- tebral compression fracture with a 27.6% compression rate and wit- hout central canal compromise. T2 weighted sagittal image (A) and T2 weighted axial image (B). 102 J Korean Geriatr Soc 13(2) June 2009

$Bo Ram Kim, et al: Delayed Subsequent Refracture of a Thoracolumbar Vertebral Compression Fracture Fig. 2.$ 로운압박골절의심하에흉요추부단순촬영검사를당일시행하여확인한결과, 제12번흉추부에서속발성압박골절로인한심한척추체의높이감소소견이관찰되었다 (Fig. 2). 이에응급으로흉요추부전산단층촬영을시행하여상기소견과함께압박된척추체의후방골절편이중심척수관쪽으로후방돌출된소견까지확인한후척수병증이동반되었을가능성을의심하여응급으로입원하여신경외과와협진후수술적가료를위해전과시켰다.

로운압박골절의심하에흉요추부단순촬영검사를당일시행하여확인한결과, 제12번흉추부에서속발성압박골절로인한심한척추체의높이감소소견이관찰되었다 (Fig. 2). 이에응급으로흉요추부전산단층촬영을시행하여상기소견과함께압박된척추체의후방골절편이중심척수관쪽으로후방돌출된소견까지확인한후척수병증이동반되었을가능성을의심하여응급으로입원하여신경외과와협진후수술적가료를위해전과시켰다.

신경외과에서는골절된제12번흉추체의심한높이감소및중심척수관쪽으로후방돌출된소견등으로불안정성골절로판단하고입원후 1주일시점에서흉추 12번척추체제거후그물망 (mesh) 으로척추체재건술과동시에흉추 11번과요추 2번사이 Kaneda 기기를이용한전방외측고정술을시행하였고, 1차수술후 1개월이지난시점에서여전히수술부위의불안정성이계속존재하여흉추 10번과요추

3 Bo Ram Kim, et al: Delayed Subsequent Refracture of a Thoracolumbar Vertebral Compression Fracture Fig. 2. Thoracolumbar simple X ray shows subsequent progression of T12 vertebral compression fracture at 18 months from onset. Flexion view (A) and extension view (B). 로운압박골절의심하에흉요추부단순촬영검사를당일시행하여확인한결과, 제12번흉추부에서속발성압박골절로인한심한척추체의높이감소소견이관찰되었다 (Fig. 2). 이에응급으로흉요추부전산단층촬영을시행하여상기소견과함께압박된척추체의후방골절편이중심척수관쪽으로후방돌출된소견까지확인한후척수병증이동반되었을가능성을의심하여응급으로입원하여신경외과와협진후수술적가료를위해전과시켰다. 전산단층촬영소견상제12번흉추는 86.5% 의압박률을보이고있었다 (Fig. 3). 신경외과에전과된후시행된골밀도검사상, 제3 요추부에서 T-score -2.9, 제4 요추부에서 T-score -3.0으로골다공증의소견도관찰되고있었다. 신경외과에서는골절된제12번흉추체의심한높이감소및중심척수관쪽으로후방돌출된소견등으로불안정성골절로판단하고입원후 1주일시점에서흉추 12번척추체제거후그물망 (mesh) 으로척추체재건술과동시에흉추 11번과요추 2번사이 Kaneda 기기를이용한전방외측고정술을시행하였고, 1차수술후 1개월이지난시점에서여전히수술부위의불안정성이계속존재하여흉추 10번과요추 3번후방기기고정술을추가로시행하였다 (Fig. 4). 2차수술후 2주일간의술후가료를받은후요통및보행장애, 배뇨장애등에대한재활치료를위해재활의학과로전과되었으며, 전과당시근력은상하지모두정상으로측정되었으며, 감각 Fig. 3. Thoracolumbar CT shows subsequent progression of T12 vertebral compression fracture at 18 months from onset. Sagittal (A) and coronal (B) views show an 86.5% compression rate and a retropulsion of the fracture segment into the central canal. Fig. 4. Postoperative simple X rays show T11 L2 anterolateral fusion with T12 corpectomy and mesh implantation and subsequent T10 L3 posterior fusion one month after first operation. AP view (A) and lateral view (B). 이상이나배변장애는동반되지않았으나, 배뇨곤란호소하여하루 2-3회정도간헐적도뇨법을시행중이었다. 보행시에는최소한의도움이필요한상태였으나, 유발전위검사상에서는척수병증을의심할만한소견은없었다. 1개 J Korean Geriatr Soc 13(2) June

4 김보람외 : 흉추부척추압박골절의지연된속발성압박골절 월간의재활치료후자가배뇨및독립보행가능한상태로퇴원하였으나퇴원시수술부위에서시각상사척도 (visual analog score) 7-8에해당하는심한흉요추부통증을호소하여마약성진통체패치까지부착한채로퇴원하여퇴원후 3개월까지처방되었다. 수술후 1년이지난시점까지도흉요추부통증으로인해 50 m 이상독립보행이어려운상태여서전동스쿠터를처방받은상태이다. 고찰 척추압박골절환자에서골절부위의속발성혹은진행성재골절은가장주의해야할합병증이지만, 발병률에대한정확한문헌보고는없는실정이다. 또한, 급성기압박골절의치료로서보존적치료와척추혹은후만성형술을선택하는기준도아직까지는논란의여지가많으나, 일반적으로척추체압박률이 40% 이상이거나, 통증이시각상사척도기준 4 이상일때척추혹은후만성형술을초기치료로시행하는것으로알려져있다 2,3). 더욱이우리나라의경우에는건강보험규정상만 80세이하에서는압박골절후 2주가지나야척추성형술이보험급여로인정되기때문에보존적치료는아직까지도가장널리사용되고있는실정이다. 본증례환자의경우에도교통사고로인한척추압박골절이었기에발병초기 2주내에는경피적척추성형술을비용부담문제로인해시행할수없었을것이다. 보존적치료는방사선검사상에서안정성골절일때일정기간의침상안정및진통제투약등을한후 6-8주간척추보조기를착용한상태에서조심스럽게움직임및일상활동량을늘리면서물리치료및운동치료를하게된다. 대부분 6-8주지난시점에서통증은소실되는것으로알려져있다. 반면, 경피적척추성형술을시행할경우즉각적인 (12-24시간이내 ) 통증경감효과가존재하며, 1주이내에통증이없거나, 경미한상태로일상생활동작수행이가능하다 5-9). 그러나장기간의추적관찰상수개월후의통증정도는보존적치료를시행한경우와시각상사척도의기준에서통계적으로유의한차이는없는것으로알려져있다 7,8). 본증례환자의경우에도외부병원자기공명영상소견을미루어발생초기에안정성골절로진단되어 6개월이라는충분한기간의보존적치료를입원상태에서 받은후퇴원하였다고진술하고있었다. 하지만, 결과적으로속발성재발성압박골절이진행되었는데, 27.6% 압박률상태에서 86.5% 의압박률상태까지악화된상태이면서, 후방골절편이중심척수관으로의후방돌출되어척수손상의가능성까지의심되는상황에서본원에내원하였다. 속발성으로재압박이진행되었을때에환자는분명히수상초기처럼심한통증을호소하면서움직임및일상생활동작의저하를다시호소하였을것이나, 퇴원후 12개월이지난시점에서척추혹은후만성형술까지할수없을정도의심한소견상태로본원에내원하여결국수술적치료를받게되었다. 수상초기부터본원에서치료한환자가아니기때문에 6개월간의초기입원치료기간동안의자세한임상양상및치료내용등을알수는없는제한점이있으나, 발생후 1년동안은후만변형의진행, 추가혹은속발성골절발생등의합병증발생여부를방사선학적검사로추적관찰하는것이권유되고있는데 2), 본증례는척추압박골절의보존적치료를시행한후적절한추후경과관찰이이루어지지않았다는과오를지적할수있겠다. 따라서, 본저자들은본증례를통하여척추압박골절환자에서보존적치료혹은척추성형술과같은최소침습적중재시술을한후 1년간의주기적인임상경과및방사선학적경과관찰의중요성을강조하고자하였다. 요약 척추압박골절은골다공증성골절의가장흔한형태중하나이며, 대부분의척추압박골절은궁극적으로무증상혹은최소한의잔여증상을남기게되지만, 많은수에서상당한통증을느끼면서일상생활의저해와장애를겪게된다. 특히, 척추압박골절환자에서골절부위의속발성혹은진행성재골절은가장주의해야할합병증이지만, 발병률에대한정확한문헌보고는없는실정이다. 이에본저자들은보행자교통사고로인한낙상에준하는충격에의해발생한골다공증성척추압박골절환자에서보존적치료를시행한후 18개월이지난시점에서속발성재골절이발견되어뒤늦게수술적치료를받은 77세남자환자 1 예를보고하면서척추압박골절환자에서보존적치료혹 104 J Korean Geriatr Soc 13(2) June 2009

5 Bo Ram Kim, et al: Delayed Subsequent Refracture of a Thoracolumbar Vertebral Compression Fracture 은척추성형술과같은최소침습적중재시술을한후 1년간의주기적인임상경과및방사선학적경과관찰의중요성을강조하고자하였다. 참고문헌 1. Pluijm SM, Tromp AM, Smit JH, Deeg DJ, Lips P. Consequences of vertebral deformities in older men and women. J Bone Miner Res 2000;15: Freedman BA, Potter BK, Nesti LJ, Giuliani JR, Hampton C, Kuklo TR. Osteoporosis and vertebral compression fractures-continued missed opportunities. Spine J 2008;8: Prather H, Watson JO, Gilula LA. Nonoperative management of osteoporotic vertebral compression fractures. Injury 2007;38 Suppl 3:S Karlsson MK, Hasserius R, Gerdhem P, Obrant KJ, Ohlin A. Vertebroplasty and kyphoplasty: new treatment strategies for fractures in the osteoporotic spine. Acta Orthop 2005;76: Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine 2003;28:S Wong J, Chow E, de Sa E, Rowsell C, Probyn L, Christakis M, et al. Immediate pain relief and improved structural stability after percutaneous vertebroplasty for a severely destructive vertebral compression fracture. J Palliat Med 2009;12: Rousing R, Andersen MO, Jespersen SM, Thomsen K, Lauritsen J. Percutaneous vertebroplasty compared to conservative treatment in patients with painful acute or subacute osteoporotic vertebral fractures: three-months follow-up in a clinical randomized study. Spine 2009;34: Masala S, Mammucari M, Angelopoulos G, Fiori R, Massari F, Faria S, et al. Percutaneous vertebroplasty in the management of vertebral osteoporotic fractures: short-term, midterm and long-term follow-up of 285 patients. Skeletal Radiol. Forthcoming Alvarez L, Alcaraz M, Pérez-Higueras A, Granizo JJ, de Miguel I, Rossi RE, et al. Percutaneous vertebroplasty: functional improvement in patients with osteoporotic compression fractures. Spine 2006;31: Kim MJ, Lindsey DP, Hannibal M, Alamin TF. Vertebroplasty versus kyphoplasty: biomechanical behavior under repetitive loading conditions. Spine 2006;31: J Korean Geriatr Soc 13(2) June

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical