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1 대한척추외과학회지제 16 권제 4 호 Journal of Korean Spine Surgery Vol. 16, No. 4, pp 235~242, 2009 DOI: /jkss 성인에서방사선학적외상소견이없는외상성경수손상의자기공명영상을이용한진단및예후 박희전 이필은 김완기 심영준 연세대학교원주의과대학정형외과학교실 Diagnosis and Prognosis of Adult Post-traumatic Cervical Cord Injury Without Radiographic Evidence of Trauma Using Magnetic Resonance Imaging Heui-Jeon Park, M.D., Phil-Eun Lee, M.D., Wan-Ki Kim, M.D., Young-Jun Shim, M.D. Department of Orthopedic Surgery Yonsei University, Wonju College of Medicine, Wonju, Korea Abstract Study Design: This is a retrospective review of 10 consecutive patients with spinal cord injury without radiographic evidence of abnormalities (SCIWORA) and 17 spinal cord injury patients without radiographic evidence of trauma (SCIWORET). Objectives: We wanted to assess the MRI and clinical findings, the prognosis and effect of anterior decompression of the spinal cord in SCIWORET patients. Summary of the Literature Review: SCIWORET is not uncommon among middle-age and elderly people. It is less reported in adults as compared with children. There are no studies on the method for the treatment or the effectiveness of anterior decompression of the spinal cord. Materials and Methods: From February 1994 to December 2005, this study included 27 patients who had cervical spinal cord injury without radiographic evidence of trauma on the plain roentgenography and MRI. Ten patients had no spinal cord compression (SCIWORA patients, group 1) and 17 had their spinal cord compressed from the anterior (SCIWORET patients, group 2), We conservatively treated the group 1 patients and 10 of the group 2 patients, and anterior decompression and fusion were done for 7 of the group 2 patients. Neurological evaluation was performed initial and at last follow up using an ASIA motor score and the Frankel grade. Results: The patients who had spinal cord edema on MRI had a better prognosis than those who had contusion (p=0.06). There is no statistical difference between the two groups for the neurologic changes at the initial period and the last follow up period (p=0.06, 0.61). Decompression of the spinal cord anteriorly was not effective for the neurologic recovery (p=0.25) and the involved segments were not related to the neurologic changes (p=0.34, 0.25). Conclusions: It was presumed that patients with edema of the spinal cord had a better prognosis than those with contusion of the spinal cord. There was no difference between the SCIWORA and SCIWORET groups for the neurologic changes and anterior decompression was not effective for the recovery of neurologic symptoms. This study was limited by its retrospective nature and the small number of patients, so a multi-center study is needed. Key Word: Cervical cord injury, MRI, Prognosis Address reprint requests to Heui-Jeon Park, M.D. Department of Orthopaedic Surgery, Wonju College of Medicine, Yonsei University 162 Ilsan-dong, Wonju, Kangwon-do, Korea Tel: , Fax: , par73@yonsei.ac.kr Received: Accepted:

2 대한척추외과학회지 Vol. 16, No. 4, 2009 서 론 급성외상성척수병증의임상적양상을보이나평면방사선사진과전산화단층촬영에서이상소견을보이지않는것을 SCIWORA (Spinal Cord Injury Without Radiographic Abnormality) 라고 Pang 과 Wiberger 1) 에의해처음기술되었다. SCIWORA 의발생빈도, 병인및손상정도는연령에따라다른데이는척추의해부학적, 생리학적차이에의한것으로알려져있으며, 특히 16 세이상에서근골격의손상이나탈구없이척수의손상이오는경우는매우드물다 1,2,3,4). 최근에는경추의외상후방사선학적진단에전산화단층촬영보다는자기공명영상촬영을많이이용하게됨에따라인대손상이나외상성추간판탈출등의진단이보다용이하게되었고, SCI- WORA 를자기공명영상에서이상소견을보이지않는경우로정의한다면그빈도는더욱감소할것으로생각된다. 자기공명영상은해상력이좋고골조직에의한인공음영이없으며 pulse sequences 를선택할수있어척수손상의진단과예후를예측하는데도움을줄뿐만아니라경막외출혈, 추간판탈출과같은신경조직주위의상태를잘알수있다 5,6). 자기공명영상에서척수의허혈성변화, 부종 (edema), 좌상 (contusion) 등의소견은진단뿐만아니라예후인자로도기여한다. 치료에대해서는손상받은척추가기계적인불안정성을보이지않으므로대부분에서보존적치료를시행하나척수강의압박이동반된경우의치료에서감압의효과에대한보고는많지않다. 본연구는성인에서평면방사선사진과자기공명영상에서외상의소견없이발생한외상후경수손상환자를대상으로자기공명영상소견, 임상양상, 치료방법에따른결과와신경증상의회복및예후에대해비교분석하여향후치료의방침으로삼고자한다. 연구대상및방법 연구대상은 1994 년 2 월부터 2005 년 12 월까지본원에서경추부외상으로입원치료받은 284 례의경수손상환자중평면방사선사진과자기공명영상에서외상소견을보이지않으면서척수손상소견을보인환자를대상으로하고이중감염, 종양, 외상또는경부동통으로치료받은과거력이있는환자를제외한 27 례를대상으로하였다. 남자 19 명, 여자 8 명이었고, 평균연령은 48.8 세 (25~70 세 ), 평균추시기간은 29.5 개월 (24~132 개월 ) 이었다. 손상원인은교통사고 7 례, 추락사고 6 례, 자전거 사고 4 례, 둔기타박 2 례, 실족 8 례이었으며, 손상부위는제 3-4 경추부위가 10 례, 1-2 경추부위 3 례의순이었으며, 단분절손상은 18 례, 다분절손상이있는경우는 9 례이었다. 연구방법은환자를평면방사선사진과자기공명영상촬영에서외상이나척수의압박소견이없이척수손상만있는군 (1 군, 10 명, SCIWORA) 과외상에의한추간판탈출또는주위연부조직의손상을보이지않으면서기존의추간판돌출에의한척수압박소견이동반되어있는군 (2 군, 17 명, Spinal Cord Injury Without Radiological Evidence of Trauma, SCIWORET) 으로나누었다. 자기공명영상촬영은 16 명의환자에서는수상후 48 시간이내에, 나머지 11 명의환자는 7 일이내에시행하였고, 시상면및축상면의 T1, T2 강조영상과지방억제 T2 강조영상 (fat supression T2 weighted image) 을얻었으며 MRI 의판독은 2 인의진단방사선과의사의일치된소견으로하였다. 척수손상의진단은정상, 부종 (edema), 좌상 (contusion), 종창 (swelling) 으로구분하였으며, 척수부종은 T1 강조영상에서동신호강도의종창을보이고, T2 강조영상에서균일한고신호강도를보이는경우로 (Fig. 1), 좌상은 T1 강조영상에서정상이거나척수의부분적인확장소견, T2 강조영상에서고신호강도를보이는척수부종을보이는경우나급성출혈이동반된경우에는 T1, T2 강조영상모두에서초기에는저신호강도를보이는경우로하였으며 (Fig. 2), T1, T2 강조영상의소견에관계없이척수의직경이팽창으로인해지주막하공간의소실이있는경우를종창으로분류하였다 7). 추시자기공명영상에서신경교증 (gliosis) 은 T1 강조영상에서국소저신호강도, T2 강조영상에서국소고신호강도를보이면서 Gd 증강되는경우로하였으며, 척수공동 (syrinx) 은 T1 강조영상에서국소저신호강도, T2 강조영상에서주위에고신호강도를보이나 Gd 증강되지않는경우로하였다. 신경학적평가는미국척수손상학회 (American Spinal Injury Association, ASIA) 의운동기능점수와 Frankel 분류 8) 를이용하여수상초기와최종추시를비교하였다. 치료는외상후 24 시간이내에응급실에도착한모든환자에서 methylprednisolone 30 mg/kg 를처음 15 분동안에정맥주사후, 23 시간동안에 5.4 mg/kg/hr 를투여하였으며, 경추견인또는경경추보조기 (Miami J brace) 를이용하여경추고정을시행하였다. 2 군 17 명의환자중초기환자 8 례에서전방감압및유합술을시행하였으며, 모든환자에서가능한한빨리수동적및능동적인관절가동범위운동과근육강화운동등의물리치료와작업치료를시행하였다. 통계학적분석은 SPSS Ver 프로그램을이용하여

방사선소견상외상소견이없는척수손상 박희전외 Fig. 1. 58-year old man with acute spinal cord injury. MRI of the cervical spine was obtained trauma day(a, B) and 12 months (C, D) after injury.

(C) Sagittal midline T1-weighted image shows isointensity lesion at C3-4 level. (D) T2-weighted image shows ill defined diffuse hyperintensity lesion at C3-4 level, indicating gliosis. Fig. 2.

3 방사선소견상외상소견이없는척수손상 박희전외 Fig year old man with acute spinal cord injury. MRI of the cervical spine was obtained trauma day(a, B) and 12 months (C, D) after injury. (A) Sagittal midline T1-weighetd image shows isointensity cord lesion at C3-4. (B) T2-weighted image shows diffuse hyperintensity cord lesion at C3-4, indicating the existence of edema. (C) Sagittal midline T1-weighted image shows isointensity lesion at C3-4 level. (D) T2-weighted image shows ill defined diffuse hyperintensity lesion at C3-4 level, indicating gliosis. Fig. 2. A 48-year old woman presenting Frankel C. MRI of the cervical spine was obtained 2 days (A, B) after injury and 1 year (C, D, E) after anterior decompression and fusion. (A) Sagittal T1-weighted image shows slightly hypointensity cord lesion at C4-5. (B) T2-weighted image shows relatively well defined hyperintensity cord lesion at C4-5, indicating existence of cord contusion, and slightly protruded disc. (C) Sagittal midline T1- weighted image shows isointensity lesion at C4-5 level. (D) T2-weighted image shows ill defined diffuse hyperintensity lesion at C4-5 level. (E) T1-weighted Gadullium enhanced image shows hypointensity(not enhanced) lesion at C4-5 level, indicating gliosis

4 대한척추외과학회지 Vol. 16, No. 4, 2009 두군간의경추전만각, 유합분절전만각, 추체높이의변화는 paired T-test 로검정하였으며유의확률 (p 값 ) 이 0.05 이하인경우를통계학적의의가있는것으로하였다. 결 과 1. 자기공명영상소견 수상후시행한자기공명영상촬영에서척수부종을보인경우는 12 례, 좌상을보인경우는 15 례이었고, 부종소견을보인 12 례중 4 례, 좌상소견을보인 15 례중 5 례에서 2 분절이상의광범위한병변을보였다. 수상 6 개월경과후추시자기공명영상을촬영한 17 례중단분절에부종소견을보였던 8 례중 3 례에서, 단분절에서좌상소견을보였던 10 례중 6 례에서신경교증소견을보였고, 다분절에서부종소견을보였던 4 례중 3 례에서, 다분절에서좌상소견을보였던 5 례전례에서척수공동소견을보였다. 2. 신경학적검사소견 가 ) 자기공명영상과신경학적소견초기척수부종을보인 12 례의운동기능점수는평균 63.0(±32.8) 점, 좌상의소견을보인 15 례의운동기능점수는평균 40.3(±26.7) 점, 최종추시에서는각각 89.7(± 14.5) 점, 73.0(±24.8) 점으로양군간에통계학적차이를보이지않았으며 (p=0.06, 0.06), 운동기능점수의호전정도는 26.7(±27.7) 점, 32(±17.2) 점으로양군간에통계학적차이는없었다 (p=0.51). 운동기능점수는 p=0.06 으로통계학적으로유의수준에는미치지못하지만약한상관관계 (mild relationship) 를보여, 부종군이좌상군보다손상초기와최종추시에서양호한신경학적증상을보이는것으로추정된다 (Table 1). 나 ) 척수의압박소견과신경학적소견초기에시행한검사상운동기능점수는 1 군에서평균 47.3(±31.6) 점, 2 군에서 57.8(±30.0) 점으로양군간에통계학적차이는없었으며 (p=0.60), 최종추시시평균운동기능점수는 1 군은 78.3(±25.3) 점으로 31.0(±21.7) 점의호전을보였고, 2 군은 82.8(±19.7) 점으로 29.1(± 21.8) 점의호전을보였으나통계학적차이는보이지않았다 (p=0.61, 0.83)(Table 1). Frankel 등급은수상초기 1 군은 B 4 례, C 4 례, D 2 례이었고, 2 군에서는각각 9 례, 7 례, 1 례이었으며, 최종추시에서 2 등급의신경호전을보인경우는 1 군에서 3 례, 2 군에서 7 례로평균 1.2 등급과 1.3 등급의호전이었으나양군간에통계학적차이를보이지는않았다 (p=0.75, 0.23). 다 ) 전방감압과신경학적소견전방에서압박소견을보였던 2 군 17 례중 8 례에서전방감압및유합을시행하였으며, 감압을시행한 8 례의술전운동기능점수는평균 66.9(±20.1), 수술을시행하지않은 9 례는평균 44.6(±33.3) 을보여양군간에차이가없었으며 (p=0.14), 최종추시에서수술을시행한군에서는 88.4(±8.2) 점으로 21.6(±15.1) 의호전을보였고, 수술을시행하지않은군에서는 78.9(±24.5) 점으로 34.3(±24.9) 의호전을보였으나통계학적차이는보이지않았다 (p=0.27, 0.25)(Table 1). Table 1. Neurologic changes between the groups (ASIA score) Initial Follow up Improvement Edema (n=12) 63.0(±32.8) 89.7(±14.5) 26.7(±27.7) Contusion (n=15) 40.3(±26.7) 73.0(±24.8) 32.7(±17.2) p value *SCIWORA (n=10) 47.3(±31.6) 78.3(±25.3) 31.0(±21.7) SCIWORET (n=17) 57.8(±30.0) 82.8(±19.7) 29.1(±21.8) p value Decompression (n=8) 66.9(±20.1) 88.4(± 8.2) 21.6(±15.1) Non operation (n=9) 44.6(±33.3) 78.9(±24.5) 34.3(±24.9) p value Single leve l(n=18) 54.7(±27.3) 85.2(±16.2) 30.5(±21.8) Multiple level (n=9) 41.7(±37.9) 69.6(±31.2) 27.7(±21.6) p value *SCIWORA; spinal cord injury without radiographic abnormality SCIWORET; spinal cord injury without radiographic evidence of trauma

5 방사선소견상외상소견이없는척수손상 박희전외 라 ) 이환분절과신경학적소견단분절에서척수병변을보인 18 례에서초기운동기능점수는 54.7(±27.3), 다분절인경우에는 41.7(±37.9) 로양군간에차이가없었으며 (p=0.34), 최종추시에서는각각 85.2(±16.2) 과 69.6(±31.2) 로 30.5(±21.8) 점과 27.7(21.6) 점의호전을보였으나양군간에통계학적차이를보이지는않았다 (p=0.25, 0.77)(Table 1). 고 찰 평면방사선사진과전산화단층촬영에서이상소견을보이지않고급성외상성척수병증의임상적양상을보이는것을 SCIWORA 라고하며, 모든부위의척수에서발생할수있으나경추에서그빈도가가장높다. 호발하는연령은 8 세이하의소아와 60 세이상의성인으로 16 세에서 35 세사이의젊은성인에서보다높은빈도를보인다 9). 소아의척추는성인에비해 1) 후관절의방향이좀더수평이고, 2) 추체의상부종판의전방이설상형 (anterior wedging) 이고, 3) 관절낭과인대에탄력성이있기때문에굴곡, 신전또는신연시에운동분절간에지나친운동이일어날수있어결과적으로인대손상이나골절없이신경의손상이일어날수있다 10). Crooks 와 Brikett 11) 는중년이후에는골절이동반되지않은척수손상이일어날수없다고하였으나, 고령의환자들은대부분퇴행성척추병변에의해척수강의시상면상직경이좁아져있어과신전에의한외상을받으면추체후방의골극과후방인대사이에척수가끼어척수의중심성허혈및혈종을형성하는급성중심성척수증후군을일으킨다. 경부운동으로인한척수강의길이가변화함에따라주위의연부조직들도생리적으로정상범위내에서변형이발생하므로척수와신경의지속적인변형이이루어져야한다 12). 그러나생리적운동범위를넘는과도한변형에의해신경구조물들이적응할수없을정도의변형력을받게되면손상을받게된다. 손상력이척수에는손상을줄수있지만주위의골조직이나인대에손상을주기에는손상력이작을때에는 SCIWORA 와같이골조직이나연부조직에는손상이없고척수손상만이생길수있을것으로생각된다. 이러한비생리적운동에는과골곡, 과신전, 회전성변형, 신연력과충격파등이있다. 첫째, 과굴곡은척수의길이가최대한신장되어척수의혈류장해를일으키게되며 13) 치상인대 (dentate ligament) 에의한척수의구속 (tethering) 이이러한상태를더욱악화시킨다 14). 둘째, 과신전에의해후종인대 와황색인대사이에척수가꽉끼게되어척수의압박이가장심하게나타날수있데이는주로제 3 경추와 6 경추사이에서일어난다 15). 셋째, 회전성변형력에의한손상은치상인대와척추신경근에의해척수의다른부분보다연막 (pia mater) 이더단단하게고정되는척수부위의내부에전단력이발생하여손상을일으키게되며척수내회백질이회전성가속도에의해손상받게된다 16). 넷째, 경부의연부조직총상은척수로부터척수신경근의건열과척수내출혈을일으켜서척수손상을주거나또는진탕파동에의해척수손상을일으킬수있다 17). Holmes 18) 는척추에직접가격을받았을때골구조물에손상을주기에는부족하지만이러한운동이척수에 shock-wave oscillations 을생성하여골성척수강에대한척수의 slapping 손상 을일으킬수있음을보고한바있다. 성인에서척추관협착, 강직성척추염또는추간판탈출증과같은관절병증이동반되지않은경우에방사선학적외상소견을보이지않고발생되는척수손상은드물며, 이러한경추의퇴행성병변은 SCIWORET 과많은연관성을보인다 19,20). 퇴행성경추병증을가지고있는성인에서척수전방으로돌출된후방골극과후방에서주름진황색인대에의한압박으로인해제 3-6 경추사이에서척수의압박이가장심하게나타나며이는경미한외상에의해서도임상적으로중심성척수증후군을일으킬수있다 21,22). 일반적으로높은에너지에의한손상은환축추로구성된상위부와제 5-7 경추인하부경추부위에서주로발생하고척수절단과같은심한척수손상이초래되나, 상대적으로낮은에너지에의한손상은제 경추부위에서주로발생하고신경손상도불완전손상이많은것으로보고되고있다 18,21). 신경증상의회복은초기손상의정도에따라달라진다. 자기공명영상에서정상소견을보이고경도의신경증상이 72 시간내에회복되는경우에척수진탕 (spinal concussion) 이라는용어를사용하기도하는데, 이는자기공명영상에서신호강도의변화에의한것이아니라화학적변성에의한것으로생각하며, Dare 등 23) 은부분적인신경증상을보이고자기공명영상에서정상소견을보이는환자에서완전회복을보고한바있다. 본연구에서는자기공명영상에서척수에신호강도의변화를보인환자만을대상으로하였다. 자기공명영상은척수주위와실질의병변을가장잘알수있는방사선학적검사방법이며, 특히 T2 강조영상에서출혈, 좌상, 부종에따른신호강도의변화를확실하게관찰할수있으며이러한신호강도의변화와임상결과에대해서는여러문헌에보고되었다. Bon

6 대한척추외과학회지 Vol. 16, No. 4, 2009 durant 등 24) 과 Kulkarni 등 25) 은급성척수손상환자에서척수내출혈이있는경우는비가역적손상을, 부종과좌상이있는경우에는확실한신경학적회복을보고하면서손상후 24~72 시간이내의자기공명영상촬영이예후를예측하는데가장도움이됨을언급하였다. Marciello 등 26) 은자기공명영상을이용하여척수손상환자 24 명을분석한결과정상적으로보이는경우예후가가장좋았고, 다분절이침범된척수부종의경우결과가좋지않았으며, 척수내출혈이있는경우결과가가장나쁜것으로보고하였다. 본연구에서는이환된분절수에따른통계학적차이를보이지는않았으나단분절이침범된경우에신경학적증상이양호하였으며, 척수부종인경우가좌상을보인경우보다초기및최종추시에서양호한신경학적소견을보였다. Flanders 등 27) 은척수의압박병변이있는경우보다없는경우가예후가더좋은것으로보고하였는데, 본연구에서는척추의압박소견이없는군에서는운동기능점수가 31.0(± 21.7), 압박이동반된군에서는 29.1(±21.81) 의호전을보여양군간에차이를보이지않았다. 본연구에서의압박이동반된군은외상으로인한추간판의탈출이나골절탈구와동반된골편에의한심한척수의압박이아닌, 환자가외상전부터가지고있던경도의추간판돌출에의한압박이므로압박이동반되지않은군과신경증상의호전정도와예후에차이가없었던것으로생각된다. 외상후발생하는척수손상의과정은축삭과미세혈관에대한기계적인일차손상과일차손상에의해촉진된하나이상의추가적인손상과정으로인한이차손상으로생각되어지고있다 28,29). 척수의이차손상은회백질을통과하여백색질로가는세동맥의혈전, 혈소판의응집또는혈관경련으로발생할수있으며 30), 특히전신성저혈압이있는경우에는손상된척수에서의자가조절의부재로인한허혈성손상이복합적으로나타나는것으로생각한다 31). 이러한척수손상의약물치료는신경의저산소증과세포의기능장해와같은이차손상을최소화하는것으로현재임상적으로입증된것은 methylprednisolone 이며 GM1-gangliside 는현재활발히연구가진행되고있으며임상적용도시도되고있다 32,33). 본연구의대상환자들도수상후 24 시간이내에응급실에내원시다량의스테로이드를투여하였다. 경추의골절 - 탈구가없이발생한외상성척수손상의치료는비수술적인보존적치료로비교적양호한신경학적비교적양호한예후를보고하고있으며, 본연구에서도운동기능점수가평균 30.2(±21.3), Frankel 등급은평균 1.2 이상호전되었으며완전마비가있었던환자는없었고모든환자에서신경증상의호전을보였다. Laud 와 Ramani 34) 는 T2 강조영상에서미만성고신호강도를보이는사지마비환자에서후궁절제술을시행한후명확한신경학적증상의호전을보고한바있어, 저자들도이러한감압술이척수병증환자의신경학적증상의호전에상당한기여를할것으로생각되어초기에전방의압박이동반된환자중 8 례에서전방감압술을시행하였으나시행하지않은군과신경증상회복에통계학적차이를보이지는않았다. 이는척수병증의원인이추간판탈출로인해발생되는척수병증과달리, 전방에서척수를압박하고있던추간판의돌출은계속적인압박으로인해척수병증을일으킬정도는아니고주된원인은외상시척수에가해진외력에의한것으로사료된다. 결 론 방사선소견상외상소견이없이외상후발생한척수손상환자에서자기공명영상촬영은진단및신경증상의예측에유효하며, 척수부종의경우가좌상보다초기및최종추시에서양호한신경증상을보이는것으로추정되었다. 척수의압박과이환분절수는신경증상의정도및예후에영향이없었으며전방감압또한신경증상호전에효과적이지못하였다. 본연구는후향적이고연구대상이적은한계가있어향후이에대한전향적이고다기관연구가이루어져야할것으로사료된다 참고문헌 01) Pang D, Wilberger JE Jr: Spinal cord injury without radiographic abnormalities in children. J Neurosurg 1982; 57: ) Choi JU, Hoffman HJ, Hendrick EB, Humphreys RP, Keith WS: Traumatic infarction of the spinal cord in children. J Neurosurg 1986; 65: ) Hill SA, Miller CA, Kosnik EJ, Hunt WE: Pediatric neck injuries: A clinical study. J Neurosurg 1984; 60: ) Ruge JR, Sinson GP, McLone DG, Cerullo LJ: Pediatric spinal injury: the very young. J Neurosurg 1988; 68: ) Levitt MA, Flanders AE: Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury. Am J Emerg Med 1991; 9: ) Mirvis SE, Geisler FH, Jelinek JJ, Joslyn JN, Gellad F:

7 방사선소견상외상소견이없는척수손상 박희전외 Acute cervical spine trauma: evaluation with 1.5T MR imaging, Radiology 1988; 166: ) Silberstein M, Hennessy O: Implicatinons of focal spinal cord lesions following trauma: evaluation with magnetic resonance imaging. Paraplegia 1993; 31: ) Frankel HL, Hancock DO, Hyslop G, et al.: The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969; 7: ) Scher AT: Cervical spinal cord injury without evidence of fracture or dislocation. An assessment of the radiological features. S Afr Med J 1976; 12: ) Gupta SK, Rajeev K, Khosla VK, et al.: Spinal cord injury without radiographic abnormality in adults. Spinal cord 1999; 37: ) Crooks F, Birkett AN: Fractures and dislocations of the cervical spine. BR J Surg 1944; 31: ) Chirossel JP, Vanneuville G, Passagia JG, et al.: Biomechanics and classification of traumatic lesions of the spine. Adv Tech Stand Neurosurg. 1995; 22: ) Lyness SS, Wagman AD: Neurological deficits following cervical manipulation. Surg Neurol 1974; 2: ) Wider BL: Hypothesis: the etiology of midcervical quadriplegia after operation with the patient in the sitting position. Neurosurg 1982; 11: ) Taylor AR: The mechanism of injury to the spinal cord in the neck without damage to the vertebral column. J Bone Joint Surg Br 1951; 33: ) Kobrine AI: The neuronal theory of experimental traumatic spinal cord dysfunction. Surg Neurol 1975; 3: ) Simpson RK Jr, Robertson DP, Narayan PK: Penetrating spinal cord injury. (in Narayan RK, Wilberger JE Jr, Povlishock JT eds. Neurotrauma. New York, McGraw-Hill Inc: , 1996) 18) Holmes G: Spinal injuries of warfare. Br Med J 1915; 2: ) Firooznia H, Ahn JH, Rafii M, Raqnarsson KT: Sudden quadriplegia after a minor trauma. The role of preexisting spinal stenosis. Surg Neurol 1985; 23: ) Hayashi K, Yone K, Ito H, Yanase M, Sakou T: MRI findings in patients with a cervical spinal cord injury who do not show radiographic evidence of a fracture or dislocation. Paraplegia 1995; 33: ) Bhatoe HS: Cervical spinal cord injury without radiological abnormality in adults. Neurol India 2000; 48: ) Chen TY, Lee ST, Lui TN, et al.: Efficacy of surgical treatment in traumatic central cord syndrome. Surg Neurol 1997; 48: ) Dare AO, Dias MS, Li V: Magnetic resonance imaging correlation in pediatric spinal cord injury without radiographic abnormality. J Neurosurg 2002; 97: ) Bondurant FJ, Cortler HB, Kulkarni MV, McArdle CB, Harris JH Jr: Acute spinal cord injury; A study using physical examination and magnetic resonance imaging. Spine 1990; 15: ) Kulkarni MV, McARDLE CB, Kopanicky D, et al.: Acute spinal cord injury; MR imaging at 1.5 T. Radiology 1987; 164: ) Marciello MA, Flanders AE, Herbison GJ, Schaefer DM, Friedman DP, Lane JI: Magnetic resonance imaging related to neurologic outcome in cervical spinal cord injury. Arch Phys Med Rehabil 1993; 74: ) Flanders AE, Schaefer DM, Doan HT, Mishkin MM, Gonzalez CF, Northrup BE: Acute cervical spine trauma: Correlation of MR imaging findings with degree of neurological deficit. Radiology 1990; 177: ) Allen AR: Surgery of experimental lesion of spinal cord equivalent to crush injury of fracture dislocation of spinal column. A preliminary report. JAMA 1911;146: ) Collins WF: A review and update of experiment and clinical studies of spinal cord injury. Paraplegia 1983; 21: ) Tator CH, Fehlings MG: Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg 1991; 75: ) Senter HJ, Venes JL: Loss of autoregulation and posttraumatic ischemia following experimental spinal cord trauma. J Neurosurg 1979; 50: ) Geisler FH, Coleman WP, Grieco G, Poonian D: The Sygen multicenter acute spinal cord injury study. Spine 2001; 26: ) Geisler FH, Dorsey FC, Coleman WP: Recovery of motor function after spinal cord injury; a randomized placebo-controlled trial with G-1 ganglioside. N Engl J Med 1991; 324: ) Laud NS, Ramani PS: Patterns of spinal injuries. (in Ramani PS ed. Spinal Surgery Vol 1. Dept of Neuro and Spinal Surgery, Mumbai, LTM Medical College: , 1996)

8 대한척추외과학회지 Vol. 16, No. 4, 2009 국문초록 연구계획 : 후향적연구연구목적 : 본연구의목적은성인에서외상후평면방사선사진과자기공명영상에외상소견없이발생한경수손상환자를대상으로치료방법에따른신경증상의회복및예후에대해분석하여향후치료의방침으로삼고자한다. 대상및방법 : 1994년 2월부터 2005년 12월까지외상후발생한경수손상으로입원, 치료받은 284명의환자중평면방사선사진과자기공명영상촬영에서외상의소견을보이지않고경추부척수손상만을보인 27명을대상으로하였다. 남자 19명, 여자 8명이었고, 평균연령은 48.8(27~70) 세이었으며, 추시기간은평균 29.5(24~132) 개월이었다. 연구방법은척수의압박소견이없이척수손상만있는군 (1군, 10례 ) 과추간판돌출등으로인한척수압박소견이동반된군 (2군, 17례 ) 으로나누어, 자기공명영상소견과임상양상, 치료방법에따른결과와예후에대해비교하였다. 결과 : 초기 MRI에서척수부종을보인경우가좌상을보인경우보다초기와최종추시에서양호한신경학적증상을보이는것으로추정되었다 (p=0.06). 초기와최종추시에서각군간의운동지수는통계학적차이를보이지않았으며 (p=0.60, 0.61), 2군중전방감압을시행하지않은경우운동지수는 34.3(±24.9), 전방감압을시행한경우에는 21.6(± 15.1) 의호전을보여수술로인한차이를보이지않았으며 (p=0.25), 또한병변에이환된분절수도신경증상에영향이없었다 (p=0.34, 0.25). Frankel 등급은 1군에서는 B에서 D로 2등급호전된경우가 3례 (27.3%), 1등급호전된경우는 8례이었으며, 2군에서는각각 6례 (35.3%), 11례로양군간에통계학적차이를보이지않았다 (p=0.75, 0.23). 결론 : 자기공명영상촬영에서부종을보인경우가좌상을보인경우보다예후가양호한것으로추정되었다. 추간판돌출등으로인한척수의압박여부가신경증상의정도및회복에차이를보이지않았으며또한척수의전방감압도신경증상의호전에영향을주지는못했다. 본연구는후향적이고연구대상이적은한계가있어향후이에대한전향적이고다기관연구가이루어져야할것으로사료된다. 색인단어 : 경추척수손상, 자기공명영상, 예후 통신저자 : 박희전강원도원주시일산동 162 연세대학교원주의과대학정형외과학교실 Tel: , Fax: , par73@yonsei.ac.kr

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