pissn: eissn: Allergy Asthma Respir Dis 4(1):38-43, January ORIGINAL ARTICLE 발열과호흡

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1 pissn: eissn: (1):38-43, January ORIGINAL ARTICLE 발열과호흡기증상으로입원한영아에서호흡기바이러스검출유무에따른임상적고찰 박누리, 정진아, 권경아 동아대학교의과대학소아과학교실 Clinical considerations of febrile infants with respiratory symptoms according to the respiratory viral detection Nury Bag, Jin-A Jung, Kyoung Ah Kwon Department of Pediatrics, Dong-A University College of Medicine, Busan, Korea Purpose: Respiratory viral infection is one of the most common diseases in febrile infants. This study evaluates the clinical characteristics of febrile infants who were hospitalized for respiratory symptoms, with or without respiratory viral detection. Methods: Seventy-six hospitalized infants aged 28 9 days with fever and respiratory symptoms from January 211 to December 212 were enrolled in this study. We performed reverse transcriptase polymerase chain reaction to identify 7 respiratory viruses from nasopharyngeal swabs. Also, we retrospectively reviewed the medical records to analyze the clinical features. Results: Respiratory viruses were detected in 45 patients (RVP group). Respiratory syncytial virus (n= 16) was most frequently detected, followed by human rhinovirus (n = 1). Age, sex, past illness, and sibling s respiratory symptoms showed no differences between the 2 groups. Infants in the RVP group had a significantly higher incidence of tachypnea (22.2%) and abnormal breathing sounds (wheezing and rales, 57.8%) than those in the negative group (P=.21, P=.2 each). There were no significant differences in laboratory findings between the 2 groups. Conclusion: In our study, RSV was the most common virus in febrile infants aged 28 9 days with respiratory symptoms. Tachypnea and abnormal breathing sounds were more reliable clinical features to guess the detection of respiratory viruses. Further studies are required to confirm the values of these clinical features in febrile infants who have lower respiratory tract infections. (Allergy Asthma Respir Dis 216;4:38-43) Keywords: Fever, Respiratory symptoms, Infants, Respiratory viruses 서론발열은병원에내원하는소아들의가장흔한증상들중하나이며, 특히소아에서는감염이가장흔한발열의원인으로알려져있다. 1,2 소아감염의원인은대부분바이러스이기때문에발열로내원한환아의다수가별다른치료없이저절로좋아지며대증치료만으로호전된다. 3,4 그러나, 발열로내원한 9일미만의영아에서는 8.5% 12% 가중증세균감염이원인인것으로알려져있으며 4 세균감염이있더라도증상이가볍거나비특이적일수있어임상양상만으로첫진료에서는중증세균감염유무를판단하는것은어렵기 때문에실제바이러스감염이있는경우라도우선적으로항생제를사용하면서경과를관찰하는경우가많다. 호흡기감염은영아에서흔하게관찰되는감염질환이며, 특히영아에서하기도감염은증상이중하고, 호흡곤란을동반하여입원이필요한경우가많지만, 이경우에도바이러스가원인인경우가 9% 로보고되고있다. 5,6 특히메타뉴모바이러스 (human metapneumovirus), 인플루엔자바이러스 (influenza virus), 파라인플루엔자바이러스 (parainfluenza virus), 라이노바이러스 (human rhinovirus), 호흡기세포융합바이러스 (respiratory syncytial virus) 등이급성하기도감염으로입원한영아들에게서자주검출되는것 Correspondence to: Kyoung Ah Kwon The Korean Academy of Pediatric Allergy and Respiratory Disease Department of Pediatrics, Dong-A University College of Medicine, 49 Busandaehak-ro, Mulgeum-eup, The Korean Academy of Asthma, Allergy and Clinical Immunology Yangsan 5612, Korea This is an Open Access article distributed under the terms of the Creative Tel: , Fax: , hap99@naver.com Commons Attribution Non-Commercial License Received: July 21, 215 Revised: October 27, 215 Accepted: November 2, 215 ( 38

2 박누리외 열성호흡기감염영아의임상적고찰 으로알려져있다. 7,8 따라서, 발열이동반된영아의호흡기감염에서원인바이러스를규명하면불필요한항균제사용을감소시킬수있으며, 원인바이러스의감염이확인된환자를격리시켜병원내전파를예방할수있다. 9 최근국내에서도급성호흡기감염의원인바이러스에대한연구가활발하게이루어지면서, 지역이나계절에따른유행과원인바이러스에따른임상양상의특성에대해비교적잘알려져있다 하지만, 임상경과가다소상이한신생아를제외한영아만을대상으로급성호흡기감염에대한연구는많지않은것으로알려져있다. 이에저자들은발열과호흡기증상으로입원한생후 28일에서 9일미만영아들을대상으로하여호흡기바이러스검출유무에따른환아들의역학적특성과임상양상의차이를알아보고자하였다. 대상및방법 1. 대상및방법 211년 1월부터 212년 12월까지발열과호흡기증상 ( 기침, 콧물, 코막힘, 가래, 호흡곤란등 ) 을주소로동아대학교병원소아청소년과에입원한생후 28일이상 9일미만의영아 83명을대상으로조사하였다. 발열은병원방문전집에서측정하거나병원에내원하여측정한직장체온이 38 C 이상인경우로정의하였다. 모든대상환아들은혈액검사 ( 전체혈구계산, C-반응단백 ) 와배양검사, 소변분석검사와배양검사, 흉부방사선검사를시행하였다. 소변은무균채뇨백으로검체를얻었고, 소변분석검사에서백혈구수가 1/HPF (high power field) 이상증가하여있거나아질산염이양성일때소변세균배양검사에서단일세균이 1 5 CFU (colony forming unit)/ml 이상인경우를요로감염으로진단하였다. 16 심하게아파보이는 (toxic appearing) 환아에대해서는뇌척수액분석검사를시행하였으며, 백혈구수가 1/mm 3 이상인경우를수막염으로진단하였고, 뇌척수액세균배양검사에서세균이동정된경우를세균수막염으로진단하였다 명의환아들중혈액배양검사가양성이거나수막염이동반된환아는없었으나, 요로감염으로진단된 7명은연구대상에서제외하였다. 호흡기바이러스 7종 ( 아데노바이러스, 인플루엔자 A 바이러스, 인플루엔자 B 바이러스, 메타뉴모바이러스, 라이노바이러스, 호흡기세포융합바이러스, 파라인플루엔자바이러스 ) 역전사중합효소연쇄반응검사 (reverse transcriptase polymerase chain reaction, RT-PCR) 를위해비강인두도말검체 (nasophayngeal swab) 를사용하였다. 비강인두도말검체채취를위해먼저환자콧구멍양끝에서귓불까지의길이를측정하였으며, 검사용기에포함된면봉을측정한길이의절반만큼코의바닥을따라수평으로깊숙이삽입하여적어도 4 5회정도돌려분비물이눈에보일정도의검체를 채취하였다. 검체채취가동일한방법으로이루어지도록하기위해숙련된의사 2명이전담하여검사를시행하였다. 검체로부터바이러스의 RNA를분리한후 random primer로 RT 반응을실시하였으며, Seeplex Respiratory Virus 7 detection kit (Seegene, Seoul, Korea) 로검사한후전기영동하여결과를확인하였다. 급성바이러스성하기도염분류는청진시호기성천명이주로들리고흉부방사선소견이정상이거나과팽창을보이는경우는급성세기관지염, 청진상수포음이주로들리고흉부방사선촬영상폐침범이없으면기관지염, 흉부방사선검사상폐침윤을보이거나청진시악설음이들리는경우는폐렴으로진단하였다. 18 그외, 마른기침, 콧물등의증상만보이는경우는감기로정의하였다. 2. 의무기록고찰의무기록을통해대상환아의나이, 성별, 과거병력, 분만방법, 수유형태, 형제유무, 환아가입원할당시형제의호흡기증상 ( 기침, 콧물, 코막힘, 가래, 호흡곤란등 ) 유무, 입원계절, 입원기간, 발열기간및다양한임상양상 ( 활동력, 보챔, 수유량, 소화기증상, 발진, 호흡곤란, 비정상적인폐음유무등 ) 을후향적으로검토하였다. 빈호흡은 28일 3개월사이영아의평균호흡수 (35±15 breaths/ min) 보다많은경우로정의하였다 통계분석자료분석을위한통계처리는 IBM SPSS Statistics ver. 22. (IBM Co., Armonk, NY, USA) 을이용하여분석하였다. 집단에따른빈도비교는 Pearson 카이제곱을사용하였으며, 기대빈도가 5보다작은경우는 Fisher의정확한검정을사용하였다. 또한, 평균비교는독립 K 표본비모수검정인 Kruskal-Wallis 검정을사용하였다. P 값이.5 미만인경우를통계학적으로유의하다고판단하였다. 결과 1. 검출된호흡기바이러스의종류총 76명중호흡기바이러스가검출된환아 ( 호흡기바이러스양성군 ; respiratory virus positive [RVP 군 ]) 가 45명 (56.3%), 호흡기바이러스검사음성인환아 ( 호흡기바이러스음성군 ; respiratory virus negative [RVN군 ]) 가 31명이었다. RVP군의원인바이러스를분석한결과, 호흡기세포융합바이러스 16명 (35.6%), 라이노바이러스 1 명 (22.2%), 파라인플루엔자바이러스 8명 (17.8%), 메타뉴모바이러스 3명 (6.7%), 인플루엔자 A 바이러스 3명 (6.7%), 아데노바이러스 1명 (2.2%), 파라인플루엔자바이러스와아데노바이러스가같이검출된환아 1명 (2.2%), 파라인플루엔자바이러스와인플루엔자 A 바이러스가같이검출된환아 1명 (2.2%), 파라인플루엔자바이러스와메타뉴모바이러스가같이검출된환아 1명 (2.2%), 호흡기세포 39

3 Bag N, et al. Febrile infants with respiratory symptoms No. of cases 융합바이러스와라이노바이러스가같이검출된환아 1 명 (2.2%) 이 었다 (Fig. 1). 검출된바이러스가적어유행시기가뚜렷하게나타나 지는않았지만가장많이검출된호흡기세포융합바이러스의경우 1 월부터다음해 4 월까지가장많이검출되었다 (Fig. 2). 2. 호흡기바이러스양성군과음성군의비교 1) 인구학적특징 RSV hrv PIV hmpv Flu A ADV Co-inf. Fig. 1. Numbers of detected viruses in respiratory virus positive group. Parainfluenza virus and adenovirus (n = 1), parainfluenza virus and influenza A virus (n= 1), parainfluenza virus and metapneumovirus (n= 1), respiratory syncytial virus and rhinovirus (n= 1). RSV, respiratory syncytial virus; hrv, human rhinovirus; PIV, parainfluenza virus; hmpv, human metapneumovirus; Flu A, influenza virus type A; ADV, adenovirus; Co-inf., co-infection. No. of cases RSV hrv PIV hmpv Flu A ADV Fig. 2. Monthly incidence of detected viruses from 211 to 212. RSV, respiratory syncytial virus; hrv, human rhinovirus; PIV, parainfluenza virus; hmpv, human metapneumovirus; Flu A, influenza virus type A; ADV, adenovirus. 연구대상의평균나이는 RVP 군 1.6±.7 개월, RVN 군 1.7±.7 개월로유의한차이가없었다 (P =.47). RVP 군에서남아의비율 이 62.2% 으로여아보다많았으며, RVN 군에서도남아의비율이 61.3% 로여아보다많았지만, 두군사이에남아의빈도차이는없 었다 (P =.934). 과거병력에서는 RVN 군이 35.5% 로 RVP 군 (13.3%) 에비해유의하게많았다 (P =.23). 출산형태와수유형태 는두군사이에유의한차이가없었다. 형제가있는경우 (RVP, Table 1. Demographic characteristics of enrolled patients Characteristic RVP (n= 45) RVN (n= 31) P-value Age (mo) 1.6±.7 1.7±.7.47 Male sex 28 (62.2) 19 (61.3).934 Past illness 6 (13.3) 11 (35.5).23 Prematurity 2 1 Fever 1 5 Jaundice 1 Congenital disease 1 1 TTN 1 Pneumonia 1 Gastroenteritis 1 2 Delivery type.48 NSVD 28 (62.2) 16 (51.6) C-sec 17 (37.8) 15 (48.4) Feeding type.212 Breast feeding 14 (31.1) 11 (35.5) Formula feeding 5 (11.1) 8 (25.8) Mixed 26 (57.8) 12 (38.7) Having siblings 35 (77.8) 23 (74.2).718 Respiratory symptoms of siblings 23 (51.1) 13 (41.9).431 Values are presented as mean± standard deviation or number (%). RVP, respiratory virus positive; RVN, respiratory virus negative; TTN, transient tachypnea of newborn; NSVD, normal spontaneous vaginal delivery; C-sec, cesarean section. 77.8%; RVN, 74.2%; P =.718) 와입원당시형제가호흡기증상을 가지고있었던경우 (RVP, 51.1%; RVN, 41.9%; P =.431) 는 RVN 군 에비해 RVP 군에서많았으나, 통계학적으로유의한차이는없었 다 (Table 1). 진단명으로분류하였을때, RVP 군에서는폐렴이 21 명 (46.7%) 으 로가장많았고, 다음으로감기 11 명 (24.4%), 기관지염 9 명 (2.%), 세기관지염 4 명 (8.9%) 으로대부분이하기도감염이었으며, RVN 군 에서는감기 22 명 (71%) 으로가장많았고, 다음으로폐렴 4 명 (12.9%), 기관지염 3 명 (9.7%), 세기관지염 2 명 (6.4%) 순이었다 (Fig. 3). 검출된바이러스종류별질환의빈도는호흡기세포융합바이러 스와파라인플루엔자바이러스의경우폐렴이 9 예 (52.9%) 와 5 예 (45.5%) 로가장많았으며, 라이노바이러스의경우감기가 5 예 (45.5%) 로가장많았다 (Fig. 4). 2) 임상양상의특징 입원했던계절은두군사이에유의한차이가없었으며 (P =.16), 입원기간도 RVP 군 6.5±2. 일, RVN 군 6.±1.8 일로유의 한차이가없었다 (P =.279). 발열기간역시 RVP 군 1.9±1.1 일, RVN 군 1.7±1.2 일로유의한차이는없었다 (P =.394) (Table 2). 입원당시부모의주관적인판단에의한환아의활력감소 (RVP, 17.7%; RVN, 12.9%; P =.567), 보챔 (RVP, 13.3%; RVN, 25.8%; 4

4 박누리외 열성호흡기감염영아의임상적고찰 (%) RVP RVN URI Bronchiolitis Bronchitis Pneumonia Fig. 3. Distribution of clinical diagnosis according to the groups. RVP, respiratory virus positive; RVN, respiratory virus negative; URI, upper respiratory tract infection. No. of cases RSV hrv PIV Pneumonia Bronchiolitis Bronchitis URI hmv Flu A ADV Fig. 4. Distribution of detected viruses according to the clinical diagnosis in respiratory virus positive group. RSV, respiratory syncytial virus; hrv, human rhinovirus; PIV, parainfluenza virus; hmpv, human metapneumovirus; Flu A, influenza virus type A; ADV, adenovirus; URI, upper respiratory tract infection. Table 2. Comparison of clinical manifestations between RVP and RVN groups Variable RVP (n= 45) RVN (n= 31) P-value Season of admission.16 Spring 14 (31.1) 1 (32.3) Summer 11 (24.4) 12 (38.7) Fall 6 (13.3) 5 (16.1) Winter 14 (31.1) 4 (12.9) Duration of admission (day) 6.5± 2. 6.± Fever duration (day) 1.9± ± Decreased activity 8 (17.7) 4 (12.9).567 Irritability 6 (13.3) 8 (25.8).168 Poor oral intake 12 (26.7) 8 (25.8).933 Ill looking 17 (37.8) 13 (41.9).716 Gastrointestinal symptoms (vomiting, diarrhea) 2 (4.4) 1 (5.6).789 Skin rash 2 (4.4) 3 (16.7).366 Tachypnea 1 (22.2) 1 (5.6).21 Abnormal lung sound (rales or wheezing) 26 (57.8) 7 (38.9).2 Values are presented as number (%) or mean± standard deviation. RVP, respiratory virus positive; RVN, respiratory virus negative. Table 3. Comparison of laboratory data between RVP and RVN groups RVP (n= 45) RVN (n= 31) P-value WBC 11,221.6± 3, ,642.6± 4, Segment neutrophil (%) 37.6± ± ANC 4,315.1± 2,36.3 4,789.2± 3, CRP 1.6± ± Values are presented as mean± standard deviation. RVP, respiratory virus positive; RVN, respiratory virus negative; WBC, white blood cell; ANC, absolute neutrophil count; CRP, C-reactive protein. P =.168), 그리고식욕감소 (RVP, 26.7%; RVN, 25.8%; P =.933) 는두군사이에유의한차이는없었다. 의사의판단으로환아가아파보이는경우 ( 급성병색 ) 는 RVP군과 RVN군에서비슷하였다 (RVP, 37.8%; RVN, 41.9%; P =.43). 소화기증상과피부발진은 RVN군에서조금더많았으나, 유의한차이는없었다. 빈호흡은 RVP군에서 22.2% 로 RVN군의 5.6% 보다유의하게더많았으며 (P =.21), 나음, 천명음과같은호흡음의이상도 RVN군에비해 RVP군에서유의하게더많았다 (RVP, 57.8%; RVN, 38.9%; P =.2). 3) 검사실소견백혈구는 RVP군 11,221.6±3,313.5/mm 3, RVN군 12,37.5± 3,862.1/mm 3, 분엽핵중성구도 RVP군 38.%±13.1%, RVN군 41.1%±13.4% 로두군사이에유의한차이는없었다 (P =.637, P =.514). C-반응단백역시 RVP군 1.6±2.1 mg/dl, RVN군 2.± 2.2 mg/dl로두군에서유의한차이는없었다 (P =.417) (Table 3). 고찰소아에서발열이동반된호흡기감염의경우연령에따라원인과평가방법이다르며, 특히신생아는미숙한면역체계로인해감염의증상과징후가잘나타나지않기때문에발열로내원한신생아가건강해보이고신체검진에서특이소견이관찰되지않더라도입원하여검사를시행하고항생제를사용하는것이권고된다. 1 따라서, 본연구에서는검사와치료법이다소상이한신생아를제외한생후 28 9일영아만을대상으로하였다. 발열로내원한영아에서흔하게사용되는저위험군진단기준들에는공통으로환아의과거력, 급성병색유무, 신체검진의특이소견, 백혈구와절대호중구수, 소변검사의이상소견등이포함되어있다 본연구에서도과거병력, 임상증상, 신체검진, 백혈구와절대호중구수등의생화학지표를감별인자로조사항목에포함시켰는데, 빈호흡과호흡음이상만바이러스양성군에서유의하게많았다. 이는이번연구에서는발열과함께호흡기증상을호소하는영아들을대상으로 41

5 Bag N, et al. Febrile infants with respiratory symptoms 하였기에결과에서다른연구들과다소차이가있었던것으로생각한다. 급성호흡기감염이의심되는소아에서바이러스를검출하는검사법으로는직접항원검사, 바이러스배양검사, 혈청학적특이항체검출법등이있으나, 이검사들은바이러스검출빈도가 5% 이하로낮았다. 그러나최근에사용하는다중역전사중합효소연쇄반응 (multiplex RT-PCR) 은민감도와특이도가우수한것으로알려져있으며, 14 최근이검사방법을이용한경우대상, 지역, 시기에따라차이가있지만국내소아급성하기도감염환아에서바이러스검출률은 41.8% 83.1% 로높았다. 11,14,15 검출률은연령이어릴수록높았는데, 6개월미만에서 23.6%, 6 11개월 16%, 1세에서 12.3%, 2 세에서 12.4%, 3 5세에서 15.8% 로 6세미만소아에서대부분 (65.6%) 발생하였다. 15 이번연구에서도 56.3% 의검출률을보여다른보고와유사한결과를보였다. 이번연구에서가장많이검출된바이러스는호흡기세포융합바이러스 (37.5%) 와라이노바이러스 (2.%) 로다른국내연구와유사한결과를보였다. 대부분의국내연구에서소아하기도감염의원인으로호흡기세포융합바이러스가가장흔하게검출되었으며, 검출률은 23.7% 35% 정도였다. 8,1,11,13,14 호흡기세포융합바이러스는영아와 2세미만소아바이러스하기도감염 ( 특히, 폐렴과세기관지염 ) 의가장중요한원인병원체이며, 8,17,23 특히 3개월미만의바이러스하기도감염의가장중요한원인 (3명중 1명이상에서 ) 으로, 검출평균연령 (9개월) 도가장낮은것으로알려져있다. 14 입원한영아들에서는호흡기세포융합바이러스 A 감염이질환의중증도와더욱관련이있으며, 24 호흡기세포융합바이러스감염이 Th2 세포의사이토카인분비를촉진시켜천식으로발전된다는보고도있다. 25 국내소아하기도감염환아에서라이노바이러스의검출률은 5.8% 25.6% 로다양하였으며, 28년질병관리본부의자료에의하면우리나라소아에서라이노바이러스가상기도감염의가장흔한원인이지만하기도감염에서의비중은매우낮은것으로나타났다. 26 그러나, 최근연구들에서는라이노바이러스가하기도감염및천식악화의중요한원인으로도주목받고있으며, 15,27,28 특히라이노바이러스 C가라이노바이러스 A보다천식악화로인한입원과연관성이높은것으로보고되고있다. 29,3 이번연구에서호흡기바이러스음성군에비해양성군에서는빈호흡과호흡음이상만이의미있는차이가있었기에, 열성호흡기감염영아에서는현병력이나호흡기증상의가족력보다는환아자신의호흡기증상및호흡음이상유무가호흡기바이러스감염여부를판단하는데있어좀더중요한예측인자가될수있을것으로생각한다. 하지만, 이번연구는호흡기바이러스 7종에대한검사만이루어졌기때문에바이러스음성군이라할지라도 7종에포함되어있지않는다른바이러스에의한감염가능성도배제할수없을것으로생각한다. 열성호흡기감염증의경우원인병원체가세균인지바이러스인 지에따라치료가달라지는데, 바이러스감염의유무를모르는경 우환자의상태나증상의중증도에따라일차적인치료수단으로 항생제를사용하는경우가많은것으로알려져있다. 하지만, 비세 균성감염에서경험적항생제치료를시행할경우항생제오남용뿐 만아니라입원기간연장등환아들에게불필요한치료를행하게 되는결과를가져온다. 과거에비해백신보급률이높아지고위생 환경이좋아지면서중증호흡기감염의원인으로세균감염의빈 도가많이감소하였고, 실제호흡기증상으로중환자실에입원한 소아에서도호흡기바이러스검출률이 66% 로높았으며, 원인바이 러스로는호흡기세포융합바이러스, 라이노바이러스, 아데노바이 러스, 파라인플루엔자바이러스, 인플루엔자바이러스등이검출되 었다는국내보고도있어, 31 소아의중증호흡기감염에서도바이러 스의중요성을간과할수없을것으로생각한다. 본연구에서는대상환자의수가많지않고, 호흡기바이러스 7 종 에대해서만검사가시행되었기에원인으로확인된호흡기바이러 스의종류에따른임상적특징을자세하게조사하지못하였으며, 한개대학병원에입원한환자들을대상으로하였기에지역사회를 대표할수없다는한계점이있다. 또한, 이번연구에서는호흡기바 이러스 7 종에대해서만검사가시행되어졌기때문에, 앞으로이지 역소아의바이러스성하기도감염증의원인과유행의특징을밝히 고치료에도움을줄수있도록더많은수의바이러스를검출할수 있는 multiplex RT-PCR 검사를이용한다기관연구가필요할것으 로생각한다. 이번연구결과에서열성호흡기감염증으로입원한영아의절 반정도에서바이러스가검출되었으며, 특히, 호흡기세포융합바이 러스와라이노바이러스가가장많이검출되었다. 또한, 원인바이 러스가규명된경우는그렇지않은경우보다빈호흡과수포음이 관찰되는경우가더많았다. 이처럼하기도감염을의심할수있는 명확한증상이나징후가있는경우호흡기바이러스검출률이좀 더높으므로환아의증상유무에따라선택적으로호흡기바이러 스검사를시행함으로써불필요한호흡기바이러스검사를줄이는 데도움이될것으로생각한다. 하지만, 이번연구에서는앞에서거 론한바와같은여러가지제한점으로인하여빈호흡이나호흡음 이상이호흡기바이러스검출률이높을것임을추측할수있는귀 중한임상양상이될지에대하여보다체계적인연구가요구되는 바이다. REFERENCES 1. Nield LS, Kamat D. Fever without focus. In: Kilegman RM, Stanton BF, St. Geme JW III, Schor NF, Behrman RE. Nelson textbook of pediatrics. 19th ed. Philadelphia: WB Saunders Co., 211: Nelson DS, Walsh K, Fleisher GR. Spectrum and frequency of pediatric 42

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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