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1 435 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 초음파유도국소신경차단술을이용한하퇴절단술 송재황 강찬 황득수 강동훈 유창현 충남대학교의과대학정형외과학교실 Ultrasound-Guided Regional Nerve Block in Below-Knee Amputation Jae-Hwang Song, M.D., Chan Kang, M.D., Ph.D., Deuk-Soo Hwang, M.D., Ph.D., Dong-Hun Kang, M.D., and Chang-Hyun Yoo, M.D. Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea Purpose: This study compared the clinical results of an ultrasound (US)-guided regional nerve block with those of general anesthesia in below-knee amputation (BKA) surgery. In addition, the 1-year mortality rate of BKA patients was evaluated in relation to the preoperative comorbidity and postoperative hemoglobin level. Materials and Methods: Among 47 patients who underwent BKA between January 2011 and August 2016, 18 patients in the US-guided regional nerve block group (group 1) and 29 patients in the general anesthesia group (group 2) were analyzed retrospectively and compared. For the clinical assessment, the 30-day mortality, 1-year mortality, postoperative hemoglobin level, and postoperative complications of both groups were investigated. The visual analogue scale (VAS) pain scores at postoperative 1, 6, and 12 hours for both groups were evaluated. The 1-year mortality of BKA patients was also evaluated in relation to the preoperative comorbidity and postoperative hemoglobin level (hemoglobin<7 g/dl). Results: Significant differences in the 30-day mortality were observed between the two groups (p=0.023). Group 1 showed a higher 30-day mortality but the 1-year mortality was similar in both groups (p=0.051). The postoperative hemoglobin level was similar in the two groups (p=0.085). The VAS pain scores for the postoperative 1-hour and 6-hour differed significantly between the two groups (p<0.001). The VAS pain scores for postoperative 12-hour showed no significant difference (p=0.10). The 1-year mortality rate of both groups was not affected by hypertension, diabetes mellitus, arteriosclerosis obliterans, and postoperative hemoglobin less than 7 g/dl, but was affected by chronic kidney disease (CKD) (Pearson s chi-square=14.39, p<0.05). Conclusion: Although US-guided regional nerve block showed comparable 1-year mortality and postoperative hemoglobin levels compared to general anesthesia in BKA, it showed better results in postoperative 1, 6 hour pain control than general anesthesia. The 1-year mortality of BKA was affected by CKD. Therefore, careful consideration is needed for patients with CKD before undergoing BKA regardless of the anesthetic methods. Key words: amputation, nerve block, general anesthesia, mortality, comorbidity Received October 11, 2017 Revised November 3, 2017 Accepted November 9, 2017 Correspondence to: Chan Kang, M.D., Ph.D. Department of Orthopaedic Surgery, Chungnam National University School of Medicine, 282 Munwha-ro, Jung-gu, Daejeon 35015, Korea TEL: FAX: faschan@daum.net ORCID: Jae-Hwang Song s current affiliation: Department of Orthopaedic Surgery, Konyang University School of Medicine, Daejeon, Korea Dong-Hun Kang s current affiliation: Daejeon Centum Hospital, Daejeon, Korea 서론 혈관중재술과여러구제수술의발달로외상이나종양등에의한하지절단이감소하여전체대절단 (major amputation) 의수는감소하였다. 1) 그러나평균수명의증가와이에따른당뇨병과말초혈관질환 (peripheral artery disease) 의증가로당뇨와말초혈관질환에의한절단의빈도는증가하는양상을보인다. 특히미국통계에따르면매년 120,000예이상의대절단이시행되고있다. 2) The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 436 Jae-Hwang Song, et al. 그러나대절단을시행받는많은환자에서심각한동반질환이있는경우가많고, 이로인하여최근의수술전후관리의많은발전에도불구하고대절단후의사망률은하퇴절단 (below-knee amputation) 에서 14%, 대퇴절단 (above-knee amputation) 에서 30% 로높게보고되고있다. 3-5) 하퇴절단군에서심근경색, 심부전등의질병이환률과사망률이높게보고되어최근에는이러한부작용을줄이기위한여러연구가진행되었다. 3,6) 최근초음파유도국소신경차단술을이용한하퇴절단에대한연구도보고되었다. 6,7) Lin 등 6) 은초음파유도국소신경차단술군이다른마취군들과비교하였을때 30일사망률에서유의한차이가없다고보고하였다. 그러나다른연구에서는초음파유도국소신경차단술이전신마취로인한심근경색등의심혈관계합병증을줄일수있다고보고하였고, 최근유럽, 미국, 아시아에서는여러하지수술과시술에있어서초음파유도국소신경차단술이전신마취보다합병증과통증조절면에서우수한결과를보인사례들을다수보고하고있다. 7-12) 본저자들은하퇴절단시에초음파유도국소신경차단술이매우유용할것이라고생각하였다. 그러나지금까지하퇴절단시초음파유도국소신경차단술과전신마취의술후사망률과합병증, 술후혈색소의변화, 통증조절에대한전반적인비교연구는지금까지없었다. 이에저자들은초음파유도국소신경차단술을이용하여하퇴절단을시행하여전신마취군과의임상적결과를비교, 분석하고평가하고자하였다. 이와함께술전과거력과술후혈색소가하퇴절단술환자의 1년사망률에미치는영향을분석해보았다. 대상및방법 1. 연구대상본연구의마취와수술은환자의서면동의를얻어시행하였고연구는충남대학교병원임상시험심의위원회 (institutional review board) 의승인을얻어진행되었다. 2011년 1월부터 2016년 8월까지말초혈관질환, 당뇨병성감염성병변등으로하퇴절단을시행한환자 47 예가운데초음파유도신경차단술군 18 예 (1 군 ) 와전신마취군 29예 (2군) 를대상으로후향적연구를진행하였다. 1 군에서국소신경차단술은대퇴신경 (femoral nerve, FN)+ 좌골신경 (sciatic nerve, SCN) 에 9예 (50.0%) 가시행되었고 FN+SCN+ 외측대퇴피부신경 (lateral femoral cutaneous nerve, LFCN), FN+SCN+ 후대퇴피부신경 (posterior femoral cutaneous nerve, PFCN), FN+SCN+PFCN+LFCN에각각 3예 (16.6%) 시행되었다 (Table 1). 본연구에서모든수술과 1군의국소신경차단술은단일술자에의해서수술이시행되었고 2군의전신마취는본원마취과의사에의하여시행되었다. 수술직후통증을호소하게되는 2군에 서도술후통증조절을위하여자가통증조절 (patient controlled analgesia) 장치나정맥주사, 근육주사를이용하여진통제를투여하였다. 2. 마취방법 1) 초음파유도국소신경차단술한명의정형외과의사에의하여병동이나외래에서초음파 (AC- CUVIX V-20; Samsung Medison Co. Ltd., Seoul, Korea) 를이용하여수술전최소한시간이전에국소신경차단술이시행되었다. 마취제는 1% lidocaine 30 ml와 0.75% ropivacaine 20 ml를 50 ml syringe에섞어 23 gauge spinal needle이달린정맥도관에연결하였다. 본저자들의이전보고에서와같은방법으로초음파유도하 LFCN, FN, SCN, PFCN과 spinal needle tip의실시간위치를확인하며선택적으로신경차단술을시행하였다 (Fig. 1). 8,10) 2) 하퇴절단술수술방법하퇴절단은보편적으로시행되는수술방법으로시행되었다. 13) 본저자들은주로하퇴절단단의골길이가 cm 되는부위에서절단술을시행하였다 (Fig. 2). 환측하지가허혈성병변이면후방피판의길이를전방피판의길이보다길게하였고비허혈성병변이면전방피판과후방피판의길이를동일하게하였다. 양군의모든수술에서출혈량을줄이기위하여대퇴근위부에지혈대 (tourniquet) 를착용하였다. 3. 임상적평가술후임상적평가로는양군의술후 30일사망률, 1년사망률, 술후혈색소변화, 술후합병증, visual analogue scale (VAS) 을이용한수술후 1시간, 6시간, 12시간의평균 VAS 통증점수를비교하였고 1군에서는수술중의부작용, 마취효과발현시간, 마취지속시간도함께조사하였다. 또한두군의환자에서술전과거력과술후혈색소 ( 혈색소<7 g/dl) 에따른하퇴절단술환자의 1년사망률을분석해보았다. 모든통계분석에는 SPSS software를이용하였다 (IBM SPSS ver. 22.0; IBM Co., Armonk, NY, USA). 마취방법과과거력, 술후혈색소에따른사망률분석에서는 c 2 test를시행하였고각군의수술전후혈색소비교는 paired t-test를, 양군의술후혈색소비교는 independent t-test를시행하였다. 양군의통증점수비교에서는 Mann-Whitney test를시행하였다. 두군의환자에서술전과거력과술후혈색소 ( 혈색소<7 g/dl) 에따른하퇴절단술환자의 1년사망률을분석시에는 Pearson s chi-square를시행하였다. 모든분석에는통계적유의성을위해 95% 의신뢰구간을두었다.

437 Ultrasound-Guided Regional Nerve Block in Below-Knee Amputation Table 1.

0 (40 82) 66.4 (23 95) Sex (male/female) 12/6 20/9 Follow-up period (mo) 28.5 (12 68) 45.

Anesthesia FN+SCN: 9 FN+SCN+LFCN: 3 FN+SCN+PFCN: 3 FN+SCN+PFCN+LFCN: 3 Diabetic infective lesion: 17 Peripheral artery disease: 8

FN, femoral nerve; SCN, sciatic nerve; LFCN, lateral femoral cutaneous nerve; PFCN, posterior femoral cutaneous nerve.

3 437 Ultrasound-Guided Regional Nerve Block in Below-Knee Amputation Table 1. Demographics of Both Groups Variable Ultrasound-guided regional nerve block group (n=18) General anesthesia group (n=29) Age (yr) 65.0 (40 82) 66.4 (23 95) Sex (male/female) 12/6 20/9 Follow-up period (mo) 28.5 (12 68) 45.6 (12 78) Preoperative diagnosis Diabetic infective lesion: 10 Peripheral artery disease: 7 Post-traumatic osteomyelitis: 1 Anesthesia FN+SCN: 9 FN+SCN+LFCN: 3 FN+SCN+PFCN: 3 FN+SCN+PFCN+LFCN: 3 Diabetic infective lesion: 17 Peripheral artery disease: 8 Acute trauma: 3 Post-traumatic osteomyelitis: 1 General Values are presented as median (range) or number only. FN, femoral nerve; SCN, sciatic nerve; LFCN, lateral femoral cutaneous nerve; PFCN, posterior femoral cutaneous nerve. A B C D Figure 1. Ultrasound images of the lateral femoral cutaneous nerve (A), femoral nerve (B), sciatic nerve (C), posterior femoral cutaneous nerve (D) are shown. The dotted circles indicate the injected nerve with a spinal needle that is also indicated by the white arrows.

438 Jae-Hwang Song, et al. A B Figure 2. (A) A 66-year-old female diagnosed with arteriosclerosis obliterans had an acute ischemic gangrenous change in her right foot.

Configuration of the Results in Both Groups Variable Ultrasound-guided regional nerve block group (n=18) General anesthesia group (n=29) p-value 30-day mortality 3 (16.7) 0 (0.0) 0.

4 438 Jae-Hwang Song, et al. A B Figure 2. (A) A 66-year-old female diagnosed with arteriosclerosis obliterans had an acute ischemic gangrenous change in her right foot. (B) Belowknee amputation was performed in emergency under an ultrasound-guided nerve block. Table 2. Configuration of the Results in Both Groups Variable Ultrasound-guided regional nerve block group (n=18) General anesthesia group (n=29) p-value 30-day mortality 3 (16.7) 0 (0.0) year mortality 5 (27.8) 2 (6.9) Postoperative hemoglobin (g/dl) 8.5± ± Postoperative 1 hour VAS 0.7± ±0.96 <0.001 Postoperative 6 hours VAS 1.1± ±0.76 <0.001 Postoperative 12 hours VAS 3.9± ± Operative duration (min) 115.0± ± Values are presented as number (%) or mean±standard deviation. VAS, visual analogue scale. 결과 양군모두에서수술중생체징후변동에의한문제는없었고다른마취로의전환도없었다. 술후 30일사망률은 1군에서 3예사망하여 16.7% 였고, 2군에서는아무도사망하지않았으며이는통계적으로유의한차이를보였다 (p=0.023). 술후 1년사망률은 1군에서 5예사망하여 27.8%, 2군에서는 2예사망하여 6.9% 였고, 이는통계적으로유의한차이를보이지않았다 (p=0.051). 술후평균혈색소는 1군에서 8.5±1.23 g/dl, 2군에서 9.2±1.20 g/dl로양군모두에서술전혈색소 (1군-9.9±1.50 g/dl, 2군-10.4±0.99 g/dl) 에비해유의하게감소하였으나 (p<0.05) 두군의술후혈색소수치는유의한차이가없었다 (p=0.085). 수술후합병증으로 1군에서는상처봉합부위괴사 3예, 상처부위감염 1예, 근위부로의혀혈성괴사진행 1예가보고되었고, 2군에서는상처봉합부위괴사 4예, 상처부위감염 3예, 심부비골신경절단단의신경종 1예가보고되었으며이들모두는합병증에대한재수술이시행되었 다. 수술후 1시간, 6시간, 12시간의평균 VAS 통증점수는 1군에서각각 0.7±1.03 (0-3), 1.1±1.23 (0-4), 3.9±0.87 (3-6) 이고 2군에서는각각 7.9±0.96 (6-9), 6.8±0.76 (6-8), 4.6±1.32 (3-8) 였다. 수술후 1시간, 6시간의 VAS 통증점수는양군에서통계적으로유의한차이가있었으나 (p<0.001) 12시간후의 VAS 통증점수는유의한차이가없었다 (p=0.10). 1군에서수술중부작용으로지혈대통증 (tourniquet pain) 이 4예에서관찰되었고과장된통증호소와상황에맞지않는의사표현을하는기이성흥분 (paradoxical hyperexcitation) 이 1예에서관찰되었다. 14,15) 국소마취효과발현시간은평균 27.8±9.5분 (10-60분) 이었고마취지속시간은 10.1± 2.2시간 ( 시간) 이었다. 평균수술시간은 1군에서 115.0분 (80-180분), 2군에서 123.4분 (80-200분) 으로유의한차이가없었다 (p=0.13) (Table 2). 두군의 1년사망률은고혈압 (p=0.18), 당뇨 (p=0.18), 폐쇄성동맥경화증 (p=0.05), 술후 7 g/dl 미만의혈색소 (p=0.85) 와유의한상관관계가없었으나만성신부전과는유의한상관관계가있었다

5 439 Ultrasound-Guided Regional Nerve Block in Below-Knee Amputation (Pearson s chi-square=14.39, p<0.05). 고찰 Aragón-Sánchez 등 3) 에의하면 75세이상의환자, 수술후폐합병증이나심장합병증이동반된환자에서사망률이유의하게높았고, 수술후상처와관련된합병증이발생한환자나당뇨환자에서는유의하게높지않았다고보고하였다. Aulivola 등 4) 은대절단환자에서장기간생존율에영향을유의하게미치는요소는당뇨와만성신부전의과거력이라고보고하였다. 본연구에서하퇴절단술후 1년사망률은고혈압, 당뇨, 폐쇄성동맥경화증과는연관이적었으나만성신부전과는유의하게연관성이높았다. 저자마다과거력에따른하퇴절단술후의생존율, 사망률결과가다른이유에대하여 confound bias, selection bias에대한체계적인고찰이필요하고추후다기관무작위임상연구가필요할것으로생각된다. 최근에는하퇴절단술에서마취방법에따른임상적결과의차이가보고된바있다. 6) 이전의연구에서도허혈성말초혈관질환환자또는당뇨족환자의족부, 족관절수술에서국소신경차단술의유용성및우수한임상적결과가보고되었다. 16) 고위험당뇨족환자의수술시 Gutman 등 17) 은전신마취군이나척추마취군에서이환율과사망률이 20% 이상이었지만 Kaufman 등 16) 은국소신경차단술군에서 30일사망률이 4% 로감소하였다고보고하였다. 하퇴절단에서도초음파유도국소신경차단술을이용하면전신마취전필요한술전검사의시간적, 경제적비용을줄일수있고전신마취후발생하는심혈관계합병증등의부작용을감소시킬수있다. Bech 등 7) 은초음파유도국소신경차단술을이용하여아무런마취, 수술후합병증없이대절단을시행한사례를보고하였다. 초음파유도하국소신경차단술의다른장점은수술직후통증을호소하게되는전신마취와달리마취효과가수시간지속되어술후통증조절에도효과가있다는점에있다. 8,10,12) 따라서저자들은초음파유도하국소신경차단술을이용하여하퇴절단을시행하면전신마취후에발생할수있는여러합병증을감소시킬수있을뿐아니라수술직후의통증조절에효과적일것으로생각하였다. Lin 등 6) 의연구에서는대퇴절단과하퇴절단시행시 30일사망률의결과만비교하였고합병증과통증조절의효과에대해서는연구가진행되지않았다. 또한 Lin 등 6) 은국소신경차단술시 FN, SCN, 복재신경 (saphenous nerve), 슬와신경 (popliteal nerve) 에주입했다고기술하였지만이는결국 FN, SCN만마취하는결과를보이므로 LFCN, FN, SCN, PFCN을차단한본저자들의술기가대퇴근위부에지혈대착용이필요하고하퇴부의근위부까지수술이이루어지는하퇴절단술에더적합하다고생각한다. 본연구에서술후 30일사망률은 1군에서 16.7%, 2군에서 0% 로 1군에서오히려사망률이유의하게높았다. 이는 Lin 등 6) 의연구에서초음파유도국소신경차단술군이다른마취군들과비교하였을때 30일사망률에서유의한차이가없다는결과와차이가있었다. 본연구의결과는국소신경차단술군이전신마취군보다단기간사망률이적을것이라는저자들의예상과는반대의결과였는데, 이는연구해당기간초기에술전검사상보다안정적인환자에게는전신마취를주로시행하고국소신경차단술은당뇨족환자에서패혈증이진행되거나말초혈관질환환자에서급성으로허혈성병변이근위부로진행되는경우와같이생체징후가불안정한환자에서우선적으로시행되었기때문이다. 1군에서술후 30일이내사망한 3예모두에서공통적으로고혈압, 당뇨, 만성신부전, 폐쇄성동맥경화증의과거력이보고되었다. 술후 1년사망률은양군간의유의한차이가없었다. 양군의술후혈색소는유의한차이가없었다. 이는두군모두에서대퇴근위부에지혈대를착용하여수술중출혈을최소화하였기때문으로생각된다. 지혈대통증은보통국소신경차단환자에서지혈대압력상승후 1시간째발생하는데본저자들은 1 군에서이러한상황을미리방지하기위하여최대한 FN, SCN, PFCN의최대한근위부에서신경차단술을시행하였고경우에따라서 LFCN의마취도시행하였다. 15) 또한지혈대통증이일어나면지혈대압력을감소시켜야하므로이러한상황이발생하기전에최대한빨리하퇴부대혈관들의결찰을시도하였다. 수술중, 수술후혈색소가많이감소한경우에는농축적혈구 (packed red blood cells, PRC) 수혈을시행하였는데술후 3일이내의기간동안 PRC 수혈을 1군에서는 400 ml 2예, 800 ml 6예시행하였고 2 군에서는 400 ml 8예, 800 ml 5예, 1,200 ml 3예를시행하였다. 술후 7 g/dl 미만의혈색소와 1년사망률의연관성이통계적으로유의하지않다는것에서는이러한수혈의효과가작용한것으로생각된다. 본연구에서술후합병증으로 1군에서는상처봉합부위괴사 3예, 상처부위감염 1예, 근위부로의혀혈성괴사진행 1예가보고되었고, 2군에서는상처봉합부위괴사 4예, 상처부위감염 3예, 심부비골신경절단단의신경종 1예가보고되었다. Ploeg 등 18) 은하퇴절단후 10.4% 에서수술부위감염, 7.8% 에서상처부위괴사등의합병증이발생한다고보고하였다. 1군에서수술중부작용으로지혈대통증이 4예에서관찰되었고기이성흥분이 1예에서관찰되었다. 14,15) 지혈대통증은수술후평균 55.6분에호소하였는데환자가수술부위와상관없는대퇴부통증을호소시즉시지혈대커프의압력을감소시켜통증을해결하였고기이성흥분을보인환자에게는 flumazenil을투여하여이상증세를가라앉혔다. 본연구에서수술후 1시간, 6시간의통증점수는양군에서통계적으로유의한차이가있었으나 12시간후의통증점수는유의한차이가없었는데, 이결과의원인으로는수술직후통증을느끼는전신마취와달리 1% lidocaine 30 ml와 0.75% ropivacaine 20

6 440 Jae-Hwang Song, et al. ml를사용한 1군의평균국소마취지속시간이 10.1시간이었기때문이라고생각한다. 8,10) 저자들은하퇴절단시환자들이전신마취에서회복하여극심한통증을호소하게되므로국소신경차단이야말로술후통증조절에매우효과적일것이라고주장한다. 본연구의제한점으로는후향적연구라는점과장기간추시가이루어지지않았다는점이다. 다른연구에서는술후 2년사망률, 5년사망률에서도조사가이루어졌지만본연구는비교적짧은추시기간동안이루어졌다. 술후사망률및다른임상적결과비교시시험군과대조군의과거력, 나이, 성별등의여러요인들을동일하게설정하지않고연구를진행하였으므로 selection bias, confound bias의가능성을배제하지못한다. 본연구에척추마취군을포함시키지않은것과참여한환자군이상대적으로적었다는것도제한점을가진다. 또한술후통증의조사에서는수술부위의통증만조사되었고절단술후흔히발생될수있는환상지통및환상지감각에대한조사는시행되지않았다. 19) 결론 하퇴절단에서초음파유도신경차단술은전신마취와 1년사망률, 술후혈색소비교에서유의한차이는없었으나수술후의통증조절에서우수한결과를보였다. 술전과거력중에서는만성신부전이하퇴절단술후 1년사망률과유의한상관관계가있었다. 초음파유도신경차단술은하퇴절단시효과적인마취방법의하나로고려될수있으나만성신부전환자에서는마취방법과상관없이주의하여선택적으로사용해야할것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. 2009;50: Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to Arch Phys Med Rehabil. 2008;89: Aragón-Sánchez J, Hernández-Herrero MJ, Lázaro-Martínez JL, et al. In-hospital complications and mortality following major lower extremity amputations in a series of predominantly diabetic patients. Int J Low Extrem Wounds. 2010;9: Aulivola B, Hile CN, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139:395-9; discussion Subramaniam B, Pomposelli F, Talmor D, Park KW. Perioperative and long-term morbidity and mortality after aboveknee and below-knee amputations in diabetics and nondiabetics. Anesth Analg. 2005;100:1241-7, table of contents. 6. Lin R, Hingorani A, Marks N, et al. Effects of anesthesia versus regional nerve block on major leg amputation mortality rate. Vascular. 2013;21: Bech B, Melchiors J, Børglum J, Jensen K. The successful use of peripheral nerve blocks for femoral amputation. Acta Anaesthesiol Scand. 2009;53: Kim YM, Joo YB, Kang C, Song JH. Can ultrasound-guided nerve block be a useful method of anesthesia for arthroscopic knee surgery? Knee Surg Sports Traumatol Arthrosc. 2015;23: Marcus AJ, Lotzof K, Kamath BS, et al. A new approach: regional nerve blockade for angioplasty of the lower limb. Cardiovasc Intervent Radiol. 2006;29: Song JH, Kang C, Hwang DS, Hwang JM, Shin BK. Fentanyl patches to supplement ultrasound-guided nerve blocks for improving pain control after foot and ankle surgery: a prospective study. J Foot Ankle Surg. 2016;55: Yazigi A, Madi-Gebara S, Haddad F, Hayeck G, Tabet G. Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks. J Clin Anesth. 2005;17: Song JH, Kang C, Hwang DS, Hwang JM. Ultrasound-guided nerve block for skin grafting on large diabetic ulcer of foot and leg: a technical report. J Korean Foot Ankle Soc. 2014;18: Canale ST, Beaty JH. Campbell's operative orthopaedics e-book. 12th ed. Philadelphia (PA): Elsevier Mosby; Thurston TA, Williams CG, Foshee SL. Reversal of a paradoxical reaction to midazolam with flumazenil. Anesth Analg. 1996;83: Cole F. Tourniquet pain. Curr Res Anesth Analg. 1952;31: Kaufman JL, Stark K, Shah DM, Chang BB, Koslow AR, Leather RP. Local anesthesia for surgery on the foot: efficacy in the ischemic or diabetic extremity. Ann Vasc Surg. 1991;5: Gutman M, Kaplan O, Skornick Y, Klausner JM, Lelcuk S,

7 441 Ultrasound-Guided Regional Nerve Block in Below-Knee Amputation Rozin RR. Gangrene of the lower limbs in diabetic patients: a malignant complication. Am J Surg. 1987;154: Ploeg AJ, Lardenoye JW, Vrancken Peeters MP, Breslau PJ. Contemporary series of morbidity and mortality after lower limb amputation. Eur J Vasc Endovasc Surg. 2005;29: Borghi B, D'Addabbo M, White PF, Gallerani P, Toccaceli L, Raffaeli W, et al. The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesth Analg. 2010;111:

8 442 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 초음파유도국소신경차단술을이용한하퇴절단술 송재황 강찬 황득수 강동훈 유창현 충남대학교의과대학정형외과학교실 목적 : 하퇴절단술시시행되는마취방법중초음파유도국소신경차단술과전신마취가임상적결과에미치는영향을비교분석 하고자하였다. 또한술전과거력과술후혈색소 (hemoglobin) 에따른하퇴절단술환자의 1년사망률을분석해보았다. 대상및방법 : 2011년 1월부터 2016년 8월까지말초혈관질환, 당뇨병성감염성병변등으로하퇴절단을시행한환자 47예가운 데초음파유도신경차단술군 18 예 (1 군 ) 와전신마취군 29 예 (2 군 ) 를대상으로하였다. 술후임상적평가로는양군의술후 30 일사 망률, 1 년사망률, 술후혈색소의변화, 술후합병증, visual analogue scale (VAS) 을이용한수술후 1 시간, 6 시간, 12 시간의평균 VAS 통증점수를비교하였다. 또한양군의환자에서술전과거력과술후혈색소 ( 혈색소 <7 g/dl) 에따른하퇴절단술환자의 1 년사망률을분석해보았다. 결과 : 술후 30 일사망률은 1 군에서 3 예사망하여 16.7% 였고, 2 군에서는아무도사망하지않았으며이는통계적으로유의한차이를 보였다 (p=0.023). 술후 1 년사망률은 1 군에서 5 예사망하여 27.8%, 2 군에서는 2 예사망하여 6.9% 였고, 이는통계적으로유의한차 이를보이지않았다 (p=0.051). 술후평균혈색소는 1 군에서 8.5 g/dl, 2 군에서 9.2 g/dl 로양군모두에서술전혈색소에비해유의 하게감소하였으나두군의술후혈색소수치는유의한차이가없었다 (p=0.085). 수술후 1 시간, 6 시간의 VAS 통증점수는양군에 서통계적으로유의한차이가있었으나 (p<0.001) 12 시간후의 VAS 통증점수는유의한차이가없었다 (p=0.10). 두군의 1 년사망률은고혈압, 당뇨, 폐쇄성동맥경화증, 술후 7 g/dl 미만의혈색소와유의한상관관계가없었으나만성신부전과는유의한상관관계가 있었다 (Pearson s chi-square=14.39, p<0.05). 결론 : 하퇴절단에서초음파유도신경차단술은전신마취와 1 년사망률, 술후혈색소비교에서유의한차이는없었으나수술후 1 시간, 6 시간의통증조절에서우수한결과를보였다. 술전과거력중에서는만성신부전이하퇴절단술후 1 년사망률과유의한상관 관계가있었다. 초음파유도신경차단술은하퇴절단시효과적인마취방법의하나로고려될수있으나만성신부전환자에서는마 취방법과상관없이주의하여선택적으로사용해야할것으로생각된다. 색인단어 : 절단술, 신경차단술, 전신마취, 사망률, 동반질환 접수일 2017 년 10 월 11 일수정일 2017 년 11 월 3 일게재확정일 2017 년 11 월 9 일책임저자강찬 35015, 대전시중구문화로 282, 충남대학교의과대학정형외과학교실 TEL , FAX , faschan@daum.net ORCID 송재황저자현소속 : 건양대학교병원정형외과. 강동훈저자현소속 : 대전센텀병원. 대한정형외과학회지 : 제 53 권제 5 호 2018 Copyright 2018 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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