86 Hanyang Medical Reviews Vol. 31, No. 2, 2011 nal pain syndrome), 허혈성만성통증질환 (angina pain) 등에이용되고있고효과가좋은편이다. 저자는본논문에서척수자극술에관련된적응증, 작용기전, 수술방법및환자관리등에대

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1 HANYANG MEDICAL REVIEWS Vol. 31 No. 2, 만성통증에대한척수자극술치료법 Spinal Cord Stimulation for Control of Chronic Pain 김영수한양대학교의과대학신경외과학교실 Young Soo Kim, M.D., Ph.D. Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Korea 책임저자주소 : , 서울성동구행당동 17 번지 한양대학병원신경외과 Tel: , Fax: ksy8498@hanyang.ac.kr 투고일자 : 2011 년 4 월 8 일심사일자 : 2011 년 4 월 28 일게재확정일자 : 2011 년 5 월 13 일 Abstract Spinal cord stimulation (SCS) has undergone a variety of technical modifications and advances and has been applied to a variety of pain conditions. The group of patients in which SCS has been most commonly applied is those with chronic back and leg pain, failed back surgery syndrome (FBSS), complex regional pain syndrome or other ischemic pain syndromes. Goal of its treatment is palliative treatment and suppression of severity of pain intensity and frequency, although the mechanism of action of SCS has not been well known. The author reviews indications, surgical techniques, mechanism of action of SCS and management of the patient. Key Words: Failed back surgery syndrome, Chronic pain, Spinal cord stimulation 서론만성통증에대한치료는어려운점이많다. 그이유로는정확한병태생리가밝혀져있지않으며또한정신신체장애가포함되기때문이다. 하지만여러방향에서치료는시도되어왔다. 만성통증에대한치료는그목표에따라다양한치료방법을선택할수있다. 이는다른말로하면만성통증의치료가어려우므로다양한치료방법을시도해볼수있다는이야기와같다. 통증의치료는그원인치료로이루어질수있으나만성통증의경우는이와는다른치료방법이선택된다. 특히체성통증과신경인성통증이복합된척추수술후통증증후군과같은경우통증의양상에따른다양한치료방법을선택할수있으며또한치료목표또한통증완화를목표로하는경우가주를이룬다. 특히신경완화시술법의이용으로척수자극술의이용이활발해지고있다. 척수자극술은 1967년도 Shealy 등 7 이최초로척수강내전극자극술및척수경막외전극자극술을시행한것을처음으로보고한이후에최근까지여러형태의전극및전류발생장치가개발되어신경인성통증및여러불인통에널리사용되고있다. 이시술의기전으로는 1965년 Melzack과 Wall 4 의 Gate- Control 이론을근거로시작되었다. 이이론에따르면척수의후각에서촉감과진동감을전달하는 A-beta 구심신경이통증을전달하는 C 와 A-delta 구심신경의중추신경계로의통증전달을조절하는것이다. 이를근거로 Shealy 7 가처음으로척수강내전극자극술을시도하였으나당시에는신경생리기전이잘알려져있지않았다. 그러나최근에신경생리학적연구가발달하여척수자극술의효과는전극접촉척수부위와상척수부에서척수후각내연결신경세포 (interneuron) 들간에전기적작용과신경화학적기전으로통증조절을설명하고있다. 임상적으로는장기간에걸친여러가지통증치료법들과물리치료에전혀반응하지않는만성요통의경우에척수자극술을고려해볼수있다. 척추수술후증후군 (failed back surgery syndrome), 복잡국부통증증후군 (complex regio-

2 86 Hanyang Medical Reviews Vol. 31, No. 2, 2011 nal pain syndrome), 허혈성만성통증질환 (angina pain) 등에이용되고있고효과가좋은편이다. 저자는본논문에서척수자극술에관련된적응증, 작용기전, 수술방법및환자관리등에대하여설명하고자한다. 본론 척수자극술은어떠한환자에적용이가능한가? 우선만성통 증환자들중에서신경인성통증이동반된환자가좋은결과 를보인다. 대표적인질환으로척추수술후증후군 (failed back surgery syndrome, or postoperative back pain), 복 잡국부통증증후군 (complex regional pain syndrome), 마 미총손상후통증, 척수손상후통증들과허혈성질환통증대 표적으로심근경색증으로동반되는만성흉통에도효과적이 다 (Table 1). 예를들어설명하면한환자가요통및방사통 으로, 추간판제거술, 신경공확장술, 그리고척추유합술등 수술을받게되어해당신경근분포지역에심한통증이지속 되며, 감각둔마및근력의약화그리고이질감을호소하는 경우이다. 이런환자가강한진통제를복용해도통증조절이 안되며, 신경블럭을하여도일시적으로통증이감소하나이 후다시재발하는환자의경우에척수자극술은효과적이다. 이에반하여척수자극술을할수없는경우로는내과적수술 부적응증, 정신과적문제, 심박동기를사용해야할경우등 이다 (Table 2). 수술에사용되는기기는체내척추경막외에삽입하는전극 이있다. 전극은와이어형과패들형이있다. 와이어형은 4 극 과 8 극이있으며전극의노출사이즈와전극간의간격에따 른여러가지형태가있다. 이는경피적으로척수외강에로바 Table 1. Indications to Spinal Cord Stimulation Failed Back Syndrome (FBS) or low back syndrome or failed back Radicular pain syndrome or radiculopathies resulting in pain secondary to FBS or herniated disk Postlaminectomy pain Multiple back operations Unsuccessful disk surgery Degenerative Disk Disease (DDD Peripheral causalgia Epidural fibrosis Arachnoiditis or lumbar adhesive arachnoiditis Complex Regional Pain Syndrome (CRPS) 늘을찌르고삽입하는것이다. 패들형은국소마취하에척수 후궁을미세절제한후척추경막외로삽입한다. 8 극과 16 극 의두가지형태가있다. 이러한전극과연결되는전류발생장 치가있다. 이장치는재충전이가능한것과일회용두가지 가있으며현재크기에따라몇가지가있다. 수술의방법은방사선투시기하에환자를엎드린채로요추 부를소독한다. 이후국소마취를한후토이바늘 (14 게이지 ) 을척추경막외에삽입한다. 이후와이어형전극을방사선투 시기모니터링하에바늘을통하여전극을삽입한다. 예를들 면제 4-5 요추신경근부위에심한통증을가진환자이면제 8 흉추높이까지전극을삽입한다. 이때전극은 8 극을사용 하는것이편리하다. 이후체외전류발생장치와전극을연결 하여각전극에자극을보내어테스트를한다. 이때환자가 호소하는통증부위를전부포함되는것을확인해야한다. 전 기자극으로인한저린감이허리나다리혹은발목등에오는 것을확인하면서전극의위치를조절할수있다. 전극자극시 험으로통증이있는부위에저린감이오는것을확인하면전 극에외부전극연결장치를연결한후에전극을고정하고수 술을마친다. 이후병실에서체외전류발생장치에연결하여 실제로통증이어느정도호전되는지를수일간관찰한다. 이 때환자가입원전에호소하는통증내용과통증의빈도와그 강도를기록하였다가시술후전기자극후변화를기록한다. 수일간테스트기간동안통증의빈도와강도가 50% 이상줄 어들고환자가만족하게되면체내전류발생장치를삽입한다 (Fig. 1). 일반적인척수자극술의임상효과로는우선신경인성통증 과교감신경유도통증에효과가있고, 전기자극시발생하 는저린감이통증부위를포함해야통증이조절된다. 만성통 증에효과적이고급성통증에는효과가없다. 통증의성질에 따라서는작열감통증과이질통 (allodynia) 을동반한경우 Table 2. Contraindications to Spinal Cord Syndrome Medical Coagulopathy Sepsis Psychological or Behavioral Untreated major cormobidity Serious drug-related behavioral problems Inability to cooperate Secondary gain Technical Demand cardiac pacemaker Magnetic resonance imaging needs

3 Spinal Cord Stimulation for Control of Chronic Pain 87 Fig. 1. These pictures show postoperative finding of spinal cord stimulation. Electrode is located in the level of T8-9 and implantable pulse generator is inserted into subcutaneous space of left flank. 효과적이다. 자극을하면수분후에통증이감소하며, 수분 혹은수시간자극후에는통증완화가지속되는현상을보인다. 3, 5 척수자극술의기전을확실히밝혀져있지않지만다음과같 이설명하고있다. 척수에위치한전극은전자가이동하는음 극에서자극이이루어진다. 전극은음극과양극으로임의로 정할수있다. 음극 (cathode) 에접촉된신경세포는과이온 화 (hyperpolarized) 되며이후에활동전위 (action potential) 의전달이감소하게된다. 또한직경이굵은구심신경섬 유는음극부위에서쉽게자극된다. 이구심신경이척수후각 에서 gate 를닫게된다. 일반적으로통증부위의저린감을 만들기위해서는해당감각부위의상방을자극한다. 전극이 중앙에있는경우우선배주 (dorsal column) 내굵은구심신 경이자극되어 gate 를닫게되어야한다. 전기량이올라가 서후각으로들어오는구심신경을직접자극하는것은기본 적전기자극술로인한통증조절보다는불쾌감을줄수있 다. 하지만척추수술후증후군중에 battered root syndrome 에의한통증인경우손상이예상되는구심신경근을직접자극해야통증을완화시키는경우도있다. 1, 2 전기자극시전류량을크기조절에는기본적인자극방법이 있다. 우선전류를올리면처음저린감을느끼는감작역치 (perception threshold) 시점의전류량에서, 더증가시키면 저린감이심해서참기어려운불편역치 (discomfort threshold) 시점의전류량이치료범위에해당된다. 따라서각전극이자극되는부위와통증부위완화정도를일일이검토하여자극을시행해야한다. 척수전기자극시자극이말초신경으로도전달되는데이때에말초신경의일차구심신경의전도능력을감소시켜통증을완화시키기도한다. 전기자극빈도가높으면배주내로넘어가는일차구심신경의척수후각내로의분지를차단하게된다. 대개의경우환자가통증조절에효과적인주파수는최고 Hz이며낮은경우에는통증을악화시킨다. 동물실험에의하면척수자극시척수후각내유발자극이척수시상회로를억제하는효과를보이며또한중추신경계에서 anterior pretectal nucleus ( 전방전개핵 ) 가자극이되어 descending inhibitory system ( 하방억제회로 ) 이활성화되는것을보고하고있다. 전기자극형태에따른효과는음극과양극의거리와위치에따라결정된다. 음극이전류를보내척수를자극하는부위를형성하는데이때양극이가까운거리에위치하면자극범위가양극에끌려가는형태를보이나만일양극이멀리위치하면음극의자극형태는일정한둥근모양을보이게된다. 특히전류가척수내로많이들어가기위한전기자극형태를만드는것이통증조절효과에중요한인자가된다. 전기자극의효과는후주의약 0.25 mm 이내에서위치하는 A-beta 신

4 88 Hanyang Medical Reviews Vol. 31, No. 2, 2011 경섬유에해당한다. 후주는중심에서외측으로갈수록신경 섬유의굵기가굵어진다. 사람에게척수자극술후에신경화학적변화에대한연구는 없으나여러실험모델로척수후각내변화에대한보고들이 있다. 이에따르면전기자극은척수후각내 gamma amino butyric acid (GABA), substance P (SP), 5-HT, glycine 분 비를유도한다. 또한 Glutamate, aspartate, 기타 excitatory amino acid 분비를감소를유도한다. 1 신경생리학적면에서척수자극술의효과를보면, 전기자극 은분명히 A-beta 구심신경에주작용을한다. 또한척수후각 내의 wide dynamic range (WDR) neuron 이손상된신경 에서의만성적자극에따라신경병증통증을유발하게된다. 척수전기자극은이효과를억제한다. 5, 6 교감신경계에대한척수전기자극의효과도분명하다. 협심 증이나허혈성통증동물모델에서실험한결과에따르면협 심증에의한통증모델에서통증의절반을감소시키며허혈 성모델에서는말초혈관확장현상을동반하면서통증감소 효과를보인다. 이는척수후각내에 WDR neuron 의억제와 구심성교감신경의억제및원심성교감신경에대한 antidromic ( 역방향의 ) 효과를모두보인다. 전기자극술의프로그램은환자주관적통증에따라환자마 다다르게조절해야한다. 기본적으로각전극의음극과양극 을정해야하며정한전극에각기자극빈도 (frequency, Hz) 그리고전기파의폭 (pulse width) 그리고전류의크기 (amplitude) 그리고자극시간과휴식시간을정하는것이 다. 위에서설명하였던바와같이환자가통증을호소하는부 위에감작역치이상의전기가가도록한다. 척추수술후증후군은, 문헌에의하면수술후 10% 에서 40% 의환자에서발생한다고보고되고있다. 그원인으로는부적 절한수술대상선택, 수술시의신경손상, 기술적실패, 과다 한유합, 수술후섬유화, 지주막염등이원인이된다. 척추수 술후증후군의일부는재수술의적응이되지않으며대개의 환자는보존적인치료에반응하지않아난치성만성통증으 로진행하게된다. 그리고이때척수자극술은최소침습적인치료의한방법으로선택되어질수있다. 8 치료의결과는효과적이다. 일차수술후테스트기간에양성 반응을보인환자의경우일반적으로 60-70% 의통증감소를 보인다. 저자의경우척추수술후증후군환자의 8 명에서모 두 70% 이상의 Visual analog scale ( 시통증계 ) 의통증호전 을보였으며 2 명의복잡국부통증증후군환자들에서 60% 이 Table 3. Potential Complications and Adverse Effects of Spinal Cord Stimulation Spinal cord or nerve injury Cerebrospinal fluid leakage Infection Bleeding Hardware failure Electrode migration or malposition Electromagnetic field exposure 상의통증감소를보였다. 척수자극술에서성패에가장큰영향을미치는요인은전극 의위치로, 환자의증상과일치하는부분에이식하는것을원 칙으로하여상지에증상이있을때는경추부, 하지에증상이 있을때는흉추부에전극을위치시킨다. Barolat 등 1 은상지 통에는경추제 5, 6 번, 하지통에는흉추제 10, 11 번에전극 을위치시켜야한다고하였고, 혹은상지통에는경추제 3, 4 번, 하지통에는흉추 9, 10 번에위치시켜야한다고하였다. 척수자극술후에발생하는합병증으로는감염과전극이부 러지거나혹은빠지는현상이발생할수있다. 감염이되는 경우는부득이하게제거해야한다. 그리고 3 개월후에다시 삽입하면된다. 일상생활혹은과도한허리운동으로전극이 많이움직이게되면부러지거나빠질위험이있다. 따라서처 음수술시전극의고정에신중하여야하며만일빠지거나부 러지면전극을다시삽입하여야한다 (Table 3). 결론 약물로통증이조절되지않으며, 신경블록과같은중재적치 료에도불구하고통증이조절되지않는만성통증의경우신 경인성통증이포함된환자에서는척수자극술로훌륭한통 증조절효과를기대할수있다. 척수자극술의치료기전은 확실히알려지지않았다. 그러나, 척수자극술은만성적으로 유발되는통증이척수후각내신경세포의변화를일으켜발 생되는만성통증을조절할수있으며, 또한적절한전류조절 프로그램을사용하여통증을다양한방법으로조절할수있 으므로, 맞춤형통증조절도가능하다. 만성통증에시달리 는많은환자에게각환자에게맞는척수자극프로그램을적 용하여서서히통증을경감시켜는치료법이다.

5 Spinal Cord Stimulation for Control of Chronic Pain 89 References 1. Barolat G, Oakley JC, Law JD, North RB, Ketcik B, Sharan A. Epidural spinal cord stimulation with a multiple electrode paddle lead Is effective in treating intractable low back pain. Neuromudulation 2001;4: Bennett DS, Aló KM, Oakley J, Feler CA. Spinal cord stimulation for complex regional pain syndrome I [RSD]: a retrospective multicenter experience from 1995 to 1998 of 101 patients. Neuromudulation 1999;2: Feirabend HK, Choufoer H, Ploeger S, Holsheimer J, van Gool JD. Morphometry of human superficial dorsal and dorsolateral column fibres: significance to spinal cord stimulation. Brain 2002;125: Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150: Meyerson BA, Linderoth B. Mode of action of spinal cord stimulation in neuropathic pain. J Pain Symptom Manage 2006;31:S Oakley JC, Weiner RL. Spinal cord stimulation for complex regional pain syndrome: a prospective study of 19 patients at two centers. Neuromudulation 1999;2: Shealy CN, Mortimer JT, Reswick JB. Electrical inhibition of pain by stimulation of the dorsal columns: preliminary clinical report. Anesth Analg 1967;46: Taylor RS. Spinal cord stimulation in complex regional pain syndrome and refractory neuropathic back and leg pain/failed back surgery syndrome: results of a systematic review and meta-analysis. J Pain Symptom Manage 2006;31:S13-9.

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