18-19최재형

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1 대한응급의학회지제 24 권제 4 호 Volume 24, Number 4, August, 2013 증 례 경부추간관절차단후발생한경추경막외혈종 순천향대학교부천병원응급의학과 최재형 조영순 김호중 Cervical Epidural Hematoma Following a Facet Joint Nerve Block Jae Hyung Choi, M.D., Young Soon Cho, M.D., Ho Jung Kim, M.D. Facet joint nerve blocks is the most commonly utilized interventions in managing chronic spinal pain. A fluoroscopically directed facet joint nerve block for pain management may result in a rare complication of spinal epidural hematoma causing acute myelopathy. Although this complication is well-known with epidural anesthesia (where it is usually seen with impaired hemostasis), there are surprisingly few case reports of epidural hematoma after a facet joint nerve block. We report here a case of a 58-year-old man, with no evidence of coagulopathy and not taking antiplatelet medication, having a sudden onset of acute cervical myelopathy from a large cervical epidural hematoma one hour after a facet joint nerve block. Following prompt surgical evacuation of the clot, the patient made a nearly complete recovery. Spinal epidural hematoma after spinal puncture is usually associated with impaired hemostasis. However, this case illustrates that it may occur in the absence of known risk factors. The delayed onset and the absence of risk factors have implications for the use of this procedure in chronic pain management. Key Words: Spinal epidural hematoma, Nerve block, Pain management 책임저자 : 조영순경기도부천시원미구중동 1174 순천향대학교부천병원응급의학과 Tel: 032) , Fax: 032) emer0717@schmc.ac.kr, emdr@schmc.ac.kr 접수일 : 2013년 7월 14일, 1차교정일 : 2013년 7월 18일게재승인일 : 2013년 7월 30일 본연구는순천향대학교학술연구비의일부지원으로수행하였음. 459 Department of Emergency Medicine, College of Medicine, Soonchunhyang University 서 만성척추통증은흔한질환이며원인이분명하지않은경우가대부분이다 1,2). 이에따른치료법역시다양하며수술적치료가적응증이아닌경우신경차단술을이용한통증조절이보편화되었다. 그중신경축차단과추간관절차단이가장흔하게사용하는치료법이다 3-8). 추간관절차단은안전한치료법으로알려져있으며시술후경막외혈종이발생한례는보고된바없다 5-9). 저자들은특별한질병및외상이없는상태에서, 오른쪽어깨통증을주소로추간관절차단술을받고경추경막외혈종이발생한 58세남자환자를 1례경험하였기에문헌고찰과함께보고하고자한다. 증 평소고혈압및고지혈증외에특이사항이없던 58세남자환자는최근발생한오른쪽어깨통증으로개인의원에서오른족제 5, 6과 6, 7 경추간추간관절차단술을받았으며시술 1시간후발생한왼쪽편마비를주소로응급의료센터에내원하였다. 시술후경부의심한운동및외상의증거는없었다. 경부통증은없었으며증상발현 1시간만에내원하였다. 과거력상 5년전부터고혈압으로 Norvasc 5 mg, 1년전부터고지혈증으로 Lipitor 10 mg을복용한것이외에는기타병력이나가족력상특이소견은없었다. 내원시환자의의식은명료하였으며, 활력징후는혈압 100/70 mmhg, 맥박수는분당 74회, 호흡수는분당 15 회, 체온 36.6 C 이었다. 신체검사상경동맥의잡음은들리지않았으며, 흉부청진상심음및호흡음은정상이었다. 복부의압통및반발통은없었으며, 늑골척추각압통도관찰되지않았다. 양상지에서요골동맥과상완동맥, 양하지에서대퇴동맥과족배동맥은좌우대칭적으로정상촉지되었으며, 기타특이소견은보이지않았다. 신경학적검사 론 례

460 / 대한응급의학회지 : 제 24 권제 4 호 2013 상동공은양측이대칭상태였으며, 대광반사는정상이었고안면신경검사도정상범주였다. 사지근력검사상오른쪽상지의 Grade II 및하지의 Grade II 근력저하가관찰되었으며, 왼쪽상지의 Grade Ⅳ 근력저하가관찰되었다. 왼쪽하지의근력은정상범주였다. 상하지의감각은좌우대칭으로모두정상범주였다.

경추부에대한단순 X-선촬영에서몇개의골극외에특이소견은발견되지않았다 (Fig. 1A). 뇌병변을감별하기위해시행한초기뇌전산화단층촬영에서도특이소견은없었다. 경추부의해부학적이상및종양등과같은감별진단을위해경추부전산화단층촬영을시행하였다. 경추부전산화단층촬영소견상제 3경추에서제 6경추까지척추오른쪽뒤쪽에주변과경계가있는난원형의형태의종괴가관찰되었다 (Fig.

2 460 / 대한응급의학회지 : 제 24 권제 4 호 2013 상동공은양측이대칭상태였으며, 대광반사는정상이었고안면신경검사도정상범주였다. 사지근력검사상오른쪽상지의 Grade II 및하지의 Grade II 근력저하가관찰되었으며, 왼쪽상지의 Grade Ⅳ 근력저하가관찰되었다. 왼쪽하지의근력은정상범주였다. 상하지의감각은좌우대칭으로모두정상범주였다. 심부건반사는정상범주였으며, 소뇌기능은정상이었고, 병적반사는관찰되지않았다. 내원후시행한검사실소견에서말초혈액검사, 생화학검사및요검사는정상범주였다. 혈액응고검사상프로트롬빈시간 10.7/0.95(sec/INR), 활성화부분트롬보플라스 틴시간 22.5초로출혈성소인은관찰되지않았다. 흉부단순촬영및심전도에서특이소견보이지않았다. 경추부에대한단순 X-선촬영에서몇개의골극외에특이소견은발견되지않았다 (Fig. 1A). 뇌병변을감별하기위해시행한초기뇌전산화단층촬영에서도특이소견은없었다. 경추부의해부학적이상및종양등과같은감별진단을위해경추부전산화단층촬영을시행하였다. 경추부전산화단층촬영소견상제 3경추에서제 6경추까지척추오른쪽뒤쪽에주변과경계가있는난원형의형태의종괴가관찰되었다 (Fig. 1B) 종괴의정확한위치및성상그리고척수병증 A B Fig. 1. Initial C-spine lateral view and non enhanced computerized tomography. (A) C-spine lateral view shows multiple bony spurs (white arrow head). Otherwise, unremarkable. (B) Computerized tomography image showing a lentiform shaped mass at right posterior epidural space on the cervical 3 to 6 levels (black arrow). A B C Fig. 2. Initial magnetic resonance image findings of cervical spine. Axial T1 (A) and T2 (B) and mid-sagittal T2 (C) weighted images. There is a lentiform shaped mass at right posterior epidural space on the cervical 3 to 6 levels (white arrow). The hematoma compresses the spinal cord at posterior aspect. But, compressive myelopathy is not combined because of normal cord signal intensity (white arrow head). This finding indicates acute compression of cord and still no pathologic change of the cord.

3 최재형외 : 경부추간관절차단후발생한경추경막외혈종 / 461 유무를알기위해자기공명영상촬영을시행하였다. 자기공명영상에서제 3경추에서제 6경추부위에걸쳐서척수오른쪽뒤쪽의 T1 강조영상에서등신호강도를보이고 T2 강조영상에서척수보다뚜렷하게고신호강도를보이며, 척수와경계가뚜렷한난원형병변이보여경막외혈종으로생각하였다 9) (Fig. 2). 경막외혈종에의한척수압박증소견은있었으나, 눌려진척수의신호강도는정상으로압박성척수병증은보이지않았다 (Fig. 2). 척수압박증상을최소화하기위해스테로이드를고용량요법으로정주하였다. 내원 3시간후경추 3-5번에걸쳐추궁절제술 (laminectomy) 과혈종제거를시행하였으며, 수술소견상명확한출혈부위는보이지않았다. 수술 2일째부터오른쪽상하지의근력이 grade Ⅳ 이상으로회복되고수술 4일째에는오른쪽상하지및왼쪽상지의근력이거의정상화되었다. 입원 15일후별다른합병증없이회복하여퇴원하였다. 고찰신경차단술로인한척추의경막외혈종은매우드문질환이다. Wulf 11) 는경막외마취로인한경막외혈종은 190,000 의시술당 1건이라고기술했다. 또한 Manchikanti 등 9) 은 43,010건의추간관절차단에서경막외혈종이발생한경우는단한번도없었다고기술했다. 연구된바에의하면신경차단술로인한척수강내출혈위험인자는혈액응고장애, 항응고제및항혈소판제복용, 척추의구조적이상, 고령, 여성, 그리고반복된천자등이있다 12-15). 본증례에서는수술용투시장치 (C-arm) 을이용하여마취통증의학전문의가시술하였으며환자는척추의구조적이상이나혈액응고장애가없었으며항혈소판약물및항응고제약물의투여력도없었다. 척추경막외혈종의원인은다양하나증상및진단과치료는동일하다 11,15-18). 본증례에서와같이드물게는통증없이신경학적결손이나타나는예도있으나, 대부분의경우에서는목이나등의통증, 손상부위척수와일치하는신경학적결손이나타난다. 그러나신경학적결손은통증이시작된이후에나타날수있으므로특히신경차단술이나항응고치료를받는환자에서갑자기설명할수없는통증을호소하는경우에는척추경막외혈종을의심하여야한다. 진단을위해서는어느부위에서어느정도의혈종이고여있는지를확인할수있는비침습적인자기공명영상촬영이가장좋은방법이다. 전산화단층촬영또는척수강조영술등을고려해볼수있으나척수강조영술은척추천자를해야하며척추천자는이질환의유발요인이되므로현재는사용되지않는다. 치료의선택은신경손상의심한정도, 증상발현부터진 단까지의시간, 자기공명영상소견등에따라달라진다. 증상이경미하거나영상결과를보기전에증상이확실히호전된경우는보존적요법을우선으로한다 19). 증상의진행이빠르거나신경학적결손이심한경우응급감압추궁절제술이적절한치료이다 20). 본증례의경우증상이 1시간만에진행하였으며중증의편마비증상을보여응급수술이필요하다고판단하였다. 신경학적회복은혈종의양, 수술전신경학적결손의정도, 첫증상발현과수술까지의시간간격에달려있다 18,20). 일반적으로 24시간이상지연되면영구마비될가능성이있으며, 8시간이내에수술이이루어지면완전회복도가능하다 16-18). 그러나 24시간이후에도신경학적회복이완전한경우도보고되었다 21). 본증례의경우증상발생후약 3시간만에진단이이루어졌으며, 수술은약 4시간만에이루어졌다. 수술이후신경학적회복은양호하였다. 적절한치료를하지않은경우에는경추부에생긴경막외혈종은사망에이르게할수있고흉추부에생긴경우완전한신경마비가가능하며요추부에생긴경우는추간판탈출증과유사한증상을보이며신경학적결손을빈번히보인다 18). 자발성척수경막외혈종에서경추부에위치한경우사망률이유의하게높았는데이경우의환자들은호흡부전, 폐색전증, 심근경색증이사망의주된원인으로보고되었다 20). 본증례의경우경추부에국한된경막외혈종이었으며증상이뇌졸증과감별하기어려웠지만비교적빠른진단과수술이이루어졌고별다른합병증은발생하지않았다. 만성경부통증의가장흔한원인은추간관절증후군이다. 또한추간관절증후군의호발부위역시경부가 55% 로가장흔하며, 목, 어깨및상지의통증이주증상이다 22). 추간관절차단술은주로추간관절증후군의진단과치료에사용하는시술이며경부추간관절증후군에서추간관절차단술의통증경감으로인한진단율은 75% 이상으로보고되었다 6-8). 추간관절차단술후발생하는흔한합병증은추간관절주변의혈관내약물주입과국소혈종에의한통증이있으며, 그외경막천자, 신경손상, 및감염등이있다 9,23-31). 경막천자에대한증례는몇몇보고되었으나본증례와같이그로인하여발생한경막외혈종에대한증례는보고된바없었다. 본증례의보고와같이추간관절차단후발생하는경추경막외혈종은매우드문질환으로서전산화단층촬영이나자기공명영상등의영상학적검사를시행하기전까지는진단이매우어렵고, 임상양상으로보면오히려뇌병변으로오인하기쉽다. 이러한이유로진단이지연될경우호흡마비, 영구적신경학적손상등의심각한손상을초래할수있으므로, 신경차단시술을받았거나경막외혈종의위험인자가있는환자에서단순한척추통증혹은설명할수없는신경증상이있다면강력한의심하에조기에진단이이

4 462 / 대한응급의학회지 : 제 24 권제 4 호 2013 루어질수있도록적극적으로진료하는것이환자의예후에도움이되리라생각된다. 참고문헌 01. Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA. 1998;280: Cote P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine(Phila Pa 1976). 1998;23: Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12: Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, et al. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 2010;13:E Manchikanti L, Datta S, Derby R, Wolfer LR, Benyamin RM, Hirsch JA. A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 1. Diagnostic interventions. Pain Physician. 2010;13:E Falco FJ, Erhart S, Wargo BW, Bryce DA, Atluri S, Datta S, et al. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician 2009;12: Datta S, Lee M, Falco FJ, Bryce DA, Hayek SM. Systematic assessment of diagnostic accuracy and therapeutic utility of lumbar facet joint interventions. Pain Physician. 2009;12: Falco FJ, Datta S, Manchikanti L, Sehgal N, Geffert S, Singh V, et al. An updated review of the diagnostic utility of cervical facet joint injections. Pain Physician. 2012;15:E Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7,500 episodes with 43,000 nerve blocks. Pain Physician. 2012;15:E Rothfus WE, Chedid MK, Deeb ZL, Abla AA, Maroon JC, Sherman RL. MR imaging in the diagnosis of spontaneous spinal epidural hematomas. J Comput Assist Tomogr. 1987;11: Wulf H. Epidural anaesthesia and spinal haematoma. Can J Anaesth. 1996;43: Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79: Wysowski DK, Talarico L, Bacsanyi J, Botstein P. Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med. 1998;338: Armstrong RF, Addy V, Breivik H. Epidural and spinal anaesthesia and the use of anticoagulants. Hosp Med. 1999;60: Horlocker TT, Wedel DJ. Anticoagulation and neuraxial block: historical perspective, anesthetic implications, and risk management. Reg Anesth Pain Med. 1998;23: Kirazli Y, Akkoc Y, Kanyilmaz S. Spinal epidural hematoma associated with oral anticoagulation therapy. Am J Phys Med Rehabil. 2004;83: Clark MA, Paradis NA. Spinal epidural hematoma complicating thrombolytic therapy with tissue plasminogen activator--a case report. J Emerg Med. 2002;23: Lonjon MM, Paquis P, Chanalet S, Grellier P. Nontraumatic spinal epidural hematoma: report of four cases and review of the literature. Neurosurgery. 1997; 41: Jamjoom ZA. Acute spontaneous spinal epidural hematoma: the influence of magnetic resonance imaging on diagnosis and treatment. Surg Neurol. 1996;46: Groen RJ, van Alphen HA. Operative treatment of spontaneous spinal epidural hematomas: a study of the factors determining postoperative outcome. Neurosurgery. 1996;39: Van Schaeybroeck P, Van Calenbergh F, Van De Werf F, Demaerel P, Goffin J, Plets C. Spontaneous spinal epidural hematoma associated with thrombolysis and anticoagulation therapy: report of three cases. Clin Neurol Neurosurg. 1998;100: Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5: Verrills P, Mitchell B, Vivian D, Nowesenitz G, Lovell B, Sinclair C. The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines. Spine(Phila Pa 1976). 2008;33:E Lee CJ, Kim YC, Shin JH, Nahm FS, Lee HM, Choi YS, et al. Intravascular injection in lumbar medial branch block: A prospective evaluation of 1433 injections. Anesth Analg. 2008;106: Manchikanti L, Malla Y, Wargo BW, Cash KA, McManus CD, Damron KS, et al. A prospective evaluation of bleeding risk of interventional techniques in chronic pain. Pain Physician. 2011;14: Marks RC, Semple AJ. Spinal anaesthesia after facet joint

5 최재형외 : 경부추간관절차단후발생한경추경막외혈종 / 463 injection. Anaesthesia. 1988;43: Berrigan T. Chemical meningism after lumbar facet joint block. Anaesthesia. 1992;47: Thomson SJ, Lomax DM, Collett BJ. Chemical meningism after lumbar facet joint block with local anaesthetic and steroids. Anaesthesia. 1993;46: Magee M, Kannangara S, Dennien B, Lonergan R, Emmett L, Van der Wall H. Paraspinal abscess complicating facet joint injection. Clin Nucl Med. 2000;25: Kim SY, Han SH, Jung MW, Hong JH. Generalized infection following facet joint injection -A case report-. Korean J Anesthesiol. 2010;58: Doita M, Nabeshima Y, Nishida K, Fujioka H, Kurosaka M. Septic arthritis of lumbar facet joints without predisposing infection. J Spinal Disord Tech. 2007;20:290-5.

제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄 Program 1 ANESTHESIA (Room 2층 대강당) >> Session 4 Updates on PNB Techniques PNB Techniques for shoulder surgery: continuou

제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄 (Room 2층 대강당) >> Session 4 Updates on PNB Techniques PNB Techniques for shoulder surgery: continuous vs single injection, interscalene vs supraclavicular approach 의정부성모병원