09-08 진종문(국)

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1 CSE REPORT Print ISSN Online ISSN Non-operative Treatment of Femoral Neuropathy Caused by Iliacus Hematoma: Case Report Jong-Mun Jin, MD*, Soon Yong Kwon, MD, Hyun-Jin Lee, MD, Ju Yeob Lee, MD Department of Orthopaedic Surgery, The Catholic University of Korea, Yeouido St. Mary s Hospital, Department of Orthopaedic Surgery, Seoul Daeyoon Hospital* Treatment of femoral neuropathy caused by iliacus hematoma can be divided according to operative treatment and non-operative treatment. Recently, percutaneous drainage has been more popular because it is relatively simple, convenient, and less invasive. fter warfarin overuse, a 71-year-old male patient visited the emergency room with femoral neuropathy caused by a left iliacus muscle hematoma measuring approximately mm, mm in size on coronal and sagittal computed tomography angiograhy. Without trauma, weakness of the left hip flexor and left knee extensor was noted with strength of 2/5 (poor) each. Immediate medical treatment using vitamin K and fresh frozen plasma was started and percutaneous drainage was performed. Two days after visiting the emergency room, neurological symptoms were improved and non-operative treatment was continued. Twenty four days after being hospitalized, the size of the hematoma was reduced to approximately mm, mm in size. pproximately three months after hospitalization, most of the hematoma was absorbed. fter one year, mild atrphy of quadriceps and mild diffuse pain were noted, however, no other symptoms were observed. Key Words: Iliacus hematoma, Femoral neuropathy, Non-operative treatment, Percutaneous drainage 장골근의혈종으로인한대퇴신경병증은정형외과영역에서는비교적드문질환으로주로항응고제치료를받거나혈액응고장애를갖고있는환자에서보고되고있으며외상이나인공고관절재치환술후에도그보고가있다 1-5). 장골근혈종의압박으로인한대퇴신경병증의치료는신경 Submitted: November 8, st revision: December 26, nd revision: March 3, 2014 Final acceptance: March 10, 2014 ddress reprint request to Soon Yong Kwon, MD Department of Orthopaedic Surgery, The Catholic University of Korea, Yeouido St. Mary's Hospital, ro, Yeongdeungpo-gu, Seoul , Korea TEL: FX: sykwon@catholic.ac.kr This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 학적증상의유무, 혈종의발생속도, 크기등에따라크게수술적치료와비수술적치료로나눌수있으며최근에는영상의학과및의료기술의발전으로비교적비침습적인도관을이용한경피적배액술이수술적치료를대신해애용되고있다. 본증례에서와파린과다복용후장골근혈종으로인한대퇴신경병증의경피적도관배액술과보존적치료에대해보고하고자한다. 증례보고 71 세남자환자로좌측대퇴부통증및근력저하를주소로응급실로내원하였다. 환자는내원 4 년전승모판막치환술시행후와파린 2 mg 을투여중이었으며 3 년전다발혈관뇌경색으로헤파린요법을시행하였다. 특별한외상의기왕력은없었으며진찰소견상환자의좌측하지와좌측상지, 좌측둔부와양측서혜부하단부위에반상출혈이관찰되었다. 좌측고관절을굴곡하고있었고고관절신전시에통증을호소하였다. 좌측서혜부의위쪽으로약 10 5 cm 50 Copyright c 2014 by Korean Hip Society

Jong-Mun Jin et al. Non-operative Treatment of Femoral Neuropathy Caused by Iliacus Hematoma 의종물이촉지되었으며경한압통이있으나열감은없었다. 대퇴전내측부와하지내측부의이상감각이있었으며도수근력검사에서좌측고관절의굴곡과슬관절의신전이각각 2 등급 (poor) 이었다.

2 Jong-Mun Jin et al. Non-operative Treatment of Femoral Neuropathy Caused by Iliacus Hematoma 의종물이촉지되었으며경한압통이있으나열감은없었다. 대퇴전내측부와하지내측부의이상감각이있었으며도수근력검사에서좌측고관절의굴곡과슬관절의신전이각각 2 등급 (poor) 이었다. 대퇴동맥과슬와동맥, 발등동맥은모두촉지되었다. 내원전혈색소수치는 14.3 g/dl 였으나응급실내원당시혈색소수치는 9.7 g/dl 였으며 37 시간뒤에 7.6 g/dl 까지감소하였다. 혈소판수치는정상이었으나 prothrombin time international normal range (INR) 은 5 이상으로증가되어있었고환자의복용약을조회한결과약 1 개월전부터와파린을 2 mg 더복용하였던것으로나타났다. 입원당일촬영한복부및골반혈관조영컴퓨터단층촬영에서좌측장골근내에혈종이관찰되었고조영제의혈관외유출은관찰되지않았다 (Fig. 1). 혈종은등밀도음영과저밀도음영이혼합된것으로아급성혈종으로생각되었으며크기는컴퓨터단층촬영의관상면상 mm, 시상면상 mm 로확인되었다. 즉시와파린투여를중단하고신선동결혈장 1 pint (145 cc) 를수혈하였으며, 수혈후 prothrombin time INR 은 4.91 로확인되었다. 추가로비타민 K 5 mg 을투여하였고투여후의 prothrombin time INR 은 3.72 였다. 초음파유도하에돼지꼬리모양도관을삽입하였으나배액이거의되지않았다. 입원후 1 일부터 prothrombin time INR 은 2.0 이하로유지되었다. 입원후 2 일째, 혈액학적안정성을찾았지만도관을통한배액이없어감압을위한수술적치료를계획하던중, 환자의대퇴부통증이줄었고슬관절의신전이 2 단계 (poor) 와 3 단계 (fair) 사이로호전되는양상을보였다. 도관을통한배액은여전히없어입원 9 일째제거하였다. 입원 13 일째부터대퇴사둔근강화훈련과선자세균형훈련을실시하였으며신경학적증상은미약하지만서서히호전되었다. 입원 24 일째, 컴퓨터단층촬영추시결과혈종의크기는관상면상 mm, 시상면상 mm 크기로감소하였으며 (Fig. 2), prothrombin time INR 은 1.5 이하로유지되어퇴원하였다. 응급실내원후약 3 개월째, 전산화단층촬영에서혈종은대부분흡수되었다 (Fig. 3). 도수근력검사에서좌측고관절의굴곡은 5 단계 (normal), 슬관절의신전은 4 등급 (good) 으로측정되었고이상보행은없었으며이상감각도거의소실되었다. 약 12 개월후의최종추시에서, 건측에비해자세히보면알아차릴수있는대퇴사두근의경한근위축과경한미만성심재성통증이있었으나, 보행장애나다른증상은관찰되지않았다. 고 찰 항응고제치료를하는환자의 % 가후복강내출혈을일으키고 1,2,6) 항혈소판제들의사용에관한연관성도보고되고있다 5). 해부학적연구에서장골근과대퇴신경위의근막은강해서근육내혈종이발생하는경우쉽게늘어나지않으며장요근홈통에서는대퇴신경으로가는혈액순환이좋지않아대퇴신경병증이발생한다 6,7). 혈역학적안정성이있으며진행하는출혈이없고, 혈종의크기가작아신경학적증상이없거나미미한경우보존적치료를생각해볼수있으나 4,6,8), 운동기능의확연한장애가있거나병변의진행이빠르거나신경학적으로더나빠질가능성이있는큰혈종의경우에는감압술이나배액술등의수술적치료를고려해야한다고하였다 3,6,9). 본증례에서는큰혈종으로인한 Fig. 1. The abdominal and pelvic computed tomographic angiography. xial () and sagittal () images revealing a hematoma in the left iliacus muscle (white arrowheads). 51

혈종으로인한대퇴신경병증의경우도관을통한배액및감압술은비교적간단하고비침습적이며절개를통한합병증의위험이적고, 급성출혈이진행한다하더라도지속적인배액을통해신경학적증상의악화를방지할뿐만아니라감압의효과도기대해볼수있다.

3 운동신경마비와이상감각이있어개방적감압술을고려해볼수있었으나, 자기공명영상에서아급성혈종으로판단되어크기의증가가능성이작고진행되는신경학적증상이없으며혈액학적안정을빨리회복하였기때문에비교적비침습적이며간단한, 도관삽입을통한배액을실시하였다. 아급성출혈로인한혈종의조직화로인해배액이이루어지지않았음에도불구하고배액관은 9 일까지배치해두었는데이것은새로운급성출혈로혈종의크기가커질경우를대비하기위해서였다. 입원 2 일째부터미미하지만통증및신경학적증상이완화되어보존적치료를지속하였다. 문헌중조기의수술적감압을추천하는주장이있으나 9), 최근의료기술의발달로비침습적인시술이계속발달되고있으며환자또한그것을선호하는경향이있다. 혈종으로인한대퇴신경병증의경우도관을통한배액및감압술은비교적간단하고비침습적이며절개를통한합병증의위험이적고, 급성출혈이진행한다하더라도지속적인배액을통해신경학적증상의악화를방지할뿐만아니라감압의효과도기대해볼수있다. 수술적배액으로대퇴신경의감압을 48 시간이상지연할경우영구적인장애를남긴다는보고를 10) 감안하더라도 48 시간뒤에도관을통한배액이실패하였을경우절개를통한감압술을 2 차적으로실시할수있다. 장골근주위의신경을압박하여신경병증을생기게 Fig. 2. Computed tomographic images at 24 days after hospitalization. xial () and sagittal () images show a decreased amount of hematoma in the left iliacus muscle (white arrowheads). Fig. 3. Computed tomographic images at 3 months after hospitalization. xial () and sagittal () images show complete dissolution of the hematoma (black arrows). 52

4 Jong-Mun Jin et al. Non-operative Treatment of Femoral Neuropathy Caused by Iliacus Hematoma 하는정도의큰혈종은먼저도관삽입을통한배액및감압을시도해보고, 신경학적증상이생긴후 1-2 일간의세심한관찰을통해신경학적증상이완화되는경우에는보존적치료를통해좋은결과를얻을수있을것으로생각된다. 항응고제를투여받고있는환자에서하복부나하지의통증과함께신경학적증상이동반되는경우에는장골근혈종으로의한대퇴신경병증을감별해야한다. 혈동역학적안정성을위해내과적치료가병행되어야하며, 신경병증을초래할정도의큰혈종은먼저도관삽입을통한배액및감압을시도해보고, 신경학적증상이생긴후 1-2 일간의세심한관찰을통해신경학적증상이완화되는경우에는보존적치료를통해추시하면서증상완화를기대해볼수있을것이다. 48 시간동안증상이완화되지않거나감압이전혀이루어지지않은경우에는개방적배액을통한수술적치료가필요할것으로생각된다. REFERENCES 01.shrani, Osip J, Christie, Key NS. Iliopsoas haemorrhage in patients with bleeding disorders-- experience from one centre. Haemophilia. 2003;9: alkan C, Kavakli K, Karapinar D. Iliopsoas haemorrhage in patients with haemophilia: results from one centre. Haemophilia. 2005;11: Guivarc'h M. Hematoma of the iliac psoas muscle. 29 cases. J Chir (Paris). 1997;134: Marquardt G, arduzal ngles S, Leheta F, Seifert V. Spontaneous haematoma of the iliac psoas muscle: a case report and review of the literature. rch Orthop Trauma Surg. 2002;122: Nakao, Sakagami K, Mitsuoka S, Uda M, Tanaka N. Retroperitoneal hematoma associated with femoral neuropathy: a complication under antiplatelets therapy. cta Med Okayama. 2001;55: Parmer SS, Carpenter JP, Fairman RM, Velazquez OC, Mitchell ME. Femoral neuropathy following retroperitoneal hemorrhage: case series and review of the literature. nn Vasc Surg. 2006;20: Nobel W, Marks SC Jr, Kubik S. The anatomical basis for femoral nerve palsy following iliacus hematoma. J Neurosurg. 1980;52: Patel, Calfee R, Thakur N, Eberson C. Non-operative management of femoral neuropathy secondary to a traumatic iliacus haematoma in an adolescent. J one Joint Surg r. 2008;90: Kong WK, Cho KT, Lee HJ, Choi JS. Femoral neuropathy due to iliacus muscle hematoma in a patient on warfarin therapy. J Korean Neurosurg Soc. 2012;51: Wicky S, Mayor, Schnyder P. Clinical impact of imaging iliopsoas hematomas during anticoagulation. Emerg Radiol. 1995;2:

5 국문초록 장골근내혈종으로발생한대퇴신경병증의비수술적치료 : 증례보고 진종문 * 권순용 이현진 이주엽가톨릭대학교여의도성모병원정형외과, 서울대윤병원정형외과 * 혈종의압박으로인한대퇴신경병증의치료는수술적치료와비수술적치료로나누어볼수있다. 최근에는비교적간단하고편리하며비침습적인도관을이용한경피적배액술이애용되고있다. 본증례는장골근혈종으로인한대퇴신경마비의비수술적치료에대해보고하고자한다. 71 세남자환자로와파린과다복용후컴퓨터단층촬영의관상면상 mm, 시상면상 mm 크기의좌측장골근혈종으로인해대퇴신경병증이나타났다. 특별한외상의기왕력은없었으며도수근력검사에서좌측고관절의굴곡과슬관절의신전이각각 2 단계 (poor) 로약화되어있었다. 신선동결혈장과비타민 K 5 mg 을투여하여 prothrombin time international normal range (INR) 을교정하였고입원 2 일째부터신경학적증상이완화되어비수술적치료를지속하였다. 입원 24 일째컴퓨터단층촬영추시결과혈종의크기는관상면상 mm, 시상면상 mm 크기로감소하였고, 약 3 개월뒤에는혈종이대부분흡수되었다. 1 년후, 최종추시상대퇴사두근의경한위축과경한미만성통증이있었으나다른증상은관찰되지않았다. 색인단어 : 장골근혈종, 대퇴신경병증, 비수술적치료, 경피적배액술 54

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