07-김진수

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1 대한척추외과학회지제 15 권제 2 호 Journal of Korean Spine Surg. Vol. 15, No. 2, pp 106~110, 2008 척추경나사못을이용하여골유합을얻은척추경단열 - 증례보고 - 김진수 # 김기택 석경수 이정희 이상훈 어재형 서울의료원정형외과학교실 #, 경희대학교의과대학정형외과학교실 Fusion of Pedicular Cleft Using Pedicle Screw Fixation - A Case Report - Jin-Soo Kim, M.D. #, Ki-Tack Kim, M.D., Kyung-Soo Suk, M.D., Jung-Hee Lee, M.D., Sang-Hun Lee, M.D., Jae-Hyung Eoh, MD. Abstract Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Korea # Department of Orthopedic Surgery, College of Medicine, Kyung Hee University, Seoul, Korea There is a broad range of lumbar pedicular and neural arch anomalies, with spina bifida occulta and spondylolysis being especially common. It is very rare for a pedicular cleft to be associated with contralateral spondylolysis in the same vertebral segment. We observed L4 spondylolisthesis, clefting of the left L4 hypertrophied pedicle associated with contralateral spondylolysis, and spinal stenosis on a radiographic study of the lumbar spine. Operative treatment was performed, with posterior decompression, partial removal of the hypertrophied pedicle, posterior lumbar interbody fusion using a cage, and posterior instrumentation. The patient s neurologic symptoms resolved after operative treatment. Fusion of the left pedicle cleft was observed on 6-month follow-up CT. We report one case of pedicular cleft fusion using pedicle screw fixation and present a review of the relevant literature. Key Words: Spondylolisthesis, Spondylolysis, Pedicular cleft, Pedicle screw. 서 론 요추부척추경과신경궁에다양한범주의기형이발생할수있으나대개의경우척추이분증또는척추분리증이다 1). 척추분리증은 5~7% 의빈도로나타나지만척추경단열 (retrosomatic cleft, pedcicular cleft) 은매우드물게보고되고있다 2,3,4,5). 저자들은제 4 요추척추전방전위 증환자에서관찰된일측성척추경단열과반대측척추분리증에대하여척추경나사못고정술을이용한수술적치료로우수한임상적및방사선적결과를얻었기에이를문헌고찰과함께보고하는바이다. 증례보고 45 세여자환자로내원 2 년전부터특별한외상없이 Address reprint requests to Jung-Hee Lee, M.D. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1, Heogi-dong, Dongdaemun-gu, Seoul , Korea. Tel: , Fax: , ljhos@khmc.or.kr 본논문의요지는 2007 년도대한척추외과학회추계학술대회에서포스터로발표되었음

척추경단열의수술적유합 김진수외 Fig. 1. Plain radiographs show that olisthesis of 4 th lumbar vertebra, hypertrophy of the left 4 th lumbar pedicle and contralateral spondylolysis. Fig. 2.

(B) Axial CT image shows radiolucent gap in left pedicle with hypertrophic and sclerotic change and the lytic defect in right pars interarticularis. 발생한요통과좌측하지로의방사통을주소로내원하였다.

2 척추경단열의수술적유합 김진수외 Fig. 1. Plain radiographs show that olisthesis of 4 th lumbar vertebra, hypertrophy of the left 4 th lumbar pedicle and contralateral spondylolysis. Fig. 2. Computed tomographic findings of pedicular cleft. (A) 3D reconstruction CT image shows the cleft traverse the whole thickness of the left pedicle. (B) Axial CT image shows radiolucent gap in left pedicle with hypertrophic and sclerotic change and the lytic defect in right pars interarticularis. 발생한요통과좌측하지로의방사통을주소로내원하였다. 이학적검사에서하요추부압통및굴곡신연시통증을호소하였고, 좌측족배굴곡근력저하및감각이상소견이관찰되었다. 단순방사선소견에서제 4 요추의척추전방전위증, 좌측척추경의비후및반대측척추분리증이관찰되었고, 동적검사에서수평전위 5 mm 및시상면에서각운동 23 로분절불안정성이관찰되었 다 (Fig. 1). 전산화단층촬영소견에서제 4 요추좌측척추경의단열, 경화, 비후및우측척추분리증이관찰되었다 (Fig. 2). 자기공명영상촬영소견에서제 4 요추좌측척추경의단열및비후, 제 4-5 요추간추간판의팽윤으로추간공에서제 4 요추신경근의압박소견, 제 4-5 요추간후관절비후및추간판팽윤으로중심부와외측함요부의척추관협착증이관찰되었다 (Fig. 3). 전신골주사검사에서는좌측척추경의경계가불명확한소견이관찰되었고 Bone SPECT (single photon emission computed tomography) 소견에서제 4 요추좌측척추경의국소적섭취증가가관찰되었다 (Fig. 4). 보존적치료에도불구하고임상증세가지속되어후방감압술로추궁절제술, 내측후관절절제술과추간공절제술을시행하였다. 좌측제 4 요추의신경근이비후된척추경에압박되어척추경의내측및하연의일부를제거하였고단열된부위의섬유조직을골정과큐렛으로제거하여단열된척추경의골유합을도모하였다. 이후안정화술식으로척추경나사못고정술및 cage 를이용한후방추체간유합술을시행하였다. 술후환자의임상증세는호전되었고, 술후 6 개월에시행한전산화단층촬영소견에서제 4 요추좌측척추경의골유합소견이관찰되었다 (Fig. 5). 고 찰 전형적인척추는출생시 1 개의골화된추체중심과

대한척추외과학회지 Vol. 15, No. 2, 2008 Fig. 3. MR findings of pedicular cleft. (A) Sagittal, coronal MR images show the cleft and hypertrophy of the left 4th lumbar pedicle.

h lumbar nerve root on left foramen by disc bulging and central, lateral recess stenosis by hypertrophied facet joint and disc degeneration. Fig. 4.

3 대한척추외과학회지 Vol. 15, No. 2, 2008 Fig. 3. MR findings of pedicular cleft. (A) Sagittal, coronal MR images show the cleft and hypertrophy of the left 4th lumbar pedicle. (B) Axial images show compression of 4th lumbar nerve root on left foramen by disc bulging and central, lateral recess stenosis by hypertrophied facet joint and disc degeneration. Fig. 4. (A) Whole body bone scan shows no uptake on 4th lumbar vertebra, (B) Bone SPECT (single photon emission computed tomography) images show tracer uptake on left 4th lumbar pedicle. 개의골화된척추궁을갖는다. 추체의후외측은척추궁의확장에의해골화가진행되므로성인의척추체는추체중심과인접한신경궁의일부로형성된다. 일차골화중심의유합과정의이상은다양한선천적기형을야기한다 1). 이러한단열이척추경에서나타난경우를척추경단열 (pedicular cleft, retrosomatic cleft), 협부에서나타난경우를척추분리증 (spondylolysis) 그리고후궁에서나타난경우를후궁단열 (retroisthmic cleft) 로분류할수있다 (Fig. 6). 척추궁단열은매우드물게보고되고있다 2,3,4,5,6,7). Stewart 7) 는척추경단열 2 예에서단열부위에서가골형 성과유합을관찰하며단열의원인으로외상의가능성을제시하였으나, 대부분이러한단열의원인은선천적기형으로보고되고있으며 1,5,6,8), 척추경단열의조직학적연구결과단열부위는연골로채워져있고연결이끊어져있음이보고되고있다 4). 또한단열된척추경은편측또는양측으로발생할수있고, 신연되거나단축될수있고, 비후된소견과반대측척추분리증이동반되는경우등다양한형태로발생할수있다 3,4,5,8,9). 본증례에서도단열된척추경의비후된소견과반대측척추분리증이동반되었다. 척추경단열의임상증상은대부분요통으로임상적

척추경단열의수술적유합 김진수외 치료가필요하였고, 수술적치료후임상증세의호전이관찰되었다. 술후 6 개월에시행한전산화단층촬영소견에서단열된척추경의유합이관찰되었고본증례에서와같이척추전방전위증이동반된경우는매우드물며 2,9), 척추경나사못고정술로척추경단열의유합을얻은결과는문헌으로보고된바없어문헌고찰과함께보고하고자한다. 참고문헌 Fig. 5.

(1) persistent neural central synchondrosis; (2) pedicular cleft (retrosomatic cleft); (3) pars interarticularis cleft (spondylolysis); (4) retroisthmic cleft; and (5) paraspinous and (6) spinous

4 척추경단열의수술적유합 김진수외 치료가필요하였고, 수술적치료후임상증세의호전이관찰되었다. 술후 6 개월에시행한전산화단층촬영소견에서단열된척추경의유합이관찰되었고본증례에서와같이척추전방전위증이동반된경우는매우드물며 2,9), 척추경나사못고정술로척추경단열의유합을얻은결과는문헌으로보고된바없어문헌고찰과함께보고하고자한다. 참고문헌 Fig. 5. Postoperative 6 months follow-up 3D reconstruction and axial CT images show fusion of cleft of left pedicle. Fig. 6. Schematic neural arch clefts. Viewed from above. (1) persistent neural central synchondrosis; (2) pedicular cleft (retrosomatic cleft); (3) pars interarticularis cleft (spondylolysis); (4) retroisthmic cleft; and (5) paraspinous and (6) spinous cleft (spina bifida). 중요성은적으나 1,5,8,10), 요추부에발생할수있는종양, 혈관기형및신경섬유종등과감별이필요하다 1). 척추전방전위증이동반되고비후된척추경단열로신경근압박이발생하여수술적치료가필요할수있다 9). 본증례에서도척추전방전위증과동반된척추관협착증과척추경단열의비후등으로추간공협소가관찰되어수술적 01) Kalideen JM, Satyapal KS, Bayat F: Case report: pedicular cleft associated with bilateral pars interarticularis defects and transverse process hypoplasia of a fifth lumbar vertebra. Br J Radiol 1994; 67: ) Merki A: Unilateral retrosomatic vertebral arch cleft L4 associated with spondylolisthesis L5. Z Orthop Ihre Grenzgeb 1968; 104: ) Seegelken K, Schulte GA: Clefts of the vertebral arch (observation of a retrosomatic cleft). Fortschr Geb Rontgenstr Nuklearmed 1972; 116: ) Dietemann JL, Macedo R, Medjek L, Babin E, Wackenheim A: Bilateral pedicular cleft in a patient with neurofibromatosis. Ann Radiol (Paris) 1981; 24: ) Johansen JG, McCarty DJ, Haughton VM: Retrosomatic clefts: computed tomographic appearance. Radiology 1983; 148: ) Barclay-Smith E: Multiple Anomaly in a Vertebral Column. J Anat Physiol 1911; 45: ) Stewart TD: The age incidence of neural-arch defects in Alaskan natives, considered from the standpoint of etiology. J Bone Joint Surg Am 1953; 35: ) Soleimanpour M, Gregg ML, Paraliticci R: Bilateral retrosomatic clefts at multiple lumbar levels. AJNR Am J Neuroradiol 1995; 16: ) Ha KY, Park JS: Variant spondylolisthesis with unilateral spondylolysis and contralateral retrosomatic cleft (pedicular defect). J Korean Soc Spine Surg 1997; 4: ) Abraham T, Holder L, Silberstein C: The retroisthmic cleft. Scintigraphic appearance and clinical relevance in patients with low back pain. Clin Nucl Med 1997; 22:

5 대한척추외과학회지 Vol. 15, No. 2, 2008 국문초록 요추부의척추경과신경궁에다양한기형이발생할수있고대부분척추이분증또는척추분리증이다. 척추경의단열과반대측척추분리증이동반된경우는매우드물다. 방사선소견에서제 4요추의전방전위증, 좌측척추경의단열및비후, 반대측척추분리증및척추관협착증이관찰되어수술적치료로후방감압술및비후된척추경을일부제거하여신경근을감압하였고, cage를이용한후방추체간유합술및후방기기고정술을시행하였다. 술후신경학적증상은소실되었고, 술후6개월방사선소견에서단열이관찰되었던제 4요추좌측척추경의골유합소견이관찰되어문헌고찰과함께보고하고자한다. 색인단어 : 척추전방전위증, 척추분리증, 척추경단열, 척추경나사못 통신저자 : 이정희서울시동대문구회기동 1번지경희대학교의과대학정형외과학교실 Tel: Fax: ljhos@khmc.or.kr

09-이재철

09-이재철 대한척추외과학회지제 14 권제 2 호 Journal of Korean Spine Surg. Vol. 14, No. 2, pp 115~119, 2007 척추관협착증환자에서발견된제 4 요추부선천성편측척추경결손 - 증례보고 - 김연일 이재철 최우석 신병준 순천향대학교의과대학정형외과학교실, 척추센터 Congenital Absence of a Pedicle of L4