KISEP Clinical Article J Korean Neurosurg Soc , 2003 외상이나지주막염에의한척수공동증의수술적치료 장현동 박관호 지문표 김재오 김정철 Operative Treatments in Syringomyelia Caused

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1 KISEP Clinical Article J Korean Neurosurg Soc , 2003 외상이나지주막염에의한척수공동증의수술적치료 장현동 박관호 지문표 김재오 김정철 Operative Treatments in Syringomyelia Caused by Trauma or Arachnoiditis Hyeon Dong Jang, M.D., Kwan Ho Park, M.D., Moon Pyo Ji, M.D., Jae Oh Kim, M.D., Jung Chul Kim, M.D. Department of Neurosurgery, Korea Verterans Hospital, Seoul, Korea Objective:Most cases of syringomyelia with arachnoid scarring were related to spinal trauma or inflammatory reaction. The aim of this study is to analyze the influence of arachnoid scarring on the altered dynamics of cerebrospinal fluid(csf) and determine the proper treatment. Methods:Between Jan 1991 and Dec 2001, We have operated on 15 patients with progressive neurological deficits associated with syringomyelia. We analyze the clinical presentations, radiographic and magnetic resonance images. Results:As to cause of syringomyelia, 11 patients were related with trauma and 4 patients were tuberculous meningitis. Shunting procedures underwent in 11 patients and 5 showed clinical improvement. Subarachnoid adhesiolysis and expansile duraplasty were performed in 4 patients and 3 experienced clinical improvement. The 6 patients with shunting procedures were neurologically deteriorated and 4 were reoperated. Conclusion:The arachnoid scarring interferes with CSF flow and causes syringomyelia. Successful long-term outcome in the surgical treatment of syringomyelia caused by focal arachnoid scar appeared to require microsurgical dissection of scar and expansile duroplasty. For extensive arachnoid scarring over multiple spinal levels or after previous surgery, shunting procedure may be indicated only. KEY WORDS:Arachnoid scarring Cerebrospinal fluid Syringomyelia Shunt Microsurgical dissection Duraplasty. 서 론 ReceivedMay 10, 2002 AcceptedSeptember 12, 2002 Address for reprintskwan Ho Park, M.D., Department of Neurosurgery, Korea Verterans Hospital, 6-2 Dunchon 2-dong, Gangdong-gu, Seoul , Korea Tel , Fax Drons@hanmir.com 대상및방법 264 J Korean Neurosurg SocVolume 33March, 2003

HD Jang, et al. 결 Table 1. Clinical features of 15 cases with syringomyelia 과 Interval to Sx(mo) Extent of syrinx L2 Fx 60 C7-T10 Hypesthesia and weakness of Rt. L/Ext. 69/M T23 Fx 366 C7-T3 Rt.

1세이며, 40대가 6명, 20대, 5 67/M L2 Fx 382 C2-T12 Pain and weakness of Lt. U/Ext. 30대가 각각 3명, 60대가 2명, 50 6 49/M C4 Fx 267 C5-T2 Pain and weakness of both U/Ext.

arm 9 49/M C56 Fx 60 Cases Age/ Sex Cause 1 30/M 2 C2-T3 New presentation at diagnosis Quadriparesis, hypesthesia below C5 dermatome 10 33/M L1 Fx 108 C5-T10 Lt.

$C cervical, T thoracic, L lumbar, MED medulla oblongata, Fx fracture, L/Ext. lower extremity, U/Ext. upper extremity, Men meningitis, TB tuberculosis, Rt. right, Lt.$ left, mo months, m male 척수공동증의 원인은 외상이 11 명이고 지주막염이 4명이었다. 외상 에 의한 경우는 추락사고가 5명, 교 통사고가 5명, 폭발사고가 1명이었 으며 지주막염에 의한 경우는 4명 으로 모두 결핵성 뇌막염이 원인이 었다(Table 1).

left, mo months, m male 척수공동증의 원인은 외상이 11 명이고 지주막염이 4명이었다. 외상 에 의한 경우는 추락사고가 5명, 교 통사고가 5명, 폭발사고가 1명이었 으며 지주막염에 의한 경우는 4명 으로 모두 결핵성 뇌막염이 원인이 었다(Table 1).

2 HD Jang, et al. 결 Table 1. Clinical features of 15 cases with syringomyelia 과 Interval to Sx(mo) Extent of syrinx L2 Fx 60 C7-T10 Hypesthesia and weakness of Rt. L/Ext. 69/M T23 Fx 366 C7-T3 Rt. L/Ext. weakness, Trunk hypesthesia 3 43/M T6 Fx 192 T3-T8 Pain and weakness of Rt. Leg 분포는 24세부터 67세로 평균연령 4 56/M L1 Fx 216 T1-T3 Pain and numbness of Rt. arm 은 43.1세이며, 40대가 6명, 20대, 5 67/M L2 Fx 382 C2-T12 Pain and weakness of Lt. U/Ext. 30대가 각각 3명, 60대가 2명, /M C4 Fx 267 C5-T2 Pain and weakness of both U/Ext. 7 49/M C5 Fx 244 C3-C4 Hypesthesia and paraparesis of both L/Ext. 8 42/M C5 Fx 240 Med-C7 Pain weakness and of Rt. arm 9 49/M C56 Fx 60 Cases Age/ Sex Cause 1 30/M 2 C2-T3 New presentation at diagnosis Quadriparesis, hypesthesia below C5 dermatome 10 33/M L1 Fx 108 C5-T10 Lt. arm pain 11 46/M T6 Fx 222 C7-T11 Both leg numbness, paraparesis 12 28/M 44 C5-T4 Paraparesis 연령과 성별분포 척수공동증을 진단받을 당시 연령 대가 1명이었다. 환자 15명은 전부 남자로 상이군인과 전직경찰이었다 (Table 1). 발병원인 13 24/M 50 T6-T7 Numbness and weakness of Lt. L/Ext /M 23 C3-T7 Pain and weakness of both L/Ext /M 66 C6-T4 Numbness and weakness of both L/Ext. C cervical, T thoracic, L lumbar, MED medulla oblongata, Fx fracture, L/Ext. lower extremity, U/Ext. upper extremity, Men meningitis, TB tuberculosis, Rt. right, Lt. left, mo months, m male 척수공동증의 원인은 외상이 11 명이고 지주막염이 4명이었다. 외상 에 의한 경우는 추락사고가 5명, 교 통사고가 5명, 폭발사고가 1명이었 으며 지주막염에 의한 경우는 4명 으로 모두 결핵성 뇌막염이 원인이 었다(Table 1). 성 변화를 발견하고, 척추강조영술과 CT 척추조영술 및 조 영제 증강을 포함한 자기공명영상으로 척수공동증과 지주막 임상증상 및 징후 반흔을 알 수 있었으며 선천적 기형과 종양은 제외시켰다. 환자의 임상양상은 사지의 근력약화 12례, 사지의 감각이 수술받은 15례 중 11례는 척수공동 단락술만을 받았고, 4 상 11례, 사지의 동통이 4례로 관찰되었다. 신경증상과 징후 례는 지주막 유착박리술(subarachnoid adhesiolysis)과 경 가 진행되면서 사지의 감각이상 13례, 하지의 근력약화 9례, 막성형술(expansile duraplasty)을 받았다. 수술 전후의 자 상지의 근력약화와 동통 6례, 배뇨 또는 배변장애가 6례에 기공명영상에서 공동의 크기를 비교하였으며 만약 임상증상 서 나타났다. 신경증세가 양측성인 경우가 11례, 일측성은 4 이 악화되거나 수술 후에 공동의 크기가 줄지 않으면 추적 례로 나타났으며 그중에서 우측은 3례였고 좌측이 1례였다. 정밀검사를 하였다. 추적관찰은 5개월에서 83개월이었으며 원인이 발생된 후 척수공동증을 진단 받기까지 짧게는 23 평균 38개월이었다. 개월에서 길게는 382개월이었고, 평균 169개월이 경과되었다 (Table 1). 영상진단소견 외상 후 척수공동증의 원인은 척 추골절이 11례이며 골절부위는 경 추 4례, 흉추 3례, 요추가 4례였다 (Table 1). 지주막염성 척수공동증 4례는 결핵성 뇌막염이 원인이었다. A B C D E Fig. 1. Radiological findings in a 67-year-old man who developed the posttraumatic syrinx after L2 burst fracture. Initial magnetic resonance(mr) images revealing enlargement of the cervical spinal cord below C6-7. A T1-weighted MR image showing no evidence of syrinx. B T2-weighted MR image showing high signal. C, D Preoperative MR images show large syrinx extending from C2 to T12. E MR image obtained 16 months after expansile duraplasty, showing a well-collapsed syrinx. J Korean Neurosurg Soc/ Volume 33/ March, 례 모두 MRI검사를 받았으며 T1-강조영상에서 공동은 동신호 강도의 척수내에 저신호강도로 나 타났지만(Fig. 1C, D) 척수공동증 이 발생되기 이전의 T2-강조영상 에서는 고신호강도(high signal)로 265

3 수술방법 수술후경과 Table 2. Surgical results of 15 cases with syringomyelia Cases Surgery Postop. syrinx Clinical results F/Umo Cause of failure Reoperation 1 SP Unchanged Unchanged 5 Proximal dislocation AL & DP 2 AL & DP Decreased Sensory improvement 6 3 SSA Increased Unchanged 83 Shunt obstruction SPL 4 SSA Decreased Pain improvement 52 5 AL & DP Decreased Motor improvement 8 6 SSA Unchanged Unchanged 54 Septation of syrinx SSA 7 AL & DP Increased Unchanged 10 Arachnoid scarring 8 SSA Decreased Unchanged 40 Septation of syrinx 9 SSA Unchanged Improved AL & DP Decreased Pain improvement SP Decreased Sensory improvement SSA Unchanged Unchanged 53 Shunt obstruction SSA 13 SSA Decreased Motor improvement SP Decreased Pain improvement SSA Decreased Unchanged 68 Shunt obstruction F/Ufollow-up, ALadhesiolysis, DPduraplasty with lyophilized dura, SPsyringo-peritoneal shunt, SSAsyringo-subarachnoid shunt, SPLsyringo-pleural shunt, momonths 266 J Korean Neurosurg SocVolume 33March, 2003

4 고찰 A Fig. 2. Magnetic resonancemr images obtained in a 24-yearold man showing the syrinx that developed after tuberculous meningitis. APreoperative MR image showing the cervical spine in a patient who syrinx extending from medulla oblongata to C7. BMR image obtained 44 months after syringo-subarachnoid shunt shows that top syrinx collapsed and syrinx inferior to C4-5 remained. B J Korean Neurosurg SocVolume 33March,

$C5 burst fracture. APreoperative MR image showing cervicothoracic syrinx.$

5 - 268 A Fig. 3. Magnetic resonancemr images obtianed in a 42-yearold man who developed the syrinx following C5 burst fracture. APreoperative MR image showing cervicothoracic syrinx. BMR image obtained 32 months after syringo-peritoneal shunt, revealing collapsed syrinx and expansion of ventral subarachnoid space at C6-T1. B J Korean Neurosurg SocVolume 33March, 2003

6 - 결론 References 1. Aboulker J:La syringomyelie et les liquides intrarachidiens. Neurochirurgie 25(Suppl):1-144, Anton HA, Schweigel JF:Posttraumatic Syringomyelia:The British Columbia Experience. Spine 11: , Asano M, Fujiwara K, Yonenobu K, Hiroshima K:Post-traumatic Syringomyelia. Spine 21: , Aubin ML, Baleriaux D, Cosnard G, Crouzet G, Doyon D, Halimi P, et al:mri in syringomyelia of congenital, infectious, traumatic or idiopathic origin. A study of 142 cases. J Neuroradiol 14: , Barbaro NM, Wilson CB, Gutin PH, Edwards MS:Surgical treatment of syringomyelia. Favorable results with syringoperitoneal shunting. J Neurosurg 61: , Barnett HJM, Jousse AT:Posttraumatic syringomyelia(cystic myelopathy), in Vinken PJ, Bruyn GW(eds):Handbook of Clinical Neurology. Vol 26:Injuries of the spine and spinal cord. Part II. Amsterdam:North Holland, 1976, pp Batzdorf U, Klekamp J, Johnson JP:A critical appraisal of syrinx cavity shunting procedures. J Neurosurg 89: , Cho KH, Iwasaki Y, Imamura H, Hida H, Abe H:Experimental model of posttraumatic syringomyelia:the role of adhesive arachnoiditis in syrinx formation. J Neurosurg 80: , Dolan RA:Spinal adhesive arachnoiditis. Surg Neurol 39: , Edgar R, Quail P:Progressive post-traumatic cystic and non-cystic myelopathy. Br J Neurosurg 8:7-22, El Masry WS, Biyani A:Incidence, management and outcome of posttraumatic syringomyelia In memory of Mr Bernard Williams:J Neurol Neurosurg Psychiatry 60: , Fischbein NJ, Dillon WP, Cobbs C, Weinstein PR:The Presyrinx state:a Reversible Myelopathic Condition That May Precede Syringomyelia. AJNR Am J Neuroradiol 20:7-20, Jang BJ, Haah ES, Chi MP, Kim JO, Kim JC:Surgical Treatment of Syringomyelia Secondary to Tuberculous Meningitis. J Korean Neurosurg Soc 25: , Jinkins JR, Reddy S, Leite CC, Bazan C III, Xilong L:MR of Parenchymal Spinal Cord Signal Change as a Sign of Active Advancement in Clinically Progressive Posttraumatic Syringomyelia. AJNR Am J Neuroradiol 19: , Klekamp J, Batzdorf U, Samii M, Bothe HW:Treatment of syringomyelia associated with arachnoid scarring caused by arachnoiditis or trauma. J Neurosurg 86: , Klekamp J, Volkel K, Bartels CJ, Samii M:Disturbances of Cerebrospinal Fluid Flow Attributable to Arachnoid Scarring Cause Interstitial Edema of the Cat Spinal Cord. Neurosurgery 48: , Lee KH, Lee JH, Lee JS, Hong SK:Expansile duraplasty for Posttraumatic Syringomyelia. J Korean Neurosurg Soc 29: , Levi AD, Sonntag VK:Management of posttraumatic syringomyelia using an expansile duraplasty. Spine 23: , Levi El, Heiss JD, Kent MS, Riedel CJ, Oldfield EH:Spinal cord swelling preceding syrinx development. J Neurosurg 92(Suppl 1): 93-97, McLean DR, Miller JD, Allen PB, Ezzeddin SA:Posttrumatic syringomyelia. J Neurosurg 39: , Milhorat TH, Capocelli AL Jr, Anzil AP, Kotzen RM, Milhorat RH: Pathological basis of spinal cord cavitation in syringomyelia:aanalysis of 105 autopsy cases. J Neurosurg 82: , Ohata K, Gotoh T, Matsusaka Y, Morino M, Tsuyuguchi N, Sheikh B, et al:surgical management of syringomyelia associated with spinal adhesive arachnoiditis. J Clin Neurosci 8:40-42, Rossier AB, Foo D, Shillito J, Dyro FM:Posttraumatic cervical syringomyelia:incidence, clinical presentation, electrophysiological studies, syrinx proteins and results of conservative and operative treatment. J Korean Neurosurg SocVolume 33March,

7 Brain 108: , Sgouros S, Williams B:A critical appraisal of drainage in syringomyelia. J Neurosurg 82:1-10, Sgouros S, Williams B:Management and outcome of posttrumatic syringomyelia. J Neurosurg 85: , Sherman JL, Barkovich AJ, Citrin CM:The MR apperarnce of syringomyelia:new observations. AJR Am J Roentgenol 148: , Stoodley MA, Gutschmidt B, Jones NR:Cerebrospinal Fluid Flow in an Animal Model of Noncommunicating Syringomyelia. Neurosurgery 44: , Tator CH, Briceno C:Treatment of syringomyelia with a syringosubarachnoid shunt. Can J Neurol Sci 15:48-57, Williams B:Post-traumatic syringomyelia, an update. Paraplegia 28: , Williams B, Terry AF, Jones F, McSweeney T:Syringomyelia as a sequel to traumatic paraplegia. Paraplegia 19:67-80, J Korean Neurosurg SocVolume 33March, 2003

KISEP Clinical Article J Korean Neurosurg Soc , 2002 공동지주막하단락술을시행한척수공동증환자의임상분석 한석 김주한 임동준 조태형 박정율 박윤관 정흥섭 서중근 Evaluation of Syringo-Subarachno

KISEP Clinical Article J Korean Neurosurg Soc 3121-26, 2002 공동지주막하단락술을시행한척수공동증환자의임상분석 한석 김주한 임동준 조태형 박정율 박윤관 정흥섭 서중근 Evaluation of Syringo-Subarachnoid Shunt for Syringomyelia Seok Han, M.D., Joo Han Kim,