Case Report J. of Advanced Spine Surgery Volume 1, Number 2, pp 97~101 JASS Traumatic Spinal Subdural Hematoma at Thoracolumbar Spine after Massage -

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1 Case Report J. of Advanced Spine Surgery Volume 1, Number 2, pp 97~101 JASS Traumatic Spinal Subdural Hematoma at Thoracolumbar Spine after Massage - Case Report - Seok-Woo Kim, M.D., Ph.D., Sang Hoon Paik, M.D., Ho Dong Lyu, M.D., Ji Hoon Nam, M.D. Spine Center, Department of Orthopedic Surgery, Hallym University Sacred Heard Hospital, School of Medicine, Hallym University A 45 year-old male was brought to our hospital with severe back pain and motor, sensory impairment in both lower extremities. He had no underlying diseases including coagulapathy. Motor weakness below both hip joint and decreased sensory below T12 dermatome, voiding dysfunction were examined. The MRI showed a spinal subdural hematoma at the thoracolumbar region, which was extremely rare. Medical treatment was applied without surgical interventions. After two weeks, motor weakness, sensory impairment, and voiding dysfunction were improved. And he returned to his daily activities. We present this case and literature reviews because traumatic spinal subdural hematoma is an extremely rare disease and the condition was treated successfully in conservative manner. Key Words: Thoracolumbar spine, Traumatic spinal subdural hematoma, Conservative manner 척추경막하출혈은드문질환으로척추의천자및수술력, 외상력, 혈액응고장애, 종양, 동정맥기형 (arteriovenous malformation) 등을가진환자에게서보고된바있으나, 그보고의빈도가많지않다 1). 더욱이외상에의해발생되는척추의경막하혈종은매우드물고현재까지단 13례만이보고되고있으며대부분의경우두개강내출혈과연관된경우가많아여타질환이없이단독으로흉요추부에발생한경막하출혈은국내는물론국외에서도현재까지그보고가드물다 2). 이에본증례에서는두부외상과연관없이마시지를받은이후발생한심한요통과신경증상을동반한 41세남자환자의흉요추부에단독으로발생한경막하출혈을수술적치료없이효과적으로치료하였기에문헌고찰과함께보고하고자한다. 증례보고 41세남자환자로내원 4일전, 태국으로여행가서허리를꺾고뒤틀고밟는등의마사지를받은이후, 화장실에서앉았다일어나려던중허리부터시작하여아래로내려오는극심한통증과양측하지에힘이빠져보행이불 가능한증상이발생하여귀국하여응급실로내원하였 다. 내원당시두통이나오심등의증상은없는상태로흉 요추경계부위의극심한통증과압통을호소하였고양 측고관절굴곡 (grade III), 슬관절신전 (grade II), 족무지 신전 (grade IV) 의운동기능감소가관찰되었다. 또한제 12 흉추피부분절이하의감각저하가관찰되어윗분 절의피부분절감각에비해촉각, 통각에서손상된양상 을보였다. 환자는배뇨장애로인하여복부팽만감은있 으나소변이나오지않는다고호소하였으며도뇨관삽 입후약 1200cc 의소변이확인되었다. 그외양측족부의 Babinski 반사가양성을보였다. 단순방사선상경도의 퇴행성변화외엔척추체의명백한이상소견이없었으 며혈액검사상 C- 반응단백만경미하게증가하였다. 급 성추간판탈출증, 종양, 척수강내혈종등에대한평가를 위하여자기공명영상을실시하였으며시상면상에서제 12 흉추부터제 1 요추에걸친방추형의종괴가관찰되었 Corresponding author: Seok-Woo Kim, M.D. Spine Center, Department of Orthopaedic Surgery, Hallym University, 896 Pyeongchon-dong, Dongan-gu, Anyang-si, Gyeonggi-do , Korea TEL: , FAX : seokwookim@yahoo.com Copyright 2011 Korean Society for the Advancement of Spine Surgery 97

으며횡단면상에서척추강내에좌측에서척수를압박하고있는양상을보였다 (Fig. 1). 종괴는 T1 강조영상에서중간신호강도를, T2 강조영상에서저신호강도를보이며 gadolinium 정맥주사후에조영증강을보이지않아급성기의혈종으로판단되었다. 환자는다른기저질환이나출혈성질환의과거력이없었으며혈액종양의가족력역시없었다. 또한지난수년간어떠한약물의복용역시없다고진술하였다.

2 으며횡단면상에서척추강내에좌측에서척수를압박하고있는양상을보였다 (Fig. 1). 종괴는 T1 강조영상에서중간신호강도를, T2 강조영상에서저신호강도를보이며 gadolinium 정맥주사후에조영증강을보이지않아급성기의혈종으로판단되었다. 환자는다른기저질환이나출혈성질환의과거력이없었으며혈액종양의가족력역시없었다. 또한지난수년간어떠한약물의복용역시없다고진술하였다. 추가적으로시행한혈소판수, 프로트롬빈시간및 INR(international normalized ratio), 활성화부분트롬보플라스틴시간을포함하는혈액응고지표상이상소견은없었으며혈청전해질및혈당수치역시정상화범위에있었다. 환자는정맥주사로덱사메타손을 25mg 부터시작하여하루에 5mg 씩감량하였으며절대침상안정을취하면서경과를관찰하였으며증상변화에따라수술적혈종제거역시준비중이였다. 입원 2 일째부터근력및감각기능이회복되는양상을보여입원 2주째에제 4,5번요추피부분절에서약 10% 의감각저하만이남아있었으며양측하지의근력은모두정상화 Fig. 1. Magnetic resonance image(mri) showing acute spinal subdural hematoma. (A) Sagittal T2-weighted image demonstrating low signal intensity with in anterior spinal canal extending from T12 to L1(white arrow). (B) Sagittal T1-weighted image revealing intermediate signal intensity lesion within the tecal sac at T12-L1(double arrow). Axial T2-weighted (C) and T1-weighted (D) image showing acute subdural hematoma compressing spinal cord from left side. 98

되었다. 입원 2주째에시행한 MRI에서종괴의크기는약 40% 가량줄어있었으며 T1 및 T2 강조영상에서모두고신호강도를보여아급성기의혈종에합당한소견을보였다 (Fig. 2). 환자는입원 3주째에불편감없이자가배뇨를잘하는상태로퇴원하여일상에복귀하였다. 고찰 경막하출혈은혈액학적기저질환이나외상이나뇌수술, 혈관질환, 종양등과같은선행요인과연관되어발 생하는드문질환이다 1).

3 되었다. 입원 2주째에시행한 MRI에서종괴의크기는약 40% 가량줄어있었으며 T1 및 T2 강조영상에서모두고신호강도를보여아급성기의혈종에합당한소견을보였다 (Fig. 2). 환자는입원 3주째에불편감없이자가배뇨를잘하는상태로퇴원하여일상에복귀하였다. 고찰 경막하출혈은혈액학적기저질환이나외상이나뇌수술, 혈관질환, 종양등과같은선행요인과연관되어발 생하는드문질환이다 1). 대다수의척추경막하출혈은혈액학적질환이나항응고치료에의해발생하지만약 5% 이내에서어떤위험인자에대한증거없이발생하며이런경우혈종은자연발생했다고판단된다 3). 본증례에서환자는어떠한혈액학적기저질환에대한개인력및가족력을가지고있지않았으며지난수년간어떠한약물도복용한바가없었다. 또한환자는혈액검사상어떤이상도보이지않았다. 외상후발생하는척추경막하출혈은극히드물어영어권논문에서단 13례만이보고된바있다. 뇌전산화단층촬영을시행하기전에치료가이루 Fig. 2. Follw-up MRI study showing subacute spinal subdural hematoma with decreased size compared to previous MRI. T2-weighted (A,C) and T1- weighted (B,D) image demonstrating high signal intensity with in anterior spinal canal extending from T12 to L1 compressing spinal cord from left side. 99

4 어진 3례를제외하면 10례중 6례에서두개강내출혈을동반하고있었다 2). 몇몇논문에서는두개강내출혈과척추경막하출혈이연관되어있다고설명하고있다. Hung 등 4) 은두개강내의압력이척추경막하및지주막하공간간의전단력을증가시켜경막내측의열상과출혈을일으킨다고하였다. 하지만이가설은두개강내혈종과연관되어있지않은외상성척추경막하출혈의기전을설명할수없다. 본증례역시두부의외상병력이나환자가호소하는증상및징후가관찰되지않았다. 비록척추경막하출혈의정확한병인이밝혀지지는않았지만척추의독특한해부학에대한지식이외상성척추경막하출혈의병인을어느정도이해하는데도움을준다. 두개강내의경막의구조와달리척추의경막하공간은연결정맥이나주요한혈관이없이경막의외측경계를따라미세한혈관들의연결구조만이존재한다. 또한상대적으로두껍고혈관이풍부한경막외지방조직이존재하여척추의경막은뼈와인접해있지않다. 이러한차이점이왜척추에서경막외혈종이경막하혈종보다호발하는지설명해준다. 외상성척추경막하출혈의병인을설명하는다른두개의이론이제안된바있다. 먼저 Rader 5) 는갑작스럽고급격한복부및흉부의압력증가가척추의경막하공간의혈관내압력을증가시켜순간적으로혈관안과밖의압력간의불균형이생기고이로인하여척추혈관의파열이발생한다고하였다. 본증례에서도마사지중심하게등부위를누르고밟는행위중발생한급격한복부및흉부의압력증가로인하여혈관내압력의증가가발생하였고이로인하여척추경막하공간의상대적으로얇고작은혈관에손상을주었을것으로생각된다. 두번째이론은지주막하공간에서단독으로생긴혈종이경막하공간으로파열되어확장된다는것이다 6). 이이론은자발성경막하출혈및지주막하출혈의보고로지지받은바있다 7). 척추내출혈은급격히척수나말총을압박할수있기때문에빠른진단이필수적이다. 척추경막하출혈의임상증상은매우다양하여혈종의위치와크기에따라경미한요통에서부터마비까지나타날수있다. 일반적으로즉각적인진단및척수의비가역적인손상이일어나기전에빠른수술적혈종제거가필요하다고여겨지고있으나 1,8), 몇몇저자들은경하거나회복을보이는신경결손을보이는환자에서보존적치료로써좋은결과를가 져온바를보고한바있다 9,10). 본증례에서는내원당시신경학적이상소견이뚜렷이관찰되어즉각적인스테로이드사용을하였으며이후빠른회복을보여수술적치료없이보존적요법만을사용하여 2주후에는정상에가까운극적인회복을보였다. 척추경막하출혈의진단에는위험인자에대한의심과더불어자기공명영상이진단뿐만아니라그범위와위치, 신경압박정도를파악하는데에필수적이며전산화단층촬영보다도월등히우월하다 4). 또한퇴행성척추질환, 종양등과같은구별하기힘든증상들을나타내는경우에있어서도그감별진단을위하여필수적이다. 저자들은이매우드문증례를보고함으로써이질환을인식하고혈종의위치와환자의임상적신경학적증상과진행의정도에따라즉각적인감압수술에서보존적치료까지다양하게관리할수있으며급성으로진행하는심한신경학적증상이없는경우에는보존적치료를통하여도좋은임상적결과를가져올수있음을문헌적고찰을통하여확인하였다. REFERENCES 1. Russell NA, Benoit BG:Spinal subdural hematoma. A review. Surg Neurol, 20: , Cho DC, Sung JK: Traumatic subacute spinal subdural hematoma successfully treated with lumbar drainage. Case report. J Spinal Disord Tech, 22:73-6, Lecouvet FE, Annet L, Duprez TP, Cosnard G, Scordidis V, Malghem J: Uncommon magnetic resonance imaging observation of lumbar subdural hematoma with cranial origin. J Comput Assist Tomogr, 26: , Hung KS, Lui CC, Wang CH, Wang CJ, Howng SL: Traumatic spinal hematoma with spontaneous resolution. Spine, 27: 534-8, Rader JP: Chronic subdural hematoma of the spinal cord. N Engl J Med, 253: , Masdeu JC, Breuer AC, Schoene WC: Spinal subarachnoid hematomas; clue to a source of bleeding in traumatic lumbar punctures. Neurology, 29: , Swann KW, Ropper AH, New PF, Poletti CE: Spontaneous spinal subarachnoid hemorrhage and subdural hematoma. Report of two casess. J Neurosurgery, 61: , Bortolotti C, Wang H, Fraser K, Lanzino G: Subacute spinal subdural hematoma after spontaneous resolution of cranial subdural hematoma: causal relationship of coincidence? Case 100

5 report. J Neurosurgery, 100: , Kang HS, Chung CK, Kim HJ: Spontaneous spinal subdural hematoma with spontaneous resolution. Spinal Cord, 38: , Juvonen T, Tervonen O, Ukkola V, Klintrup HE: Widespread posttraumatic spinal subdural hematoma-imaging findings with spontaneous resolution: case report. J Trauma 36: , 마사지이후흉요추부에발생한외상성경막하출혈 - 증례보고 - 김석우, 백상훈, 류호동, 남지훈한림대학교의과대학정형외과학교실 45세남자환자가태국에서허리에마사지시술을받은이후발생한극심한흉요추부통증과양측하지의근력저하및감각저하를호소하며본원에내원했다. 혈액응고장애를포함한여타기저질환은없었다. 이학적검사상제 12 흉추피부분절이하의감각저하및양측고관절이하의근력저하및배뇨장애가관찰되었다. MRI 상매우희귀한척추경막하출혈로진단되었으며, 수술적치료없이약물치료만으로근력, 감각저하및배뇨장애가호전되어일상에복귀하였다. 외상성척추경막하출혈은매우희귀한질병이며본원에서수술없이보존적치료로서성공적으로치료하였기에문헌고찰과함께증례를보고하는바이다. 색인단어 : 흉요추부, 외상성척추경막하출혈, 보존적치료 101

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar