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1 J Oriental Rehab Med 2006;16(4):83-95 고연석 박태용 공재철 오원교 송용선 신병철 원광대학교한의과대학한방재활의학과교실 The Safety of Cervical Chuna Manipulation; Mechanism, Adverse Reactions and Cases Report Youn-Seok Ko, O.M.D., Tae-Yong Park, O.M.D., Jae-Cheol Kong, O.M.D., Won-Kyo Oh, O.M.D., Yung-Sun Song, O.M.D., Byung-Cheul Shin, O.M.D. Dept. of Oriental Rehabilitation Medicine, College of Oriental Medicine, Won-Kwang University Objectives : The aim of the present study was to report the safety of cervical Chuna manipulation treatment (CCMT). We investigated the mechanism and complications of adverse reactions associated with CCMT, and newly demonstrated three cases in litigation. Methods : We searched relevant case reports, surveys, and review articles using a comprehensive databases of online and bibliography, combed adverse cases in clinical field. Results : A relative-to-absolute contraindication to cervical Chuna manipulation was circulatory and haematological disorders, neurological disorders, bone-weakening and destructive disorders, articular derangement or psychological factors. The majority of adverse reactions were mild or moderate in 85~90%, began within 4 h and generally disappeared within the next 24 h, at least one of them was reported by 30.0~60.9% of the patients after cervical manipulation. The most common were local discomfort (15.2~53.0%), headache (10.0~19.8%), stiffness (19.5~25.0%), tiredness (10.0~12.1%), or radiating discomfort (10.0~23.0%). The two of reported clinical cases were the occurrence of retropharngeal hematoma and cervical herniated disc disease after CCMT. The one was not a fault of practitioner, but complain for compensation. Conclusions : Manipulation of the cervical spine may also be associated with higher complication rates than previously reported. Although It is difficult to estimate the incidence of cervical manipulation complications, it is important to differentiate those patients who are susceptible to adverse reactions in order to inform them correctly. Key words : Chuna manipulation, Safety, Cervical spine, Mechanism, Adverse reaction, Complication 접수 : 2006년 9월 17일, 수정 : 2006년 10월 4일, 채택 : 2006년 10월 11일 교신저자 : 신병철, 전북익산시신용동 344-2, 원광대학교익산한방병원한방재활의학과교실 Tel : (063) , Fax : (063) , shinbc@hanmail.net 83

2 Ⅰ. 서론 추나요법은척추관절계의모든구조적변위에의하여발생하는병리적현상을다양한추나기법을통하여경결또는위축된근육등에피동적운동을통한자극을주거나변위를바르게교정해줌으로써관련기관의조절기능을정상적인상태로회복시키는기법이다 1). 추나치료에의해초래되는심각한손상은상대적으로드물며, 적절한추나치료는다른치료방법들에비하여시술자에의한손상을초래하는일이비교적적다. 그러나척추추나요법은관절가동저항점이후강한수동적운동을포함하기때문에부적절한수기및동작에대한위험요소들을반드시숙지해야하며, 오진과부적절한기술에의한추나치료는손상을유발하거나관련된질병을악화시킬수있으며, 심지어생명을구할수있는효과적이고적절한치료를지연시킬수도있다 2,3). 현재까지국내에서경추추나치료에대한긍정적효과를제시한연구로는경항부통증질환에대한추나요법의임상효과에대한보고 4) 와추골동맥과기저동맥혈류에대한경추추나요법의긍정적치료효과에대한보고 5,6) 가있으며이들또한잘못된추나기법의경우부정적효과를초래할가능성에대해배제할수없음을언급하고있다. 최근국내에서부적절한추나시술로인해심각한부작용이초래될수있는가능성을암시해주는많은보고가있어왔으며, 현재까지국내에서는경추추나치료후발생한부작용에대한증례보고만있는상태이나 7-9), 국외에서는부작용에대한증례보고뿐만아니라 Hurwitz EL 등 10,11) 의경부통증에대한경추교정치료후발생한부작용으로경부통증및경직 (stiffness) 의증가, 두 통, 방사통등의발생에대한보고, Malone DG 등 12) 의경추교정치료후발생한합병증에대한 5년간의후향적연구에서신경병증 (radiculopathy), 척수병증 (myelopathy), Brown-Sequard syndrome, 추골동맥폐색 (vertebral artery occlusion) 등의합병증에대한보고, Klougart N 등 13,14) 의경추교정치료로인한뇌혈관질환발병율에있어서의교정부위와기법에따른위험률에대한보고등교정치료후발생되는부작용및합병증에대한계통적이고후향적인연구가더욱활발히이루어지고있다. 이에저자는경추추나치료의부작용과금기증에대한명확한인식과한계설정및국내외에보고되고있는경추추나요법시술후발생되는합병증에대해고찰하고, 경추추나시술후발생된부작용으로인해소송이발생되었던임상증례 3예를보고하여향후추나치료로발생될수있는합병증에대한활발한연구가진행되어추나치료가근거중심의학으로발전하기위한계기가될수있게하고자이를보고하는바이다. 1. 손상기전 Ⅱ. 본론 경추는척추에서가동성이가장큰부분으로외부적인충격에의해손상받기쉬우며, 기능적으로상위경추와하위경추의 2부분으로나뉜다. 상위경추는환추 (C1), 축추 (C2) 로구성되며환추- 후두관절과환추- 축추관절로이루어져있어각각굴곡, 신전운동과축회전운동에중요한역할을한다. 하위경추는제3-6경추로굴곡과신전시매우큰유연성을보인다 3). 제6경추이상의횡돌기에는추골동맥의통로 84

인횡돌기공 (transverse foramen) 이있어이곳을통해추골동맥이뇌로혈류를공급하는구조를이루고있다 (Fig. 1). 경추추나치료와신경계의국소허혈사이의직접적인관계를명확하게추정하는것은어렵지만, 추골동맥의독특한경로와경추신경과추골과의밀접한관계및특이한임상징후로인해서로관련성이있는것으로인식되고있다.

3 인횡돌기공 (transverse foramen) 이있어이곳을통해추골동맥이뇌로혈류를공급하는구조를이루고있다 (Fig. 1). 경추추나치료와신경계의국소허혈사이의직접적인관계를명확하게추정하는것은어렵지만, 추골동맥의독특한경로와경추신경과추골과의밀접한관계및특이한임상징후로인해서로관련성이있는것으로인식되고있다. 경추의해부학적구조는추골동맥에기계적인압박과외상을유발할수있는가능성을가진인접구조들간의관계를가지고있으며, 뇌저동맥의기능부전은하나또는양쪽의추골동맥또는그분지의일시적, 부분적또는완전한폐쇄의결과이다. 압박에의해일어나는척수동맥증후군의증상과증후는척추수기요법후에현훈, 가벼운어지러움, 보행실조, 현기증, 조화운동불능, 보행장애, 구역감, 구토, 연하곤란, 안면한쪽또는반신의감각이상, 갑작스런두경부의통증을포함한다 15). 경추교정에의한추골뇌저동맥손상기전은경부의회전등으로인해추골동맥에외상이발생하면 C1-C2, C2-C3 영역에서의추골동맥내막이찢어지면서내막하조직이노출되고저항으로혈액덩어리가형성되어혈전이나색전의생성을 초래하게되고결과적으로소뇌후하동맥에서폐색혹은뇌저동맥에서의폐색을유발하게된다. 머리와경부동작은이들혈관현상과연계되고경추추나치료와관련이있으며경부의회전이혈관폐색을가장쉽게유발시키는운동임이많은연구에서확증되었다. 즉경추의회전시대측의추골동맥이더욱손상되며경추의회전과신전이함께될때는대측추골동맥과더불어동측의추골동맥도함께손상될수있다. 하지만측굴과신전운동은개별적으로는혈관의흐름에거의영향을미치지못한다고알려져있다. 그러므로추나를시술하려는의사에게있어서추골뇌저동맥의순환장애를인지하는것은매우중요하며추골-뇌저동맥의순환장애를평가하는것이필수적이다 2). 2. 부작용 1) 경추추나치료의상대적, 절대적금기및합병증 척추추나요법의금기증의범주는해를끼치지않는수기술 (manipulation) 또는가동술 (mobilization) 과같은비적응증 (non-indication) 에서부터생명을위협하는수기술이나가동술같은전형적 Fig. 1. Vertebral artery. 85

4 인금기증까지이른다 15). 추나치료의합병증과부작용의원인으로는지식부족, 기술부족, 합리적지식과태도부족등에의한경우가대다수를차지하고있으며, 부적절한진단습관및방사선학적평가, 좋지못한기술의선택이나실행, 과도하고불필요한수기요법의사용등부적절한진료로인해합병증발생의위험이증가하고있다. 정골추나치료의금기증및합병증에대하여혈관성, 관절성, 외상, 골약화질환, 신경학적, 염증 성, 정신적인범주에따른상대적금기 (Table Ⅰ) 와절대적금기 (Table Ⅱ) 의내용은다음의표와같다 2,3). 경추추나치료의상대적금기는합병증의유발가능성이높기때문에주의가필요하거나혹은적절한추나수기법으로교체해야하는상황을의미하며절대적인금기시에는문제부위의추나치료를금해야하는데, 상대적이거나절대적인금기증이라하더라도추나기법별로정골추나가아닌경근추나나도인추나등의기법이사용될수있다 3). Table Ⅰ. Relative Contraindications to Cervical Manipulation Treatment Classification Relative contraindications Complications Vascular disorder Arteriosclerosis Dislodged thrombus, Hemorrhage Articular disorder Osteoarthritis (late stage) Increased instability and pain Neurologic compromise Rheumatoid arthritis Increased inflammation Ankylosing spondylitis Increased inflammation Instability of joint Increased instability Trauma Stable fracture Severe sprains Increased instability Bone-weakening disorder Osteomyelitis, osteoporosis, osteomalacia Pathologic fracture Neurological disorder Dizziness Stroke, Paralysis Severe pain, agnosia Unnecessary or Increased pain Space-occupying lesions Permanent neurologic deficits Psychological factor Malingery (Feigned illness) Prolonged treatment Hysteria Hypochondriasis Treatment dependency Table Ⅱ. Absolute Contraindications to Cervical Manipulation Treatment Classification Absolute contraindications Complications Vascular disorder Vertebrobasilar insufficiency Brain stem stroke Aneurysm Rupture, hemorrhage Trauma Protrusion disc herniation with radiculopathy Permanent neurologic injury Unstable fracture Delay of treatment Increased instability Dislocation Increased instability Permanent soft tissue injury Bone-weakening disorder Bone tumor Pathological fracture Bone tuberculosis Other Lack of regular training of manipulation treatment 86

5 2) 경추추나치료의부작용에관한문헌고찰국내외로부적절한추나시술로인해심각한부작용이초래될수있는가능성을암시해주는많은보고가있어왔으며, 현재까지국내에보고된경추추나요법시술후발생한부작용에대한임상사례로는척추기저동맥계뇌경색, 뇌졸중, 경 막파열등이있으며 7-9), 국외에서는경추추나요법시술후발생한부작용및합병증에대한임상사례뿐만아니라후향적연구가더욱활발히이루어지고있다. 현재까지보고되고있는경추교정치료후발생된부작용의계통적, 후향적연구에대한논문은다음과같다 (Table Ⅲ). Table Ⅲ. Results of Adverse Reactions after Cervical Manipulation Treatment First author (year) Number of interventions, patients Results of adverse reactions Lee KP 16) (1995) 177 patients stroke (55 cases), myelopathy (16 cases), radiculopathy (30 cases) Senstad O 17) (1996) Rivett DA 18) (1996) Klougart N 13) (1996) Assendelft WJ 19) (1996) 368 treatments 95 patients 476 participants 238 patients survey 1: 226 Chiropractors' Association(response rate 54%) survey 2: 40 chiropractors (response rate 72.5%) 295 complications of spinal manipulations from the literature Leboeuf-Yde C 20) (1997) 625 patients (73%) Senstad O 21) (1997) Barrett AJ 22) (2000) 4712 treatments 1058 new patients 108 participants 68 patients moderate or slight reactions (90%) discomfort (34%), local or radiating symptoms (23%) exacerbation (1 case) CVA (5 cases) one case of CVA appeared for every estimated 1.3 million cervical treatment sessions and 1 for every 0.9 million upper cervical treatment sessions 165 VBAs, 13 cerebral complications other than VBAs. VBA range from 1 per 20,000 patients to 1 per 1 million cervical manipulations. local discomfort (44%), fatigue or headache (10% each), nausea, dizziness or other reactions (< 5%) at least 1 reaction (55%), local discomfort (53%), headache (12%), tiredness (11%), radiating discomfort (10%), actions were mild or moderate reactions (85%), dizziness, nausea, hot skin, or other complaints (< 5%) adverse reactions (53%), extra pain (14 cases), radiating pain (9 cases) Malone DG 12) (2002) 22 patients radiculopathy (21 cases), myelopathy (11 cases), Brown-Sequard syndrome (2 cases), vertebral artery (VA) occlusion (1 case) Haldeman S 23) (2002) 134,466,765 cervical manipulations (10-year period) 23 cases of vertebral artery dissection Cagnie B 24) (2004) 465 responses at least 1 reaction (60.9%), headache (19.8%), stiffness (19.5%), local discomfort (15.5%), radiating discomfort (12.1%), fatigue (12.1%) Hurwitz EL 10) (2004) Hurwitz EL 11) (2005) Oppenheim JS 25) (2005) 280 participants (83%) 336 participants 280 patients 18 patients 6 cervical spine injury (33%) adverse symptoms (30.4%), increased neck pain or stiffness (25%) at least 1 adverse symptom (30%), most commonly increased pain and headache central cord syndrome (4 cases), radiculopathy (2 cases) 87

3) 미발표임상사례및소송증례 (1) 증례 1 55세남자로우측경항부통증, 경추부관절가동역제한을주소로 2006. 03.

환자는당일 OO병원응급실처치후 2006. 03. 16 촬영한경추부자기공명영상 (Cervical MRI) 상경추부혈종 (Retropharyngeal hematoma) 진단하 (Fig. 2) 입원치료후혈종및통증이호전되었다.

6 3) 미발표임상사례및소송증례 (1) 증례 1 55세남자로우측경항부통증, 경추부관절가동역제한을주소로 OO한의원내원하여스트레스및과로로인한낙침증후군으로진단하침치료 ( 견우, 곡지, 외관혈등 ), 습식부항요법 ( 독맥경대추혈부위, 족소양담경견정혈부위 ), 한방물리요법 ( 핫팩, 한방외용약을이용한통증부위마사지 ), 추나요법 ( 제6-7경추부좌위후방회전교정법 ) 시행후당일저녁경항부통증의증가및통증으로인한자세제한이악화되었다고하였다. 환자는당일 OO병원응급실처치후 촬영한경추부자기공명영상 (Cervical MRI) 상경추부혈종 (Retropharyngeal hematoma) 진단하 (Fig. 2) 입원치료후혈종및통증이호전되었다. 환자는과거력상경추부혈종을일으킬만한특이한합병증이나증상을가지고있지않았고한의원내원당시의추나시술후통증이발생되었으며, 경추부혈종이발생된시점과치료 가시행된시점이일치하고촬영된 MRI상뚜렷한경추부혈종소견을보였으며, 입원치료중시행된혈액검사상 ESR, CRP 등이상승된점, 기타다른치료 ( 침치료, 습식부항요법, 한방물리요법 ) 에의해혈종이발생되기어려운위치에발생된점등으로미루어보아추나치료와환자의경추부혈종의발생과는인과관계가있는것으로사료된다. (2) 증례 2 평소척추강협착증 ( 제5요추 -제1천추간 ) 으로인한요통, 우하지방사통증에대해 OO병원치료받으시던 51세여자환자로, 요통, 우하지방사통, 경항부불편감을주소로 OO한의원초진및방사선사진 (X-ray) 상척추강협착증 ( 기존질환 ), 상부경추정열이상, 한증 ( 寒症 ) 으로진단하침치료, 한약물요법, 한방물리요법, 추나요법 ( 굴곡신연기법, 상부경추교정치료 ) 등시술받던중, 시행된추나치료후양측상지부위마비감, 경항부통증, 두통, 우측상지통증및거 A B Fig. 2. Cervical MRI (A; T2 sagittal view, B; T2 axial view). These images demonstrate bend like abnormal lesion at prevertebral space of C2, 3, 4, 5 levels; soft tissue injury with hematona collection (see arrows). 88

상제한등증상발생하였다. 환자상기증상에대하여동일한의원에서지속적인치료받던중 2006. 04. 28 교통사고발생하여당일 OO병원에서입원하였다. 환자사고전발생했던경항부통증및우측상지방사통증의호전이없어 2006.05.

시술된경추부추나치료는상부경추교정기법으로이는시술자의기법에대한기술의부족으로인한부적절한자극이나시술의과격함으로인하여부작용의발생율이높을수있다는점등으로미루어보아경추간판탈출증이경추부추나치료와관련된것으로사료된다.

7 상제한등증상발생하였다. 환자상기증상에대하여동일한의원에서지속적인치료받던중 교통사고발생하여당일 OO병원에서입원하였다. 환자사고전발생했던경항부통증및우측상지방사통증의호전이없어 시행된경추부자기공명영상 (Cervical MRI) 상제5-6번, 6-7번경추간판탈출증진단되었으며특히제6-7번경추간판의 T2 영상에서고신호강도영역 (high-intensity zone (HIZ)) 이있어 (Fig. 3) 급성손상에의해발병된것으로사료된다. 또한상기환자가 경추추나치료이전에는경추부위에별다른증상을호소하지않았으며, 경추부위에대한기존의료기관의진료가없었다는점, 환자병력상교통사고의경추편타손상에의한발병을배제할수없으나경추추나 요법시술후경항부통증과우측상지방사통증등이발생된점, 시술된경추부추나치료는상부경추교정기법으로이는시술자의기법에대한기술의부족으로인한부적절한자극이나시술의과격함으로인하여부작용의발생율이높을수있다는점등으로미루어보아경추간판탈출증이경추부추나치료와관련된것으로사료된다. (3) 증례 3 25세여자환자로사고당일 3~4일전부터별다른이유없이목을돌리기힘들정도의통증이발생하여 경추부통증과양측어깨통증을주소로 OO한의원에내원하여기존방사선검사상이상이없다는소견및촉진상근육통또는항강증으로진단되었다. 상기진단으로의료인은환자를바로눕게하여경추 3-4번부위로 B A C Fig. 3. Cervical MRI (A; T2 sagittal view, B; T2 axial view of C5/6, C; T2 axial view of C6/7). The above cervical MRI shows focal protrusion disc herniation on central aspect of C5/6, disc herniation with annular tear of C6/7 (see arrows). 89

근육마사지후, 다시바로일어나서좌우로스트레칭을시도하던도중환자가통증이극심하게증가되었다고호소하여환자의통증호소에따라침치료와부항요법으로보완적시술을시행하였다. 환자는 2005.10.

$26 동일병원경추부컴퓨터단층촬영 (Cervical spine CT) 및자기공명영상 (MRI) 상경추 6, 7번극돌기골절진단되었으며, CT상 fracture margin 에약간의 sclerotic change 를보이고인접연부조직의부종이나출혈이뚜렷하지않다$ 의료인이시술한경추부위근육마사지요법이나스트레칭은경추추나의연부조직이완기법 ( 신전법 ) 에해당되는것으로충분히안정시키고적절한힘을가하여시행하면별다른부작용이 발생하지않는수기법으로, 경추의강직과운동장애에도가볍게사용할수있는기법이다.

의료인이시술한경추부위근육마사지요법이나스트레칭은경추추나의연부조직이완기법 ( 신전법 ) 에해당되는것으로충분히안정시키고적절한힘을가하여시행하면별다른부작용이 발생하지않는수기법으로, 경추의강직과운동장애에도가볍게사용할수있는기법이다.

고찰 추나치료는손상을유발하거나관련된질병을악화시키거나적절한치료를지연시킬수도있다. 어떤조건들은국소적인추나치료의금기사항이될수있지만, 이러한조건들이다른형태의추나치료혹은다른부위에대한교정치료를모두금하는것은아니다.

8 근육마사지후, 다시바로일어나서좌우로스트레칭을시도하던도중환자가통증이극심하게증가되었다고호소하여환자의통증호소에따라침치료와부항요법으로보완적시술을시행하였다. 환자는 OO병원경추부단순방사선검사 (C-spine X-ray), 동일병원경추부컴퓨터단층촬영 (Cervical spine CT) 및자기공명영상 (MRI) 상경추 6, 7번극돌기골절진단되었으며, CT상 fracture margin 에약간의 sclerotic change 를보이고인접연부조직의부종이나출혈이뚜렷하지않다 는판독소견을보였다 (Fig. 4). 이는골절이비교적시간이경과되었음을시사하는것으로한의원치료 2일의시간경과로는보이기어려운 CT상소견이며최소약 2-3주전목부위의외부적인강한충격에의한것으로사료된다. 의료인이시술한경추부위근육마사지요법이나스트레칭은경추추나의연부조직이완기법 ( 신전법 ) 에해당되는것으로충분히안정시키고적절한힘을가하여시행하면별다른부작용이 발생하지않는수기법으로, 경추의강직과운동장애에도가볍게사용할수있는기법이다. 또한국내외의문헌보고에서도목의스트레칭으로인한경추극돌기골절에관한증례및합병증이전혀보고되지않고있다. 상기정황들로보아의료인의추나치료로인한경추극돌기골절은그가능성이희소하며, 이는환자의추가적보상이익과관련된것으로사료된다. Ⅲ. 고찰 추나치료는손상을유발하거나관련된질병을악화시키거나적절한치료를지연시킬수도있다. 어떤조건들은국소적인추나치료의금기사항이될수있지만, 이러한조건들이다른형태의추나치료혹은다른부위에대한교정치료를모두금하는것은아니다. 예를들면, 비록암환자가추나치료에의해우선적으로관리되지않을지라도적절한추나치료에의해현저한동통완 A B C D Fig. 4. Cervical spine X-ray, MDCT and MRI (A; X-ray LAT view, B; CT view, C; 3D CT view, D; T2 sagittal view of MRI). These images demonstrate spinous process fractures of C6, C7 (see arrows), sclerotic change of fracture margin (see B, C arrows) and no acute lesion without definite soft tissues swelling, focal high intensity or fluid collection (see B, D arrows). 90

9 화를얻을수있고보다나은삶을영위할수도있다 3). 추나치료에의해초래되는심각한손상은상대적으로드물며, 적절한추나치료는다른치료방법들에비하여시술자에의해손상을초래하는일이비교적적지만교정이약간의위험을동반한다는사실은항상염두하여야한다. 고속, 저진폭추력 (thrust) 에바탕을둔경추추나치료의금기는이치료기법을사용했을때의위험성이얻을수있는유익함보다클경우로, 환자가교정기법을견디지못하거나극심한통증이있는경우에는치료기법의변경이나절차의변화가있어야한다. 또한교통사고등으로인하여경추부위의외부적인충격에의한손상환자의경우는방사선사진에의한골절의감별에주의해야한다 2,3). 숙련된기술로적절하게활용되는추나치료는건강에관련된문제를관리하고예방하는데있어안전하며효과적이다. 모든상황에서정상적인진단평가를행하고추나치료의합병증과금기사항을잘인지한다면인위적인손상을피할수있다. 경추추나치료의상대적금기증은합병증의유발가능성이높기때문에주의가필요하거나혹은추나기술의변형이있어야하는상황을의미하며, 절대적인금기시에는문제부위의추나치료를금해야한다. 또한추골뇌저의순환장애징후나신전-회전검사에양성반응이나타날경우에는경추의신전과회전을이용하는교정기법치료는주의해야할금기사항이다. 그밖에신경학적결손을수반하는추간판탈출, 불안정성척추골절, 골종양으로인한골약화등의질환에도경추추나치료가금기이며, 또한추나기법의정식수련의결핍으로인해잘못된기술이나부적절한치료기법을사용하는것도추나치료의절대적금기에해당된다 2,3). WHO guidelines 15) 에서는경추추나치료의확실한금기증으로 Dens 형성부전, 급성골절, 척수종양, 척추결핵, 골수염등의급성감염, 뇌막내종양, 척수내혈종, 경추의악성종양, 상부경추의기형, 경추탈구등에대해명시하고있으며, 경추추나치료로인한의료사고에대해서는뇌저동맥에서의사고, Horner`s syndrome ( 교감신경성안근마비 ), 횡격막마비, 척수병증 (myelopathy), 경추추간판손상, 병적골절등의발생위험이있음을언급하였다. 척추추나치료의합병증의대부분은오진과부적절한기술의사용에서발생된다. 예를들어추골동맥기능부전을갖고있는환자의경우경추추나치료시경색이나동맥파열등이발생될위험성이높다. Mann T 등 26,27) 은경추교정치료후추골동맥의해리로인한뇌졸중의발생률이 6 배이상증가한다고보고하였으나유의해야할점은기존에추골동맥의해리로인한두통이나경부통을치료하기위해교정치료를받은사람이포함되어있을가능성이있다는것이다. 심한염좌환자의경우추나치료로인해오히려염증이나통증의증가를야기할수있으며, 골절환자의경우치유의지연및불안전성의증가로인해이차적인합병증으로나타날수있다. Hufnagel A 등 28) 은경추교정치료의합병증으로추골동맥의가성동맥류, 소뇌경색, 경동맥및추골동맥의손상, 추골기저동맥의경색, 경동맥혈관경련, 청력소실, 시야결손, 시상부위경색등에대해보고하였으며, Ernst E 29,30) 는경추교정치료후발생된심각한부작용에관한임상보고들의 systematic review를통해경추간판탈출에의한합병증, 횡격막신경손상에의한횡격막마비, 출혈, 척수신경병증, 경막파열로인한두개강내저혈압등의손상에대해보고하고척추교정의안전성에대한이전까지연구의한계를 91

10 극복하기위한전향적인연구가시급함을강조하였다. 상기미발표된임상증례 1의급성경항부염좌환자에게추나요법을시술하여발생된경추부혈종에관한보고와증례 2의추나치료후발생된경추간판탈출증에관한보고를통해, 경추부추나를시술할때급성염좌가비록추나치료의상대적금기에해당되지만환자의상태를고려하지않고무리하게부적절한추나기법을사용하게되면심각한합병증이발생될수있음을반드시숙지해야할것이다. 또한증례 3의경우처럼추나시술에있어의료인의과실은아니나환자의보상심리로인한소송이발생될수있음을주의해야한다. 시술자는추나요법의시술전에반드시환자의병력, 증상, 이학적검사및진단방사선검사등의임상검사소견에기초한임상진단을내려야하고이러한조건이수기치료에합당한지를판단하여수기치료의금기질환을감별해야한다. 또한추나치료에영향을줄수있는비정상적인구조적변화를파악하고환자의증상과건강에임상적인관련이있는정적및기능적생체역학적관련성을찾아치료에임하여교정치료로인해발생할수있는위험으로부터환자를보호해야할것이다. 현재까지국내에보고된추나치료후발생한부작용논문 5편 7-9,31,32) 의임상 8예 ( 추나치료와관련없는경부손상 2예는제외 ) 와미발표된상기임상 2예 (1예는의료인과실이아니므로제외 ) 등총 10예의부작용에대해고찰한결과, 문헌검색상편수가적어다소의미가떨어질수있으나현재까지고찰된증례문헌에서추나시술자는각각의료인이 5예 (50%), 비의료인 3예 (30%), 미확인 2예 (20%) 로확인되었다. 시술자가한의사인경우총 5예에서추나교육정도를분석한결과, 학회중심의공인된기관을통한정식추나교육을수료한경우가 1예 (10%), 학회이외의교육을통한수련이 3예 (30%), 미확인 1예 (10%) 였다. 증례의수가적고시술자나그교육정도를확인할수없는경우가다수있었지만, 추나치료에의해발생된부작용은학회를통한정식교육의결핍과상관성이높은것으로나타났으며대학차원의추나교육에대한강화가필요할것으로사료되었다. 끝으로아직까지국내에서는추나치료로인해발생된부작용이나합병증에관한임상보고및연구가많지않은실정으로, 향후국내에서도정확한부작용발생빈도와추나치료의안전성에관한지속적인연구가필요하며관련학회와기관이참여하여계통적이고전향적인연구를해야할것이다. Ⅳ. 결론 1. 경추추나치료에의한부작용의 85~90% 정도는경도나중등도의증상이며, 심각한부작용이나합병증발생률은낮은것으로보고되었다. 2. 경추추나치료부작용의대부분은국소부위불편감 (15.2~53.0%), 두통 (10.0~19.8%), 경직감 (19.5~25.0%), 피로 (10.0~12.1%), 방사통증 (10.0~23.0%) 등으로보고되었다. 3. 경추추나치료의금기증및합병증은혈관성, 관절성, 외상성, 골약화질환, 신경학적, 정신적인범주에따라분류되며, 추나에대한정식수련의결핍또한수기치료의중요한금기이다. 92

11 4. 추나시술시환자의병력, 이학적검사및진단방사선검사등이반드시선행되어야하며, 시술자는상대적, 절대적금기증에대해숙지하여야한다. 5. 미발표된임상 3예는각각경추추나치료후발생된경추부혈종, 급성경추간판탈출증에관한보고와, 마지막증례는의료인의시술과무관한환자의보상심리로인한소송과관련된보고이다. 6. 추나치료로인한부작용과합병증을줄이기위해서는대학교육이나학회를통한정식교육및체계적이고충분한시간의수련이필요하다. 감사의글 본연구는 2005년도원광대학교교비연구비지원에의해수행되었습니다. 참고문헌 1. 한방재활의학과학회. 한방재활의학. 서울 : 군자출판사. 2005: Thomas F. Bergmann, David H. Peterson, Dana J. Lawrence. Chiropractic technique( 한국어판 ). 서울 : 대한추나학회출판사. 2000: 신병철, 신준식, 이종수, 임형호공저. 정형추나의학. 서울 : 척추신경추나의학회. 2006: 김기옥, 이종수. 추나요법이경항부통증질환에미치는임상적효과. 대한추나의학회지. 2000;1 (1): 신병철, 김도환, 김상돈, 송용선. 경추추나요법이추골동맥과기저동맥혈류에미치는영향. 대한추나의학회지. 2000;1(1): Hong ES, Deng MY, Cheng LH, Zhou S, Wang B, Zhang A, Li Y, Wang H. Effect of vertebral manipulation therapy on vertebrobasilar artery blood flow in cervical spondylosis of vertebral artery type. Zhongguo Zhong Xi Yi Jie He Za Zhi. 2005;25(8): 박기정, 윤상수, 박정혁, 장대일, 김의종, 최우석, 정경천. 경부척추조작술또는경부수상과관련된척추기저동맥계뇌경색 3례. 대한신경과학회지. 1997;15(4): 이상호, 이종립, 김성수. 경추추나치료후발생한뇌졸중 1례. 대한한의학회지. 2000;21(4): 공재철, 박태용, 고연석, 원재균, 박단서, 신병철. 경추추나치료후발생한경막파열환자 1례보고. 척추신경추나의학회지. 2006;1(1): Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study. J Manipulative Physiol Ther. 2004;27(1): Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine. 2005;30(13): Malone DG, Baldwin NG, Tomecek FJ, Boxell CM, Gaede SE, Covington CG, Kugler KK. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus. 2002;13 (6):ecp1. 93

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04조남훈 Received : 2011. 11. 16 Reviewed : 2011. 11. 25 Accpeted : 2011. 12. 5 A Case Report of Prescribing Yanghyeolgeopung-tang(yangxuequfeng-tang) to Two Patients with Cervical Disc Herniation and Headache