Journal of Soonchunhyang Medical Science 14(2) p.179~186 December 요추척추관협착증에대한자기공명영상의진단가치 이경석, 심재준, 윤석만, 도재원, 윤일규, 배학근 순천향대학교천안병원신경외과학교실 Diagn

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1 Journal of Soonchunhyang Medical Science 14(2) p.179~186 December 요추척추관협착증에대한자기공명영상의진단가치 이경석, 심재준, 윤석만, 도재원, 윤일규, 배학근 순천향대학교천안병원신경외과학교실 Diagnostic Value of the MRI on the Lumbar Spinal Stenosis Kyeong-Seok Lee, Jae-Jun Shim, Seok-Mann Yoon, Jae-Won Doh, Il-Gyu Yun, Hack-Gun Bae, M.D. Department of Neurosurgery, Soonchunhyang University Chonan Hospital, Chonan, Korea Abstract We evaluated the diagnostic value of the MRI on the lumbar spinal stenosis. From January to June 2008, MRI on the lumbar spine was done in 112 consecutive patients who were admitted to the Soonchunhyang University Chonan Hospital. They admitted to the department of neurosurgery in 35%, orthopedics in 30%, internal medicine in 19%, and others in 16%. There were 49 males and 63 females. The age was not more than 40 years in 45% and over 40 in 55%. Lumbar spinal stenosis was clinically diagnosed in 11 patients(9.8%), while it was radiologically diagnosed in 5 patients(4.5%). The narrowest AP length was less than 10 mm in 65%, 10~12 mm in 25%, and over 12 mm in 10%. The diagnosis of lumbar spinal stenosis should not be made simply by the AP length of the narrowest level in the MRI, especially in Korea. KEY WORDS : Spinal Stenosis, Low Back Pain, Magnetic Resonance Imaging, Diagnosis 서론 1) 요추척추관협착증은 1950년대 Verbiest가처음으 로기술하였다. 1) 그가기술한요추척추관협착증은 선천성과후천성, 두가지유형이있었는데, 선천성은 전후경이 10 mm, 후천성은 10~12 mm 이하라고하 였다. 2) 초기엔척수조영술을이용하여척추관의크기 를측정하였으나, 나중에는전산화단층촬영(CT) 이나 자기공명영상(MRI) 을이용하였다. 최근에는 MRI나 MR 교신저자 : 이경석주소 : 충남천안시동남구봉명동 23-20, 순천향대학교천안병원신경외과 Tel : kslshl@schca.ac.kr 접수일 : 2008년 10월 31 일 / 게재확정일 : 2008년 12월 15일 척수조영술(MRM) 을이용하기도한다. 3) 또한초기엔전 후경만으로측정하였으나, 단면적(cross-sectional area) 이나 4) 척추관추체비 (spinal canal vertebral ratio) 를진 단에이용하기도한다. 5) 이동의하는진단기준은없다. 6) 여러이유로요추 MRI 그러나아직까지모든사람들 검사를했던환자들을대상으 로하여전후경이 10mm 또는 12mm 이하였던환자 들의특성을조사분석하여요추척추관협착증에대 한 MRI 의진단가치를알아보고자하였다. 대상및방법 2008년 1월부터 6월까지 6개월동안순천향대학교

2 180 순천향의과학 : 제14권 2호 2008 Table 1. Age and sex distribution Age(yr) Male Female Total (%) ~ (16.1) 21~ (28.6) 41~ (30.4) 61~ (25.0) Total (100) Table 2. Distribution of admitted department Department Cases (%) NS 39 (34.8) OS 33 (29.5) IM 21 (18.8) GS 5 (4.5) PR 4 (3.6) NR 3 (2.7) UR 2 (1.8) OT 5 (4.5) NS=Neurosurgery; OS=Orthopedic Surgery; IM=Internal Medicine; GS=General Surgery; PR=Rehabilitation; NR=Neurology; UR=Urology; OT=Others 천안병원에입원하여요추 MRI 검사를했던환자연 속(consecutive) 112 례를대상으로하였다. 남자가 49 례, 여자가 63 례로여자가조금더많았다(Table 1). 40세이하가 45%, 41세이상이 55% 로 41세이상이 조금더많았다. 이들은입원한이유와진단은서로 다르지만, 요추부분의 MRI 검사를했던환자로신경 외과(35%), 정형외과(30%), 그리고내과(19%) 환자가 대부분을차지하였다 (Table 2). 대상환자의나이와성별, 그리고요추 MRI 영상을 조사하였다. 요추척추관의전후길이는병원의 Picture Archiving and Communication System(PACS) 을이 용하여실제길이를측정하였다. MRI 영상중시상 (sagittal) 면정중앙을촬영한영상을이용하여제 12 흉추부터제 1 천추까지길이를측정하였고, 가장짧은 부위를조사하였다(Fig. 1). 측만이나자세로인해정 중앙을촬영하지못한경우에는중앙바로앞이나뒤 에인접한영상을이용하여측정한뒤가장긴길이 를이용하였다(Fig. 2). 수술로인해정중앙의해부학 적구조가변형된경우에는횡단면영상에서가장긴 길이를측정하였다 (Fig. 3). 임상진단은퇴원할때기록된병명에따랐고, 영상의 학적진단은판독지에기록된병명에따랐다. 1. 가장좁은부위 결과 가장좁은부위는남녀모두제 고, 그다음이제 3~4 요추였다(Table 3). 2. Table 3. Level of the narrowest spinal canal Level Male Female Total (%) T12-L (1.8) L (10.7) L (11.6) L (16.1) L (50.9) L5-S (8.9) 가장좁은부위의전후길이 4~5요추가가장흔했 가장좁은부위의전후길이는전체대상환자중 절반이넘는 73 례(65.2%) 에서전후길이가 10 mm 미만이었고, 12 mm 이상은 10% 에도미치지못하였 다 (Table 4). Table 4. Frequency of narrow spinal canal in MRI Length (mm) Male Female Total (%) < (65.2) 10~ (25.0) 12< (9.8) Table 5. Average AP length of the narrowest lumbar spinal canal Age(years) Male(N) Female(N) ~ (8) 11.01(10) 21~ (6) 8.74(5) 31~ (10) 7.98(11) 41~ (12) 7.84(7) 51~ 8.69(13) 8.31(30)

3 이경석 : 요추척추관협착증에대한자기공명영상의진단가치 181 Fig. 1. The narrowest AP length was measured directly using the PACS images in midline sagittal MRI image. 3. 가장좁은부위의전후길이와나이의비교 연령대별가장좁은부위의전후길이평균은남녀 모두 10대가가장길었고 40대이후에는별다른변화 가없었다 (Table 5). 4. 진단비교

4 182 순천향의과학 : 제14권 2호 2008 Fig. 2. When the midline sagittal MRI image was inadequate, the longest length was used among three consecutive images. 임상진단과영상의학적진단은 18 례(16%) 에서서로 달랐는데, 임상적으로가장많았던진단은골절과같 은외상성질환이었고, 판독지에기록된영상학적진단 으로가장많았던진단은퇴행성질환이었다 (Table 6).

5 이경석 : 요추척추관협착증에대한자기공명영상의진단가치 183 Table 6. Diagnostic impressions Impression Clinical Radiological Trauma Degenerative Malignancy 9 10 Normal 4 7 Infection 3 4 Other 요추협착증의빈도 임상적으로요추협착증으로진단했던경우는 11례 (9.8%) 였고, 영상의학적으로요추협착증으로진단한경 우는 5 례(4.5%) 였는데, 두진단이일치한경우는 3례 (2.7%) 뿐이었다(Table 7). 진단이다른경우는임상적 으로요추협착증이라고진단하였으나, 는추간판질환으로진단된경우가 영상의학적으로 5 례로가장많았다. Fig. 3. When the midline structure was deformed, the longest length was used in the cross-sectioned MRI image. Table 7. Incidence of clinical and radiological diagnosis of lumbar stenosis Clinical Radiological No. of Cases Stenosis HLD 5 Stenosis Stenosis 3 Stenosis Degeneration 3 HLD Stenosis 1 Spondylolisthesis Stenosis 1 HLD=herniated lumbar disc 고찰 가장좁은부위는남녀모두제 4~5요추가가장흔 했고, 그다음이제 3~4 요추였다. 우리나라사람들의 시체를이용한요추관전후길이를측정한보고 7) 에 따르면가장좁은부위가남자는제 3 요추, 여자는제 4 요추였다고하나, 정상성인을대상으로 MRI로척추 관면적을측정한보고에따르면여자는제3~4요추간 이 mm2, 제4-5요추간이 mm2로 3~4요

6 184 순천향의과학 : 제14권 2호 2008 추간이더좁았으나, 남자는제3~4요추간이 mm2, 제4~5요추간이 mm2로제4~5요추간이 더좁았다고하여저자들의결과와비슷하였다. 가장좁은부위의전후길이는전체대상환자중 절반이넘는 65% 에서전후길이가 10 mm 미만이었 고, 12 mm 이상은 10% 에도미치지못하였다. 임상 적으로아무런증상이없지만 이는소위위양성이 려져있지만, MRI 절대협착으로분류되는 MRI에서협착증으로보 21% 에달한다는보고 8) 는잘알 촬영한대상환자의절반이상이 10 mm 미만으로조사된것 은주목할만한사실이다. 이러한결과는무증상환자 32례중 14 례(44%) 가정상이었고, 18 례(56%) 가모두 방사선학적으로경도~ 중증협착증으로진단되었다는 보고 9) 보다그비율이높다. 이는 63례의여자환자 중가장많은 20례가 60세이후인점을고려하면 MRI 를찍은환자들중골다공증에의한압박골절때 문에 MRI를찍고입원한여자환자가상대적으로많 았기때문으로보인다. 하지만아시아인들이서구인에 비해척추관이상대적으로더좁으며, 10) 보다는전체적인판독이더유용하다고 11) 특정측정치 하기때문 에, 우리나라에서는더빈도가높을가능성은있다. 이런점을고려할때우리나라에서단순히척추관의 전후길이만으로요추협착증을진단해서는안되리라 본다. 요추협착증의진단에가장많이이용되고가장 정확도가높은검사방법이 MRI 라고하지만, 방사선 학적소견만으로요추협착증을진단하기엔적절하지 않다는최근의보고 12) 와일치하는결과였다. 연령대별가장좁은부위의전후길이평균은남녀 모두 10 대가가장길었고, 40대이후에는별다른변 화가없었다. 척추의퇴행성변화는 10대부터시작하 여, 13) 나이가들수록증가하며, 14) 40세까지남자의 80%, 여자의 65% 에서퇴행성변화를확인할수있다 는보고와일치하는소견이었다. 이연구에서는임상적으로요추협착증으로진단했던 경우는 11 례(9.8%) 였고, 영상의학적으로요추협착증으 로진단한경우는 5 례(4.5%) 였는데, 두진단이일치한 경우는 3 례(2.7%) 뿐이었다. 진단이다른경우는임상 적으로요추협착증이라고진단하였으나영상의학적으 로는추간판질환으로진단된경우가 5례로가장많았 다. 환자의증상이신경근병증에상응하는증상이없 고, 요통과신경인성파행을호소할경우엔임상의사 는추간판탈출증보다는요추협착증이란진단을더 선호하겠지만, 그러한임상소견을알지못한상태에 서는추간판탈출증이란진단이더용이하리라본다. 그러나추간판탈출증과요추협착증의엄격한감별은 매우어렵다. 15) 임상진단과영상의학적진단은 18 례(16%) 에서서로 달랐는데, 임상적으로가장많았던진단은골절과같 은외상성질환이었고, 판독지에기록된영상학적진 단으로가장많았던진단은퇴행성질환이었다. 척추 질환의진단에 MRI는매우유용한보조진단방법이 기때문에두진단이비교적일치하며, 일치하지않은 경우는주로임상적으로골절이의심되었으나최근의 골절이아니었거나영상의학적으로는정상이었던경우 들이었다. 요추협착증의진단에 MRI는 CT나척수조 영술에비해더정확하다고한다. 한편, 영상의학적진단기준에따른진단이믿을만하 지않다면, 증상이나검사또는전기생리학적검사를 이용해야하는데, 이또한특징적인소견은없다고한 다 년대처음발표되었던요추협착증이, 한때 우리나라에서는증례로보고될 16,17) 정도로드문질환 이었는데, 2000년대엔가장많이진단되고수술을하 는질병이되었다. MRI에의한무증상요추협착증이 매우흔하다는점은정확한진단기준이확립되지않 은상태에서 MRI 검사의빈도의증가가요추협착증 환자의증가에영향을줄가능성이크다. 결론 요추 MRI 검사를했던환자 112례를대상으로하여 요추척추관협착증에대한 MRI의진단가치를조사하 였다. 임상적으로요추협착증으로진단했던경우는 11 례(9.8%) 였고, 영상의학적으로요추협착증으로진단한 경우는 5 례(4.5%) 였는데, 가장좁은부위의전후길이 는전체대상환자중절반이넘는 65% 에서전후길

7 이경석등 : 요추척추관협착증에대한자기공명영상의진단가치 185 이가 10 mm 미만이었고, 12 mm 이상은 10% 에도 미치지못하였다. 우리나라에서단순히척추관의전 후길이만으로요추협착증을진단해서는안되리라 본다. 참고문헌 1.1Verbiest H : A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br 36-B(2): , Verbiest H : Results of surgical treatment of idiopathic developmental stenosis of the lumbar vertebral canal. A review of twenty-seven years' experience. J Bone Joint Surg Br 59(2): , Fritz JM, Delitto A, Welch WC, Erhard RE : Lumbar spinal stenosis : a review of current concepts in evaluation, management, and outcome measurements. Arch Phys Med Rehabil 79: , Schoenstrom N, Boleander NF, Spengler DM : The pathomorphology of spinal stenosis as seen on CT scans of the lumbar spine. Spine 10: , Zheng F, Farmer JC, Sandhu HS, O'Leary PF : A novel method for the quantitative evaluation of lumbar spinal stenosis. HSS J 2(2): , Konno S, Hayashino Y, Fukuhara S, Kikuchi S, Kaneda K, Seichi A, Chiba K, Satomi K, Nagata K, Kawai S : Development of a clinical diagnosis support tool to identify patients with lumbar spinal stenosis. Eur Spine J 16(11): , Lee HM, Kim NH, Kim HJ, Chung IH : Morphometric study of the lumbar spinal canal in the Korean population. Spine 20(15): , Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 72(3): , Haig AJ, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Choksi VR, Geisser ME, Parres CM : Spinal stenosis, back pain, or no symptoms at all? A masked study comparing radiologic and electrodiagnostic diagnoses to the clinical impression. Arch Phys Med Rehabil 87(7): , 요추관협착증연구회 : 요추관협착증의진단과치료. 영창의학서적, 서울, pp41-56, Haig AJ, Weiner JB, Tew J, Quint D, Yamakawa K : The relation among spinal geometry on MRI, paraspinal electromyographic abnormalities, and age in persons referred for electrodiagnostic testing of low back symptoms. Spine 27(17): , Haig AJ, Geisser ME, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Phalke VV : Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms. J Bone Joint Surg Am 89(2): , Mirkovic S, Garfin SR, Rydevik B, Lipson SJ : Pathophysiology of spinal stenosis. Instr Course Lect 41: , Powell MC, Wilson M, Szypryt P, Symonds EM, Worthington BS : Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women. Lancet 2(8520): , 이경석 : 요통의새로운치료. 고려의학, 서울, pp80-88, Moon CT, Choi SK, Byun BJ, Lee IS : A Case of Coexisting Cervical and Lumbar Spinal

8 186 순천향의과학 : 제14권 2호 2008 Stenosis. J Korean Neurosurg Soc 14(4): , 최형집, 이선호 : Two Cases of Spinal Stenosis. 대한정형외과학회지 9:509~513, 1974.

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