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1 J. Korean Continence Society 2003;7:37-42 척수손상환자에서손상부위에따른비디오요역동학검사의유형 인하대학교의과대학비뇨기과학교실 The Video-Urodynamic Findings of Spinal Cord Injury Patients according to the Injured Level Ji-Hyun Yang, Sung-Min Lee, Ju-Hyung Ahn, Jin-Kwan Jeoung and Tack Lee From the Department of Urology, College of Medicine, Inha University, Incheon, Korea Purpose: Spinal cord injuries can lead to varying degrees and patterns of neurologic deficits, which depend on the level of the injury, duration, completeness. So we analyzed the relationship between the types of neurogenic bladder and the level of injury in the spinal cord injury. Materials and Methods: From June 1997 to August 2002, one-hundred twenty seven spinal cord injury patients were studied by neurological and urological examination and video-urodynamic evaluation. The neurogenic bladder in spinal cord injury were analyzed into five types according to the injured level. Results: The 94 males and 33 females had a mean age of 45.7±15.1 years (range 15 to 92). Mean follow up interval after injury was 33.9±48.4 months. Injured level was classified into five levels; cervical, thoracic, lumbar, and sacral. Of the 127 patients 37 (29.1%) was cervical, 18 (14.2%) was thoracic, 33 (26.0%) was lumbar, and 39 (30.7%) was sacral. When all patients were divided suprasacral and infrasacral lesion. Typically, suprasacral lesions show detrusor hyperreflexia, and infrasacral lesions have detrusor areflexia. 30 (37.5%) of 88 suprasacral lesions and 12 (30.8%) of 39 infrasacral lesions were presented to atypical. 35.7% of patients have combine spinal lesion, but 47.6% of patients have no causes for atypical patterns. 3 (27.3%) of 11 patients were followed up, they changed neurogenic pattern. Conclusions: In our results, video urodynamic findings showed that about 30 percent patients had atypical patterns of neurogenic bladder, and they have underlying disease about 52.4%. And 27% of followed patients changed neurogenic pattern of bladder. So, urodynamic study have an important role in the spinal cord injury for diagnosis of neurogenic pattern and selection proper treatment, catching out the interval change and correction of treatment method, and evaluation of prognosis. (J. Korean Continence Society 2003;7:37-42) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ Key Words: Spinal cord injury, Urodynamics, Neurogenic bladder 교신저자 : 이택, 인하대학교부속병원비뇨기과인천시중구신흥동 3 가 ꂕ Tel: , Fax: lt11@inha.ac.kr 서 척수손상환자에서손상부위는신경학적손상을결정짓 론 Vol. 7, No. 1,

2 는중요한요소이며이에따라신경인성방광의양상도변화하게된다. 일반적으로요추상부의손상인경우는배뇨근과반사방광을보이게되며 (1,2), 요추이하의부위에서는배뇨근무반사방광을보이는것으로알려져있다 (3). 그러나다른여러연구에서각집단의 20% 의환자에서는이와다른양상을보이는것으로밝혀져있는데 (4), 그대표적인이유들은다음과같이알려져있다. 첫째, 척수동맥이손상된경우직접손상을받은부분의상하부로손상이광범위하게퍼질수있으며 (3), 둘째, 손상당시여러군데를동시에손상받는경우손상부위와맞지않는양상을보일수있다 (4). 그외에손상이전의환자상태나배뇨이상등으로손상후상태가크게영향을받을수있다. 그러므로이런비전형적인신경인성방광의형태를보이는환자들에서여러다른현상들을일으킬수있는요인들에대해정확히이해하는것이척수손상환자들의신경인성방광에대한요역동학검사적진단을이해하는데매우중요한열쇠가될것으로생각된다. 이에저자들은본원에서 127명의척수손상환자들에서비디오요역동학검사를시행하여손상부위에따른신경인성방광의양상과각각의임상적인요인들을후향적으로비교, 분석하여보았다. 대상및방법 1. 대상 1997년 6월부터 2002년 8월까지척수손상으로인하대병원비뇨기과에내원하여치료받은환자중척수성쇼크시기를지나안정기에들어간 127명 ( 남자 94명, 여자 33명 ) 을대상으로하였다. 배뇨증상에영향을미칠수있는방광류, 당뇨, 뇌졸중, 방광의염증및감염의병력, 배뇨증상유무를조사하여, 내원당시척수손상이외에는다른이상을보이지않고관련자료가충실한환자를대상으로의무기록과검사결과를후향적으로분석하였다. 대상환자는남자환자가 94명, 여자환자가 33명이었고수상당시평균연령은 45.7±15.1세 (15~92) 이었다. 평균유병기간은 31.5±29.4개월, 평균추적조사기간은 33.9± 48.4개월이었다. 수상의원인을살펴보면교통사고 64명, 추락에의한손상 38명, 기타손상이 25명이었다 (Table 1). 2. 방법기초병력과문진및신경학적검사와기본적인검사로혈액검사, 요검사, 요배양검사를시행하였다. 모든환자에서척수쇼크시기를배제하기위하여수상후최소한 6개월이경과한후비디오요역동학검사를시행하였으며, 수상후최초요역동학검사까지걸린시간은평균 28.9±32.5개월 (6~256) 이었다. 요역동학검사는 Dantec 사의 Menuet 기종을사용하였다. 앙와위상태에서 7Fr, 세갈래도관을요도를통해방광에삽입하여방광내압을측정하였다. 요역동학기계를투시기 (fluoroscopy) 와연결하여방광, 요관및요도의해부학적변화와압력변화를동시에관찰 (synchronization) 하였다. 신경인성방광의분류는 1) 배뇨근-외요도괄약근부조화를동반한배뇨근과반사, 2) 배뇨근-외요도괄약근부조화를동반하지않은배뇨근과반사, 3) 비지속적배뇨근수축으로다량의잔뇨를동반하는배뇨근과반사, 4) 배뇨근무반사, 5) 정상다섯가지로나누었다. 배뇨근-외요도괄약근부조화는배뇨시외요도괄약근의근수축수치가증가할 Table 1. Clinical parameter of spinal cord injury patients ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ Total Cervical Thoracic Lumbar Sacral No. of Pts Sex Male Female Mean age at injury (±SD) 45.7± ± ± ± ±14.6 Follow up (month, mean±sd) 33.9± ± ± ± ±38.0 Injury mechanism Traffic accident Fall down Others

3 척수손상환자에서손상부위에따른비디오요역동학검사의유형 경우로하였고, EMG의영상만으로제대로알수없었던경우에는비디오영상에서배뇨근수축이있을때요도로요누출이막히는현상이나타나는경우로하였다. 또한, 비지속적배뇨근수축으로다량의잔뇨를동반하는배뇨근과반사는신경적요인이나배뇨근수축의장애, 또는신경계와배뇨근과의부조화로인해불완전한배뇨근수축을유발하는경우로, 다양한배뇨근수축력을보이거나 fluctuating spasm을일으키게된다. 본연구에서는이를잔뇨가 100 cc 이상남을때로정의하였다. 상기이상소견이없는경우는정상으로정의하였다. 신경손상위치에따른환자의분포와각유형을천수상부 ( 경수, 흉수, 요수 ) 와천수하부로나누어각각의분포를비교해보았다. 천수상부의손상을가지면서 1), 2), 3) 의유형을보이는경우와천수하부손상시 4) 의유형을보이는경우를전형적유형으로분류하였고, 천수상부손상시 4) 유형을보이거나천수하부손상시 1), 2), 3) 의유형을보이는경우를비전형적유형으로분류하였다. 또한, 비전형적유형으로나타난경우기저질환의동반유무를조사하였다. Table 2. Distribution of patients according to injured level ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ No. of Pts. (%) Cervical 37 (29.1) Thoracic 18 (14.2) Lumbar 33 (26.0) Sacral 39 (30.7) Total 127 결 손상부위별환자분포는전체 127명중경수 37례 (29.1%), 흉수 18례 (14.2%), 요수 33례 (26.0%), 천수 39례 (30.7%) 였다 (Table 2). 각각의손상부위별신경인성방광의유형은다음과같다 (Table 3). Table 4. The comparison between the suprasacral and infrasacral injury ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ Suprasacral (%) Infrasacral (%) Typical* 58 (67.0) 27 (69.2) Atypical 30 (33.0) 12 (30.8) Total *: Defined that suprasacral lesion shows detrusor hyperreflexia and infrasacral lesion shows detrusor areflexia, : Defined that suprasacral lesion shows detrusor areflexia and infrasacral lesion shows detrusor hyperreflexia 과 1. 천수상하부손상별양상의차이 손상부위를천수상부와천수하부로나누었을때천수상부에서전형적유형을보인경우가 58례 (66.7%), 천수하부에서 27례 (69.2%) 였다. 그러나약 30% 에서는비전형적유형을보였다 (Table 4). 2. 비전형적유형의동반질환분석 비전형적유형을보인환자들에서동반질환의유무를분석하기위해병력및의무기록을조사해보았다. 천수상부 Table 3. The classification of urodynamic findings according to the injury level ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ Cervical (%) Thoracic (%) Lumbar (%) Sacral (%) DH with DESD 20 (54.1) 7 (38.9) 7 (21.2) 6 (15.4) DH without DESD 8 (21.6) 0 (0.0) 5 (15.2) 2 (5.1) DH with USDC 3 (8.1) 4 (22.2) 4 (12.1) 3 (7.7) DA 6 (16.2) 7 (38.9) 16 (48.5) 27 (69.2) Normal 0 (0.0) 0 (0.0) 1 (3.0) 1 (2.6) Total DH: detrusor hyperreflexia, DESD: detrusor external sphincter dyssynergia, USDC: unsustained detrusor contraction, DA: detrusor areflexia. Vol. 7, No. 1,

4 Table 5. Analysis of underlying disease in atypical patterns ꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚꠚ Level Combine Tbc Conversion DM lesion spondylosis disorder No cause Total C Suprasacral T L Infrasacral S Total C: cervical, T: thoracic, L: lumbar, S: sacral, DM: diabetes mellitus, Tbc: tuberculosis. 환자중에서배뇨근무반사를보인 30례중 10례 (33.3%) 에서는천수하부손상이동시에발견되었고 2례 (6.7%) 에서는당뇨병성신경인성방광, 1례 (3.3%) 에서는정신과적으로전환장애 (conversion disorder), 1례 (3.3%) 에서는결핵성골질환이동반되었고 16례 (53.3%) 에서는다른질환이없었다. 천수하부환자이면서배뇨근과반사방광을보인 12례중 5례 (41.7%) 에서는천수상부손상이동반되었고 5례 (41.7%) 에서는다른질환이발견되지않았다. 천수하부손상이면서당뇨성신경인성방광이동반된 2례에서는과민성방광의소견을보였다 (Table 5). 3. 신경인성방광양상의변화 33.9±48.4개월의추적관찰기간동안비디오요역동학검사를시행했을때 11례의환자중 3례 (27.3%) 에서방광유형의변화를보였다. 1례에서는배뇨근-외요도괄약근부조화를동반한배뇨근과반사에서배뇨근-외요도괄약근부조화를동반하지않은배뇨근과반사로, 1례에서는배뇨근무반사에서배뇨근-외요도괄약근부조화를동반하지않은배뇨근과반사로, 1례에서는비지속적배뇨근수축으로다량의잔뇨를동반하는배뇨근과반사에서배뇨근-외요도괄약근부조화를동반한배뇨근과반사로변화하였다. 고찰미국에서척수손상환자는매년백만명당약 32명의발생률과백만명당약 906명의유병률을보인다. 대략 85% 의환자에서 12번째흉수상부의척추에손상이발생하는데이는협소한척수관에기인하며 (3,10,12) 약 55% 의환자에서사지마비를, 45% 에서하지마비를보이게된다. Toyohiko 등 (10) 은신경학적으로불완전손상과완전손상의비 가 53.8% 와 46.2%, Arnold 등 (11) 은 58.6% 와 41.4% 로불완전손상이약간더많다고보고하였으나본연구에서는불완전손상이약 92.1% 로월등히많아, 타논문과큰차이를보였다. 그원인은타연구의경우완전손상이많은흉수및경수손상률이본연구의 43.3% 에비해약 67% 로높았기때문으로생각한다. 척수손상시배뇨근과활동을보이는기전은다음과같다. 첫째, 대뇌피질에위치하는수의적배뇨중추의손상으로수의적통제기능의소실되는경우와, 둘째, 흉수와요수사이에위치하는요도의수의근을조절하는교감신경의손상이동반될경우이다. 이런경우배뇨근의수축이외요도근의확장보다먼저, 또는동시에발생하는배뇨근-외요도근부조화를동반하기도한다 (5). 반면, 배뇨근무반사방광은천수반사궁의손상으로방광충만이발생함에도불구하고배뇨근의수축이발생하지않는다 (3,5). 일반적으로천수상부손상의경우는배뇨근과반사방광의유형을보이고천수하부손상의경우는배뇨근무반사방광의유형을보이게된다. 그러나, 이와반대의양상을보이는경우가약 33% 를차지하고있으며 Beric 등 (13) 이비전형적유형을보이는경우에대해보고하였다. 그원인으로는동시다발적인척수손상과잠재적손상을들었는데, 이런잠재적손상은급성외상이나혈관손상, 외상후척수공동증, 지주막염, 척수강협착증등을유발하며이로인해척수손상부위와달리비전형적신경인성방광의유형이나타나게된다고하였다 (4). 본연구에서도비디오요역동학검사를통해약 70% 에서는손상부위에따라전형적인유형을진단하였으나약 30% 에서는비전형적유형을보였다. 따라서, 척수손상환자에서정확한진단과적절한치료를위해서는요역동학검사를시행하는것이필요하리라생각한다. 40

5 척수손상환자에서손상부위에따른비디오요역동학검사의유형 비전형적인유형을보이는환자에서신경인성방광의유형에영향을줄수있는병력을조사해보았다. 천수상부손상의경우동시에존재했던천수하부의손상이가장많은부분을차지했으며당뇨를각각 4년, 12년간앓고있던환자들에서는당뇨성무반사방광을보여신경손상의위치에상관없이배뇨근무반사방광의유형을보였다. 또한결핵성골질환을앓고있던환자 1례에서는경수부터요수까지전신경부위에화농성농양이동반되어척수염과신경염을앓았던경우였다. 전환장애 (conversion disorder) 를진단받은 1례의환자에서는사고이후하반신불수를보여손상위치를확인하기위해시행한컴퓨터전산화촬영이나자기공명영상에서손상의증거가없었다. 그러나신경및근전도검사에서하반신불수에맞는소견을보였고이때나타나는무반사방광을보였다. 천수하부손상의경우는동시에존재했던천수상부의손상이 5례로가장많은부분을차지했다. 천수하부손상이면서각각당뇨를 10년, 3년간앓았던환자들에서과반사방광을보인경우는정확한원인을알수없었다. 환자의 50% 에서는다른질환의기왕력을발견할수없었다. 따라서척수손상의위치만을가지고신경인성방광의유형을결정하는것은매우위험한일이며향후적절한치료를시행하기위해서는요역동학검사와과거력의조사가뒷받침되어야하겠다. Kaplan 등 (14) 은 1991년요역동학검사를통한척수손상환자의신경인성방광분류에대해보고하였다. 이를본연구결과와비교하면, 손상부위별환자분포는경수가 37%, 흉수가 31%, 요수가 21%, 천수가 11% 를차지하는것에반해본원의결과에서는각각 29%, 14%, 26%, 31% 로나타나천수손상의환자가비교적더많았다. 손상부위별신경인성방광의양상에서도약간의차이를보였는데, Kaplan의경우천수상부의손상에서전형적으로나타나는배뇨근과반사방광이흉수에서 100%, 요수에서 60% 관찰되었으나, 본연구에서는 61% 와 48% 로비교적낮게나타났다. 반면, 천수의손상에서전형적으로나타나는배뇨근무반사방광은각 64% 와 69% 에서관찰되어두연구가비슷한결과를보였다. 이런결과의차이는완전손상률이 Kaplan의연구결과에서더높게나타났고동반된천수하부질환이본연구에서더많은비율을차지했던점에서기인하는것이라생각한다. 결론척수손상환자에서약 70% 에서는손상부위에따라전형 적인신경인성방광의유형을보였으나약 33% 에서는비전형적인소견을보였고또한추적관찰기간동안비디오요역동학검사를반복시행했을때신경인성방광유형의변화를보이는경우도약 27% 에서나타났다. 또한, 비전형적인유형을보이는경우기저질환이약 50% 에서동반되므로자세한병력과신경학적, 정신과적검사와함께요역동학검사를시행하는것이중요하리라생각한다. 따라서손상당시신경학적소견과손상부위만으로신경인성방광을단정하기보다는요역동학검사를시행하여정확한진단을내리는것이매우중요하다고할수있다. 또한추적검사시에도신경학적소견만을기초하는것보다요역동학검사를재시행하여방광상태의변화의유무등을진단하여적절한치료를하는것이중요하리라고생각한다. 참고문헌 1) Blaivas JG. The neurophysiology of micturition: a clinical study of 550 patients. J Urol 1982;127: ) Yalla SV, Andriole GL. Vesicourethral dysfunction following pelvic visceral ablative surgery. J Urol 1984;132: ) Yalla SV, Fam BA. Spinal cord injury. In: Krane RJ, Siroky MB. editors. Clinical neurourology. 2nd ed. Boston: Little Brown and company, 1979; ) Tosi L, Righetti C, Terrini G, Zanette, G. Atypical syndromes caudal to the injury site in patients following spinal cord injury. A clinical, neurophysiological and MRI study. Paraplegia 1993;31: ) Bradley WE, Conway CJ. Bladder representation in the pontine-mesencephalic reticular formation. Exp Neurol 1966;16: ) Fletcher TF, Bradley WE. Neuroanatomy of the bladder-urethra. J Urol 1978;119: ) Nygaard IE, Kreder KJ. Spine update. Urological management in patients with spinal cord injuries. Spine 1996;21: ) Wein AJ, Barrett DM. Voiding function and dysfunction: a logical and practical approach. Chicago: Yearbook medical publishers, 1988; ) Bhatia NN, Bradley WE. Neuroanatomy and physiology: Innervation of the urinary tract: Raz S, ed. Female urology. Philadelphia: WB Saunders, 1983; ) Watanabe T, Rivas DA, Chancellor MB. Urodynamics of spinal cord injury. Urol Clin North Am 1996;23: ) Arnold EP, Fukui J, Anthony A, Utley WL. Bladder function following spinal cord injury: a urodynamic analysis of the outcome. Br J Urol 1984;56: ) Fam BA, Sarkarati M, Yalla SV. Spinal cord injury. In: Yalla SV, McGuire EJ, Dlbadawi A, Blaivas JG. editors. Neurour- Vol. 7, No. 1,

6 ology and Urodynamics. New York: Macmillan Publishing company, 1998; ) Beric A, Dimitrijevic MR, Light JK. A clinical syndrome of rostral and caudal spinal injury: neurological, neurophysiological, and urodynamic evidence for occult sacral lesion. J Neurol Neurosurg Psychiatry 1987;50: ) Kaplan SA, Chancellor MB, Blaivas JG. Bladder and sphincter behavior in patients with spinal cord lesions. J Urol 1991;146:

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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