추골동맥손상을동반한안면과경부의관통성외상치험예 추골동맥손상을동반한안면과경부의관통성외상치험예 송우식 김인권 이상현 황윤정 안정용 * 포천중문의과대학교분당차병원구강악안면외과, 신경외과 * Abstract PENETRATING INJURY OF FACE AND NECK WIT

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1 송우식 김인권 이상현 황윤정 안정용 * 포천중문의과대학교분당차병원구강악안면외과, 신경외과 * Abstract PENETRATING INJURY OF FACE AND NECK WITH THE VERTEBRAL ARTERY INJURY : A CASE REPORT Woo-Sik Song, In-Kwon Kim, Sang-Hyun Lee, Yun-Jung Hwang, Jung-Yong Ahn* Department of Oral & Maxillofacial surgery, Dept. of Neurosurgery* Pundang CHA Hospital, Pochun CHA Medical College. With the exception of gun shot wound, the incidence of penetrating injury of face and neck areas nonorganic foreign bodies is relative low. But the diagnostic evaluation and therapeutic management of penetrating facial wounds need careful decision, when the anatomic proximity of the major vessels and nerve is considered. Penetrating facial trauma with concomitant vascular injury present challenging problems, the immediate complication of this vascular injury are severe bleeding, hematoma formation, shock, obstruction of airway. The vascular injury is conformed by angiography. In this report, a industrial tool(long tack) fired by explosive air is penetrated into face and to neck. In angiograms penetrating injury of the vertebral artery is detected. We performed the embolization of the vertebral artery with coils and manual removal of the foreign body without any complication was followed. Key words : Penetrating injury, Vertebral artery, Angiogram Ⅰ. 서론 이물질에의한안면부의관통성외상의원인은총상이대부분을차지하나, 압축공기에의해발사되는못, 납작못, 앵커용고리등의산업용기구, 젓가락, 칼, 가위, 우산대, 작살총등에의한손상도보고되어지고있다 1-5). 안면과경부에는내악동맥 (internal maxillary artery), 안면동맥 (facial artery), 경동맥 (internal and external carotid artery) 그리고추골동맥 (vertebral artery) 등의손상시생명을위협할수있는다량의출혈을야기하는주요혈관이분포하므로손상을야기한이물질주위의해부학적구조물을정확히파악해야한다. 그러나이물질이금속성일경우 CT 나 MRI 영상에서정확한해부학적위치를파악하기어려우므로평면방사선사진, 임상검사, 병력조사및혈관조형술을통하여인접한주요혈관의손상유무를정확히파악한후외과적으로이물질을완전노출한후제거하던지 비외과적술식으로단순하게제거해야한다 4-6). 본원에서는압축공기에의해발사되는산업용큰납작못 (long tack) 의오발로인해안면을관통후경추골절을야기하면서경부에함입된경우에서혈관조영술로추골동맥 (vertebral artery) 의손상을확인하고추골동맥을 coil 을사용한혈관색전술 (embolization) 시행후이물질을비외과적술식으로합병증없이성공적으로제거하였기에이에보고하고저한다. Ⅱ. 증례보고 2000 년 10 월 16 일 49 세남자목공이아파트실내장식공사장에서압축공기에의해발사되는큰납작못 (long tack) 을천정에박는작업을하던중오발로인하여납작못이좌측안면부를관통하여박혔으며납작못의머리부분은체외로돌출된상태였다 (Fig. 1). 현장에서옆의동료가납 447

대한악안면성형재건외과학회지 : Vol. 23, No. 5, 2001 작못의머리부위를잡고손으로잡아당겨제거를시도하였으나실패한후곧장본원응급실로내원하였다. 내원시현저한출혈이나혈종형성의증상은없었으며혈압 110/70mmHg, 맥박 72 회 / 분, 호흡수 20 회 / 분, 체온 36.4 도로생징후는안정상태였으며환자의의식도명료한상태였다.

The patient at the time of admission to the emergency room, the industrial tool(long tack) penetrating into the left cheek. 이물질의구강내관통이의심되어연구개부및편도주위를관찰하였으나이물질의존재는확인되지않았다.

혈관조영상에서좌측추골동맥의관통성손상을확인하였으며좌측내경동맥 (internal carotid artery) 은정상소견을보였다.

2 대한악안면성형재건외과학회지 : Vol. 23, No. 5, 2001 작못의머리부위를잡고손으로잡아당겨제거를시도하였으나실패한후곧장본원응급실로내원하였다. 내원시현저한출혈이나혈종형성의증상은없었으며혈압 110/70mmHg, 맥박 72 회 / 분, 호흡수 20 회 / 분, 체온 36.4 도로생징후는안정상태였으며환자의의식도명료한상태였다. 구강악안면외과에서초진시안면부에서납작못주위로약간의출혈이있을뿐경부에서의종창이나출혈등의증상은보이지않았으며구강검사시개구장애가있었으며좌측상악협점막의열상이나출혈등은관찰되지않았다. Fig. 1. The patient at the time of admission to the emergency room, the industrial tool(long tack) penetrating into the left cheek. 이물질의구강내관통이의심되어연구개부및편도주위를관찰하였으나이물질의존재는확인되지않았다. Skull P- A, Skull lateral view 상에서안면에서경부를지나는거대한금속성의이물질을확인하였으며 (Fig. 2) 경추골절가능성으로신경외과검진의뢰하였으며신경외과검진결과경추골절과추골동맥손상이의심되어 MRI 촬영을하였으나금속성의물질로인하여판독불가하여방사선과에서혈관조형술을시행하였다. 혈관조영상에서좌측추골동맥의관통성손상을확인하였으며좌측내경동맥 (internal carotid artery) 은정상소견을보였다. 따라서이물질제거시다량의출혈이예상되어국소마취하에손상된추골동맥의원위부와근위부에 coils 로혈관을막는 GDC 색전술 (Guglielmi Detachable Coils Embolizations) 을시행하여손상된추골동맥부위를완전히고립시켰다 (Fig. 3). 혈관색전술시행후환자를수술실로옮겼으며전신마취를위한기관삽관술시목을뒤로제낄경우경추손상의가능성이있고환자의개구량이제한된상태여서국소마취하에기관절개술을시행후전신마취를유도하였다. 수술은우선구강악안면외과에서안면부에서비외과적술식으로이물질제거시도후실패할경우신경외과에서경부에대한외과적접근을통해이물질을노출시켜제거하기로결정하였다. 다행히구강악안면외과에서안면부에서납작못의머리부를손으로잡아조심스럽게당기기를수차례실시한결과납작못이제거되었다. 납작못이빠진자리로약간의출혈이있었을뿐별다른특이사항이없었으며빠진자리로기구를집어넣어상악동관통유무를확인하였으나관통을확인할수없었으며구강검사시에도구강좌측협점막의열상등은 Fig. 2. Lateral and anteroposterior radiographs of the skull demonstrating large foreign body penetrating into face and neck. 448

coils were located at the proximal and distal portion

View of patient after removal of foreign body. Fig. 5.

$Postoperative facial CT demonstrating the fracture of$ the atlas(arrow), but the wall of maxillary sinus is

The long tack is passed between maxillary tuberosity

3 Fig. 3. After GDC(Guglielmi Detachable Coils) embolization, coils were located at the proximal and distal portion of injured vertebral artery(arrow). Fig. 4. View of patient after removal of foreign body. Fig. 5. View of long tack, the length of 130mm and the width of 5mm. Fig. 6. Postoperative facial CT demonstrating the fracture of the atlas(arrow), but the wall of maxillary sinus is intact. Fig. 7. The long tack is passed between maxillary tuberosity and coronoid process of the mandible, and arrived at the atlas. Fig. 8. The vertebral artery arise from subclavian artery, pass upward through transverse foramina of vertebra and enter the cranial cavity. 449

4 대한악안면성형재건외과학회지 : Vol. 23, No. 5, 2001 전혀없이깨끗한상태였다 (Fig. 4). 창상부의피부를단순봉합하고수술을종결하였으며회복실에서도심한출혈등의증상은관찰되지않았다. 제거된납작못의크기는길이 130mm, 폭 5mm 정도였다 (Fig. 5). 수술후 facial CT 를촬영한결과 (Fig. 6) 좌측상악동의천공이관찰되지않았지만제 1 경추 (Atlas) 의골절이확인되어납작못이좌측안면부피부를관통하였지만상악동과구강내를침범하지않고상악결절부 (maxillary tuberosity) 와하악골의오훼돌기 (coronoid process of mandible) 의사이를지나경추부로함입되면서제 1 경추의골절을야기한것으로추정하였다 (Fig. 7). 골절된제 1 경추는신경외과에서보존적치료후양호한상태로환자는퇴원하였다. Ⅲ. 총괄및고찰 안면과경부의관통성외상 (penetrating injury) 은물체가연조직이나경조직을관통하여조직내에남겨있으며이로인해유발된조직의손상은표재성으로존재하거나심층까지포함할수있으며이경우조직내에남겨진물체는이물질 (foreign body) 로불리워진다. 이러한관통성외상과는달리통과성외상 (perforating injury) 는물체가연조직과경조직을완전히통과하여조직내에남아있지않으며입구와출구에조직의손상만있는것을말한다 5). 관통성외상을유발하는물체는총탄이나총탄파편이대부분을차지하나유리조각, 나무조각, 칼날, 산업용기구등도보고되어지고있다 1-6). 두경부를지나는주요혈관으로경동맥과추골동맥이있으며이들혈관에나타나는손상의기전을이해하는것은환자의진단과임상적평가에대단히중요하다. 총경동맥 (common carotid artery) 과내경동맥 (internal carotid artery) 의손상은둔상 (blunt injury) 과관통성외상 (penetrating injury) 그리고구강내외상에의해야기되며, 둔상은 blunt neck trauma 에의해발생하며빈도가적으며, 주로자동차사고, 물체에의한경부의가격등에의해발생한다. 이들혈관손상의유형은연축 (spasm), 혈전 (thrombosis), 동맥류 (aneurysm), 위동맥류 (pseudoaneurysm), 그리고드물게완전절단 (complete transection) 등이있다. 둔상에의해나타나는회전손상 (rotary injury) 은급작스럽고심한회전과과신장에의해제 1 경추 (atlas) 와제 2 경추 (axis) 측방의내경동맥의신장과압박에의해발생하며, 혈관내막의손상 (intimal tear) 으로발생하는혈전증 (thrombosis) 의임상증상은실어증 (aphasia), 의식혼미, 경련, 운동신경이나감각신경장애, 반신마비 (hemiparesis), 졸림현상, 기억상실 (amnesia) 등이있으며, 위동맥류 (false aneurysm) 은혈관벽의연속성파괴에의해나타나며, 동맥류 (aneurysm) 은혈관내막손상에의해혈관벽으로혈액이통과하여발생한다. 관통성외상에 의해유발되는증상은혈관열상 (laceration), 동정맥류 (arteriovenous fistula), 위동맥류 (false aneurysm) 가있다. 그리고구강내외상에의한경동맥손상은어린이가물체를물고앞으로넘어질때발생한다. 외경동맥 (external carotid artery) 의손상도둔상과관통성외상에의해발생하지만인두구조물 (pharyngeal structure) 에의해보호되므로손상이드물게발생한다. 추골동맥의손상으로둔상은회전외상에의해발생하며관통성외상에의해위동맥류, 동정맥류가발생한다 7). 이와같이두경부에주요혈관과신경이지나며소화기관과기도가인접해있으므로두경부의관통성외상의처치는외상의원인, 이물질의종류, 외상의부위, 연조직과경조직의손상의범위에따라다양하며진단과치료는아직도논란이되고있다 8-12). 모든관통성외상에서이물질을외과적박리로노출시켜야하는지는많은논란이있으며특히근육깊히박힌이물질을외과적으로근육박리를시행하여위치를확인하는것은논란이다 8). 이런관통성외상의가장치명적인것은주요혈관손상으로인한다량의출혈이므로혈관조형술을시행하여혈관손상의유무를확인후외과적개방을선택적으로시행하거나비외과적술식으로이물질을제거하는것이추천되고있다 12-15). 이러한혈관조영술은구강악안면영역및경부에서내악동맥 (internal maxillary artery), 경동맥 (internal and external carotid artery), 안면동맥 (facial artery), 추골동맥 (vertebral artery) 등의손상이의심될때특히진단적가치가높다 5). 외상성동맥류 (traumatic aneurysm) 는혈관벽이물체에의해부분적으로손상을입었을때발생하며혈관벽의결손부위가일시적으로막혔다가나중에동맥류가파열되면심한출혈로생명을위협하는상황이유발될수있으며또한이물질제거시에심한출혈이발생할수있으므로사전에혈관조영술로혈관손상유무를정확히진단할필요성이있다 5). 혈관손상의유무를임상적증상만으로진단하는것은많은어려움이있다. 임상적으로심한출혈이가장확실한증상이며이외에큰혈종형성, 실혈로인한쇽, 혼수상태등이진단에도움을주는증상이다 13). 그러나 Salvatore 등 8) 은 72 명의혈관손상환자중 46 명이무증상을보였다고하였으며이러한무증상현상으로혈관손상이없다고진단하지말것을권하였으며, 46 명의혈관손상환자중 9 명이혈관조영술상에서혈관손상을보였으며, 경동맥이나추골동맥손상을입은 22 명중 11 명이무증상을보였다고하였다. 손상된혈관의치료는재혈관화술 (revascularization) 과 coil 을이용한색전술 (emoblization) 그리고혈관결찰술 (ligation) 등이있다 8,14,15). 본증례에서환자는응급실내원시이물질의끝부분이안면부에남겨진관계로구강악안면외과에의해초진되었으 450

5 며초진시혈관손상의임상증상인다량의출혈, 혈종형성, 쇽상태, 혼수상태등을전혀보이지않았지만혈관조영술상에서추골동맥손상을확인하고 coil 을이용한색전술을시행후이물질을외과적개방없이손으로뽑아제거하였다. 구강악안면외과는주로외경동맥 (external carotid artery), 내악동맥 (internal maxillary artery), 안면동맥 (facial artery), 설동맥 (lingual artery) 등의손상에관한증례는가끔접하지만경추를따라주행하는추골동맥의손상을접하는경우는아주드물다. 추골동맥은척추동맥으로도불리우며이는뇌로가는동맥으로쇄골하동맥 (subclavian artery) 에서나오며제 6 경추 (6th cervical vertebra) 의횡돌공 (foramen transversarium) 에들어가상위 6 개경추의횡돌공을상행하여제 1 경추 (atlas) 에이르러추골동맥구 (groove for vertebra) 및대후두공 (foramen magnum) 을거처두개강 (cranial cavity) 로들어간다. 그리고교 (pons) 의하면에서좌우추골동맥이합쳐져뇌저동맥 (basilar artery) 가되는동맥 7) 으로 (Fig. 8) 주로신경외과영역에서많이취급하는동맥이다. 추골동맥은경부의심층에존재하고경추의보호를받으므로외상에의해쉽게손상을입지않아서 4,977 명의혈관손상환자중 3 명만이추골동맥손상이있었다고보고되고있으며 15) Fogelman 등 14) 은추골동맥손상은 50% 의치사율을보고하였다. 추골동맥손상의진단은경부의관통성외상의경우에도출혈등의임상증상이나타나지않는경우에는혈관조영술에의해진단이가능하므로구강악안면외상환자에서도경부의손상이의심스러우면신경외과나방사선과등과의협진에의해경추나추골동맥손상의조기진단에만전을기해야하겠다. Ⅳ. 결론 본증례는안면부에관통성으로함입된이물질이안면부반대편에있는경부의추골동맥손상을야기한경우로혈관손상의증상인심한출혈등이없었지만혈관조영상에서추골동맥손상을확인하고추골동맥에대해 coil 을사용한색전술시행후이물질을제거하였다. 따라서구강악안면외과에서안면부외상환자취급시관통성외상이의심 될경우에는인접타과와의협진이필요하며또한다량의출혈등혈관손상의임상증상이없는경우에도혈관조영술을시행하여주요혈관의손상유무를확인해야할필요성이있겠다. 참고문헌 1. Sedhojm AW, Leathers RD, Belton MJ, Bhobrial G : Fan blade injury to the maxillofacial region : a case report. J Oral Maxillofac Surg 56:98-100, Delso-Liebel MA, Kaminishi RM, Pineda A : Nail gun injury to the maxillofacial region : report of a case. J Oral Maxillofac Surg 54: , Aldegheri A, Adam P, Huet P : Unusual maxillofacial injury caused by a model airplane. J Oral Maxillofac Surg 57: , Ewbank RL : An unusual penetrating injury. J Oral Surg 24: , Cohen MA, Boyes-Varley G : Penetrating injuries to the maxillofacial region. J Oral Maxillofac Surg 44: , Hong SX, Baek JY, Cha IH : Penetrating injuries by foreign body in the head and neck region. J Korean association of maxillofacial plastic and reconstructive surgeons Vol.22. No.3: , Davis JM, Zimmerman RA : Injury of the carotid and vertebral arteries. Neuroradiology 25:55-69, Salvatore JA, Sclafani, Cavaliere G, Atweh N, Duncaan AO, Scalea T : The role of angiography in penetrating neck trauma. The Journal of Trauma Vol.31,No.4: , Golueke P, Sclafani S, Phillips T, Goldstein A, Scalea T, Duncan A : Vertebral artery injury-diagnosis and management. The Journal of Trauma Vol 27,No.8: , Gussack G, Jurkovich G : Penetrating facial trauma. Southern Medical Journal Vol. 81,No.3: , Elerding S, Manart FD, Moore EE : A reappraisal of penetrating neck injury management. The Journal of Trauma Vol.20,No.8: , Sickels JE, Bear SE, Pirok DJ, Pevsner PH : Vascular injury and penetrating facial trauma. J Oral Surgery 37: , Bostwick J, Schneider WJ, Jurkiewicz MJ, Stone HH : Penetrating injuries of the face and neck. Southern Medical Journal Vol 69,No.5: , Meier DE, Brink BE, Fry WJ : Vertebral artery trauma - acute recognition and treatment. Arch Surg Vol 116: , Buscaglia LC, Crowhurst HD : Vertebral artery trauma. The American Journal of Surgery Vol 138: , 저자연락처우편번호 경기도성남시분당구야탑동 351 포천중문의과대학교분당차병원치과구강악안면외과송우식 원고접수일 2001 년 7 월 30 일게재확정일 2001 년 8 월 13 일 Reprint requests Woo-Sik Song Dept. of OMFS, Pundang CHA Hospital, Pochun CHA Medical College 351, Yatap-Dong, Pundang-Gu, Sungnam-city, Kyunggi-Do, , Korea Tel FAX maxilla@cha.ac.kr Paper received 30 July 2001 Paper accepted 13 August

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Jksvs019(8-15).hwp Grade I Grade II Grade III 12 대한혈관외과학회지 : 제 20 권 제 1 호 2004 Control Group A Group B Fig. 4. Microscopic findings of vein wall in control, group A and group B on the day of 7 after venous occlusion. The