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1 원저 J Korean Neurol Assoc / Volume / October, 006 울산대학교의과대학신경과학교실 김성렬정선주성영희김미선이명종 The clinical characteristics of lower back pain in Parkinson s Disease Sung Reul Kim, R.N., Sun Ju Chung, M.D., Sung Young Hee, M.D., Mi Sun Kim, R.N., Myoung Chong Lee, M.D. Department of Neurology, University of Ulsan College of Medicine, Seoul, Korea Background: Lower back pain (LBP) in Parkinson s disease (PD) is common but frequently overlooked, due to the tendencies of focusing on the management of the motor symptoms and signs by most neurologists. Uncontrolled LBP may impact on the activities of daily living of the PD patients. However, study on the LBP in PD has been rarely reported. Methods: Sixty three PD patients with LBP were included, between October 00 and April 005. We investigated the clinical characteristics of LBP and response to the management prospectively. Results: Eleven male and 5 female patients were included and the mean age was 6. years. On lumbar MRI and/or X-ray, degenerative spondylosis was detected in patients, bulging discs in 30, and fractures in 9. Fourteen patients reported improvement of LBP after levodopa therapy. Young age at onset and abrmally flexed posture correlated with the responsiveness of LBP to levodopa therapy (p<0.05, respectively). These responders were more frequently experiencing motor fluctuation and dyskinesia than the n-responders (p<0.05, respectively). Conclusions: LBP in PD has diverse etiologies and clinical features. Some PD patients with LBP show response to levodopa therapy. We suggest that the prudent evaluation and proper management of LBP are important to achieve the better activities of daily living in PD patients. J Korean Neurol Assoc (5):5-5, 006 Key Words: Parkinson's disease, Lower back pain, Levodopa 서 론 파킨슨병은흑질의도파민성신경세포의소실을초래하는퇴행성뇌질환이다. 1 파킨슨병의증상은운동성증상과비운동성증상으로나뉘어지며, 운동성증상은안정시진전, 서동증, 경직, 균형장애, 보행동결, 구부정한자세등이있고, 비운동성증상은수면장애, 통증, 변비, 소변장애, 발한장애, 피로, 우울, 불안등이있다. -5 Received February, 006 Accepted May, 006 *Sun Ju Chung, M.D. Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center 3-1 Pungnap-dong, Songpa-gu, Seoul, 13-36, Korea Tel: Fax: sjchung@amc.seoul.kr 파킨슨병환자중통증을경험하는환자는약 3~50% 정도로보고되나대부분의의료진들이운동성증상호전에초점을맞추어치료하고, 통증자체가매우주관적인증상이기때문에간과되기쉽다. 6-9 파킨슨병환자의통증양상은근골격계문제로인한통증, 신경통, 근긴장이상증으로인한통증, 서동증과관련한불편감등으로다양하고, 발생부위도다양하여허리, 다리, 어깨와목의통증을호소한다. -9 이중허리통증은구부정한자세, 체간부와사지의경직, 서동증으로인한유연성과운동성의감소로발생하고, 엉덩이로뻗치는방사통 (radiating pain) 이동반되기쉬우며파킨슨병의모든시기에발생가능하다. 10 적절히조절되지않은허리통증은환자의독립적인일상생활수행능력 (activity of daily living; 이하 ADL) 에영향을미칠수 5 J Korean Neurol Assoc Volume No. 5, 006

2 있으며, 환자에게우울증도일으킬수있다는보고도있다. 9,11-1 그러나, 파킨슨병환자의허리통증에대한연구는극히드물다. 따라서본저자들은파킨슨병환자들이경험하는허리통증의임상적인양상과이를호전시키기위하여시행된치료, 레보도파치료에호전을보이는허리통증을지닌환자의특성에대하여알아보고자하였다. 대상과방법 1. 대상 00 년 10월 1일부터 005 년 월 30일까지서울아산병원신경과를방문한파킨슨병환자중허리통증으로인하여독립적인일상생활수행에어려움이있는 63명을대상으로하였다. 파킨슨병의진단은 UK Parkinson's disease society brain bank 의임상기준에근거하였으며, 13 다계통위축 (multiple system atrophy) 이나진행성핵상마비 (progressive supranuclear palsy) 등의비특이성파킨슨증후군 (atypical parkinsonism) 이의심되는환자나약물에의하여파킨슨병증상이초래된환자는제외하였다.. 방법 1) 일반적및임상적특성환자의연령, 성별, 환자의파킨슨병발병연령, 유병기간, 일일레보도파투여용량, 운동변동 (motor fluctuation) 유무, 이상운동증 (dyskinesia) 유무, modified Hoehn and Yahr 단계를병력기록지와면담을통하여조사하였다. ) 허리통증과관련한특성허리통증발생연령, 허리통증의유병기간, 허리통증의발생시기 ( 파킨슨병발병과관련한 ), 통증의양상, 자세에따른통증의변화, 약물치료, 수술치료, 물리치료, 스테로이드주사치료여부및이에대한효과, 이외의시행한기타치료, 레보도파치료후허리통증의호전유무를병력기록지와면담을통하여조사하였다. 3) 방사선학적결과허리통증으로인하여시행된요추자기공명영상 (lumbar magnetic resonance imaging; Lumbar MRI) 과요추 X선사진 (Lumbar X-ray) 을분석하였다. ) 통계및분석통계학적분석을위해 SPSS 11.5 를이용하였고, 허리통증특성의분석은기술통계를이용하였으며성별에따른허리통증, 임상적특성과레보도파치료에대한허리통증의호전의관계는 t-test와 chi-square (χ ) 를이용하였다. 레보도파치료에대한허리통증의호전에영향하는요인은로지스틱회귀분석을이용하였다. Table 1. Demographic and disease characteristics of PD a patients with LBP b Characteristics 결 Male / Female (n) Mean age±sd c Mean age at onset±sd Mean PD duration Median Hoehn and Yahr stage Mean age at LBP onset±sd LBP duration±sd 과 1. 환자의일반적및임상적특성 본연구에포함된환자는총 63명으로남자는 11명, 여자는 5명이었다. 같은기간에파킨슨병으로내원한환자는남자 69 명, 여자 91 명으로여자환자에게허리통증이많은것으로나타났다 (p<0.001). 환자의평균연령은 6.±.9 (3~0) 세, 파킨슨병의평균발병연령은 5.±10.5 (3~) 세, 유병기간은평균 6.6±.1 (0.5~5) 년이었다 (Table 1).. 허리통증의특성 파킨슨병이발생하기 1년이전에허리통증이발생한환자는 1명 (.6%) 이었고파킨슨병이발생한 1년전후로허리통증이발생한환자는 명 (11.1%), 1년이후에발생한환자는 3명 (60.3%) 이었다. 자세에따른허리통증은 걸을때 통증을느끼는환자가 명 (69.%) 으로가장많았고, 서있을때 31명 (9.%), 허리를펼때 3명 (36.5%), 일어설때 1명 (33.3%), 앉아있을때 19명 (30.%) 순으로통증을호소하였으며, 명 (1.%) 은 항상아프다 고하였다. 3명 (6.3%) 은엉덩이나다리뒤로의방사통 (radiating 11 / 5 6.±.9 5.± ±.1 5.± ±. a Parkinson s disease, b Lower back pain, c Standard deviation J Korean Neurol Assoc Volume No. 5,

3 김성렬정선주성영희김미선이명종 pain) 을경험하고있었고, 16명 (5.%) 에서는허리통증과함께걸을때심하게허리가굽는현상이나타났다. 환자들은이러한허리통증을다양하게기술하였다. 끊어진다 (n=1), 당긴다 (n=6), 저리다 (n=6), 뻗친다 (n=), 뻐근하다 (n=), 시리다 (n=3), 빠질듯이아프다 (n=3), 무겁다 (n=), 내려앉는다 (n=1), 벌에쏘인듯이아프다 (n=1), 숨이찰정도로아프다 (n=1), 쑤신다 (n=1), 힘줄이오그라들정도로아프다 (n=1) 3. 방사선학적특성총 63명의환자중 35명은요추자기공명영상 (Lumbar MRI) 과요추 X선사진 (Lumbar X-ray) 을촬영하였고 5명의환자는요추자기공명영상만을, 15명은요추 X선사진만을촬영하였다. 9명의환자는골절을보였으며추간판탈출증을보인 30명의환자중 6명은추간판탈출증이경미하였고 명은중증도, 명은심한추간판탈출증을보였다 (Table ).. 허리통증의치료와레보도파에대한허리통증의반응환자중 11명은허리수술을시행받았고 31명은경막하스테로이드주사치료를받았다. 이외에도물리치료, 약물요법이시 Table. Radiologic findings of PD a patients with LBP b 행되었다 (Table 3). 스테로이드주사치료를받은환자의 5% 가치료후증상이호전되었고, 호전된환자의 55% 는효과의지속시간이수일이내로일시적이었다. 물리치료를받은환자의 0% 가물리치료후증상이호전되었고, 호전된환자의 50% 는지속효과가일시적이었다. 전체 63명중 1명 (.%) 은레보도파투여후허리통증이호전되었고, 30명 (.6%) 은레보도파치료에반응이없었다. 1명 (.6%) 은반응여부를모르겠다고하였고, 1명은오히려약효과가있을때허리통증이악화된다하였다. 이중레보도파치료에대하여허리통증이호전되는그룹과호전되지않은그룹을분석하여보았을때, 호전된그룹은파킨슨병의발병연령이낮은것으로나타났고 (p=0.00) 파킨슨병의유병기간이긴것으로나타났다 (p=0.0). 또한호전된그룹은운동변동 (p= 0.00) 과이상운동증 (p=0.0) 이많은것으로나타났으며, 비정상적인구부정한자세 (abrmally flexed posture) 를보이는환자가더많은것으로나타났다 (p=0.009). 골절이있는환자의허리통증은레보도파치료에호전을보이지않았다 (p=0.09). 그러나, 허리통증에대한레보도파치료의반응여부는환자의연령, 성별, 허리통증의기간, 레보도파의용량, 허리통증의발생시기, modified Hoehn and Yahr 단계, 골절을제외한방사선학적결과와관련이없었다 (Table, 5). 레보도파치료에대한허리통증의호전여부의예측인자를알 Characteristics Degenerative spondylosis Bulging disc mild moderate severe Disc space narrowing Stesis Fracture a Parkinson s disease, b Lower back pain Frequency (%) (n=55) (0%) 30 (5.5%) 6 (6.%) (6.%) (6.%) 11 (0%) 11 (0%) 9 (16.3%) Table. Correlation between responsiveness to Levodopa and clinical characteristics Characteristics Age Age at onset Levodopa response (=1, =30) Mean (±SD c ) 61. (±10.) 66. (±.) 51. (±13.) 60.1 (±.6) p-value d Table 3. Treatment modalities of LBP a Modalities Operation Epidural steroid injection Pysical therapy NSAIDs b Muscle relaxant Benzodiazepine Frequency (%) (n=63) 11 (1.5%) 31 (9.%) 1 (.6%) 35 (55.6%) 16 (5.%) 19 (30.%) a Lower back pain, b Non-steroidal anti-imflammatory drugs PD a duration Age at LBP b onset LBP duration Levodopa dosage (mg) a Parkinson s disease, d p<0.05 b Lower back pain, 9. (±6.1) 6.1 (±.6) 5.3 (±10.9) 60. (±9.).0 (±5.) 6.0 (±.6) 65.1 (±31.6) 5.3 (±66.1) c Standard deviation, 5 J Korean Neurol Assoc Volume No. 5, 006

4 Table 5. Correlation between responsiveness to Levodopa and clinical characteristics Items Category Levodopa response (n=) chi-square (χ ) Sex male female Motor fluctuation c Dyskinesia c Camptocormia c Onset time of LBP a before the PD b simultaneously after the PD Hoehn and Yahr stage a Lower back pain, b Parkinson s disease, c p<0.05 아보기위한로지스틱회귀분석에서운동변동이있는그룹은 3.1배 (OR, 3.1; 95% CI, : p=0.009), 비정상적인구부정한자세가있는그룹은.61 배 (OR,.61; 95% CI, : p=0.036) 레보도파에치료에대하여허리통증이호전되는것으로나타났다. 고찰 본연구는파킨슨병환자의운동성증상못지않게많은고통을초래하는비운동성증상중허리통증에관한국내최초의보고이다. 파킨슨병환자를대상으로한본연구는다른질환없이허리통증만을지닌환자의임상양상과약물치료, 방사학적소견에대한이전의보고와유사한결과를보였다. 1 본연구에서허리통증은여자환자에게더많이나타났으며, 그원인은지금까지명확히밝혀지지않았으나우울과불안등의사회심리적요인과해부학적구조의차이등여러가지가능성이제기되고있다. 11,1,1,15 본연구에포함된 1명의환자는파킨슨병진단전허리통증이발생하여 1차의료기관에서 1년간지속적인치료를받았으나호전이없어본원정형외과방문후신경과로의뢰되었다. 신경 과방문당시허리통증이외에서동증과경미한경직, 구부정한자세를보여파킨슨병으로진단받았고, 레보도파치료후서동증과함께허리통증은호전되었다. 또한방사선학적소견이정상이며몇년간지속적인허리통증을호소했던환자는뇌심부자극술후운동성증상의개선과함께허리통증이호전되었다. 따라서이러한환자들은허리통증이파킨슨병증상으로나타난대표적인예로볼수있다. 11명의환자는허리통증으로허리수술을시행받았고 5명은파킨슨병발병이전에 6명은발병이후에시행받았다. 파킨슨병발병후허리통증이발생한 1명의환자는본원에서검사후허리수술을권하지않았으나외부에서재진료후수술을받았고허리통증은개선되지않았다. 따라서수술전검사와함께신경학적검진및허리통증원인에대한정확한평가가중요하다. 본연구에포함된 16 명의환자는허리통증과함께걸을때심하게허리가굽는현상이관찰되었고, 이중 명은허리통증이레보도파치료로호전을보였다. 그러나심하게허리가굽은자세는레보도파치료로도큰호전을보이지않았다. 기존의연구들은허리배굴증 (camptocormia) 을호전시키기위해투여된레보도파치료는효과가경미하거나없다고보고하였으나허리배굴증을보이는환자의허리통증에대하여는보고된바가없 J Korean Neurol Assoc Volume No. 5,

5 김성렬정선주성영희김미선이명종 으므로이에대한추후연구가필요하다. 16,1 레보도파치료로허리통증이호전된그룹은호전되지않은그룹보다운동변동과이상운동증이많은것으로나타났다. 이는파킨슨병의비운동성증상인통증이운동증상처럼변동을보여통증의호전을보다잘인식한결과라고생각된다. 비운동성증상변동에대한이전연구들은통증이나이상감각증, 정좌불능 (akathisia) 등의감각증상, 과도한땀이나호흡곤란, 빈뇨등의자율신경계증상, 우울이나기분의상승 (euphoria), 환각과같은정신과적인증상이운동성증상의변동과함께변동을보일수있다고보고하였다. 이중조이거나저린감, 통증등의감각증상은 0% 의환자에게서변동을보였다. 1,19 따라서, 통증이레보도파치료에대하여변동을보이는환자는다른비운동성증상변동이있는지면밀한관찰이필요할것이다. 본연구에포함된환자중 3 명은골밀도검사 (bone densitrometry) 를시행하였다. 이중 5명은요추부위의골밀도가정상이었고 명은감소하였으며 (osteopenia) 16명에게는골다공증이나타났다. 이전의한보고는파킨슨병환자의골밀도가일반인과비교하여유의미한차이가없다고하였고, 0 파킨슨병없이만성허리통증을지닌환자를대상으로한다른보고에서는허리통증이있는환자의골밀도가일반인보다낮다고하였다. 1 그러나, 만성허리통증을동반한파킨슨병환자의골밀도에관한보고는아직없으므로추후연구가필요하다. 허리통증을호전시키기위한주사치료와물리치료는각각 5%, 0% 의환자가증상호전을보였고이중 50% 의환자는그효과가수일이내로일시적이었다. 이러한치료로증상호전을보이지않는환자뿐아니라호전된일부의환자도통증호전을위하여뜸, 부황, 한약, 카이로플락틱 (chiropractic), 스포츠마사지를처방된치료와함께병행하였고, 이로인하여상당한수준의비용을소요하고있었다. 따라서, 이러한허리통증으로인한치료비용과사회적손실에대한추후연구도필요하다. 이상과같이파킨슨병환자의허리통증은다양한임상양상을지니며병변을동반하지않은일부환자의허리통증은레보도파치료에대하여호전을보일수있다. 허리통증은그자체만으로환자에게고통을안겨줄수있으며때로는증상을호전시키지못하는수술을초래할수있고, 증상의호전을보이지않는보완대체요법등으로상당한경제적인부담을안겨줄수있다. 따라서, 의료인들은파킨슨병환자의허리통증을신중하게평가하고적절히치료함으로써환자가보다나은독립적인일상생활을영위할수있도록하는것이중요하다. 마지막으로본연구의제한점은연구에포함된환자중방사선학적소견이정상이며허리통증을동반한파킨슨병환자가 3 명밖에되지않아이에대한정확한분석이이루어지지않은점이다. 또한파킨슨병이 50세이상에서호발하는퇴행성질환임을감안할때허리통증이동반되지않은환자에서도방사선학적소견이정상이아닐수있으므로방사선학적소견을해석하는데에어려움이있었다. 따라서, 본저자들은방사선학적소견이정상이며허리통증이동반된파킨슨병환자에대한추후연구를제언하는바이다. REFERENCES 1. Gibb WR. Neuropathology of Parkinson s disease and related syndromes. Neurol Clin 199;10: Adler CH. Nonmotor complication in Parkinson s disease. Mov Disord 005;0: Duvoisin RC, Golbe LI, Mark MH, Sage JI, Walters AS. Parkinson s disease handbook; a guide for patients and their families. 1st ed. New York: The American Parkinson Disease Associations Inc, 1996; Shulman LM, Taback RL, Bean J, Weiner WJ. Comorbidity of the nmotor symptoms of Parkinson s disease. Mov Disord 001; 16: Hillen ME, Sage JI. Nonmotor fluctuations in patients with Parkinson s disease. Neurology 1996;: Jahanshahi M, Marsden CD. Parkinson s disease. 1st ed. New York: Demos Medical Publishing Inc, 000;1.. Ford B. Pain in Parkinson s disease. Clin Neurosci 199;5:63-.. Serratrice G, Michel B. Pain in Parkinson s disease patients. Rev Rheum Engl Ed 1999;66: Mott S, Kenrick M, Dixon M, Bird G. Pain as a sequela of Parkinson disease. Austr Fam Physician 00;33: Weiner WJ, Shulman LM, Lang AE. Parkinson s disease: a complete guide for patients and families. 1st ed. London: The Johns Hopkins University Press, 001;33-3,5-6, Inman SL, Faut-Callahan M, Swanson BA, Fillingim RB. Sex differences in responses to epidural steroid injection for low back pain. J Pain 00;5: Atalay A, Arslan S, Dincer F. Psychosocial function, clinical status, and radiographic findings in a group of chronic low back pain patients. Rheumatol Int 001;1: Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagsis of idiopathic Parkinson s disease: a clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry 199;55: Robinson ME, Dannecker EA, George SZ, Otis J, Atchison JW, Fillingim RB. Sex differences in the associations among psychological factors and pain report: a vel psychophysical study of patients with chronic low back pain. J Pain 005;6: Norton BJ, Sahrmann SA, Van Dillen FL. Differences in measurements of lumbar curvature related to gender and low back pain. J Orthop Sports phys Ther 00;3: Azher SN, Jankovic J. Camptocormia: pathogenesis, classification, and response to therapy. Neurology 005;65: Djaldetti R, Mosberg-Galili R, Sroka H, Merims D, Melamed E. Camptocormia in patients with parkinson s disease characterization 56 J Korean Neurol Assoc Volume No. 5, 006

6 and possible pathogenesis of an unusual phemen. Mov Disord 1999;1: Witjas T, Kaphan E, Azulay JP, Blin O, Ceccaldi M, Pouget J, et al. Nonmotor fluctuations in Parkinson s disease; frequent and disabling. Neurology 00;59: Gunal DI, Nurichalichi K, Tuncer N, Bekiroglu N, Aktan S. The clinical profile of nmotor fluctuations in Parkinson s disease patients. Can J Neurol Sci 00;9: Wood B, Walker R. Osteoporosis in Parkinson s disease. Mov Disord 005;0: Gaber TA, McGlashan KA, Love S, Jenner JR, Crisp AJ. Bone density in chronic low back pain: a pilot stydy. Clin Rehabil 00;16:6-0. J Korean Neurol Assoc Volume No. 5, 006 5

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical