Journal of Korean Society of Spine Surgery Idiopathic Spinal Cord Herniation Sung-Soo Kim, M.D., Ph.D. J Korean Soc Spine Surg 2017 Jun;24(2):

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(2):121-128. Originally published online June 30, 2017; https://doi.org/10.4184/jkss.2017.24.2.121 Korean Society of Spine Surgery Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505,

1 Journal of Korean Society of Spine Surgery Sung-Soo Kim, M.D., Ph.D. J Korean Soc Spine Surg 2017 Jun;24(2): Originally published online June 30, 2017; Korean Society of Spine Surgery Asan Medical Center, 88 Olympic-ro 43 Gil, Songpa-gu, Seoul, 05505, Korea Tel: Fax: Copyright 2017 Korean Society of Spine Surgery pissn eissn The online version of this article, along with updated information and services, is located on the World Wide Web at: This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Review Article J Korean Soc Spine Surg Jun;24(2): Sung-Soo Kim, M.D., Ph.D. Department of Orthopedic Surgery, Haeundae-Paik Hospital, College of Medicine, Inje University, Busan, Korea, Study Design: Literature review. Objectives: The aim of this study was to provide insight into idiopathic spinal cord herniation (ISCH) in terms of clinical presentation, pathophysiology, diagnosis, classification, and treatment. Summary of Literature Review: ISCH is a rare disorder characterized by anterior displacement of the spinal cord through a ventral dural defect. It has increasingly been recognized and described over the past 10 years. Materials and Methods: Review of the English-language literature on ISCH. Results: ISCH occurs in middle-aged adults with a female preponderance. The most common clinical presentation is Brown- Sequard syndrome, which can progress to spastic paraparesis. Its pathophysiology is unknown. However, some authors proposed that inflammation may play an important role in the emergence of a dural defect. Magnetic resonance imaging typically shows an anterior kink of the thoracic spinal cord with an obliteration of the ventral subarachnoid space and the widened dorsal subarachnoid space. Surgery is generally recommended for patients with motor deficits or progressive neurological symptoms. The posterior approach has been used because it allows wide exposure of the spinal cord. The surgical treatment of ISCH consists of spinal cord reduction from the ventral dural defect, which can be managed with enlargement, direct repair, or duraplasty (dural repair with a patch). In recent years, duraplasty has been used more frequently than enlargement of the dural defect. Conclusions: ISCH causing thoracic myelopathy could be safely treated with surgical management. The possibility of this disease should be kept in mind when treating patients with progressive myelopathy. Key words: Spinal cord herniation, Idiopathic cord herniation, Dural defect, Duraplasty 특발성척수탈출증은흉추부의척수 (thoracic spinal cord) 가전방의경막결손 (ventral dural defect) 을통하여경막밖으로빠져나가면서발생되는드문질환으로자발성척수탈출증 (spontaneous spinal cord herniation) 으로불리기도한다 년 Wortzman 등 1) 에의해처음보고된후현재까지약 200예가보고되었다. 2-8) 이질환에대한인식이빠르게증가되고, 자기공명영상 (magnetic resonance imaging, MRI) 이널리사용됨에따라최근 10년이내에많은증례가발견되었다. 하지만지금까지도이에대한병태생리, 자연경과, 수술방법및결과에대해서는여러의문점과논란이있는실정이다. 척수탈출증은외상성 (traumatic), 의인성 (iatrogenic; postoperative), 특발성 (idiopathic) 으로발생될수있다. 외상성과의인성척수탈출증은경막손상이전방보다는후방에서대부분나타나주로후방으로척수가탈출되고경추부및흉추부에서발생하지만, 특발성척수탈출증은전방경막결손을통하여전방으로척수가탈출되고흉추부에서주로발생하는특징이있다. 여기에서는알려진증례를바탕으로특발성척수탈출증의임상양상, 병태생리, 영상소견과감별진단, 치료에대해알아 보고자한다. 본론 1. 임상양상 모든성인에서발생할수있지만, 주로중년층 (middle-aged adults) 에서나타났으며환자들의평균연령은 51 세 (22~78 세 ) 였다. 여자가남자보다 2 배많았고, 흉추부중간 (mid-thoracic level) 부위인제 3-7 흉추에서높은빈도로발생하여, 특히제 Received: February 3, 2017 Revised: February 6, 2017 Accepted: March 31, 2017 Published Online: June 30, 2017 Corresponding author: Sung-Soo Kim, M.D., Ph.D. ORCID ID: Department of Orthopedic Surgery, Haeundae-Paik Hospital, College of Medicine, Inje University, 875 Haeundae-ro, Haeundae-gu, Busan, 48108, Korea TEL: , FAX: sskim@paik.ac.kr Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 121

3 Sung-Soo Kim Volume 24 Number 2 June , 5흉추에서가장많이관찰되었다. 4) 경막결손은환자의 1/3 은추체후방에서, 2/3는추간판후방에서보였다. 증상은탈출된척수의부위와위치에의해결정되는데, 일반적으로진행하는척수증 (progressive myelopathy) 을보이나대부분의경우서서히증상이나타나증상시작부터진단이나치료받기까지평균 5.2년 (6개월 ~36년 ) 이소요되었다. 4) Brown-Sequard 증후군이전체환자의 66% 로가장흔한증상이며, 강직성부전마비 (spastic paraparesis) 가 30% 에서관찰되었다. 단독감각결손 (isolated sensory deficit) 은 3%, 단독근력결손 (isolated motor deficit) 은 1% 에서보고되었고, 그외증상으로배뇨와배변장애, 흉추부통증이있었다. 5) 이런증상은병의초기에는척수의외측부분이탈출되어외측척수시상로 (lateral spinothalamic tract) 의이상으로통증과온도감각의소실이발생하며, 탈출이진행되면서피질척수로 (corticospinal tract) 가침범되어서서히진행하는근력약화와하지강직이나타나는것으로판단된다. A B C Fig. 1. The arachnoid membrane in a ventral dural defect is herniated and cerebrospinal fluid moves freely in and out of the defect. (A) An extradural arachnoid cyst is present. (B) The opening of the dural defect is blocked by the spinal cord. An adhesion between the spinal cord and arachnoid is found at the edge of the dural defect. (C) The spinal cord is herniated through the dural defect. There is a possibility of cord tethering, strangulation, incarceration, and ischemia. 2. 병태생리현재까지흉추부에전방경막결손이발생하는정확한기전에대해서는알려져있지않지만, 몇가지가설이제시되고있다. 선천성경막결손, 1) 이중전방경막 (duplicated ventral dura) 에서내측경막의결손, 9) 탈출된추간판이나석회화된추간판에의한침식 (erosion) 과염증 (inflammation), 10) 추체후방의골결손, 외상 11) 등이가설로거론되고있으며, 이가설들중에서가장설득력이있는것은염증이라고판단된다. 경막의전방에서발생되는여러병변 ( 추간판탈출증, 골결손등 ) 에서일어나는염증으로인해경막과유착 (adhesion) 이일어나고, 이로인해경막이얇아지면서결국결손 ( 구멍 ) 이발생할수있을것으로여겨진다. 전방경막결손은정중앙에서나타나는전방 (ventral) 형과약간외측에서나타나는전측방 (ventrolateral) 형으로크게나눌수있다. 어떤이유에의해서든지흉추부에전방경막결손이일단발생되면이결손을통하여지주막 (arachnoid membrane) 이빠져나가면서뇌척수액이들어오고나갈수있게된다 (Fig. 1A). 이것은경막외부는음압 (negative pressure) 인상태이고, 경막안에서는뇌척수액의박동 (pulsation) 이존재하기때문이다. 6) 경막결손을통한뇌척수액의움직임은경막결손을더크게만들수있을것이다. 시간이흐르면서경막결손부위에척수가놓이게되면서결손의가장자리는지주막과유착이일어나결손부위가척수로막혀지는시점이생기게된다 (Fig. 1B). 이후경막외부의음압과경막내의뇌척수액박동은척수를경막결손을통해계속적으로이동시키게되어궁극적으로척수탈출증이발생하게되는것이다 (Fig. 1C). 탈출된부위에 서척수는움직임이없어지고고정되게 (tethering) 되면서탈출된척수에긴장과손상을발생시켜증상을유발하는것으로설명되고있다. 그리고탈출된척수에서일어나는고정이나조임 (strangulation) 으로발생될수있는전방척수동맥 (anterior spinal artery) 의허혈 (ischemia) 이증상을유발할수있는또다른원인으로생각할수있다. 더욱이특발성척수탈출증이가장많이발생되는흉추부중간은척수중에서혈액공급이가장좋지않은부위 (watershed zone) 로허혈성손상이쉽게발생할수있는곳이며, 이동맥허혈은수술후증상이호전되지않는이유로도여겨지기도한다. 특발성척수탈출증이흉추부에주로발생되는것은흉추부는정상적으로후만을형성하여이부위의척수는경막내의전방에위치하는점, 굴곡과신전의영향, 심장과폐의운동에의해척수가전방으로움직이는점으로설명된다. 3. 진단이질환의진단에는 MRI가가장유용하다. 최근에는영상기술의발전으로고해상도 (high-resolution) MRI, 얇은절편 (thin-section) MRI, 위상차 (phase-contrast) MRI가개발되면서보다쉽게진단할수있게되었고, 비슷한양상을보이는다른질환을감별할수있게되었다. 과거에는잘못된진단이내려진경우가종종있었으며특히, 경막내지주막낭종 (intradural arachnoid cyst) 과의감별이어려워이를위해컴퓨터단층척수강조영술 (computed tomographic myelography; CT myelography) 이사용되었으나요즈음에는거의사용되지않는다. 하지만 MRI를촬영할수없는환자에서는현재에도 122

Journal of Korean Society of Spine Surgery A B C D Fig. 2. Idiopathic spinal cord herniation in a 43-year-old man. He had a tingling sensation in his left leg for 3 years.

There were CSF flow artifacts in the dorsal subarachnoid space in MRI (A, B) and no blockage of free-flowing contrast agent on the CT myelogram (C, D).

4 Journal of Korean Society of Spine Surgery A B C D Fig. 2. Idiopathic spinal cord herniation in a 43-year-old man. He had a tingling sensation in his left leg for 3 years. (A, B) T2-weighted MRI and (C, D) a CT myelogram show anterior displacement of the spinal cord with an obliteration of the ventral subarachnoid space and an enlarged dorsal subarachnoid space at T2-3. There were CSF flow artifacts in the dorsal subarachnoid space in MRI (A, B) and no blockage of free-flowing contrast agent on the CT myelogram (C, D). MRI, magnetic resonance imaging; CT, computed tomography. CT myelography 는유용하게사용된다. MRI로척수전방에있는지주막하공간이소실되면서척수의일부가경막외로전위되어있고, 척수후방의지주막하공간이넓어져있지만척수후방에고형종괴 (solid mass) 나낭종 (cyst) 이없다면특발성척수탈출증을진단할수있다. 즉 MRI 시상면영상에서척수가전방으로전위되어 C 또는 S자형으로구부러져있으면서후방의지주막하공간이커져있고, 횡단면영상에서전방으로전위된척수가전방의경막에붙어경막과척수사이에뇌척수액이존재하지않으며일부의척수는경막외로이동되어있다 (Fig. 2). 때때로척수위축으로인해척수가얇아질수도있으며척수신호강도의변화가동반되는경우도있다. 척수후방의경막내지주막낭종 (intradural arachnoid cyst) 은척수를전방으로전위시켜특발성척수탈줄증과비슷한영상소견을보일수있으므로감별진단에유의하여야한다. 특발성척수탈출증의경우에는척수후방의지주막하공간이넓어져있지만낭종은존재하지않기때문에정상적인뇌척수액의흐름과박동이존재하지만, 지주막낭종의경우에는정상적인뇌척수액의흐름과박동이존재하지않는다 (Fig. 3). 그러므로 MRI에서척수후방의넓어진공간에서뇌척수액의박동에의한인공음영 (artifact) 이보이거나위상차 MRI에서정상적인뇌척수액의흐름을관찰할수있다면지주막하낭종을배제할수있을것이다. 또한 CT myelography 에서조영제가척수후방에서정체 (retention) 되거나충만결손 (filling defect) 을보이지않고, 정상적인뇌척수액의흐름을가진다면특발성척수탈출증을진단할수있다. 7,12) 그리고특발성척수탈출증에서는 MRI 횡단면영상에서신경근 (nerve root) 이후방지주막공간을가로질러가는것이보일수있지만, 지주막낭종에서는신경근이낭종에의해전위되어낭종의변연부에서관찰되므 A Fig. 3. Intradural arachnoid cyst in a 37-year-old woman. She experienced weakness in the lower extremities. (A, B) T2-weighted MRI shows anterior displacement of the spinal cord with a widened subarachnoid space at T2-3. There was no cerebrospinal fluid flow artifact in the dorsal subarachnoid space, and the spinal cord was compressed by an intradural arachnoid cyst. MRI, magnetic resonance imaging. 로감별점으로사용될수있다 (Table 1). 13) 그외감별하여야할 질환으로유피낭종 (epidermoid cyst), 낭종성신경초종 (cystic schwannoma) 와같은경막내종양 (intradural tumor), 횡단척 수염 (transverse myelitis), 지주막염 (arachnoiditis), 경막외의농 양과혈종및종괴등에의한경막외압박성병변 (extradural compressive lesion) 등이있다. 4. 분류 현재까지특발성척수탈출증에서널리사용되고광범위하 게평가된분류법은없는상태이나 2009 년 Imagama 등 14) 은 영상소견을바탕으로분류를시도하였다. 이분류에서는시상 면 MRI 를기준으로탈출정도에따라 K 형, D 형, P 형으로나 B 123

5 Sung-Soo Kim Volume 24 Number 2 June 2017 Table 1. Different findings in imaging studies between idiopathic spinal cord herniation (ISCH) and intradural arachnoid cyst (IDAC) Imaging study ISCH IDAC MRI Dorsal CSF flow artifact + Dorsal CSF flow in phase-contrast imaging Normal Abnormal Nerve roots in axial image Traversing Peripheral CT myelography Retention of dye or filling defect + 누었고, 횡단면 MRI에서경막결손의위치에따라 C형과 L 형으로나누었다. K형은척수가전방으로명확하게구부려져 (kinking) 있는경우이며, D형은척수가탈출부위에서완전히사라진 (discontinuous) 경우, P형은전방지주막하공간은소실되었으나척수의구부러짐은거의없는 (protrusion; no/little kinking) 경우로정의하였고, 경막결손이전방경막의정중앙에있는경우를 C형 (central), 그렇지않는경우를 L형 (lateral) 이라고하였다. 5. 치료특발성척수탈출증은드문질환으로자연경과 (natural history) 가명확하지않기때문에적절한치료지침이나계획이결정되어있지는않다. 일반적으로보전적치료와수술적치료로나눌수있고, 환자개개인에상태와경과에따라정해져야한다. 보전적치료는근력약화나진행성의척수증을보이지않는환자에게시행하는것이좋을것이며, 15,16) 신경학적증상이진행하거나근력약화가있는환자에게는수술적치료가필요하다. 4-6,16) A B 가. 보전적치료보전적치료를지속한 15예를조사한보고 16) 에서평균 33개월 (1~96 개월 ) 관찰하여신경학적상태는변화되지않았다. 물론보전적치료나경과관찰중에신경학적증상이진행하는경우에는수술적치료를시행되었다. 그리고특발성척수탈출증이진단되고 6개월이후에자연적으로척수탈출증이호전된증례도보고된바있다. 17) 나. 수술적치료수술의목적은경막결손부위에서발생되는척수의조임 ( 또는고정 ) 을풀고척수를정상적인경막내위치로이동시키면서재탈출을방지하여, 악화되는신경학적증상을정지시키면서궁극적으로회복시키는것이다. 과거에전방수술로치료한예 1) 가보고되었으나수술시야가 C Fig. 4. (A) A ventral dural defect in the inner dura of the duplicated anterior dura. (B) The spinal cord is herniated through the dural defect and is ultimately constricted. (C) The spinal cord is released by enlargement of the defect. 좁아사용되지않았으며대부분의보고는광범위하게척수를 노출시킬수있는후방수술로치료되었다. 후방수술은필요한 부분에후궁절제술 (laminectomy) 을시행하고경막을열어척 수전방에서병변을찾아야하는데, 이과정에서척수에대한 124

Journal of Korean Society of Spine Surgery 직접적인견인을피하기위해치상인대 (dentate ligament) 를경막부위에서잘라서치상인대를조심스럽게견인하여척수를이동시키거나회전시켜척수의전방을노출시킨다. 이때신경근이방해가된다면자를수있다. 이후진행되는후방수술은크게두가지로나눌수있다. 첫번째는경막결손을더크게만드는방법 (Fig.

6 Journal of Korean Society of Spine Surgery 직접적인견인을피하기위해치상인대 (dentate ligament) 를경막부위에서잘라서치상인대를조심스럽게견인하여척수를이동시키거나회전시켜척수의전방을노출시킨다. 이때신경근이방해가된다면자를수있다. 이후진행되는후방수술은크게두가지로나눌수있다. 첫번째는경막결손을더크게만드는방법 (Fig. 4) 으로일본에서주로시행되었다. 9,18,19) 이들은기본적으로이중전방경막에서내측경막에결손이발생하여척수탈출증이발생한것으로인식하여, 탈출된척수주위의경막을제거하여경막결손을넓히게되면척수의조임 ( 또는고정 ) 을풀어줌과동시에재탈출을막을것이라고판단하였다. 이술식은비교적간단하고척수의견인이최소화되는장점이있다. 두번째는경막결손주위에서보통존재하는지주막유착을박리하여척수를경막내로이동시킨뒤에경막결손을직접봉합 20) 하거나경막결손을패취 (patch) 로덮는경막성형술 (duraplasty) 3,7,8,21,22) 을시행하여원인이되는경막결손을직접교정하는방법이다. 직접봉합을하기위해서는척수가과도하게견인되는단점이있어최근에는경막성형술 (Fig. 5) 이많이보고되는경향이다. 경막성형술에사용되는이식물로는근육, 근막, 지방, 소의심막 (bovine pericardium), Teflon, Gore-Tex 등이있다. 다. 수술중척수감시 (Intraoperative cord monitoring) 수술중척수를직접적으로조작하게되므로수술과관련된신경합병증을예방하기위해수술중척수감시가필요하다. 수술중척수의부분적기능이아니라전반적인기능을감시하기위해서감각경로를감시하는체성감각유발전위 (somatosensory evoked potential) 와운동경로를감시하는운동유발전위 (motor evoked potential, MEP) 를동시에사용하게된다. 그리고특발성척수탈출증수술에서는근육에서기록하는근육운동유발전위 (muscle MEP, mmep) 뿐만아니라수 술이시행되는척수의원위부경막에서기록되는경막운동유발전위 (epidural MEP, emep) 도함께사용하도록추천되고있다. 4,13,23) 이는 mmep의이상소견이지속되는것만으로는한시적마비와영구적마비를감별하지못하지만, emep의 D파를사용하면한시적마비와영구적마비를감별할수있기때문이다. 즉 mmep가소실된이후에도 emep의 D파에이상소견이나타나지않는다면이는수술후한시적마비를의미하는것이지만, 두검사모두에서이상소견이지속되는경우에는영구적마비가수술후에나타남을의미한다. 라. 수술결과 Saito 등 24) 은경막결손을직접봉합하는수술로환자의 20% 가악화되었으나, 경막결손을더크게하는수술이나경막성형술에서는환자의 10% 가악화되었다고보고하였다. 이후 129 례를대상으로한메타분석 4) 에서경막결손을더크게하는수술과경막성형술을비교하였는데, 술후근력회복은경막결손을더크게하는수술이더우수하였다. 그리고이연구에서 Brown-Sequard 증후군이강직성부전마비보다수술후결과가좋은것으로조사되었다. 수술적치료를시행받은 159예를정리한다른보고 16) 에서는수술후신경학적소견이호전된경우는 74%, 변화하지않은경우는 18%, 나빠진경우는 8% 로수술의결과는대체적으로양호하였다. 영상분류에따른보고 14) 에서는 P형이수술후회복이좋았으며, C형이술전마비가심했을뿐만아니라수술후결과도좋지않았다. Nakamura 등 19) 은경막결손을더크게하는수술을 16예에서시행하고평균 9.6년 (5~23년 ) 의장기추시결과를보고하였는데재발된경우는없었으며수술시환자의나이가어릴수록, 증상기간이짧을수록수술후회복은좋다고하였다. 하지만경막결손을더크게하는수술을시행한후에척수탈출증 A B C D Fig. 5. Surgical procedure of duraplasty. (A) After dural opening, the dentate ligaments can be found. (B) The dentate ligaments are cut, which enables free mobilization of the spinal cord. The edge of the ventral dural defect is then confirmed. (C) The spinal cord is gently reduced inside the dura, and a patch is inserted and slid into the ventral side of the spinal cord. (D) Both ends of the patch are trimmed and sutured on the dural edge

7 Sung-Soo Kim Volume 24 Number 2 June 2017 이재발된경우가보고되었고, 다른합병증으로경막결손을통해뇌척수액이경막밖으로빠져나가면서발생할수있는두개내저혈압 (intracranial hypotension) 이나자세성두통 (positional headache) 의가능성이있을수있다는점은유의하여야한다. 20,25) 최근에는수술술기와미세현미경을포함한기기의발전으로인해정상적인경막의구조를만들어주는경막성형술이더많이이용되어보고되는경향이다. 결론 특발성척수탈출증은진행성흉추부척수증을일으킬수있는드문질환이지만치료될수있다. MRI에서척수전방의지주막하공간이소실되면서척수가전방으로전위되어구부러져있다면반드시이질환을의심하고다른질환, 특히척수후방의경막내지주막낭종과감별하여야한다. 수술은척수감시하에서경막결손부위에있는척수의조임 ( 또는고정 ) 을풀어주고경막성형술로경막결손부위를처치하여야할것이다. REFERENCE 1. Wortzman G, Tasker RR, Rewcastle NB, et al. Spontaneous incarcerated herniation of the spinal cord into a vertebral body: A unique cause of paraplegia. case report. J Neurosurg. 1974;41: Darbar A, Krishnamurthy S, Holsapple JW, et al. Ventral thoracic spinal cord herniation: Frequently misdiagnosed entity. Spine (Phila Pa 1976). 2006;31:E Chaichana KL, Sciubba DM, Li KW, et al. Surgical management of thoracic spinal cord herniation: Technical consideration. J Spinal Disord Tech. 2009;22: Groen RJ, Middel B, Meilof JF, et al. Operative treatment of anterior thoracic spinal cord herniation: Three new cases and an individual patient data meta-analysis of 126 case reports. Neurosurgery. 2009;64(Suppl): Sasani M, Ozer AF, Vural M, et al. Idiopathic spinal cord herniation: Case report and review of the literature. J Spinal Cord Med. 2009;32: Shin JH, Krishnaney AA. Idiopathic ventral spinal cord herniation: A rare presentation of tethered cord. Neurosurg Focus. 2010;29:E Prada F, Saladino A, Giombini S, et al. Spinal cord herniation: Management and outcome in a series of 12 consecutive patients and review of the literature. Acta Neurochir (Wien). 2012;154: Payer M, Zumsteg D, De Tribolet N, et al. Surgical management of thoracic idiopathic spinal cord herniation. technical case report and review. Acta Neurochir (Wien). 2016;158: Nakazawa H, Toyama Y, Satomi K, et al. Idiopathic spinal cord herniation. report of two cases and review of the literature. Spine (Phila Pa 1976). 1993;18: Najjar MW, Baeesa SS, Lingawi SS. Idiopathic spinal cord herniation: A new theory of pathogenesis. Surg Neurol. 2004;62: Borges LF, Zervas NT, Lehrich JR. Idiopathic spinal cord herniation: A treatable cause of the Brown-Sequard syndrome: case report. Neurosurgery. 1995;36: Haber MD, Nguyen DD, Li S. Differentiation of idiopathic spinal cord herniation from CSF-isointense intraspinal extramedullary lesions displacing the cord. Radiographics. 2014;34: Barrenechea IJ, Lesser JB, Gidekel AL, et al. Diagnosis and treatment of spinal cord herniation: A combined experience. J Neurosurg Spine. 2006;5: Imagama S, Matsuyama Y, Sakai Y, et al. Image classification of idiopathic spinal cord herniation based on symptom severity and surgical outcome: A multicenter study. J Neurosurg Spine. 2009;11: Massicotte EM, Montanera W, Ross Fleming JF, et al. Idiopathic spinal cord herniation: Report of eight cases and review of the literature. Spine (Phila Pa 1976). 2002;27:E Summers JC, Balasubramani YV, Chan PC, et al. Idiopathic spinal cord herniation: Clinical review and report of three cases. Asian J Neurosurg. 2013;8: Samuel N, Goldstein CL, Santaguida C, et al. Spontaneous resolution of idiopathic thoracic spinal cord herniation: Case report. J Neurosurg Spine. 2015;23: Watanabe M, Chiba K, Matsumoto M, et al. Surgical management of idiopathic spinal cord herniation: A review of nine cases treated by the enlargement of the dural defect. J Neurosurg. 2001;95(Suppl): Nakamura M, Fujiyoshi K, Tsuji O, et al. Long-term surgical outcomes of idiopathic spinal cord herniation. J Orthop Sci. 2011;16: Inoue T, Cohen-Gadol AA, Krauss WE. Low-pressure 126

8 Journal of Korean Society of Spine Surgery headaches and spinal cord herniation. case report. J Neurosurg. 2003;98(Suppl): Akutsu H, Takada T, Nakai K, et al. Surgical technique for idiopathic spinal cord herniation: The hammock method. technical note. Neurol Med Chir (Tokyo). 2012;52: Batzdorf U, Holly LT. Idiopathic thoracic spinal cord herniation: Report of 10 patients and description of surgical approach. J Spinal Disord Tech. 2012;25: Novak K, Widhalm G, de Camargo AB, et al. The value of intraoperative motor evoked potential monitoring during surgical intervention for thoracic idiopathic spinal cord herniation. J Neurosurg Spine. 2012;16: Saito T, Anamizu Y, Nakamura K, et al. Case of idiopathic thoracic spinal cord herniation with a chronic history: A case report and review of the literature. J Orthop Sci. 2004;9: Maira G, Denaro L, Doglietto F, et al. Idiopathic spinal cord herniation: Diagnostic, surgical, and follow-up data obtained in five cases. J Neurosurg Spine. 2006;4:

9 Review Article J Korean Soc Spine Surg Jun;24(2): 특발성척수탈출증 김성수인제대학교의과대학해운대백병원정형외과학교실 연구계획 : 문헌고찰 목적 : 특발성척수탈출증의임상양상, 병태생리, 진단, 분류및치료에대해알아보고자하였다. 선행문헌요약 : 특발성척수탈출증은척수가전방의경막결손을통하여빠져나가는질환으로비교적드물게발생하지만, 최근 10 년동안빠르게인식 되면서많은증례가보고되고있다. 대상및방법 : 영문으로보고된특발성척수탈출증에대한문헌을조사하여고찰하였다. 결과 : 특발성척수탈출증은주로성인중년층에서발생하며여자에서호발된다. 가장흔한임상양상은 Brown-Sequard 증후군이며, 이것이악화되어 강직성부전마비로나타날수도있다. 정확한발생기전을알려져있지않지만, 염증이경막결손을형성하는데중요한역할을한다는주장은설득력이 있다. 자기공명영상에서흉추부척수가전방으로전위되어있으면서척수전방에지주막하공간이소실되어있고, 척수후방의지주막하공간은넓어진 소견을보인다. 수술은일반적으로근력약화가있거나신경학적증상이진행하는경우에필요하다. 광범위하게척수를노출시킬수있는후방수술이이 용된다. 수술은빠져나간척수를경막내로이동시킨다음, 경막결손에대해서는경막결손을더크게하는방법, 직접봉합하는방법, 패취를이용한경 막성형술을시행하는방법이있다. 최근에는경막성형술이더자주사용되어보고되고있다. 결론 : 특발성척수탈출증은흉추척수증을유발할수있으나수술로비교적안전하게치료될수있다. 진행성척수증을가진환자를진료할때이질환을 반드시유념하여야한다. 색인단어 : 척수탈출증, 특발성척수탈출증, 경막결손, 경막성형술 약칭제목 : 특발성척수탈출증 접수일 : 2017년 2월 3일수정일 : 2017년 2월 6일게재확정일 : 2017년 3월 31일교신저자 : 김성수부산광역시해운대구해운대로 875 해운대백병원정형외과학교실 TEL: FAX: sskim@paik.ac.kr 128 Copyright 2017 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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