Case Report J Korean Bone Joint Tumor Soc 2011; 17: 요추부척추관협착증과동반된경막내신경초종 : 증례보고

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1 Case Report J Korean Bone Joint Tumor Soc 2011; 17: Intradural Schwannoma Associated with Lumbar Spinal Stenosis: A Cese Report 소재완 김태헌 권세원순천향대학교의과대학천안병원정형외과학교실 요추부척추관협착증과경막내종양이동반되어있는환자에서, 척추관협착증에대한수술적치료만시행하였다가수술후증상이잔존할수있다. 본증례는척추신경이척추관협착증으로인한외적인압박과함께, 종양의공간점유로경막내압박을동반하였던경우로, 신경감압술과경막내종양의제거를동시에시행하여성공적으로치료되었기에문헌고찰과함께보고하는바이다. 71세여자환자가하부요통및양측하지로의방사통을주소로내원하였다. 자기공명영상에서제 4-5 요추부는척추관협착증소견과함께제 5 요추- 제 1 천추부에경도의척추전방전위증소견이관찰되었고, 제 4 요추체부위에서타원형의경막내공간의대부분을점유하는종괴가관찰되었다. 후방도달법으로감압술및유합술을시행한다음, 정중경막절개술을통해종괴를제거하였다. 조직검사상신경초종으로진단되었고, 수술후증상은현저히호전되었다. 색인단어 : 요추, 척추관협착증, 경막내신경초종 척추신경초종은척수종양중가장높은발생률 (25-37%) 을보이며남녀발생비의차이는없는것으로보고된다. 1-3) 대부분경막내척수외 (intradural extramedullary) 에위치하나드물게는경막외 (extradural) 또는척수내 (intramedullary) 에서도발생한다. 발생부위는전척추에걸쳐균등하게발생하나흉추부에더많이발생한다. 요추부에발생한종양인경우, 초기에는신경근의지배영역을따라동통과감각장애가나타난다. 따라서, 척추관협착증이신경초종과동반된경우척추관협착증에대한수술적치료만시행하면증상이잔존할수있는데, 이두가지를동시에수술하여좋은결과를얻은 1예를경험하여문헌고찰과함께보고하는바이다. 증례보고 71세여자환자가내원 6개월전부터보행이어려울정도로심해진하부요통및양측하지로의방사통을주소로내원하였다. 이학적소견상우측장무지신근과족배굴근, 족저굴근의근력이약 4등급으로저하된소견있으면서양측제 4, 5 요추신경근과 접수일 2011 년 10 월 27 일심사수정일 2011 년 11 월 18 일게재확정일 2011 년 11 월 25 일교신저자권세원천안시동남구봉명동 23-20, 순천향대학교의과대학천안병원정형외과학교실 TEL , FAX osos@schmc.ac.kr * 본논문의요지는 2011 년도대한척추외과학회춘계학술대회에서발표되었음. 제 1천추신경근지배부위로감각저하소견이있었다. 양하지슬개건반사와아킬레스건반사는정상이었고파행으로인하여보행이 100 m 이내로제한되어있었다. 단순방사선사진상제 4-5 요추부와제 5 요추- 제 1 천추부에퇴행성변화와함께추체간격이좁아진소견및굴곡- 신전측면사진상제 5 요추- 제 1 천추부에경도의척추전방전위증소견이관찰되었다 (Fig. 1). 요추부자기공명영상에서제 4-5 요추부는양측에경도의척추관협착증소견과함께제 5 요추- 제 1 천추부에경도의척추전방전위로인한양측제 5 척추신경근압박소견이관찰되었다 (Fig. 2). 또한제 4 요추체부위에서경막내에 T1 강조영상에서저신호강도, T2 강조영상에서중간신호강도, 가톨리늄조영에서강조가되는타원형의경막내공간의대부분을점유하는종괴가관찰되었다 (Fig. 3). 후방도달법을이용하여, 제 4, 5 요추의후궁을전절제하고신경감압술을시행한뒤, 척추경나사못과케이지, 절제한후궁골편을이용하여제 4-5 요추부와제 5 요추- 제 1 천추부의추체간유합술을시행하였다 (Fig. 4). 그런다음, 제 4 요추체부위에서정중경막절개술을시행하고살펴보니, 신경근과연결되어있는양상의종괴가관찰되어, 신경근을보존하면서종괴를제거하였다 (Fig. 5A). 종괴는약 cm 크기의타원형의피막이잘발달된양상이었다 (Fig. 5B). 조직학적진단은신경초종으로확인되었다 (Fig. 6). 수술후증상은현저히호전되었고, 추시 1년째까지증상의재발및신경학적특이소견은없었다. 대한골관절종양학회지 : 제17 권제2 호 2011 Copyrights 2011 by The Korean Bone and Joint Tumor Society 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.

2 107 Figure 1. Preoperative plain radiographs. (A, B) Anteroposterior (A) and lateral (B) radiographs show degenerative spondylosis in L4-5-S1 level. (C, D) Flexion (C) and extension (D) lateral radiographs show spondylolisthesis on L5-S1 level. Figure 2. T2-weighted sagittal and axial MR images. (A-C) Serial sagittal MR images show foraminal stenosis on L4-5 level and spondylolisthesis on L5-S1 level. (D) Axial MR image shows spinal stenosis on L4-5 level. (E) Axial MR image shows spondylolisthesis on L5-S1 level. Figure 3. MR images, myelogram and CT myelogram show space occupying mass on L4 level. (A) T1-weighted sagittal and axial MR image shows low-signal intensity lesion. (B) T2-weighted sagittal and axial image shows iso-signal intensity lesion. (C) Gadolinium enhanced sagittal and axial MR image shows high-signal intensity lesion. (D) Myelogram and CT myelogram show space occupying lesion.

3 108 소재완 김태헌 권세원 Figure 4. Postoperative plain radiographs. (A, B) Anteroposterior (A) and lateral (B) radiographs show posterior decompression and interbody fusion using pedicle screws and cages on L4-5-S1 level. 고 찰 신경초종은슈반세포에서기원하고전형적으로후신경근에서발생하며상대적으로무혈관성의원형으로성장한다. 요추부에발생하는신경초종의빈도는약 48% 로보고되고있다. 조직학적으로신경초종은방추형세포가주를이루는형 (Antoni type A) 과점액변성세포가주를이루는형 (Antoni type B) 의두종류가있다. 4) 추간판탈출증이나척추관협착증과같은요추부질환과의감별이쉽지않고천천히자라는특징때문에척수나신경근의압박으로인한증상이나타나서야진단이된다. 신경초종의초기증상은종양의위치에따라다르지만대개복부통증으로나타나며 5) 특징적증상은와상 (supine position) 에서심해지는양상의동통인데, 그이유는와상에서종괴로인해정맥의압력이증가하여신경의국소적압박이증가하기때문이다. 6) 동통의양상은주로편측에국한되나양측으로나타나기도하며, 드물게는종양이위치한부위에칼로찌르는듯한통증이나타나기도한다. 근력저하는요천추부에발생한경우종양이진행되기전까지명확히나타나지않는다. 최근에는자기공명영상이척추종양의진단에중요한역할을하고있는데, 크기, 모양, 경막이나척수와같은인접조직과의해부학적관계평가에도도움이되고있다. 자기공명영상에서신경초종은 T1 강조영상에서저신호강도, T2 강조영상에서고신호강도, 조영증강영상에서불균질하게조영되는종물로나타난다. 신경초종의치료는완전절제이나, 신경근전체가종양내에 Figure 5. (A) Intraoperative finding shows oval shaped mass communicating with nerve root (arrow). (B) Gross finding of tumor shows well encapsulated ovoid mass measured cm. 포함되어신경근의절단없이는종양의완전제거가불가능한경우도있다. 7) 대부분의보고에서는종양이천천히자라기때문에신경학적결손이예상된다면부분절제를하여신경근을보존하는것을권고하였다. 8,9) 저자들의경우에도신경근을보존하면서종괴를절제하였다. 본증례에서는자기공명영상소견상척추관협착증은심하지않았으나경막내공간의대부분을차지할정도로종양의크기가커서심한동통과함께근력저하와감각저하가동반된증상

4 109 Figure 6. Microscopic histologic feature ( 400) shows palisading pattern which is the specific finding of Schwannoma. (A) H&E stain. (B) Immunohistochemical stain. 을보이고있었다. 척추관협착증과동반된경막내신경초종은동일한지배영역에발생할경우동일신경근에대한척추관협착증에의한외적압박과종양의공간점유로인한경막내압박이동시에발생하여감별이용이치않아어느한질환에대한수술적치료만을시행할경우증상이잔존되는경우가발생할수있다. 따라서본증례와같은환자가내원했을때는자세한병력청취와함께이학적진찰및방사선학적검사를시행한후, 정확한진단하에척추관협착증에대한감압수술만으로충분할지, 종양의절제도같이시행해야할지수술전계획이필요할것으로생각된다. 결론적으로, 두질환으로인하여내, 외측으로척추신경압박이동시에있을경우신경감압술과함께종양의절제를통한내측감압을동시에시행하는것이수술후성공적인결과를초래할수있을것으로사료된다. 참고문헌 1. Celli P, Trillò G, Ferrante L. Spinal extradural schwannoma. J Neurosurg Spine. 2005;2: De Verdelhan O, Haegelen C, Carsin-Nicol B, et al. MR imaging features of spinal schwannomas and meningiomas. J Neuroradiol. 2005;32: Dorsi MJ, Belzberg AJ. Paraspinal nerve sheath tumors. Neurosurg Clin N Am. 2004;15: Jung HW, Lim SB, Kim DW, Shin BJ, Kim YI. Pre-sacral giant schwannoma: removal by a combined anterior and posterior approach: a case report. J Korean Soc Spine Surg. 2001;8: Shin BJ, Lee JC, Yoon TK, et al. Surgical treatments of intradural extramedullary tumor. J Korean Soc Spine Surg. 2002;9: Broager B. Spinal neurinoma; a clinical study comprising 44 cases with a discussion of histiological origin and with special reference to differential diagnosis against spinal glioma and meningioma. Acta Psychiatr Neurol Scand Suppl. 1953;85: Cervoni L, Celli P, Scarpinati M, Cantore G. Neurinomas of the cauda equina clinical analysis of 40 cases. Acta Neurochir (Wien). 1994;127: Schneider RC, Kahn EA, Crosby ECC. Spine and spinal cord tumors. In: Mcgauley JL, ed. Correlative Neuro-surgery. 3rd ed. Springfield: Charles C Thomas; Wilkins RH, Rengachary SS. Spinal intradural tumors. In: Stein BM, ed. Neurosurgery. New York: McGraw-Hill;

5 110 소재완 김태헌 권세원 Intradural Schwannoma Associated with Lumbar Spinal Stenosis: A Cese Report Jae-Wan Soh, M.D., Tae-Heon Kim, M.D., and Sai-Won Kwon, M.D. Department of Orthopaedic Surgery, Soonchunhyang University Hospital, College of Medicine, Soonchunhyang University, Cheonan, Korea In the patient who has intradural mass associated with spinal stenosis, if the operation for spinal stenosis is performed alone, the symptom may remain. We report with literature review that we achieved the successful outcome after simultaneous decompression of spinal stenosis and space occupying mass removal in the case of intradural and extradural compression. A 71-year-old female patient suffering from low back pain and radiating pain of both lower extremities admitted. In magnetic resonance imaging, spinal stenosis on L4-5 and spondylolisthesis on L5-S1 compressed dural sac and intradural space occupying mass on L4 level compressed. By posterior approach, decompression and interbody fusion were carried out. Then mass was removed with median durotomy. Pathologic diagnosis was schwannoma and the symptom was improved remarkably. Key words: lumbar, spinal stenosis, intradural schwannoma Received October 27, 2011 Revised November 18, 2011 Accepted November 25, 2011 Correspondence to: Sai-Won Kwon, M.D. Department of Orthopaedic Surgery, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, 23-20, Bongmyeong-dong, Dongnam-gu, Cheonan , Korea TEL: FAX: osos@schmc.ac.kr