대한방사선의학회지 1996; 35(5) : 대전자와좌골결핵성병변의단순방사선학적소견 1 함소희 이예리 김응조 김동진 2 성기준 2 임종남 3 목적 대전자와좌골에발생한결핵성병변의단순X선촬영소견을알아보고이를바탕으로가능하면발생원인을추정하여보고자하였다. 대상및방법

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1 대한방사선의학회지 1996; 35(5) : 대전자와좌골결핵성병변의단순방사선학적소견 1 함소희 이예리 김응조 김동진 2 성기준 2 임종남 3 목적 대전자와좌골에발생한결핵성병변의단순X선촬영소견을알아보고이를바탕으로가능하면발생원인을추정하여보고자하였다. 대상및방법 좌골과대전자에글병변이있어병리조직학적검사상걸핵으로진단된 14 명의환자를대상으로단순X선사진상의골과주위연부조직의변화를후향적으로알아보고이소견을바탕으로가능한병인을추정하여보았다. 결과 : 12여 에서공통적인소견으로피질골의외측에만성적인미란을보였는데그정도는경미한미란에서부터피질골의완전한파괴까지다앙하였으며 2여 에서는골파괴가심하여진행된글수엽과유사한소견을보였다. 골막반응은 5여 에서관잘할수있었고미란추위해면골의소견으로는경화성변화가 8예로가장흔하였다. 이러한글파괴소견외에병변주위연부조직에부글또는석회화가 12예에서동반되었다. 결론 좌글과대전자에발생하는걸핵성골병변은만성적외적파괴를시사하는만성미란의특징적인소견을보였으며이와같은소견을보일경우에유추가능한이들병변의원인의하나로주위활액낭엽과같은연부조직병변을생각할수있다. 서 론 대상및방법 결핵은근골격계의어느부위에서나발생이가능한질병 이지만대부분은척추와장골또는관절에발생한다 (1). 드물게는좌골 (i schium) 또는대퇴골의대전자 (greater trochanter) 에발생하기도하는데단순 X 선소견상화농성 골수염또는골연골증 (osteochondrosis) 등과같은다른 원인의골병변과의감별이필요하다 (2). 그리고병변이발 생하는위치의특이성때문에흔히발생하는부위의병변 과는다른병인이일부관여되었으리라추정되었다. 이질 환에대해소수의보고가있었으나 (2-7) 방사선학적소견 의연구보다는임상적연구가대부분이였고병인도불확실 하여이들병변이왜이부위에발생하는지에대해서도논 란이있어왔다. 저자들은이들병소의단순 X 선사진의방 사선학적소견을알아보고가능하면이를기초로하여병 언을유추하여보고자하였다. 1 한국전력공사부속한일병원진단방사선과 2 연세대학교원주의과대학진단방사선과학교실 3 건국대학교의과대학진단방사선과학교실 이논문은 1996 년 5 월 2 일접수하여 1996 년 9 월 25 일에채택되었음 1962년부터 1990년까지내원하여처음촬영한단순X선사진에서대전자와화골에골병변이있어수술을시행받고병변의골조직과주위연부조직의병리조직검사상결핵으로진단된 14명의환자를대상으로하였다. 처음내원당시의증상은골병변주위연부조직의종창또는동통이모든예에서보였고 5예에서농루가동반되었는데그기간은 1 개월에서 20년까지다양하였다. 전예에서근골격계의다른부위에결핵성병변은없었으며 5예에서활동성폐결핵이동반되었다. 연령분포는 13세부터 70세까지 ( 평균4þ셰 ) 였으며, 남자는 9명여자는 5명이었다. 내원당시처음촬영한병변을포함한골반또는고관절의단순전후사진만을대상으로 1명의방사선과의사가방사선소견을후향적으로분석하였고추적검사와기타의검사는연구대상에포함되지않았다. 14예중대전자병변이 7예, 좌골병변이 7예였으며좌골병병의경우 7예 r모두에서좌골조면에위치하였고좌골체 (i schial body) 까지침범된경우가 5예, 좌골지 (ischial ramus) 와치골지 (pubic ramus) 까지침범된경우가각각 1 예썩있었다. 방사선학적소견은주로피질골의파괴양상과병변주위해면골과연분조직의변화에중점윷두어관찰하였고가능하면이 793-

대한방사선의학회지 1996: 35(5) : 793-797 결과를기초로병변주위의해부학적구조와연계하여골병변의원인을추정하여보았다. 결과단순방사선사진소견상대전자와화골병변은동일한양상의방사선학적골파괴양상을보였다. 12예에서공통적언소견으로피질골의외측에만성적인미란을보였는데그정도는경미한미란에서부터피질골의완전한파괴까지다양한정도의골파괴를보였다 (Fig. 1, 2).

2 대한방사선의학회지 1996: 35(5) : 결과를기초로병변주위의해부학적구조와연계하여골병변의원인을추정하여보았다. 결과단순방사선사진소견상대전자와화골병변은동일한양상의방사선학적골파괴양상을보였다. 12예에서공통적언소견으로피질골의외측에만성적인미란을보였는데그정도는경미한미란에서부터피질골의완전한파괴까지다양한정도의골파괴를보였다 (Fig. 1, 2). 2예에서는피질골의완전한파괴와함께해면골의파괴까지동반되어진행된성한골수염과유사한소견을보였으며원래형태가소실되어있었다 (Fig. 3). 미란의형태는그진행정도에따라다양하였으며경미한경우에는미란과정상피질골이흔재하여피질골의외측이불규칙한모양을보이며 (Fig. 1) 미란이진행될수록압흔 (thumb printing) 또는정상형태의소설로나타났다. 이러한미란주위의해면골의소견은경화성변화 (sclerosis) 가 8예에서관찰되어가장흔하였고 5예에서는골막반응이관찰되었는데모두미란의변연에위치한고형 (solid type) 의양상으로나타났다. 이러한골파괴소견외에병변주위연부조직에다양한크기의골편이 8예에서관찰되었는데병변의피질골에서파괴되어떨어져나온부골로생각되었다.12예에서는주위연부조직에다양한형태의석회화음영을보여연부조직의만성적병변을시사하였다 (Table 1). 고찰골염 (osteitis) 이발생하는경로는일차적원인으로혈 류를통한혈행성골수엽이가장흔하며이차적원언으로 는골주위연부조직의염증성질환즉봉와직염 (cellulitis), 결핵성한냉농양 (cold abscess) 또는드물게골주 위에발생한활액낭엽 (bursitis) 이그원인이될수있다. 대전자의결핵성골병변은 1870 년 Teale 가처음발표하였 으며그빈도는근골격계에발생하는결핵의 1-2% 정도 로보고되고있다 (2-4). 그러나좌골에발생하는결핵은 극히드블어증례보고정도가발표되어있다 (5). Alvick 등 (3) 은 36 예의결핵성대전자염 (tuberculous trochanteritis) 을보고하였으며 11 예는결핵성요추염과척추주 위한냉농양이동반되어있어직접파급에의한병변으로 Fig. 1. Left hip anteroposterior radiograph of case 11 demonstrates cortical erosion, ragged appearence on the uter cortex of the with periosteal reaction and calcifications(arrow) or destructed bone fragments(arrow) in the adjacent soft tissues. Table 1. 8ummary of Tuberculous Osteitis in 14 Patients Radiologic Findings Case 1. F/58 2. F/57 3. F/57 4. F/28 5. M/61 6. M/18 7. M/45 8. M/20 9. F/ M/ M/ M/ M/ M/13 Lesion : presence Periosteal Reaction Cortical Erosion perforation perforation moderate severe severe moderate severe moderate G. T ; greater trochanter - : abscence calcifi :calcification Marrow Change osteoporotic osteolytic osteolytic Calcifi. 80ft Tissue 8equestrum

3 함소희외 대전자와좌콜결핵성병변 추정하였고 25예는혈행성파급또는주위활액낭염에의한이차적병변으로생각하였다. 특히초기병변이골막반 Fig. 2. Right hip anteroposterior radiograph of case 4 shows a ragged irregular contour of the greater trochanter, some loss of bone in this area and amorphous calcifications(arrowhead) or sequestrum(arrow) in the soft tissues lateral to the trochanter 응또는골피질의외면에골미란소견을단순X선사진상에서보였다면주변활액낭염에의한이차적병변일가능성이높다하였다. Lampe 등 (6) 은 17예의보고에서골내에국한된병소가있는것을발견하여이러한병변이골자체에서시작된일차적병변이라고추정하였다. Lindahl( 4) 은결핵성대전자염 35예를보고하였는데 10예는활액냥에국한된경우로방사선소견은정상이었고 25예는세가지양상의방사선소견을보였는데첫째는퇴행성변화와함께외측골피질에골염소견을보였고둘째양상은대전자에서떨어져나온골편이주변연부조직에보이는것이며셋째양상은대전자내에국한된골파괴양상을보이는것이었다. Donovan 등 (7) 의보고에의하면대전자에결핵성병변을가진 5예모두에서골병변과동반하여병리조직학적으로진단된활액냥염이발견되었고골병변의초기방사선소견은골피질의미란과함께연부조직에석회화를보였으며만성병변은대전자의상외측에골파괴와함께농양과농루 (sinus) 를형성하는것이특정이라하였는데본연구에서도유사한소견을보였고특히만성병변은농루를주소로오는경우가많았다 (Fig. 4). 본연구에서는좌골병병이 7예로 50% 였으나보고된연구는극히드블다. Chafetz 등 (5) 이 1 예보고하였는데 CT 소견상인접대둔좌골활액낭 (gluteoischial bursa) 의종창과함께추적검사에서인접좌골의정진적골파괴를보였으며결핵성활액낭염에의한이차적좌골염으로확진되었다. 이들연구의대전자와좌골의결핵성병변의방사선소견은세가지형태로분류하여볼수있다. 첫째는가장흔한소견으로펴질골의 Fig. 3. Left hip anteroposterior radiograph of case 1 shows irregular severe destruction of greater trochanter with loss of normal contour and numerous calcific shadows(arrows) in the adjacent soft tissues Fig. 4. Sinogram of case 14 with cortical erosion on the shows sinus tract and internal cavity formation in the soft tissues adjacent

4 대한밤사선의학회지 1996 : 35(5) : 다양한정도의미란인데본연구와일치하는소견이다. 둘째는피질골의변화없이해면골에국한된골파괴소견을보여병변이해면골에국한된골수염으로생각되는경우로써계속진행된다면본연구의완전한골파괴로보이는두예와같은소견을보일가능성이있을것이다. 셋째는부수적소견으로연부조직의변화인데석회화, 골편, 농루등의소견을보일수있다. 그리고이들연구에의하면대전자와좌골의결핵성병변은여러경로에의해발생할수있다. 즉첫째는대전자또는좌골로의혈행성파급에의한골수엽이데본연구에서심한골파괴를보였던 2예도이러한가능성을배제할수없다. 둘째경로는요추와주위조직에일차적으로발생한결핵성병변에서기원한한냉농양이파급되어직접골병변을유발하는것이다. 그러나본연구에서는폐외의다른부위에결핵성병변이없었기때문에이러할가능성은적다. 셋째경로는활액냥과같은병변주위의연부조직에결핵이혈행성감염이된후주위골조직에병변을일으키는것이다. 즉본연구에서와같은방사선소견 밀도의음영이보였고, 8예에서는미란주위해면골에경화성변화를동반하였는데수술후병리조직검사에서도주위연부조직과활액냥에서도결핵이확진봐었다. 이는주위연부조직에결핵성병변이선행되었고이차적으로만성적골병변을유발하였다는것을시사한다. 그러나골파괴가심하여원래의정상형태가소설된두예에서는병인추정이불가능하여골수염과활액낭염중어느것이선행질환인지알수없다. 결론적으로본연구의대전자와좌골의결핵성병변은만성적외적마란의특정적인방사선학적소견을보였 며이를바탕으로유추가능한병언의한가지가셜은이들병변이활액냥엽과같은골병변주위의연부조직에서기원한염증성질환에의해유발된것이라는것이나정확한병언을밝혀내기위해서는추적검사를하여점진적골미란의소견을연구하거나주위연부조직의변화를직접볼수있는전산화단층촬영또는자기공명영상소견을포함한연구가필요하리라생각된다. 을유발할가능성이많은병인이다. 그러나위와같은여러 보고는임상소견중심의연구이며방사선학적소견을기초 로한것은없었다. 즉병변의방사선학적소견보다는주위 참 고 C 그 τr 헌 연부조직과의해부학적연관성특히활액냥과의관계에기 초한병인추정이였다. 대전자외측에는대둔대전자활액 낭 (gluteotrochanteric bursa) 이대둔근과대전자사이에 위치하며좌골즈면과대둔근사이에는대둔좌골활액낭이 정상적으로위치하는데인체에서가장크며염증성질환이 비교적호발하는활액냥이다. 따라서여기에결핵성활액 낭염이발생하면대전자또는좌골에 1 차적골병변을유 발할수있다. 그러나이러한해부학적연관성이외에도이 들병변이골외의원인에의한것임을시사하는방사선학 적소견이본연구에서관찰되었는데즉대부분의예즉 14 예중 12 예에서외인성골파괴를시사하는외측피질골의 미란과함께골병변주위에부골또는석회화로보이는고 1. Crenshaw AH. Campbell s operative orthopaedics. 7th ed. St. Louise: Mosby, 1987 : Aidan FL. Tuberculosis 01 the greater trochanter. J Bone Joint Surg[Br] 1982: 64(2): Alvick 1. Tuberculosis 01 the greater trochanter. Acta Orthop Scand 1950; 19 : Olov Li ndah l. Tuberculous trochanteritis. Acta Tuber Scand 1952 ; 26 : Chaletz N, Genant HK. Ischiogluteal tuberculous bursitis with progressive bony destruction. J Can Assoc Radiol 1982; Lampe CE, Viborg. Tuberculous osteomyelitis 01 the greater trochanter. Acta Orthop Scand 1953 ; 22: Donovan MS, Sosman MC. Tuberculosis 01 the greater trochanter and its bursa. AJR 1942 ; 48 : w m

5 함소희오 I : 대전자와좌을결핵성병번 Journal of the Korean Radiological Society 1996: 35(5) : Radiographic Features of Tuberculous Osteitis in Greater Trochanter and Ischium 1 So Hee Hahm, M.D., Ye Ri lee, M.D., Dong Jin Kim, M.D. 2 Ki Jun Sung, M.D. 2, Jong Nam lim, M.D. 3 10epartment of Oiagnostic Radiology, Hanil Hospital Affiliated to KEPCO 20epartment of Oiagnostic Radiology, Wonju College of Medicine, Yonsei University 30epartment of Oiagnostic Radiology, College of Medicine, Kon Kuk University Purpose: To evaluate, il possible, the radiographic leatures 01 tuberculous osteitis in the greater trochanter and, and to determine the cause 01 the lesions. Materials and Methods: We retrospectively reviewed the plain radiographic lindings ptients with hist 이 ogically proven tuberculous osteitis involving the greater trochanter and. In each case, the lollowing were analyzed : morphology 01 bone destruction, including cortical erosion; periosteal reaction ; presence or abscence 01 calcilic shadows in adjacent soft tissue. On the basis 01 an analysis 01 radiographic leatures and correlation 01 the anatomy with adjacent structures we attempted to determine causes. Results : 01 the 14 cases evaluated, 12 showed varrious degrees 01 extrinsic erosion on the outer cortical bone 01 the greater trochanter and ; in two cases, bone destruction was so severe that the radiographic leatures 01 advanced perlorated osteomyelitis were simulated. In addition to lindings 01 bone destruction, in these twelve cases, the presence 01 sequestrum or calcilic shadows was seen in adjacent soft tissue Conclusion: Tuberculous osteitis in the greater trochanter and showed the characteristic lindings 01 chronic extrinsic erosion. On the basis 01 these lindings we can suggest that these lesions result Irom an extrinsic pathophysiologic cause such as adjacent bursitis. Index Words : Bones, inlection Bones, radiography Tuberculosis, skeletal Address r eprint r equests t o: 80 H ee Hahm, M.D., Department of Diagnostic Radiology, Hanil Hospital Affiliated to KEPCO, ~ sangmundong, Dobong-ku, 8eou!, Korea. Tel Fax

6 국제학술대회일정표 [NJ Sandwichcursus Uroradiology (1997/06/13-14) venue: De Jaarbeurs Utrecht, The Netherlands contact: Mrs. F.E. Blommendaal, NVvRd, P.O. Box 8171, 3503 RD Utrecht, The Netherlands (tel: ; fax: ) 60th Annual Scientific Meeting of the Canadian Association of Radiologists (1997/06/15-20) venue: Westin Hotel Otawwa, Ontario, Canada. contact: Suzanne Charette, Ex. Dir., Canadian Ass. of Radiol., Buchan Street, Montreal QC H4P 2R9, Canada (tel: ; fax: ) International Stent Congress (1997/ 06/19-22) venue Zoo Gesel1schaft Haus Frankfurt, Germany contact: Dr. D. Liermann, Hosp. J.W. Goethe Univ., Hs23A, Theodor-Stern-Kai 7, Frankfurt am Main, Germany. (tel: ; fax ) Int. Conf. European Society of Gastro-Intestinal & Abdominal Radiology (1997/06/ 25-28) venue: Academic Medical Centre Amsterdam, The Netherlands contact: Dr. J.W.A.J. Reeders, AMC, Meibergdreef 9, 1105 Az Amsterdam, The Netherlands (tel: ; fax: ) Car 97 : Computer Assisted Radiology (1997/06/25-28) venue: ICC Berlin, Germany. contact: Prof. H.U. Lemke, c/otu Berlin SekrCG-FR3-3, Franklinstrasse 28-29, D Berlin, Germany (te1: ; fax: ) Up-Date Course on Ultrasound and Computed Tomography (1997/ 08/08-10) venue: Maksoud Plaza Hotel Sao Paulo, Brazil. contact: Regina Carvalho, Soc. Paulista Radiologia, Av. Paulista 491, 40 andar, Cjs. 41 e 42, CEP 01311c909 Sao Paulo, Brazil (tel : ; fax: ) Annual Meeting and Exhibition of the Soc. of Magnetic Resonance in Medicine (1997/08/09-15) venue: Hilton Hotel San Francisco, CA, USA. contact: LyneUe Corning, SMRA, 1918 University Avenue, Berkeley, CA 94704, USA (te ; fax: ) Annual Meeting European Association of Nuclear Medicine (1997/08/ 21-25) venue: Glasgow, Scotland, United Kingdom. contact: Mrs. E. de Ranitz-Holdorp, CONGREX Holland, Keizersgracht 782, 1017 EC Amsterdam, The Netherlands. (tel: ; fax: ) Estro/ Erted Teaching Course: Radiation Physics for Clinical Radiotherapy (1997/08/ 31-04) venue: Leuven, Belgium contact: ESTRO Secretariat, UH Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium (tel: ; fax : ) Bolnitza 97-8th Int. Trade Fair for Hospital Equipment and Supplies (1997/09/ 00-00) venue: St. Petersburg, Russia contact: Morag" Grabenackerstrasse 15, CH-4142 Muenchenstein/BL, Switzerland. (tel ; fax: ) First nternational Congress of Academic and Teaching Radiologists (1997/09/ 01-03) venue: Palais des Congres Tours, France contact: Prof. J-F. Moreau, MD, FACR, Service de Radiologie, 161 rue de Sevres, Paris Cedex 15, France. (tel: ; fax: ) 8th Triennial Congress World Fed,. of Ultrasound in Medicine and Biology (1997/ 09/ 01-05) venue: Buenos Aires, Argentina. contact: Congresos Internacionalis, Moreno 584, 9th 1100r, 1091 Buenos Aires, Argentina. (tel : ; fax: ) Annual Meeting American College of Radiology (ACR) (1997/ 09/06-10) venue: At1anta, CA, USA. contact: John J. Curry, Ex. Dir., ACR, 1891 Preston White Drive, Reston, Virginia 22091, USA. (tel ; fax: ) 48th Annual GEN. & SC. Meeting Royal Australasian College of Radiologists (1997/ 09/ 11-16) venue: Adelaide Convention Ctr. Adelaide, Australia. contact: Marg Scarlett, Convention Network, 224 Rouse Street, Port Melbourne, Australia 3207 (tei: ; fax ) ESDIR Seminar - Interventional Techniques : Chest and Abdomen (1997/09/ 12-13) venue: Dublin, Ireland. contact: Prof. D. MacErlaine, Dean, Fac. of Radiologists, 123 St Stephen 5 Green, Dublin 2, Ireland (tel: ; fax: ) 23rd Annual Congress of the European Society of Neuroradiology (1997/ 09/ 16-20) venue: Oxford, United Kingdom. contact: Dr. J. V. Byrne, The Radc1iffe Infirmary, Woodstock Road, Oxford OX2 6HE, United Kingdom (tel: ; fax )

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317 318 319 320 1 3 5 5 5 5 2 321 : 1.,,,,, 06 2. X-ray beam penetration (density) (contrast) 03 3. patch coating, precipitation, flaking 03 4. centering 03 5. Esophagus, cardia, fundus, body, angle, antrum,