Technical Note J. of Advanced Spine Surgery Volume 5, Number 2, pp 65~69 Journal of Advanced Spine Surgery JASS Simple Neurolysis Technique of Adhesio

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1 Technical Note J. of Advanced Spine Surgery Volume 5, Number 2, pp 65~69 JASS Simple Neurolysis Technique of Adhesiolysis and Direct Drug Injection to Root and Intervertebral Disc Lesion at Anterior Dural Site: A Technical Note Sang-Wook Park, M.D. 2), Cheol-Jung Yang, M.D. 1), Sang-Hoon Back, M.D. 2), Jae-Hyuk Shin, M.D. 1), Ho-Guen Chang, M.D. 1) Department of Orthopedic Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine 1) Department of Orthopedic Surgery, Tantan Hospital 2) Injection therapy is a major component of conservative management for spinal disorders like herniated nucleus pulposus (HNP) and spinal stenosis. The most common problem faced during the injection transforaminal, interlaminar or caudal epidural block is delivering the drug at the exact site of lesion due to adhesions more so when there has been a previous open spinal surgery. Conventional neurolysis effect was limited because adhesiolysis and drug delivery were in the posterior epidural space. So, we report a simple neurolysis technique which can inject drugs directly to nerve roots and intervertebral discs at anterior epidural space through the caudal approach using conventional neurolysis devices. Keywords: Lumbar, Herniated nucleus pulposus, Anterial dural approach, Neurolysis 서론 요통과하지방사통이있는추간판탈출증이나척추관협착증등의환자들에대하여수술적가료이전에보존적가료로써요추경막외차단술 (Epidural block) 이널리시행되어왔다. 1) 경막외차단술은경신경공 (transforaminal) 경막외차단술, 추궁판사이 (interlaminar) 경막외차단술, 미추 (caudal) 경막외차단술등이있으며, 이전연구된보고에따르면단기효과가있음을보고하는경우도있으나, 2) 위약 (placebo) 주사와비교했을때효과의차이가크지않음을보고하는경우도있는등 3) 요추경막외차단술의효과에대해서는아직논란이있다. 신경성형술 (Neurolysis) 은경막외공간에도관을삽인한후이를조작하여유착부위를박리하고약물을목표병변에투여하는술식으로, 주로경막의후방에유착박리와약제투입으로그효과를기대하게된다. 4) 그러나경막의후방에서접근하게되는경우에는병변부위인경막전방 의신경근과추간공부위에직접적인유착치료와약제투 입을하기에는그효과가제한적이다. 5,6) 이를해소하기위 해경막내시경 (Epiduroscope) 나내시경이달린신경성형 술기기를사용해볼수있으나, 고가의수술장비가요구 되고술기습득시까지시간이걸린다는단점이있다. 이에 저자들은통상적으로사용하는신경성형술기기를이용 하여미추접근법을통해병변부위인경막전방의신경근 과추간판에직접적으로약제투입이가능한간단한굴곡 형신경성형술을보고하고자한다. Corresponding author: Ho-Guen Chang, M.D. Department of Orthopedic Surgery, Hallym University Dongtan Sacred Heart Hospital, 7 keun Jae Bong Gil, Hwasung City Kyungi Do Korea, TEL: , FAX: hgc2000@dreamwiz.com Copyright 2015 Korean Society for the Advancement of Spine Surgery 65

2 재료및방법 1. 대상 2014년 10월부터 2015년 06월까지한림대동탄성심병원과탄탄병원외래로요통과하지방사통, 엉치통을주소로내원한환자들에대하여일반영상과자기공명영상검사에서추간판및요추의상태에따라서진단을결정하였고, 이중추간판탈출증과척추관협착증이있는환자 20명을대상으로신경성형술을시행하였다 (Table 1). 2. 수술수기신경성형술의기본은기존신경성형술기기의사용이다. 1) 환자를방사선테이블에복와위로눕게한다. 2) 25 gauge의바늘을사용하여 1% lidocaine 약 2.5cc를천추열공주위에국소마취한뒤, 도관을삽입하고조영제를투여하여도관이경막외공간내로들어간것을확인한다. 3) 신경성형술기기를천추열공에삽입된도관을통하여집어넣은후 (Fig. 1), 제 3천추높이에서기기끝을굴곡시켜방사선투시기 (C-arm) 상에서경막전방으로이동하는것을확인한다 (Fig. 2). 4) 방사선투시기상에서기기의끝이제 5요추-제 1천추간높이까지올라간것을확인한이후 (Fig. 3), 필요한상위높이까지삽입시킨다. 통상적으로는제2-3 요추간높이까지가능하다 (Fig. 4). Table 1. Patient Demographics Case Age Sex Diagnosis Level Previous operation Postoperative symptom Complications 1 57 F HNP L4-5-S1 L4-5-S1 None Poor (persistent radiating pain) None, Severe Pain on neurolysis 2 33 F HNP L3-4(moderate)-5 L3-4-5 None Good None, Moderate pain on neurolysis 3 29 M HNP L4-5(moderate) L4-5 None Good None 4 43 M Spodylytic spondylolisthesis L5-S1 HNP L4-4-5-S M Spinal stenosis L45(severe) HNP L5-S1(rt.) L3-4-5-S1 3 년전 Root block Good L4-5-S1 None Poor (Back pain, Radiating pain) 6 23 M HNL L4-5(mild) L4-5 None Well (Back pain 2Mo, No radiating) None, 8 개월뒤 Radiating pain 발생 None, Block 시행후증상지속되어 OP M Spodylytic spondylolisthesis L5-S1 L4-5-S1 None Good (No back pain) None, 2 개월뒤 Radiating pain 재발 8 34 F HNP L4-5(Ruptured, Migrated) HNPL5-S F Foraminal stenosis L3-4 Rt. Foraminal stenosis L4-5 both None L4-5-S1 None Well None, PO 조절후 2 개월뒤 Disckectomy L3-4-5 None Poor (Back pain, Radiating pain) None, Back pain 호전되나 Radiating pain 지속 M HNP L3-4 (foraminal stenosis) L3-4 None Good None, 4 개월뒤 Back pain 발생 F Spinal stenosis L4-5-S1 L4-5-S1 None Good None, 다리통증은지속 M HNP L4-5 L4-5 None Well None, 아직아픔 M HNP L5-S1 L5-S1 None Well None, 수술후좋아지다가지금은좀악화 F HNP L4-5, L5-S1 L4-5-S1 None Well None, 수술후 2 주까지좋아진이후아픔 M HNP L4-5 L4-5 None Poor None, 최근더나빠짐, 증상이나빠져가는 추세 M HNP L5-S1 L5-S1 1 년전 Root block Well None, 50% 정도효과 M Spinal stenosis L3-4-5 L4-5-S1 None Good None, 다리만조금아프다 M Spinal stenosis L4-5 L4-5 None Good None, 허리만조금아픔 M HNP L4-5-S1 L4-5-S1 None Well None, 증상조금호전 F HNP L4-5 L4-5 1 달전 Root block Good None, 증상호전 66

5) 쉽게상부요추분절까지올라가면그대로신경성형술을진행하지만, 상부로진행이안될경우기기의끝을반복적으로굴곡-신전시키면서유착부위를박리한다. 더불어생리식염수를천천히주입하면서유착을박리하면서상부로전진한다.

7) 이와같은방법으로제 2요추부터제 1천추까지추간판과신경근의유착을박리하면서약제를투입할수있다. 8) 척추관협착증의경우도병변부위에따라서유착박리와약제투입을반복하면서아래쪽으로신경성형술을시행한다.

Trochar was inserted into the epidural space through sacral hiatus. Fig. 2.

3 5) 쉽게상부요추분절까지올라가면그대로신경성형술을진행하지만, 상부로진행이안될경우기기의끝을반복적으로굴곡-신전시키면서유착부위를박리한다. 더불어생리식염수를천천히주입하면서유착을박리하면서상부로전진한다. 6) 병변인신경근부위에도달하게되면통상적으로환자는신경근병증에준하는심한신경통을호소하게되는데, 보통이위치가상관절돌기와횡돌기의교차점부근이되며이위치에정해진약제를투입한다 (Fig. 5). 7) 이와같은방법으로제 2요추부터제 1천추까지추간판과신경근의유착을박리하면서약제를투입할수있다. 8) 척추관협착증의경우도병변부위에따라서유착박리와약제투입을반복하면서아래쪽으로신경성형술을시행한다. 9) 병변이양측인경우에는한쪽을먼저시행한후, 다른쪽을위에서아래로내려오면서신경성형술을시행 Fig. 1. Trochar was inserted into the epidural space through sacral hiatus. Fig. 2. Catheter tip moved to anterior epidural space at S3 level. Fig. 3. Catheter tip moved L5-S1 level anterior epidural space. Fig. 4. Catheter tip moved L2-L3 level anterior epidural space. 67

Fig. 5. Catheter tip was reached correct place at L2-3 level on anteroposterior view. 한다. 10) 통상적인약제의요법은 2% 리도카인 6cc, 생리식염 수 6cc, 베타메타손 1cc 로이를혼합하여총 13cc 를준 비한후각각의부위에 1.5-2.0cc 씩을투입하였다. 3.

4 Fig. 5. Catheter tip was reached correct place at L2-3 level on anteroposterior view. 한다. 10) 통상적인약제의요법은 2% 리도카인 6cc, 생리식염 수 6cc, 베타메타손 1cc 로이를혼합하여총 13cc 를준 비한후각각의부위에 cc 씩을투입하였다. 3. 수술전후처치 시술시간은평균 40 분정도걸렸으며, 시술후입원은하 루시행하였고특별한합병증이없는경우에는다음날퇴 원하였다. 고찰 1952 년 Robecchi 와 Capra 7) 에의해경막외차단술이처 음소개된이후요통및하지방사통을호소하는환자에대 해진단및치료목적으로시행한경막외차단술의유용성 에대해많은보고가있다. 특히수술적치료는높은의료 비용에도불구하고효과에대한충분한근거가없고부작 용이발생할수있어, Kim 등 8) 이보고하였듯이경막외차 단술등과같은최소침습주사요법들은수술적치료를시 행하기전에우선적으로시행을고려해보야야할만한치 료이다. 경막외차단술은경신경공 (transforaminal) 경막외차단 술, 추궁판사이 (interlaminar) 경막외차단술, 미추 (caudal) 경막외차단술등이있으며효과에대해서는아직논란이 있다. 2,3) 더구나시술시요추후방의근육들및횡돌기등 의골구조물들로인하여주사바늘을병변부위에정확하게위치시키기어렵고, 혈관내주사가능성이있는단점이있으며, 9) 척추수술실패증후군 (Failed Back Surgery Syndrome) 처럼개방적척추수술을시행한후에병변이다시악화되거나유착등의이유로통증이악화된경우에는수술반흔으로인하여주사바늘을병변부위로도달시키는데어려움이있는경우가많다. Racz 등 4) 에의해보고된신경성형술 (Neurolysis) 은경막외공간에도관을삽인한후이를조작하여유착을박리하고고농도의약물을목표한병변에투여하는술식으로, 주로경막의후방에유착박리와약제투입으로그효과를기대하게된다. Manchikanti 등 10) 에따르면단순히미추경막외차단술을시행한환자보다신경성형술을같이시행한환자군에서통증감소등의효과가크다고보고되고있다. 굴곡-신전이가능한신경성형술기기로경막의후방으로접근하는경우에는병변부위인경막전방의신경근과추간공부위로기기의끝이가까이도달하지못하여약제투입의효과가다소떨어질수있다. 5,6) 따라서신경성형술기기를제3천추높이에서기기끝을굴곡시켜방사선투시기상에서경막전방으로이동한것을확인한후, 병변부위쪽으로신경성형술기기의끝을반복적으로굴곡-신전시키면서전진하여병변에도달하게되면, 다른최소침습적주사요법들보다유착박리와약제투입을보다직접적이고효과적으로할수있게된다. 추간판탈출증병변에서는신경성형술기기의끝을반복적으로굴곡-신전시키면서추간판과신경근추간공쪽으로전진하게되는데, 이때통상적으로환자는신경증병증에준하는심한신경통을호소한다. 보통이위치가상관절돌기와횡돌기의교차점이되는데, 저자들은이위치가병변과가장근접한위치라고판단하였고이곳에정해진약제를투입하였다. 이러한방법으로제2요추부터제1천추높이까지추간판과신경근의유착을박리하고약제를주입하면서신경성형술을시행한다. 척추관협착증의경우에서는추간판탈출증보다는공간이좁고방해물이많아서전진하는데더욱어려움이있다. 이를해결하기위해생리식염수를서서히주입하고굴곡-신전을반복하면서병변부위를향해유착박리를하며전진을한다. 만약전진이잘되지않으면다시아래로내려간후약간반대쪽으로가서다시위쪽으로전진하면대부분조그마한공간으로기기의끝이통과될수있게된다. 이러한방법으로척추관협착증에서는한쪽을먼저위에서아래로내려오면서시술하고이후반대쪽을시술하여양측에신경성형술을시행한다. 68

5 본연구는경막전방으로의신경성형술을시행하는술식을보고하는문헌으로, 추후경막후방으로의신경성형술및다른경막외차단술을시행한환자들과의임상결과를비교한후그결과를보고할수있을것으로사료된다. REFERENCES 1. Young IA, Hyman GS, Packia-Raj LN, et al. The use of lumbar epidural/transforaminal steroids for managing spinal disease. J Am Acad Orthop Surg. 2007;15: Luijsterburg PA, Verhagen AP, Ostelo RW, et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J. 2007;16: Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine(Phila Pa 1976). 2005;30: Racz GB, Heavner JE, Trescot A. Percutaneous lysis of epidural adhesions--evidence for safety and efficacy. Pain Pract. 2008;8: Racz GB, Noe C, Heavner JE. Selective Spinal Injections for Lower Back Pain. Curr Rev Pain. 1999;3: Anderson SR, Racz GB, Heavner J. Evolution of epidural lysis of adhesions. Pain Physician Jul;3(3): Robecjji A, Capra R. Hydrocortisone (compound F); first clinical experiments in the field of rheumatology. Minerva Med. 1952;43: Kim SB, Jeon TS, Park WK, et al. Transforaminal selective nerve root blocks for treating single lumbosacral radiculopathy: The short-term outcome and efficiency. J Korean Orthop Assoc. 2009;44: Gofeld M, Bristow SJ, Chiu SC, et al. Ultrasound-guided lumbar transforaminal injections: feasibility and validation study. Spine (Phila Pa 1976). 2012;37: Manchikanti L, Cash KA, McManus CD, et al. The preliminary results of a comparative effectiveness evaluation of adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis: a randomized, equivalence controlled trial. Pain Physician. 2009;12:E 경막전방에서신경근과추간판에유착박리와약제투입이가능한간단한신경성형술 : 술기보고 박상욱 2), 양철중 1), 백상훈 2), 신재혁 1), 장호근 1) 한림대학교의과대학동탄성심병원정형외과학교실 1), 탄탄병원정형외과 2) 많은의사들은추간판탈출증이나척추관협착증등요추병변의환자들에대하여수술적가료를바로시행하기보다는수술전에최소침습주사요법으로경막외차단술을먼저시행해본다. 그러나이전에시행되었던경신경공 (transforaminal) 경막외차단술, 추궁판사이 (interlamina) 경막외차단술, 미추 (caudal) 경막외차단술등은병변의위치에직접적으로신경유착치료나약제투입시행이제한적인경우가종종있다. 더욱이개방적척추수술을시행한후에병변이다시악화되거나유착등의이유로하지증상이심해진경우에는더욱더병변부위로의도달에어려움이있다. 통상적인신경성형술 (Neurolysis) 은경막의후방에유착치료와약제투입이시행되어그효과가제한적이다. 이에저자들은통상적으로시술하는신경성형술기기를이용한미추접근법을통해, 병변부위인경막전방의신경근과추간판에직접적으로약제투입이가능한간단한굴곡형신경성형술을보고하고자한다. 색인단어 : 요추, 추간판탈출증, 경막전방접근법, 신경성형술 69

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