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1 대한한방내과학회지제 38 권 5 호 (2017 년 10 월 ) J. Int. Korean Med. 2017;38(5): 유근정, 황규상, 이준영, 이언정원광대학교한의과대학전주한방병원 A Case Report of Korean Medicine Treatment of Chronic Peroneal Nerve Palsy Keun-jeong Yu, Gyu-sang Hwang, Jun-yeong Lee, Un-jung Lee Wonkwang University Jeonju Oriental Medicine Hospital ABSTRACT Objective: This case report describes the effects of Korean medicine treatment on chronic peroneal nerve palsy. Methods: One patient with peroneal nerve palsy was treated 6 months after onset with various Korean medicine treatments, such as acupuncture, cupping, herbal medicine (Bojungikki-tang and Palmijihwang-tang), and Hominis Placental pharmacopuncture for 14 days. The Manual Muscle Test (MMT), range of motion (ROM) of the ankle, and a numerical rating scale (NRS) were used to evaluate the effectiveness of treatment. Results: After 14 days of treatment, the scores for all 3 scales were improved. The MMT grade increased from 1-3 to The ankle ROM was restored to a nearly normal range. The NRS showed a considerable improvement, decreasing from 7 to 2. No side effects were noted. Conclusions: Korean medicine may be effective for the treatment of chronic peroneal nerve palsy, but further studies are needed. Key words: peroneal nerve pasly, foot drop, range of motion of ankle, Bojungikki-tang and Palmijihwang-tang, hominis placental pharmacopuncture Ⅰ. 서론 비골신경은 L4, 5와 S1, 2 신경근의섬유를함유하고있으며, 좌골신경중외측에위치하고있다. 대퇴부의원위 1/3 부위에서경골신경과분리된다음, 비골의경부를외측으로돌아, 하퇴부전방구획으로들어가게된다. 비골경부를지난다음 투고일 : , 심사일 : , 게재확정일 : 교신저자 : 이언정전북전주시덕진구덕진동 원광대학교전주한방병원 TEL: ejlee1016@hanmail.net 본논문은 2017 년원광대학교교비지원에의해서수행됨. 표재및심부분지로나뉜다. 비골경부에서신경이골의바로위를지나면서피하에위치하므로, 이부위에서열상되기쉽고, 슬관절탈구나비골및경골상단부의골절시손상되기쉬우며, 수술후에도간혹마비가발생하는일이있다. 또한석고나부종에의하여신경이압박되면서마비되는경우도비교적흔하다 1. 비골신경마비의임상증상으로는발의신근과외전근의마비에따른발과근위지절의신전장애와외반장애및족하수가나타나며, 보행시에는발끝과외측면을끌면서특유의계상보행 (Steppage gait) 을하게된다. 이에대한현대의학적인비골신경마비의치료는주로 3개월간보존치료를시행하 668

2 유근정 황규상 이준영 이언정 되신경손상정도및보존치료의반응도에따라수술요법을고려해야한다고알려져있다 2,3. Togrol 4 은자연치료되는경우도있으므로 3개월까지보존적치료를시행하되손상의정도가심하고조기에처치를하였음에도호전이없는경우수술요법을하는것이좋다고하였다 3. 한의학에서비골신경마비는증후로보아肢體萎弱無力, 甚則不能持物或行步, 患肢肌肉萎縮, 肢體瘦削등을주증으로하는痿症의범주에속하며 5, 침구치료, 약침, 한약, 한방물리치료, 도침등을통해호전되는경우가발표되고있으나 6-9 대부분자연경과로도호전을보이는급성기의치료였으며, 보존적인치료에도호전이없는치험례에대한발표는드물었다. 이에저자는비골신경마비발생 6개월간다른보존적인치료를받았음에도증상이남아있는환자에대하여한방치료를통하여눈에띄는호전을보이는증례가있어이를보고하는바이다. Ⅱ. 증례 1. 성명 : 서 (M/45) 2. 진단명 : 비골신경마비 (Peroneal Nerve Palsy) 3. 주소증 : Rt. lowerlimb weakness & Gait disturbance 4. 신체검사 : EHL(Extensor Hallicus Longus) G3 TA(Tibialis Anterior) G1 EDL(Extensor Digitorum Longus) G1 muscle weakness(+) 5. 발병일 : 2015년 07월 18일 6. 입원치료기간 : 2016년 01월 06일 ~2016년 01월 20일 5. 과거력 : Prostatis NOS 외별무 6. 가족력 : Non specific 7. 현병력 2015년 07월 18일 slip down으로인해 Rt. knee pain & Foot drop 발생. 타병원 MRI 상 Rupture of Posterior cruciate ligament, 근전도상 Peroneal Nerve Palsy Dx. 이후물리치료, 재활치료시행 하다가 Rt. lowerlimb weakness 호전없어 2015 년 10월초경타병원에서 Ankle brace 처방 (hyperdorsiflexion 상태유지 ) 받았으나별무호전. 2016년 1월 6일전라북도전주소재 한방병원입원 8. 변증 : 舌紅苔薄白, 脈沈細無力, 面色萎黃, 腰膝酸軟, 手足冷感辨證 ) 陽氣俱虛 9. 치료방법 1) 침술 : 동방침구제작소에서제작한 mm의 1회용멸균호침을사용하였다. 비골신경유주부위와근력저하를보이는근육위의穴인陽陵泉 (GB34), 足三里 (ST36), 上巨虛 (ST37), 豊隆 (ST40), 解谿 (ST41), 太衝 (LR3) 등을補瀉法없이直刺하였다. 또한각穴位에전침을연결하였으며전침은저주파치료기 ( 진원메디칼, Mixed 2~4 Hz freequency) 로하였고환자가자극을느끼고근육에가벼운수축이일어나는정도까지증가시켜 15분간유지하였다. 침치료는월요일 ~ 금요일까지일 2회, 토요일 ~ 일요일일 1회시행하였으며, 따라서입원기간동안총 24회침치료를시행하였다. 2) 한약 : 신경회복과補陽, 補氣에효과가있는처방인보중익기탕합팔미지황탕 (Table 1) ( 황기 8 g, 감초 6 g, 백출 6 g, 인삼 6 g, 당귀 4 g, 진피 4 g, 승마 2 g, 시호 ( 식 ) 2 g, 숙지황 (9증) 12 g, 산수유 8 g, 산약 8 g, 목단피 6 g, 백복령 6 g, 계피 4 g, 부자 ( 포 ) 1 g/1첩 ) 을달여입원기간 14일과퇴원후 10일간 2첩 #3로복용케하였다. 3) 약침 : 비골두아래비골신경유주부위에따른穴位에소염, 자양작용을목적으로자하거약침 ( 자생한방병원자하거약침 ) 1 cc를여러穴位에나누어일 1회, 총 15회피하주입하였다. 4) 부항치료 : 환자가근무력증상을보이는환측전경골근과비골두부위에대하여습, 건식부항치료를일 1회실시하였다. 5) 물리치료 : 일 1회, 주 6회좌측하퇴부위로 669

3 EST, H/P을실시하였다. 10. 평가척도 1) Manual Muscle Test(MMT)(Table 2) : EHL (Extensor Hallicus Longus), TA(Tibialis Anterior), EDL(Extensor Digitorum Longus) 의 MMT grade(0~5) 를측정하였다. 2) Ankle ROM : 환자의발을능동 Dorsi flexion, Eversion 시켜고니오미터를이용하여각도를측정하였다. 3) Numerical Rating Scale(NRS) : 환자가주관적으로느끼는증상정도를 0~10까지의숫자로표현하도록하였다. 통증은없었으나발등부위로감각저하및이상감각이있었는데, 이감각을 NRS를통해점수를매기게하였다. 감각이정상일때를 0으로보고감각이전혀없거나이상감각이심할때점수를 10으로하여 0~10 까지중에숫자로표현하도록하였다. Table 1. Prescription of Palmijihwang-tang and Bojungikgi-tang Herb Scientific name Amount (g) 黃芪 Astragali Radix 8 甘草 Glycyrrhizae Radix 6 白朮 Atractylodes macrocephala Koidzumi 6 人蔘 Ginseng Radix 6 當歸 Angelicae gigantis Radix 4 陳皮 Citrus unshiu 4 升麻 Cimicifuga heracleifolia Komarov 2 柴胡 Bupleurum falcatum 2 熟地黃 Rehmanniae Radix preparata 12 山茱萸 Cornus officinalis 4 山藥 Dioscorea batatas 8 牧丹皮 Moutan Radicis Cortex 6 白茯笭 Hoelen alba 6 桂皮 Cinnamonum zeylanicum Beryn 4 附子 Aconitum carmichaeli Debeaux 1 Total amount 79 Table 2. Manual Muscle Test (MMT) Grade % Qualitative value Muscle strength Normal Complete ROM against gravity, with full resistance 4 75 Good Complete ROM against gravity, with some resistance 3 50 Fair Complete ROM against gravity, with no resistance 2 25 Poor Complete ROM against gravity omitted 1 10 Trace Evidence of slight contractility, with no joint motion 0 0 Zero No evidence of muscle contractility 11. 치료경과 1) MMT : 각각의 MMT grade가시간경과에따라증가함을볼수있다 (Table 3). 2) Ankle ROM : 발목관절을능동으로 Dorsi flexion, Eversion 시켜서각도를측정한결과시간이지남에따라 ROM이증가하는것을볼수있다 (Table 4). 3) NRS : 환자는발등전체적으로먹먹하고둔 하다는감각저하및이상감각을호소하였고, 통증은호소하지않았으므로먹먹하고둔한정도를 NRS로측정하였다. 정상적인감각을 0, 무감각을 10으로하여표현하게하였다. NRS의정도가시간이감에따라점점감소함을볼수있었는데, 퇴원당시정상에이르지는못하였다 (Table 5). 670

4 유근정 황규상 이준영 이언정 Table 3. Changes of MMT Grade from January 6th to January 20th 1/6 1/8 1/10 1/12 1/14 1/16 1/18 1/20 EHL MMT grade TA MMT grade EDL MMT grade Table 4. Changes of Ankle ROM from January 6th to January 20th 1/6 1/8 1/10 1/12 1/14 1/16 1/18 1/20 Dorsiflexion ROM Eversion ROM Table 5. Changes of NRS from January 6th to January 20th 1/6 1/8 1/10 1/12 1/14 1/16 1/18 1/20 NRS Ⅲ. 고찰및결론 말초신경은 Ⅰ, Ⅱ 뇌신경을제외한모든뇌신경과척추신경을말한다. 말초신경을손상시키는원인은다양한데그중에외부압박손상은타박이나잘못된지혈대의착용과같이잠정적인외부압박에의해발생한다. 이러한압박에의한손상은대부분생리적신경차단으로예후가좋다 10,11. 표재비골신경의포착은발생빈도는드물지만여러가지원인이보고되고있다 12. 표재비골신경이포착되면표재비골신경의지배영역인원위하퇴부의전외측부위와족부의배부에통증을호소하고, 감각의이상을보이기도한다 13. 비골신경마비에대한치료는반드시수술이필요한경우가아니라면먼저압박요인을제거하고보존요법을시행함을원칙으로한다. 물리치료등이기능회복에도움이될수있으며, 이에부가적으로족관절-족부보장구도보행을돕기위해사용할수있다 14. 하지만 3개월이지난후에도임상적호전이나 EMG 검사상회복이보이지않을때 는수술을해야하며, 운동지각기능회복의예후는시간이지날수록좋지않고손상후수술을하기까지 12개월이지나면운동기능회복이불량한것으로알려져있다 15,16. 한의학에서비골신경마비는下肢無力, 下肢痿弱등의증상이나타나기때문에 痿證 의범주에속한다. 원인에대해서 素門痿論 에서熱傷津液, 悲哀太甚, 思慮無窮, 所願不得, 入房太甚, 有漸於濕, 遠行勞倦이라하였고 17. 痿證의치료에대해서는 治宜獨取陽明, 補其營而通其腧, 調氣虛實, 和其逆順, 筋脈骨肉, 各以其時受月, 卽病已矣. 라하여陽明經을위주로取穴하고營을補하여氣의虛實을조화롭게하여야한다했다 18. 본증례에서는보통보존적치료기간으로보는 3개월이지나 6개월의보존적치료에도호전이없는비골신경마비환자에대하여침구, 부항, 약침, 한약등의한방치료를시행하였다. 舌紅苔薄白, 脈沈細無力, 面色萎黃, 腰膝酸軟, 手足冷感, 병정이오래된점, 전체적인기력저하양상을통해한방적인변증상陽氣虛로보았다. 素門痿論 의 治宜獨取陽明 이론에근거하여침치료와부항, 자하거약침치료를足陽明胃經인足三里 (ST36), 上巨虛 (ST37), 豊隆 (ST40), 解谿 (ST41) 및비골신경의주행경로에해당하는足少陽膽經의陽陵泉 (GB34), 懸鐘 (GB39), 太衝 (LR3) 등에시행하였다. 671

5 紫河車약침액은태반의융모조직에서추출하여가수분해한황갈색의약침제제로 19, 약리학적으로는세포증식인자인간세포증식인자, 코로니형성자극인자, 각종인터루킨, 인터페론을함유하고있다고알려져있다 20. 甘味에鹹味를겸하고性이溫하지만燥하지않으며, 肺, 肝, 腎三經에들어가氣血을大補하고腎精을補益하여久病으로因한身體虛弱혹은體質虛弱, 氣血不足및腎虛精虧등을治하는데應用한다 21. 이에병정이오래되어氣血雙虛한본증례에적합하고신경과근육의조직재생에대한효과를근거로하여紫河車약침을응용하게되었다. 탕약으로는八味地黃湯合補中益氣湯을응용하였는데, 舌紅苔薄白, 脈沈細無力, 面色萎黃, 手足冷感, 腰膝酸軟의증상으로보아陽氣俱虛로변증할수있었고, 陽虛의대표처방인八味地黃湯과氣虛의대표처방인補中益氣湯합방을투여하였다. 八味地黃湯은마미증후군으로인한하지의痺通, 痿證에대한효과보고와 22, 대상포진척수염으로유발된척수손상환자에서하지痿證에대한효과보고가있다 23. 補中益氣湯은근위축에대한실험연구에서 heat-shock protein 72 발현유도증가, 근단백질합성촉진에대한효과가밝혀진바있으며 24, 痿證과痺證의범주로볼수있는다발성경화증에서효과가있었다는보고도있었다 25. 비골신경마비에대한한방치료연구로는김등 9,26 이급성기의비골신경마비환자에대하여침도침술을통해호전을보인증례를보고한바있고, 설등 27 이압박으로인한급성총비골신경마비환자에게침, 약침, 운동요법시행을통해호전된예를보고한바있으며, 장등 28 이침구와자하거약침으로호전된급성비골신경마비로인한족하수에대하여발표하였다. 최등 29 은발병 2개월이지난비골신경마비환자에대하여한약, 침구, 물리치료를통해호전을보인증례에대한보고하였고, 이등 30 은발병 3개월후말초신경병증으로진단된족하수환자에게한약, 침, 운동요법, 물리치료를시행 하여호전된예에대하여발표하였다. 기존의대부분의연구보고가발병후일주일이내의급성기비골신경마비에대한치험례이고, 최등 29 의보고는급성기는아니었으나보존적치료기간의기준으로보는 3개월이내의치험례였고, 이등 30 은발병 3개월후의비골신경마비환자였으나 3개월동안어떠한보존적치료도받지않았다. 압박손상으로인한말초신경마비에서는자연적인회복도가능하다는점에서위의연구들은자연경과의경우와비교하는대조연구가부족하였다고볼수있다. 본증례에서는자연적인회복시간을훨씬경과하여보존적치료기간의기준으로볼수있는 3개월이지나는기간동안충분한보존적인치료 ( 물리치료, 보조기착용 ) 를받았음에도효과가없는환자에대하여 14일동안의한방치료를통해유의한호전을보인점에서비골신경마비에대한한방치료의효과를확인할수있었으며, 다른보존적치료에도호전을보이지않는 6개월이경과한마비증상에있어서도수술적치료가아닌또다른보존적치료인한방치료가효과를보인다는것을확인한점에서의미가있다고사료된다. 다만본증례의경우퇴원당시환자의증상이완전한회복을보이지않았다는점, EMG 검사의미시행으로결과에대한객관성이떨어진다는점, 여러가지치료중정확히어떤치료의효과인지불분명하다는점, 또한단일증례에불과하다는한계가있다. 그러므로향후더많은증례를대상으로한연구보고가이루어져야하며이중맹검대조군연구등이추가적으로필요할것으로사료된다. 참고문헌 1. The Korean Orthopedic Association. Orthopaedics. the fifth edition. Seoul: Choishin Medical Publishers; 1999, p Jo DC, Lim GM, Lee JH, Park TY, Moon SJ, 672

6 유근정 황규상 이준영 이언정 Kong JC, et al. Oriental Medicine Treatment for Common Peroneal Neuropathy after Traffic Accidents; 2 cases report. J Oriental Rehab Med 2012;22(3): Chu MG, Kim SJ, We J, Choi JB. A Clinical Cases Study of Foot Drop Caused by Common Peroneal Neuropathy(CPN). J Oriental Rehab Med 2007;17(3): Togrol E. Bilateral peroneal nerve palsy induced by prolonged squatting. Mil Med 2000;165(3) : The Society of Korean Medicine Rehabilitation. Oriental Rehabilitation Medicine: the 3 rd edition. Seoul: Gunja Publishers; 2011, p Hwang JU, Lee JY, Won SH, Kim DY, Kim SH, Park HS. Case Report of Foot Drop Patient Treated with Electroacupuncture. J of Korean Acupuncture & Mosibustion Medicine Society 2005;22(05): Lee SH, Choi SY, Lee SK, Gug YJ, Kim DJ. Clinical Study on 1 Case of Patient with the Foot Drop Diagnosed as Peripheral Neuropathy. J of Korean Acupuncture & Mosibustion Medicine Society 2006;23(1): Jang WS. A Case of Foot Drop Treated with Placenta Pharmacopuncture. J of pharmacopuncture 2009;12(1): Kim MS, Kim JH, Lee JY, Yeom SR, Kwon YD. Case Report of Korean Medical Treatment on Acute Peroneal Nerve Palsy Patient Caused by Prolonged Immobilization. J Oriental Rehab Med 2015;25(3): The Korean Neurosurgical Society. Neurosurgery. Seoul: The Korean Neurosurgical Society; 2012, p The Korean Orthopedic Association. Orthopaedics. Seoul: Choishin Medical Publishers; 2006, p , Hirose CB, McGarvey WC. Peripheral Nerve Entrapments. Foot Ankle Clin N Am 2004; 9: Hockenbury RT and Johns JC. A Biomechanical in Vitro Comparison of Open Versus Percutaneous Repair of Tendon Achilles. Foot ankle 1990;11: Meals RA. Peroneal Nerve Palsy Complicating Ankle Sprain: Report of Two Cases and Review of the Literature. J Bone Joint Surg 1996; 48: Krackow KA, Maar DC, Mont MA, Carroll IV. Surgical Decompression for Peroneal Nerve Palsy After Total Knee Arthroplasty. Clin Orthop 1993;292: Cho SG, Chung BS, Yun HS, Lee JH, Lee SH, Seo DM, et al. Clinical Study on a Case of Axonotmesis of Common Peroneal Mononeropathy by Using 3times EMG Studies. J of pharmacopuncture 2001;4: Yang YG. The Translation of Huangdi Neijing Suwen. Seoul: Yiljong; 1991, p Hong WS. Exquisite Huangdi Neijing Suwen. Seoul: Institute of Oriental Medicine; 1985, p Kim EG, Kim SK, Han JH, Sim YS, Lee JH. The Clinical Report of Asthmatic Patients with CVA by Treatment of Hominis Placenta Aqua Acupuncture. KPI 2004;7(3): Korean Pharmacopuncture Institute. A Clinical Guideline of Pharmacopuncture. Seoul: Hansung; 1999, p Seo BI, Kim SC. Bonchojibseong. Seoul: Tree & Earth; 2000, p Hwang HJ, Kwak MA, Lee EJ, Park CS, Byun JS, Park CG. One Case Study on the Cauda Equina Syndrome. J Int Korean Med 2001; 673

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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