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1 대한족부족관절학회지 : 제 8 권제 호 J Korean Foot Ankle Soc. Vol 8. No.. pp.-7, 광주보훈병원정형외과 박봉주 김주오 양경호 최승준 The Effect of Peripheral Neurolysis in Diabetic Feet Bong-Ju Park, M.D., Ju-O Kim, M.D., Gyoung-Ho Yang, M.D., Soeng-Jun Choi, M.D. Department of Orthopaedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea =Abstract= Purpose: We evaluated the effect of nerve decompression for restoration of plantar sweating and sensation in diabetic neuropathic feet, and we selected diabetic neuropathic patients with the possibility of overlying entrapmental neuropathy. Materials and Methods: From June to May, we have investigated and follow-up examed patients with diabetic neuropathic feet, with decreased sensation in their lower limb, who underwent peripheral nerve decompression. The surgical procedure was multiple neurolysis of the common peroneal nerve, posterior tibial nerve and its three branches of one limb. We compared the operated limb with the opposite, unoperated limb. We performed history taking, physical examination, sweat secretion test, touch sensory test using Semmes-Weinstein monofilaments and electrodiagnostic study, pre-operatively and post-operatively. Results: On 6 months after the operation, the post-operative tests showed that there were noticeable improvements to sensation, statistically (P<.), but there was no change in the sweat secretion test. According to the Cseuz criteria, 7 patients out of the patients who received the multiple neurolysis showed excellent or good results. Conclusion: We observed that the peripheral nerve neurolysis could be benefit for improving sensation and alleviating pain of the diabetic neuropathic feet with nerve entrapmental symptoms, but there was no change in the sweat secretion on short-term follow-up. To identify whether the effect will be continued or not, additional follow-up will be required. Key Words: Diabetic neuropathic feet, Entrapmental neuropathy, Peripheral neurolysis 서 론 당뇨병의합병증중하나인당뇨병성말초신경병증은발의보호감각소실을초래하며, 족부병변발생의하나의주요원인으로알려져있으나, 아직까지당뇨병성말초신경병증은진행성이고비가역적이며치료가어려운것으로 Address for correspondence Ju-O Kim, M.D. 88-, Sanwol-dong, Gwangsan-gu, Gwangju, 6-7, Korea Department of Orthopaedic Surgery, Gwangju Veterans Hospital Tel: Fax: ortho@kornet.net 알려져있다,). 당뇨병은또한수근관증후군발생의위험인자중하나로알려져있으며, 당뇨병을가진수근관증후군환자를대상으로신경감압술을시행하였을경우효과가있는것으로보고된이후, 최근에는 Dellon 등에의해당뇨병환자의다른부위의신경이상에대해서도신경감압술 - -
2 을통한감각회복과동통완화등의기능적회복이가능하리라는보고가있다,,7,8,9). 그이론적근거로는말초신경의감소된축삭형질류 (axoplasmic flow) 와소비톨 (sorbitol) 축적과같은대사성이상으로신경내부종이발생하고, 족근관이나수근관등과같이해부학적으로좁아진부위에서포착성신경병증 (entrapmental neuropathy) 과같은만성자기압박상황에놓이게된다는것이다. 저자들은이러한보고들의결과확인을위해신경포착의가능성이있는당뇨병성말초신경병증환자를대상으로증세가더심한하지에말초신경감압술을시행하였으며, 기존의보고들과는다르게자율신경기능회복에도어떠한변화가나타나는지알아보고자하였다. 대상및방법본연구는 년 6월부터 년 월까지당뇨병환자중발의감각저하및이상감각으로내원한환자 7명과당뇨병성족부궤양으로입원치료중인환자 명을대상으로하였다. 예모두가남성으로평균연령은 6세 (-7세) 이고, 제 형당뇨병에이환된자로당뇨병의평균이환기간은.년 ( 범위 -년 ) 이었다. 또한족부궤양과거력을가지고있었으며, 양측족부가이환된당뇨병성말초신경병증환자였다. 이학적검사상경골내과후연의후경골신경주행지역을타진시틴넬징후양성을나타낸경우는 예중 예였고, 비골경부의총비골신경주행지역을타진시틴넬징후양성은 예였다. 또한모든예에서족배동맥과후경골동맥이촉지되었다. 8예에서야간의저린감과함께간헐적동통, 예모두에서이상감각 (paresthesia) 을보였고, 예에서는신발이벗겨진것도인식하지못한경험이자주있었다. 모든환자가혈당조절을위해내분비내과에서약물치료를받고있었으며, 입원중에는인슐린을사용하여혈당을조절하였다. 예서는야간의저린감에대해항우울제를사용하기도했다. 감각이상을보기위한 Semmes-Weinstein monofilament (SW 단일필라멘트 ) 를이용한접촉압감각검사는굵은유수신경섬유 (large myelinated nerve fiber) 의변화를감지해서당뇨병성말초신경병증을조기에진단할수있는간편하고유용한방법으로, 이중.7 SW 단일필라멘트가당뇨병성말초신경병증의조기발견에매우효과적이어서선별검사방법으로권장되고있다,,,). 본원에서는당뇨병성신경병증으로진단된환자와정상인을대상으로.7 SW 단일필라멘트검사를하여신경영역별반응을비교하였으며, 정상인은.7 섬유가닥에대해위치에 상관없이 99% 이상에서반응을보인반면, 당뇨병환자에서는같은신경지배영역이더라도위치에따른반응의유무가존재함을확인하였다. 그리하여.7 섬유가닥을정상범위상한치로정하고, 감각지배영역을고려한발바닥부위 9군데와발등부위 6군데의고안된부위에검사를시행하였다. 검사방법으로는우선환자를앙와위로눕히고검사자가어느부위를찌르는지보지못하게한상태에서양측족부를알코올로깨끗이닦은후각각의족부에대해 군데를검사하였다. 검사부위는말초신경분지들의감각영역을고려하여발바닥부위중에서엄지발가락과셋째, 다섯째발가락의정중부, 첫번째, 세번째, 다섯번째중족골두부위, 발중간부위의중심과전외측부위, 발뒤꿈치, 그리고발등부위중에서첫번째와두번째발가락의기저부사이, 첫번째지절부위, 네번째, 다섯번째근위지절부위, 발등중앙부, 외과전상부에서시행하였다 (Fig. ). 검사하고자하는부위에대해수직으로 SW 단일필라멘트가휘어질정도의힘으로약 초간찔렀으며, 궤양, 반흔, 굳은살, 괴사조직부위는피해검사부위를무작위로바꾸어가며시행하였고, 환자들에게느낌이 온다-안온다 라는대답만으로감각을느낄수있는지를술전과술후에양하지에각각검사하여감각호전효과가있는지를비교하였다. 술후감각호전효과에대한통계적유의성은 Mann-Whitney 검사를이용하였고, 유의수준이. 미만인경우통계적유의성이있는것으로보았으며, 통계적분석은 PSPP 통계패키지를이용하였다. 땀분비검사로는 Ninhydrin test를이용하였으며 7,8), Figure. The site of Semmes-Weinstein monofilament test. There are fifteen sites. The sites include the volar surface of the first, third and fifth metatarsal head and toe, centromedial, lateral midfoot and heel, also the dorsum of the midfoot, first web space, anterolateral ankle, first, fourth, and fifth toe. - -
3 박봉주 김주오 양경호 최승준 땀에서분비된아미노산이 Ninhydrin 시약과반응하여분홍색을나타내는것이이검사의원리로서염색된아미노산은피부의다른부분에서는생성되지않는물질로땀샘의활동성을반영한다. 환자발에서분비된땀의인화는술전과술후 6개월에각각얻었으며일관된방법을사용하였다. 환자를 No. Whatman filter paper에약 분동안맨발로서있도록한후, 펜을사용하여발의외곽선을그렸으며, 검사시실내온도는평균섭씨 도였다. 아세톤용매를사용하여 Ninhydrin % 용액을만든후, 환자가서있던 filter paper 위에분무후 시간동안섭씨 도온도에놓아두면 Ninhydrin 양성부분은분홍색점들로나타났으며, 술전과술후의 Ninhydrin 양성정도를비교하였다 (Fig. ). 이와함께신경-근전도검사를술전과술후에시행하여서로비교하였다. 수술적치료의적응증은당뇨병성신경병증환자에서감각저하와함께족부궤양과거력이있으며, 틴넬징후양성 Figure. Normal foot sweat print (Left) versus diabetic foot sweat print (Right). 이거나, 작열통 (burning pain) 이주된 (predominant) 증상을이루는경우를제외한이상감각, 자통 (stabbing pain), 쑤시는 (aching) 증상을보이는신경포착이의심스런경우로정하였다. 수술은환자가주관적으로더심하다고느끼는부위를대상으로하였으며, 수술을시행한부위는우측하지가 6예, 좌측하지가 예였다. 수술은척추마취하에앙와위자세에서말초신경감압술을시행하였으며 9,), 모든예에서총비골신경과후경골신경및이의분지인내 외측족저신경분지및내측종골신경분지를감압했으며, 먼저수술을받았던 예에서는하지전방부에서천비골신경감압술을, 다른 예서는발등에서심비골신경감압술을시행하였으나, 신경압박요인을발견할수없어그후의수술에서는포함시키지않았다. 후경골신경에대한감압은족근관부위에서시행하였으며, 내과끝부분으로부터근위부 cm, 후방 cm 지점에서피부절개를시작하여내과원위부의발바닥쪽으로의굴곡진내측절개를하여피하조직과지방을젖히고굴근지대를노출시켰다. 굴근지대근위부에서원위부까지절개하여개방한후, 장지굴건 (flexor digitorum longus tendon) 후방에위치한후경골신경을노출시켜충분히가동성있게만들었고, 이때함께주행하는후경골동맥과정맥에손상을주지않도록주의를하였다. 특히후경골신경을무지외전근의원위부까지가동성있게만드는것을중요하게여겼으며, 하방으로내 외측족저신경분지사이의격막과무지외전근의심부근막유리술도같이시행하였다. 총비골신경에대한감압은비골경부를중심으로상하로 cm 크기의피부절개를한후장비골근 (peroneus longus muscle) 의천부근막 (superficial fascia) 을절개하고, 근육심부의섬유밴드를박리하여가동성있게하였다. 신경외막을박리하는외신경박리술은후경골신경에만제한적으로사용하였다 (Fig. ). Figure. Photographs show neurolysis scenes of posterior tibial nerve and its branches (A) and common peroneal nerve (B). - -
4 공기지혈대제거후지혈을위해양극성응혈기가사용되었으며, 총비골신경과후경골신경감압부위에는드레인을삽입하여혈종이생기지않도록하였다. 관주 (irrigation) 후에피하조직과피부봉합만시행하고, 절개된굴근지대나근막등은봉합하지않았으며, 봉합후연성압박드레싱을하였다. 술후에는석고부목은사용하지않았고, 주간체중부하만제한하였다. 퇴원후주기적인외래추시를통해경과관찰을하였다. 결 Table. Result of Operation Based on Cseuz Criteria Patient's satisfaction of result Excellent (-7% improved) Good (7-% improved) Fair (-% improved) Poor (less than %) Worse or no change Total 과 자각증상에대한문진에서무겁게느껴지던하지의이상감각은술후모든환자에서호전되었으며, 야간의저린감과동통은 6예에서호전을보였다. 환자자신의자각증상의호전에중점을둔 Cseuz 등 6) 의판정을적용하여술후 6개월째에 7예 (7%) 에서양호 (good) 이상의결과를보였으며, 신발이벗어진것도인식하지못한경험이있던 예에서보통 (fair) 과불량 (poor) 의결과를나타내었다 (Table ). No. 술후반대편다리에대한동일수술에대한의향은 8명이가지고있었으며, 명은좀더결과를지켜보고난후수술을결정키로하였다. 한편, 수술당시족부궤양이있던 예중 예에서소독시술전느끼지못했던심한궤양통증을호소하였으며, 예는경한통증을호소하였다. 술후 6개월째일률적으로시행한접촉압검사상, 수술을받은하지에서받지않은하지에비해발등과발바닥에서각각술후에유의할정도의감각호전을보였으나 (Table, 발등 P=., 발바닥 P=.), Ninhydrin 시약을이용한땀분비검사에서는술후에특별한변화소견이관찰되지않았다. 한편, 신경-근전도검사에서는모든예에서당뇨병성신경병증의소견이보였으며, 술전에보였던감각신경활동전위의진폭과전도속도의감소는술후에도크게변하진않았다. 수술소견상총비골신경및후경골신경은모든감압부위에서신경혈관다발이압박되어있었고, 상당수에서압박부위근위부의신경은비후되어굵어져있었다. 가장압박하는구조물은무지외전근의근막이었으며, 굴근지대비후는모든예에서관찰되었다. 천비골신경 예와심비골신경 예는모두압박소견이보이지않았다. 한편, 혈관성띠 (vascular leash) 나결절종 (ganglion) 과같은다른신경압박요인은관찰되지않았다. 술후합병증으로는드레인을삽입하지않은총비골신경주위에혈종이 예있었다. 고찰당뇨병성신경병증을가진환자를대상으로신경포착 Table. Comparison of Preoperative and Postoperative 6 Months Semmes-Weinstein Monofilament Tactile Test Operated lower extremity Non-operated lower extremity Subject Preoperative Postoperative Before After NTPS* NTPD NTPS NTPD NTPS NTPD NTPS NTPD A B C D E F G H I J Mean... *; Number of tactile perception in the sole, ; Number of tactile perception in the foot dorsum
5 박봉주 김주오 양경호 최승준 (nerve entrapment) 이의심스러운부분에서신경감압술을시행한본연구의결과는감각호전정도에차이는있었지만, 예를제외한 8% 의발등과 예를제외한 9% 의발바닥에서감각호전을보였다. 저자들의이러한호전된결과는 Dellon 등 7) 에의해증상이있는당뇨병성신경병증환자에서신경감압술을시행한후약 8% 에서증상의호전이있었다는보고와도비슷한결과였음을확인할수있었으나, 7.% 에서완전정상감각으로회복되었다는 Wood 등 ) 의보고와는달리완전히감각을회복한경우는없었다. Wood는압박성신경병증에서수술적감압술이성공적인결과를가져온경우당뇨병성신경병증의자연경과가바뀔지도모르며, 이런병적인변화에대한빠른확인이중요하다하였다. 당뇨병환자에서족부감각저하를일으키는당뇨병성신경병증의기전에대해서는아직정확히알려져있지않으나, 현재까지는알도스환원효소, 산화스트레스, 필수지방산결핍, 향신경성성장인자 (neurotropic growth factor) 감소, 미세혈류의구조적및기능적변화등이관여할것으로알려져있다,,). 본연구는당뇨병성신경병증의증상은최소한어느정도의신경압박에의해기인된다는이론에토대를두고있다. 이에의하면당뇨병환자의말초신경에대사성이상으로신경섬유내초부종 (endoneural edema) 이발생하고, 이로인해수근관이나족근관 (tarsal tunnel) 과같이해부학적으로좁아진부분에서이곳을지나는신경이이차적으로만성자기압박에놓이게된다는이론이다. 이에저자들은당뇨병환자에서흔히발생하는피부건조가감각신경과함께포함되어있는자율신경의압박에의한것으로보고술후동통이나감각신경의호전뿐만아니라자율신경기능의변화까지알아보고자하였다. 그결과술후 7% 에서양호이상의주관적증상회복과, 접촉압감각검사상에서도유의할만한감각신경의회복을보였으나, 자율신경의기능인땀분비는수술후에도특별한변화를보이진않았다. 이러한상반된결과는각각의신경섬유의특성과연관이있으리라사료된다. 감각호전이시작되는시점을객관적으로평가하진못하였으나, 환자의주관적증상의호전은 예에서술후 -일내에, 예에서는수주후에일어났다. 한편, Dellon 등 7) 은신경감압술후눌려있던신경에혈액공급이증가함에따라몇주내에어느정도의감각의회복과지각부전 (dysesthesia) 의감소가가능하다고하였다. 본연구에서는틴넬징후를신경포착의지침으로이용하여틴넬징후음성인경우연구대상에서배제하고, 음성군 (negative group) 에대해서는좀더임상적연구를기다 려보아야한다고했던 Dellon 등 ) 의보고와는달리틴넬징후양성인환자뿐만아니라, 작열통이주된증상을이루는경우를제외한이상감각, 자통등의증상을보이는환자에서도감압술을시행하였다. 그리하여틴넬징후를보인환자중 예와그렇지않은환자의 예에서빠른증상의회복을보였다. 압박성신경병증의진단에서 Kunschner 등 ) 은틴넬징후는유용성이비교적낮다고하였으며, Gellman 등 9) 은민감성이떨어지는검사로보고한바있다. 국내연구 6) 에서도중증의수근관증후군임에도불구하고틴넬징후는 8% 만이양성으로나타났다고보고한예가있어틴넬징후를압박성신경병증의절대적지표로간주하는것은부적절한것으로보인다. 그러나, 한문헌 ) 에의하면압박성신경병증증상의발현빈도에서틴넬징후는 8% 를차지하는이상감각다음으로 77% 의상위비중을차지했으며, 둔감과동통은각각 %, % 로이보다낮은비중을차지하였다고한예도있다. 당뇨발에나타난증상이주로신경병증때문인지또는혈관병성허혈때문인지는단정하기어려운경우가많으므로, 저자들은혈관병성허혈에의한신경증상의배제를위해연구대상으로발의동맥이촉지되는 예를선정하고, 허혈성증상의가능성이많은혈관중재술 (vascular intervention) 을받았던 예와당뇨병성만성신부전환자 예는대상에서배제하였다. Wood 등 ) 은특발성신경병증, 후외상성신경병증, 화학독성신경병증, 마약또는알코올중독, 당뇨병외의전신적혹은대사성질환에대해비적응증으로구분한바있다. 신경-근전도는본원신경과전문의에의해시행되었으며, 모든예에서술전과술후특별한변화가나타나진않았다. Dellon 등 7) 의보고에서는술전과술후평균 6개월에신경-근전도검사를시행한결과당뇨병성신경병증이전체의.%, 당뇨병성신경병증에압박성신경병증이병발된경우가 8.% 를차지하였으며, 각각의경우 %, 8% 에서신경-근전도검사상호전을보였고, 약 8% 에서신경기능의호전이있었다고하였다. 이와는달리 9% 에서증상의호전이있었던 Wieman 등 9) 의보고에의하면, 술후에근전도검사에서의미있는정보를얻지못했으며모든환자가탈수초화 (demyelination) 의증거와함께혼합성축삭이상 (mixed axonal abnormality) 을보였고, 신경전도검사에서도술전과술후에어느환자에서도눈에띄는현저한차이를관찰할수없었다고하여본원과유사한결과를보고하였다
6 결 론 본연구는당뇨병성신경병증환자에서신경기능저하의원인으로대사성이상뿐만아니라신경압박에의한기계적원인이어느정도는기여한다는이론에토대를두고있다. 그리하여수술적방법이이런환자에있어또다른치료대안의하나가될수있음을알아보고자하였다. 이를위해하지에신경포착증상이있는당뇨병성말초신경병증환자를대상으로신경감압술을시행한후단기추시에서수술적치료가발의감각회복과동통완화에도움이됨을확인하였으나, 땀분비기능은별다른변화를보이지않았다. 단기추시에서의이러한결과가지속성을가지는것인지에대해서는보다장기추시가필요할것으로사료된다. REFERENCES. Aszmann OC, Kress KM and Dellon AL: Results of decompression of peripheral nerves in Diabetics. A prospective, blinded study. Plast Reconstr Surg, 6(): 86-8,.. Birke JA and Sims DS: Plantar sensory threshold in ulcerative foot. Lepr Rev, 7: 6-67, Brodsky JW: The diabetic foot. In Surgery of the Foot and Ankle, 7th ed, pp , edited by MJ Coughlin, RA Mann, Mosby, St. Louis, Chafee H: Treatment of diabetic neuropathy by decompression of the posterior tibial nerve. Plast Reconstr Surg, 6(): 8-8,.. Cho YO: The etiology and diagnosis of diabetic foot. Diabetes vol. appendix : -6, Cseuz KA, Thomas JE, Lambert EH, Love JG and Lispcomb R: Long term result of operation for the carpal tunnel syndrome. Mayo Clin Proc, : -, Dellon AL: Treatment of symptomatic diabetic neuropathy by surgical decompression of multiple peripheral nerves. Plast Reconstr Surg, 89(): , Dellon AL, Mackinnon SE and Seiler WA: Susceptibility of the diabetic nerve to chronic compression. Ann Plast Surg, : 7-9, Gellman H, Gelberman RH, Tan AM and Botte MJ: Carpal tunnel syndrome. J Bone Joint Surg, 68-A: 7-77, Kim YY, Seo JS, Ahn MW and Ahn JC: Patient outcomes after open release of the carpal ligament on the carpal tunnel syndrome. J of Korean Orthop Assoc (): 9-97, Kochman AB, Carnegie DH and Burke TJ: Symptomatic reversal of peripheral neuropathy in patients with diabetes. J Am Pediatr Med Assoc, 9: -,.. Kumar S, Fernando DJS and Veves A: Semmes- Weinstein monofilaments: a simple, effective and inexpensive screening device for identifying diabetic patients at risk of foot ulceration. Diabetes Res Clin Prac, : 6-68, 99.. Kunschner SH, Ebramzadeh E, Johnson D, Brien WW and Sherman R: Tinel's sign and phalen test in carpal tunnel syndrome. Orthopedics, : 97-, 99.. Laughlin RT, Calboun JH and Mader JT: The Diabetic Foot. J Am Acad Orthop Surg, : 8-, 99.. Lee EW, Kang SY, Jang EC, Jin WJ and Seo KM: Quantitative sensory test for the detection of diabetic peripheral neuropathy. J of Korean Orthop Assoc, (): 8-88, Lee KH, Park MR and Kim DK: Results of treatment of severe carpal tunnel syndrome. J of Korean Hand Surgery, (): -, Oommen PK: Posterior tibial neurovascular decompression for restoration of plantar sweating and sensibility. Indian J Lepr, 68(): 7-8, Rao KS, Balakrishnan S, Oommen PK and Siddalinga MK: Restoration of plantar sweat secretion in the feet of leprosy patients. Indian J Lepr, 9(): -9, Wieman TJ and Patel VG: Treatment of hyperesthetic neuropathic pain in diabetics. Decompression of the tarsal tunnel syndrome. Ann Surg, (6): 66-66, 99.. Wood WA and Wood MA: Decompression of peripheral nerves for diabetic neuropathy in the lower extremity. J Foot Ankle Surg. (): 68-7,
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