Case Report J Korean Orthop Assoc 2012; 47: 227-231 http://dx.doi.org/10.4055/jkoa.2012.47.3.227 www.jkoa.org 골절 / 탈구가없는하경추부신전손상에서발생한광범위한전경추부혈종에의한기도압박 Airway Compression as a Result of Extensive Prevertebral Hematoma Following Extension Injury of Lower Cervical Spine without Fracture/Dislocation 송경진 이광복 박혁전북대학교의학전문대학원정형외과학교실, 전북대학교병원임상의학연구소 77세남자로경추부의신연-신전손상후발생한호흡곤란, 양수부저림증상및수지근력약화를주소로내원한환자로, 자기공명영상검사상전종인대및경장근손상, 광범위한전경추부혈종소견을보였다. 저자들은골절없이연부조직손상만으로도호흡곤란을일으킬수있을정도의광범위한전경추부혈종이발생된경우를문헌고찰과함께보고하고자한다. 색인단어 : 호흡곤란, 전경추부혈종, 신연 - 신전손상 전경추부혈종은대개감압술이필요할정도의호흡곤란을일으키지는않으나, 광범위하게발생하여기관을압박하거나전위시키는경우에는호흡곤란을일으켜감압수술이필요한경우도있다. 1,2) 이러한경우는대개경추부유합술후출혈에의하거나경추골절이나탈구등심한손상에의해출혈이일어나발생한다. 3) 그러나저자들은골절없이단지전종인대및경장근같은연부조직손상만으로도광범위한출혈및혈종형성으로기관을압박, 호흡곤란이발생한경우가있어서보고하고자한다. 증례보고 77세남자로교통사고로인한과신전손상후에심한호흡곤란 (dyspnea), 경부통증, 양수지의저림과굴곡력약화를주소로응급실에내원하였다. 과거력상특별한병력은없었다. 혈액학적검사상정상범위소견이었다. 내원당시단순방사선측면사진상제5-6 경추에퇴행성척추증 (degenerative spondylosis) 이관찰 접수일 2011 년 8 월 5 일수정일 2011 년 10 월 18 일게재확정일 2011 년 12 월 27 일교신저자이광복전주시덕진구건지로 20, 전북대학교의학전문대학원전북대학교병원정형외과학교실 TEL 063-250-2586, FAX 063-271-6538 E-mail osdr2815@naver.com 되었고, 경추의골절소견은없었으며, 경추의정렬도정상소견이었다. 그러나후인두공간 (retropharyngeal space) 이제3 경추에서 29.3 mm, 후기도공간 (retrotracheal space) 은제6 경추에서 53.9 mm로광범위한전경추부연부조직음영증가, 기도압박및전방전위가관찰되었다 (Fig. 1A). 경추부컴퓨터단층촬영상 (computed tomography) 에도경추의골절 / 탈구소견은보이지않았지만, 광범위한연부조직음영에의한기도압박및전위를보였다 (Fig. 2). T1-, T2-weighted magnetic resonance images상신호강도가섞여다양하게보이는 (high/low mixed signal intensity) 음영이제1 경추에서제4 흉추까지광범위하게형성이되어있어혈종으로생각하였고, 이혈종에의해기도와식도의압박및전위가보였으며, 제5-6, 6-7 경추간전방종인대 (anterior longitudinal ligament) 파열및경장근 (longus colli) 의파열, 추간판후방탈출이보였다 (Fig. 3). 호흡곤란은심하였으나, 동맥혈산소포화도가정상범위여서, 응급혈종제거술을시행하지않고 1주일간산소포화도측정및연속적인단순방사선검사와함께관찰하였고, 단순방사선검사상혈종의연부조직음영의감소소견 (Fig. 1B) 을보였으나여전히연하곤란과신경학적증상이지속되어, 제5-6, 6-7 전방경추추간판제거및골유합술의정규수술을시행하였다 (Fig. 1C). 수술소견상전경추부에광범위한혈종형성, 전척추근막 (prevertebral fascia) 파열, 전종인대파열, 경장근의심한타박상과파열, 외상성추간판탈출증, 후종인대파열을관찰할수있 대한정형외과학회지 : 제 47권제 3호 2012 Copyright 2012 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
228 송경진 이광복 박혁 Figure 1. (A) Initial C-spine lateral radiograph shows extensive prevertebral soft tissue shadow (retropharyngeal space at C3: 29.3 mm, retrotracheal space at C6: 53.9 mm) without fracture/dislocation from C1 to thoracic area. The retropharyngeal space lies between the pharynx the pharynx and the cervical spine. (B) Post-trauma 1 week C-spine lateral radiograph shows the decrease of prevertebral soft tissue shadow compare to initial C-spine lateral radiograph. (C) Immediate post-operative C-spine lateral radiograph showed marked decrease of prevertebral soft tissue shadow and anterior cervical discectomy and fusion with plate and cage construct at C5-7. Figure 2. Sagittal (A) and axial (B) computed tomography images show the compression and deviation of trachea (asterix) by extensive prevertebral soft tissue shadow (arrows) and no bony abnormality. 었으나혈관손상등의출혈점은관찰되지않았다 (Fig. 4). 수술후호흡곤란이호전되었으며, 추시 6개월에양수지의저림및굴곡력약화등신경학적증상또한호전되었다. 고찰 전경추부의혈종형성이상경추에서상흉추까지광범위하게나타나는원인으로는항응고제나고용량의아스피린의복용, 하갑상동맥 (inferior thyroid artery) 의손상, 척추체의골절및탈구, 4) 상 위경추부수술후등이보고되고있다. 1) 일반적으로척추체의골절이나탈구없이단순히전종인대나경장근과같은연부조직만의손상으로인한혈종형성은호흡곤란을일으킬정도로광범위한경우는드문것으로보고되고있다. 5) 그러나본증례에서는골절없이전종인대및경장근의파열만으로광범위한혈종이발생하였다. 골절이없는환자에서호흡곤란을일으킬정도의전경추부의연부조직부종에대한검사로단순방사선영상에서계측하는후인두공간의측정에대한연구는일반적이나 magnetic resonance
229 광범위한전경추부혈종 Figure 3. Sagittal (A, C) and axial (B, D) T1, T2-weighted magnetic resonance images show the deviation and compression of trachea (asterix) and esophagus (arrow head) by extensive hematoma in the prevertebral space (arrows) from C1 to T4, the tear of anterior longitudinal ligament and longus coli muscle, disc herniation C5-6, C6-7. Figure 4. Operative photo shows the extensive hematoma and longus coli muscle tear (white arrows). imaging (MRI) 촬영을통해연구한경우는찾아볼수없었다. 2,3) 이증례에서는전경추부연부조직음영증가의원인이부종이아닌혈종이라는것을 MRI 촬영을시행하여확인하였고, MRI 소견상제5-6, 6-7 경추간전방종인대파열및경장근 (longus colli) 의파열이광범위한혈종의원인이라고판단하였다. 또한수술시야상에서도경장근의파열과그로인한출혈을확인할수있었다. 광범위한혈종에의한기도압박의경우에는호흡중지 (respiratory arret) 가발생하여사망할수있어, 기관삽관이나혈종제거와같은응급감압술이필요할수있다. 응급으로기관삽관이나혈종제거술을시행하였을경우가장큰장점은즉각적인기도확보로인해생명의위협을피할수있다는점이다. 일반적인기관삽관의기준은동맥혈산소분압이 70 mmhg 이하로감소되었을때시행하는것으로알려져있다. 6) 그러나응급감압술의정확 한시행기준은없다. 본증례에서처럼광범위한혈종에의해기도압박및전위로인해심한호흡곤란이있어도, 동맥혈산소포화도나동맥혈산소분압이정상범위인경우에는즉시혈종제거와같은감압술이필요한지에대해서는생각해볼필요가있다. 즉, 동맥혈산소분압이위험한수준으로낮다면, 즉시혈종제거술이필요하다. 그러나, 동맥혈산소분압이정상범위인경우에는혈종이감소하는지를관찰해보거나또는술자나환자가호흡곤란의악화가능성을고려하여감압술을시행할수도있다. 먼저경과관찰을선택한경우에는단순방사선사진의연속촬영으로연부조직음영의증가나감소가있는지와동맥혈산소분압을측정하면서감압술여부를판단하면될것이다. 그러나즉각적인혈종제거술을시행한다면수술자나환자의불안함과증상은해결할수있으나, 호흡곤란이시간의흐름에따라호전될수있는환자에게불필요한수술을하는우를범할수도있으며, 술후에오히려수술에따른연부조직부종증가로호흡곤란이더악화될가능성도있어치료결정에어려움이따른다. 또한단순한혈종의제거술뿐만아니라경추추간판제거및골유합술등의수술을추가할경우외상직후에혈종과연부조직의손상으로정상해부학적구조의확인이어려워수술의결과에악영향을미칠수있다. 기존보고에서경추부의광범위한혈종의치료를살펴보면, 2,3) 동맥혈산소분압의측정없이주관적인증상에따라인공삽관을고려하고, 혈종의양에따라응급으로혈종제거를고려하였다. 저자들도환자의주관적인증상을주시하며, 연속적인측면단순방사선사진상후기도공간의감소및동맥혈산소분압의정상범위내유지가확인되어경과관찰하기로결정하였다. 또한기존보고에서전경추부의혈종은 1주일안에감소하는경우
230 송경진 이광복 박혁 가있어, 3) 저자들도일주일간관찰하였고, 연속적방사선사진상연부조직음영이감소되는소견과호흡곤란이호전되어, 추간판탈출증에의한신경학적증상의해결을위해경추추간판제거및유합술 / 고정술을정규수술로시행하였다. 골절이나탈구가동반되지않은전종인대및경장근의파열만으로도호흡곤란을일으킬정도의광범위한전경추부혈종을일으킬수있으므로주의할필요가있으며, 응급으로기도삽관이나혈종제거수술이필요할수있다. 이때환자의주관적인증상도중요하지만, 연속적인동맥혈산소분압의측정과측면단순방사선사진촬영을통해혈종제거술의적절한시점을결정할수있으리라생각한다. 참고문헌 1. Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cervical corpectomy for myelopathy. J Bone Joint Surg Am. 1991;73:544-51. 2. Howcroft AJ, Jenkins DH. Potentially fatal asphyxia following a minor injury of the cervical spine. J Bone Joint Surg Br. 1977;59:93-4. 3. Kuhn JE, Graziano GP. Airway compromise as a result of retropharyngeal hematoma following cervical spine injury. J Spinal Disord. 1991;4:264-9. 4. O'Donnell JJ, Birkinshaw R, Harte B. Mechanical airway obstruction secondary to retropharyngeal haematoma. Eur J Emerg Med. 1997;4:166-8. 5. Silberstein M, Tress BM, Hennessy O. Prevertebral swelling in cervical spine injury: identification of ligament injury with magnetic resonance imaging. Clin Radiol. 1992;46:318-23. 6. Fauci AS, Longo DL. Critical care medicine. Fauci AS, Braunwald E, Kasper DL, et al., ed. Harrison's principles of internal medicine. 17th Edition. New York: The McGraw-Hill Companies; 2008. 1681-5.
231 광범위한전경추부혈종 Airway Compression as a Result of Extensive Prevertebral Hematoma Following Extension Injury of Lower Cervical Spine without Fracture/Dislocation Kyung-Jin Song, M.D., Kwang-Bok Lee, M.D., and Hyuk Park, M.D. Department of Orthopedic Surgery, Chonbuk National University Medical School, Research Institute of Clinical Medicine, Chonbuk National University Hospital, Jeonju, Korea A 77-year-old man presented with severe dyspnea, neck pain, tingling sensation in both hands, and weakness after an acute prevertebral soft tissue hematoma due to distractive-extension injury. Magnetic resonance images demonstrated an extensive hematoma accumulation, anterior longitudinal ligament and longus colli muscle injuries. We report here a case of dyspnea due to an extensive prevertebral hematoma by soft tissue injury without cervical vertebral fracture and/or dislocation and a review the relevant literature. Key words: dyspnea, prevertebral hematoma, distractive-extension injury Received August 5, 2011 Revised October 18, 2011 Accepted December 27, 2011 Correspondence to: Kwang-Bok Lee, M.D. Department of Orthopedic Surgery, Chonbuk University Hospital, Chonbuk National University Medical School, 20, Geonji-ro, Deokjin-gu, Jeonju 561-712, Korea TEL: +82-63-250-2586 FAX: +82-63-271-6538 E-mail: osdr2815@naver.com