대한척추외과학회지제 14 권제 2 호 Journal of Korean Spine Surg. Vol. 14, No. 2, pp 115~119, 2007 척추관협착증환자에서발견된제 4 요추부선천성편측척추경결손 - 증례보고 - 김연일 이재철 최우석 신병준 순천향대학교의과대학정형외과학교실, 척추센터 Congenital Absence of a Pedicle of L4 in the Spinal Stenosis - A Case Report - Yon-Il Kim, M.D., Jae Chul Lee, M.D., Woo-Seok Choi, M.D., Byung-Joon Shin, M.D. Department of Orthopedic Surgery, Spine Center Soonchunhyang University College of Medicine, Seoul, Korea Abstract Congenital absence of a lumbar pedicle is an uncommon anomaly, and most cases are asymptomatic and discovered incidentally. A 72-year-old man presented with lower back pain that radiated to his bilateral lower extremities. Physical examination revealed no neurological deficits. Plain radiographs of the lumbar spine revealed absence of the left L4 pedicle, along with hypertrophy and sclerosis of the contralateral pedicle. Magnetic resonance imaging showed stenosis of the L3-4 neural canal. Computed tomography revealed absence of the left L4 pedicle associated with hypertrophy and sclerosis of the right L4 pedicle and facet joint. The symptoms of the patient were resolved after posterior decompression without fusion. Here, we report one case of congenital absence of an L4 pedicle detected in a spinal stenosis patient who need to undergo a decompressive surgery for the spinal stenosis caused by contralateral facet hypertrophy. Key-Words: Congenital absence of pedicle, Lumbar, Spinal stenosis, Posterior decompression 서 론 요추부의선천성편측척추경결손은대부분의경우증상이없거나우연히발견되는드문이상으로일측척추경의무형성과반대측척추경의경화및비대를보이며, 수술적치료를요한경우는거의보고되어있지않다 1,2,3). 저자들은제 3 요추 - 제 4 요추간척추관협착증환 자에서발견된제 4 요추부좌측선천성척추경결손증례를통해진단과치료시주의점을문헌고찰과함께보고하는바이다. 증례보고 72 세남자환자는약 2 년전부터시작되고한달반전 Address reprint requests to Byung-Joon Shin, M.D. Department of Orthopedic Surgery, College of Medicine, Soonchunhyang University 657 Hannam-dong, Youngsan-gu, Seoul, 140-743, Korea Tel: 82-2-709-9056, Fax: 82-2-796-3682, E-mail: schsbj@hosp.sch.ac.kr 본논문의요지는 2006 년도대한정형외과학회에추계학술대회에서포스터로발표되었음. - 115 -
대한척추외과학회지 Vol. 14, No. 2, 2007 부터악화된하요추부통증과양하지의방사통을주소로내원하였다. 과거력상고혈압과당뇨병이있었고수술력상특이사항은없는상태였다. 병력청취상약 10 미터정도보행시파행을보이고있었고, 이학적검사에서양하지직거상검사및심부건반사는정상소견이었고운동및감각검사상신경학적이상소견은없는상태였다. 단순방사선검사에서전반적인척추체에골극이형성되어있는퇴행성변화소견을보이면서제 4 요추부좌측척추경이관찰되지않았고우측척추경의비대와음영이증가되어있는심한퇴행성변성소견이관찰되었다 (Fig. 1). 자기공명영상검사에서는제 3, 4 요추간추간판의중심성팽윤소견이관찰되면서제 3, 4 요추의신경관이좁아져있는척추관협착소견이있었고, 제 3, 4 요추간우측후관절의퇴행성변화가관찰되었다. 전산화단층검사에서도제 3, 4 요추의신경관이좁아져있었고경막낭이압박된소견이관찰되었다. 또한, 제 4 요추부좌측척추경결손을보이면서우측척추경이인접척추체의척추경에비해비대되어있었고경화된소견이관찰되었다 (Fig. 2). 제 3, 4 요추간우측후관절의비대및경화, 관절간격의감소를보이는퇴행성변화소견이있었고제 4 요추의극돌기가약간우측으로전위되어있는소견이관찰되었다. 삼차원재구성전산화단층촬영상제 4 요추부의좌측척추경결손소견을입체적으로파악할수있었다 (Fig. 3). 제 3, 4 요추간척추관협착증진단하에후방감압술 시행하였고, 추체간안정성을유지하기위해좌측으로접근하여좌측은후궁부분절제술시행하고우측은 undercutting 감압술시행하였으며, 수술후 1 년추시에서환자의하지방사통은소실되었으며, 경도의요통이남아있었다. 고 찰 선천성요추부편측척추경결손이있는경우, 장기간의체중부하에의한반응으로반대측척추경의비대및경화등의변화를유발할수있으며, 이로인하여척추관협착증등의질환이속발될수있다고보고되어있다 1,2,3). 본증례에서는제 3, 4 요추간척추관협착증진단하에시행한검사상제 4 요추부좌측척추경결손을발견하였고우측척추경의비대, 경화및인접분절후관절의퇴행성변화소견을관찰할수있었다. 임상적으로는선천성척추경결손을자기공명영상을이용하여염증성병변이나신생물등의용해성병변과감별하는것이중요하며, 방사선사진소견상일측척추경결손및반대측척추경의비대, 극돌기의전위, 관절돌기의이상이관찰되는경우컴퓨터단층촬영으로골성구조의이상을파악할수있다고되어있다 1,2). 본증례에서도환자의외견및이학적소견에서염증혹은악성신생물을시사할만한소견은발견하지못하였으며, 술전시행한삼차원재구성전산화단층촬영에서단순방사선사진 Fig. 1. Preoperative AP (A) and lateral (B) radiographs of a 72-year-old man suffering from spinal stenosis at L3-4 level. Arrow indicates absence of the left L4 pedicle. - 116 -
요추부선천성척추경결손 김연일외 Fig. 2. CT scans shows absence of the left pedicle and hypertrophy of the right pedicle of L4 vertebra. Degenerative changes of the right L4-5 facet joint was also noted. Arrow indicates the rudimentary bony connection between the vertebral body and the left side transverse process, instead of the pedicle. Fig. 3. Three-dimensional (A) & 2-D (B) reconstructed CT image shows absence of the left pedicle at L4 (arrow-pointed). - 117 -
대한척추외과학회지 Vol. 14, No. 2, 2007 에서파악하기어려운골성구조의이상및변화소견을입체적으로이해할수있었다. 선천성요추부척추경결손이확실한경우초음파검사를시행하여비뇨생식기계이상여부를확인하는것이권장된바있다 2). 그러나본증례에서는배뇨불편증상등의비뇨기계질환이의심되는소견이없고, 요검사등도정상이어서초음파검사는시행하지않았다. 선천성척추경결손은생체역학적측면에서의척추경자체의결손보다는동반된변형이나기능적장애가더중요하다고보고되어있다 1). 요추부후관절의주된역할은신전및회전응력에대하여안정성을확보하는것으로알려져있다 4,5). 생체역학적실험에서일측후관절전절제를시행한경우요추부의불안정성이유발되었고특히축성회전에중요한불안정성이유발되었다고한다 6). 후관절의기능중또다른하나는해당분절의축성부하를공유하는것이며, 후관절에가해지는부하는중립시 9% 에서신전시 15% 로변화한다고보고되어있다. 만약일측후관절의기능이적절하지못한경우반대측관절이더많은부하를지탱하여야하고, Kornberg 는이와유사한상태에서일측척추궁협부의결함이반대측후관절의변성을유발한다고보고하였다 7). 본증례에서도선천성일측척추경결손이건측척추경의골성변화및후관절의변성을유발하여요추부척추관협착증을유발한것으로사료된다. 이전에보고된척추경결손증례의대부분은증상이없거나보존적치료에잘반응하는하요추부통증이유일한증상이었다 1,2,3). 저자는일측척추경결손및수술적치료가필요한신경학적이상을수반하는증례를경험하였고제 3, 4 요추간척추관협착증진단하에후방감압술을시행하였다. 이와같은증례에서는수술전일측척추경결손을진단함으로써이후발생할수있는추체간불안정성에대한추체유합술시행여부를고려할수 도있으며, 장기적인추시를통하여추체간불안정성발생과통증발현여부를관찰을하는것이필요할것으로사료된다 8). 질환의치료를위한가장적절한선택을위해수술전검사소견을면밀히검토함으로써적절한수술방법을결정할수있으리라생각된다. 참고문헌 01) Kaito T, Kato Y, Sakaura H, Yamamoto K, Hosono N: Congenital absence of a lumbar pedicle presenting with contralateral lumbar radiculopathy. J Spinal Disord Tech 2005; 18: 203-205. 02) Mizutani M, Yamamuro T, Shikata J: Congenital absence of a lumbar pedicle. Spine 1989; 14: 890-891. 03) Villas C, Barrios RH: Congenital absence of the pedicles and the neural arch of L2. Eur Spine J 1997; 6: 354-356. 04) Lorenz M, Patwardhan A, Vanderby R: Load-bearing characteristics of lumbar facets in normal and surgically altered spinal segments. Spine 1983; 8: 122-130. 05) Sharma M, Langrana NA, Rodriguez J: Role of ligaments and facets in lumbar spinal stability. Spine 1995; 20: 887-900. 06) Abumi K, Panjabi MM, Kramer KM, et al.: Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine 1990; 15: 1142-1147. 07) Kornberg M: Spondylolithesis with unilateral pars interarticularis defect and contralateral facet joint degeneration. Spine 1988; 13: 712-713. 08) Park KW, Kim BH, Lee JH, Song KS, Lee CK, Chang BS: Congenital absense of thoracic spine pedicle: Case report. J Korean Soc Spine Surg 2006; 13: 219-223. - 118 -
요추부선천성척추경결손 김연일외 국문초록 요추부의선천성편측척추경결손은대부분의경우증상이없거나우연히발견되는드문이상으로수술적치료가필요한경우는거의없다고보고되어있다. 증례는 72세남자로하요추부통증과양하지의방사통을호소하였고, 이학적검사에서신경학적이상소견은없었다. 단순방사선검사에서제 4 요추부좌측척추경이관찰되지않았고우측척추경의비대와음영이증가되어있는소견이관찰되었으며, 자기공명영상검사에서는제 3, 4 요추의신경관이좁아져있는척추관협착소견이있었고, 전산화단층검사에서제 4 요추부좌측척추경결손을보이면서우측척추경이인접척추체의척추경에비해비대되어있었고경화된소견이관찰되었다. 제 3, 4 요추간척추관협착증진단하에후방감압술시행하였고, 수술후환자의증상은호전되었다. 건측후관절의퇴행성변화에의한척추관협착증의치료과정에서발견된제 4 요추부좌측선천성척추경결손증례를문헌고찰과함께보고하는바이다. 색인단어 : 선천성척추경결손, 요추부, 척추관협착증, 후방감압술 통신저자 : 신병준서울특별시용산구한남동 657번지순천향대학교의과대학서울병원정형외과학교실, 척추센터 Tel: 82-2-709-9056 Fax: 82-2-796-3682 E-mail: schsbj@hosp.sch.ac.kr - 119 -