ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 27 권, 제 2 호, 2014 년 4 월 J Korean Fract Soc 2014;27(2):157-161 http://dx.doi.org/10.12671/jkfs.2014.27.2.157 Case Report 후궁성형술을이용한천골횡골절의치료 - 증례보고 - 장영수 장작 배성주 배찬일 박성배 한전병원정형외과 Laminoplasty for Treatment of Transverse Sacral Fracture - A Case Report - Young Soo Jang, M.D., Jak Jang, M.D., Sung Ju Bae, M.D., Chan Il Bae, M.D, Sung Bae Park, M.D. Department of Orthopaedic Surgery, KEPCO Medical Foundation, Seoul, Korea The transverse sacral fracture is rare; however, if it accompanies neurological injury or instability, difficult surgical treatment may be necessary. We performed surgical decompression and laminoplasty in a patient with neurological deficits and anterior displacement of S2 on S1. The patient showed a successful clinical outcome by neurological improvement. Key Words: Sacrum, Transverse fracture, Decompression, Laminoplasty 천추의골절에서횡골절은드물게발생하고대부분비수술적인방법으로치료하게되나심한신경학적이상을보이거나불안정한골절인경우까다로운수술적치료가필요할수있다. 1-3) 수술적방법으로추궁절제술을통한신경의감압, 골절부의정복및국소금속판이나장천나사를이용한내고정술등이여러논문에서소개되고있지만후궁성형술을이용한수술은국내외문헌상에서보고된바가없다. 4-6) 이에본저자들은심한분쇄골절및신경학적결손을동반한제1-2 천추의횡골절환자에서후궁감압및성형술에의한치료결과를문헌고찰과함께보고 Received November 23, 2013 Revised December 17, 2013 Accepted January 20, 2014 Address reprint requests to: Jak Jang, M.D. Department of Orthopaedic Surgery, KEPCO Medical Foundation, 308 Uicheon-ro, Dobong-gu, Seoul 132-703, Korea Tel: 82-2-901-3078ㆍFax: 82-2-900-1745 E-mail: supercc@naver.com Financial support: None. Conflict of interest: None. 하는바이다. 증례보고 2 층높이에서실족하여추락한 21 세여자환자로천골부위및양측하지의방사통과양측족부의통증을호소하며본원응급실에내원하였다. 이학적검사상요천추부의심한동통과함께좌측하지의전반적인감각저하를보였고, 특히좌측족근관절의족저굴곡근력이 3 등급으로관찰되었으나항문주위의감각이상, 항문괄약근의긴장성감소는보이지않았다. 단순방사선영상과전산화단층촬영상제 1-2 천추사이에서 Denis 제 3 형 1) 의천추공 (sacral canal) 부위의손상및 Roy-Camille 제 2 형, 5) 즉제 1 천추의후방전위를보였으며척수관을침범하는분쇄골절소견이보였다 (Fig. 1). 자기공명영상 (magnetic resonance imaging) 촬영결과좌측제 1 천추신경, 제 1 천추공주위의신경압박소견이관찰되었다 (Fig. 2). 좌측하지의심한방사통과 Copyright c 2014 The Korean Fracture Society. All rights reserved. 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. 157
158 Young Soo Jang, et al. Fig. 1. (A, B) Initial computed tomography scan shows a displaced comminuted sacral fracture with narrowing of the sacral canal at the S1-S2 level. Fig. 2. Preoperative sagittal (A) and axial T1-weighted magnetic resonance (B), T2- weighted magnetic resonance (C) images showing left S1 nerve root compression due to a displaced S1 sacral body and hematoma. 지속되는좌측족부의근력약화를보였고전위된골절부가신경을누르고있는것을확인하여수상 2 일째수술을결정하였다. 수술은후방종절개를사용하여제 1-2 천추골의후궁성형술을시행하였고전위된제 1 천추골을 bone impactor 를사용하여정복술을시행하려했으나환전한정복은힘들었다. Open door technique 으로후궁을확장시킨후압박된신경이감압되도록신경주위의혈종및골편을제거하였으며, 절제된좌측추궁판부위에제 1-2 천추의극돌기를제거한후미니금속판을이용하여고정하였다. 수술직후부터양측하지의심한방사통이감소되었고좌측족근관절의근력약화는관찰되지않았다. 술후방 사선사진및컴퓨터단층촬영상후궁의확장된소견을보였다 (Fig. 3, 4). 환자는술후 4 주에부분체중부하로보행이가능하였으며, 감각이상이나운동이상등은관찰되지않았다. 술후 3 개월째천추부의통증은없었으며수상전의일상생활이가능한상태로신경학적이상의호전과함께좋은결과를보였다. 고 전체골반골절중천추부의골절은 15%-45% 로비교적흔하나이중횡골절은 4%-5% 정도로드물게발생하는것으로보고되고있다. 1,4,5) 이러한골절의치료는신경증상의 찰
Laminoplasty for Treatment of Transverse Sacral Fracture 159 Fig. 3. (A, B) Postoperative X-rays show surgical decompression by laminoplasty and stabilization by mini plates and screws. Fig. 4. (A, B) Postoperative computed tomography shows the expanded central canal of the sacrum after laminoplasty. 유무와골절의안정도에따라서그치료법이달라진다. Gibbons 등 7) 은 Denis 의위치 1) 에따른천추골절의분류중척수관부위골절 ( 제 3 구역, 천추공내측부위 ) 을다시종골절과횡골절로세분하여치료방법을소개하였고, 특히본예와같은횡골절에서심한신경증상이동반된경우적절한수술적감압을시행하여만족할만한결과를보였다고보고하였다. 또한 Roy-Camille 등 5) 은상부횡골절을다시네가지형태로분류하였는데제 1 형은상부골편의전방각변형만있는경우, 제 2 형은상부골편이하부골편의후방으로전위되는경우로제 1, 2 형은굴곡형골절로설명하였으며제 3 형은상부골편이하부골편의전방으로전위되는경우로신전형골절이라고기술하였다. 제 4 형은축성압박력에의한제 1 천추골의분절골절로설명하였다. 이중신경손상이동반된제 2, 3 형에대하여적절한 신경감압과내고정술을시행하여신경증상의호전을얻었다. Denis 등 1) 도 8 예중 5 예에서수술을통한증상의호전을보고하였다. 이외에도많은저자들이골절형태가불안정하고신경증상이심한경우에는횡골절의수술적치료가필요하다는견해를보였다. 5-9) 그러나전위된골편을정복하는것이기술적으로어려우며, 천추의특성상적절한고정방법을선택하기가쉽지않고, 감압을위해후궁절제술만을시행했을경우골 - 피부간의직접적인접촉에의해통증을일으킬수있을뿐만아니라연부조직의손상및합병증이발생할수있다. 10) 또한광범위한후궁절제술시행후에도불완전한신경손상이존재하는경우그다음의수술방법을선택하기가쉽지않다. 따라서본저자들은수술적치료의한방법으로후궁성형술을소개하고자하였다.
160 Young Soo Jang, et al. 본증례는 Denis 의제 3 구역중에서도 Roy-Camille 의분류법상제 2 형골절에해당되었고심한신경증상이존재하였으며후에지속적인동통이남을수있다고판단하여수술을결정하였다. 수술시후방종절개로접근한후 open door technique 과미니금속판을이용하여신경의감압을얻고자하였다. 술후신경증상이회복되었으며최종추시상지연성신경학적문제가발생하지않았고컴퓨터단층촬영상압박되었던신경주변의확장된소견이확인되었다. 이와같은신경학적손상이동반된불안정한천추횡골절환자에서후궁성형술을이용하여충분한신경의감압을얻을수있었고, 이러한효과적인수술방법이국내외문헌에서유사한예를찾기매우드물어문헌고찰과함께보고하는바이다. References 1) Denis F, Davis S, Comfort T: Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res, 227: 67-81, 1988. 2) Fardon DF: Displaced transverse fracture of the sacrum with nerve root injury: report of a case with successful operative management. J Trauma, 19: 119-122, 1979. 3) Fountain SS, Hamilton RD, Jameson RM: Transverse fractures of the sacrum. A report of six cases. J Bone Joint Surg Am, 59: 486-489, 1977. 4) Carl A, Delman A, Engler G: Displaced transverse sacral fractures. A case report, review of the literature, and the CT scan as an aid in management. Clin Orthop Relat Res, (194): 195-198, 1985. 5) Roy-Camille R, Saillant G, Gagna G, Mazel C: Transverse fracture of the upper sacrum. Suicidal jumper's fracture. Spine (Phila Pa 1976), 10: 838-845, 1985. 6) Sapkas GS, Mavrogenis AF, Papagelopoulos PJ: Transverse sacral fractures with anterior displacement. Eur Spine J, 17: 342-347, 2008. 7) Gibbons KJ, Soloniuk DS, Razack N: Neurological injury and patterns of sacral fractures. J Neurosurg, 72: 889-893. 8) Byun YS, Chang SA: Sacral fractures. J Korean Fract Soc, 24: 371-381, 2011. 9) Taller S, Lukás R, Suchomel P, Krivohlávek M: Surgical treatment of dislocated transverse fractures of the sacrum. Acta Chir Orthop Traumatol Cech, 70: 151-157, 2003. 10) Ahn YJ, Yang BK, Yi SR, et al: The treatment of transverse fracture of the upper sacrum according to Roy-Camille classification (suicidal jumper's fracture): 4 cases report. J Korean Soc Spine Surg, 19: 110-115, 2012.
ISSN 1225-1682 (Print) ISSN 2287-9293 (Online) 대한골절학회지제 27 권, 제 2 호, 2014 년 4 월 J Korean Fract Soc 2014;27(2):157-161 http://dx.doi.org/10.12671/jkfs.2014.27.2.157 Case Report 후궁성형술을이용한천골횡골절의치료 - 증례보고 - 장영수 장작 배성주 배찬일 박성배 한전병원정형외과 천추의횡골절은드물게발생하지만신경손상과불안정한골절전위가동반된경우까다로운수술적치료를필요로하는경우가있다. 신경학적이상이있으며전방으로전위가동반된제1-2 천추횡골절환자에서, 수술적신경감압술및후궁성형술을시행하여신경학적회복을통한성공적인치료결과를보인 1예를보고하고자한다. 색인단어 : 천골, 횡골절, 감압술, 후궁성형술 접수일 2013. 11. 23 수정일 2013. 12. 17 게재확정 2014. 1. 20 책임저자장작서울시도봉구우이천로 308, 한전병원정형외과 Tel 02-901-3078, Fax 02-900-1745, E-mail supercc@naver.com Copyright c 2014 The Korean Fracture Society. All rights reserved. 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. 161