0CLINICAL ARTICLE0 J Kor Neurotraumatol Soc 2009;5:68-73 ISSN 1738-8708 척추경막외농양의치료결과및예후인자분석 부산대학교의학전문대학원신경외과학교실 김영하 손동욱 김성훈 이상원 송근성 Spinal Epidural Abscess: Result of 39 Patients and Evaluation of Prognostic Factors Young Ha Kim, MD, Dong Wuk Son, MD, Sung Hoon Kim, MD, Sang Weon Lee, MD and Geun Sung Song, MD Department of Neurosurgery, Pusan National University Shool of Medicine, Yangsan, Korea Objective: Despite advances in neuroimaging and neurosurgical care, spinal abscess remains a challenging problem with high morbidity rate. So we conducted a retrospective study to define its clinical feature and to evaluate its prognostic factors. Methods: The charts of 39 patients with spinal epidural abscess over a 6-year period (from January 2001 to December 2006) were reviewed and analyzed. Results: The 39 spinal epidural abscess included 22 men and 17 women with a mean age of 58 years. Localized spinal pain, paralysis, fever/chilling were the common manifestations. The most common pathogens were Mycobacterium tuberculosis, but we could not found pathogen in 19 cases. Decreased initial level of consciousness (drowsy-stupor) may predicted a poor prognosis, but no statistic significance. Conclusion: Localized back pain in a febrile patient with significant risk of epidural abscess warrants an immediate evaluation. neurological recovery can be obtained despite severe neurologic deficit when treated by early diagnosis and prompt surgical intervention. (J Kor Neurotraumatol Soc 2009;5:68-73) KEY WORDS: Spinal epidural abscess Surgery. 서 론 척추경막외농양은비교적드문질환이지만임상상태에따라종종응급수술을요할수도있는심각한질환으로최근그발생빈도가증가하는추세이다. 1,10,17) 전산화단층촬영과자기공명촬영등의진단기술의발달로인해빠르고정확한진단이가능해졌고, 새로운항생제의개발과수술적치료방법의발달로이전보다예후의호전은있었지만이러한발전에도불구하고아직이환율과사망률은높은실정이다. 최근보고에의하면사망률이 Received: August 7, 2009 / Revised: August 11, 2009 Accepted: September 22, 2009 Address for correspondence: Dong Wuk Son, MD Department of Neurosurgery, Pusan National University Shool of Medicine, Beomeo-ri, Mulgeum-eup, Yangsan 626-870, Korea Tel: +82-55-360-2126, Fax: +82-55-360-2156 E-mail: theworkholic@naver.com 18 31% 로알려져있으며 5,7,9) 이러한높은이환율과사망률은증상의모호함으로인한조기진단과적절한수술적치료의지연에기인한다. 저자들은척추경막외농양으로진단되어치료를시행한 39명의환자들에대해후향적으로분석하여그결과와예후에영향을미치는인자를규명하고자한다. 대상및방법 2001년 1월부터 2006년 12월까지본원신경외과에서척추경막외농양으로진단되어치료를받은 39명을대상으로조사를실시하였다. 이들에대한임상소견, 수술여부및수술소견, 술후의경과를의무기록지를통하여조사하였으며단순촬영, 전산화단층촬영및자기공명영상등의방사선검사소견을조사하였다. 예후는최종외래방문시다음과같은지료를이용하여분류하였다 : 0, 68 Copyright c 2009 Journal of Korean Neurotraumatology Society
Young Ha Kim, et al. 사망 ; 1, 침상생활을하는마비상태 ; 2, 중등도의장애 ( 독립보행불가능 ); 3, 경도의장애 ( 독립보행가능 ); 4, 신경학적이상없음. 이러한분류를통하여예후지표가 0~2 인환자군을예후불량군그리고예후지표가 3~4 인경우를예후양호군으로분류하여양군을비교하여예후관련인자를판별하고자하였다. 모든통계자료는 SPSS를이용하여분석하였으며 Chi-square test 와 t-test 를시행하여 p value 가 0.05 미만인경우를통계학적유의성이있는것으로하였다. 코올중독, 척추신경근마취, 외상등이있었다 (Table 2). 원인균주로는 mycobacterium tuberculosis가 11예로가장흔하였으며 staphylococcus aureus가 7예로다음으로흔한균주였다 (Table 3). 임상증상임상증상으로는 34예에서배부또는경부에동통, 26 예에서고열이있었으며, 26예에서부분마비혹은완전마비가발생하였고 5예에서괄약근마비 ( 배변배뇨장 결 과 35 30 Men Women 예후군에따른환자군별특성예후군을예후양호군과예후불량군으로분류하였을때예후양호군 31명, 예후불량군 9명으로분류되었으며 (Table 1) 각군의성별및연령분포는 Figure 1, 2와같았으나통계학적유의성을보이지는않았다. 유발인자및원인균동반질환및추정되는원인으로서당뇨병, 척추수술이각 7예로가장많았고, 그외만성간질환, 폐결핵, 알 TABLE 1. s assessment Score No. of patients (%) 0 Dead 02 (05) 1 Confined to bed, plegic 02 (05) 2 Moderate disability, precluding 04 (11) independent walking 3 Slightly disabled but independently 10 (26) ambulatory 4 Without neurological deficit 21 (53) 0-2 outcome 08 (21) 3 or 4 outcome 31 (79) 25 16 20 15 10 15 6 5 2 0 FIGURE 2. Comparison of gender between poor and good group. TABLE 2. Predisposing factors Predisposing factor No. of patients (%) Diabetes mellitus 07 (17) Liver cirrhosis 01 (02) Pulmonary tuberculosis 05 (12) Alcoholism 05 (12) Neoplasm 01 (02) Spine surgery 07 (17) Spinal nerve block 02 (05) Trauma 03 (07) Multiple medical illness 05 (12) None 11 (28) Case number 16 14 FIGURE 1. Comparison of age distribution between poor and good group. 12 10 8 6 4 2 0 <30 31-40 41-50 51-60 61-70 >70 Age p=0.432 (Fisher s exact test) www.neurotrauma.or.kr 69
Spinal Epidural Abscess 애 ), 3 예에서의식혼미를보였다 (Table 4). 예후인자본연구의대상인 39명의척추경막외농양환자의위험인자와예후군간의상관관계는다음과같았다. 39명의척추경막외농양환자에서예후양호군은 31명, 예후불량군은 8명이었다. 예후양호군의평균연령은 57.7± TABLE 3. Causative organisms Causative organism No. of patients (%) Staphylococcus aureus 07 (17) MRSA 05 (12) MSSA 02 (5)0 Escgerichia coli 01 (2)0 Citrobacter diversus 01 (2)0 Mycobacterium teberculosis 11 (28) No growth 19 (48) MRSA: Methicillin-resistant Staphylococcus aureus, MSSA: Methicillin-sensitive Staphylococcus aureus TABLE 4. Clinical manifestation Symptoms/signs No. of patients (%) Fever/Chills 26 (66) Back/Neck pain 34 (87) Impaired consciousness 03 (7)0 Local tenderness 19 (48) Paresthesia 12 (30) Paraysis 26 (66) Bladder dysfunction 05 (12) 12.5 세였고, 예후불량군의평균연령은 58.4±12.8세였다. 남녀성비는예후양호군에서 16 : 15이였고, 예후불량군에서는 6 : 2이었다. 양군에있어서나이와성별의차이는통계학적으로유의성을보이지않았다. 초기의식상태는예후양호군에서명료및기면이각각 30 : 1이었으며, 예후불량군에서는 6 : 2이었으며, 이들두군간의초기의식상태의차이는통계학적으로유의하지않았다 (p>0.05). 증상의기간, 기저질환, 방광기능장애, 치료방법역시통계학적유의성을보이지않았으나입원당시, 근력의경우예후양호군에서현저하게좋은상태를보였으며이는통계학적으로유의성을나타내었다 (Table 5). 평균백혈구치는예후양호군 / 예후불량군에서각각 8344.3 ±20.1/9369.7±30.5이었다 (p>0.05). 평균혈소판수치는예후양호군 / 예후불량군에서 293.4±13.4/335.7± 22.7 ( 10 3 per mm 3 ) 이었다 (p>0.05). 그외 hemoglobin (Hb), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) 및병원균의차이도유의성을나타내지않았다 (Table 6). 방사선학적소견을분석하였을때농양의발생부위의분포, 척추관내의위치, 척수의신호강도의변화, 농양의길이는예후양호군과예후불량군에서통계학적인유의성을보이지않았다. 조영증강의형태에따라척추경막외농양을 phlegmon ( 균일한조영증강을보이는경우 ) 와 abscess ( 조영증강이없거나주변부조영증강을보이는경우 ) 로분류하였을때예후양호군에서 abscess/phleg- TABLE 5. Predictor of outcomes (1) No. p-value Age Mean±SD 57.7±12.5 58.1±12.8 0.880 Sex Female 17 15 2 0.420 Male 22 16 6 Initial LOC Alert 36 30 6 0.090 Drowsy 03 01 2 Duration of symptom Number 31 8 0.210 Median (range), d 6 (1-30) 7 (1-45) Underlying disease Yes 28 23 5 0.660 No 11 08 3 Motor deficit at Adm Normal 16 16 0 Paresis 24 18 6 0.015 Plegia 02 00 2 Bladder dysfuction Yes 05 03 2 0.260 No 34 28 6 Treatment Surgical 16 12 4 0.690 Medical 23 19 4 LOC: level of consciousness 70 J Kor Neurotraumatol Soc 2009;5:68-73
Young Ha Kim, et al. TABLE 6. Predictor of outcomes (2) No. p-value Pathogen Tuberculosis 11 09 2 1.00 Non-tuberculosis 28 22 6 WBC (/ul) Mean±SD.8344±20.10.9369±30.50 0.89 Hb (g/dl) Mean±SD 11.3±1.20 11.15±0.800 0.77 PLT (10 3 /ul) Mean±SD 293.4±13.40 335.7±22.70 0.92 ESR (mm/hr) Mean±SD 70.1±8.10 77.6±8.30 0.06 CRP (mg/dl) Mean±SD 7.48±3.50 9.26±3.80 0.21 WBC: white blood cell, Hb: hemoglobin, PLT: platelet, ESR: erythrocyte sedimentation rate, CRP: C-reactive protein TABLE 7. Predictor of outcomes (3) MRI feature No. p-value Location of spine Cervical 07 05 2 0.650 Thoracic 10 07 3 Lumbar 22 19 3 Location of canal Anterior 20 16 4 1.000 Posterior 11 09 2 Circumference 08 07 1 Contrast-enhancement pattern Abscess 28 25 3 0.030 Phlegmon 11 06 5 Abnormal spinal cord signal Yes 03 01 2 0.100 No 36 30 6 50% central canal stenosis Yes 19 11 8 0.012 No 20 20 0 Abscess length >3 cm Yes 24 19 5 1.000 No 15 12 3 mon 은 25/6 예후불량군에서 3/5 의비를보였으며이는통계학적으로유의성을나타내었다 (p<0.05). 또한신경관의 50% 이상을차지한경우가예후양호군과불량군에서각 11명과 8명으로이또한통계학적으로유의성을나타내었다 (p<0.05)(table 7). 고찰 역학척추경막외농양은발생빈도가비교적드문질환으로연간입원환자 10,000명당 0.18~1.96명에서관찰된다. 21) 비교적고령에서호발하며평균연령은 62세, 60~70 대에가장흔하다. 2,25) 본연구에서는예후양호군의평균연령은 57.7 세, 예후불량군의평균연령은 58.4 세로유의한차이를보이지않았다. 척추경막외농양의위험인자로는당뇨병, 척추외상, 정맥주사남용, 척추수술, 원격감염병소가있는경우, 그리고간경화, 종양, 알코올중 독, 만성신장질환등에의한면역저하등이있는데, 최근고령화와함께이런위험인자의증가, 진단기술의발달등으로인해그발생빈도가증가추세에있다. 13,18,21) 임상양상및병태생리척추경막외농양을가진환자는다양한형태의임상양상을가지는데, 대표적인임상양상은배부또는경부동통, 열, 그리고운동마비로이중요배부통증이가장흔하다. 7,9,17,22) 일반적으로증상은배부또는경부동통으로시작하여시간이지남에따라점차악화되어신경근동통으로진행후운동마비순서로나타나는데항상일정한것은아니며수일내에급속히진행되는경우도있다. 척추경막외농양은요추에가장호발하며흉추, 경추순으로나타나는데본연구에서도요추에서가장많은빈도를보였다. 발생부위는척추의어느부위에발생하였는가에따라다르게나타나게된다. 경추에발생한척추경막외농양은대개척수의전방에위치하는반면, 흉 www.neurotrauma.or.kr 71
Spinal Epidural Abscess 추나요추의경우는후방의병변이더흔하다. 이는경추의경우추간판염이나척추염을동반하는빈도가높은것과관련이있다. 25) 원인균으로는그람양성균특히황색포도상구균이가장흔하며, 3,4,8) 최근에는그외의그람음성균과혐기성세균이원인인경우가증가하고있는데, 이는정맥주사남용이증가하는것에의한다. 6,8,9) 진단조영증강자기공명촬영은가장효과적인방사선학적진단법으로대표적인소견은 T1 강조영상에서고신호또는등신호, T2 강조영상에서고신호를보이는조영증강이되는종괴이다. 5,7) 본연구에서도모든환자에있어조영증강자기공명촬영을시행해확진하였다. 이것은염증부위를정확하게발견하여농양의전체범위및척추주위침범여부를파악하여농양의정확한위치를알게해줌으로써수술적접근법의결정에도움을준다. 단순촬영이나전산화단층촬영을같이시행하여정확한병변의정도를파악할수있으나, 척추골의침범을과장되게나타내는단점이있다. 16,20) 또한자기공명촬영은병소가치유되면조영증강이현저히감소하게되므로적혈구침강속도와함께치료결과의판정에도움을준다. 20,21) 전산화단층척수조영술은과거에경막외농양을진단하는방법이었으나최근에는자기공명영상에부적합한삽입물이있는환자등의경우에제한적으로사용된다. 혈액학적검사에서백혈구증다증, 혈구침강속도및 CRP 의증가가대표적이며혈액배양검사에서균동정이되지않는경우도있다. 루어지고신경학적증상이거의없는경우와기저질환으로인해수술의위험성이높은일부환자에제한된치료방법으로신중히고려해야한다. 예후및예후인자적절한치료를시행하지않은경우에는증상이지속적으로진행하여사망하게된다. 척추경막외농양의예후에영향을미치는인자로는나이, 신경관의압박정도, 농양의위치, 수술시의소견 (phlegmon/abscess), 패혈증동반여부, 증상지속기간등이보고된바있다. 10) Soehle 등 22) 도 2002 년에예후에대해보고하였는데, 입원당시의근력정도가좋을수록, 백혈구수가 14,000 개 /μl 이하인경우에예후가더좋은것으로평가하였다. 본연구에서는입원당시의근력정도, 신경관의압박정도, 조영증강의형태가 abscess 의형태를띠는경우가좋은예후와연관이있는곳으로나타났다. 이중 abscess 의형태를띠는것이좋은예후를나타내는것은아마도좀더급성의소견으로수술적치료에더좋은반응을나타냈기때문일것이다. 그리고많은저자들이언급한것처럼 24시간이후에수술을시행한경우나쁜예후를보였으므로, 근력저하가발생한후 24시간이내에수술적치료를행하는것은필수적이다. 5,10,14,15) 하지만 24시간이내에수술을시행하더라도완전마비가있었던환자에서는역시나쁜예후를예측할수있다. 22) 결론 치료척추경막외농양의치료원칙은즉각적인수술적척수감압술과배농및항생제치료이다. 8,11,12,24) 수술을시행함으로써확실한병리학적진단및원인균을알수있으며, 척수의감압과함께필요시안정화를동시에할수있다. 19) 진단되는즉시세균배양검사를시행하고항생제치료를시행하여야한다. 추궁절제술이가장자주시행되는감압술이지만, 경막전방에농양이존재하거나, 추체제거술및골융합술이필요할때에는전방접근법이이용되며골이식이필요할경우는자가골이식이추천된다. 13,19) 모든환자에서수술적치료가필요한것은아니며, 신경학적결손이없거나경증인경우, 기저질환때문에수술의위험도가높은경우, 광범위한척추침범이있는경우, 또는완전마비가 48시간이상지속된경우비수술적인치료를우선고려할수있다. 10,23) 하지만이는혈액배양이나전산화단층촬영하침생검등에서원인균의배양이이 결론적으로척추경막외농양의심각한이환율과사망률을막기위해서는조기진단과치료가필수적이다. 따라서척추경막외농양의위험인자를가진환자에서국소적동통이있으면바로적혈구침강속도를측정하여증가되어있거나또는진행하는신경학적증상이있다면즉시조영증강자기공명촬영을시행해야한다. 척추경막외농양의경우조기진단과빠른수술적가료가신경학적결손이있기전에행해지면신경학적호전도양호하며비록심한신경학적결손이있다하더라도완전마비가아니라면운동마비가발생한지 24시간이내에감압술을시행하여좋은결과를얻을수있다. 중심단어 : 척추경막외농양 수술 결과. REFERENCES 1) Ahl T, Hedström M, von Heijne A, Hammers Stiernstedt S. Acute spinal epidural abscess without concurrent spondylodiscitis. 72 J Kor Neurotraumatol Soc 2009;5:68-73
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