대한응급의학회지제 17 권제 5 호 Volume 17, Number 5, October, 2006 증 례 물리적결박에의한상완신경총손상 1 례 조선대학교의과대학응급의학교실, 광주현대병원응급의학과 1 박용진 김성중 박광철 1 A Case of Brachial Plexus Injury Due to Physical Restraint 서 론 Yong Jin Park, M.D., Seong Jung Kim, M.D., Gwang Cheol Park, M.D 1. The brachial plexus may be visualized simply as beginning with five nerves and terminating in five nerves. It begins with the anterior rami of C5, C6, C7, C8, and the first thoracic nerve. It terminates with the formation of the musculocutaneous, median, ulnar, axillary, and radial nerves. The anatomy of the brachial plexus can be confusing, especially because of frequent variations in the length and the caliber of each of its components. The most common type of injury is one involving a motorcycle or bicycle crash in which a forceful impact on the shoulder depresses the entire shoulder girdle and avules a portion of the plexus. The injuried area is usually the upper trunk althrough the lower trunk can be involved either in addition to or as the main site of injury. Our case involves brachial plexus injury due to physical restraint that had been used to avoid using a pharmachologic restraint. Key Words: Brachial plexus injury, Physical restraint Department of Emergency Medicine, Chosun University Hospital, Hyundai Hospital 1 Gwangju, Korea 책임저자 : 김성중광주광역시동구서석동 588번지조선대학교병원응급의학교실 Tel: 062) 220-3285, Fax: 062) 224-3501 E-mail: ksj@chosun.ac.kr 접수일 : 2006년 3월 6일, 1차교정일 : 2006년 4월 6일게재승인일 : 2006년 8월 4일 500 상완신경총 (Brachial plexus) 이란제 5경추에서제 1 흉추까지 5개의신경근이상지로분포하여각각운동과감각등을담당하면서목아래부분에서겨드랑이까지뭉쳐있는부분을말한다 (Fig. 1). 해부학적으로매우복잡한주행을이루고있으며외부충격에비교적쉽게노출되는곳에위치하고있고이신경다발이여러가지원인에의해서손상당하여팔의기능인운동과감각이마비되는경우를상완신경총손상 (Brachial plexus injury) 이라고한다 1-3). 의식혼미와난폭한행동을주소로응급의료센터에내원하는환자중빠른응급처치와검사를위해물리적및약물적결박이필요한경우가흔히발생한다. 약물적결박이잘되지않고약물에의한부작용이나타날가능성이있는환자에서물리적결박을하는경우가많은데, 본원내원환자중응급의료센터에서물리적방법에의한사지결박후왼쪽상지영구마비증상이발생한상완신경총손상환자 1례를경험하여이를보고한다. 증례혼미한의식을주소로내원한 39 세남자환자는내원 2 년전부터두통과조울증으로개인병원에서간헐적인약물치료를해오던환자로최근 1달처방약을 15 일만에다복용하였고내원하루전에는새로처방받은여러봉지의약을한번에먹고약 20 시간동안승용차운전석유리창에왼쪽팔을들고기댄자세로고정되고의식이혼미한상태에서보호자에게발견되어 119 구급대에의해구조시알아들을수없는말로소리를지르고난폭한행동을보여본원응급의료센터에내원하였다. 과거력상건설업에종사하고 10 갑년의흡연력과하루 70 mg의소주를거의매일섭취하였으며개인병원에서 NSAID (Non Steriodal Anti Inflammatory Drug), Diazepam, Amiltriptyline, Imigran을복용하고있었다.
박용진외 : 물리적결박에의한상완신경총손상 1 례 / 501 Fig. 1. Brachial plexus anatomy 사지의근력에는이상소견은없었다. 신경학적검사상글라스고우혼수척도 (Glasgow coma scales, GCS) 는 10점 ( 개안반응 :3, 응답반응 :3, 운동반응 :4) 이었고심부건반사는모두정상이었다. 내원당시실시한동맥혈가스검사는 ph 7,416, PaCO 2 36.1 mmhg, PaO 2 49.8 mmhg, HCO 3 23.1 mmol/l, SaO 2 86.1%, 일반혈액검사는백혈구 20,880/mm 3, 혈색소 12.7 g/dl, 일반화학검사는 Na/K/Cl 139/4.0/94 meq/l, Myoglobin 405 ng/ml, 그외특이소견없었다. 심전도검사상 140 회의동성빈맥이었으며흉부방사선검사상좌하엽에폐렴을의심하는소견을보였고혼미한의식때문에시행한뇌전산화단층촬영, 뇌척수액검사상특이소견은관찰되지않았다. 환자는간헐적으로혼미한의식을보이며침대위에서난동을부렸다. 내원 2 일째에환자간헐적인혼미한의식상태와폭력적인행동조절되지않아결박은유지된상태였으며혈액검사상특이소견은보이지않았다. 내원 3 일째에의식상태가명료해지면서보호자에의해결박이풀어졌고 Fig. 2. Physical restraint 응급의료센터내원당시혼미한의식과폭력적인행동이조절되지않아사지와흉부를솜붕대와탄력붕대를이용하여결박을시행하였고외상의흔적은없었다 (Fig. 2). 생체징후는혈압 170/100 mmhg, 맥박수 108 회 /min, 호흡수 28회 /min, 체온 36.0 였다. 간헐적혼미한의식상태와제어되지않는행동을보이며외상의흔적은없었고흉부검진상빠른호흡과빈맥외에특이사항없었으며복부검진, 그후환자는갑자기왼쪽상완부의근력저하와작열감, 저림을호소하였다. 이에시행한쇄골, 흉부, 경골, 양측어깨단순방사선소견상특이소견은보이지않았으며신체검사상좌측상완부와엄지손가락, 손바닥부근의감각약화를호소하였고척골쪽손목굽힘근의운동능력은유지되나좌측이두근, 삼두근, 어깨세모근, 요골쪽손목굽힘근은우측에비해운동능력이떨어져보였다. 3 주후신경유발전위검사, 근전도, 신경전도검사를예약하였고본원입원치료권유드렸으나자의퇴원하였다. 내원 3 주후검사위해내
502 / 대한응급의학회지 : 제 17 권제 5 호 2006 원한환자는계속왼쪽상완부의근력저하와작열감, 저림등을호소하였고신체검사상처음과큰변화없었으며체성감각유발전위 (Somatosensory evoked potential, SEP) 검사는정상이었고 (Table 1), 근전도와신경전도검사에서상부줄기 (upper trunk) 신경손상의상완신경총손상이의심되는소견을보였다 (Table 2,3). 계속보존적치료에도불구하고내원 3, 6개월후환자는동일한증상을호소하였으며근전도및신경전도소견도동일하였다. 내원 12 개월후왼쪽상완부의감각, 운동신경의영구장애로상완신경총손상진단하에장애진단서발급되었다. 고찰상완신경총손상의원인은교통사고, 낙상및추락사고, 칼에의한손상, 기계에손이빨려들어가는경우, 출생시태아의손상등이지만오토바이사고에의한경우가가장많은데, 어깨와머리사이가과도하게견인되어상완신경총이신장되어늘어나는대부분견인손상이다. 이때심하면신경근에서뽑히게되는데손상당시상지의외전각도 에따라 90 로견인된경우에는제 7경추부위가, 90 이상으로견인된경우는제 8경추와제 1흉추부위가, 상지가하부로견인된경우는제 5, 6경추부위가손상되기쉽고, 때로는견관절탈구나골절, 쇄골골절이나쇄골하혈관등이같이손상되는경우가있다 1-3). 임상적유형은가장특이적으로상완신경총손상시근력마비가있으며이는완전마비부터부분마비까지여러형태로나타나지만, 이런기능마비에대해포괄적으로언급한보고는많지않다. Millesi 4) 는주관절마비가가장많고다음으로완관절마비, 수지마비의순으로많다고보고하였다. 상완신경총의상부줄기가주로손상된 Erb 형마비는견관절외전근및외선근이마비되어상박이내전및내선된상태가되고또한주관절굴곡근및외선근의마비가초래되지만원위부전박이나손의기능은정상이며그예후도비교적좋다 5-7). 반면에상완신경총의하부줄기가주로손상된 Klumpke형의마비는견관절및상박의운동근은보존되나손과원위부전박의근육의마비를초래하게되며예후도비교적나쁘다 5,7). 상완신경총손상여부를알기위해서는임상증상과이학적검사를포함하여전기진단검사를실시하여정확한진단 Table 1. Somatosensory evoked potential study Stimulation Site Recoring Latency (msec) Significant Rt. median nerve(at wrist) Scalp (Cz'-Fz) N19--19.40 (4.40uv) Normal Lt. median nerve(at wrist) Scalp (Cz'-Fz) N19--19.60 (3.20uv) Normal Rt. ulnar nerve(at wrist) N19--19.50 Normal Lt. ulnar nerve(at wrist) N19--19.80 Normal Table 2. Nerve conduction study Nerve Segment DL (msec) A (mv) NCV (m/sec) Rt/Lt Rt/Lt Rt/Lt Motor Median (Elbow-APB) 4.9/3.4 4.0/17 36/57 Ulnar (Elbow-ADQ) 3.0/2.8 9.0/10 68/70 Axillary (Erb's point-deltoid) 4.8/2.9 3.0/10 Musculocutaneous (Erb's point-biceps) 7.5/5.1 3.5/7.0 Suprascapular (Erb's point-ss) 5.4/2.5 3.2/7.0 Radial (Erb's point-eip) 5.2/3.2 1.0/6.0 24/70 Sensory Median (2nd finger-wrist) 4.6/3.5 18/30 Ulnar (5th finger-wrist) 2.8/3.0 34/40 Radial (Thumb-wrist) 5.0/3.0 8/28 DL: Distal Latency APB: Abductor Pollicis Brevis A: Amplitude ADQ: Abductor Digiti Quinti NCV: Nerve Conduction Velocity SS: Supraspinatus EIP: Extensor indicis Pollicis
박용진외 : 물리적결박에의한상완신경총손상 1 례 / 503 과병변부위의확인을하여야만한다. 이학적검사상상지와몸통부위의근위축, 견관절의아탈구, 견갑골의익상, 교감신경장애소견, Honer증후군, 상박골및상지골의골절, 근력및감각기능저하, 상지관절의운동제한, Tinel 증후군, 혈관박동여부를검사하여야하고단순방사선촬영상에서는경추의골절, 쇄골골절, 견관절탈구여부와횡경막거상여부를관찰, 호흡신경의손상여부를추정한다. 전산화단층촬영, 자기공명영상검사등도도움이되며근전도검사와신경전도검사를시행하여상완신경총의손상부위를알수있어야한다. 전기진단검사를시행할때에는근전도검사와신경전도검사를함께시행하여야하며, 1986년 Maiorchik 등 8) 과 2002년 Van Beek 9) 는상완신경총손상의진단을위해체성감각유발전위를검사하는것도유용하다고보고한바있다. 또한경추조영술은수상후 4주후부터시행한다. 상완신경총손상의치료는보존적요법과수술적요법으로대변할수있다. 개방성창상을동반한신경손상의경우, 창상의처치와함께신경손상의정도를정확하게검사한후신경봉합을하게되나, 비개방성손상에의한신경마비의경우는자연회복의가능성유무를판단하여보존적치료를할것인지수술적치료를할것인지결정하여야한다. 외상이없이견인손상인경우에는, 약 3개월정도기다려신경기능의회복여부를관찰한다음, 회복되지않으면손상신경에대한재건술을시도한다. 상완신경총손상환자의치료방법결정에있어서가장중요한것은상부신 경절병변과하부신경절병변을구별하는것이다 10). 이중상부신경절병변의경우는봉합이불가능하므로처음부터재건술, 신경재생또는보존적요법으로치료하는것이타당하겠으며하부신경절병변의경우는봉합이가능하므로일차적으로수술을시도할수있다. 이를구별하기위한문진, 이학적검사, 전기진단검사, 감각신경전도검사, 경추부척수조영법, 척추전산화단층촬영등여러방법들이있으나상완신경총의변형과진단방법들의오차로정확한병변부의진단은상당히어려움이있으나최근미세수술의발달로수술에의한치료법이예후가좋아짐에따라이를조기에구별하여야할필요성도증가하였다 11). 대부분상완신경총의손상부위가예후에영향을미치는가장중요한요인이라고생각되는데, 즉신경절이전병변보다신경절이후병변이, 하부줄기병변보다상부줄기병변이쇄골상부병변보다쇄골하부병변이예후가좋은것으로발표되고있다 12-15). 응급의료센터내에서의식이혼미한환자가진정이되지않고계속난동을보이면약물적및물리적방법을사용하여진정을시키고있으나약물적방법에무리가있을경우물리적방법을사용하여결박을하고있는데, 응급의료센터내에서솜붕대와탄력붕대를이용하여사지를물리적으로결박한후사지관절의움직임과감각을지속적으로검사하여신경손상의발생가능성을평가하여야하며환자가한쪽어깨, 손목, 팔꿈치부위의운동, 감각신경이상을호소하면상완신경총손상을반드시의심해보아야한다. Table 3. Electromyographic findings of right upper extremity (Initial examination) Muscle Insertional Spontaneous activity Motor unit potential activity FP 1) PSW 2) FSP 3) Recruitment Dur/Amp 4) Abductor pollicis brevis Increased ++ ++ Decreased P 5) /S 6) Abductor digiti minimi N 7) N N Dorsal interossei N N N Flexor carpi radialis Increased ++ ++ Decreased P/S Flexor carpi ulnaris N N N Extensor carpi radialis Increased ++ Decreased P/S Biceps brachi Increased ++ ++ Decreased P/S Triceps brachi Increased ++ ++ Decreased P/S Deltoideus Increased ++ ++ Decreased P/S Supraspinatus Increased ++ ++ Decreased P/S Infraspinatus Increased + ++ Decreased P/S Phomboideus major N N N 1. FP: Fibrillation potentials 2. PSW: Positive sharp wave 3. FSP: Fasciculation potentials 4. Dur/Amp: Duration/Amplitude 5. P: Prolonged 6. S: Small 7. N: Normal
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