Case Report pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2015 Sep;22(3):118-122. http://dx.doi.org/10.4184/jkss.2015.22.3.118 Posterior Ring pophysis Fracture ssociated with Lumbar Disc Herniation Treated by Immobile ony Fragment Excision - Case Report - Woo Dong Nam, M.D., Jae Hwan Cho, M.D.*, Jemin Yi, M.D., Jaewoo Lee, M.D. Department of Orthopaedic Surgery, College of Medicine Kangwon National University, Chuncheon, Korea Department of Orthopaedic Surgery, san Medical Center, College of Medicine, University of Ulsan, Seoul, Korea* Study Design: case report. Objectives: We report a case of posterior ring apophysis fracture (PRF) with lumbar disc herniation treated by immobile bony fragment excision. Summary of Literature Review: PRF causes severe radiculopathy, so treating with surgery is common. Materials and Methods: 30-year-old male diagnosed with PRF with lumbar disc herniation was treated with discectomy, but his clinical symptoms were not relieved. Consequently, bony fragment excision, extended laminectomy and interbody fusion were also done. Results: Radicular pain was relieved and showed good clinical outcome. Conclusions: When treating PRF, bony fragment excision and extended laminectomy should be considered even if an immobile bony fragment exists. Key Words: Posterior ring apophysis, ony fragment, Interbody fusion 서론 후방연골단판골절 (Posterior Ring pophysis Fracture, PRF) 은비교적흔하지않은병변으로주로신체활동이왕성한젊은연령의남자에서발견된다. 1) 명칭에있어서도후방연골단판분리증 (posterior ring apophyseal separation), 척추변연부골절 (fracture of the vertebral limbus) 또는후방 Schmorl 결절 (posterior Schmorl node) 등으로다양하게언급된다. 1,2) 성인에서발견되는 PRF는추간판탈출증환자의약 5.7% 에서관찰된다. 3) 대부분뚜렷한외상력을기억하지못하며추간판탈출증과유사한임상적양상을보이나, 소위 좌골신경통성측만 (sciatic scoliosis) 를포함하여보다심한신경근자극증상을호소하며, 1,4) 보존적치료의실패가단순추간판탈출증에비해서높다. 5,6) 수술적으로치료할경우에는추간판탈출증에대해시행되는최소침습적감압술에좋은결과를얻기도하나척추관을크게침범하는중심성병변의경우광범위한후궁절제술과골편절제, 심지어유합술이필요할수도있다 1,4,5,7) 저자들은 PRF 로내원하여단순추간판절제술로치료하였으나호전이없어광범위감압술및추체간유합술시행후호전 된치험예를바탕으로임상적고려사항과치료방법에대해고 찰하였다. 증례보고 30 세남자환자로 3 개월전부터발생한요통과좌측이더심한 양측하지방사통을주소로내원하였다. 병력상성장기를포함 하여기억하는외상력은없었으며내원전타병원에서시행받은 신경성형술을포함한여러시술과보존적치료에통증의호전 이없었다. 이학적검사상하지직거상검사는좌우각각 40 /40 였으며 Received: January 12, 2015 Revised: May 6, 2015 ccepted: ugust 12, 2015 Published Online: September 30, 2015 Corresponding author: Jemin Yi, M.D. Department of Orthopaedic Surgery, Kangwon National University Hospital 17-1 Hyoja 3-dong, Chuncheon 200-722, Korea TEL: +82-33-258-9209, FX: +82-33-258-2149 E-mail: firekimdo@gmail.com 118 Copyright 2015 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Posterior Ring pophysis Fracture (PRF) Treated y Immobile ony Fragment Excision Fig. 1. (-) sagittal and axial T2 weighted MRI of L4-5 level shows herniated disc material and bony fragment (white arrow) located centrally and markedly occupying the spinal canal space. ony defect (asterisk) was noted at the posterior endplate of L5. 신경학적검사상감각, 운동신경기능은정상이었다. 수술전통증정도는 Visual nalogue Scale (VS) 상요통이 8점, 하지방사통은좌측과우측이각각 8/4점이었고 Oswestry Disability Index (ODI) 는 31점이었다. 술전시행한단순방사선사진에서는특이소견이관찰되지않았다. 자기공명영상에서는요추제 4-5분절에탈출된추간판과제 5요추상위종판후방에서척추관내로돌출된골편및제 5요추종판후방의골결손을보여 PRF 로진단되었다 (Fig. 1). 최초수술은환자의주증상이좌측하지방사통임을고려하여좌측후궁일부절제술과추간판절제술을시행하였다. 수술중소견은신경근과경막이돌출된골편과유착이심하여세심한박리가필요하였고, 골편은후방척추체에완전히고정되어있었다. 골편은제 5요추종판후방에완전히고정되어있어추간판절제술만을시행하였다. 1,8) 추간판절제술후제 5요추신경근은감압되어자유로워진소견이관찰되었다 (Fig. 2). 수술후환자의좌측하지방사통은전혀호전이없었고오히려우측하지방사통은술전 VS 4점에서술후 6점으로악화되었다. 수술후시행한자기공명영상과전산화단층촬영상좌측함요부의감압된소견이관찰되었다 (Fig. 3). 경막외스테로이드주사를포함하여 2개월간보존적치료를하였으나통증이호전되지않아, 수술후 2개월에 2차수술을시행하였다. 2차수술은광범위양측후궁절제술후골편과추간판을 Fig. 2. n intraoperative microscopic photo shows adequate decompression at the lateral recess to the foramen and mobilization of the left L5 root. 만곡절골도 (curved osteotome) 과 Kerrison 천공기 (Kerrison punch) 를이용하여최대한절제하였다. 시야에서관찰되지않 는가장중앙부위의골편은 Ebstein 등 5) 과 sazuma 등 7) 의방 법과유사하게임팩터를이용하여전방의척추간으로밀어낸 후제거하였다. 골편절제를위해광범위후궁절제술을시행하였기에 2 차적 인척추분절간불안정증이우려되어, PEEK 케이지를이용하여 119
Woo Dong Nam et al Volume 22 Number 3 September 2015 Fig. 3. (-) Postoperative MRI and CT show a decompressed left lateral recess. Fig. 4. (-) fter second operation, a sagittal and axial MRI shows adequate decompression was done at the L4-5 level. 추체간유합술을시행하였다. 환자가젊은연령인점과골밀도가정상이므로기기고정술없이도케이지가침강하지않고골유합에문제가없을것으로기대하여기기고정술은시행하지않았다. 2차수술직후양측하지의방사통이호전되었으며자기공명 영상검사상수핵과골편의완전절제와경막의감압이충분함을확인할수있었다 (Fig. 4). 최종추시인술후 3년째에 VS 점수는요통이 3점, 하지방사통은좌, 우측이각각 3,1점으로양호한결과를보였으며 ODI 점수도술전 31점에서술후 8점으로호전되었다. 방사선소견상케이지의침강및케이지와추체간 120
Journal of Korean Society of Spine Surgery Posterior Ring pophysis Fracture (PRF) Treated y Immobile ony Fragment Excision Fig. 5. Postoperative views after three years, (-) The anteroposterior and lateral views of the plain radiograph show bony union. 저음영소견을보이지않아유합된것으로생각되었다 (Fig. 5). 토의 요추부위에서발생하는 PRF 는대개청소년기및청년기에발생하는것으로알려져있는데그이유는연골단판의형성과정과관련이있으며연골단판이척추체에유합되는 18세이전에외상을겪으면 Sharpy s fiber 에의해연골단판이견인되어발생하는것으로알려져있다. 9) 추간판탈출증의 5.7% 에서 PRF 가동반되는것으로보고되며, 많은사례에서간과되는경향이있다. 1,4) 또한성장기환자와달리성인환자의대부분은뚜렷한외상력을기억하지못한다 1,5). 증상은대개단순추간판탈출증보다심한신경근자극을호소하며보존적치료에실패하는경우가많으며, 5,6) 이러한점을치료계획시고려하여야한다. 저자들이경험한사례역시심한증상과보존적치료의실패로수술적치료를하게되었다. 수술적치료방법에있어서는아직다양한의견이소개되고있으며, 특히골편의절제필요유무와추가적유합수술의필요성에대해서는논란의여지가있다. Savini 등 4) 과 Epstein 등 5) 은만족스러운결과를얻기위해골편을절제해야함을주장하였으나후에 kahaddar 등 1) 과 Shirado 등 8) 은척추체에고정된골편의경우방사통의원인이골편이아닌탈출된추간판이므로골편을제거하지않아도되나고정되지않은골편의경우추간판탈출 증과골편의이탈이동시에일어난것으로생각되어골편을반드시제거해야함을주장하였다. 저자들역시단측방사통을호소하며작은골편이관찰되는두환자에대해단측접근에의한최소감압과수핵절제술만으로도좋은결과를얻은바있다. 그러나중앙부의큰골편이척추관을침범했을때는후방접근법의경우광범위한후궁절제술과일부후관절의절제를통해서만경막전방의골편절제가가능하다. 저자들은수술중골편이골단판후방에완전히고정되어있는것을확인하여골편절제술을시행하지않았다. 현미경시야상에서외측함요부에서신경공까지충분한신경근의움직임이허용될정도의수핵절제와감압을시행하였으나수술후증상이호전되지않았다. 2개월간의보존적치료에도불구하고증상이호전되지않아서 2차수술을통해광범위한감압술및추체간유합술을시행한후에야증상이호전되었다. 골편이골단판에고정되어있었으나단순추간판절제술만으로증상이호전되지않은이유는탈출된추간판및추체후방의골편에의한척추관압박이비교적심하였기때문으로생각된다. 골편의절제시에대개작은크기의절골도 (osteotome) 와 Kerrison 천공기 (Kerrison punch) 를사용하지만임팩터 (impactor) 를이용하여골편을전방으로밀어낸후제거하는방법이유용하다. 5,7) 유합술의추가필요여부에대해서는아직이견이있으나광범위한감압술로인해수술후분절간불안정증이우려되는경우에는유합술이필요하다. 4,7) 121
Woo Dong Nam et al Volume 22 Number 3 September 2015 PRF 가추간판탈출증에동반될경우수술적치료를요하는비율이높았으나, 1,4,5,7) 수술후예후는일반적수핵탈출증과유사한것으로보고되었으며합병증의발생역시유사한것으로보고되고있다. 1) 저자들의경험에서도경막과골편간의유착이관찰되었으나조심스런박리와과도한신경근견인을주의하여합병증발생없이수술이가능하였다. 향후골편및추간판의척추관침범정도와위치, 골절편의고정여부와술후임상적결과에대한전향적다중인자분석을통해 PRF 의병리에대한이해를도울수있을것으로생각된다. REFERENCES 1. khaddar, elfquih H, Oukabli M, oucetta M. Posterior ring apophysis separation combined with lumbar disc herniation in adults: a 10-year experience in the surgical management of 87 cases. J Neurosurg Spine. 2011;14:475-83. 2. eggs I, ddison J. Posterior vertebral rim fractures. r J Radiol. 1998:71:567 72. 3. Yang IK, ahk YW, Choi KH, Paik MW, Shinn KS. Posterior lumbar apophyseal ring fractures: a report of 20 cases. Neuroradiology. 1994;36:453 5. 4. Savini R, Di Silvestre M, Gargiulo G, Picci P. Posterior lumbar apophyseal fractures. Spine (Phila Pa 1976). 1991;16:1118 23. 5. Epstein NE. Lumbar surgery for 56 limbus fractures emphasizing noncalcified type III lesions. Spine (Phila Pa 1976). 1992; 17:1489 96. 6. Chang CH, Lee ZL, Chen WJ, Tan CF, Chen LH. Clinical significance of ring apophysis fracture in adolescent lumbar disc herniation. Spine (Phila Pa 1976). 2008;33:1750 4. 7. sazuma T, Nobuta M, Sato M, Yamagishi M, Fujikawa K. Lumbar disc herniation associated with separation of the posterior ring apophysis: analysis of five surgical cases and review of the literature. cta Neurochir (Wien). 2003;145:461-6. 8. Shirado O, Yamazaki Y, Takeda N, Minami. Lumbar disc herniation associated with separation of the ring apophysis:is removal of the detached apophyses mandatory to achieve satisfactory results? Clin Orthop Relat Res. 2005;(431):120 8. 9. anerian KG, Wang M, Samberg LC, Kerr HH, Wesolowski DP. ssociation of vertebral end plate fracture with pediatric lumbar intervertebral disk herniation: value of CT and MR imaging. Radiology. 1990;177:763 5. 고정된골편절제술로치료한요추추간판탈출증과동반된후방연골단판골절 - 증례보고 - 남우동 조재환 * 이제민 이재우강원대학교의학전문대학원정형외과학교실, 울산대학교서울아산병원정형외과학교실 * 연구계획 : 증례보고목적 : 고정된골편절제술로치료한요추추간판탈출증과동반된연골단판골절 1예를보고하고자한다. 선행문헌의요약 : 후방연골단판골절은심한신경근자극증상을일으켜수술적치료를요하는경우가흔하다. 대상및방법 : 요추추간판탈출증과동반된연골단판골절을진단받은 30세남자에서추간판절제술을하였으나호전이없어골편절제술, 광범위후궁절제술및추체간유합술을시행하였다. 결과 : 술후방사통이호전되었으며양호한임상결과를얻었다. 결론 : 연골단판골절을치료할때골편이고정된경우에도골편절제술및광범위후궁절제술을고려해야한다. 색인단어 : 후방연골단판, 골편, 추체간유합술 약칭제목 : 고정된골편을절제하여치료한연골단판골절 122