Journal of Korean Society of Spine Surgery Cervical Intervertebral Disc Calcification in Children - A Case Report- Dong-Eun Shin, M.D., Chang-Soo Ahn, M.D., Yong-Suk Cho, M.D. J Korean Soc Spine Surg 2011 Dec;18(4):254-258. Originally published online December 31, 2011; http://dx.doi.org/10.4184/jkss.2011.18.4.254 Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2011 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this article, along with updated information and services, is located on the World Wide Web at: http:///doix.php?id=10.4184/jkss.2011.18.4.254 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.
Case Report pissn 2093-4378 eissn 2093-4386 J Korean Soc Spine Surg. 2011 Dec;18(4):254-258. http://dx.doi.org/10.4184/jkss.2011.18.4.254 Cervical Intervertebral Disc Calcification in Children - A Case Report- Dong-Eun Shin, M.D., Chang-Soo Ahn, M.D.*, Yong-Suk Cho, M.D. Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Korea Department of Orthopaedic Surgery, CHA Gumi Medical Center, CHA Hospital, Korea* Study Design: A case report. Objectives: This case report presents a child who was treated conservatively after having being diagnosed with cervical intervertebral disc calcification. Summary of Literature Review: Cervical intervertebral disc calcification is considered as a degenerative change of spine. It is common in adults and in most cases, no symptoms are observed. In children, by contrast, it is a rare condition and frequently accompanies symptoms such as severe neck pain and dysphagia. Materials and Methods: A 7-year-old male patient who suffered from neck pain and torticollis without trauma had been diagnosed with cervical intervertebral disc calcification and was treated conservatively. He was discharged after symptom relief, and has been followed up and observed in our outpatient department. Results: The improvements of symptom and radiographic findings were found in the month follow up. Conclusions: Cervical intervertebral disc calcification shows similar symptoms to laryngopharyngeal abscess, traumatic injury and infective spondylitis, but through careful physical examination and radiologic evaluation, differential diagnosis is possible. After diagnosis, conservative treatment alone is sufficient. Antibiotic usage and surgical treatment are avoidable. Key Words: Children, Cervical spine, Intervertebral disc, Calcification 서론 소아에서의추간판석회화증은 1924 년처음보고된이래현재까지약 200 례정도보고된드문질환이며, 퇴행성변환의일환으로나타나는성인에서의추간판석회화증과는다른원인과경과를취하는것으로알려져있다. 대부분상부경추에호발하며, 경추부통증, 사경및연하곤란과같은비특이적인증상을나타내기에농양이나감염성척수염, 그리고외상성손상과혼동될수있어항생제의남용및수술적치료등의과도한치료가시행될가능성이있어정확한문진, 이학적검사및영상학적검사를통한진단과안정및보존적치료를통하여호전된증례를보고하고자한다. 증례보고 환자는 7세된여아로내원 2주일전부터갑자기발생한좌경부동통및운동장해를주소로본원외래로내원하였다. 과거력상특이할만한병력이나외상은발견할수없었고, 이학적검사상, 경추부통증및경도의사경과함께목의신전시 심해지는통증으로경추부운동이제한되는소견이관찰되었 다. 그이외의견갑부및상지로방사되는신경학적이상은동 반되지않았다. 혈액검사및기타임상병리검사상백혈구가 13830/mm2 ( 정상치 4000~10000/mm2), 단핵구 72% ( 정상치 43~73%), ESR 33mm/hr ( 정상치 1~20mm/hr), CRP 5.16mg/ dl ( 정상치 0~0.3mg/dL) 로상승된것이외의다른특이소견은 보이지않았다. Received: September 3, 2011 Revised: November 28, 2011 Accepted: December 1, 2011 Published Online: December 31, 2011 Corresponding author: Chang-Soo Ahn, M.D. Department of Orthopaedic Surgery, CHA Gumi Medical Center, CHA University, 855 Hyungkok-dong, Gumi-si, Gyongsangbuk-do 730-040, Korea TEL: 82-31-780-5289, FAX: 82-31-708-3578 E-mail: techcho123@naver.com 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. 254 Copyright 2011 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Cervical Intervertebral Disc Calcification Fig. 1. Initial X-ray. Intervertebral disc calcification at C2-3 with right anterior hernication with inferior migration and associated retropharyngeal widening (A) AP view (B) Lateral view Fig. 2. Initial MRI. Acute symptomatic intervertebral disc calcification at C2-3 with right sided prevertebral hermiation of the calcification migrating inferiorly (A) T2WI Axial view (B) T1WI Sagittal view 255
Dong-Eun Shin et al Volume 18 Number 4 December 2011 Fig. 3. Spinal CT. Acute symptomatic intervertebral disccalcification at C2-3 with right sided prevertebral hermiation of the calcification migrating inferiorly (A) Axial view (B) Sagittal view 단순방사선소견상 (Fig. 1) 제 2, 3 경추간판이전하방으로탈출되어있는명확한음영증가소견이관찰되었다. 입원시 37.2 도의미열과혈액학검사상에서의미약한염증소견을보여추간판농양의감별위해초기에시행한자기공명영상소견상 (Fig. 2) 농양등의감염성질환소견은보이지않았으며, T1 및 T2 강조영상모두에서저신호강도를보이는석회화음영을관찰할수있었다. 또한척추강내수핵탈출및척수압박소견도보이지않아보존적치료로침상안정및 NSAID(Ibuprofen 20mg/ kg/day) 사용만을유지하며증상을관찰하기로했다. 내원 3일째경부의통증이완화되었으며, 혈액학적소견또한 ESR 16 mm/hr ( 정상치 1~20mm/hr), CRP 0.18 mg/dl ( 정상치 0~0.3mg/dL) 로감소하여석회화에대한정밀관찰위하여시행한전산화단층촬영상 (Fig. 3) 제 2, 3번경추간판의우측에전하방으로탈출되는모양의다발성석회화음영이관찰되었다. 보존적치료후통증, 경부의운동제한, 및사경등의모든증상이사라져입원 5일째퇴원하였으며 2개월추시관찰결과증상의재발및이학적검사상의이상은발견되지않았으며단순방사선소견상 (Fig. 4.) 석회화음영이감소되었음을관찰할수있었다. 고찰 소아에서특별한외상력없이생긴갑작스런경부통증과운동제한이있는경우, 가장먼저염증성질환및종양에대하여의심해보아야하며, 세균성추간판염, 골수염, 농양, 및척추염등의염증성질환과유골성골종및골모세포종등의종양성질환의감별진단을위해방사선학적검사와혈액검사를시행해야한다. 1) 추간판석회화증은퇴행성변화의일환으로증상없이성인에있어서흔하게나타나는반면소아에서나타나는추간판의석회화증은비교적드물어지금까지대략 200례정도가보고되어있다. 신생아에서부터청소년시기까지모두나타날수있지만 6~10 세에가장흔하게나타난다고알려져있으며, 2,3) 발병원인에대해서는이전에있었던외상과본례에서와같이혈역학적이상소견을들어염증성질환이제기되었지만뚜렷한연관성을찾아내지못하였다. 4) 그이외에도연골석회화증이나부갑상선항진증및비타민 D 과잉과같은대사성질환과의연관성에대해서도연구되었으나밝혀내지못하였다. 5) Swischuk 등은외상이나감염, 혈관염등의여러요인에의해유발된이차적인추간판내수핵으로의혈액공급장애가일시적인석회화를발생 256
Journal of Korean Society of Spine Surgery Cervical Intervertebral Disc Calcification Fig. 4. F/U X-ray after 2 months. Detcreased intervertebral disc calcification at C2-3 (A) AP view (B) Lateral view 시키고혈액공급의재개에의해서소실된다고주장하였다. 6) 주증상은경추부운동제한이나사경등을동반한경부동통이며드물게는경부의상지통을나타내기도한다. 경우에따라서는본례에서와같이 ESR/CRP 및백혈구등의염증을나타내는지표의증가와함께미열을동반하는경우가흔하게보고되나 7) 신경관의침범에의한방사통, 척추증등의신경학적증상을나타내는경우는거의없다. 8) Dai 등은증상이평균한달정도지속되며단순방사선상석회화는 5개월가량지속된다고보고했다. 4) 또한 Sonnabend 등은 90% 정도에서방사선상석회화소견이없어지나약 8% 가량에서는석회화음영이소실되지않았고다발성으로나타난군에서는각각의추간판석회화음영이서로다른속도로소실됨을보고하였다. 7) 성인과는달리소아에있어서는경추에가장호발하며증상또한흉추나요추에발병하는경우에비해경우에발병하는경우에비해급성증상을동반하는경우가많다. 5,9) 척추단순방사선소견상대부분수핵안에석회화가관찰되며, 척추체의형태변화가동반되나이러한방사선학적소견은증상의정도와는관련이없고, 4,10) 약 30% 의환아에서추간판돌출 (Protrusion) 이관찰되나이또한증상과는관련이없었다고보고하였다. 7) 결론 소아에있어서경추추간판석회화증은매우드문질환으로써이환된환아들은흔히사경및운동제한을동반한갑작스런경부통증호소한다. 이러한증상들은보존적치료만으로보통수주안에회복되며또한좋은예후를보인다. 다만감염성질환및종양에대한감별을위한최소한의검사는필요할것으로사료된다. REFERENCES 1. Herring JA, Hensinger RN. Cervical disc calcification. J Pediatr Orthop. 1988:8:613-6. 2. Gerlach R, Zimmermann M, Kellermann S, Lietz R, Raabe A, Seifert V. Intervertebral disc calcification in childhood a case report and review of the literature. Acta Neurochir (Wien). 2001:143:89-93. 3. Calderone M, Severino M, Pluchinotta FR, Zangardi T, Martini G. Idiopathic intervertebral disc calcification in childhood. Arch Dis Child. 2009:94:233-4. 257
Dong-Eun Shin et al Volume 18 Number 4 December 2011 4. Dai LY, Ye H, Qian QR. The natural history of cervical disc calcification in children. J Bone Joint Surg Am. 2004:86:1467-72. 5. Girodias JB, Azouz EM, Marton D. Intervertebral disk space calcification. A report of 51 children with a review of the literature. Pediatr Radiol. 1991:21:541-6. 6. Swischuk LE, Jubang M, Jadhav SP. Calcific discitis in children: vertebral body involvement (possible insight into etiology). Emerg Radiol. 2008:15:427-30. 7. Sonnabend DH, Taylor TK, Chapman GK. Intervertebral disc calcification syndromes in children. J Bone Joint Surg Br. 1982:64:25-31. 8. Bagatur AE, Zorer G, Centel T. Natural history of paediatric intervertebral disc calcification. Arch Orthop Trauma Surg. 2001:121:601-3. 9. Silverman FN. Calcification of the intervertebral disks in childhood. Radiology. 1954:62:801-16. 10. Dhammi IK, Arora A, Monga J. Calcified thoracic intervertebral disc at two levels as a cause of mid-back pain in a child: a case report. J Orthop Sci. 2002:7:587-9. 소아에서의경추추간판석회화증 - 증례보고 - 신동은 안창수 * 조용석차의과학대학교분당차병원정형외과학교실, 차의과학대학교구미차병원정형외과학교실 * 연구계획 : 증례보고목적 : 본연구의목적은소아의경추추간판에생긴석회화증에대해보존적인치료로완치된증례를보고하고자함이다. 선행문헌의요약 : 경추추간판의석회화증은척추의퇴행성변화의일종으로성인에게있어서는흔하게볼수있으며, 대부분특별한증상을나타내지않는다. 반면소아에있어서는매우드물게나타나며, 심한경추부통증과연하곤란등의증상을동반하는경우가흔하다. 대상및방법 : 특별한외상력없이경부통증과사경을주소로외래로내원한 7세남아는경추추간판석회화증을진단받고보존적인치료후증상호전되어퇴원하였으며이후 2개월후추시관찰하였다. 결과 : 본환자는정확한이학적검사및자기공명영상에의해경추추간판석회화증으로진단후보존적일치료만을시행증상호전되어 5일째퇴원하였으며, 2개월추시관찰상증상및영상의학적소견이호전되는양상을보였다. 결론 : 경추추간판석회화증은인후두농양이나외상성손상또는감염성척추염과감별해하지만, 진단후에는보존적치료만으로효과적이다. 색인단어 : 소아, 경추, 추간판, 석회화 약칭제목 : 경추추간판석회화증 258