246 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2013; 48: 246-250 http://dx.doi.org/10.4055/jkoa.2013.48.3.246 www.jkoa.org 민상혁 윤성현 이준열 단국대학교의과대학정형외과학교실 Intervertebral Foraminal Widening Caused by the Tortuous Cervical Vertebral Artery Sang-Hyuk Min, M.D., Sung-Hyun Yoon, M.D., and Joon-Yeul Lee, M.D. Department of Othopedic Surgery, Dankook University Medical College, Cheonan, Korea Tortuousity of the vertebral artery is clinically uncommon because it rarely causes symptoms. We described a patient with pain in the neck and both upper extremities in whom diagnosis of intervertebral foraminal widening and deformity of the vertebral artery were suggested by results of radiography and magnetic resonance. We confirmed the tortuous vertebral artery by results of computed tomography angiography. Correlation of the patient s symptoms and abnormalities was not clear; conservative treatment was administered. Key words: cervical spine, tortuous vertebral artery, computed tomography angiography 은임상적으로흔하 지않은병리소견이다. Hadley 1) 는최초로사체부검을통해이병 리의사례를발표한바있으며, 해외의여러논문에서사례연구 를통해이병리소견에대해서보고하였으나국내에서는아직보 고된자료가없다. 본사례연구에서는후경부동통및양측상지 의방사통을주소로내원한 72 세여자환자의단순경추방사선 촬영, 자기공명영상촬영및전산화단층촬영혈관조영술을이용 하여을진단받은 1 예에대하여문헌고찰과함께보고하는바이다. 증례보고 72 세여자환자가 1 년전부터시작된후경부동통및양측상지 전체의방사통을주소로내원하였으며, 시각통증등급은경부동 통이 5 점, 양측상지방사통이 4 점이었다. 환자의경추부병변에 Received February 4, 2013 Revised May 22, 2013 Accepted May 27, 2013 Correspondence to: Sang-Hyuk Min, M.D. Department of Orthopaedic Surgery, Dankook University Medical College, 201 Manghyang-ro, Dongnam-gu, Cheonan 330-715, Korea TEL: +82-41-550-3950 FAX: +82-41-556-3238 E-mail: osmin71@naver.com 대한이학적검사및신경학적검사는모두정상소견을보였다. 경추부측면방사선촬영에서경추 4-7 번간척추체간간격의축소와경추부좌측사면방사선촬영에서경추 3-4 번간추간공의확장소견을관찰할수있었다 (Fig. 1). 경추 4-7 번간의척추체간간격의축소는퇴행성변화에의한것으로생각되며확장된추간공의원인을파악하기위해자기공명영상촬영및전산화단층촬영혈관조영술을시행하였다. 자기공명영상촬영에서경추 3-4 번간에추간공의확장소견을보였으며, 내부로혈관으로의심되는관형의구조물이확인되었다 (Fig. 2). 의심되는구조물의정확한감별을위하여전산화단층촬영혈관조영술을시행하였으며, 검사상좌측경추추골동맥의고리임을확인할수있었고, 경추 3-4 번간좌측사행성경추추골동맥으로진단하였다 (Fig. 3, 4). 본증례에서는사행성경추추골동맥에의한신경압박소견이관찰되지않았으며, 방사통이좌측상지에국한된것이아니라양측상지에걸쳐전반적으로나타난점등을미루어보아사행성경추추골동맥에의한것으로생각되지않아추간공절개술이나신경감압술등의적극적인수술적치료보다는물리치료및약물치료를이용한보존적치료를시행하였으며, 이후증상의호전을보였다. The Journal of the Korean Orthopaedic Association Volume 48 Number 3 2013 Copyright 2013 by The Korean Orthopaedic Association 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.
247 Figure 1. Plain radiographs of the cervical spine in the lateral (A) and oblique plane (B) show C4-7 intervertebral space narrowing, C3-4 intervertebral foraminal widening. Figure 2. Sagittal (A) and coronal (B) T2 weighted magnetic resonance images show the left tortuous vertebral artery (arrows). 고찰 경추추골동맥은쇄골하동맥에서기시하여경추 6번의횡돌기공으로들어와상위경추를따라주행한다. 아주드문예에서경추추골동맥의신장및사행성변형이발견되며이로인해추간공의확장소견및인접척추체의골미란소견이관찰되기도한다. Hadley 1) 는 21예의사체부검을통한연구에서 4예의사행성경추추골동맥을발견하였으며사행성경추추골동맥으로인한인접척추체의골미란소견이관찰되었음을보고한바있다. 그러나임상에서사행성경추추골동맥은매우드문소견으로, 이에대하여보고된예가많지않다. Glover 등 2) 은사행성경추추골 동맥이경추부동통및상지방사통, 편두통등의증상을일으키기도한다는보고를한바있으나, 일반적으로경추추골동맥의변형이임상적증상을일으키는경우가많지않아임상적으로발견하지못하는것으로생각된다. 3,4) Freilich 등 5) 의연구에따르면사행성경추추골동맥은경추 4-5 번간에서가장흔하게발생하며경추 3-4 번간에서두번째로흔하다. 또한주로좌측경추추골동맥에주로발생하며, 양측성또는다발성으로발생하는경우는드물다고보고되고있다. 본증례에서는 Freilich 의연구결과에서처럼두번째로많이호발하는것으로알려져있는좌측경추 3-4 번간에서경추추골동맥의사행성변형이관찰되었으며, 경추부 3번추체후외측에골미
248 민상혁 윤성현 이준열 Figure 3. Sagittal (A) and coronal (B) reformatted images of 3 dimensional computed tomography angiography show the loop of the left vertebral artery in the widened C3-4 intervertebral foramen (arrows). Figure 4. Tridimensional image of the left tortuous vertebral artery (arrow). 란소견이관찰되었다. 방사선촬영상관찰된추간공의확장소견은여러가지원인에 의해서관찰될수있으며 Schimmel 등 6) 은신경섬유종, 신경초종 등의아령형태의종양들이종종이소견과관련되어나타날수 있고드물게수막종, 전이암또는형질세포종등이나타난다고 보고하였다. Danziger 와 Bloch 7) 는선천적척추경무형성증또한 이소견의드문이유중의하나라고보고하였으며외측수막류는 흉추에서척추체간공의확장을일으킨다고보고하였다. 이러한 종양과혈관변형과의감별을위하여자기공명영상촬영또는전 산화단층촬영혈관조영술이일반적으로사용되며, 5,8) 본증례에 서는자기공명영상촬영및 3차원재건영상을이용한전산화단층촬영혈관조영술을사용하여사행성척추추골동맥을진단하였다. 경추부의디스크제거술등의수술적치료중추골동맥의손상은약 0.5% 에서발생한다고알려져있으며, Smith 등 9) 은추골동맥손상이있었던 10예에대하여보고하는등추골동맥손상은경추부수술시가장주의해야할합병증중의하나로알려져있다. 일반적인경추부디스크제거술시구추관절의외측연까지감압술을시행하게되며, 이는추골동맥의주행경로와인접하기때문에매우주의해서감압술을시행하게된다. 추골동맥의사행성변형이있는경우에는동맥의직경이증가할뿐아니라정상적인추골동맥의주행과비교하여내측으로주행하기때문에구추관절에더욱가깝게위치하게된다. 따라서사행성추골동맥이있는환자의감압술시추골동맥손상의가능성이높아질수있으므로더욱주의해야할것으로생각한다. 사행성경추추골동맥이진단되었을때, 이변형과환자의증상과의상관관계를파악하는것이중요할것으로생각한다. Anderson 과 Shealy 3) 는사행성경추추골동맥에의한신경압박증상이있는경우에서추간공절개술이나신경감압술등의수술적치료가도움이될수있으며, Maiuri 등 10) 은환자의증상과병변과의상관관계가없다고판단하여보존적인치료를시행하여좋은결과를얻었음을보고하였다. 본증례에서도환자의임상적증상이사행성경추추골동맥과의상관관계가없다고판단하여물리치료및약물치료등의보존적치료를시행하였다. 사행성경추추골동맥은추간공확장소견의드문원인중의하나이며, 이와같은변형을보이는사례에서감별진단의하나로염두에두어야할것으로생각한다. 정확한감별진단을위하
249 여전산화단층촬영혈관조영술이나자기공명영상촬영이도움이될것으로생각한다. 이러한사행성경추추골동맥이진단되었을때이변형과환자의증상과의상관관계를파악하는것이중요하며, 본증례를포함한대부분의경우무증상이거나환자의증상과병변의상관관계가일치하지않는경우가많으므로치료방침의결정에신중을기해야할것으로생각한다. 참고문헌 1. Hadley LA. Tortuosity and deflection of the vertebral artery. Am J Roentgenol Radium Ther Nucl Med. 1958;80:306-12. 2. Glover JR, Kennedy C, Coral A. Tortuous vertebral artery-- onset of symptoms during pregnancy. Clin Radiol. 1990;41:66-8. 3. Anderson RE, Shealy CN. Cervical pedicle erosion and rootlet compression caused by a tortuous vertebral artery. Radiology. 1970;96:537-8. 4. Sganzerla EP, Grimoldi N, Vaccari U, Rampini PM, Gaini SM. Cervical vertebral erosion due to tortuous vertebral artery. Surg Neurol. 1987;28:385-9. 5. Freilich M, Virapongse C, Kier EL, Sarwar M, Bhimani S. Foramen transversarium enlargement due to tortuosity of the vertebral artery. Computed tomographic appearance. Spine (Phila Pa 1976). 1986;11:95-8. 6. Schimmel DH, Newton TH, Mani J. Widening of the cervical intervertebral foramen. Neuroradiology. 1976;12:3-10. 7. Danziger J, Bloch S. The widened cervical intervertebral foramen. Radiology. 1975;116:671-4. 8. Babin E, Haller M. Correlation between bony radiological signs and dolichoarterial loops of the cervical vertebral artery. Neuroradiology. 1974;7:15-7. 9. Smith MD, Emery SE, Dudley A, Murray KJ, Leventhal M. Vertebral artery injury during anterior decompression of the cervical spine. A retrospective review of ten patients. J Bone Joint Surg Br. 1993;75:410-5. 10. Maiuri F, Iaconetta G, Gallicchio B, Briganti F. Coiling of the vertebral artery presenting with neuralgic pain. Clin Neurol Neurosurg. 1997;99:56-9.
250 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2013; 48: 246-250 http://dx.doi.org/10.4055/jkoa.2013.48.3.246 www.jkoa.org 민상혁 윤성현 이준열 민상혁 윤성현 이준열 단국대학교의과대학정형외과학교실 사행성경추추골동맥은증상을일으키지않는경우가많아임상적으로발견하기어려운병리소견이다. 이번증례에서는후경부동통및양측상지의방사통을주소로내원한 72세여자환자의단순경추방사선촬영, 자기공명영상촬영에서추간공의확장및추골동맥의변형소견을발견하였으며, 전산화단층촬영혈관조영술을이용하여사행성경추추골동맥을진단하였다. 이에대하여환자의임상적증상과병리소견과의상관관계가일치하지않다고판단하여보존적치료를시행하였던사례에대하여문헌고찰과함께보고하는바이다. 색인단어 : 경추, 사행성추골동맥, 전산화단층촬영혈관조영술 접수일 2013 년 2 월 4 일수정일 2013 년 5 월 22 일게재확정일 2013 년 5 월 27 일교신저자민상혁천안시동남구망항로 201, 단국대학교의과대학정형외과학교실 TEL 041-550-3950, FAX 041-556-3238, E-mail osmin71@naver.com 대한정형외과학회지 : 제 48 권제 3 호 2013 Copyright 2013 by The Korean Orthopaedic Association 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.