CASE REPORT http://dx.doi.org/10.5371/hp.2013.25.3.237 Print ISSN 2287-3260 Online ISSN 2287-3279 Septic Hip Arthritis with Iliopsoas Abscess Detected after Spine Operation : A Case Report Jae Min Ahn, MD, Jong Seo Lee, MD, Dong Joon Kang, MD, Ji Min Lee, MD Department of Orthopaedic Surgery, Pusan National University School of Medicine, Busan, Korea In the elderly patients who complain of pain in the buttock and leg, it is not easy to distinguish whether the pain comes from the lesion of the hip or from the spine. A 78-year-old female who was treated conservatively for persistent pain in the right buttock and leg after an operation for spinal stenosis in the local clinic visited our clinic. Septic hip arthritis with severe femoral head destruction and multiple abscesses in the buttock and iliopsoas muscle were diagnosed 2 months postoperatively, and spinal abscess in the site of the previous operation was detected by a subsequent MRI study. To avoid such a delay of the diagnosis and treatment, it is important to suspect hip joint lesion earlier for the source of persistent pain after a spine operation. Further more, diagnostic evaluation is necessary to rule out co-infection of the spine or iliopsoas muscle when a hip joint infection exists. Key Words: Septic hip arthritis, Iliopsoas abscess, Spine operation 서 론 고령환자에서흔한척추의만성퇴행성질환과급성화농성고관절염이동반된경우모호한증상으로감별이쉽지않고 1), 간과될경우패혈증으로진행하여생명이위험할수있다 2,3). 저자는수년간지속된둔부및하지통증으로척추의유합수술이시행되어, 진단및치료가지연된둔부 Submitted: April 22, 2013 1st revision: June 4, 2013 2nd revision: July 22, 2013 3rd revision: August 23, 2013 Final acceptance: August 25, 2013 Address reprint request to Dong Joon Kang, MD Department of Orthopaedic Surgery, Pusan National University Hospital, 1-10 Ami-dong, Seo-gu, Busan 602-739, Korea TEL: +82-51-240-7248 FAX: +82-51-240-8395 E-mail: cibacoll@hanmail.net 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. 농양을동반한화농성고관절염을경험하고치료하였기에보고하고자한다. 증례보고 78 세여자환자가우측둔부동통을주소로응급실로내원하였다. 과거력상고령과당뇨병, 뇌경색이있었고, 수년간하요추부통증및하지방사통으로타병원에서보존적요법으로치료받았으나최근증상이심하여시행한요추 MRI 상척추관협착증이관찰되어요추 4, 5 번 - 천추 1 번간감압술및척추유합수술을하였으며, 이후에도지속되는둔부통증에대하여보존적치료를받으며약 2 달경과후시행한고관절단순방사선검사및 MRI 상대퇴골두의심한손상을동반한고관절감염및둔부의농양이발견되어본원으로전원되었다 (Fig. 1). 응급실내원당시혈압수축기 100 mmhg, 이완기 60 mmhg, 맥박 84 회 / 분, 체온섭씨 36.4 C 였으며, 의식은기면상태였고, 혈액검사상백혈구 14.48 103/μL, 호중구 83.3%, 혈색소 10.2 g/dl, C- 반응성단백 25.53 mg/dl 이었다. 이학적검사상우측둔부의압통및국소부위열 Copyright c 2013 by Korean Hip Society 237
감, 부종이있었으며둔부부종부위에시행한근육천자상약 75 cc 의화농성농이흡입되었다. 타병원의고관절 MRI 상우측둔부의커다란농양및우측화농성고관절염이확인될뿐아니라, 우측장요근의농양및우측하요추부의금속삽입물주변에높은신호강도가관찰되어척추 MRI 를시행한결과척추유합부주위의농양이확인되었다 (Fig. 2). 응급수술을시행하여먼저복와위에서척추의이전절개를통하여접근하자농양이발견되어배양검사를실시하고기구제거및변연절제, 배액관삽입후상처를봉합한뒤, 좌측측와위에서우측장골능을따라서장골와 A B Fig. 1. (A) Plain X-ray shows femoral head destruction with acetabuluar subchondral bone involvement in the right hip joint. (B) MRI shows septic arthritis and buttock abscess with psoas muscle involvement in the right hip joint. A Fig. 2. (A) MRI shows right iliopsoas muscle infection. (B) MRI shows infectious finding in the previous spine operation site. B 238 www.hipandpelvis.or.kr
Jae Min Ahn et al.: Septic Hip Arthritis with Iliopsoas Abscess Detected after Spine Operation: A Case Report Fig. 3. Plain X-ray shows insertion state of unipolar antibiotics-mixed cement spacer after femoral head resection and debridement of right hip joint. Fig. 4. Plain X-ray shows the last follow up after the revision of 2nd stage reimplantation. A B C Fig. 5. Serial follow up lumbar plain X-rays checked at postoperative (A) 1 day, (B) 4 weeks, and (C) 8 weeks show gradual narrowing and destruction of the hip joint space in the right hip. www.hipandpelvis.or.kr 239
로접근하여장요근의농양을배액하고후외측도달법으로접근하여둔근내다량의농양을제거하였다. 대퇴골두및비구의심한파괴가관찰되어대퇴경부를절골하여대퇴골두를제거하고비구내손상된연골을변연절제한뒤다량의관류를시행하고, 항생제와시멘트를섞은후 threaded- Steinman pin을이용하여단극성 (unipolar) 형태의삽입물을만들어대퇴근위부에삽입하였다 (Fig. 3). 응급실내원당시의혈액배양검사와응급수술시의척추및고관절농양배양검사결과에서모두메티실린내성황색포도상구균이배양되어지속적인항생제치료및수회의변연절제술을시행하여 C-반응성단백의수치및상처의호전을보였으나, 섬망및담낭염의발생등전신상태의악화를보여, 외과적수술및내과적약물치료등으로전신상태가호전되기를기다린후 6개월째 AML (Anatomic Medullary Locking, Depuy, Warsaw, IN, USA) 대퇴주대와 Pinnacle (Depuy) 비구컵을이용하여고관절전치환술을시행하였다. 이후경과가호전되어퇴원하였으나여러차례의수술을포함한오랜기간의감염치료로연부조직이손상되고외전근이약화된결과우측고관절의반복적인탈구가발생하여고관절전치환술후 6개월째경부가긴대퇴골두를사용하여재치환술을시행하였지만여전히탈구가재발하여외전보조기를지속적으로착용하기로하였다. 재치환술후 2년째 Harris 고관절점수는 83점이며상처및혈액검사상감염의재발소견은보이지않고, 우측외전근의약화로인하여 Trendelenburg 양성소견을보이고있으며, 지팡이를이용한독립보행중이다 (Fig. 4). 여하요추및골반에서의감염이발생하면원위부로직접전파되어고관절및근위대퇴부의감염을초래할수가있으며, 반대로고관절의감염이골반내로파급될수있다 5). 즉요근이척추와고관절을연결시켜주는통로의역할을하며대부분원위부로의감염의전달이발생하며근위부로의감염의전달은드물다 6). 본증례에서는척추수술후발생한감염이요근을경유하여장골및고관절로전파되었을경우와반대로고관절의감염이척추수술부위로감염을전달시켰을경우의 2 가지가능성을고려할수있다. 최초척추수술당시의검사결과와병력을재검토한결과, 당뇨병이있었으며척추수술수일전에둔부에수차례침을맞았고, 척추수술전검사상백혈구 31.58 103/μL, C- 반응성단백 25.23 mg/dl 였다. 그러나고관절및요추단순방사선검사와요추 MRI 만시행되어최초의고관절감염의존재여부는명확히알수는없었다. 2 가지중어떠한경우라도고관절병변에대한진단및치료가지연될경우심각한후유증이초래될수있다. 척추수술후요추의추시단순방사선사진상이미우측고관절간격이점차감소되어완전히소실되는과정이관찰되므로이러한소견을미리인지하고고관절병변을의심하여적극적인검사를시행하였다면조기에진단및치료가이루어졌을것으로생각된다 (Fig. 5). 본증례와같은진단및치료의지연으로인한심각한후유증을피하기위하여척추수술후지속적인둔부및하지통증에대한원인으로서고관절병변의의심이필요하며고관절감염발생시척추및장요근감염의동반여부를감별하기위한적극적인진단적평가가필요하다. 고 찰 REFERENCES 척추질환및고관절질환이있는환자가호소하는증상은하지방사통을포함하거나포함하지않는둔부및서혜부동통이므로통증부위가명확하지않아서증상만으로척추질환과고관절질환을감별하기가쉽지가않다 1). 특히고령의환자에서척추의만성퇴행성질환과급성화농성고관절염이동반된경우기존의질환및모호한증상때문에고관절감염이간과될수있다. 화농성고관절염환자의상당수에서영구적인관절손상이진행되고, 전신상태의악화를초래하는다양한합병증이발생할수있으며특히고령의환자에서는사망률이증가한다 2,4,5). 요근은 12 번째흉추에서 5 번째요추사이의외측돌기및요추체외측면에서시작되어골반을가로지르며장근과합쳐져장요근이되어고관절전방부를거쳐대퇴골소전자에까지이르는근육이다. 이러한해부학적구조로인하 01.Kumagai K, Ushiyama T, Kawasaki T, Matsusue Y. Extension of lumbar spine infection into osteoarthritic hip through psoas abscess. J Orthop Sci. 2005;10:91-4. 02.Gavet F, Tournadre A, Soubrier M, Ristori JM, Dubost JJ. Septic arthritis in patients aged 80 and older: a comparison with younger adults. J Am Geriatr Soc. 2005;53:1210-3. 03.Gruenwald I, Abrahamson J, Cohen O. Psoas abscess: case report and review of the literature. J Urol. 1992;147: 1624-6. 04.Molloy A, Laing A, O Shea K, Bell L, O Rourke K. The complications of septic arthritis in the elderly. Aging Clin Exp Res. 2010;22:270-3. 05. Dala-Ali BM, Lloyd MA, Janipireddy SB, Atkinson HD. A case report of a septic hip secondary to a psoas abscess. J Orthop Surg Res. 2010;5:70. 06.Sadat-Ali M, al-habdan I, Ahlberg A. Retrofascial nontuberculous psoas abscess. Int Orthop. 1995;19:323-6. 240 www.hipandpelvis.or.kr
Jae Min Ahn et al.: Septic Hip Arthritis with Iliopsoas Abscess Detected after Spine Operation: A Case Report 국문초록 척추수술후발견된요장근농양을동반한화농성고관절염 : 증례보고 안재민 이종서 강동준 이지민부산대학교의과전문대학원정형외과학교실 고령환자에서둔부및하지동통을호소하는경우고관절과척추의병변을감별하기가쉽지않다. 본원응급실로방문한 78 세여자환자는타병원에서척추관협착증수술을받은후에도지속되는우측둔부및하지통증에대하여보존적치료하던중, 수술후약두달째시행한방사선검사상대퇴골두의심한손상및근위대퇴골을침범한화농성고관절염과둔부농양및장요근내농양이확인되어, 추가적으로시행된요추 MRI 상척추수술부위의농양이발견되었다. 이러한진단및치료의지연을피하기위하여척추수술후지속적인통증에대한원인으로서고관절병변의의심이필요하며고관절감염발생시척추및장요근감염의동반여부를감별하기위한적극적인진단적평가가필요하다. 색인단어 : 화농성고관절염, 장요근농양, 척추수술 www.hipandpelvis.or.kr 241