대한척추외과학회지제 14 권제 2 호 Journal of Korean Spine Surg. Vol. 14, No. 2, pp 110~114, 2007 급성마미증후군환자의수술적치료후 May-Thurner 증후군으로생긴심부정맥혈전증 - 증례보고 - 유정현 김형수 정수태 박재형 김주학 차승도 정광규 박상준 관동대학교의과대학명지병원정형외과학교실 Deep Vein Thrombosis in May-Thurner Syndrome Patient after Operative Treatment of Acute Cauda Equina Syndrome - A Case Report - Abstract Jeong-Hyun Yoo, M.D., Hyung-Soo Kim, M.D., Soo-Tai Chung, M.D., Jai-Hyung Park, M.D., Joo-Hak Kim, M.D., Seung-Do Cha, M.D., Kwang-Gyu Jung, M.D., Sang-Joon Park, M.D. Department of Orthopaedic Surgery, Kwandong University, College of Medicine, Kyunggi, Korea May-Thurner syndrome, compression of the left common iliac vein by the right common iliac artery, or intimal hypertrophy of the vein resulting from chronic pulsatile force of the right common iliac artery, may results in deep vein thrombosis on the left lower extremity. A patient presented to our facility with deep vein thrombosis caused by May-Thurner syndrome, and showed post-operative fever, pain, and tenderness over the left leg, showing severe lumbar disc herniation with acute cauda equina syndrome. This syndrome should be considered as one of the causes of deep vein thrombosis in the left lower extremity. Key-Words: May-Thurner syndrome, Cauda equine syndrome, Deep vein thrombosis 서 론 May-Thurner 증후군은우측총장골동맥에의하여좌측총장골정맥이압박되거나, 동맥의맥박에의한만성적자극으로인해, 정맥의내막이증식되어내강이분할되거나좁아지는질환으로, 정맥의저류를유발하여만성적으로심부정맥혈전증을유발하기도한다 1,2,3). May- Thurner 증후군의발생빈도는전체하지정맥질환의약 2~5% 정도이고 3), 요추부유합술후심부정맥혈전증의발생도 3.7% 로보고된바있는데 4), 저자들은급성마미 증후군을동반한심한요추추간판탈출증환자를수술한후에발열, 좌측하퇴부동통및압통을보인환자에서 May-Thurner 증후군으로인해야기된심부정맥혈전증을경험하였기에문헌고찰과함께보고하는바이다. 증례보고 내원직전트럭추돌사고후발생한양측하지마비및대, 소변장애를주소로내원한 47 세남자로, 이학적검사상양하지의근력약화및감각저하를보였고, 요 Address reprint requests to Hyung-Soo Kim, M.D. Department of Orthopaedic Surgery, Myongji Hospital, Kwandong University, College of Medicine 697-24 Hwajung-dong, Dukyang-ku, Koyang, Kyunggi, 412-270, Korea Tel: 82-31-810-5429, Fax: 82-31-810-6537, E-mail: kimknee@kd.ac.kr 본논문의요지는 2006 년제 50 차대한정형외과학회추계학술대회에서발표되었음. - 110 -
급성마미증후군환자의수술적치료후 May-Thurner 증후군으로생긴심부정맥혈전증 - 증례보고 - 유정현외 추부자기공명영상소견상요추 2-3 번간, 3-4 번간의심한추간판탈출증소견을보여급성마미증후군으로진단되었다 (Fig. 1). 증상발현 12 시간이내에후방감압술및기기고정술을이용한후외방유합술을시행하였다 (Fig. 2). 수술후 1 주부터혈구침강속도와 C- 반응성단백질수치가증가되고경도의발열이지속되었으며수술부위의감염소견은없었다. 양측상지의정맥주사부위의발적및종창의소견이있어정맥염진단하에항생제투여를시행하였으며정맥염의소견은수일내소실되었으나혈구침강속도는 71, C- 반응성단백질수치가 13.13 으로감소하지않고수술후 3 주부터는 38 C 이상의발열증세를보였다. 추시자기공명영상을촬영하였으나심부감염소견은없었으며, 이학적검사상좌측하퇴부의동통, 압통및 Homan 징후양성소견보여심부정맥혈전증의심하에시행한하지혈관조영전산화단층촬영소견상제 4 요추높이에서정맥내강의외부압박에의한협소소견과좌측총장골정맥부위의혈전이보였으며좌측하퇴부에도심부정맥혈전이보였다 (Fig. 3, 4). 응급으로하대정맥여과장치삽입및혈전제거술을시행하였고, 다음날좌측총장골정맥의압박부위에스텐트를삽입하였다 (Fig. 5). 스텐트삽입직후발열은없었으며술후 4 주에혈구침강속도와 C- 반응성단백질수치도정상으로회복되었다. 맥의압박과동맥의맥박에의해정맥내피가자극되어증식이유발되었을것으로보고하였다. Cockett 과 Thomas 5) 는우측총장골동맥이좌측총장골정맥을압박하여발생되는장골정맥압박증후군과이로인한급성장골대퇴심부정맥혈전증의특징을최초로기술하고, 우측에비해좌측에심부정맥혈전증이더잘발생함을기술하였다. 이를동반한환자에서증상이없을수 고 찰 May 와 Thurner 1) 는사체연구를통해 22% 에서우측총장골동맥에의한좌측총장골정맥의압박을기술하고, 정맥내막의변화에의해정맥이막혀있는병변을보고하였으며, 이는우측총장골동맥에의한좌측총장골정 Fig. 2. Simple lateral radiograph shows posterolateral fusion with instrumentation. Fig. 1. MRI finding of Lumbar spine. (A) Sagittal T2-weighted MRI of lumbar spine shows severe herniated lumbar disc in lumbar area. (B) Axial T2-weighted MRI of lumbar spine shows severe lumbar disc herniation between L2 and L3. (C) Axial T2- weighted MRI of lumbar spine shows severe lumbar disc herniation between L3 and L4. - 111 -
대한척추외과학회지 Vol. 14, No. 2, 2007 Fig. 3. A picture shows compression of left common iliac vein by right common iliac artery. Fig. 4. CT venogram shows compression of left common iliac vein by right common iliac artery. Fig. 5. Stent is inserted to the compressed site of left common iliac vein. 도있는데, 이는잘발달된측부정맥에기인한다고주장하였다. 본증례에서도수술전심부정맥혈전증을의심할수있는증상이나, 이학적소견이없어혈관에관한별도의검사없이수술을시행하였다. 수술전, 후 lordosis 의변화소견은없어수술후 May-Thurner 증후군이 발생한것보다는증상이없던 May-Thurner 증후군환자에서수술후침상안정에의해심부정맥혈전증이병발한것으로사료된다. May-Thurner 증후군의발생빈도는전체하지정맥질환의약 2~5% 정도이고 3), 하지심부정맥혈전증의약 12~20% 정도를차지하며 6) 좌측장골대퇴정맥혈전증원인의약 50~60% 로보고되고있다 7). 요추부유합술후심부정맥혈전증은 3.7% 에서발생하며 4), 우리나라의경우 1.3% 에서발생한다고보고되었다 8). 이를예방하기위해 40 세이상의고령, 악성종양에대한수술, 전방도달술기, 장시간의수술, 수술전후활동감소와같은위험요인이있는환자의경우, 수술전, 후로저분자량 heparin (low-molecular-weight heparin) 이나, 저용량미분할 heparin (low-dose unfractionated - 112 -
급성마미증후군환자의수술적치료후 May-Thurner 증후군으로생긴심부정맥혈전증 - 증례보고 - 유정현외 heparin) 의사용과간헐적인풍선압박이유용할수있다고하며, 이런위험요인이없는환자에서는조기의지속적인활동이권장되고있다 9). Salzman 과 Harris 10) 는임상적으로혈전은술후 1 주에서 2 주사이에주로형성된다고하였으며, 본증례에서는증상발현이술후 1 주부터된것으로판단된다. 심부정맥혈전증은임상적인증상으로는 25% 정도만진단될정도로정확도가떨어진다고하며, 혈전증의약 50% 에서는임상적으로아무런증상이없다고하였다 10). 진단방법으로교차연계 fibrin 의파괴산물인 D- 이량체의혈액내상승은진단의특이도가낮으며, 혈구침강속도와혈액내 C- 반응성단백질의상승은심부정맥혈전증과의상관관계는아직논란이많으나심부정맥혈전증의급성염증반응과관련이있다 11). 심부정맥혈전부위에서의표재피부의온도상승및적외선을이용한체열촬영술도약 90% 의감수성을갖는다 12). 저자들의증례에서혈구침강속도증가와 C- 반응성단백질의상승은심부정맥혈전증의급성염증반응에의한것으로사료되며, 38 C 이상의발열증세는심부정맥혈전부위의온도상승에기인한것으로사료된다. 초음파를이용한진단은비침습적이고반복적으로시행할수있으며, 비교적가격이저렴하고진단율이높은장점이있어선별적인검사로유용하나, 하퇴부로갈수록진단율이떨어지며검사자의기술및경험에따라결과가달라질수있는단점이있다 10,12,13,14). 정맥조영술은 99% 이상의정확도를보여확진수단으로주로사용되나동통을유발하고, 침습적이며, 비용과시간이많이필요할뿐만아니라조영제자체에대한과민반응과신부전을초래할수있고정맥혈관내피의손상으로인해 1~3% 에서심부정맥혈전을유발하는단점이있다 14). 그밖에심부정맥의유통성 (patency) 을확인하거나, 혈전에선택적으로부착되는방사성동위원소를사용하는검사가있다 10). 본증례의경우전산화단층촬영을통한정맥조영술로진단하였는데저자들은이검사가필요한시간과비용이적고환자의협조여부에큰영향을받지않는장점이있는것으로판단된다. May-Thurner 증후군으로인한심부정맥혈전증에대한치료로는최근스텐트의삽입을통한혈관내술기의유용성이보고되고있다 2). 본증례에서도하대정맥여과기삽입, 혈전용해후스텐트를삽관하여치료하였다. 심부정맥혈전증의수술전, 후의예방이무엇보다중요할것으로판단되는데위험요인이있는환자에서는증상이없더라도수술후 1~2 주에심부정맥혈전증의선별검사가필요할것이다. 위험요인이없는본증례의경우에서와같이척추수술후발열과혈구침강속도, C- 반응성단백질증가가있는경우에는수술부감염과함께심부정맥혈전증을의심해보아야하며, 특히좌 측하지에만발생한심부정맥혈전증의경우 May- Thurner 증후군도고려해야할것으로사료된다. 참고문헌 01) May R, Thurner J: The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology 1957; 8: 419-427. 02) Patel NH, Stookey KR, Kertcham DB, Cragg AH: Endovascular management of acute extensive iliofemoral deep venous thrombosis caused by May-Thurner syndrome. J Vasc Interv Radiol 2000; 11: 1297-1302. 03) Taheri SA, Williams J, Powell S, et al.: Iliocaval compression syndrome. Am J Surg 1987; 154: 169-172. 04) Turner JA, Ersek M, Herron L, et al.: Patient outcomes after lumbar spinal fusion. JAMA 1992; 268: 907-911. 05) Cockett FB, Thomas ML: The iliac compression syndrome. Br J surg 1965; 52: 816-821. 06) Markel A, Manzo RA, Bergelin RO, Strandness DE Jr: Pattern and distribution of thrombi in acute venous thrombosis. Arch Surg 1992; 127: 305-309. 07) Mickley V, Schwagierek R, Rilinger N, Gorich J, Sunder-Plassmann L: Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation. J Vasc Surg 1998; 28: 492-497. 08) Lee HM, Suk KS, Moon SH, Kim DJ, Wang JM, Kim NH: Deep vein thrombosis after major spinal surgery: Incidence in an East Asian population. Spine 2000; 25: 1827-1830. 09) Geerts WH, Heit JA, Clagett GP, at al.: Prevention of venous thromboembolism. Chest 2001; 119: 132-175. 10) Salzman EW, Harris WH: Prevention of venous thromboembolism in orthopedic patients. J Bone and Joint Surg 1976: 903-913. 11) Lehr S, Vormittag R, Vukovich T, at al.: Basal highsensitivity-c-reactive protein levels in patients with spontaneous venous thromboembolism, Thromb haemost 2005: 488-493. 12) Goldhaber SZ: Pulmonary Embolism and Deep Vein Thrombosis. Philadelphia, WB Saunders Co: 79-97, 1985. 13) Kearon C, Julian JA, Newman TE, Ginsberg JS: Noninvasive diagnosis of deep vein thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative. Ann Inter Med 1998; 128: 663-677. 14) White RH, Goulet JA, Bray TJ, Daschbach MM, - 113 -
대한척추외과학회지 Vol. 14, No. 2, 2007 McGahan JP, Hartling RP: Deep-vein thrombosis after fracture of the pelvis; assessment with serial duplex-ultrasound screening. J Bone and Joint Surg 1990: 495-500. 국문초록 May-Thurner 증후군은우측총장골동맥에의하여좌측총장골정맥이압박되거나, 동맥의맥박으로인한정맥내막증식으로내강이좁아지는질환으로, 좌측하지의심부정맥혈전증을유발할수있다. 저자들은급성마미증후군을동반한심한요추추간판탈출증환자를수술한후에발열, 좌측하퇴부동통및압통을보인환자에서 May-Thurner 증후군으로인해야기된심부정맥혈전증을경험하였기에문헌고찰과함께보고하는바이며, 좌측하지에만발생한심부정맥혈전증의원인으로본증후군도고려해야할것으로사료된다. 색인단어 : May-Thurner 증후군, 마미증후군, 심부정맥혈전증 통신저자 : 김형수경기도고양시덕양구화정동 697-24 관동대학교의과대학명지병원정형외과학교실 Tel: 82-31-810-5429 Fax: 82-31-810-6537 E-mail: kimknee@kd.ac.kr - 114 -