Journal of Korean Society of Spine Surgery Selective Laminoplasty For Cervical Myelopathy - 3 Cases Report - Dhong Won Lee, M.D., Jeong Gook Seo, M.D. J Korean Soc Spine Surg 2012 Sep;19(3):116-121. Originally published online September 30, 2012; http://dx.doi.org/10.4184/jkss.2012.19.3.116 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.2012.19.3.116 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. 2012 Sep;19(3):116-121. http://dx.doi.org/10.4184/jkss.2012.19.3.116 Selective Laminoplasty For Cervical Myelopathy - 3 Cases Report - Dhong Won Lee, M.D., Jeong Gook Seo, M.D. Department of Orthopedic Surgery, Inje University, Seoul Paik Hospital, Seoul, Korea Study Design: 3 cases report. Objectives: We present 3 cases of cervical myelopathy treated successfully by selective laminoplasty on 2 levels or less, using Kurokawa technique with a review of the relevant articles. Summary of Literature Review: As there were no clear criteria for the numbers of the laminae that require decompression in a standard laminoplasty, a wide level laminoplasty from C3 to C7 has been generally done. As a result, complications such as axial pain, C5 root paresis, and loss of range of motion have been reported commonly. To reduce these complications, recent studies have attempted less invasive procedures, such as selective laminoplasty or preservation of posterior ligament and muscle components. Materials and Methods: There were two cases of developmental stenosis and one posterior compressive stenosis that underwent selective laminoplasty. The posterior shift of the spinal cord and the dural expansion were measured by magnetic resonance imaging at 3 or 4 weeks after surgery. Clinical outcomes were evaluated by Japanese Orthopedic Association (JOA) score. Axial pain was classified as follows; never: Grade 0; mild: Grade 1; moderate: Grade 2; and severe: Grade 4. Results: The spinal cord had a tendency to shift posterioly and the dura mater was expanded in all cases. Clinical outcomes and axial pain were also improved in all. Conclusions: Selective laminoplasty that enabled the surgeon to perform a less invasive surgery preserving operative time and the patient to have a lower risk of C5 root paresis is effective for the developmental stenosis or posterior compressive stenosis less than 3 levels. Key Words: Cervical myelopathy, Selective laminoplasty 서론 경추척수증에대한수술적치료로서한, 두부위에국한된전방압박괴 (anterior compression mass) 1) (Fig. 1) 에의한척수압박은일반적으로전방도달감압술을시행하지만, 3부위이상의다발성협착이나척추관의직경이 13mm 이하의발달성협착 (developmental stenosis), 또는황색인대비후등의후방구조물의압박에의한척수증은후방도달감압술을시행해야충분한감압효과를기대할수있다. 후방도달감압술로서수술후불안정을초래하는추궁판절제술보다후방골성구조물을만들어줌으로써신전근의기능을유지하게해주는추궁판성형술이널리시행되고있고여러문헌들에서좋은결과가보고되었다. 2,3) 그러나일반적으로추궁판성형술은척수의후방전위를위해제3 경추부터제 7경추까지광범위하게시행되기때문에수술후축성경부통증, 5번경추신경의마비, 경부운동범위의감소등이흔한것으로보고되고있다. 4) 이러한합병증을줄이기위한방안으로선택적감압술, 후방인대근육복합체의보 존등의덜침습적인방법들이시도되고있다. 1,5,6) 저자들은 3 례 의경추척수증환자에서 Kurokawa 방법 4) 을이용한선택적추 궁판성형술을시행하여좋은임상결과를얻었기에문헌고찰과 함께보고하는바이다. Received: March 5, 2012 Revised: May 15, 2012 Accepted: June 4, 2012 Published Online: September 30, 2012 Corresponding author: Jeong Gook Seo, M.D. Department of Orthopedic Surgery, Inje University, Seoul Paik Hospital, 85, 2-Ga Jeo-dong, Jung-Gu, Seoul, Korea TEL: 82-2-2270-0028, FAX: 82-2-2270-0023 E-mail: hd1404@hanafos.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. 116 Copyright 2012 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Selective Laminoplasty for Cervical Myelopathy 증례보고 증례 1 39세남자로내원 6개월전넘어지면서턱을바닥에부딪힌후후경부통증및양측손과발이저린증상이나타났다. 내원 1 개월전부터는목을뒤로젖히는동작시에양측하지의힘이빠지고, 양측손과발의저림이심해져내원하였다. 이학적검사상상하지근력감소및병적반사는없었으나양측손과발에서일정신경근지배영역과일치하지않는감각이상을보였고보행이부자연스러웠다. 배뇨장애로는최근 1개월내 3차례의실변을호소하였다. 종합적으로 Japanese Orthopedic Association (JOA) 점수는 13점이었다. 단순방사선측면사진에서경추 3,4 번의전후척추관직경은 11mm 정도이었고, Pavlov 비율 (Fig. 2) 7) 은 0.6과 0.63 으로척추관전후직경협소를보였다. 7) 자기공명영상검사상 T2 강조시상면에서경추 3,4번사이의전방압박괴의크기는 2.89mm 이었고, 횡단면에서좌측으로돌출된연성추간판탈출증을보였다. 전방지주막하공간의압박이있으며척수내고신호강도를보이고황색인대의후방압박이심한제 3,4 경추간분절을주된병변으로간주하고, 3번경추에 Kurokawa 방법을이용한선택적추궁판성형술과 4번경추상부추궁판부분절제술을하였다. 수술후 3주째 JOA 점수는 17 점, Hirabayashi 회복률은 100% 이었다. 후경부통증은환자가주관적으로호소하는정도를 4등급 (0: 통증없음, 1: 약물혹은물리치료를필요로하지않는경미한통증, 2: 약물이나물리치료로조절이필요한통증, 약물이나물리치료에도조절이안되 는통증 ) 로나누어평가하였다. 5) 환자는후경부통증을약물치료가필요없을정도의경미한통증으로표현하였다. 수술후 3 주째시행한자기공명영상검사상 T2 강조시상면을보았을때제 3,4 경추간에서후방전위는 (Fig. 3) 8) 0.6mm, 경막의팽창은 (Fig. 4) 8) 1.2mm 로측정되었다 (Fig. 5). 증례 2 68세남자로내원 1개월전부터악화되는보행장애, 상지근력약화를호소하였다. 입원당시이학적검사상상하지근력감소는없었으나양측손과발에서일정신경근지배영역과일치하지않는감각이상을보였고, 건반사는슬개건반사와족관절반사가양측에서증가되어있었다. 병적반사로양측에서간대성경련을보였다. 2주전부터빈뇨, 야간뇨, 절박뇨등의배뇨장애소견도보였다. 종합적으로 JOA 점수상 11점이었으며, 단순방사선측면사진에서제 4,5,6 경추간분절에서추간판간격감소및후외방골극형성이관찰되었으나전후척추관직경은정삼범위였다. 자기공명영상검사상제 4,5,6 경추간분절에서전방압박괴의크기는 2.17mm, 2.67mm 이었고, 후방에서는황색인대의비후가관찰되었으며제 4,5 경추부척수내고신호강도를보였다. 전방압박과황색인대의비후로인한후방압박소견을보이는제 4,5,6 경추간분절을주된병변으로간주하고, 5 번경추에 Kurokawa 방법을이용한선택적추궁판성형술과 4 번경추하부추궁판부분절제술을하였다. 수술후 4주째 JOA 점수는 15점, Hirabayashi 회복률은 66% 이었다. 환자의후경부 Fig. 1. For measuring of the anterior compression mass, a baseline is drawn to link the middle point of posterior vertebral body margin, and the distances from the baseline to the posterior edge of anterior compression mass is measured. Fig. 2. This figure shows the schematic measurement of the Pavlov ratio which is the anteroposterior diameter of the spinal canal (A) divided by the anteroposterior diameter of the vertebral body (B). 117
Dhong Won Lee et al Volume 19 Number 3 September 2012 통증정도는등급 2( 약물이나물리치료로조절이필요한통증 ) 이었다. 수술후 4주일째시행한자기공명영상검사상후방전위는제 4,5 경추간분절에서 1.32mm, 제 5,6 경추간분절에서 1.61mm, 경막의팽창은제 4,5 경추간분절에서 4.85mm, 제 5,6 경추간분절에서 4.67mm 로관찰되었다 (Fig. 6). 증례 3 72세여자로약 1주전보행하다갑자기양측하지의힘이풀리며주저앉은후부터하지근력약화가진행되어보행장해로본원에내원하였다. 당시이학적검사상우측상하지의경한근력약화, 좌측하지의무지신전근, 족관절굴곡근및신전근등의심한근력약화를보였다. 양측손과발에서일정신경근지 Fig. 3. This is the schematic of the method of estimating the posterior shift of the spinal cord. Initially, the distance from the posterior edge of each vertebral body or disc level to the center of the spinal cord is measured by T2-weighted midsagittal MRI before surgery. A repeated measurement is taken using the same method after surgery. The difference between the two measurements determines the posterior shift. Fig. 4. This is the schematic of the method of estimating the expansion of dura meter. The distances from anterior to posterior edge of dura mater is measured before and after surgery using T2-weighted midsagittal MRI. The expansion is determined by calculating the difference of the diameter between before and after surgery. 118
Journal of Korean Society of Spine Surgery Selective Laminoplasty for Cervical Myelopathy Fig. 5. (A) Preoperative T2-weighted midsagittal MRI shows marked cord compression and intramedullary high signal at C3-4. The size of the anterior compression mass at C3-4 is 2.89mm. (B) Postoperative T2-weighted midsagittal MRI shows the slightly posterior migration of cord and the expansion of dura mater. The posterior shift is 0.6mm and the expansion of the dura mater is 1.2mm at C3-4. 배영역과일치하지않는감각이상, 양측하지의심부건반사증가, Ankle clonus 양성소견등이관찰되었다. 1개월전부터빈뇨와야간뇨등의배뇨장애소견을보였다. 종합적으로 JOA 점수상 7점이었으며, 단순방사선측면사진에서제 3,4 경추간분절에서추간판간격감소및후외방골극형성이관찰되었으나전후척추관직경은정삼범위였다. 자기공명영상검사상제 3,4 경추간분절에서의전방압박괴의크기는 3.16mm 이었고, 후방에서는황색인대의비후및석회화로인한후방척수압박소견과척수내고신호강도가관찰되었다. 전방추간판돌출에의한압박과후방황색인대의비후가심한제 3,4 경추간분절을주된병변으로간주하고일차적으로후방감압술시행후결과에따라이차적전방감압술시행을결정하기로하였다. 3번경추에 Kurokawa 방법을이용한선택적추궁판성형술과 4번경추상부추궁판부분절제술을하였다. 수술후 4주째의 JOA 점수는 12점, Hirabayashi 회복률은 50% 이었다. 환자의후경부통증정도는등급 1이었다. 수술후 4주일째시행한자기공명영상검사상제 3,4 경추간분절에서후방전위는 0.74mm, 경막의팽창은 5.28mm 로관찰되었다. 환자는수술후증상회복에만족하여이차전방감압수술은시행하지않았다 (Fig. 7). Fig. 6. (A) Preoperative T2-weighted midsagittal MRI shows marked both andterior and posterior cord compression at C4-5-6 and intramedullary high signal at C4-5-6. The size of the anterior compression mass at C4-5 is 2.17mm, C5-6 is 2.67mm. (B) Postoperative T2-weighted midsagittal MRI shows the posterior migration of cord and the expansion of dura mater. The posterior shift is 1.32mm at C4-5, 1.61mm at C5-6 and the expansion of the dura mater is 4.85mm at C4-5, 4.67mm at C5-6. Fig. 7. (A) Preoperative T2-weighted midsagittal MRI shows marked both anterior and posterior cord compression and intramedullary high signal at C3-4. There are calcific changes of the ligamentum flavum at C3-4 and C4 posteriorly. The size of the anterior compression mass at C3-4 is 3.16mm. (B) Postoperative T2-weighted midsagittal MRI shows the slightly posterior migration of cord and the expansion of dura mater. The posterior shift is 0.74mm and the expansion of the dura mater is 5.28mm at C3-4. 119
Dhong Won Lee et al Volume 19 Number 3 September 2012 고찰 경추척수증은증상발현기간이길어질수록불가역적인손상을초래하므로조기에진단하여수술적치료를하는것이예후에좋은것으로보고되고있다. 9) 후방압박, 전방과후방압박, 발달성협착증이원인인척수증에서전방도달법을시행하면충분한감압을얻을수없으며, 후방의압박요인이지속적으로남아있기때문에후방도달법또는필요에따라전후방도달법을시도하는것이효과적이다. 7) 후방도달법으로후방신전근의기능을유지할수있는추궁판성형술이널리시행되고있고, 10) 추궁판성형술을통해척추관을후방에서확장해줌으로써척수를직접적으로감압시켜주는효과와척수가후방으로이동하면서전방의압박에서떨어지는간접적효과를얻을수있다. 그러나기존의추궁판성형술은감압이필요한추궁판부위에대한명확한선별기준이없이경추 3번부터 7번까지광범위하게시행되어왔다. 1-3) 이로인해과도한후방전위에의한 5번경추신경근마비, 광범위한후방인대근육복합체손상에따른축성경부통증, 술후경추부운동범위의감소등의합병증이흔히발생한다. 4) 이러한합병증을방지하기위한방안으로덜침습적인선택적추궁판성형술등이보고되고있다. 1,5) 저자들의문헌고찰에서현재까지일본에서 Tsuji 1) 등의몇보고가있으나국내에서는아직이에대한보고는찾아볼수없었다. 저자들은후방감압술의적응증에해당되는발달성협착증이있었던 1례와황색인대의비후및석회화로인해후방압박이심했던 2례를대상으로선택적추궁판성형술을시행하여임상학적개선을얻을수있었다. 수술전외상력등의과거력조사와주관적증상에대한문진, 신경학적검사, 단순방사선검사, JOA score 측정, 자기공명영상검사등을실시하였다. 자기공명영상검사에서는 T2 강조시상면에서압박에의해지주막하공간이소실된부위를병변부위로간주하였는데, 특히압박과동반하여척수내신호강도변화가있는부위를주된병변부위로결정하였다. 전방압박괴의크기는 T2 강조시상면에서협착이관찰되는분절의상, 하척추체후방을잇는경계선의중심으로부터전방압박의후방경계면까지의거리로측정하였다. 1) 수술의범위는협착이가장심한부위의바로상위추궁판부터성형술을시작하여하부로는협착이존재하는최하위부위의추궁판상부 1/3~1/2 을부분절제하는것으로하였다. 수술후 3,4 주째자기공명영상검사로척수의후방전위정도및경막의팽창정도를확인하였고, Hirabayashi 회복률을산출하여임상학적개선정도를판단하였다. 후방전위의정도는 T2 강조시상면에서수술전과후의추간판의본래후방경계면에서부터척수중심까지의거리를구한후차이값을산출하였다. 8) 경막의팽창정도는 T2 강조시상면에서수술전과후의경막의전후직경을 측정한후차이값을산출하였다. 8) 전례에서수술후 5번경추신경근의마비는발생하지않았고, JOA 점수의회복률은기존의추궁판성형술에서보고되는결과와같은양호한호전을보였다. 2,3) 척수의후방전위가 3mm 정도일때신경학적상태의만족할만한개선이이루어진다는보고가있다. 8) 그러나기존의추궁판성형술을시행하였을때의후방전위를측정한연구결과이기때문에선택적인추궁판성형술시의후방전위정도와임상학적개선과의관계에대해서는향후더많은연구가이루어져야할것이다. 전방압박괴의크기가 6mm 이상일경우에선택적인추궁판성형술을시행하면불충분한감압의발생가능성이높아수술범위를확장해야한다. 1) 그러나본증례들과같이전방압박량의크기가 6mm 미만이며발달성협착증인경우나황색인대비후등과같이후방압박이심한경우에선택적인추궁판성형술을시행하면, 후방전위가많이일어나지않아도척추관을확장시켜줌으로써직접적인감압효과를얻을수있기에유용하다고생각된다. 선택적인추궁판성형술에관한최근문헌들을고찰해보면단기적추시결과만보고되어있어장기적예후를예측하기는어렵다. 1,5) 또한, 본연구들의후경부통증및 JOA 점수등의결과도단기적추시결과이기때문에이에대한추가증례의보완및장기적인추시가필요할것으로사료된다. 수술후 1년이상추시시에추가적으로경추부의움직임정도를평가하기위하여굴곡및신전스트레스촬영도시행하여야하겠다. 발달성협착증이있거나황색인대변성으로인한후방압박이주된요인인 2 부위이하의경추척수증환자에서는기존의광범위추궁판성형술보다는덜침습적이며수술시간이단축되고, 술후제5 신경근마비등의합병증발생가능성이적은선택적인추궁판성형술이효과적이라고할수있다. REFERENCES 1. Tsuji T, Asazuma T, Masuoka K, et al. Retrospective cohort study between selective and standard C3-7 laminoplasty. Minimum 2-year follow-up study. Eur Spine J. 2007;16:2072-7. 2. Seichi A, Takeshita K, Ohishi I, et al. Long-term results of double-door laminoplasty for cervical stenotic myelopathy. Spine (Phila Pa 1976).2001;26:479-87. 3. Kawaguchi Y, Kanamori M, Ishihara H, Ohmori K, Nakamura H, Kimura T. Minimum 10-year followup after en bloc cervical laminoplasty. Clin Orthop Relat Res. 2003;(411):129-39. 120
Journal of Korean Society of Spine Surgery Selective Laminoplasty for Cervical Myelopathy 4. Hale JJ, Gruson KI, Spivak JM. Laminoplasty: a review of its role in compressive cervical myelopathy. Spine J. 2006;6(6 Suppl):289-98. 5. Kato M, Nakamura H, Konishi S, et al. Effect of preserving paraspinal muscles on postoperative axial pain in the selective cervical laminoplasty. Spine (Phila Pa 1976). 2008;33:E455-9. 6. Wang SJ, Jiang SD, Jiang LS, Dai LY. Axial pain after posterior cervical spine surgery: a systematic review. Eur Spine J. 2011;20:185-94. 7. Law MD Jr, Bernhardt M, White AA 3rd. Evaluation and management of cervical spondylotic myelopathy. Instr Course Lect. 1995;44:99-110. 8. Shiozaki T, Otsuka H, Nakata Y, et al. Spinal cord shift on magnetic resonance imaging at 24 hours after cervical laminoplasty. Spine (Phila Pa 1976). 2009;34:274-9. 9. Okada M, Minamide A, Endo T, et al. A prospective randomized study of clinical outcomes in patients with cervical compressive myelopathy treated with opendoor or French-door laminoplasty. Spine (Phila Pa 1976). 2009;34:1119-26. 10. Hirabayashi S, Yamada H, Motosuneya T, et al. Comparison of enlargement of the spinal canal after cervical laminoplasty: open-door type and double-door type. Eur Spine J. 2010;19:1690-4. 경추척수증에대한선택적추궁판성형술 - 3 례보고 - 이동원 서정국인제대학교서울백병원정형외과 연구계획 : 3 증례보고 목적 : 본연구의목적은 3 례의경추척수증에서 Kurokawa 방법을이용한 2 부위이하의선택적추궁판성형술을시행하여좋은임상결과를얻었기에 문헌고찰과함께보고하는바이다. 선행문헌의요약 : 경추척수증에대한치료로널리시행되고있는기존의추궁판성형술은수술이필요한추궁판의범위에대한명확한선별기준없이 경추 3 번부터 7 번까지광범위하게시행되어왔다. 그결과, 수술후축성경부통증, 5 번경추신경의마비, 경추부운동범위의감소등이흔히보고되고 있다. 이러한합병증을줄이기위한방안으로선택적후궁판성형술, 후방인대근육복합체의보존술등의덜침습적인방법들이시도되고있다. 대상및방법 : 후방감압술의적응증에해당되는발달성협착증이있었던 2 례와황색인대의비후및석회화로인해후방압박이심했던 1 례를대상으 로선택적추궁판성형술을시행하였다. 수술후 3~4 주째에자기공명영상검사를시행하여경막의팽창, 척수의후방전위등을평가하였고, 임상학적 개선은 Japanese Orthopedic Association (JOA) 점수로평가하였다. 후경부통증정도는 4 등급 (0: 통증없음, 1: 약물혹은물리치료를필요로하지않는 경미한통증, 2: 약물이나물리치료로조절이필요한통증, 약물이나물리치료에도조절이안되는통증 ) 으로나누어평가하였다. 결과 : 전례에서수술후 3~4 주째시행한자기공명영상검사상경막의팽창, 척수의후방전위를보였고, 임상학적결과및후경부통증도호전되었다. 결론 : 발달성협착증이있거나황색인대변성으로인한후방압박이주된요인인세부위이하의경추척수증환자에서는기존의광범위추궁판성형술 보다는덜침습적이며수술시간이단축되고, 술후제 5 신경근마비등의합병증발생가능성이적은선택적인추궁판성형술이효과적이다. 색인단어 : 경추척수증, 선택적추궁판성형술 약칭제목 : 경추척수증의선택적추궁판성형술 121