Journal of Korean Society of Spine Surgery Motor Weakness of Right Ankle Dorsiflexion Caused by Increasing Size of Sacroiliac Joint Cyst after Posterior Lumbar Interbody Fusion in a Patient with Spinal Stenosis - A Case Report - Ji-Eun Kwon, M.D., Young-Joon Ahn, M.D., Bo-Kyu Yang, M.D., Seung-Rim Yi, M.D., Se-Hyuk Lim, M.D.,Ye-Hyun Lee, M.D., Hae-Min Kim, M.D. J Korean Soc Spine Surg 2015 Dec;22(4):178-182. Originally published online December 31, 2015; http://dx.doi.org/10.4184/jkss.2015.22.4.178 Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: 82-2-2019-3413 Fax: 82-2-573-5393 Copyright 2015 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.2015.22.4.178 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. 2015 Dec;22(4):178-182. http://dx.doi.org/10.4184/jkss.2015.22.4.178 Motor Weakness of Right Ankle Dorsiflexion Caused by Increasing Size of Sacroiliac Joint Cyst after Posterior Lumbar Interbody Fusion in a Patient with Spinal Stenosis - A Case Report - Ji-Eun Kwon, M.D., Young-Joon Ahn, M.D., Bo-Kyu Yang, M.D., Seung-Rim Yi, M.D., Se-Hyuk Lim, M.D.,Ye-Hyun Lee, M.D., Hae-Min Kim, M.D. Department of Orthopeadic Surgery, National Police Hospital, Seoul, Korea Study Design: Case report Objectives: To report a case of motor weakness caused by the increasing size of a sacroiliac joint cyst after spinal fusion. Summary of Literature Review: There have been no reports on the increased size of a sacroiliac joint cyst and motor weakness after spinal fusion. Materials and Methods: A 63-year-old female was admitted with low back pain and right sciatica. Magnetic resonance imaging (MRI) findings showed the spinal canal narrowing at L4 5 and a cystic lesion on the right sacroiliac joint. After surgery, the symptoms were relieved. Results: One month after the operation, motor function had worsened to grade 4. Follow-up MRI revealed an increase in the size of the cystic lesion. Selective nerve root blocks were performed. There was gradual improvement, and the motor grade reached grade 5 seven months after the operation. Conclusions: We recommend that surgeons evaluate the adjacent segmental lesion by MRI before performing spinal fusion. Key Words: Sacroiliac joint, Cyst, Muscle weakness, Spinal stenosis, Spinal fusion 서론 요추부질환의수술적치료방법으로흔히사용되는후방추체간유합술은고정기기의발전으로높은유합성공율및임상결과의향상을보이고있으나시행후발생하는합병증인인접분절질환에대한연구및보고가점차증가하고있다. 인접분절질환의발생원인으로유합술후가동분절이감소되어발생하는인접분절의운동성증가및생역학적변화가주된원인으로보고되고있다. 인접분절질환의대표적증상으로디스크퇴행성변화, 전후방전위증, 불안정성, 협착증, 후관절비후성관절염, 추간판탈출증및압박골절등이지속적으로보고되고있다. 1-3) 저자들은후방추체간유합술시행전천장관절부위에서관찰되었던낭종이유합술시행후크기가증가하며우측족관절배측굴곡근력의약화를유발한증례에대하여, 수술후인접분 절의운동성증가및생역학적변화에의해인접분절질환으로 진행하는과정에서나타날수있는증상으로보고하고자한다. 증례보고 63 세여자환자가 8 년전부터시작된요통및우측하지방사 통, 신경인성간헐파행을주소로내원하였다. 우측하지방사통 Received: July 22, 2015 Revised: August 18, 2015 Accepted: October 20, 2015 Published Online: December 31, 2015 Corresponding author: Young-Joon Ahn, M.D. 123, Songi-ro, Songpa-gu, Seoul, 138-708 National Police Hospital TEL: +82-2-3400-1252, FAX: +82-2-449-2120 E-mail: osahnyj@lycos.co.kr 178 Copyright 2015 Korean Society of Spine Surgery
Journal of Korean Society of Spine Surgery Motor Weakness of Ankle after Spinal Fusion A B C Fig. 1. Initial magnetic resonance imaging (MRI) reveals spinal stenosis at L4 5 in the sagittal (A) and the axial (B) images, and a cystic lesion measuring 1.6 cm 1.0 cm at the inferior surface of the right sacroiliac joint in the coronal (C) image. A B Fig. 2. Posterior decompression and posterior lumbar interbody fusion with a cage was performed at L4 5 (A, B). 은우측둔부에서대퇴부를거쳐가측장딴지로방사되는양상 이었다. 3 개월전부터우측족관절의힘이빠지는증상이있었다 고하였으며내원당시신경학적검사에서우측족관절배측굴 곡근력은 5- 로감소된상태였으며감각의저하는보이지않았 다. 단순방사선검사상특이소견은관찰되지않았으며, 자기공 명영상검사상제 4-5 요추부척추관협착증소견및우측천장 관절부위에서하측, 배측으로천추제 2 번높이까지요천골신 경총부위에 1.6 1.0 1.0 cm 크기의낭종이관찰되었다 (Fig. 1). 경막외신경차단술을통한보존적치료를시행하였으나증 상의호전이없어제 4-5 요추간후방감압술및케이지를이용 한후방추체간유합술을시행하였다 (Fig. 2). 환자는수술후요 통과간헐적파행및우측좌골신경통의호전을보였으나우측 족관절배측굴곡근력은 5- 로감소된양상이지속되었다. 수술 후 1개월에특별한외상없이동일부위의근력이 4로악화되는경과를보였으며, 우측제 1족지배측굴곡근력은건측에비해거의차이는없었으나미세한근력약화를보였고 2주뒤외래추시상정상으로회복되었다. 자기공명영상검사를재시행하였으며, 낭종의크기가 3.3 2.2 1.6 cm으로증가되어우측천장관절부위에서하측, 배측으로천추제 3번부근까지요천골신경총을압박하고있는소견이관찰되었다 (Fig. 3). 천추제 2, 3번에대한선택적신경근차단술 (dexamethasone 2.0 mg+bupivacaine 1.125 mg) 을근력이 4로악화된지 1개월및 2개월에각각한차례씩총 2회시행하며경과관찰하였다. 근력이 4로악화된지 3개월이지난시점에서근력약화는서서히호전되기시작하여, 수술후 7개월이되자정상으로회복되는경과를보였으며, 간헐파행및우측하지방사통의호전역시지속되었다. 수술 3년후재시행한자기공명영상검사상낭종의크기는 4.9 2.6 1.8 cm으로더증가한소견을보이고있었으나, 우측족관절배측굴곡근력은정상범위를유지하고있었다 (Fig. 4). 고찰 요추부후방추체간유합술시행후발생하는합병증인인접분절의변화와유발인자및치료에대한연구가지속적으로이루어지고있다. Park 등 4) 에의한문헌고찰연구에따르면, 방사선학적으로진단되는인접분절질환의유병율은연구에따라 8-100% 에이르며, 증상이있는인접분절질환은 5.2-18.5% 에이른다고보고되고있다. 주로보고되는증상은추간판의퇴행성변화가가장흔했으며, 전후방전위증, 불안정성, 인접분절의협착증, 후관절의비대성관절염, 측만증등역시자주보고되었 179
Ji-Eun Kwon et al Volume 22 Number 4 December 2015 A B Fig. 3. Follow-up MRI revealed the increased size of the cystic lesion measuring 3.3 cm 2.2 cm 1.6 cm in coronal (A) and axial (B) images (inferior and ventral aspects of the sacroiliac joint, S2 3 level). B A Fig. 4. Follow-up MRI taken after three years of the operation showed a further increase in the lesion size to 4.9 cm 2.6 cm 1.8 cm in the coronal (A) and axial (B) images. 다. 많은연구에서후관절이나추간판등에가해지는응력의증가와인접분절의가동성증가등의생역학적변화를인접분절질환의주된원인으로보고하였다. Bastian 등 3) 은흉요추부유합술시행이후인접분절의가동성을카데바를사용하여측정한생역학적연구에서인접분절이수술부위보다더가동성이적을때퇴행성변화의위험성은더높아진다고언급하였다. Ha 등 5) 은후방유합술시행이후발생한천장관절부위의퇴행성변화에대한전향적코호트연구에서기존의인접분절질환에대한연구는대부분유합술을시행한분절의근위분절에초점이맞추어져있었다고언급하며, 척추의축의하부분절을구성하여상부로부터전해지는힘을분산시키는데중요한역할을하며요천추부의움직임에의해영향을받는천장관절에대하여주목해야함을강조하였다. 이에따라유합술시행후발생 하는퇴행성변화에대한연구를진행하였다. 천장관절의퇴행성변화는컴퓨터단층촬영검사소견을통해진단하였으며유병율은 75% 로대조군 (38.2%) 에비하여유의미하게높다고보고하여유합술시행과천장관절의퇴행성변화사이의인과관계가있다고언급하였다. Ha 등 1) 은인접분절의퇴행성변화에대한수술적치료에대한연구에서유합술시행후인접분절의퇴행성변화에대한치료는보존적치료가우선이며, 수술적치료는비수술적치료가실패할경우제한적으로시행되어야한다고언급하였다. 본증례에서요추제 4-5번에대하여후방추체간유합술을시행하였으며, 인접부위인제 5요추- 제 1천추간분절및천장관절은골반내에안정적으로위치하며장요인대와장천골인대에의해견고하게고정되어있는부분으로, Bastian 등 3) 이수술부위보다인접분절의가동성이더적을경우퇴행성변화의위 180
Journal of Korean Society of Spine Surgery Motor Weakness of Ankle after Spinal Fusion 험성이더높다고언급한바에따라유합술시행이후생역학적변화에의한응력증가에취약한부위가될수있을것으로사료된다. 또한천장관절은유합부위와떨어져있으나 Ha 등 5) 이언급한대로요천추부에가해지는힘을분산시키며요천추부의움직임에영향을받는중요한관절이므로마찬가지로생역학적변화에의한영향을쉽게받을수있을것으로사료된다. 수술시행전우측천장관절부위의하측, 배측으로천추제 2 번높이까지존재하던낭종의크기는 1.6 1.0 1.0 cm로요천골신경총기시부에존재하였다. 수술이전에주증상이었던요통및우측하지방사통은수술이후호전되었으므로주로요추제 4-5번간협착증에의한증상이었을가능성이크다고사료된다. 그러나우측족관절배측굴곡근력약화증상은지속되었으므로, 협착증과천장관절부위낭종에의한증상일가능성모두를고려해야할것이다. 수술후 1개월에증상이악화되며근력이 4로감소하여재시행한자기공명영상검사상천장관절부위낭종의크기가증가되어있었고, 수술부위및인접분절인요추제 5번-천추제 1번간에는다른퇴행성변화의증거가없었으므로수술후악화된근력약화는천장관절부위낭종의크기증가에따른결과라고해석할수있을것이다. 수술이후천장관절부위에가해지는생역학적부하의변화로인해관절내변화가유발되고이로인해낭종의크기가증가했을것으로추정할수있을것이다. 자기공명영상검사이후크기가증가한낭종에대해수술적제거가필요할지에대해외과, 산부인과전문의와상의하였으나, 낭종이존재하는후복강부위로의수술적접근이어렵다고판단되어증상악화시수술적치료를시행하기로하고보존적치료를시행하며경과를관찰하였으며점차근력약화가호전되는양상을보였다. Shinichi 등 6) 은만성적으로압박된신경이추가적인급성압박에의한손상에더강한저항력을나타낼수있다는실험적논문에서, 이러한저항력을가지는원인으로대사과정이나혈관생성등에의한적응에의한가능성을언급하였다. 수술전존재하던낭종에의해압박된요천골신경총이수술후낭종의크기가급격히증가하여유발된급성압박에의해근력의약화를유발하였으나적응과정을거치며점차회복되었을것이며, 신경근차단술 (dexametasone 2.0 mg+bupivacaine 1.125 mg) 역시회복과정에관여했을것으로추정할수있을것이다. 최종추시자기공명영상검사상낭종의크기는더증가하였으나근력약화가완전히호전된것으로미루어볼때, 수술이후천장관절부위의생역학적변화가급격히이루어져낭종의크기역시급격하게변화되어근력약화가진행되었으나가역적인변화였을것으로생각된다. 이에대하여저자들은두가지가능성을고려하였는데, 첫째는낭종의크기가커지기는하였으나, 실 제로요천골신경총을압박하는방향이아닌다른방향으로크기가증가하였을가능성과, 두번째는낭종의성격상고형병변이아니기때문에크기가증가하였더라도실제로신경을압박하는부분이미약했을가능성이다. 결론 후방추체간유합술시행후천장관절부위에운동성의증가및생역학적변화가발생하며이미존재하던낭종의크기가증가하고, 이로인해근력의약화를유발하는경우는기존의인접분절질환에대한연구에서는보고되지않았던드문경우라고판단된다. 후방추체간유합술시행시인접분절의퇴행성변화를유발하는생역학적변화가발생하고, 이로인한증상이발생할수있으므로, 수술시행전수술부위이외의분절에존재하는병변을평가하기위해컴퓨터단층촬영및자기공명영상검사를통해충분히확인하는것이수술후결과예측에도움이될것으로사료된다. 본증례처럼작은낭종의경우에도수술후생역학적변화에의해크기의변화가발생할수있으므로, 증상발생시추시자기공명영상검사를통해먼저병변을확인하는것이필요하며, 적극적인수술적치료의필요성여부에대하여서는다른인접분절질환에서와마찬가지로보존적치료를먼저시행한이후판단하는것이좋을것으로사료된다. REFERENCES 1. Ha KY, Kim YH, Kang KS. Surgery for Adjacent Segment Changes after Lumbosacral Fusion. J Korean Soc Spine Surg. 2002;9:332-40. 2. Hwang CJ, Lee SW, Ahn YJ, et al. Risk Factors for Adjacent Segment Disease After Lumbar Fusion. J Korean Soc Spine Surg. 2008;15:44-53. 3. Bastian L, Lange U, Knop C, et al. Evaluation of The Mobility of Adjacent Segments after Posterior Thoracolumbar Fixation: A Biomechanical Study. Eur Spine J. 2001;10:295-300. 4. Park P, Garton HJ, Gala VC, et al. Adjacent Segment Disease after Lumbar or Lumbosacral Fusion: Review of the Literature. Spine (Phila Pa 1976).2004;29:1938-44. 5. Ha KY, Lee JS, Kim KW. Degeneration of Sacroiliac Joint After Instrumented Lumbar or Lumbosacral Fusion: A Prospective Cohort Study over Five-Year Follow-up. Spine (Phila Pa 1976). 2008;33:1192-8. 6. Kikuchi S, Konno S, Kayama S, et al. Increased Resistance 181
Ji-Eun Kwon et al Volume 22 Number 4 December 2015 to Acute Compression Injury in Chronically Compressed Spinal Nerve Roots: An Experimental Study. Spine (Phila Pa 1976).1996;21:2544-50. 척추관협착증에서후방유합술시행후우측천장관절부위낭종크기증가로인한우측족관절배측굴곡근력약화 - 증례보고 - 권지은 안영준 양보규 이승림 임세혁 이예현 김해민국립경찰병원정형외과 연구계획 : 증례보고목적 : 후방추체간유합술후우측천장관절부위낭종크기증가에의한우측족관절근력약화의증례를보고한다. 선행문헌의요약 : 후방추체간유합술후천장관절부위낭종크기증가에의한족관절근력약화는보고된바없다. 대상및방법 : 63세여자환자가요통및우하지방사통으로내원하여제 4-5 요추부척추관협착증으로진단받았으며, 자기공명영상검사상우측천장관절부위하측, 배측방향으로낭종이관찰되었다. 수술후요통과우하지방사통은호전되었다. 결과 : 수술 1개월후족관절배측굴곡근력이 4로감소되어재시행한자기공명영상검사상낭종의크기가증가된소견관찰되었다. 신경근차단술시행하였고이후 3개월지난시점부터근력약화는호전되기시작하여수술후 7개월에근력이정상으로회복되었다. 결론 : 수술전영상검사를통해수술후결과에영향을줄수있는인접부위병변을미리평가하는것이도움이될것으로사료된다. 색인단어 : 천장관절부위, 낭종, 근력약화, 척추관협착증, 후방요추체간유합술 약칭제목 : 유합술시행후족관절근력약화 182