대한영상의학회지 2011;64:423-428 말총증후군에서허리자기공명영상의유용성 1 문태용 백승국 이인숙 2 목적 : 대소변장애증상을가진말총증후군의치료를위한허리자기공명영상의유용성을알아보았다. 대상과방법 : 오줌보근전도검사로배뇨장애를가진말총증후군에서허리자기공명영상을시행했던환자 10명을대상으로하였다. 그진단은말총유착거미막염 4예, 척수원뿔위축 3예, 허리척주관협착증 3예, 결핵연수막염 1예, 엉치뼈전이암 1예, 그리고경질막동정맥샛길 1예였다. 결과 : 척주관협착증 3예는감압후궁절제술, 엉치뼈전이암 1예는방사선조사, 결핵연수막염 1예는항결핵제투여, 경질막동정맥샛길 1예는아교색전술, 말총유착거미막염 1예는항콜린제재및스테로이드요법으로 5일이내부터대소변장애증상이호전되기시작하였고, 나머지 4예는허리복막지름술과신경줄기세포이식술로치료계획을세웠다. 결론 : 배뇨장애를가진말총증후군환자에서허리자기공명영상은척주관내원인질병을규명하고치료계획을설정할수있는검사방법이었다. 말총증후군 (Cauda equina syndrome) 이란허리척주관가시도되었다 (3). 이후허리자기공명영상으로말총증후군의 (lumbar spinal canal) 내질병으로인해대소변기능장애, 원인질병을규명하고적절한응급적치료로증상이완화또는요통, 좌골신경통, 다리쇠약, 항문주위감각저하, 발기불능등회복되었던증례를보고하고있지만그들의보고는대부분단의증상을나타내는증후군으로, 그중대소변조절장애는정편적이다 (4, 5). 치료는소염제주입, 감압후궁절제술신적일상을황폐화하는심각한합병증이되기도한다 (1). 말 (decompression laminectomy), 허리복막지름술등원인질총증후군은대부분요추추간판탈출증이나허리척추수술후유환에따라다양하게보고되고있으며, 엉치신경분절에서중간증환자에서발생하며드물게는척수원뿔 (conus medullaris) 곧창자얼기나오줌보얼기자율신경사이신경신호전달을일부을포함한그이하말총을침해하는여러가지질병으로도발라도개선하면증상이완화되기때문에정확한진단과적절한생할수있다 (1). 신경학적으로척주관 (spinal canal) 안쪽두치료가필요하다. 번째세번째네번째엉치신경 (sacral nerve) 분절이있는척이에본저자들은말총증후군환자에서적절한치료방침을수원뿔이나이하말총에외상, 염증, 감염, 허혈, 또는압박에설정하는데허리자기공명영상검사의중요성을강조하고자의해골반안에중간곧창자얼기 (middle rectal plexus) 및오하였다. 줌보얼기 (urinary bladder plexus) 자율신경의신경신호전달을방해하여대소변장애를가져오는것으로보고있다 (2). 대상환자진단은, 요류동태 (urodynamic) 검사나오줌보 (urinary 본대학병원에대소변장애로내원한환자중그증상과요류 bladder) 근전도검사 (electromyography) 로그증후군이추동태및오줌보근전도검사로말총증후군이의심되는환자중정되면자기공명영상으로원인질환을찾는다. 1980년자기공허리자기공명영상을시행한 10명의환자를대상으로하였다. 명영상이임상적으로응용된이래, 강직성척추염환자에서발환자들의연령은평균 49.4세 ( 최고 72세최저 26세 ) 남자 6명생한말총증후군을진단하기위해최초로자기공명영상검사여자 4명으로남녀비는 1.5 대 1였다. 증상은하부요통 8예, 좌골신경통 6예, 하지무력증 5예, 안장 (saddle) 또는항문주위 1 양산부산대학교병원및감각저하및무감각 5예였고전례에서직장또는방광의조임 2 부산대학교병원영상의학과및부산대학교병원의학연구소근기능장애가있었다. 배뇨장애증상이갑작스럽게나타난경이논문은부산대학교자유과제학술연구비 (2년) 에의하여연구되었음이논문은 2011년 1월 10일접수하여 2011년 3월 1일에채택되었음. 우는 6예, 천천히나타난경우는 4예였다. 기왕력으로 1년이상 423
문태용외 : 말총증후군에서허리자기공명영상의유용성 20년사이허리수술을경험한환자는 3예였다. 치료는감압후궁절제술, 방사선조사 (radiation therpy), 아교색전술 (glue emoblization), 항콜린 (anti-choline) 제제및스테로이드 (steroid) 요법, 그리고항결핵제투여가있었다 (Table 1). 미막염 3예, 외상성척수원뿔위축 3예, 요추추간판탈출증 2예, 허리척주관협착증 2예, 결핵연수막염 1예, 경질막동정맥샛길 (dural arteriovenous fistula) 1예, 엉치뼈전이암 1예였다 (Table 2). 자기공명영상기법과소견허리자기공명영상은 1.5T MR 기기 (Magnetom Avanto, Siemens, Erlangen, Germany) 를사용하였다. 전례에서시상단면 (sagittal) T1 강조영상 (TR ms/te ms = 350/9.6) 과 T2 강조영상 (TR ms/te ms = 2500/96) 그리고축단면 (axial) T1 강조영상 (TR ms/te ms = 340/9.4) 과 T2 강조영상 (TR ms/te ms = 4800/100) 을얻었으며, 이중여섯예에서는 Gadolinium-DTPA (Magnevist, Bayer- Schering, Berlin, Germany) 조영제 0.2 ml/kg 용량을주입한 T1 강조영상시상단면과축단면을지방감산으로얻었다. 자기공명 T2 강조영상에서병소범위가위로가슴뼈 (thoracic spine) 제11/12번수위의척수에병변이있었던경우는 2예, 허리뼈 (lumbar spine) 제1번수위척수는 3예, 그리고말총이있는허리뼈제2/3번, 제4번, 제4/5번, 제5번과엉치뼈 (sacral spine) 첫번째수위에, 그리고엉치뼈제2번수위에각각 1예였다. 자기공명 T2 강조영상과조영제를주입한 T1 강조영상으로진단한척수강내질병으로는척추수술후유증이 4예, 유착거 결과허리자기공명영상으로진단된 10예중 6예즉, 엉치뼈전이암은방사선조사, 허리척주관협착증 (lumbar canal stenosis) 은감압후궁절제술, 유착성거미막염은국소항염제, 뇌수조조영술 (cisterography) 의조영제부작용은전신소염제, 경질막동정맥샛길은아교색전술, 결핵연수막염은항결핵제치료로 5 일이내대소변장애증상이호전되었다 (Figs. 1-3). 허리자기공명영상으로진단된 10예중 4예즉, 일례의감압후궁절제술후경질막게실은허리복막지름술그리고 3예의척수위축 (cord atrophy) 은신경줄기세포 (neural stem cell) 이식술 (implant) 로치료계획을세웠다 (Fig. 4). 고찰대소변장애를가져오는말총증후군은대단히드문질환으로심한허리통증을호소하는환자 2천명중 1예정도로그빈도가매우낮으나, 외과의사들의보고에의하면요추추간판 Table 1. Background Data of Ten Patients with Cauda Equina Syndrome No. Age / Sex Symptoms* Onset Past-histories 01 66/M C, D, E Rapid Nonspecific 02 26/F D, E Rapid Nonspecific 03 39/F A, B, E Rapid Back surgery at 20 years ago 04 31/M A, B, C, E Slow Nonspecific 05 59/M A, D, E Slow Nonspecific 06 72/F A, B, E Rapid Nonspecific 07 32/M A, B, D, E Rapid Back surgery at 1 year ago 08 46/M A, C, E Slow Nonspecific 09 60/M A, B, C, D, E Slow Nonspecific 10 63/F A, B, C, E Slow Back surgeries at 2 and 7 years ago Note. Symptoms*; A = low back pain, B = unilateral or bilateral sciatica, C = bilateral weakness of the lower extremities, D = saddle or perianal hypoesthesia or anesthesia, E = rectal and/or bladder sphincter dysfunction Table 2. Lumbar MRI Findings and Therapeutic Plans in the Patients with Cauda Equina Syndrome No. Age / Sex Lumbar MRI Diagnoses Therapeutic Plans 01 66/M Metastatic tumor on the 2nd sacral body Radiation therapy 02 26/F Allergic arachnoiditis after cisternography Anticholinergic & steroid 03 39/F Spinal canal stenosis Decompression laminectomy 04 31/M Dural arteriovenous fistula with congestion Glue embolization 05 59/M Tuberculous leptomeningitis involving the CM Anti-tuberculous medication 06 72/F Arachnoiditis Steroid infusion, physical therapy 07 32/M Dural diverticula with previous laminectomy Lumboperitoneal shunting 08 46/M CM atrophy and adhesive arachnoiditis of CE Neural stem cell implant 09 60/M CM atrophy and adhesive arachnoiditis of CE Neural stem cell implant 10 63/F CM atrophy and DISH Neural stem cell implant Note. CM = conus medullaris, CE = cauda equina, DISH = diffuse idopathic skeletal hyperostosis 424
대한영상의학회지 2011;64:423-428 탈출증환자의 1-16%, 허리수술을했던환자의 2-3% 에서말총증후군을경험하였다고보고하고있다 (6-8). 본저자들은 10명중 6명환자에서척추추간판변성이동반되어있기는하였으나, 척추추간판탈출로인해척추협착증이있었던한예를제외하고는, 그척추추간판변성이말총증후군의주요인이아니었기때문에따로언급하지않았다. 말총증후군의진단에는반드시오줌보의기능장애가동반되어야하는것은아니다 (9). 그러나요류동태검사는말총증후군을조기진단하는데도움이된다 (10). 신경해부학적으로, 교감신경과부교감신경섬유로구성된골반의자율신경얼기에는곧창자조임근 (rectal sphincter) 기능을조절하는중간곧창자얼기그리고오줌보조임근의기능을조절하는오줌보얼기가있다. 넙다리신경 (Femoral nerve) 은척수에서나온두번째세번째그리고네번째허리신경으로구성되고, 좌골신경 (sciatic nerve) 은네번째다섯번째허리신경과첫번째두번째그리고세번째엉치신경으로구성된다. 골반의자율신경얼기는넙다리신경배쪽 (ventral) 일차가지 (primary branch) 에서형성된허리신경얼기와좌골신경일차가지에서형성된엉치신경얼기두가지가있고, 이둘은허리엉치신경줄기에연결되어있다. 척수원뿔은척수의엉치구역을말하는데열한번째와열두번째가슴뼈몸통사이추간판에서열두번째가슴뼈와첫번째허리뼈 사이추간판까지그사이에위치하고있어엉치신경뿌리와가지를내린다. 모든신경은척수등쪽 (dorsal) 에는감각신경뿌리로피부로부터감각을받아들이고척수배쪽에는운동신경뿌리로근육운동을조정한다 (11). 신경조직학적으로, 말총은허리뼈제1번과 2번사이에서끝나는척수의아래부분으로종말끈 (filum terminale) 과신경다발 (bundle of nerve root) 로구성되어있고, 말총신경뿌리는신경막세포 (Schwann cell) 가없고위쪽삼분의일부분에미세혈관연결부위엔혈관이비교적취약하다 (2). 따라서말총부위에병변이생기면요통, 한쪽또는양쪽좌골신경통, 양쪽다리쇠약, 항문주위감각저하또는무감각, 발기불능등이곧창자나오줌보조임근의기능장애와함께나타나게되는데이를말총증후군이라한다 (1, 2). 척수원뿔증후군은말총증후군과유사한증상을나타내는질병이나, 임상적으로전자는대소변장애증상이먼저나타나고다리마비증상이따라오는경과를취하나후자는다리감각이상이나쇠약이먼저나타나고대소변장애증상이뒤따라나타나는경과를보인다 (12). 본증례들은이를구분하지않고일괄말총증후군으로다루었다. 대소변장애를가져오는말총증후군은척수원뿔이하말총신경뿌리에기계적압박, 염증그리고정맥울혈이나허혈등으로인해나타날수있다 (2). Fig. 1. 66-year-old male with metastatic tumor on the 2nd sacral spine complained of cauda equina syndrome. Sagittal contrast enhanced T1 weighted MR image reveals bony destruction of the 2nd sacral spine body (arrow). 425 Fig. 2. 31-year-old male with dural arteriovenous fistula at the level of the L2 spine. Sagittal contrast enhanced T1-weighted MR image reveals multifocal enhancing high signal area in the conus medullaris (white arrow) due to venous congestion and multifocal dark signal void area in the cauda equina (black arrow) due to rapid blood flow of arteriovenous fibula.
문태용외 : 말총증후군에서허리자기공명영상의유용성 A B Fig. 3. 59-year-old male confirmed to tuberculous leptomeningitis with caudal equina syndrome including acontractile neurogenic bladder, constipation, and right lower leg pain. Sagittal (A) and axial (B) contrast enhanced T1-weighted MR images reveals ringlike peripheral enhancement lesions (arrows) in the conus medullaris. 말총증후군은국소적인압박만으로그증상이나타나는것이아니고척주관내광범위한염증성또는허혈성질환으로인해발생한다고보는그이유는, 많은척주관압박질환중극히일부에서발생하고, 척주관협착증수술후발생빈도가높은점, 후궁절제술만으로는말총증후군이회복되지않는점, 그리고강직성척추염환자에서경질막게실이있는환자에서허리복막지름술로말총증후군의증상이호전된다는점을들수있다 (7, 8, 13). 척추경질막내말총연수막에발생한원발성암이나전이암으로인해말총증후군이발생할수있다 (1, 2). 그러나엉치뼈척주관내발생한전이암이말총증후군을유발하였다는문헌보고는아직없다. 전립샘암환자에서엉치뼈팽창성전이암으로인해말총증후군이유발된경우, 두번째세번째네번째엉치신경이통과하는엉치뼈구멍이전이암으로인해압박또는폐쇄되므로말총증후군이유발되었을것으로예상한다. 이에방사선조사는종양내출혈을억제하고종양을위축시켜척주관내신경압박을이완시키므로증상호전을기대할수있다 (1, 2, 8). 뇌수조조영술에사용되는조영제로인한부작용으로발생한말총증후군의경우허리자기공명영상검사상특이한이상소견이없을수도있다. 이러한경우자기공명영상은내과적치료와외과적치료를결정하는데도움이되며, 조영제과민성반응으로나타난말총증후군의배뇨장애는항콜린제및스테 Fig. 4. 63-year-old female with segmental cord atrophy at the 로이드맥요법등내과적으로그증상을완화할수있다. 문헌 level above the conus medullaris (CM). Sagittal T2-weighted 에의하면배뇨장애를가진말총증후군환자 43% 가자기공명 MR image reveals abnormal slender portion (white arrows) at 영상에서이상소견을발견할수없었다 (5). the cord above the CM consistent with cord atrophy required 자기공명영상에서발견된척추관협착증은감압후궁절제술, neural stem cell implant therapy. 426
대한영상의학회지 2011;64:423-428 유착성거미막염은스테로이드주입및물리치료로대소변장애를가진말총증후군의증상을완화시킬수있다 (2, 14-16). 경질막동정맥샛길은척수속질내지속적인높은정맥압으로인해울혈이생기고허혈성척수병증을유발한다 (17). 이는아교색전술로치료가능하였다. 척주관내결핵수막염이나척수염에관한자기공명영상소견이보고된적있으나말총증후군을유발한사례보고는없다 (18). 뇌척수액분석과허리자기공명영상으로결핵연수막염의진단은가능하고항결핵제투여로대소변장애를초래한말총증후군의증상을완화할수있다. 자기공명영상에서경질막게실이있는경우척주관내뇌척수액의주기적인맥성압력이신경섬유에손상을입혀말총증후군이발생하였을가능성을고려할수있다 (10). 이러한경우허리복막지름술시술을추천하고있다 (13). 척수원뿔주위외상성척수위축이있는경우신경줄기세포이식술을추천하고있다 (19). 대소변장애를가진말총증후군은, 척수원뿔이나그위쪽척수의위축병소를제외하고는대부분원인질병에다소나마적절한치료를하면쉽게그증상이완화된다. 예상하건대말총증후군은척수원뿔의두번째세번째그리고네번째엉치신경분절, 그리고그들엉치신경의뿌리및신경들을모두침범하였을때그증상이나타나고, 그일부가치료또는제거되어일부의신경분절이회복되어도말총증후군의그증상은회복될수있기때문에, 더이상신경이비가역적변성이되기전에신속하고정확한진단과적절한치료가필요한것이다. 본연구는배뇨장애를호소하는환자에서오줌보근전도검사로말총증후군을의심하여그원인을찾기위해허리자기공명영상을시행했던환자였기때문에말총증후군의일반적인빈도와는일치하지않을수있고, 또한비교적조기에진단이되어적절한치료에임했기때문에그치료효과도일반적인문헌의보고와는차이가있을것으로생각한다. 비록증례가적기는하지만, 말총증후군은자기공명영상으로조기에그원인질병을규명하고그에적절한치료를시도하므로대소변장애증상을경감또는완화할수있다는것을알게되었다. 따라서허리자기공명영상은대소변장애를호소하는말총증후군에있어서그원인질병을규명하고응급치료계획을세우는데중요한역할을한다고볼수있다. 참고문헌 1. Fraser S, Roberts L, Murphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil 2009;90:1964-1968 2. Ba B, Wu H, Jia LS, Yuan W, Shi GD, Shi JG. Cauda equina syndrome: a review of clinical progress. Chin Med J 2009;122:1214-1222 3. Kerslake RW, Mitchell LA, Worthington BS. Case report: CT and MRI of the cauda equina syndrome in ankylosing spondylitis. Clin Radiol 1992;45:134-136 4. Coscia M, Leipzig T, Cooper D. Acute cauda equina syndrome: diagnostic advantage of MRI. Spine 1994;19:475-478 5. Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 2007;21:201-203 6. Tait MJ, Chelvarajah R, Garvan N, Bavetta S. Spontaneous hemorrhage of a spinal ependymoma: a rare cause of acute cauda equina syndrome. Spine 2004;29:E502-E505 7. Kostuik JP, Harrington I, Alexander D, Rand W, Evans D. Cauda equina and lumbar disc herniation. J Bone Joint Surg Am 1986;68: 386-391 8. Gleave JR, Macfarlane R. Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Br J Neurosurg 2002;16:325-328 9. Mangialardi R, Mastorillo G, Minoia L, Garofalo R, Conserva F, Solarino GB. Lumbar disc herniation and cauda equina syndrome: considerations on a pathology with different clinical manifestations. Chir Organi Mov 2002;87:35-42 10. Storm PB, Chou D, Tamargo RJ. Lumbar spinal stenosis, cauda equina, and multiple lumbosacral radiculopathies. Phys Med Rehabil Clin North Am 2002;13:713-733 11. Agur AMR, Lee MJ. Grant s atlas of anatomy, 9th Ed. Philadelphia: Williams & Wilkins, 1991:246-254 12. Olcay L, Aribas BK, Gokce M. A patient with acute myeloblastic leukemia who presented with conus medullaris syndrome and reviewth conusliterature. J Pediatr Hematol Oncol 2009;31:440-447 13. Lamer AJ, Pall HS, Hockley AD. Arrested progression of cauda equina syndrome of ankylosing spondylitis after lumboperitoneal shunting. J Neurol Neurosurg Psychiatry 1966;61:115-116 14. Spector LR, Madigan L, Rhyne A, Darden B, Kim D. Cauda equina syndrome. J Am Acad Orthop Surg 2008;16:471-479 15. Lee JW, Myung JS, Park KW, Teom JS, Kim KJ, Kim HJ, et al. Fluoroscopically guided caudal epidural steroid injection for management of degenerative lumbar spinal stenosis: short-term and long-term results. Skeletal Radiol 2010;39:691-699 16. McCarthy MJ, Aylott CE, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine 2007;32:207-216 17. Jellema K, Tijssen CC, van Gijn J. Spinal dural arteriovenous fistulas: a congestive myelopathy that initially mimics a peripheral nerve disorder. Brain 2006;129:3150-3164 18. Gupta RK, Gupta S, Kumar S, Kohli A, Misra UK, Gujral RB. MRI in intraspinal tuberculosis. Neuroradiology 1994;36:39-43 19. Ruff CA, Fehlings MG. Neural stem cells in regenerative medicine: bridging the gap. Panminerva Med 2010;52:125-147 427
문태용외 : 말총증후군에서허리자기공명영상의유용성 J Korean Soc Radiol 2011;64:423-428 The Usefulness of Lumbar Spine MRI for Cauda Equina Syndrome 1 Tae Yong Moon, M.D., Seung Kug Baik, M.D., In Sook Lee, M.D. 2 Departments of Radiology, Pusan National University 1 Yangsan Hospital and 2 Pusan National University Hospital Medical Research Institute, Pusan National University Hospital, Busan, Korea Purpose: To understand the usefulness of the lumbar MRI studies to establish therapeutic plans for cauda equina syndrome (CES) including the management of rectal and bladder dysfunction symptoms. Materials and Methods: We retrospectively reviewed the lumbar MRI studies of 10 patients with CES. Their diagnoses included four adhesive arachnoiditis of cauda equina (CE), three conus medullaris atrophies, three spinal canal stenoses, one tuberculous leptomeningitis, one metastatic tumor on the sacral canal, and one dural arteriovenous fistula with venous congestion of the conus medullaris. Results: In 6 of the 10 total cases the symptoms of rectal and bladder dysfunction were resolved by decompression laminectomies (n=2), irradiation (n=1), glue embolization (n=1), anticholine and steroid infusion (n=1), and anti-tuberculous medication (n=1) within at least 5 days. The 4 other cases were settled by lumboperitoneal shunting and neural stem cell implants. Conclusion: The study results indicate that lumbar MRI is the modality of choice in search for the causative lesion and to subsequently set up the best therapeutic plans for patients with CES. Index words : Cauda Equina Polyradiculopathy Magnetic Resonance Imaging Spinal Stenosis Motor Neuron Disease Address reprint requests to : Tae Yong Moon, M.D., Department of Radiology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongnam 626-770, Korea. Tel. 82-55-360-1831 Fax. 82-55-360-1846 E-mail: tymn@pusan.ac.kr 428