331 Review J Korean Orthop Assoc 2014; 49: Update on Management of Compressive Neuro

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1 331 Review J Korean Orthop Assoc 2014; 49: Update on Management of Compressive Neuropathy 이석하 이승준 건국대학교의학전문대학원정형외과학교실 pissn : , eissn : Carpal Tunnel Syndrome Suk-Ha Lee, M.D., Ph.D., and Seoung Joon Lee, M.D., Ph.D. Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, Korea Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome. The elevated pressure in the carpal tunnel causes compression of median nerve. Although the diagnostic criteria for carpal tunnel syndrome are not clear, the diagnosis is based on the patient history and physical examination and may be confirmed by electrodiagnosis with nerve conduction test or ultrasonography. Nonsurgical treatments are generally recommended for early carpal tunnel syndrome and surgical treatments are preferred for failed nonsurgical treatment, however there is controversy regarding the optimal time when the surgery should be performed. Results of surgical treatment are usually satisfactory, however there are also complications after surgical treatment. In order to achieve good results without complications, normal anatomy around the median nerve and its anatomical variations should be thoroughly understood before the operation and careful surgical technique is absolutely required. Key words: carpal tunnel syndrome, median nerve 서론 (carpal tunnel syndrome) 은가장흔한말초신경포 착증후군 (peripheral nerve entrapment syndrome) 으로서상승된 수근관내의압력으로정중신경이압박되어발생한다. 정중신 경이지배하는감각영역, 즉엄지, 제 2, 3 수지에저림감또는감 각이상등의감각증상과무지구 (thenar) 의근육위축에따른엄 지의근력약화증상이나타난다. 의진단을위하 여는환자의병력청취와이학적검사가중요하며근전도 (electromyography), 신경전도검사 (nerve conduction test) 및초음파 (sonography) 등의보조적인검사들은확진에도움이된다. 보존 적치료와수술적치료로대부분만족스러운결과를얻을수있 Received May 30, 2014 Revised August 25, 2014 Accepted September 17, 2014 Correspondence to: Seoung Joon Lee, M.D., Ph.D. Department of Orthopaedic Surgery, Konkuk University Medical Center, Neungdong-ro, Gwangjin-gu, Seoul , Korea TEL: FAX: lsjmd@naver.com 으나양호한결과를얻기위해서는수근관주위의정확한해부학적지식과수술전정확한진단및치료가필요하다. 따라서본문에서는수근관의정상해부학과변이, 의진단방법및치료방법, 그리고치료결과에대해기술하고자한다. 본론 1. 해부학수근관은배측의수근골과수장측의횡수근인대로이루어진공간으로손목횡단면의약 20% 를차지하며 9개의굴곡건과정중신경이지나간다. 정상횡수근인대의두께는평균 mm로알려져있으나이있는경우에는두께가평균 6.0 mm까지증가할수있으며, 횡수근인대는약 24도수장측에서배측으로경사져서주행하기때문에내시경을이용한수근관유리술시내시경의삽입각도에주의하여야한다. 1) 일반적으로정중신경은수근관내에서가장수장측에위치하고중앙에서요측에위치하지만정중신경이전완부에서두가닥으로분리되어수근 The Journal of the Korean Orthopaedic Association Volume 49 Number Copyright 2014 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

332 이석하 이승준 관으로들어오는변이가있을수있으며이런변이는지속성정중동맥 (persistent median artery) 과연관되어있기때문에초음파검사에서수근관내에서동맥의혈류가확인되면정중신경의변이가있을수있다는것을예상해야한다 (Fig. 1). 2) 또, 수근관내에서정중신경의운동분지에대한정상해부학과변이를알고있어야한다.

2 332 이석하 이승준 관으로들어오는변이가있을수있으며이런변이는지속성정중동맥 (persistent median artery) 과연관되어있기때문에초음파검사에서수근관내에서동맥의혈류가확인되면정중신경의변이가있을수있다는것을예상해야한다 (Fig. 1). 2) 또, 수근관내에서정중신경의운동분지에대한정상해부학과변이를알고있어야한다. 수근관내에서정중신경은무지구로가는운동분지를내는데약 80% 에서정중신경의요측면에서, 18% 에서는정중신경의중앙에서분지되고 1%-2% 에서는척측면에서분지를내는경우도있으며약 10% 에서는여러개의운동분지를낸다고알려져있다 (Fig. 2). 3,4) 따라서, 횡수근인대유리술 (transcarpal ligament release) 을할때절개의방향이가능한정중신경의척측면으로진행하는것이안전하다. 정중신경의운동분지가나오는위치도변이가있을수있는데, 대부분은횡수근인대의원위부에서운동분지가분지되지만 (extraligamentous) 드물게는횡수근인대밑에서 (subligamentous), 또는횡수근인대를관통하면서 (transligamentous) 분지될수있기때문에횡수근인대유리술을할때주의가필요하다 (Fig. 2). 5) 정중신경의운동분지의위치를알려주는기준선으로카프란선 (Kaplan line) 이사용된다 (Fig. 3). 카프란선은엄지의척측면에서근위수장선 (palmar crease) 에평행하게그린선으로카프란선과근위수장선사이에표재동맥궁 (superficial arterial arch) 이위치한다. 카프란선과제3 수지의장축을연결하는선이교차하는지점이정중신경의운동분지가무지구근육으로들어가는위치로, 수술절개위치와방향을결정할때도움이될수있다. 6) 정중신경의수장피부신경 (palmar cutaneous nerve) 분지는수근관절의근위주름에서근위 7-8 cm 에서분지되어장장근 (palmaris longus) 과요수근굴곡건 (flexor carpi radialis) 사이로주행을하면서무지구로향하기때문에근위전완부의전완근막 (antebrachial fascia) 을절개할때절개의위치와방향이가능한장장근의척측으로향하게해야신경손상을피할수있다. 7) 횡수근인대의원위경계부에서정중신경과척골 신경의감각분지연결이보고되고있으며 8) 이런경우에수술의절개위치가척측에위치하게되면척골신경의손상이발생하여제4, 5 수지의감각이상이발생할수있다. 또수근관내에서내재근과굴곡건변이가있을수있기때문에횡수근인대유리술을한후이들의확인이필요할수도있다. 9) 2. 원인인자급성은손목의외상, 감염, 출혈등에의해발생할수있으며 10) 만성의원인은해부학적요인, 전신적요인, 운동또는직업적요인, 그리고뚜렷한원인을알수없는특발성으로나눌수있다. 해부학적인요인으로는수근관내의종물, 지속성정중동맥, 골극, 이상근육등이있을수있으며 10,11) 비만, 알코올중독, 갑상선저하증, 류마티스관절염, 아밀로이드증, 신부전등이의전신적요인과관련이있다. 11) 정확한기전은알려진바없으나임신중에 20%-45% 에서발생할수있으며출산후증상이소실되는것으로알려져있다. 12) 원인인자로가장문제가되는것은직업적요인으로지금까지손목과수지의반복적인굴곡신전과진동기계의사용은의발생률을 2배높이는것으로알려져있으나컴퓨터작업등다른직업환경과의연관성은확인되지않았다. 13,14) Figure 1. Ultrasonography of carpal tunnel shows a persistent median artery (solid arrow) and bifid median nerve (doted arrows). Figure 2. Anatomic variations of median nerve. 1. Usual branching of the median nerve; 2. Thenar branch leaving the median nerve within the carpal tunnel (subligamentous); 3. Transligamentous course of the thenar branch; 4. Thenar branch leaving median nerve at its ulnar aspect; 5. Thenar branch crosses over the top of the transverse carpal ligament; 6. Doubled thenar motor branch. Data from the article of Lanz (J Hand Surg Am. 1977;2:44-53). 3)

333 3. 진단 1) 병력과이학적검사병력과이학적검사가을진단하는데중요하나명확한임상적진단기준과진단도구의필요성에대해서는논란이많다. 15,16) 의증상은정중신경이지배하는영역에서감각이상또는저하, 밤에심해지는통증이며손을흔들거나주무르면증상이소실됨을호소한다. 그러나모든수지에저림감을호소할수도있으며팔꿈치와어깨까지뻗치는통증을호소할수도있다.

3 진단 1) 병력과이학적검사병력과이학적검사가을진단하는데중요하나명확한임상적진단기준과진단도구의필요성에대해서는논란이많다. 15,16) 의증상은정중신경이지배하는영역에서감각이상또는저하, 밤에심해지는통증이며손을흔들거나주무르면증상이소실됨을호소한다. 그러나모든수지에저림감을호소할수도있으며팔꿈치와어깨까지뻗치는통증을호소할수도있다. 만성일경우에는수지, 특히엄지의근력약화를호소하며물건을떨어뜨리거나단추를잠글때불편함을호소하기도 한다. 감각검사로는 2-point discrimination, Semmes-Weinstein monofilaments 를할수있으며증상유도검사로는 Phalen 검사, Durkan 정중신경압박검사등을할수있다. 증상유도검사의진단적가치에대해서는이견이있으나 MacDermid 과 Wessel 17) 은 Phalen 검사, 정중신경압박검사, Tinel 검사의예민도와특이도를메타분석을한결과, Phalen 검사는 68% 예민도와 73% 특이도를, 정중신경압박검사는 64% 예민도와 83% 특이도를, Tinel 검사는 50% 예민도와 77% 의특이도를보였다고보고하였다. Durkan 18) 은정중신경압박검사에서 87% 의예민도와 90% 의특이도를보여 Phalen 검사보다는특이성, 예민도가더높고진단적가치가있다고보고하였다. Graham 등 16) 은에서나타나는임상증상과신체검사를근거로여섯가지의임상진단기준을제시하였으며 (Table 1), Katz 와 Stirrat 19) 는수부증상도표 (hand symptom diagram) 를만들어의임상진단에유용하게사용할수있게하였다 (Fig. 4). 을진단할때다른질병이없는지를확인하는것도중요하다. 피부와연부조직에문제가없는지, 근육의위축은없는지를확인하고상지의근력과수부의악력및집게력을측정한다. 6번째경추의신경근증이의증상과비슷하게나타나기때문에경추부병변과의감별을위하여 Spurling 검사가필요하며 Wright hyper- Figure 3. Kaplan cardinal line and anatomic landmarks. Dashed line is standard palmar incision and the solid arrow is the point that the recurrent motor branch of the median nerve usually enters the thenar muscles. K, Kaplan line; H, hamate hook; PL, palmaris longus; FCR, flexor carpi radialis. Table 1. CTS-6 Diagnostic Clinical Criteria for Carpal Tunnel Syndrome 1 Numbness and tingling in the median nerve distribution 2 Nocturnal numbness 3 Weakness and/or atrophy of the thenar muscle 4 Tinel sign 5 Phalen test 6 Loss of 2-point discrimination CTS-6, 6-item carpal tunnel symptoms scale. Figure 4. Katz and Stirrat hand diagram. 19) (A) Classic pattern. Symptoms affect at least two of digits 1, 2, or 3. The classic pattern permits symptoms in the fourth and fifth digits, wrist pain, and radiation of pain proximal to the wrist, but it does not allow symptoms on the palm or dorsum of the hand. (B) Probable pattern. Same symptom pattern as classic, except palmar symptoms are allowed unless confined solely to the ulnar aspect. In the possible pattern (not shown), symptoms involve only one of digits 1, 2, or 3. (C) Unlikely pattern. No symptoms are present in digits 1, 2, or 3.

4 334 이석하 이승준 abduction 검사, Adon 검사, costoclavicular compression 검사를하여흉곽터널증후군 (thoracic outlet syndrome) 을감별해야한다. 2) 전기진단검사근전도검사및신경전도검사는진단을확진하거나다른병변과감별하기위하여시행할수있으며, 치료전, 후를비교하기위한기본자료로사용될수있다. 20) 그러나임상적으로으로진단한환자중 16%-34% 에서는근전도검사가정상으로나올수있기때문에근전도검사에서정상으로나왔다고해서이없다고단정할수는없으며, 근전도검사에서음성의소견이보여도환자의증상이에합당하다면으로진단할수있다. 21) 3) 방사선검사및초음파검사단순방사선사진의촬영은을진단하는데필수적인항목은아니지만손목의단순방사선사진에서요골의부정유합, 수근관을구성하는수근골의변형등을확인할수있으며방사선사진에는손목전후방, 측면사진뿐만아니라수근관사진 (carpal tunnel view) 을같이찍어야한다. 최근고해상도초음파의발달로을진단할때초음파가유용하게사용되고있다. 수근관근위부에서초음파로측정한정중신경의단면적이 10 mm 2 이상이거나, 수근관과전완부중간부위에서정중신경의단면적비가 1.4 이상일때으로진단할수있으며 22,23) 이밖에도수근관내에서정중신경의운동성정도와정중신경내혈류정도도을진단하는기준으로사용될수도있다. 24,25) Fowler 등 26) 은의진단에서초음파의유용성에대한메타분석을한결과, 77.6% 의예민도와 86.8% 의특이도를보였다고하였으며의진단시에기존의전기진단방법에못지않게유용하다고하였다. 그러나고해상도초음파검사단독으로을확진하기에는무리가있을것으로생각되며고해상도초음파검사는수근관내에종물이있는지, 건활액막염이어느정도인지, 또정중신경또는근육의변이가있는지를확인하는데도움을주며다른임상증상과고려하여을진단하는데도움을줄수있는검사로생각된다. 4) 혈액검사혈액검사는을진단할때필수적인항목은아니나갑상선기능이상, 당뇨, 비타민 B12 부족, 엽산부족등의전신질환이과유사한증상을보일수있기때문에이들의존재여부를확인하기위하여혈액검사를할수도있다. 4. 치료치료방법은증상의정도, 이환기간, 원인, 환자의전신상태를 고려하여선택한다. 특발성에서는대부분부목고정이나스테로이드주사등의보존적치료를먼저선택할수있으며외상이나감염등에의한급성, 단무지외전근의위축이보이는만성, 보존적치료에실패한경우, 수근관내에존재하는종물이있을경우에는수술적치료를선택할수있다. 1) 보존적치료 (1) 부목고정 : 손목을 2-9 도신전하고 2-6 도척측변위를하여고정하였을때수근관내의압력이최소로된다고보고되고있으며, 27) 이를근거로한임상결과에서도부목고정이효과적으로보고되고있다. 28) 따라서처음발병한특발성의치료로부목고정을할수있으나부목고정을할때손목이과도하게굴곡되거나신전되지않게하는것이중요하며손목을중립위로하는것이일반적인방법이다. (2) 약물치료 : 임상에서실제로많은의사들이환자에게비스테로이드소염제, 스테로이드, 이뇨제, 비타민 B6, 항우울제등의다양한약을처방하고있으나스테로이드를제외하고는효과가없는것으로알려져있다. 29) 1 비스테로이드계소염제, 이뇨제 ; Celiker 등 30) 은스테로이드주사를한환자에게비스테로이드계소염제를투여한군과부목고정을한군을비교하였을때치료후 2개월째에두군모두에서증상이향상되었다고하였으나 Chang 등 29) 은비스테로이드소염제, 스테로이드, 이뇨제, 위약을투여한실험결과비스테로이드계소염제와이뇨제를투여한군에서는증상의호전이없었으며스테로이드를투여한군에서만단기간의효과가있었다고보고하였고수근관내의부종을줄이기위하여이뇨제를투여하였으나이뇨제의치료효과도분명하지않다고보고되고있다. 2 피리독신 ; Ellis 등 31) 이과피리독신결핍과의연관성을보고하면서환자에게피리독신을처방하기시작하였으나다른여러저자들은과피리독신의연관성은없다고보고하였으며피리독신효과에대한무작위실험에서도피리독신의효과는없다고보고되고있다. 32) 그러나 Kasdan 과 Janes, 33) Jacobson 등 34) 은의치료로피리독신만을복용할때에는효과가미미하나다른치료, 즉부목고정이나스테로이드주사치료와병행할때에는효과가있다고보고하면서피리독신의병행사용을권하였다. 3 스테로이드주사및경구용스테로이드 ; 수근관내스테로이드주사는비수술적치료의방법뿐만아니라을진단할수있는방법으로사용될수있으며수술후결과를예측할수있는방법으로알려져있다. Edgell 등 35) 은스테로이드주사의효과가있는환자에서수술의결과도좋다고보고하였다. 그러나스테로이드주사의효과는지속적이지않다.

5 335 Gelberman 등 36) 은스테로이드주사를맞고 6주후에환자의 76% 에서증상이좋아졌으나이들중 22% 만이 1년후까지유지된다고하였으며스테로이드주사의효과는증상이 1년미만이거나감각이상이없는경우, 증상이심하지않은환자에서효과가있다고하였다. 스테로이드주사시에정중신경이손상되지않게주의해야하며스테로이드주사효과의한계를미리환자에게설명하는것이필요하다. 또한당뇨가있는환자에서는일시적으로혈당을높일수있다는것을알고있어야한다. 스테로이드의경구투여도의치료로사용되고있다. 무작위실험에서경구용스테로이드의효과는다른경구용약과는달리에효과가있다고보고되고있으며 29) 경구용스테로이드의효과는투약후 2주까지는급격하게증상의호전을기대할수있으나 4주이상의투여에서는그효과가점점없어진다고보고되고있기때문에경구용스테로이드의사용기간은 2주를권하고있다. 36) 또한고용량과저용량 (10 mg/d) 의치료효과에차이가없기때문에저용량사용을권하고있다. 37) 2) 수술적치료 (1) 수술전고려사항 : 수술시기와수술대상을정하는것이필요하다. 일반적으로보존적치료에실패한경도에서중등도의증상을가진이좋은수술대상이다. 근육위축과감각소실이있는심한만성도수술의대상이나완전히회복되지않을수있다는것을충분히설명해야하며 double-crash syndrome 등다른말초신경질환이동반된경우에는만족스러운결과를얻지못할수도있다는것을설명해야한다. 38) (2) 언제, 누구를수술해야하는가?: 만성특발성의수술적응증과시기에대한명확한기준은없다. 일반적으로보존적치료에반응이없을경우, 수근관내에종물등의병변이있을경우에수술의적응증으로받아들여지고있으나수술의적응증에증상이심한환자의수술요구도있기때문에수술의적응증을명확하게제시하기는힘들다. 또보존적치료의효과가지속적이지않다고알려져있고수술적치료와보존적치료에대한전향적무작위실험에서도수술적치료가더효과적이며보존적치료는단기간의효과만있을뿐 1년후에는결국수술적치료가필요하다고보고되고있기때문에수술대상의범위는넓어질수있다. 39,40) 감각소실이있거나근육위축이있을경우에는수술후에도증상이남아있을수있기때문에이들증상이나타나기전의경도나중등도의상태에서수술하는것이더좋을것으로생각된다. (3) 어떤방법으로수술을할것인가?: 가장널리쓰이는방법은수근관부위에절개를하는개방형수근관유리술이다. 이방법이오랫동안사용되었으나절개부위의상흔통, 지주통 (pillar pain), 회복기간지연등의문제점을보완하기위하여 Agee 등 41) 이 one portal 을이용한내시경적수근관유리술을보고하였으며 Chow 42) 는 double portal 을이용한내시경적수근관유리술을보고하였다. 내시경적수근관유리술과개방형수근관유리술치료결과는차이가없는것으로알려져있다. 내시경적수근관유리술의장점을주장하는사람들은빠른회복기간과업무복귀를보고하고있으나 42) 무작위이중맹검실험에서두방법의치료결과에는차이가없는것으로보고되었으며내시경적수근관유리술을할경우에 5% 의재수술이필요했으며이로인해환자의만족도가더낮았다고보고되었다. 43) 이처럼개방형수근관유리술을선호하는사람들은내시경적수근관유리술이불완전한유리술과정중신경의손상발생가능성이높고지주통이나상흔통에서의미있는차이가없기때문에개방형수근관유리술이좋다고주장하고있다. 결론적으로각각의수술방법에대한이해와숙련이있다면어떤수술방법을사용하는지는중요하지않다. 다만, 손목강직이있거나수지의굴곡건활액막염이심할경우, 수근관내종물병변이있을경우에는내시경적수근관유리술은금기증으로알려져있기때문에수술전에이들의확인이필요하다. 44) 3) 수술후치료와결과수술후치료방법은수술자마다틀리지만, 수술후손목의고정은수술후결과와통증완화에영향이없는것으로보고되고있으며 45) 오히려수술직후손목과수지의능동적굴곡- 신전운동이굴곡건와정중신경의유착을방지할수있다고알려져있다. 수술후 70%-98% 에서만족스러운결과를보였다고보고되고있으며감각검사는 60% 에서정상으로회복되고집게력과악력은각각 6주와 12주경에회복되기시작하여 92% 에서정상으로회복되었다고보고되었으며 85% 에서본래의직장으로복귀할수있었다고보고되었다. 46,47) 그러나당뇨나 double-crash syndrome 등다른말초신경병변이있는경우, 알코올중독, 정신과문제가있는경우, 법적보상문제가있는경우에는좋지않은결과를보일수있기때문에수술을선택할때는유의해야한다. 38) 4) 합병증의수술후합병증은피할수없는합병증과피할수있는합병증으로나뉠수있다. 즉정중신경및척골신경의손상, 표재동맥궁의손상, 혈종, 불완전한횡수근인대유리술등은수근관주위의해부학구조를정확하게인지하고조심스럽게수술을하면발생가능성을줄일수있으나수술상흔통증, 수지강직, 복합부위통증증후군등은조심스럽게수술을하여도발생할수있기때문에수술전에환자에게설명을하는것이중요하다. 수술상흔통증은수술후 25% 에서나타나는가장흔한합병증이며일반적으로수술후 3개월내에소실되는것으로보고되고있으나 30% 정도에서는 3개월후에도지속할수있기때문

6 336 이석하 이승준 에수술전에이에대한설명이필요하다. 48) 수술상흔통증의원인을찾기위하여횡수근인대의장력의변화, 피하조직의염증반응, 수술방법의차이, 피부신경의손상, 봉합방법등여러방면으로연구가되었으나객관적인근거를제시하지못했으며, 49) 여러저자들이수술상흔통증의예상인자로우울증을제시하면서우울증이있는환자를수술할때에는수술상흔통증이발생할수있음을수술전에설명하는것이중요하다고하였다. 50,51) 수술후가장문제가되는것은증상이지속되는것이라할수있다. 수술후에도증상이좋아지지않거나재발하는경우는약 5% 에서보고되고있다. 52) 재발성수근과증후군과지속성은구별되어야하는데, 재발성은수술후증상의소실이 6개월이상지속되었다가다시증상이발생하는경우를말하며, 지속성은수술후에도통증에변화가없거나악화되는경우를말한다. 지속성을평가할때중요한것은통증의정도와양상이며수술전과비교하여이것이새로운통증인지아니면수술전과같은통증인지를확인해야한다. 지속되는통증의원인으로 Stütz 등 53) 은 55% 에서횡수근인대의불완전유리라고하였으며또한 7% 에서는통증의원인을찾을수없다고보고하였다. 재발성또는지속성의치료는정확한원인을확인하는것이필수적이며원인에따라수술적치료를해야한다. 그러나, 재발성또는지속성을재수술한후에도환자의 40%-90% 에서는증상이남아있을수있기때문에조심스러운접근이필요하다. 54) 결론 경도의을보이는환자는보존적치료를선택할수있겠으나증상이고착되거나재발하는경우에는수술적치료가필요하다. 의수술적치료결과가좋게보고되고있고수술기법이복잡하지않기때문에수술의부담감이적을수있으나좋은치료결과를얻기위하여는다음과같은몇가지가필요할것으로생각된다. 첫째, 수근관주위구조물의정상해부학에대한이해가필요하고이들의해부학적변이가있음을숙지하고있어야한다. 둘째, 예후인자가밝혀지진않았지만당뇨, 말초신경병변, 알코올중독, 정신과적문제, 법적보상등이있을경우에예상과다른치료결과를얻을수있음을알고있어야하며, 의증상이오래되었거나단무지외전근의위축등이상당히진행된경우에는일부에서는회복이완전히되지않을수있다는것을알고있어야한다. 셋째, 수술방법에상관없이수술후발생할수있는합병증에대해환자에게충분한설명이필요하다. 또수술후에도증상이지속되거나새로운증상이생겼을때증상과환자에대한정확한평가가필요하며그원인에따른적절한치료가필요하다. REFERENCES 1. Rotman MB, Donovan JP. Practical anatomy of the carpal tunnel. Hand Clin. 2002;18: Szabo RM, Pettey J. Bilateral median nerve bifurcation with an accessory compartment within the carpal tunnel. J Hand Surg Br. 1994;19: Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am. 1977;2: Mackinnon SE, Dellon AL. Anatomic investigations of nerves at the wrist: I. Orientation of the motor fascicle of the median nerve in the carpal tunnel. Ann Plast Surg. 1988;21: Davlin LB, Aulicino PL, Bergfield TL. Anatomical variations of the median nerve at the wrist. Orthop Rev. 1992;21: Riordan D, Kaplan E. Surface anatomy of the hand and wrist. In: Spinner M, ed. Kaplan s functional and surgical anatomy of the hand. Philadelphia: Lippincott; Taleisnik J. The palmar cutaneous branch of the median nerve and the approach to the carpal tunnel. An anatomical study. J Bone Joint Surg Am. 1973;55: May JW Jr, Rosen H. Division of the sensory ramus communicans between the ulnar and median nerves: a complication following carpal tunnel release. A case report. J Bone Joint Surg Am. 1981;63: Linburg RM, Comstock BE. Anomalous tendon slips from the flexor pollicis longus to the flexor digitorum profundus. J Hand Surg Am. 1979;4: Szabo RM. Acute carpal tunnel syndrome. Hand Clin. 1998;14: Michelsen H, Posner MA. Medical history of carpal tunnel syndrome. Hand Clin. 2002;18: Ekman-Ordeberg G, Sälgeback S, Ordeberg G. Carpal tunnel syndrome in pregnancy. A prospective study. Acta Obstet Gynecol Scand. 1987;66: Strömberg T, Dahlin LB, Lundborg G. Hand problems in 100 vibration-exposed symptomatic male workers. J Hand Surg Br. 1996;21: Dias JJ, Burke FD, Wildin CJ, Heras-Palou C, Bradley MJ. Carpal tunnel syndrome and work. J Hand Surg Br. 2004;29: Massy-Westropp N, Grimmer K, Bain G. A systematic review of the clinical diagnostic tests for carpal tunnel syndrome. J Hand Surg Am. 2000;25: Graham B, Regehr G, Naglie G, Wright JG. Development and

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9 339 pissn : , eissn : Review J Korean Orthop Assoc 2014; 수근관 49: 증후군 압박성신경병증의최신치료 이석하 이승준 건국대학교의학전문대학원정형외과학교실 은가장흔한말초신경포착증후군으로수근관내의압력이상승하여정중신경압박을일으킨다. 임상적진단기준이분명하지는않지만환자의증상과이학적검사로진단할수있으며초음파또는근전도와신경전도검사로확진할수있다. 일반적으로초기특발성의치료는보존적치료가추천되고보존적치료가실패하였을때수술적치료가선호되나수술적치료의최적시기에대하여는논란이있다. 대부분수술적치료의결과는만족스러우나수술후합병증도발생할수있으므로수술적치료후좋은임상결과를얻기위해서는수근관의정상해부학과변이에대한정확한이해와세심한수술기법이필요하다. 색인단어 :, 정중신경 접수일 2014 년 5 월 30 일수정일 2014 년 8 월 25 일게재확정일 2014 년 9 월 17 일책임저자이승준서울시광진구능동로 120-1, 건국대학교병원정형외과 TEL , FAX , lsjmd@naver.com 대한정형외과학회지 : 제 49 권제 5 호 2014 Copyright 2014 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

PowerPoint 프레젠테이션

PowerPoint 프레젠테이션 Physical Examination of the Wrist & Hand 연부조직촉진 (soft tissue palpation) 연부조직의촉진 (soft tissue palpation) 1) 수근관절제 1구역 ; 요골경상돌기 (radial styloid process) (1) Anatomical snuffbox - 요측연 장모지외전근 (Abd. poll. long