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1 Anesth Pain Med 28; : 임상연구 경추후지내측지차단술에서발생하는혈관내주사의빈도 : 건시술에대한연구 성균관대학교의과대학삼성서울병원마취통증의학과, * 연세대학교체육교육학과, 서울대학교의과대학마취통증의학교실 이숙영ㆍ이철중ㆍ윤세정ㆍ김태형ㆍ심우석ㆍ김경훈 * ㆍ김용철 ㆍ이상철 Intravascular injection in cervical medial branch block: an evaluation of injections Suk Young Lee, M.D., Chul Joong Lee, M.D., Ph.D., Se Jeong Yoon, M.D., Tae Hyeong Kim, M.D., Woo Seok Sim, M.D., Kyoung Hun Kim, Ph.D.*, Yong Chul Kim, M.D., and Sang Chul Lee, M.D. Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Sungkyunkwan University School of Medicine, *College of Physical Education, Yonsei University, Department of Anesthesiology and Pain Medicine, Seoul National University School of Medicine, Seoul, Korea Background: The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 9% to 67%. Cervical medial branch block (MBB) represents a useful interventional pain management procedure indicated in patients with a chronic neck pain of facet joint origin. In the current study, we prospectively evaluated the incidence of, and the factors associated with, intravascular injection during block. In addition, we assessed the efficiencies of generally accepted safety measures, such as pre-injection aspiration and intermittent fluoroscopy to avoid intravascular injections. Methods: We prospectively examined cervical MBBs in 158 patients performed by 2 physicians. Aspiration test, spot radiography, and contrast injection under real-time fluoroscopic visualization were performed sequentially without repositioning the needle. Incidences of blood flash back and the presence of intravascular contrast spread on spot radiographic images and during real-time fluoroscopy were checked. The factors studied for intravascular injection included patient age and sex and block spinal level. Results: No specific factors were found to affect the incidence 논문접수일 :28 년 1 월 1 일책임저자 : 이철중, 서울시강남구일원동 5 성균관대학교의과대학삼성서울병원마취통증의학과우편번호 : Tel: , Fax: chuljlee@skku.edu of intravascular uptake during block. The overall incidence of intravascular uptake was.% per nerve block (/), and 7 of these were predicted by pre-injection aspiration (sensitivity = 58.%) and 8 by spot radiography (sensitivity = 66.7%). Conclusions: The aspiration test with or without spot radiography frequently missed the intravascular uptake of contrast during cervical MBBs. We strongly advocate the use of real-time fluoroscopy during contrast injection to increase diagnostic and therapeutic value and to avoid possible complications. (Anesth Pain Med 28; : ) Key Words: aspiration test, cervical medial branch block, intravascular uptake, real-time fluoroscopy, spot radiography. 서 만성적인목의통증중에경추의추간관절이원인이되어이차적으로발생하는통증이 29% 에서 67% 정도로다양하게보고되고있으며, 많은경우에서재발을반복하여일상생활의제한을유발할수있다고알려져있다. 1-4) 그러나, 이러한경추의추간관절증에대한특징적인임상검사소견이나진단적영상소견이없어진단적인후지내측지차단술 (medial branch block, MBB) 이나추간관절내국소마취제주입술을추간관절증의확진을위하여시행하고있으며경추에서는진단적 MBB가비교적정확하며적은부작용을유발하는것으로보고되고있다. 1,5) 경추추간관절증의치료로는아직그효과에대해논란의여지가많지만스테로이드를함께혹은국소마취제만을이용한추간관절내주입술또는치료적 MBB가있고그밖에고주파신경차단술이있다. 1,2) 이중치료적 MBB는단기적, 장기적으로중등도의효과를보이고, 고주파신경차단술도단기적, 장기적으로중등도의효과를보인다고보고되고있다. 6,7) 진단적 MBB는소량의국소마취제만을사용하므로, 정확하게시술을시행하는것이중요하며, Manchikanti 등은 7) 조영제를투여하여시술이정확하게시행되었는지를확인하여약물이혈관내로주입됨으로써발생하는위음성반응 론 245

2 246 Anesth Pain Med Vol., No. 4, 28 과주변경막외강이나추간공으로들어감으로써발생하는위양성반응을방지할필요가있다고하였다. 요추의 MBB에서위음성반응은혈관내주사와밀접한관련이있고, 다른연구들에서도 MBB를시행할때발생할수있는혈관내약물주입이위음성반응을일으킬수있으며, 또한치료목적으로주입된국소마취제와스테로이드같은약물로인하여작열통과아나필락시스성반응등이발생할수있다고보고하였다. 8,9) 척추관련시술도중에혈관내주사를피하기위한방법의하나인약물주입전주사기의흡인검사로는모든혈관내주입을예방하기어려우므로투시장치하에조영제를투여하여혈관내주입여부를확인하는것이보다안전하다고이미보고되어있고, 1) 근래일반적인방법인주사기흡인검사후에조영제를준후시행하는순간방사선촬영으로는혈관내주입의완전한예방이어렵다고보고되었다. 11) 이에저자들은경추의진단적 MBB에서발생하는혈관내주입의빈도와이와연관된위험인자를알고자하였으며, 또한, 약물주입전주사기에음압을가하여시행한혈액흡인검사와조영제주입후순간방사선촬영으로혈관내주입을얼마나정확하게예측할수있는지를알아보고자본연구를시행하였다. 대상및방법본연구는저자들이속한병원의임상시험심사위원회 (institutional review board, IRB) 의승인을받았으며, 모든환자에게시술전에연구에대한설명을시행한후서면동의를받았다. 본연구는통증관리센터의두명의시술자에의해시행된 건의 MBB에대해시행되었다. 개월이상의만성적인경부통을호소하는환자중에추간관절부위에국소적인압통이있으며, 신경학적이상소견이없어경추의추간관절증이의심되는환자를대상으로하였고, 임산부, 조영제에알레르기가있는환자, 그리고경추부에수술을받은과거력이있는경우는대상에서제외하였다. 각시술은심전도, 말초산소포화도, 비침습적혈압계를사용하여환자의활력징후를관찰하며시행하였고, 시술중진정제는투여하지않았으며하트만용액을유지용량으로정맥내투여하였다. 시술은복와위에서시술부위를무균소독한후 C-자형영상장치의투시하에시행하였으며, C- 자형영상장치를통하여전후상과측면상을확인하면서 Rathmell과 ) Manchikanti 등이 1) 기술한일반적인경추 MBB 의뒤쪽접근방식으로 24 G Whitacre 바늘을사용하여시행하였다. 바늘끝이원하는부위에도달한후속침을제거시바늘의중심부에혈액이보이거나, 바늘에연결된연장관끝에 1 ml 주사기를연결하여 5초이상음압으로흡인하여혈액이바늘의중심부나주사기에흡인된경우를흡 인검사양성소견으로판단하였다. 혈액흡인검사후결과에상관없이바늘을움직이지않은채.5 ml의조영제 (Iopamidol R, mgi/ml, Bracco s.p.a., Milan, Italy) 를주입한후순간방사선촬영을시행하였으며, 조영제가혈관내주입의전형적인양상인사행성 (serpiginous) 으로보이거나목표부위에서조영되지않으면혈관내주입으로생각하였다. 순간방사선촬영후동일한위치에서실시간투시영상하에.5 ml의추가조영제를주입하여조영제가수초내에사라지거나사행성으로보이면혈관내주입으로판단하였다. 혈관내주입이실시간투시영상으로확진된경우는바늘의위치를재조정하여실시간투시영상하에서조영제의혈관내주입이없음을확인후약물을주입하였다. 이와같이바늘의위치를바꾼후조영제를주입한결과는이연구에포함시키지않았다. 환자의나이와성별, 혈액흡인검사, 순간방사선촬영과실시간투시영상시각각혈관내주입의유무, 차단된경추의후지내측지의수준을기록하였다. 통계분석은 Sigmastat.1 프로그램을사용하여, 각위험인자와혈관내조영제주입의연관성은경우에따라 chi square test나 Fihser s exact 검사로, 흡인시험과순간방사선촬영의위음성률의비교는 Mcnemar test로분석하였으며, P value가.5 이하이면통계적으로의미가있다고보았다. Table 1. Sensitivity, Specificity, and Predictive Values of the Aspiration Test Aspiration test Positive Negative Total Intravascular uptake during real-time fluoroscopy Positive Negative Total 7 5 결 158명의환자 ( 평균나이 58세, 범위 21 81세 ) 에게셋째뒤통수신경 (third occipital nerve) 과경추 7번의후지내측지차단술 건을시행하였으며, 162건 (44.9%) 이오른쪽, 199 건 (55.1%) 이왼쪽이었다. 전체시술에서혈관내주입의발생률은.% (/) 이었으며, 남자와여자환자에서발생률은각각.6%(1/274), 2.%(2/87) 으로통계적으로유의한차이는없었다 (P =.788). 환자의나이를 1년단위로나누었고 6세를기준으로비교하였을때가장큰차이를보였 Sensitivity = 58.%, specificity = 98.%, positive predicted value = 5.8%, negative predicted value = 98.6%, false-positive value = 46.2%, false-negative value 1.4%, efficacy of the test = 98.6%. 과

3 이숙영외 7 인 : 경추후지내측지차단시혈관내주사 247 으나, 6세이상의환자의혈관내주입의발생률은 4.4% (8/18), 6세미만에서는 2.2% (4/181) 로통계적으로유의한차이를보이지는않았다 (P =.721). 총 건의혈관내주입중에혈액흡인검사로확인된경우가 7건 ( 민감도 58.%, Table 1) 이었으며, 순간방사선촬영으로확인된경우가 8건 ( 민감도 66.7%, Table 2) 이었다. 실시간투시영상으로확진된혈관내흡인이없는 건의시술중에서, 혈액이흡인검사에서음성인경우는 4건이었고 ( 특이도 98.%, Table 1), 순간방사선촬영에서혈관내주입이발견되지않은경우가 건이었다 ( 특이도 1.%, Table 2). 혈액흡인검사에서혈액이흡인되지않은 48건의시술중에 5건은실시간투시영상으로확인한결과혈관내주입된경우였으며 ( 위음성 1.4%, Table 1), 순간방사선촬영에서혈관내주입이없었던 5건의시술중에서 4건이실시간투시영상으로확인시혈관내주입된경우였다 ( 위음성 1.1%, Table 2). 혈액흡인검사와순간방사선촬영에의한위음성율은통계적으로유의하게차이가없었으며 (P =.546), 차단된경추후내측지의수준에따른결과분석에서도각수준에서의혈관내주입발생률에유의한차이가없었다 (P =.748, Table ). Table 2. Sensitivity, Specificity, and Predictive Values of Spot Radiography with Contrast Enhancement Spot radiograph with contrast enhancement Positive Negative Total Intravascular uptake during real-time fluoroscopy Positive Negative Total Sensitivity = 66.7%, specificity = 1.%, positive predicted value = 1.%, negative predicted value = 98.9%, false-positive value =.%, false-negative value = 1.1%, efficacy of the test = 98.6%. Table. Incidence of Intravascular Contrast Uptake during Cervical Medial Branch Blocks by Level Number of blocks Number of intravascular uptake % of intravascular uptake cases Vertebral levels performed medial branch blocks C2 C C4 C5 C6 C7 Total 이번연구에서경추 MBB의효과는평가하지않았으며, 혈관내주입과연관된직접적인부작용은없었다. 고찰진단적및치료적 MBB를시행할때혈관내주입을예방하는것은위음성반응을줄일수있을뿐아니라약물의혈관내주입으로인한부작용을막을수있어여러연구를통하여예방방법과발생빈도가보고되었다. 8,11,14) 본연구에서경추 MBB 중에발생하는혈관내주입의빈도는.% 로나타났으며, 이결과는저자들이요추의 MBB 시술에관한연구에서 8) 보고한혈관내주입의빈도인 6.1% 보다낮았다. 이와같이부위에따른빈도의차이를보이는이유는요추의연구에서는본연구에서사용한바늘보다큰 22 G 바늘을사용하였고, 경추와요추의 MBB 시행을위한목표지점주위의혈관크기에차이가있었을것으로추정된다. Verrills 등은 9) 경추, 흉추, 요추의 MBB 시술에서혈관내주입의빈도가.5% 이며, 경추의 MBB 시술에서의혈관내주입의빈도는.9% 라고보고하여본연구결과와유사하였으나, Verrills 등의연구는실시간투시영상을이용하여혈관내주입을판단하지않고순간방사선촬영을통하여혈관내주입을확진하였기에실제혈관내주입빈도보다낮게파악되었을가능성이매우높다. 본연구에서혈관내주입을발견하는데있어흡인검사의민감도는 58.% 였다. Ferman 등은 14) 경추경추간공경막외주입술연구에서흡인검사의민감도를본연구의결과보다낮은 45.9% 로보고하였는데, 저자들은이처럼흡인검사의민감도가낮은이유를바늘을통하여저절로혈액이역류하기에정맥계의혈류가너무느리다는것과흡인을할때발생하는음압으로인하여정맥의허탈이일어나역류가안되는것으로생각하였다. 또한저자들의요추의 MBB 연구에서의 8) 결과는 4.1% 로앞의두연구에비해낮게나왔다. 이런차이는각부위의혈관의크기, 환자의혈관내용적, 사용된바늘의내경등과흡인검사를시행할때주사기에가하는음압의세기와흡인하는시간등의차이에의해발생할수있다고생각된다. 본연구와저자들의요추에서의 MBB 연구에서주사기에가하는음압의세기와흡인하는시간을동일하게적용하였음에도민감도에서차이를보인이유는위에서언급하였던그외의인자들, 즉사용된바늘과목표지점부위의혈관의크기등에차이가있는것으로추정된다. 이와같은이유와결과들로판단했을때혈액흡인검사가음성이라고하여도 MBB를시행하는중에발생하는혈관내주입을모두발견하기는어렵다고여겨진다. 반면, 흡인검사의특이도는 98.% 로, Furman 등이 14) 보고한 97% 와유사하였으며, 저자들의연구의 99.5% 와도 8) 유사하였다.

4 248 Anesth Pain Med Vol., No. 4, 28 본연구에서혈관내주입을확인하기위하여조영제를주입한직후시행한순간방사선촬영의민감도는 66.7% 로관찰되어흡인검사에비하여는비교적높은민감도를보였으며, 위음성반응도 1.1% 로흡인검사의 1.4% 에비하여는낮게나타났다. 그러나, 혈관내주입이일어남에도순간방사선촬영에서는음성으로나타날수있는경우가약 % 에이른다. 저자들의요추 MBB 연구에서, 바늘끝이부분적으로혈관안에걸쳐있는경우에조영제가일부는혈관내로, 일부는혈관밖으로주입이되므로순간방사선촬영으로는발견하기어렵지만실시간투시영상은혈관내로조영제가섭취되는것과목표지점에조영제가축적되는것을동시에보여주므로도움이될수있다고보고한바가있다. 8) 비록요추에서이기는하지만 Kaplan 등은 15) MBB 도중일단정맥주입이발생한경우바늘의위치를조정하여정맥섭취가일어나지않더라도 5% 에서위음성반응을보인다고보고하였다. 따라서, 경추 MBB에서도혈관내주입이일어났을경우바늘의위치를재조정하여혈관내주입이일어나지않도록한상태에서약물을주입하더라도위음성반응을보일가능성이클것으로생각된다. 흥미로운점은, 실시간투시영상으로혈관내주입이아니라고확진된 건의시술중에서 6건이혈액흡인검사에서양성으로나왔다는점이다. 이러한소견은시술중에발생한주변조직의손상이나, 시술하는바늘이목표지점을향해진행하는중간에혈관구조물을통과하여발생하는것으로생각할수있다. 8,14) 저자들의경험상이러한현상은시술자가정확한목표지점에도달하기위하여바늘의위치를여러번교정하는경우에조직의손상을증가시키고혈관구조물을지날가능성을높여발생이증가하는것으로여겨진다. 8) 또한경추 MBB의경우는피부로부터목표지점까지의경로주변에큰혈관들이근접해있어더욱이러한현상이보일수있을것으로생각된다. Sullivan 등은 16) 노인에서척추의퇴행성변화와정맥의환류가원활하지않으므로이러한해부학적, 생리학적변화로인하여요추의척수강내주입술에서혈관내주입의발생이증가할수있을것이라고보고하였으나, 이번연구와저자들의그전연구에서는 8) 나이에따른혈관내주입발생빈도의차이는뚜렷하지않았다. 실시간투시영상방법은혈액흡인검사나순간방사선촬영에비해더많은방사선에노출될수있다. 그러나박동성이미지, 투시영상의정확한조준, 납에이프런, 납장갑과납안경, 갑상선차단과납장벽등의보호장비를사용함으로써시술자의방사선노출을최소화할수있으며, 17) 실시간투시영상하에조영제를주입하는동안에는연장관을이용하여손의방사선조사를줄이면서시술을진행할수있다. 저자들은경추 MBB 시행에있어서혈관내주입의빈도에직접적으로영향을주는인자는없는것으로생각하며, 흡인검사와순간방사선촬영검사만으로는혈관내주입을완전히발견할수없는것을관찰하였다. 이에경추 MBB 시행시실시간투시영상하에조영제를주입함으로써 MBB의진단적, 치료적정확도를높일수있으며, 혈관내로주입된약물에의한부작용을예방할수있을것으로생각한다. 참고문헌 1. Kirpalani D, Mitra R: Cervical facet joint dysfunction: a review. Arch Phys Med Rehabil 28; 89: Manchikanti L, Singh V, Falco FJ, Cash KM, Fellows B: Cervical medial branch blocks for chronic cervical facet joint pain: a randomized, double-blind, controlled trial with one-year follow-up. Spine 28; : Enthoven P, Skargren E, Oberg B: Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis. Spine 24; 29: Manchikanti L, Singh V, Rivera J, Pampati V: Prevalence of cervical facet joint pain in chronic neck pain. Pain Physician 22; 5: Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR: Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician 25; 8: Boswell MV, Colson JD, Sehgal N, Dunbar EE, Epter R: A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 27; 1: Manchikanti L, Damron K, Cash K, Manchukonda R, Pampati V: Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT272. Pain Physician 26; 9: Lee CJ, Kim YC, Shin JH, Nahm FS, Lee HM, Choi YS, et al: Intravascular injection in lumbar medial branch block: a prospective evaluation of 14 injections. Anesth Analg 28; 16: Verrills P, Mitchell B, Vivian D, Nowesenitz G, Lovell B, Sinclair C: The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines. Spine 28; : E Stretanski MF, Chopko B: Unintentional vascular uptake in fluoroscopically guided, contrast-confirmed spinal injections: a 1-yr clinical experience and discussion of findings. Am J Phys Med Rehabil 25; 84: Jasper JF: Role of digital subtraction fluoroscopic imaging in detecting intravascular injections. Pain Physician 2; 6: Rathmell JP: Atlas of image-guided intervention in regional anesthesia and pain medicine. Philadelphia, Lippincontt williams

5 이숙영외 7 인 : 경추후지내측지차단시혈관내주사 249 & wilkins. 26, pp Manchikanti L, Schultz DM, Singh V: Cervical facet block. In: Pain Management. Edited by Waldman SD: Philadelphia, Saunders Elsevier. 27, pp Furman MB, Giovanniello MT, O'Brien EM: Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine 2; 28: Kaplan M, Dreyfuss P, Halbrook B, Bogduk N: The ability of lumbar medial branch blocks to anesthetize the zygapophysial joint. A physiologic challenge. Spine 1998; 2: Sullivan WJ, Willick SE, Chira-Adisai W, Zuhosky J, Tyburski M, Dreyfuss P, et al: Incidence of intravascular uptake in lumbar spinal injection procedures. Spine 2; 25: Botwin KP, Fuoco GS, Torres FM, Gruber RD, Bouchlas CC, Castellanos R, et al: Radiation exposure to the spinal interventionalist performing lumbar discography. Pain Physician 2; 6: 295-.

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R