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1 Brain & NeuroRehabilitation Vol. 7, No. 2, September, 편마비측어깨통증에서의견갑상신경차단술과관절강내하이알루론산염주사간의비교 순천향대학교의과대학부천병원재활의학교실김상현ㆍ김동석 Suprascapular Nerve Block versus Intra-articular Hyaluronic Acid Injection in Hemiplegic Shoulder Pain Sang-Hyun Kim, M.D., Ph.D. and Dong Suk Kim, M.D. Department of Physical Medicine and Rehabilitation, Soonchunhyang University College of Medicine Objective: To compare the pain and functional improvement of suprascapular nerve block (SSNB) and intra-articular hyaluronic acid (HA) injection in post-stroke patients with hemiplegic shoulder pain. Method: In total, 24 stroke patients were randomly assigned in the SSNB group (n = 12) or the HA group (n = 12). Ultrasound (US) guided SSNB with 10 cc of 1% lidocaine and US guided intra-articular injection with 2 cc of HA was done in each group 3 times weekly. Visual analogue scale (VAS), Fugl-Meyer scale (FMS), Wolf motor function test (WMFT), Brunnstrom stage, modified Ashworth scale (MAS), range of motion (ROM) of shoulder joint and brief pain inventory (BPI) concerning the interference of patient s function (activity, mood, walking, work, relationship, sleep and enjoy) were assessed before the injection, one week and four weeks after first injection. Results: Both groups showed significant improvements in pain assessed by VAS, but the changes between the two groups were not significantly different. There were no significant improvements and did not show any significant differences between the two groups in FMS, WMFT, Brunnstrom stage, MAS and ROM of shoulder joint. On several items of the BPI concerning the interference of patient s function (activity, mood, work, and enjoy), only SSNB group showed significant improvement, even though the differences between the two groups were not significant. Conclusion: Both SSNB and intra-articular HA injection were safe and effective in pain and functional ability in hemiplegic shoulder pain. But comparing the interference of patient s function caused by pain, only SSNB showed significant improvement. (Brain & NeuroRehabilitation 2014; 7: ) Key Words: hemiplegia, shoulder pain, stroke, nerve block, hyaluronic acid 서론 어깨통증은뇌졸중이후편마비환자에서발생하는흔한합병증으로발병이후첫 12개월내에 75% 에이르는환자들이편마비측어깨통증을호소한다. 1 이러한뇌졸중환자들의편마비측어깨통증은대부분관절운동에의해유발되지만휴식중에증상을호소하기도하며이로 Received: April 23, 2014, Revised (1st): June 5, 2014, Accepted: July 15, 2014 Correspondence to: Dong Suk Kim, Department of Physical Medicine and Rehabilitation, Soonchunhyang University College of Medicine, 170, Jomaru-ro, Wonmi-gu, Bucheon , Korea Tel: , Fax: nickel0050@gmail.com 인해재활과정을저해하거나병원내입원기간을증가시킬수있는등뇌졸중환자의회복에영향을미칠수있다. 2-4 뇌졸중환자들의편마비측어깨통증의원인으로, 뇌졸중발병초기에는어깨관절주머니의견인이나어깨관절아탈구로인한근이나인대, 관절막의염증에의해통증이발생할수있고, 뇌졸중발병후기에는어깨관절의강직으로인해어깨근육의긴장도가증가되어관절운동시에어깨통증이유발될수있다. 4,5 또한편마비환자에서어깨관절아탈구및어깨관절의안정성저하가있을경우어깨부위의말초신경손상으로인해편마비측어깨를포함한상지의통증이유발될수있다. 6 이외에회전근개손 118

2 김상현ㆍ김동석 : 편마비측어깨통증에서의견갑상신경차단술과관절강내하이알루론산염주사간의비교 상, 복합국소통증증후군등이원인으로제시되고있지만뇌졸중환자의편마비측어깨통증은여러요인에의해발생되며한가지원인으로규명할수없는경우가대부분이다. 4-7 뇌졸중후편마비측어깨통증에대한적절한치료는뇌졸중환자의재활과정및회복에매우중요하며최적의치료를위해서는다각적인접근의치료가필요하고열치료, 전기치료, 국소마취제및스테로이드국소주사, 보톨리눔독소주사등의다양한치료방법이제시되어왔다. 1,3,8-17 어깨의관절강내주사나견갑상신경차단술같은치료법은다양한어깨병변의치료에사용되어왔고편마비측어깨통증에도효과가있다고보고된바있다. 11,13,14,16,17 Kim 등 9 은관절강내스테로이드주사와관절강내하이알루론산염주사를비교한결과두치료법간통증감소효과및관절가동범위증가에있어차이가없기때문에스테로이드주사로인한부작용이나타날수있는환자에서하이알루론산염을사용하는것이좋다고보고한바있다. Yasar 등 1 은뇌졸중환자들을대상으로편마비측어깨통증에대하여견갑상신경차단술과관절강내스테로이드주사를비교한결과두치료법모두동등한통증감소효과및관절가동범위의증가를나타내는것으로보고하였다. 하지만뇌졸중환자들을대상으로견갑상신경차단술과관절강내하이알루론산염주사의효과를비교한연구는보고된바가없었으며, 기능적향상도에영향을미치는지에관한연구도보고된바없었다. 이에본연구에서는뇌졸중후발생한편마비측어깨통증에대해견갑상신경차단술과관절강내하이알루론산염주사의효과를측정하여각치료의통증감소효과및기능적향상도를비교하고자하였다. 연구대상및방법 1) 연구대상 2011년 11월부터 2013년 6월까지재활의학과로입원한환자들중, 뇌자기공명영상검사 (MRI) 혹은뇌컴퓨터단층촬영 (CT) 검사상에서확인된뇌출혈혹은뇌경색에의하여일측의편마비가발생하였고, 발병한지 12개월이내이며, 이학적검사상편마비측어깨의수동적관절운동범위제한을보이고, 편마비측어깨통증이시각사상척도상 (visual analogue scale, VAS) 6점이상인환자를대상으로하였다. 대상자중편마비측무시증상을보이는경우, 실어증이동반된경우, 간이정신상태검사 (mini-mental state examination) 에서 24점미만의인지저하가있는경우와뇌졸중발병이전에어깨의외상, 회전근개질환, 말 초신경손상의과거력이있는경우, 뇌졸중발병후복합국소통증증후군이발생한경우, 중심성동통증후군이발생한경우는연구대상에서제외하였다. 본기관의윤리위원회로부터연구에대한검토및승인을받았으며, 모든참가자에게연구절차와목적, 가능한합병증에관해설명하고동의를한참가자만을포함시켰다. 2) 연구방법연구대상의기준에부합하는환자인경우, 블록무작위배정법에따라눈가림을위하여평가자가아닌연구원이난수표에의해견갑상신경차단술군과관절강내하이알루론산염주사군에배정을하였고, 총 24명의환자들이양군에각각 12명씩배정되어시술을시행받았다. 견갑상신경차단술군의환자들은앉은자세에서어깨를중립자세로위치시킨후 1% 리도카인 10 cc를이용하여초음파유도하에견갑상신경차단술을시행받았다. 초음파유도견갑상신경차단술은 8 12 MHz의선형프로브를어깨의상외측면에종단스캔방향으로위치시켜견갑상패임 (suprascapular notch), 견갑상동맥과견갑상신경, 견갑횡인대 (transverse scapular ligament) 를확인후전방접근방식으로 10 cm 길이의 23게이지바늘을견갑상패임과극관절와패임 (spinoglenoid notch) 사이에위치시켜도플러영상을확인한후주사를시행하였다. 18 관절강내하이알루론산염주사군의환자들은앉은상태에서초음파유도후방접근법하에하이알루론산염 (Hyruan-Plus R, LG life science, Seoul, Korea) 2 cc를주사하였다. 19 초음파유도하견갑상신경차단술과관절강내하이알루론산염주사는다른연구과정에서배제된 (blinded) 숙련된재활의학과의사한명에의해시행되었고두군모두 1주간격으로총 3회에걸쳐주사를시행하였다. 연구에참여한환자들은모두같은재활치료계획아래주당 5일의운동치료와작업치료를유지하였으며그외추가적인열치료와전기치료는시행하지않았고통증에대한약물복용은시술 3 일전부터중단하도록하였다. 3) 평가도구주된결과도구 (primary outcome measurement) 로서 VAS를사용하였으며, 통증의강도를 0 10 cm의스케일에환자가직접표시하게하여측정하였다. 20 그외에환자들의편마비측상지의기능수준을측정하기위하여 Fugl- Meyer scale (FMS), Wolf motor function test (WMFT), Brunnstrom stage를측정하였고강직의변화를평가하기위하여 modified Ashworth scale (MAS) 을측정하였다. 관 119

3 Brain & NeuroRehabilitation 2014; 7: 절가동범위는각도계 (goniometer) 를사용하여측정하였고측정시반듯이누운자세에서어깨관절의굴곡, 외전, 외회전의최대각도를측정하였다. Brief pain inventory (BPI) 는한글버전 (BPI-K) 을사용하였으며, 환자들에게통증이얼마만큼기능수행 ( 전반적인활동, 기분, 보행능력, 통상적인일, 대인관계, 수면, 인생을즐김 ) 에있어영향을미치는지숫자등급 (0 = 영향없음, 10 = 통증으로수행할수없음 ) 을이용하여평가하였다. 21 모든평가는첫주사직전과 1주후및 4주후에실시하였다. 모든평가는다른연구과정에서배제된 (blinded) 한명의재활의학과의사에의해시행되었다. Table 1. Characteristics of the Patients Groups SSNB HA Gender, (male : female) 6 : 6 4 : 8 Age, mean ± SD, years 66.3 ± ± 9.9 Duration of stroke, mean ± SD, months 2.7 ± ± 2.1 Subluxation, numbers 8 6 Adhesive capsulitis, numbers 4 2 SSNB: suprascapular nerve block, HA: hyaluronic acid. 4) 통계분석방법수집된자료들은 SPSS version 17.0 (SPSS Inc. Chicago, IL, USA) 을사용하여분석하였다. 두군간의인구통계학적 (demographic) 특성및기저값 (baseline values) 에대한비교평가를위하여지속적인항목 (continuous data) 은 Mann-Whitney U 검정을, 범주형항목 (categorical data) 은 χ 2 검정을사용하였다. 시간변화에따른두군간효용성평가비교를위하여반복측정분산분석 (repeated measure analysis of variation) 을이용하였고, 각군내의시간변화에따른치료효과의유의성을보기위해일원배치분산분석법 (one way analysis of variance) 을사용하였으며유의한경우 Bonferroni 검정을통해사후분석 (post hoc analysis) 을시행하였다. 유의수준이 p<0.05인경우통계학적으로유의한것으로판단하였다. 결과 이번연구에는총 24명의환자들이포함되었으며각군당 12명이배정되었고중도탈락된경우는없었다. 인구통계자료상양군간에유의한차이는없었다 (Table 1). VAS를이용한통증지수는통계분석결과양군간에유 Table 2. The Change in the Parameters after Intervention Baseline 1 week after first injection 4 weeks after first injection Visual analogue scale SSNB 6.50 ± ± 1.36* 3.17 ± 1.59* HA 5.92 ± ± 1.59* 3.00 ± 1.04* Fugl-Meyer scale SSNB ± ± ± HA ± ± ± Wolf motor function test SSNB ± ± ± HA ± ± ± Brunnstrom stage SSNB 2.33 ± ± ± 1.83 HA 2.33 ± ± ± 1.71 Modified Ashworth scale SSNB 0.33 ± ± ± 0.51 HA 0.58 ± ± ± 0.90 Shoulder flexion SSNB ± o ± o ± 3.89 o HA ± o ± o ± o Shoulder abduction SSNB ± o ± o ± o HA ± o ± o ± o Shoulder external rotation SSNB ± o ± o ± 4.62 o HA ± o ± o ± o Values are presented as mean ± SD. SSNB: suprascapular nerve block, HA: hyaluronic acid injection. Post hoc analysis reveals significance levels: *p<0.05 in comparison with baseline level, p<0.05 in comparison with 1 week after first injection. 120

4 김상현ㆍ김동석 : 편마비측어깨통증에서의견갑상신경차단술과관절강내하이알루론산염주사간의비교 의한차이가관찰되지않았고, 각군내에서분석하였을때견갑상신경차단술군의경우시간경과에따라유의하게호전을보인것으로나타났으며 (p<0.05), 관절강내하이알루론산염주사군은 1주후, 4주후값이기저값보다유의한호전을보였으나 (p<0.05) 1주후평가와 4주후평가사이에서는유의한차이를보이지않았다 (Table 2, Fig. 1). FMS, WMFT, Brunnstrom stage, MAS 및어깨관절가동범위평가에서는양군간에유의한차이가나타나지않 았으며, 각군내에서도유의한변화를보이지않았다 (Table 2). 기능수행에관한 BPI 평가에서 전반적인활동, 보행능력, 기분, 통상적인일, 대인관계, 수면, 인생을즐김 의항목에있어양군간유의한차이는없었다. 각군내에서의시간에따른유의성분석결과견갑상신경차단술군에서 전반적인활동, 기분, 통상적인일, 인생을즐김 의항목에서첫평가에비하여 4주후평가에서유의한호전을보였지만 (p<0.05), 관절강내하이알루론산염주사군에서는모든항목에서유의한차이를보이지않았다 (Table 3, Fig. 2). 모든환자에서치료시행에따른부작용이나타난경우는없었다. 고찰 Fig. 1. Graphs shows change of visual analogue scale parameter at baseline level, 1 week after intervention and 4 weeks after intervention. VAS : Visual analogue scale. *p<0.05 in comparison with baseline level, p<0.05 in comparison with 1 week after first injection. 뇌졸중후편마비측어깨통증의원인에대하여 Yoon 등 4 은평균 2.26개의원인의복합적인작용에의해통증이유발되며이중유착성관절낭염과복합국소통증증후군의비율이가장높았다고보고하였고, Van Ouwenaller 등 22 은강직이편마비측어깨통증에기여하는중요한요소로, 정상인에서는다른근육군들의주동근- 길항근 (agonistantagonist) 작용에의해정상근력의균형 (muscular balance) 이유지되지만, 뇌졸중후에는강직의영향을받은근육군에의해상지의굴곡긴장 (flexor tone) 이증가하여견갑 Table 3. The Change in the Brief Pain Inventory after Intervention Baseline 1 week after first injection 4 weeks after first injection Brief pain inventory: activity SSNB 4.42 ± ± ± 1.21* HA 4.50 ± ± ± 2.42 Brief pain inventory: walking ability SSNB 3.58 ± ± ± 1.61 HA 2.75 ± ± ± 1.68 Brief pain inventory: mood SSNB 4.00 ± ± ± 1.16* HA 4.58 ± ± ± 2.50 Brief pain inventory: work SSNB 4.25 ± ± ± 1.08* HA 3.75 ± ± ± 2.32 Brief pain inventory: relationship SSNB 3.75 ± ± ± 1.44 HA 3.42 ± ± ± 2.58 Brief pain inventory: sleep SSNB 3.92 ± ± ± 1.08 HA 4.42 ± ± ± 3.50 Brief pain inventory: enjoy SSNB 4.00 ± ± ± 1.11* HA 4.17 ± ± ± 3.41 Values are presented as mean ± SD. SSNB, suprascapular nerve block; HA, hyaluronic acid injection. Post hoc analysis reveals significance levels: *p<0.05 in comparison with baseline level. 121

5 Brain & NeuroRehabilitation 2014; 7: Fig. 2. Graphs shows change of brief pain inventory parameters at baseline level, 1 week after intervention and 4 weeks after intervention. BPI: Brief pain inventory. *p<0.05 in comparison with baseline level. 골의후방견인과함몰, 어깨관절의내회전, 내전을유도함으로써관절운동범위가제한되고유착성관절낭염, 건염의발생률을높이게되어뇌졸중후편마비측어깨통증에기여한다고하였다. 또한 Murie-Fernandez 등 13 은뇌졸중초기단계의이완성마비상태에서견갑상완관절 (glenohumeral joint) 의아탈구에따른관절막의염증, 인대손상및어깨회전근의손상으로인해어깨통증이유발되며이로인해기능저하가발생된다고보고하였다. Zeilig 등 6 은뇌졸중후편마비측어깨에시행한감각검사에서편마비측어깨통증이있는환자에서편마비측어깨부위의열고통임계 (heat-pain threshold) 가건측어깨에비해유의하게높았고, 통각과민 (hyperpathia), 이질통 (allodynia), 지각이상 (dysethesia) 이관찰된비율이유의하게높은것으로보아신경병적인요소가편마비측어깨통증에작용하는것으로보았으며, 뇌졸중후중추성통증 (central poststroke pain) 과경직, 어깨관절아탈구, 어깨관절의안정성저하로인한말초신경의손상을신경병적원인으로제시하였다. 본연구에서는 VAS 평가상견갑상신경차단술군과관절강내하이알루론산염주사군모두유의한통증강도의경감을보였지만양군간에유의한차이점은관찰되지않았다. Lee 등 17 은편마비측어깨통증의치료에견갑상신경차단술은유의한효과가없었고위약군과차이를보이지않았다고하였다. 반면 Boonsong 등 23 은편마비측어깨통증에견갑상신경차단술의치료효과가유의하며안전한방법이라고하였다. 하지만두연구에서는어깨통증과관절가동범위에대한평가만시행하였으며상지기능평가및일상생활에서의삶의질과관련된평가는시행하지않았다. 최근에는 Adey-Wakeling 등 16 이뇌졸중발병후일년이내의환자들을대상으로시행한연구에서, 견갑상신경차단술은유의한통증경감효과를나타냈고 12주경과관찰후에도효과가지속되었으나환자의기능이나삶의질에는영향을미치지못하였다고보고한바있다. 본연구에서도 FMS, WMFT, Brunnstrom stage에서유의한변화가관찰되지않았지만기능수행에관한 BPI 평가에서는 122

6 김상현ㆍ김동석 : 편마비측어깨통증에서의견갑상신경차단술과관절강내하이알루론산염주사간의비교 관절강내하이알루론산염주사군의경우유의한효과를보이지않았으나견갑상신경차단술군에서는 전반적인활동, 기분, 통상적인일, 인생을즐김 항목에서유의한호전을보였다. 견갑상신경은어깨의감각을지배하고어깨부위통증섬유의 70% 를구성하며높은비율의교감신경섬유를포함한다. 24 견갑상신경차단술은일시적으로자율신경을동반하는구심성신경 (afferent nerve) 을차단하고어깨부위통증정보를중추신경계로전달하는것을억제하여통증감소효과를나타내며, 장기적으로는감소된말초에서의통각수용 (peripheral nociceptive input) 에의해이차적으로척수후각 (posterior horn of spinal cord) 의중추감작 (central sensitization) 이단계적으로감소하여지속적인통증감소효과를나타낸다고알려져있다 또한견갑상신경차단술에의한활액막내 substance P와신경성장인자 (nerve growth factor) 등통증유발물질의감소및어깨관절의구심성 C섬유 (afferent C fiber) 의감소가장기적인통증경감에영향을미칠수있다. 28 이와같이이번연구에서견갑상신경차단술이통증감소및일상생활에미치는영향에효과를보인것은구심성신경차단을통한일시적인효과뿐만아니라중추신경원의과흥분성변화및통증유발물질의변화로발생한신경병적통증을효과적으로조절할수있었기때문인것으로보인다 반면하이알루론산염은활액의주성분인 glycosaminoglycan으로써기계적충격흡수, 관절윤활제및관절연골조직의보전역할을하며, 관절내주사를통해연골조직변성을억제하고병적관절액을정상화시켜통증경감효과를나타낸다. 9 또한하이알루론산염주사는관절의관절가동범위를증가시키고항염증작용을통해관절통증을감소시켜어깨관절의퇴행성골관절염에서효과적이고안전한치료법이라고보고되었고어깨통증질환과유착성관절낭염에서도효과가있다고보고된바있다. 29,30 본연구결과에서도관절강내하이알루론산염주사를시행하였을때치료전에비해통증이감소되었음을알수있었다. 이는뇌졸중후편마비측어깨부위에유착성관절낭염, 어깨부위아탈구등어깨통증을유발시키는합병증이흔히동반되며, 관절강내하이알루론산염주사를통해이러한합병증을효과적으로조절할수있었기때문인것으로여겨진다. 9,31,32 하지만견갑상신경차단술과달리, 통증이기능수행에미치는 BPI 검사에서유의한차이는없었던것으로나타났으며, 이는관절강내하이알루론산염주사의경우편마비환자에동반되는신경병적통증은조절하지못하였기때문인것으로판단된다. Vieira 등 33 은신경병적통증이일상생활및삶의질에유의한영향을 미친다고보고하였고, Erdemoglu 등 34 은만성통증환자에서침해성통증 (nociceptive pain) 및신경병적통증을구분하는데에 BPI 가유의하고신뢰도있는검사이며신경병적통증에의한영향을더욱반영한다고하였다. 견갑상신경차단술은간헐적으로어지럼증, 발한등일시적인미주신경성증상이나국소적인압통등의부작용이발생할수있는것으로알려져있으나이전연구들대부분에서부작용이나타나지않았으며부작용이나타난경우에도증상이 1주일이내에호전되었다. 1,6,24 본연구에서도견갑상신경차단술및관절강내하이알루론산염주사를시행한두그룹모두부작용이나타난경우는없었다. 본연구에서는몇가지의제한점을고려해야한다. 첫째, 본연구에서는위약군 (placebo group) 을두지않았다. 위약군과의비교를통해각그룹의치료효과를입증할필요가있었으나견갑상신경차단술, 관절강내하이알루론산염주사를대조군과비교하여효과를입증한여러연구들이있었기때문에본연구에서는두치료법간의비교만시행하였다. 1,9,31,32 둘째, 치료이후통증과관절운동범위및기능적호전에관한장기적인추적관찰이이루어지지않아치료종료후장기적인효과의지속여부에대해서는알수없어, 추후치료기간및장기적인효과여부에대한보완연구가필요할것이다. 하지만본연구는뇌졸중후편마비측어깨통증에견갑상신경차단술을관절강내하이알루론산염주사와비교한첫무작위배정대조군연구로서, 두치료모두통증감소에효과적인치료임을보였으나, 통증이환자의일상생활에미치는영향과관련하여서는견갑상신경차단술에서만유의한효과를나타냈다. 또한이번연구에서는상지기능평가및강직정도평가, 관절가동범위평가등의다양한평가를시행하였다는데에그의의를둘수있을것으로보인다. 결론 본연구에서는견갑상신경차단술과관절강내하이알루론산염주사의효과를비교하였고, 연구결과두치료법사이에유의한차이없이동등한통증호전을보였다. 따라서두치료법모두안전한치료로뇌졸중환자의편마비측어깨치료에효과적으로사용될수있음을알수있었다. 하지만통증이일상생활에미치는영향을통해주관적인삶의질을각그룹내에서평가한경우, 견갑상신경차단술에서만유의한효과를보였기때문에뇌졸중환자의편마비측어깨통증치료에견갑상신경차단술이임상의의판단에따라우선적으로고려될수있을것이다. 123

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8 김상현ㆍ김동석 : 편마비측어깨통증에서의견갑상신경차단술과관절강내하이알루론산염주사간의비교 Bello A, Forte A, DeBlasio E, Trombetti C. Pain relief in early rehabilitation of rotator cuff tendinitis: any role for indirect suprascapular nerve block? Eura Medicophys. 2006;42: ) Woolf CJ. Somatic pain--pathogenesis and prevention. Br J Anaesth. 1995;75: ) Park KD, Nam HS, Lee JK, Kim YJ, Park Y. Treatment effects of ultrasound-guided capsular distension with hyaluronic acid in adhesive capsulitis of the shoulder. Arch Phys Med Rehabil. 2013;94: ) Byun SD, Park DH, Choi WD, Lee ZI. Subacromial Bursa Injection of Hyaluronate with Steroid in Patients with Peri-articular Shoulder Disorders. Ann Rehabil Med. 2011;35: ) Saito S, Furuya T, Kotake S. Therapeutic effects of hyaluronate injections in patients with chronic painful shoulder: a meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken). 2010;62: ) Blaine T, Moskowitz R, Udell J, Skyhar M, Levin R, Friedlander J, Daley M. Altman R. Treatment of persistent shoulder pain with sodium hyaluronate: a randomized, controlled trial. A multicenter study. J Bone Joint Surg Am. 2008;90: ) Vieira AS, Baptista AF, Mendes L, Silva KS, Gois SC, Lima FM, Souza I, Sa KN. Impact of neuropathic pain at the population level. J Clin Med Res. 2014;6: ) Erdemoglu AK, Koc R. Brief Pain Inventory score identifying and discriminating neuropathic and nociceptive pain. Acta Neurol Scand. 2013;128:

원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 연세대학교대학원 의학과 남상현

원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 연세대학교대학원 의학과 남상현 원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 연세대학교대학원 의학과 남상현 원위부요척골관절질환에서의초음파 유도하스테로이드주사치료의효과 - 후향적 1 년경과관찰연구 - 지도김석원교수 이논문을석사학위논문으로제출함