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1 대한내과학회지 : 제 78 권제 6 호 2010 종설 (Review) 류마티스내과영역에서의근골격초음파 연세대학교원주의과대학류마티스내과 강태영 Musculoskeletal ultrasound in rheumatology Tae Young Kang, M.D., Ph.D. Department of Rheumatology, Yonsei University Wonju College of Medicine, Wonju, Korea s technological advances in ultrasound have led to high-resolution imaging of musculoskeletal structures, ultrasonography has become an integral part of diagnosis and management in rheumatology practice. Ultrasound has several advantages over clinical examination in the diagnosis and localization of rheumatic diseases, such as joint effusion, erosion, synovitis, tendon diseases, and enthesopathy. Moreover, ultrasound improves joint aspiration accuracy and both intra-articular and soft tissue injection technique. The Doppler evaluation provides useful clinical information regarding tissue vascularity and can be used to monitor joint and soft tissue disease activity and progression. This paper presents a review of the evidence in support of the application of musculoskeletal ultrasound in rheumatology. (Korean J Med 78: , 2010) Key Words: Musculoskeletal ultrasound; Rheumatology ultrasonography; Doppler; Synovitis; Tenosynovitis 서론근골격질환에대한초음파의활용은약 30년전부터이루어져왔다. 초기에는베이커씨낭종 (aker s cyst) 이나무릎관절과같은큰구조물들의관찰에국한되었으나 1990년대들어서고해상도선형탐촉자 (linear probe) 의기술적인발전과컴퓨터연산능력의향상으로작은관절및연부조직 (soft tissue) 에대한검사가가능해지면서그활용영역이넓어져왔다 1). 최근에근골격초음파는류마티스질환에대한진단, 치료반응및예후판정에대한도구로써의활용도가점차증가하고있다. 초음파검사는안전하고, 방사선조사의위험이전혀없으며, 비침습적이고, 연부조직의평가에서 MRI (magnetic resonance imaging) 보다저렴하고실시간역동검사 (dynamic test) 가가능하며여러부위를함께관찰할수있다는장점들이있다 2). 또한삼출 (effusion), 활막염 (synovitis), 골미란 (bone erosion), 연골 (cartilage) 손상, 힘줄 (tendon) 병변등과같은근골격질환의평가및시술에대한초음파의실질적도움은류마티스내과진료에서근골격초음파의유용성을증대시켜왔다. 파워도플러 (power Doppler) 와컬러도플러 (color Doppler) 검사를통해얻어지는혈류에대한정보로다양한류마티스질환에서염증의중증도를측정할수있다. 다양한임상상황에서어떤영상기법이가장적절한것인가에대한논란이있을수있지만 3,4) 류마티스내과영역에서차지하는초음파의위상은현재빠르게상승되어가고있다. 1. 류마티스내과의근골격초음파류마티스내과에서초음파의첫활용은 1978년류마티스관절염에서활막염의증명과함께시작된것으로여겨진다 5). 이후초음파의공학적인발전으로근골격구조물들에대한고해상도의영상을얻는것이가능하게되자초음파는류마

2 - The Korean Journal of Medicine: Vol. 78, No. 6, 티스내과의사에게매력적인진료도구가되었다. 류마티스내과의사에게근골격초음파는두가지의중요한의미를가진다. 첫번째는하나의신체부위를다양한단면으로관찰할수있기때문에이학적검사 (physical examination) 의연장선으로활용할수있다는것이고, 두번째는연구에대한결과측정의객관적인도구로써활용할수있다는것이다. 또한초음파검사에숙련된류마티스내과의사는상대적으로짧은시간에다수의관절들을관찰할수있다는점이류마티스내과의사가진료의필수적인도구로초음파를활용해야하는것에대한강력한의미를부여해준다. 이러한장점에기초하여근골격초음파는산부인과의사와심장내과의사가진료에초음파를활용해온것처럼류마티스내과진료의한영역으로빠르게융합되어가고있다 6). 근골격초음파영상을이해하기위해서는근골격질환에대한해부학적, 병인론적지식의구비가필수적인사항이다. 따라서진료에초음파를활용하는류마티스내과의사는활용하지않는의사와비교하여근골격질환에대한병인및치료방법접근에대한이해력의증가와함께관절강내주사및흡인등과같은임상술기의능력이의미있게향상된다 1,7,8). 이러한이유들로독일, 이탈리아등을포함한서구의여러나라에서는류마티스내과전문의자격을획득하기위해서는일정기간동안근골격초음파를필수적으로이수해야한다 2,9). 근골격초음파는시술자의경험과숙련도에대한의존성이있는영상기법이다. 또한초음파영상에대해관찰자간및관찰자내변이 (variation) 가있을수있다. 그러나활막염, 힘줄병변, 삼출등과같은기본적인병변들을발견하고평가하는능력은기본적인수련에의해쉽게획득될수있다 10,11). 현재서로다른성격의근골격초음파교육과정들이있지만숙련된전문가의지도에의한교육이올바른류마티스내과초음파수련에기본적으로가장중요하다. 류마티스내과분야에서는유럽류마티스학회 (European League gainst Rheumatism, EULR) 와 OMERCT (Outcome Measures in Rheumatoid rthritis Clinical Trials) 초음파연구그룹이류마티스내과영역에서초음파의적용, 질환의초음파소견등에대한표준의확립과초음파교육을주관해오고있으며이에대한관심의증대와활용은전세계적으로확대되고있는추세이다 12,13). 류마티스내과의사와영상의학과의사는상보적인관계이다. 류마티스내과에서다루는영역은과거에중요시되지않았던초음파를이용한활막염, 부착부염 (enthesitis), 연골, 힘줄의평가, 골미란, 초음파유도하의천자및주사분야에초점이맞추어져있으며영상의학과의사는연부조직손상, 파열, 외상, 종양등과같은외과영역에집중되어있다 14). 그러므로류마티스내과의사와영상의학과의사가협동적으로근골격초음파를발전시켜나가는것이올바른방향이다. 2. 류마티스내과에서근골격초음파시행을위한필요사항근골격초음파를하기위해기본적으로 7.5 MHz 이상의고주파수 (high frequency) 를가진선형탐촉자가구비된초음파기계가필요하다. 탐촉자에서방출된초음파의주파수에따라투과력과해상력이결정되는데, 이두인자는서로반비례관계로주파수가높을수록투과력이감소하여관찰할수있는조직의깊이는감소하나해상력이증가하여세밀한영상을얻을수있다. 손목, 손가락, 발가락관절과같이표면에위치한관절은 10 MHz 이상의주파수를사용하며, 고 (hip) 관절처럼상대적으로깊게위치해있는관절은 5~10MHz 정도의주파수를사용한다. 최근의선형탐촉자는광대역 (broadband) 주파수 ( 예 ; 7~18 MHz) 를사용하므로한개의탐촉자로모든활막관절을관찰할수있다. 또한근골격구조물들의단면해부학, 초음파의발생, 영상형성의기본원리, 회색도 (gray-scale) 와도플러초음파원리및초음파허상 (artifact) 에대한기본적인지식과이해가필요하다 ( 표 1) 15). 3. 류마티스내과근골격초음파 : 무엇을관찰하나? ( 표 2) 1) 활막관절 (synovial joint) 류마티스내과에서초음파검사를시행하는활막관절의빈도는손목과손가락, 무릎, 발목과발가락, 어깨, 고관절, 팔꿈치관절순이다 11). 활막관절은골표면이초자연골 (hyaline cartilage) 로덮여있고, 미량의활액이들어있는관절강 (joint cavity) 이있으며, 관절강은관절낭 (joint capsule) 에의해둘러싸인공통적인특징들이있다. 정상적으로초자연골은무에코성또는저에코성으로균질하게관찰되고인접구조물들과의경계가명확하다. 소량의삼출이중수지 (metacarpophalangeal) 관절, 손목관절, 고관절, 무릎관절에서관찰될수있다. 어깨관절순 (glenoid labrum) 과고관절순 (acetabular labrum) 및무릎반월판 (meniscus) 과같은섬유연골 (fibrocartilage) 은고에코성이다. 관절낭은연골과관절주위사이의경계를형성하는부위로고에코성으로관찰된다. 정상적으로관절강내에서는도플러신호가검출되지않는다. 2) 힘줄및힘줄윤활막 (tenosynovium) 힘줄은원섬유 (fibrillar) 구조로세로스캔 (longitudinal scan)

3 - Tae Young Kang. Rheumatology ultrasonography - Table 1. asic requirements for ultrasound in rheumatology Equipment asic technical knowledge of the ultrasound equipment natomy Detailed knowledge of ultrasound-oriented cross-sectional anatomy Clinical setting To evaluate the ultrasound findings in the clinical setting Gray-scale imaging asic knowledge of the physics, artifact and main findings of ultrasound in rheumatology Doppler imaging asic knowledge of color and/or power Doppler technique Table 2. Echogenic properties of musculoskeletal structures in rheumatology Hyaline Cartilage nechoic and black Fibrocartilage Hyperechoic Joint capsule Hyperechoic one surface right and hyperechoic with posterior acoustic shadowing Ligaments Fibrillar pattern like that of tendons, but fibers may run in different directions Tendons Fine internal fibrillar pattern, hyperechoic if localized perpendicular to the probe ursae Hypoechoic or anechoic depending on the structures in the bursae Nerves Similar but more dotted, less echogenic and less fibrillar than tendons Muscles Hypoechoic and fine intramuscular hyperechoic lines represent the epi-and perimysium 에서고에코성의평행하게배열된여러개의직선들이무에코성선 (line) 들에의해구분되는형태로나타난다. 가로스캔 (transverse scan) 에서힘줄의단면은원형또는타원형이며그안은균일한분포를보이는고에코성점 (dot) 들이치밀하게패킹 (packing) 된형태로관찰된다. 해부학적으로힘줄에힘줄윤활막이있다면, 힘줄윤활막은얇은고에코성선으로관찰되며힘줄과힘줄윤활막사이에는소량의활액으로채워져있다. 힘줄윤활막은역동검사에서힘줄섬유의운동방향을따라같이움직이지않는다. 영 (acoustic shadowing) 이동반된고에코성의연속적인선으로관찰된다. 골표면아래로잔향 (reverberation) 이나타날수있다. 6) 신경 (nerve) 정상말초신경은저에코성다발성 (fascicular) 모양으로관찰되는데, 힘줄에비해보다점성 (dotted) 이고원섬유성이적다. 각각의신경다발은고에코성결합조직으로둘러싸여있으며큰신경주위에는고에코성지방이관찰될수있다. 3) 근육 (muscle) 근육은저에코성이나탐촉자의방향에따라중에코성또는고에코성으로관찰될수있다. 두꺼운고에코성선은사이막 (septum) 과감싸는근막 (investing fascia) 이며가는근육내고에코성선은근육바깥막 (epimysium) 과곁근육막 (paramysium) 이다 16). 4) 인대 (ligament) 인대는두개의골성구조물을연결하여관절의안정성에기여한다. 인대는고에코성원섬유구조로관찰되나, 힘줄보다더치밀한형태이다. 인대가여러개의층 (layer) 으로구성되어있다면, 인대섬유들이다른방향으로주행할수있다. 5) 골 (bone) 초음파는골을통과하지못하기때문에골은후방음향음 4. 류마티스내과근골격초음파 : 류마티스질환에서어떻게변하나? ( 표 3) 1) 삼출관절강의팽창은삼출의가장특징적인소견이다 ( 그림 1). 관절삼출은그부위에염증이있다는의미의표시자이기도하다. 관절삼출검출능력은초음파가이학적검사보다민감도가높다 17). 관절삼출은무에코성또는저에코성을보이며도플러신호가검출되지않는다. 2) 활막염및힘줄윤활막염 (tenosynovitis) 관절염의올바른진단과치료를위해서활막염의존재여부를확인하는것이매우중요하다. 해부학적구조상활막을가지고있는관절, 점액낭, 힘줄윤활막에삼출액이존재한다

- 대한내과학회지 : 제 78 권제 6 호통권제 598 호 2010 - Table 3.

Hyperechoic non-compressible joint space widening with villous appearance, synovial thickening one erosion n intra-articular discontinuity of the cortical surface

(hyperechoic pattern) or both (mixed pattern), may exhibit Doppler signal Focal or diffuse thickening of the tendon, loss of fibrillar echotexture and patchy

() Enlargement of the joint space due to joint effusion. () Power Doppler showing increased synovial perfusion in early rheumatoid arthritis.

D 면이는활막에염증이있다는의미이다. 삼출이없다면활막염은비정상적으로비후된고에코성활막병변을관찰하는것으로진단할수있다. 초음파로이학적검사만으로는알지못하는활막의염증을검출할수있다 7,8). 뚜렷한활막증식이관찰되기이전의초기단계에서는활막염에이환된관절의활막을따라도플러신호가비정상적으로증가될수있다 ( 그림 1).

4 - 대한내과학회지 : 제 78 권제 6 호통권제 598 호 Table 3. Pathologic ultrasound patterns in rheumatology Joint effusion nechoic compressible joint space widening and does not demonstrate a Doppler signal Synovitis Hyperechoic non-compressible joint space widening with villous appearance, synovial thickening one erosion n intra-articular discontinuity of the cortical surface that is visible in two perpendicular planes Tenosynovitis Tendinopathy Tendon sheath widening with effusion (anechoic pattern) or proliferative synovitis (hyperechoic pattern) or both (mixed pattern), may exhibit Doppler signal Focal or diffuse thickening of the tendon, loss of fibrillar echotexture and patchy hypoechogenicity ankle joint elbow joint C proximal interphalangeal joint shoulder joint Figure 1. Representative examples of sonographic pathological findings. () Enlargement of the joint space due to joint effusion. () Power Doppler showing increased synovial perfusion in early rheumatoid arthritis. (C) Synovial proliferation and villous formation are evident. (D) one erosion, defined by discontinuities of the cortical bone surface, is shown. D 면이는활막에염증이있다는의미이다. 삼출이없다면활막염은비정상적으로비후된고에코성활막병변을관찰하는것으로진단할수있다. 초음파로이학적검사만으로는알지못하는활막의염증을검출할수있다 7,8). 뚜렷한활막증식이관찰되기이전의초기단계에서는활막염에이환된관절의활막을따라도플러신호가비정상적으로증가될수있다 ( 그림 1). 활막염이진행될수록활막의증식과비후가심해지며초음파에서융모 (villous) 형태로증식되는활막이나타난다 ( 그림 1C) 18). 활막염은활막비후와증식의정도 에따라반정량적 (semi-quantitative) 으로등급을구분할수있다 19,20). 류마티스관절염은진행단계에따라다양한모양의활막증식이초음파에서관찰될수있다. 도플러를이용한활막염의평가는류마티스관절염의활성도측정에활용될수있다 21,22). 또한조기활막염을도플러초음파를통해발견하는것이가능해짐에따라염증성관절염의조기진단에초음파를이용한새로운접근법에대한시도가이루어지고있다 23). 활막염증의평가에서도플러초음파는 MRI, 관절경 (arthroscopy) 및조직생검을대체할수

- 강태영. 류마티스내과근골격초음파 - 있는비용효과적인검사법으로여겨진다 24,25). 힘줄윤활막염은조기류마티스관절염에서흔하게발생하며이환된힘줄은섬유성구조가감소되고저에코성으로변하며힘줄과힘줄윤활막사이에저에코성또는무에코성액체가저류되는것으로알수있으며 ( 그림 3) 도플러신호가검출되는활막증식이동반될수있다.

4) 골미란류마티스내과에서골의관찰중가장중요한부분은미란에대한검사이다. 미란은관절강내골표면연속성의단락이직각이되는두개 (two) 의면에서관찰되는것으로정의된다 13) ( 그림 1D). 조기류마티스관절염에서초음파를이용한미란검사는단순 X-선보다약 7배높은민감도를가지고있다 27).

5 - 강태영. 류마티스내과근골격초음파 - 있는비용효과적인검사법으로여겨진다 24,25). 힘줄윤활막염은조기류마티스관절염에서흔하게발생하며이환된힘줄은섬유성구조가감소되고저에코성으로변하며힘줄과힘줄윤활막사이에저에코성또는무에코성액체가저류되는것으로알수있으며 ( 그림 3) 도플러신호가검출되는활막증식이동반될수있다. 3) 연골의병변연골손상은관절질환을예측할수있는중요한변화로다양한류마티스질환에서연골이상소견이동반될수있다. 연골투명도 (transparency) 의소실, 연골과연부조직경계부의선명도 (sharpness) 소실, 연골두께의감소등이연골병변이있는질환에서관찰되는초음파소견이다. 연골의퇴행성변화가주된병리기전인골관절염에서는초음파에서이러한소견들이다양하게조합되어나타난다 26). 4) 골미란류마티스내과에서골의관찰중가장중요한부분은미란에대한검사이다. 미란은관절강내골표면연속성의단락이직각이되는두개 (two) 의면에서관찰되는것으로정의된다 13) ( 그림 1D). 조기류마티스관절염에서초음파를이용한미란검사는단순 X-선보다약 7배높은민감도를가지고있다 27). 혈청음성척추관절병증 (spondyloarthropathy), 결절성관절염등과같은질환에서나타나는골미란의검사에서도초음파는단순 X-선검사보다민감도가높다. 또한골피질의이상과골막반응 (periosteal reaction) 이특징인골절과골종양의관찰에초음파가활용될수있다. 5) 힘줄ㆍ인대의병변과거수십년동안근골격초음파는힘줄및힘줄윤활막검사의표준이되어왔다 28,29). 힘줄윤활막염을포함한힘줄병변 (tendinopathy), 힘줄주위조직병변, 힘줄파열은초음파로검사할수있다. 초음파는힘줄, 인대, 염발음 (snapping) 에대한검사에서역동검사가가능하기때문에 MRI보다우월한부분이있다. 팔꿈치의공통굴근 (common flexor muscle), 공통신근 (common extensor muscle), 족저근막 (plantar fascia), 아킬레스힘줄등의부착부염은초음파로관찰될수있으며 ( 그림 2) 이학적검사보다민감도가높다 30,31). 6) 근육의병변초음파로근육의부분또는완전파열을진단할수있다 32). 액체의저류또는근섬유의단락은근육파열을시사하는소견이다. 또한염증성근병변, 근농양, 석회화, 횡문근융해, 근이영양증, 근종양검사에도이용될수있다 33). 근병변의생검, 천자, 흡인등의시술에초음파는유용한도구이다. 5. 도플러초음파 (Doppler ultrasound) 회색도초음파는구조적인이상을보여주지만도플러초음파는혈류신호를감지하여표시해주기때문에근골격구조물들의혈관분포도 (vascularity) 를평가하는데유용한방법이다 ( 그림 4). 도플러초음파는관절및연부조직검사에서정상에서는관찰되지않는미세혈류를확인하여질환의진단, 활성도, 예후, 치료반응의평가에대한객관적자료로사용할수있다는것에중요한의미가있다. 컬러도플러와파워도플러모두류마티스내과초음파검사에활용될수있으나, 파워도플러가앨리어싱 (aliasing) 이발생하지않고, 각 chilles tendon chilles tendon Figure 2. Enthesopathy. () Gray-scale ultrasonography showing thickening, focal loss of the normal fibrillar echotexture with hypoechoic changes of the chilles tendon. () Power Doppler showing inflamed chilles tendon with increased vascularity

- The Korean Journal of Medicine: Vol. 78, No. 6, 2010 - extensor digitorum tendon extensor digitorum tendon Figure 3. Tenosynovitis.

In addition, nonhomogeneous or hyperechoic materials due to synovial hyperplasia are seen (yellow arrow). () Transverse scan showing hypoechoic halo around the tendon (arrows).

() Gray-scale ultrasonography showing effusion (red arrow), synovial proliferation (yellow arrow), and bone erosion (blue arrow) of the ankle joint.

Doppler semi-quantitative grading system Grade 0 No Doppler signal (color pixel)/no flow Grade 1 Single Doppler signal/little flow (three single spots or two single spots plus one confluent spot)

6 - The Korean Journal of Medicine: Vol. 78, No. 6, extensor digitorum tendon extensor digitorum tendon Figure 3. Tenosynovitis. () Longitudinal scan showing decreased echogenicity, loss of normal fibrillar pattern, and irregularity of tendon margins (red arrow). In addition, nonhomogeneous or hyperechoic materials due to synovial hyperplasia are seen (yellow arrow). () Transverse scan showing hypoechoic halo around the tendon (arrows). wrist joint wrist joint Figure 4. Gray-scale versus Doppler ultrasonography. () Gray-scale ultrasonography showing effusion (red arrow), synovial proliferation (yellow arrow), and bone erosion (blue arrow) of the ankle joint. () Power Doppler showing abnormally increased perfusion of the proliferated synovium, representing activity of arthritis. Table 4. Doppler semi-quantitative grading system Grade 0 No Doppler signal (color pixel)/no flow Grade 1 Single Doppler signal/little flow (three single spots or two single spots plus one confluent spot) Grade 2 Several Doppler signals/coherent Doppler signal/clear flow ( 50% color pixels of the intra-articular area). Grade 3 Nearly complete joint area with coherent Doppler signal/strong flow ( 50% color pixels of the intra-articular area) 도의존성 (angle dependency) 이없으며, 미세혈류검출능력이보다우수한이론적인장점들로인해 34,35) 류마티스질환검사에보다많이이용된다. 도플러신호의유무에의해염증성병변과비염증성병변을구분할수있다. 관절염의활성도를평가할때도플러초음파를통해검출되는혈류신호의관절강내면적에따라반정량적으로분류하는것이일반적이다 ( 표 4, 그림 5) 19). 또한관심영역 (region of interest) 의도플러신호화소 (pixel) 갯 수를자동으로계산하여주는소프트웨어를이용한정량적인평가방법도있다 21). 도플러초음파는염증성근병변 36), 아킬레스힘줄염 37) 같은결체조직질환의평가그리고류마티스관절염의질병활성도측정 38,39) 및치료반응을평가하는데활용되어왔다. 그러나도플러초음파영상의해석은초음파장비의성능과도플러변수들 (parameters) 의기계적인조정값그리고시술자의경험과숙련도에따라달리해석될수있다 40). 따라서

- Tae Young Kang. Rheumatology ultrasonography - metatarsophalangeal joint metatarsophalangeal joint C wrist joint D wrist joint Figure 5. Power Doppler signal grading system.

(D) Grade 3: vessel signals in more than half the area of the synovium. 도플러신호평가의표준적인기준값과재현성이구비된정량적접근법에대한표준의확립이향후정립되어야한다. 6. 신경검사근골격초음파는말초신경의모양을관찰하는데유용한도구이다.

정중신경 (median nerve) 은손목부위에서고에코성을보이는굴근지대 (flexor retinaculum) 아래를통과하는데정상적으로타원형이고원위부로주행할수록보다납작한모양으로변한다. 정중신경이수근관내에서압박되면수근관입구 (inlet) 근위부부분이팽창하여이부위의두께가증가하고저에코성을보이며, 굴근지대가위쪽으로돌출되고수근관내의정중신경은보다편평한모양으로변한다.

7 - Tae Young Kang. Rheumatology ultrasonography - metatarsophalangeal joint metatarsophalangeal joint C wrist joint D wrist joint Figure 5. Power Doppler signal grading system. () Grade 0: no flow in the synovium. () Grade 1: single-vessel signals. (C) Grade 2: confluent vessel signals in less than half the area of the synovium. (D) Grade 3: vessel signals in more than half the area of the synovium. 도플러신호평가의표준적인기준값과재현성이구비된정량적접근법에대한표준의확립이향후정립되어야한다. 6. 신경검사근골격초음파는말초신경의모양을관찰하는데유용한도구이다. 류마티스내과영역에서말초신경에대한초음파의적응증은포착신경병증 (entrapment neuropathy) 으로이중가장흔한것은수근관증후군 (carpal tunnel syndrome) 이다. 정중신경 (median nerve) 은손목부위에서고에코성을보이는굴근지대 (flexor retinaculum) 아래를통과하는데정상적으로타원형이고원위부로주행할수록보다납작한모양으로변한다. 정중신경이수근관내에서압박되면수근관입구 (inlet) 근위부부분이팽창하여이부위의두께가증가하고저에코성을보이며, 굴근지대가위쪽으로돌출되고수근관내의정중신경은보다편평한모양으로변한다. 수근관증후군의진단에대한여러기준들이제시되고있으나수근관 입구위치에서측정한정중신경단면적 >10 mm 2 의진단기준이신경전도검사 (nerve conduction study) 에의한진단과잘일치한다 41). 또한초음파는지굴근 (flexor digitorum) 의힘줄윤활막염, 요산결정체침착, 아밀로이드증, 낭종등에의해발생하는이차적원인의수근관증후군을감별하는데사용될수있다. 7. 관절천자및관절강내주사초음파유도하의시술은많은장점들을가지고있다. 바늘의삽입, 진입, 천자, 주사의전과정동안바늘의위치를실시간으로확인하며시술을할수있다 ( 그림 6). 손가락, 발가락, 손목등과같은작은관절의천자및스테로이드주사에서초음파유도에대한효과는여러연구에서증명되어왔다 42-44). 또한류마티스내과에서시행되는점액낭염, 농양, 혈종, 결절종, 베이커씨낭종등과같은병변의천자, 방아쇠손가락 (trigger finger), 수근관증후군의스테로이드주사및

- 대한내과학회지 : 제 78 권제 6 호통권제 598 호 2010 - Figure 6. Ultrasound-guided procedures. () ccurate needle (arrow) positioning to aspirate fluid or inject steroid can be guided and monitored.

석회성힘줄염의흡인과같이바늘위치의정확성이중요하여맹목주사 (blind injection) 가어려운연부조직에대한시술에서초음파유도를이용한시술은치료결과를효율적으로향상시킨다 45,46). 8. 침샘 (salivary gland) 검사쇼그렌증후군 (Sjögren syndrome) 의진단, 치료효과및예후판정에침샘초음파검사가사용된다.

8 - 대한내과학회지 : 제 78 권제 6 호통권제 598 호 Figure 6. Ultrasound-guided procedures. () ccurate needle (arrow) positioning to aspirate fluid or inject steroid can be guided and monitored. () s steroid crystals (arrow) can be seen during the injection procedure, intra-articular steroid injections can be performed more safely and effectively. 석회성힘줄염의흡인과같이바늘위치의정확성이중요하여맹목주사 (blind injection) 가어려운연부조직에대한시술에서초음파유도를이용한시술은치료결과를효율적으로향상시킨다 45,46). 8. 침샘 (salivary gland) 검사쇼그렌증후군 (Sjögren syndrome) 의진단, 치료효과및예후판정에침샘초음파검사가사용된다. 쇼그렌증후군에서이환된침샘은침샘실질의균질성이소실되고, 저에코성으로변하는등의초음파적이상소견이관찰된다 47,48). 초음파에서관찰되는변화소견은침샘생검또는침샘섬광조영술 (scintigraphy) 이상소견과연관관계가있으며쇼그렌증후군이의심되는환자에서우선적으로시행하여야하는검사로간주되고있다 49,50). 결론류마티스내과영역의근골격초음파는표준화되고정립되어야하는부분이아직남아있지만류마티스내과의사가필수적으로갖추어야할매우유용하고강력한도구로서진료와연구에많은장점들을제공하여준다. 현재류마티스질환의진단, 치료, 시술에서초음파의많은임상적적응증들이확립되어있으며활용영역이증가되고있다. 또한도플러초음파를통해얻을수있는관류에대한정보로염증성을판단하고질병활성도를측정할수있다. 염증의진단과스테로이드주사의정확성이라는의미에서근골격초음파검사는류마티스내과환자진료에서유용하다고할수있 다 32). 미래의새로운초음파기술의발전은근골격구조와류마티스질환에대한진보된영상의제공을통해류마티스내과의사들에게보다친숙하게다가올수있을것으로기대된다. 중심단어 : 근골격초음파 ; 도플러 ; 활막염 ; 힘줄윤활막염 ; 부착부염 REFERENCES 1) Wakefield RJ, Gibbon WW, Emery P. The current status of ultrasonography in rheumatology. Rheumatology 38: , ) Manger, Kalden JR. Joint and connective tissue ultrasonography: a rheumatologic bedside procedure? German experience. rthritis Rheum 38: , ) Swen W, Jacobs JW, Hubach PC, Klasens JH, lgra PR, ijlsma JW. Comparison of sonography and magnetic resonance imaging for the diagnosis of partial tears of finger extensor tendons in rheumatoid arthritis. Rheumatology 39:55-62, ) Swen W, Jacobs JW, Neve WC, al D, ijlsma JW. Is sonography performed by the rheumatologist as useful as arthrography executed by the radiologist for the assessment of full thickness rotator cuff tears? J Rheumatol 25: , ) Cooperberg PL, Tsang I, Truelove L, Knickerbocker WJ. Gray scale ultrasound in the evaluation of rheumatoid arthritis of the knee. Radiology 126: , ) Wakefield RJ, Goh E, Conaghan PG, Karim Z, Emery P. Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULR meeting. Rheumatology 42: , ) Grassi W. Clinical evaluation versus ultrasonography: who is the winner? J Rheumatol 30: ,

9 - 강태영. 류마티스내과근골격초음파 - 8) Karim Z, Wakefield RJ, Conaghan PG, Lawson C, Goh E, Quinn M, stin P, O'Connor P, Gibbon WW, Emery P. The impact of ultrasonography on diagnosis and management of patients with musculoskeletal conditions. rthritis Rheum 44: , ) Grassi W, Cervini C. Ultrasonography in rheumatology: an evolving technique. nn Rheum Dis 57: , ) tchia I, irrell F, Kane D. modular, flexible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients with hip osteoarthritis. Rheumatology 46: , ) Taggart, Filippucci E, Wright G, ell, Cairns, Meenagh G, Pendleton, Rooney M, Wright S, Grey, Grassi W. Musculoskeletal ultrasound training in rheumatology: the elfast experience. Rheumatology 45: , ) Takase K, Ohno S, Ideguchi H, Takeno M, Shirai, Ishigatsubo Y. Use of musculoskeletal ultrasound in Japan: a survey of practicing rheumatologists. Mod Rheumatol 2010 [Epub ahead of print] 13) Wakefield RJ, alint PV, Szkudlarek M, Filippucci E, ackhaus M, D'gostino M, Sanchez EN, Iagnocco, Schmidt W, ruyn G, Kane D, O'Connor PJ, Manger, Joshua F, Koski J, Grassi W, Lassere MN, Swen N, Kainberger F, Klauser, Ostergaard M, rown K, Machold KP, Conaghan PG. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 32: , ) Kane D, alint PV, Sturrock R, Grassi W. Musculoskeletal ultrasound: a state of the art review in rheumatology. Part 1: current controversies and issues in the development of musculoskeletal ultrasound in rheumatology. Rheumatology 43: , ) Filippucci E, Iagnocco, Meenagh G, Riente L, Delle Sedie, ombardieri S, Valesini G, Grassi W. Ultrasound imaging for the rheumatologist. Clin Exp Rheumatol 24:1-5, ) ruyn GW, Schmidt W. Introductory guide to musculoskeletal ultrasound for the rheumatologist. p. 25, Houten, ohn Stafleu van Loghum, ) Kane D, alint PV, Sturrock RD. Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis. J Rheumatol 30: , ) ackhaus M. Ultrasound and structural changes in inflammatory arthritis: synovitis and tenosynovitis. nn N Y cad Sci 1154: , ) Szkudlarek M, Court-Payen M, Jacobsen S, Klarlund M, Thomsen HS, Ostergaard M. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. rthritis Rheum 48: , ) Ostergaard M, Ejbjerg, Szkudlarek M. Imaging in early rheumatoid arthritis: roles of magnetic resonance imaging, ultrasonography, conventional radiography and computed tomography. est Pract Res Clin Rheumatol 19:91-116, ) Fukae J, Kon Y, Henmi M, Sakamoto F, Narita, Shimizu M, Tanimura K, Matsuhashi M, Kamishima T, tsumi T, Koike T. Change of synovial vascularity in single finger joint assessed by power Doppler sonography correlated with radiographic change in rheumatoid arthritis: comparative study of novel quantitative score with semi-quantitative score. rthritis Care Res 62: , ) 김해림, 윤종현. 류마티스관절염에서초음파의이용. 대한류마티스학회지 16:74-86, ) Freeston JE, Wakefield RJ, Conaghan PG, Hensor EM, Stewart SP, Emery P. diagnostic algorithm for persistence of very early inflammatory arthritis: the utility of power Doppler ultrasound when added to conventional assessment tools. nn Rheum Dis 69: , ) Klauser, Frauscher F, Schirmer M. Value of contrast-enhanced power Doppler ultrasonography (US) of the metacarpophalangeal joints on rheumatoid arthritis. Eur Radiol 14: ; author reply , ) Wakefield RJ, rown K, O'Connor PJ, Emery P. Power Doppler sonography: improving disease activity assessment in inflammatory musculoskeletal disease. rthritis Rheum 48: , ) Grassi W, Filippucci E, Farina. Ultrasonography in osteoarthritis. Semin rthritis Rheum 34:19-23, ) Wakefield RJ, Gibbon WW, Conaghan PG, O'Connor P, McGonagle D, Pease C, Green MJ, Veale DJ, Isaacs JD, Emery P. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. rthritis Rheum 43: , ) Campbell RS, Grainger J. Current concepts in imaging of tendinopathy. Clin Radiol 56: , ) Grassi W, Filippucci E, Farina, Cervini C. Sonographic imaging of tendons. rthritis Rheum 43: , ) alint PV, Kane D, Wilson H, McInnes I, Sturrock RD. Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. nn Rheum Dis 61: , ) Galluzzo E, Lischi DM, Taglione E, Lombardini F, Pasero G, Perri G, Riente L. Sonographic analysis of the ankle in patients with psoriatic arthritis. Scand J Rheumatol 29:52-55, ) Kane D, Grassi W, Sturrock R, alint PV. Musculoskeletal ultrasound: a state of the art review in rheumatology. Part 2: clinical indications for musculoskeletal ultrasound in rheumatology. Rheumatology 43: , ) Fornage D. The case for ultrasound of muscles and tendons. Semin Musculoskelet Radiol 4: , ) ude RO, Rubin JM, dler RS. Power versus conventional color Doppler sonography: comparison in the depiction of normal intrarenal vasculature. Radiology 192: , ) Rubin JM, ude RO, Carson PL, ree RL, dler RS. Power Doppler US: a potentially useful alternative to mean frequency-based color Doppler US. Radiology 190: ,

10 - The Korean Journal of Medicine: Vol. 78, No. 6, ) Meng C, dler R, Peterson M, Kagen L. Combined use of power Doppler and gray-scale sonography: a new technique for the assessment of inflammatory myopathy. J Rheumatol 28: , ) Richards PJ, Dheer K, McCall IM. chilles tendon (T) size and power Doppler ultrasound (PD) changes compared to MRI: a preliminary observational study. Clin Radiol 56: , ) Carotti M, Salaffi F, Manganelli P, Salera D, Simonetti, Grassi W. Power Doppler sonography in the assessment of synovial tissue of the knee joint in rheumatoid arthritis: a preliminary experience. nn Rheum Dis 61: , ) Qvistgaard E, Rogind H, Torp-Pedersen S, Terslev L, Danneskiold- Samsoe, liddal H. Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique. nn Rheum Dis 60: , ) Torp-Pedersen ST, Terslev L. Settings and artefacts relevant in colour/power Doppler ultrasound in rheumatology. nn Rheum Dis 67: , ) El Miedany YM, ty S, shour S. Ultrasonography versus nerve conduction study in patients with carpal tunnel syndrome: substantive or complementary tests? Rheumatology 43: , ) Raza K, Lee CY, Pilling D, Heaton S, Situnayake RD, Carruthers DM, uckley CD, Gordon C, Salmon M. Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis. Rheumatology 42: , ) Grassi W, Lamanna G, Farina, Cervini C. Synovitis of small joints: sonographic guided diagnostic and therapeutic approach. nn Rheum Dis 58: , ) van Vugt RM, van Dalen, ijlsma JW. Ultrasound guided synovial biopsy of the wrist. Scand J Rheumatol 26: , ) Epis O, Iagnocco, Meenagh G, Riente L, Delle Sedie, Filippucci E, Scire C, Valesini G, Grassi W, ombardieri S, Montecucco C. Ultrasound imaging for the rheumatologist: XVI. ultrasound-guided procedures. Clin Exp Rheumatol 26: , ) del Cura JL. Ultrasound-guided therapeutic procedures in the musculoskeletal system. Curr Probl Diagn Radiol 37: , ) Salaffi F, Carotti M, Iagnocco, Luccioli F, Ramonda R, Sabatini E, De Nicola M, Maggi M, Priori R, Valesini G, Gerli R, Punzi L, Giuseppetti GM, Salvolini U, Grassi W. Ultrasonography of salivary glands in primary Sjogren's syndrome: a comparison with contrast sialography and scintigraphy. Rheumatology 47: , ) Salaffi F, rgalia G, Carotti M, Giannini F, Palombi C. Salivary gland ultrasonography in the evaluation of primary Sjogren's syndrome: comparison with minor salivary gland biopsy. J Rheumatol 27: , ) Carotti M, Salaffi F, Manganelli P, rgalia G. Ultrasonography and colour Doppler sonography of salivary glands in primary Sjogren's syndrome. Clin Rheumatol 20: , ) Makula E, Pokorny G, Kiss M, Voros E, Kovacs L, Kovacs, Csernay L, Palko. The place of magnetic resonance and ultrasonographic examinations of the parotid gland in the diagnosis and follow-up of primary Sjogren's syndrome. Rheumatology 39:97-104,

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( ) Jkra076.hwp Vol. 11, No. 4, December, 2004 Objective: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic