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1 38 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 자기공명영상을이용한회전근개질환의경과관찰 원준성 이우승 박재홍 고승남 서인욱 중앙보훈병원정형외과 A Follow-Up Study of Rotator Cuff Tear Using Magnetic Resonance Imaging Jun-Sung Won, M.D., Woo-Seung Lee, Ph.D., Jae-Hong Park, M.D., Seung-Nam Ko, M.D., and In-Wook Seo, M.D. Department of Orthopedic Surgery, Veterans Health Service Medical Center, Seoul, Korea Purpose: Rotator cuff disease (RCD) is a common cause of shoulder pain. However little is known about the progression of RCD during conservative management. This study aimed to identify the progression of RCD using magnetic resonance imaging (MRI). Materials and Methods: This study was conducted between 2013 and 2015; 48 patients who underwent MRI after at least one year of conservative treatment for RCD were enrolled for follow-up analysis. Rotator cuff tear (RCT) and retraction were measured using an MRI. Tear progression was defined as an increase of 3 mm or more in tear size or retraction. Patients were divided into two groups: Small tear group and medium/large tear group. The progression of tears was analyzed. Results: RCT occurred in 25 cases and tendinosis occurred in 23 cases. The progression was observed in 12 cases (48.0%), and new tears were observed in 2 cases (8.7%). The pre-treatment tear size and retraction were 17.8 mm and 18.9 mm, respectively; while the post treatment tear size and amount of tendon retraction were 20.2 mm and 22.3 mm, respectively. The pre-treatment anteroposterior diameter of tears showed a positive correlation with the pre-treatment tendon retraction (r=0.830, p<0.001) but a negative correlation with the anteroposterior tear size progression (r=-0.473, p=0.017). Small size tears were found in 5 cases (20.0%) and medium/large size tears were found in 20 cases (80.0%). Among the 5 cases of small size tears, 4 cases (80.0%) showed progression, with a mean anteroposterior diameter of 7.4 mm and a mean amount of retraction of 5.9 mm. Among the 20 cases with medium/large size tears, 8 cases (40.0%) showed progression, with a mean anteroposterior diameter of 4.1 mm and a mean retraction of 6.8 mm. The frequency of tear progression was significantly different between the two groups (p<0.001). Conclusion: The need to use MRI monitoring during the conservative treatment of rotator cuff tears to evaluate the possibility of switching to surgical treatment. This study also suggests that an aggressive surgical treatment should be considered even for small tears, since the size of tear and retraction of tears may progress similarly regardless of the size of tear. Key words: rotator cuff, rotator cuff tear, conservative treatment, magnetic resonance imaging 서론 Received December 7, 2016 Revised April 21, 2017 Accepted July 4, 2017 Correspondence to: Jun-Sung Won, M.D. Department of Orthopedic Surgery, Veterans Health Service Medical Center, 53 Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul 05368, Korea TEL: FAX: korean@naver.com *This study was supported by a VHS Medical Center Research Grant, Republic of Korea (grant number: VHSMC 17008). 50세이상에서회전근개파열은 13%-51% 에서발생하며, 연령이증가함에따라발생빈도도증가하는것으로알려져있다. 1,2) 하지만모든 cuff tear에서통증이나기능저하등의증상이나타나지않아대부분증상이있는환자군만치료를받고있다. 많은문헌에서회전근개증후군의증상은주사나운동요법등보존적인치료후호전되는것으로보고하고있으며, 3-6) 소파열의경 The Journal of the Korean Orthopaedic Association Volume 53 Number Copyright 2018 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.

2 39 A Follow-Up Study of Rotator Cuff Tear Using MRI 우보존적치료와수술적치료의임상적결과는단기추시연구에서차이가없는것으로주장하고있다. 6-9) 이러한보존적치료는간편하고경제적이며수술에따른위험도없어초기치료로많이시행되고있다. 그러나보존적치료로인해발생하는위험은잘알려져있지않으며저평가되어있다. 보존적치료로회전근개파열의복구를기대할수없으며회전근개의파열은시간이경과함에따라크기가증가하고근위축이심해지는것으로알려져있다. 2,10,11) 또한보존적치료지속시회전근개의파열이진행하여봉합이불가능한상태로악화될수있으므로통증이있는회전근개파열에서파열의크기가크다면수술적치료를선호한다 ) 하지만회전근개파열의크기와퇴축의진행시기를예측하거나보존적치료에서수술적치료로전환시기에대한연구는없는실정이며보존적치료에따른회전근개의해부학적변화에대한연구도적다. 따라서회전근개질환으로보존적치료를시행한환자군에서전과후의자기공명영상 (magnetic resonance imaging, MRI) 을비교분석하였다. 회전근개파열의해부학적변화를파악하기위해회전근개파열의진행시기와정도를측정하고, 파열진행의예후인자를파악하여보존적치료에서수술적치료로전환시기결정또는적절한보존적치료에도움이되고자한다. 대상및방법 1. 연구대상 2013년 1월부터 2015년 12월까지견관절통증으로 MRI를촬영한 2,856예중회전근개에부분파열이나전층파열의소견이보이고최소 1년이상보존적치료를시행후자기공명영상을재촬영한 67예를선택하여후향적으로연구하였다. 외상과연관된회전근개파열 3예, 내원전수술을시행한 5예와후종인대골화증 2 예, 류마티스관절염 4예, 골관절염 5예는견관절통증과기능에영향을줄수있다고생각되어제외하였다. 최종적으로총 48예가대상군으로선정되었으며나이는평균 64.3세 ( 범위, 45-83세 ), 남성 43예, 여성 5예였고, 추시기간은평균 17.6개월 ( 범위, 개월 ) 이었다. 병원특성상남자대상자가우세하였다. 보존적치료로진통제와견봉하주사를시행하였다. 견봉하주사는환자가허리를펴고앉은자세에서보조자가팔을전하방으로부드럽게견인한후견봉의외측에서견봉하공간을목표로바늘을진입시켜약물이부드럽게진입하는지확인한다음약물을투입하였다. 동시에견관절스트레칭운동을통하여운동범위를확보하기위해노력하였다. 운동범위가정상측에비교하여 90% 이상회복된환자들을대상으로세라밴드를이용한회전근개강화운동을시행하였다. 주사는 3개월간격으로 2회까지시행하였다. 4개월이상보존적치료에반응하지않는환자는수술적치료로전환하였다. 3) 영상의학적평가는 3.0T MRI (MAGNETOM Skyra; Siemens Medical, Berlin, Germany) 을사용하여 3 mm 두께의축상단층면, 경사관상단층면, 경사시상단측면 T2 강조영상을얻었다. 건의퇴축은경사관상단층면에서대결절의내측구 (sulcus) 에서부터파열된건의외측끝을측정하였고층상분리가있는경우는아래층건을기준으로직선길이를측정하였다. 14,15) 건의전후파열은경사시상단층면에서회전근개부위에보이는연속된고신호강도의전후직선길이를측정하였다. 15) 경사시상단층면중견갑골몸통과견갑골극이 Y 모양을이루는 Y-view에서 occupation ratio를측정하였다. 16) Picture archiving communication system의 region of interest를이용하여숙련된정형외과전문의가극상와의안쪽경계를그려크기를얻었고극상근의크기를같은방법으로그려크기를얻은후극상근크기를극상와크기로나누어 occupation ratio를구하였다. MRI 촬영시 3 mm 두께로상을얻기때문에 3 mm 미만의차이는오류가있을것으로생각되어파열의크기와퇴축의진행을 3 mm 이상으로정의하였다. 10 mm 미만의소파열과 10 mm 이상의중 대파열의두군으로나누어파열의진행을분석하였으며파열의진행에따른나이, 성별, 과거력, 파열의크기를분석하였다. 2. 통계분석치료전과후의파열의전후크기와퇴축길이를 Wilcoxon singed ranks test를이용하여분석하였다. 치료전파열의전후크기, 퇴축길이, 파열의전후크기의진행, 퇴축의진행정도간의상관관계를분석하였다. 파열진행을따라두군으로나누어두군의평균을 Mann-Whitney 검정으로분석하였다. 소파열과중 대파열간의파열의빈도는 Fisher s exact 검정을사용하였다. p값이 0.05 이하일경우유의한차이가있다고정의하였으며 IBM SPSS Statistics ver. 21 (IBM Co., Armonk, NY, USA) 을이용하였다. 3. IRB 승인여부 2016년 7월 28일중앙보훈병원 Institutional Review Board (IRB) 로부터최종승인을받았으며 IRB file No. BOHUN 이다. 결과 치료전 MRI에서회전근개전층파열은 25예였으며, 회전근개부분파열은 23예였다. 전층파열에서파열의진행은 12예 (48.0%), 회전근개부분파열에서새로운파열이 2예 (8.7%) 관찰되었다. 파열크기는치료전전후직경은 17.8 mm ( 범위, mm) 에서치료후전후 20.2 mm ( 범위, mm) 로평균 5.23 mm ( 범위, mm) 증가하였고, 치료전건의퇴축은 18.9 mm ( 범위, mm) 에서 22.3 mm ( 범위, mm) 로 6.5 mm ( mm) 증가하였으며, 모두통계적으로유의한차이를보

3 40 Jun-Sung Won, et al. Table 1. Correlation between Size of Cuff Tear/Retraction and Progression Variable AP tear size Retraction AP tear progression Retraction progression AP tear size - r=0.830, p<0.001 r=-0.473, p=0.017 r=-0.219, p=0.293 Retraction - - r=-0.433, p=0.031 r=-0.394, p=0.051 AP tear progression r=0.700, p<0.001 Retraction progression AP, anteroposterior. Table 2. Comparison of Small Tear and Medium to Large Tear Variable Small tear group ( 10 mm) Medium to large group (>10 mm) Total 5 20 Sex (male:female) 5:0 18:2 Age (yr) 65.8 (60 70) 64.1 (42 75) Progression 4 (80.0) 8 (40.0) AP tear size progression (mm) 7.4 ( ) 4.1 ( ) Retraction progression (mm) 5.9 ( ) 6.8 ( ) FU period (mo) 22.9 (12 37) 17.8 (12 37) Values are presented as number only, median (range), or number (%). AP, anteroposterior; FU, follow-up. Table 3. Comparison of Progression Group and Maintain Group Variable Tear progression group Maintain group Number Sex (male:female) 11:1 12:1 Mean Age (yr) FU duration (mo) Past history (n) Times of injection Atrophy progression (%) FU, follow-up. 였다 (p<0.001). 파열의진행은평균 18.8개월 ( 범위, 12-37개월 ) 에관찰되었다. 치료전파열의전후크기는치료전퇴축과양의상관관계 (r=0.830, p<0.001), 전후크기의진행과음의상관관계 (r= , p=0.017) 를보였다 (Table 1). 치료전건의퇴축은파열크기의진행과음의상관관계 (r=-0.433, p=0.031) 를보였고파열크기의진행은퇴축의진행 (r=0.700, p<0.001) 과양의상관관계를보였다 (Table 1). 치료전파열의전후크기와퇴축정도가작을수록치료후파열크기의진행이큰양상을보였다. 파열의전후크기가 10 mm 이하인소파열은 5예 (20.0%) 였고중 대파열은 20예 (80.0%) 였다. 소파열군 5예중 4예 (80.0%) 에서파열이진행하였고파열전후크기의증가는평균 7.4 mm ( 범위, mm), 퇴축된길이의증가는 5.9 mm ( 범위, mm) 진행하였으며, 추시기간은평균 22.9개월 ( 범위, 12-37개월 ) 이었다. 중 대파열군 20예중 8예 (40.0%) 에서파열이진행하였으며전후크기는평균 4.1 mm ( 범위, mm), 퇴축은 6.8 mm ( 범위, mm) 진행하였고, 추시기간은평균 17.8개월 ( 범위, 12-37개월 ) 이었다 (Table 2). 파열의진행을기준으로두군으로나누어비교하였다. 나이, 관찰기간, 과거력개수, 견봉하주사횟수는통계적으로두군간에유의한차이를보이지않았다 (Table 3). 추시전자기공명영상에서근위축의 occupation ratio는평균 53.4%, 추시후자기공명영상에서 49.5% 였으며두군간의차이는보이지않았다. 극상근의 occupation ratio는파열이진행한군에서평균 5.1%, 진행이없 는군에서 2.9% 감소하였으나통계적인차이는없었다 (p=0.365). 그러나극상근의위축이 10% 이상진행한예는 5예 (20.0%) 였으며파열이진행된 12예중 2예, 파열의진행이없는 13예중 3예관찰되었다. 회전근개부분파열군은평균 16.3개월 ( 범위, 12-37개월 ) 추시관찰하였고전층파열로의진행은 2예에서발견되었으며 12 개월과 37개월에발견되었다. 2예모두남성이었으며점액낭측파열에서전층파열로진행하였다. 고찰 회전근개파열은노인층에서통증과기능저하의흔한원인이다. 회전근개파열의치료로보존적치료가많이시행되고있어통증을감소시키며기능의회복을보이고있지만회전근개파열의치유는기대할수없을뿐더러시간의경과에따른파열의크기, 퇴축, 근의위축이일어난다. 이러한퇴행성변화들은회전근개를해부학적위치에봉합하는것을어렵게하고수술후임상결과와재파열에도부정적인영향을준다. 7,12,17,18) 본연구에서파열의진행은 25예중 12예 (48%) 에서관찰되었으며평균 18.8개월 ( 범위, 12-37개월 ) 에발생하였다. 파열의진행의발생이평균 18.8 개월에발생하였지만 12개월에추시한 MRI에서도 5예중 3예에서파열이발견되었으므로 MRI의추시는적어도 1년을주기로시행해야하며, 파열의진행이통증의증가와관련이있다는연구결과가있으므로환자의통증이증가한다면 MRI의촬영이필

4 41 A Follow-Up Study of Rotator Cuff Tear Using MRI 요할것으로생각된다. 7,19) 파열의크기와파열의진행은유의한음의상관관계를보였다. 소범위파열의경우중 대범위파열보다파열이더진행한다. 소파열군과중 대파열군의파열의진행의빈도분석에서유의하게소파열에서파열의진행이많았다. 그러므로소파열에서도회전근개의완전파열이있다면보존적치료도가능하지만젊고통증이지속되는환자라면적극적인치료가필요할것으로생각된다. 그러나 Tashjian 20) 이주장한작은파열에서느린파열의진행을보이므로초기에보존적치료를고려할수있다는결과와반대되기때문에추가적인연구가필요하다. 회전근개파열은퇴행성변화에의한것으로파열의시작이일부분에국한된것이아니고회전근개에전반적인변화로시작된다고생각된다. 극상근이나극하근의일부분에서전층파열이시작되면건의전범위에전층파열은쉽게일어나며새로운건의파열은비교적천천히일어날것이라는가정을한다면건의전후크기보다작은소파열은힘줄의크기까지는파열의진행이빠르고그이후의진행은새로운힘줄의파열이동반되어야하므로비교적천천히발생하는것으로추측할수있다. Dunn 등 21) 은통증의정도와회전근개파열의크기나퇴축과는관계가없다고주장하였다. 그렇다면통증이없는환자회전근개파열환자에서는수술의필요성에대한의문이든다. 그러나본연구에서 60% 의환자에서파열, 퇴축, 근위축이진행하였고기간은최소 12개월에서발생하였다. 또한파열이크거나퇴축이진행한회전근개의봉합은실패할가능성이증가하며, 작은파열보다임상적결과가불량하다. 22,23) 그리고 Lambers Heerspink 등 24) 은수술이보존적치료보다기능과통증개선의결과가우수하다고하였다. 따라서회전근개파열환자에서수술적치료는환자의증상도중요하지만작은소파열의경우도건의파열이진행하므로수술후재파열의가능성을고려하여치료방법을결정해야될것으로생각된다. Occupation ratio는회전근개의위축을평가하는방법중객관적이고수치로나타나며비교적객관적인장점이있어이방법을이용하여근위축을평가하였다. 25,26) 10% 이상의근위축을보인경우에근위축이진행하였다고정의하였을때근위축은파열된군에서 2예 (16.7%) 발생하였고파열의진행이없는군에서도 3예 (23.1%) 발생하여파열이진행되지않아도극상근의위축이발생하는것을알수있었다. 전층파열의경우근육이기능을하지못하는상태이기때문에파열의진행과는상관없이근의위축이발생한것으로생각된다. 이러한극상근위축은수술후재파열과관련이있으므로전층파열의경우에는근위축으로인한봉합수술의실패를줄이기위하여수술적치료가고려되어야한다 ) 연구의제한점은후향적연구였고대상자의수가소파열의경우 5예밖에없었으므로통계적으로위음성이나왔을가능성이있다는것이다. MRI 재평가시기도통계적으로의미는없으나 30.5개월과 17.8개월로차이가있어추가적인연구가필요할것으로생각된다. 그러나회전근개파열환자에서보존적치료로만족할만한결과를얻기힘들고지속적인외래추시가어려운점을고려한다면의미있는연구라고생각된다. 또한병원특성상대상자대부분이남성으로이루어져있어인구전체를대표하지못하는한계점이있는반면회전근개질환은성별에따른차이가크지않아연구에큰영향은없을것으로생각되기는하지만여성에대한연구도추가적으로필요할것으로생각된다. 결론 회전근개파열은 48.0% 에서최소 1년에파열의크기가증가하고 20.0% 에서근위축이진행하며파열의크기가증가하지않는군에서도근위축이증가하므로회전근개파열의보존적치료시적어도 1년을주기로 MRI를추시하여수술적치료로의전환을고려해야할것으로생각된다. 또한소파열군에서도중 대파열과같이파열의크기와퇴축이진행하므로소파열의경우에도적극적인수술적치료를고려해야한다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8: Hsu J, Keener JD. Natural history of rotator cuff disease and implications on management. Oper Tech Orthop. 2015;25: Lee WH, Do HK, Lee JH, et al. Clinical outcomes of conservative treatment and arthroscopic repair of rotator cuff tears: a retrospective observational study. Ann Rehabil Med. 2016;40: Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22: Itoi E. Surgical repair did not improve functional outcomes more than conservative treatment for degenerative rotator cuff tears. J Bone Joint Surg Am. 2016;98: Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results. Bone Joint J. 2014;96:75-81.

5 42 Jun-Sung Won, et al. 7. Moosmayer S, Tariq R, Stiris M, Smith HJ. The natural history of asymptomatic rotator cuff tears: a three-year follow-up of fifty cases. J Bone Joint Surg Am. 2013;95: Moosmayer S, Lund G, Seljom U, et al. Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: a randomised controlled study of 103 patients with one-year follow-up. J Bone Joint Surg Br. 2010;92: Moosmayer S, Lund G, Seljom US, et al. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a fiveyear follow-up. J Bone Joint Surg Am. 2014;96: Keener JD, Galatz LM, Teefey SA, et al. A prospective evaluation of survivorship of asymptomatic degenerative rotator cuff tears. J Bone Joint Surg Am. 2015;97: Zingg PO, Jost B, Sukthankar A, Buhler M, Pfirrmann CW, Gerber C. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am. 2007;89: Eljabu W, Klinger HM, von Knoch M. The natural history of rotator cuff tears: a systematic review. Arch Orthop Trauma Surg. 2015;135: Tashjian RZ. Risk of tear progression in nonoperatively treated small full-thickness rotator cuff tears: commentary on an article by Sandro F. Fucentese, MD, et al.: "evolution of nonoperatively treated symptomatic isolated full-thickness supraspinatus tears". J Bone Joint Surg Am. 2012;94:e Park JS, Park HJ, Kim SH, Oh JH. Prognostic factors affecting rotator cuff healing after arthroscopic repair in small to medium-sized tears. Am J Sports Med. 2015;43: Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med. 2012;40: Tae SK, Oh JH, Kim SH, Chung SW, Yang JY, Back YW. Evaluation of fatty degeneration of the supraspinatus muscle using a new measuring tool and its correlation between multidetector computed tomography and magnetic resonance imaging. Am J Sports Med. 2011;39: Abdul-Wahab TA, Betancourt JP, Hassan F, et al. Initial treatment of complete rotator cuff tear and transition to surgical treatment: systematic review of the evidence. Muscles Ligaments Tendons J. 2016;6: Clement ND, Nie YX, McBirnie JM. Management of degenerative rotator cuff tears: a review and treatment strategy. Sports Med Arthrosc Rehabil Ther Technol. 2012;4: Yamaguchi K, Tetro AM, Blam O, Evanoff BA, Teefey SA, Middleton WD. Natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg. 2001;10: Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012; 31: Dunn WR, Kuhn JE, Sanders R, et al. Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am. 2014;96: McElvany MD, McGoldrick E, Gee AO, Neradilek MB, Matsen FA 3rd. Rotator cuff repair: published evidence on factors associated with repair integrity and clinical outcome. Am J Sports Med. 2015;43: Chung SW, Kim JY, Yoon JP, Lyu SH, Rhee SM, Oh SB. Arthroscopic repair of partial-thickness and small full-thickness rotator cuff tears: tendon quality as a prognostic factor for repair integrity. Am J Sports Med. 2015;43: Lambers Heerspink FO, van Raay JJ, Koorevaar RC, et al. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J Shoulder Elbow Surg. 2015;24: Schaefer O, Winterer J, Lohrmann C, Laubenberger J, Reichelt A, Langer M. Magnetic resonance imaging for supraspinatus muscle atrophy after cuff repair. Clin Orthop Relat Res. 2002;403: Chung SW, Kim SH, Tae SK, Yoon JP, Choi JA, Oh JH. Is the supraspinatus muscle atrophy truly irreversible after surgical repair of rotator cuff tears? Clin Orthop Surg. 2013;5: Goutallier D, Postel JM, Lavau L, Bernageau J. Impact of fatty degeneration of the suparspinatus and infraspinatus msucles on the prognosis of surgical repair of the rotator cuff. Rev Chir Orthop Reparatrice Appar Mot. 1999;85: Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg. 2003;12: Gasbarro G, Ye J, Newsome H, et al. Morphologic risk factors in predicting symptomatic structural failure of arthroscopic rotator cuff repairs: tear size, location, and atrophy matter. Arthroscopy. 2016;32:

6 43 pissn : , eissn : Original Article J Korean Orthop Assoc 2018; 53: 자기공명영상을이용한회전근개질환의경과관찰 원준성 이우승 박재홍 고승남 서인욱 중앙보훈병원정형외과 목적 : 회전근개질환은견관절통증의흔한원인이다. 그러나보존적치료시파열의진행이나파열의발생에대해서는잘알려져 있지않아자기공명영상을이용하여회전근개질환의진행정도를알아보고자하였다. 대상및방법 : 2013 년부터 2015 년까지회전근개질환으로최소 1 년이상보존적치료를시행후자기공명영상을촬영한 48 예를대 상으로하였다. 나이는평균 64.3세 ( 범위, 45-83세 ), 추시기간은평균 17.6개월 ( 범위, 12-37개월 ) 이었다. 자기공명영상에서파열의전후크기와대결절부터건의퇴축을측정하였다. 파열의크기나건의퇴축이 3 mm 이상증가시파열의진행으로정의하였다. 10 mm 미만의소파열과 10 mm의중 대파열두군으로나누어파열의진행을분석하였다. 결과 : 치료전자기공명영상에서회전근개파열은 25예였으며, 회전근개부분파열은 23예였다. 파열의진행은 12예 (48.0%), 회전근개부분파열에서새로운파열이 2예 (8.7%) 관찰되었다. 파열크기는치료전전후직경 17.8 mm, 건의퇴축 18.9 mm였으며, 치료후각각 20.2 mm, 22.3 mm였다. 치료전파열의전후크기는수술전퇴축과양의상관관계 (r=0.830, p<0.001), 전후크기의진행과음의상관관계 (r=-0.473,p=0.017) 를보였다. 소파열은 5예 (20.0%) 였고중 대파열은 20예 (80.0%) 였다. 소파열군 5예중 4예 (80.0%) 에서진행하였고전후크기는평균 7.4 mm ( 범위, mm), 퇴축은 5.9 mm ( 범위, mm) 진행하였다. 중 대파열군 20예중 8예 (40.0%) 에서파열이진행하였으며전후크기는평균 4.1 mm ( 범위, mm), 퇴축은 6.8 mm ( 범위, mm) 진행하였다. 소파열군과중 대파열군에서파열진행의빈도는통계적으로유의한차이를보였다 (p<0.001). 결론 : 회전근개파열의보존적치료시자기공명영상을통한추시관찰을통해수술적치료로의전환을고려해야할것으로생각되며소파열군에서도중 대파열과같이파열의크기와퇴축이진행하므로소파열의경우에도적극적인수술적치료를고려해야한다. 색인단어 : 회전근개, 회전근개파열, 보존적치료, 자기공명영상 접수일 2016 년 12 월 7 일수정일 2017 년 4 월 21 일게재확정일 2017 년 7 월 4 일책임저자원준성 05368, 서울시강동구진황도로 61 길 53, 중앙보훈병원정형외과 TEL , FAX , 99korean@naver.com * 이논문은 2017 년도중앙보훈병원연구개발비지원을받아수행된연구과제임 (No. VHSMC 17008). 대한정형외과학회지 : 제 53권제 1호 2018 Copyright 2018 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.

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical