93 pissn : , eissn : Symposium J Korean Orthop Assoc 2015; 50: Spin

Size: px

Start display at page:

Download "93 pissn : , eissn : Symposium J Korean Orthop Assoc 2015; 50: Spin"

승룡 방
5 years ago
Views:

1 93 pissn : , eissn : Symposium J Korean Orthop ssoc 2015; 50: Spine Intervention Using Ultrasound 흉추부초음파유도하중재술 문상호 이송 이재일 서울성심병원정형외과 Ultrasound-Guided Intervention in Thoracic Spine Sang Ho Moon, M.D., Ph.D., Song Lee, M.D., and Jae Il Lee, M.D. Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea Even though thoracic spinal pain may be less common than low back and neck pain, the prevalence of thoracic pain in the general population is 13% to 15% in the literature and it can be as disabling as lumbar or cervical pain. lthough thoracic interventions have been reported to be effective, it is rarely performed due to concerns of creating iatrogenic pneumothorax. Fluoroscopy-guided interventions are more accurate procedures than blind technique but still cannot prevent pneumothorax. In recent reports in the literature, use of ultrasoundguided interventions minimized the risk of pneumothorax and vascular puncture because ultrasound can visualize lung with pleura and also detect vascular structures by Doppler scan. Compared with fluoroscopy, ultrasound imaging has no known contraindications, produces no ionizing radiation, enables direct visualization of neurovascular and soft tissue structures, and provides real-time visualization of needle passage toward the intended target. We therefore conducted a review to investigate the feasibility of performing thoracic interventions under real-time ultrasound guidance. Key words: thoracic spine, ultrasound, intervention 서론 등이아파요. 라고호소하는환자들을임상에서만나게되면, 흉 추에는추간판탈출증등의질환이적으므로경추와요추에비해 관심을덜갖게되고흔히소염진통제와물리치료처방만을하 며경과를관찰하게되는경우가많다. 흉추부에발생하는통증 은실제로요추의 43% 나경추의 32% 보다는유병률이적으나그 래도 13%-15% 까지보고하고있으며만성혹은극심한통증으로 진행하기도한다. 1,2) 유병률에서보듯이통증을호소하는환자는 적지않음을알수있고실제로임상에서드물지않게접하곤한 다. Edmondston 과 Singer 3) 는흉추부통증의빈도가적은것은사 Received February 9, 2015 Revised March 11, 2015 ccepted March 14, 2015 Correspondence to: Sang Ho Moon, M.D., Ph.D. Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, 259 Wangsan-ro, Dongdaemun-gu, Seoul , Korea TEL: FX: msh124@paran.com 실이나통증이심하여일상생활에장애를초래하는정도는경추및요추와비슷하다고할정도로그심각성이더적은것은아니다. 이런경우방사선투시기하중재술을시행할수있으나방사선조사로인해여러문제들이발생할수있고 4) 혈관과폐를직접볼수없다는결정적단점들이있어시술에따른기흉등의위험성이있는것이사실이다. 초음파는방사선투시기로볼수없는신경과혈관등주요구조물들을실시간으로보면서시술할수있고주사제가목표물주위로퍼져나가는정도와양상을동영상으로보면서주사할수있다는큰장점을가지고있다. 따라서주요신경과혈관등의구조물로주사되거나그조직을손상시키는사고를방지할수있고주사제가퍼지는영역을보면서조절할수있기때문에안전성과정확도를높일수있는우수함을가진방법이다. 5) 그리고흉추에서는초음파영상을통해실시간으로폐를싸고있는늑막을관찰하면서이를천자하지않고안전하게시술할수있다는중요한장점을가지고있다. 저자들은흔히간과할수있는흉추부통증에대해초음파유 The Journal of the Korean Orthopaedic ssociation Volume 50 Number Copyright 2015 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

94 Sang Ho Moon, et al. 도하중재술은안전하고효과적으로시행할수있는치료방법이므로흉추부초음파유도하중재술에관하여기술하고자한다. 초음파를위한흉추부표면해부학 경추부원위부에서비교적육안으로도돌출되어있음을알수있을정도의큰돌기가만져지는데이부위가제7경추의극돌기가된다.

견갑골의내측경계를촉지하면대개제2흉추에서제7흉추극돌기의사이에걸쳐놓이게되는데견갑골극 (scapular spine) 을촉지하여그와같은높이에해당하는것이대개제3흉추극돌기에해당하고견갑골하각 (inferior angle) 은제7흉추극돌기에해당하게되므로극돌기레벨을정하는데참고로활용할수있다.

그리고한가지명심해야할것은극돌기가흉추부에서는 상당히하방으로내려와있기때문에하나의극돌기와같은높이에는, 해당극돌기의흉추보다하나원위부흉추의횡돌기와하나원위부흉추의후궁혹은해당흉추와원위부흉추간후방관절이놓이게된다는점이다. 예를들어제6흉추극돌기에서외측 1수지너비에는제7후궁혹은제6, 7 후방관절이있고 2수지너비에는제7흉추횡돌기가놓이게된다.

2 94 Sang Ho Moon, et al. 도하중재술은안전하고효과적으로시행할수있는치료방법이므로흉추부초음파유도하중재술에관하여기술하고자한다. 초음파를위한흉추부표면해부학 경추부원위부에서비교적육안으로도돌출되어있음을알수있을정도의큰돌기가만져지는데이부위가제7경추의극돌기가된다. 피하층이얇은환자에게서는그상부에있는제6경추의극돌기가먼저잘만져지기도하므로주의해야하는데대개제7경추의극돌기가더크게만져진다. 이제7경추의극돌기를기준으로하방으로극돌기들을만지면서흉추극돌기의레벨 (level) 을표시하게된다. 견갑골의내측경계를촉지하면대개제2흉추에서제7흉추극돌기의사이에걸쳐놓이게되는데견갑골극 (scapular spine) 을촉지하여그와같은높이에해당하는것이대개제3흉추극돌기에해당하고견갑골하각 (inferior angle) 은제7흉추극돌기에해당하게되므로극돌기레벨을정하는데참고로활용할수있다. 극돌기를이은정중앙선을기준으로 1수지너비 (one finger breadth) 만큼외측으로정중앙선에평행하게선을그으면여기가후궁과후방관절들이교대로놓이게되는위치가되고 2수지너비만큼외측에는횡돌기가위치하게된다. 경추와요추와는달리후방관절이상당히내측에위치하게된다는점을고려해야한다. 그리고한가지명심해야할것은극돌기가흉추부에서는 상당히하방으로내려와있기때문에하나의극돌기와같은높이에는, 해당극돌기의흉추보다하나원위부흉추의횡돌기와하나원위부흉추의후궁혹은해당흉추와원위부흉추간후방관절이놓이게된다는점이다. 예를들어제6흉추극돌기에서외측 1수지너비에는제7후궁혹은제6, 7 후방관절이있고 2수지너비에는제7흉추횡돌기가놓이게된다. 이러한관계는중간부흉추에서확실하며상부흉추는경추와유사하고하부흉추는요추와유사한형태를가지게된다. 횡돌기외측으로늑골을만질수있으며늑골의상연과하연을촉지하여그릴수있다 (Fig. 1). 사실흉추부중재술에있어서후방관절의병변으로인한연관통은척추외측주위로서로중첩이되어나타나므로통증위치와하나의후방관절을연관시키기는힘들다. 따라서통증부위보다근위부와원위부까지포함하는 4-5 레벨의다발성차단술을시행하는것이유리하므로꼭하나의레벨을정하여시술하지는않아도되는경우가대부분이고늑골신경통은레벨로미리목표를정하기보다는해당되는늑골을촉지하여압통등으로확인후혹은환자가통증을호소하며지적하여주는해당늑골에시술하게되는경우가많다. 정상흉추부의초음파소견 흉추부는곡선탐촉자 (convex probe) 와선형탐촉자 (linear probe) 를둘다사용할수있지만저자들은시술할때탐촉자를손으로 3 7 C Figure 1. () Surface anatomy of the posterior thoracic region. It is customary to count thoracic spinous processes (circular markings on the midline) from the prominence caused by the seventh cervical spinous process (black arrow) as a top. Usually the first thoracic is more prominent than the seventh cervical. The root of the spine of the scapula (white arrow) is on a level with the tip of the spinous process of the third thoracic vertebra (3), and the inferior angle with that of the seventh (7). Medial border of scapular (arrowheads) is located from the second thoracic to the seventh. () Drawing the line one finger breadth laterally from the midline, there are laminae and facet joints alternatively on this line (black arrows). Two finger breadths laterally, transverse processes are on this line (white arrows). The upper and lower margins of the rib can be palpated in the lateral aspect from the transverse process area (arrowheads). (C) Same lines as () on the artificial thoracic spine model. Dotted line explains that the spinous processes of thoracic vertebrae project posteriorly at an extreme inferior angle, such that the inferior border of the spinous process overlies the lamina and the transverse process of the vertebra below.

95 Ultrasound-Guided Intervention in Thoracic Spine 잡고고정하기에는크기가작은선형이편하고늑막을관찰하며 미세하게바늘의이동을보는데유리하다고생각하여선형탐촉 자를선호하고있다.

() Position of the probe (black bar) for () on the artificial spine model.

processes, the thoracic facet joint (arrow) can be visualized in the paramedian sagittal image. Proximal Distal Figure 4.

3 95 Ultrasound-Guided Intervention in Thoracic Spine 잡고고정하기에는크기가작은선형이편하고늑막을관찰하며 미세하게바늘의이동을보는데유리하다고생각하여선형탐촉 자를선호하고있다. 환자의자세는앉은자세에서등을굽히라 고하고시술하는것이준비면에서편하지만바늘을삽입할때 환자가움직일수있고따라서시술과정상바늘을추적하는데 어려움이있을수있다. 측와위로도가능하지만저자들은복와위 Figure 2. () Position of the probe (black bar) for () on the artificial spine model. () Ultrasonography on longitudinal scan at midline of the posterior thoracic area shows spinous processes (S) superficially. Proximal Distal Figure 3. () Position of the probe (black bar) for () on the artificial spine model. () fter the probe is slightly moved laterally over the lamina, between two hyperechoic lines which represent the inferior and superior articular processes, the thoracic facet joint (arrow) can be visualized in the paramedian sagittal image. Proximal Distal Figure 4. () Position of the probe (black bar) for () on the artificial spine model. () Probe is initially placed at a point 2 finger breadths lateral to the tip of the spinous process in a longitudinal orientation, obtaining a sagittal paramedian view of the transverse process (T), and underlying pleura (arr ows). The pleura is deeper, shimmers and moves with respiration.

96 Sang Ho Moon, et al. Proximal Distal Proximal Distal Figure 5.

Superior costotransverse ligament is seen as a collection of homogeneous linear echogenic bands alternating with echo poor areas running from 1 transverse process to the next.

4 96 Sang Ho Moon, et al. Proximal Distal Proximal Distal Figure 5. () t the sagittal paramedian view of the transverse process (T), superior costotransverse ligament (white arrows) and underlying pleura (arrowheads) can be visualized. Superior costotransverse ligament is seen as a collection of homogeneous linear echogenic bands alternating with echo poor areas running from 1 transverse process to the next. () Thoracic paravertebral space is the dotted area between superior costotransverse ligament and pleura. R R Proximal Distal Figure 6. () Position of the probe (black bar) for () on the artificial spine model. () Probe is placed more laterally on the rib in a longitudinal orientation, obtaining a sagittal paramedian view of the rib which has a rounder appearance than the transverse process (R), and underlying pleura (arrowheads). 에서베개를가슴앞에받쳐흉추후만을유지한자세로시술하고있는데이자세가시술자의탐촉자를쥔손을안정시키는데유리하고환자가움직일수있는가능성도적기때문이다. 흉추부에서종축으로정중앙선에탐촉자를대어극돌기를검사하는데촉지상이미확인한목표극돌기사이지점에위치시켜극돌기들을각각관찰한다 (Fig. 2). 이때는극돌기가상대적으로표층에위치하므로선형탐촉자로보는것이유리하다. 이위치에서종축을유지하면서탐촉자를외측으로서서히이동하면기왓장을포개놓은듯한영상을얻을수있는데이러한양상을보이면후궁에해당한다. 흉추는다른척추부와달리후방관절이상당히내측에위치하므로후궁사이의틈 (cleft) 이바로후방관절에해당하는데, 극돌기외측에서관찰되는후방관절은그해당극돌기의하관절돌기 (inferior articular process) 와해당극돌기보다하나아래원위부흉추의상관절돌기가만나는관절이된다 (Fig. 3). 여기서좀더외측으로탐촉자를이동하면높이가높아지면서후방음향조영을동반하며모가나지않고둥근마름모형태의고에코성구조물이관찰되는데바로횡돌기이다 (Fig. 4). 이횡돌기사이의공간에하부에서꾸물꾸물움직 Proximal Distal Figure 7. Doppler scan shows the intercostal artery which runs inferior and deep aspect of rib.

97 Ultrasound-Guided Intervention in Thoracic Spine 이는비교적흐릿한고에코성선을관찰할수있는데이는폐를싸고있는벽측늑막 (parietal pleura) 이보이는것이다.

여 기서좀더외측으로종축을유지한채탐촉자를이동시키면늑골을관찰할수있고늑골간공간을볼수있는데늑골이횡돌기와다른점은보다더상부면이둥글둥글해진다는것이다 (Fig. 6). 그리고 Doppler 영상을이용하면늑골의원위부전면에서늑간동맥을관찰할수있다 (Fig. 7). 시술의목표로하는극돌기의위치를종축영상면에서가운 C Figure 8.

() Trans verse scan at the midline shows the spinous process (S), lamina (L) and trans verse process (T) using a linear probe. (C) Using a curved probe, a wider image can be achieved.

5 97 Ultrasound-Guided Intervention in Thoracic Spine 이는비교적흐릿한고에코성선을관찰할수있는데이는폐를싸고있는벽측늑막 (parietal pleura) 이보이는것이다. 늑막상부에횡돌기상연에서시작하여하부횡돌기의하부로향하는고에코성구조물이관찰되는데이것이상부늑횡돌인대 (superior costotransverse ligament) 이고이상부늑횡돌인대와벽측늑막사이의공간이흉추주위공간 (paravertebral space) 이된다 (Fig. 5). 여 기서좀더외측으로종축을유지한채탐촉자를이동시키면늑골을관찰할수있고늑골간공간을볼수있는데늑골이횡돌기와다른점은보다더상부면이둥글둥글해진다는것이다 (Fig. 6). 그리고 Doppler 영상을이용하면늑골의원위부전면에서늑간동맥을관찰할수있다 (Fig. 7). 시술의목표로하는극돌기의위치를종축영상면에서가운 C Figure 8. () Position of the probe (black bar) for () on the artificial spine model. () Trans verse scan at the midline shows the spinous process (S), lamina (L) and trans verse process (T) using a linear probe. (C) Using a curved probe, a wider image can be achieved. Pleura (arrows) can be seen at the lateral side of the transverse process. Medial Lateral Figure 9. () Position of the probe (black bar) for () on the artificial spine model. () The probe is moved laterally from the midline in a transverse to the vertebral column and a partial oblique position parallel to the rib (transverse paramedian scan). Hereafter, the transverse process (T) is located in the middle of the image, and laterally indicated by visualization of the shimmering parietal pleura (white arrows) which dips medially and intercostal muscle (M) superficially. Superior costotransverse ligament (black arrows) is generally seen as a thin radio-opaque line extending from the transverse process, creating a wedge shaped pocket which represents the thoracic paravertebral space (asterisk).

98 Sang Ho Moon, et al. Figure 10. () Position of the probe (black bar) for () on the artificial spine model. () The probe is moved cranially until rib view can be obtained.

6 98 Sang Ho Moon, et al. Figure 10. () Position of the probe (black bar) for () on the artificial spine model. () The probe is moved cranially until rib view can be obtained. The rib (arrows) is more superficial than pleura with posterior acoustic shadow seen beneath it and replacing intercostal muscle area of Fig. 9. T, transverse process. 데로놓고그중심을고정하면서탐촉자를 90도회전하여횡축의영상을얻은후미세하게상하로탐촉자의위치를조절하여극돌기와후궁, 횡돌기가한평면에보이는영상을얻어각구조물들을확인할수있다 (Fig. 8). 이위치에서약간외측으로탐촉자를이동하여횡돌기가화면의중앙에위치하도록하는영상을얻을수있는데이때늑골의방향과맞추어탐촉자의외측을약간하방으로기울이는것이좋다 (Fig. 9). 이렇게하면횡돌기외측으로마치계단모양으로높이가낮아지면서늑골간공간에서보이는늑막이관찰되고늑막표면에는늑간근 (intercostal muscle) 이보이는데, 횡돌기하방과늑막사이에서상부늑횡돌인대와흉추주위공간의횡단면을관찰할수있다. 여기서탐촉자를횡축을유지하면서상방혹은하방으로이동하면늑간근이있던자리에늑골이높이올라오면서후방음향조영을동반하는양상을관찰할수있게된다 (Fig. 10). 흉추부초음파유도하중재술 기본적인위치는환자를복와위로눕게한후환자의왼쪽에앉아서시술하는것이오른손잡이시술자에겐편하다. 왼손으로탐촉자를잡고오른손으로주사기를잡게되어안정적으로시술을할수있고환자의좌, 우측모두이런자세로시술이가능하다. 중재술에있어서시술후감염이가장심각한합병증중하나이다. 이를최소화하기위하여저자들은마스크와소독장갑을착용후시술부위에베타딘을이용한피부소독을철저히실시하고탐촉자에겔을묻힌후소독된비닐을덮어서밀봉하고탐촉자표면을덮고있는비닐표면에다시베타딘으로소독을한후길이 6 cm, 굵기 23 G 주사바늘을주로이용하여시술에임하고있다. 초음파가본격적으로흉추부중재술에사용된것은비교적최근으로서향후더연구되어야할분야이다. 여기제시하는내 용들외에도증식치료에있어목표지점을확인하는데쓰이는등여러종류의시술에서초음파를사용하고있다. 현재대표적으로시술되고있는항목들은다음과같다. 1. 흉추주위차단술 (thoracic paravertebral block) 흉추주위공간 (thoracic paravertebral space) 을차단하면경막외마취와대등한효과를기대할수있어가히 말초신경계의경막외차단술 이라할정도로효과면에서강력한치료방법이다. 흉추의경막외마취는효과면에서좋을수있으나중추신경계시술이므로그에따른위험성이있는데비해흉추주위차단술은말초신경계이면서도척수에서흉추부로나가는모든신경가지들, 즉전방분지 (ventral ramus), 후방분지 (dorsal ramus), 늑간신경, 그리고통증조절에중요한역할을하는교감신경절 (sympathetic chain) 로가는교통가지 (rami communicantes) 가모두모여있는공간이므로이한곳을차단하면마치경막외차단을하는듯한총체적인통증조절효과를얻을수있다. 또한교통가지를통해자율신경계까지차단할수있으므로효과의지속시간도더오래가고, 말초이기때문에안전한장점이있다. 6,7) 따라서항혈전제를복용하고있어서경막외접근이위험한환자들에게서도말초신경계시술이기에안전하게시행할수있는방법이다. 실제로흉추주위차단술과경막외마취를비교한두편의메타분석 (meta-analysis) 논문에서통증조절의효과면에서동등하였고더구나흉추주위차단술군에서유의하게저혈압, 구토, 요폐색 (urinary retention), 폐합병증등의발생이적었다고보고하였다. 8,9) 흉추부만성통증, 다발성늑골골절뿐만아니라흉부전면, 복부, 골반부통증이나마취에도효과적으로시술할수있는방법이지만촉지에의존해시술할경우기흉등의합병증이발생할수있고 10% 이상의실패율을보고하고있다. 10,11) 그에반해초음파유도하시술은폐를싸고있는늑막을보면서시행할수있다

흉추주위공간은추간공에서신경근이바로나오자마자만나 SP Figure 11. Schematic representation of thoracic paravertebral space (TPVS).

7 99 Ultrasound-Guided Intervention in Thoracic Spine 는중요한장점을갖고있으므로안전하게시술할수있는방법 LL C TR SC RL 이된다. 또한이시술은다른부위척추에서는기대할수없는효과를보인다. 그이유는마치단면이삼각형인긴원주의형태를하여근위부와원위부레벨들끼리위, 아래로서로통하여있는형태를하고있으므로한레벨에주사하여도여러레벨의효과를얻을수있고모든신경들의근원이모여있으며자율신경계까지차단할수있기때문이다. 또한이부위의신경들은수초에싸여있지않아약제의흡수가빠르게진행됨으로써약제의작용시작시간이말초에비해빠르게되는장점이있다. 흉추주위공간은추간공에서신경근이바로나오자마자만나 SP Figure 11. Schematic representation of thoracic paravertebral space (TPVS). TPVS is a triangular column (black lined triangular column) bounded posteriorly by the transverse process and the superior costotransverse ligament (SC) which travel between two adjacent transverse processes and ribs. The medial boundary is the vertebral column and foramen. The anterior boundary is the parietal pleura. Laterally, TPVS tapers as it communicates with the intercostal space. The contents of the thoracic paravertebral space include the intercostal nerve (arrowheads), the dorsal and ventral rami, the rami communicantes (white arrow) to the sympathetic chain. medial branch (black arrow) from dorsal rami. C, spinal cord; LL, left lung; RL, right lung; TR, transverse process and rib; SP, spinous process. RL Z E V C Figure 12. Schematic representation of thoracic paravertebral space (TPVS) (dotted area) in a transverse plane. In TPVS, there are the intercostal nerve (arrowheads), the dorsal and ventral rami, the rami communicantes (white arrow) to the sympathetic chain, medial branch (black arrow) from dorsal rami. LL, left lung; RL, right lung; E, esophagus; Z, azygos vein; o, aorta; V, vertebral body; C, spinal cord. o LL C D Figure 13. (, ) ecause thoracic paravertebral space (TPVS) tapers laterally, TPVS may have larger anterior-posterior dimension (arrow) if the probe is placed medially. (C, D) TPVS may have less anterior-posterior dimension (arrow) if the probe is placed too far laterally.

12-14) 차단술은 Cowie 등 12) 과 Renes 등 13) 이소개한대로횡축영상에서횡돌기와늑막사이에서관찰되는상부늑횡돌인대를통과하여바늘을삽입하면가능하지만저자들은 O Riain 등 14) 이소개한종축영상하에서시술하는것을더선호한다. 이유는환자의위치를바꾸지않고양측을시술할수있으며목표지점까지도달하는바늘의경로도짧으므로유리하다고생각하기때문이다.

8 100 Sang Ho Moon, et al. 는공간으로서옆으로긴삼각형구조물이종축으로길게놓여진형태를하고있다 (Fig. 11). 삼각형의후방경계는상부늑횡돌인대혹은횡돌기로, 내측은추간공, 추체, 추간판등의흉추구조물들로, 전방은벽측늑막으로이루어지고외측으로가늘어지다가늑골사이공간과만나게되는데, 이흉추주위공간안에전방분지, 후방분지, 늑간신경그리고교통가지가모두모여있게된다 (Fig. 12) ) 차단술은 Cowie 등 12) 과 Renes 등 13) 이소개한대로횡축영상에서횡돌기와늑막사이에서관찰되는상부늑횡돌인대를통과하여바늘을삽입하면가능하지만저자들은 O Riain 등 14) 이소개한종축영상하에서시술하는것을더선호한다. 이유는환자의위치를바꾸지않고양측을시술할수있으며목표지점까지도달하는바늘의경로도짧으므로유리하다고생각하기때문이다. 즉횡축으로시술하면환자의시술하는쪽으로의사가앉아야하는데종축으로시행하면환자의중앙부에서양측흉추주위공간이얼마떨어져있지않으므로한쪽에서앉아양측을동시에시술할수있다. 시술방법은우선의사가엎드려있는환자의좌측에앉고횡돌기들과상부늑횡돌인대, 늑막이모두보이는종축영상을얻은후 (Fig. 5), 탐촉자의중앙을횡돌기들사이의중앙에올수있도록위치를조정한다. 이공간은내측이높은직각삼각형형태이므로내측이공간의높이가높고외측으로갈수록낮아진다. 그러므로내측이시술하기가용이하다 (Fig. 13). 여기서바늘을탐촉자의우측에서삽입하여환자의머리방향으로진행하는데 in-plane으로바늘의전장을보면서해야하지만 바늘의끝을놓친경우에는주사액을약간주입하여그양때문에조직이갈라지는 (tissue dissection) 양상을보면서위치를확인할수있다. 결국상부늑횡돌인대를뚫고늑막위까지전진한후주사액을주입하는데이때주사액에의해늑막이밀리는것을확인하면성공적으로시술하는것임을알수있게된다 (Fig. 14). 2. 늑간신경차단술 (intercostal nerve block) 늑간신경차단술이늑간신경통 (intercostal neuralgia) 이나늑골골절로인한통증조절에효과가있지만기흉을유발할수있으므로시행하기가조금은두려운시술이며문헌상으로도이러한이유로권유하고싶은시술이아니라고기술하고있다. 15) 그러나초음파를이용하면이러한합병증없이안전하게시술할수있다고보고되었는데이는실시간으로폐를싸고있는늑막을보면서바늘을삽입할수있기때문이다. 16) 늑간혈관과신경은늑골의하방전면에위치하므로초음파중재술방법은환자를엎드리게하고환자의좌측에시술자가앉은후종축영상을일단목표로하는늑골과그아래레벨의늑골을포함하도록얻는다. 즉하나의영상에좌측에는목표늑골이, 우측에는하방늑골이위치하도록한다 (Fig. 6). 여기서 Doppler 영상을통하여목표늑골의하방전면에있는늑골혈관을확인하고 (Fig. 7) 그지점주변을목표지점으로하며, 저자들은바늘을탐촉자의오른쪽, 하방늑골보다더원위부에서삽입하기시작하여하방늑골의표면에걸치면서깊게진행하게한후계속전진하여목표지점까지도달하도록한다 (Fig. 15). 이렇게각도를적 Proximal Distal Figure 14. The midpoint of the transducer is aligned midway between the 2 adjacent transverse processes in a longitudinal scan, and a needle is introduced in an in-plane approach in a cephalad orientation. The paravertebral space is entered between the 2 transverse processes avoiding bony contact. The needle (arrowheads) is advanced under direct vision to puncture the costotransverse ligament and until the needle tip is located immediately above the pleura. During the injection of local anesthetic, the pleural depression by the injectant material should be confirmed by ultrasound. Figure 15. The midpoint of the transducer is aligned midway between the 2 adjacent ribs in a longitudinal scan, and a needle introduced in an in-plane approach in a cephalad orientation. The needle (arrowheads) is advanced to the area of the intercostal vessel which has already been confirmed by Doppler scan. During injection of the local anesthetic, the pleural depression by the injectant material should be confirmed by ultrasound.

101 Ultrasound-Guided Intervention in Thoracic Spine C Figure 16. () Schematic representation of the medial branch at the upper thoracic levels (T1-T4) and lower levels (T9-T10).

() t mid-thoracic levels (T5-T8), the medial branch does not contact with bone and is suspended in the intertransverse space (arrow).

게주면서하방늑골에걸치는이유는하방늑골이바늘을깊게들어가지않도록받침대역할을해주므로늑막천공의위험을줄이기때문이다. 이후약제를주입하여늑막이수동적으로아래로밀리면제위치에주입되었음을알수있게된다. 3. 내측분지차단술 (medial branch block) 만성흉추부통증의 42%-48% 는후방관절의병변에서유래한다고보고할정도로원인의많은부분을차지하고있다.

Dreyfuss 등 20) 은실제환자들을대상으로제3, 4부터 10, 11까지의흉추간후방관절에조영제를주입하여유발되는통증의양상을기술하였는데주사한후방관절보다하나아래레벨의외측척추주위부 (paraspinal area) 에통증이발생하며많은부위가분지마다서로중첩되고중앙선을넘지않는다는것을보고하였다.

9 101 Ultrasound-Guided Intervention in Thoracic Spine C Figure 16. () Schematic representation of the medial branch at the upper thoracic levels (T1-T4) and lower levels (T9-T10). Medial branch contacts at the superolateral corner of the transverse process (arrow). () t mid-thoracic levels (T5-T8), the medial branch does not contact with bone and is suspended in the intertransverse space (arrow). (C) The T11-T12 medial branches have a course analogous to that of the lumbar medial branches, crossing the base of the transverse process (arrow). 게주면서하방늑골에걸치는이유는하방늑골이바늘을깊게들어가지않도록받침대역할을해주므로늑막천공의위험을줄이기때문이다. 이후약제를주입하여늑막이수동적으로아래로밀리면제위치에주입되었음을알수있게된다. 3. 내측분지차단술 (medial branch block) 만성흉추부통증의 42%-48% 는후방관절의병변에서유래한다고보고할정도로원인의많은부분을차지하고있다. 17,18) Manchikanti 등 19) 은후방관절로인한통증으로진단하려면추간판이상이나골절, 협착증, 신경염등의진단이배제되면서해당관절부주위로통증및압통이있고심호흡시통증이재생되는등의소견이있을경우에이를의심할수있다고하였다. Dreyfuss 등 20) 은실제환자들을대상으로제3, 4부터 10, 11까지의흉추간후방관절에조영제를주입하여유발되는통증의양상을기술하였는데주사한후방관절보다하나아래레벨의외측척추주위부 (paraspinal area) 에통증이발생하며많은부위가분지마다서로중첩되고중앙선을넘지않는다는것을보고하였다. Fukui 등 21) 은, Dreyfuss 등 20) 이기술하지않았던부위인제7경추와제1흉추간후방관절은견관절후방, 견갑골상부 (suprascapular), 견갑골상각에서하각까지의내측연을따라견갑골간부위 (interscapular region) 까지통증이유발된다고하였다. 또한제1, 2흉추간후방관절은관절부위외측척추주위부, 견갑골상부, 견갑골상각에서하각까지의내측연을따라견갑골간부위까지통증이발생하고, 제2, 3흉추간후방관절은관절부위외측척추주위부에서부터견갑골하각까지분포하며제11, 12흉추간후방관절은관절부위외측척추주위부와장골능선 (iliac crest) 의가장높은후방외측부분에각각위치한다고기술하였다. 이러한후방관절은활막관절로서척추신경의후방분지에 Lateral Medial Figure 17. Needle (arrowheads) is introduced for medial branch block by use of real-time in-plane ultrasound guidance to the target point, which is the superolateral corner of the transverse process (T) at the transverse paramedian scan. 서갈라져나오는내측분지의신경지배를받는데, 이분지를 선택적으로차단하는치료가바로내측분지차단술이다. tluri 등 22) 은내측분지차단술이후방관절통증에대해치료적으로유의 하게우수하며상대적으로관절내주사나고주파신경절제술 (radiofrequency neurotomy) 은효과가없었다고보고하였고 Manchikanti 등 19) 은만성흉추통에대한이중맹검무작위대조군연 구에서흉추부내측분지차단술이효과가있었다고보고하였다. 내측분지는요추부에서는상관절돌기와횡돌기의교차점을 지나고경추부에서는후방관절사이에있는 pillar 부위를지나게 되는데비하여흉추부내측분지의경로는일정하지않다는문제

이후더후방및하방으로진행하여후방근육층으로들어가게된다고하였다 (Fig. 16). 여기서한가지주의해야할점은한레벨의내측분지는하나아래레벨의횡돌기의외측상연을지난다는것이다. 즉제3흉추내측분지라면제4흉추횡돌기의외측상연을지나게된다. 그러므로목표로하는내측분지레벨보다아래 +1 레벨의횡돌기를주사지점으로해야한다.

그외제11, 12흉추는횡돌기가다른흉추에비해서작다는등의요추부와유사한해부학적특성을가지게되므로내측분지도요추부와유사하게상관절돌기와횡돌기의교차점을지나게되어요추부에서설명한방법대로시술하면된다. 4) 그러나제5-8까지의내측분지는뼈와접촉하지않는경로를취하여시술하는의사를곤혹스럽게한다.

10 102 Sang Ho Moon, et al. 점을갖고있다. 4,5) Chua와 ogduk 23) 은사체해부를통하여일반적인흉추내측분지경로를다음과같이기술하고있는데, 추간공에서후방분지 (dorsal ramus) 가나와외측 5 mm 이내에서내측분지로갈라지고난후주로외측으로향하지만동시에후방및하방으로진행하여횡돌기의외측상연을지나면서뼈와접촉하는유일한지점을형성하게되어여기가내측분지차단술의목표지점이되며, 이후더후방및하방으로진행하여후방근육층으로들어가게된다고하였다 (Fig. 16). 여기서한가지주의해야할점은한레벨의내측분지는하나아래레벨의횡돌기의외측상연을지난다는것이다. 즉제3흉추내측분지라면제4흉추횡돌기의외측상연을지나게된다. 그러므로목표로하는내측분지레벨보다아래 +1 레벨의횡돌기를주사지점으로해야한다. 외측상연을주사하는방법은해당횡돌기에대한횡축영상을얻은후, 횡축을유지한채탐촉자를상방으로평행이동하면횡돌기가사라지는데다시탐촉자를하방으로조금씩이동하여횡 돌기가막보이기시작하는위치에고정하고계단모양의횡돌기의외측상연을목표로바늘을외측에서시작하여내측을향해주입하면된다 (Fig. 17). 그러나이러한전형적인경로는제1-4 흉추까지와제9, 10흉추의내측분지에만해당된다. 그외제11, 12흉추는횡돌기가다른흉추에비해서작다는등의요추부와유사한해부학적특성을가지게되므로내측분지도요추부와유사하게상관절돌기와횡돌기의교차점을지나게되어요추부에서설명한방법대로시술하면된다. 4) 그러나제5-8까지의내측분지는뼈와접촉하지않는경로를취하여시술하는의사를곤혹스럽게한다. 즉경로는유사하지만경로의전체가약간상방으로이동되어있어횡돌기의외측상연을접하는대신에그상부인횡돌기사이의공간을지나게된다 (Fig. 16). 다행히횡돌기사이의공간에서늑골이횡돌기의상방을지나면서흉추체와연결이되므로초음파상으로이지점을목표로하면횡돌기사이에약제를주입하는것이된 C D Figure 18. () Position of the probe (black bar) for () on the artificial spine model. () t T5-T8 levels, medial branch passes dorsally and caudally in the intertransverse space just above to the typical target point on the superolateral corner of the transverse process. sterisk indicates the most cranial point of the superolateral corner of the transverse process. Laterally rib is shown. (C) Position of the probe (black bar) for (D) on the artificial spine model. (D) From the point of (), the probe is moved cranially into the intertransverse space. sterisks indicate the target point at the intertransverse space. The depth of the target point is the same as the depth of the transverse process of (). The height of the injection is opposite the upper border of the rib at the target level. fter the needle strikes the rib, it will be withdrawn until its tip is at the same height from the skin as that of the superolateral corner of the transverse process.

11 103 Ultrasound-Guided Intervention in Thoracic Spine 차단하게되는것이다. 이러한문헌들을종합하여저자들은내측분지차단술의레벨을결정하는데, 견갑골의내측연및견갑골간부위의통증을호소하면제1, 2흉추간및제2, 3흉추간후방관절들을목표로하여그들을지배하는제8경추내측분지 ( 제1흉추횡돌기의외측상연이주사지점이된다.), 제1흉추내측분지와제2흉추내측분지를시술하고흉추외측주위부에통증이있을때에는여러내측분지들이중첩되어연관통을유발할수있으므로제2-10까지의흉추내측분지들을주사하며장골능선이통증부위라면제10, 11흉추내측분지를목표분지로계획하고있다. Figure 19. The medial branches (black lines) to a particular joint (dotted circle) are the ones that cross the transverse process above the joint and the transverse process below the joint. Numerically, if the joint to be blocked is the Ta-Ta+1 joint, the transverse processes required are the Ta and Ta+1 transverse processes. Respectively, these are crossed by the Ta-1 and Ta medial branches. 다. 24) 즉목표로하는횡돌기사이공간에대해하방에위치하는 횡돌기와늑막이보이는횡축영상을얻은후, 횡축을유지한채 탐촉자를상방으로평행이동하면횡돌기가사라지고늑막에비 해상당히표면으로솟아오르며후방조영을동반하는늑골이나 타나게된다. 이늑골의표면을목표로하여바늘이삽입한후뼈 에닿으면약간표면으로후퇴하여횡돌기외측상연과같은높 이가되게한후주사한다. 결국사라지기직전횡돌기의외측상 연에해당하는위치와높이의늑골표면에주사하여야하는것이 다 (Fig. 18). 저자들은이러한방법보다마치방사선투시기를이용한기존 의방법처럼일단횡돌기의외측상연을찾고여기를바늘이닿 게한후바늘의방향을상방으로틀어서횡돌기사이공간쪽으 로주사한다. 이때주의해야할점은바늘을트는각도를수평면 상에서평행하게하여야한다는것이다. 만약그렇지않으면횡 돌기사이평면에놓이는내측분지에효과적으로주사액이도달 하지않거나심부의구조물을찌르는일이발생할수있기때문 이다. Moon 4) 이요추부에서이미기술한대로흉추부후방관절도두 개의내측분지의이중지배를받게된다. 예를들어제 4, 5 후방 관절은제 3 흉추신경에서유래된내측분지가제 4 흉추횡돌기의 외측상연을지나내려와지배를하는동시에제 4 흉추신경에서 유래된내측분지가제 5 흉추횡돌기의외측상연을지나내려가 다가다시올라와지배를하게된다 (Fig. 19). 공식화하자면, 만약 Ta 와 Ta+1 레벨사이의후방관절을시술하려면 Ta 와 Ta+1 의횡 돌기를목표로해야하고그럼으로써 Ta-1 와 Ta 의내측분지들을 4. 후방관절차단술 (facet block) 흉추부후방관절면은관상면 (coronal plane) 으로놓이게되므로방사선투시하에관절면이잘보이지않게되어시술하기가매우어렵다. 그러나초음파영상으로이러한관상면의후방관절을쉽게볼수있으며관상면이기에바늘의삽입이오히려편해지는장점을갖게된다. 방법은상기한대로기왓장을포개놓은듯한종축영상을얻은후 (Fig. 3), 탐촉자를잡은왼손에대하여오른손으로주사기를쥐고탐촉자의원위부 1수지혹은 2수지너비아래에서바늘의전장이보이는 in-plane 술기로써근위부를향해종축으로삽입한다. 흉추부후방관절면은관상면으로놓여있으면서근위부전방에서원위부후방으로기울어져있고원위부후방에입구가위치하므로바늘의입사각이관절면의입구를뚫고들어갈때관절면의경사와방향이일치하게되므로삽입하기에안성맞춤이된다. Stulc 등 25) 은원하는후방관절의레벨을초음파로결정하는방법을제안하였는데, 우선하방에서종축으로놓은탐촉자를상방으로서서히이동하면서첫번째로보이는늑골이 12번째늑골이되므로이것을먼저찾는다. 12번늑골을따라탐촉자를상방내측으로이동하면 12번째늑횡돌관절 (costotransverse articulation) 이보이게되는데여기서약간하방내측으로이동하면제12흉추후궁을거쳐제12흉추극돌기가보이게되고, 여기를시작점으로한다. 이시작점으로부터약간외측상방으로가면맨처음만나는후방관절이제11, 12흉추간관절이되며여기서상방으로이동하여보이는관절이제10, 11흉추간관절이되므로이런식으로세어서원하는관절까지상방으로이동한후목표관절에시술하는방법이다. 그러나흉추의후방관절은매우간격이좁으므로바늘을삽입하기가쉽지않고그러한과정에오히려관절연골및주위섬유성관절낭조직에손상을초래할가능성이있으므로보다덜침습적이고선택적으로신경을차단하는내측분지차단술이더권장할만하다고저자들은생각한다. 결론 흉추에있어서초음파유도하중재술은폐를싸고있는늑막을보면서시술할수있다는큰장점을가지고있으면서흉추주위

12 104 Sang Ho Moon, et al. 공간이나내측분지, 늑간신경을차단함으로써흉추부통증을효과적으로치료할수있는유용한방법이다. 감사의글 훌륭한그림 (Fig. 11, 12, 13) 을그려주신저자문상호의부인김희정여사에게감사드립니다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Linton SJ, Hellsing L, Halldèn K. population-based study of spinal pain among year-old individuals. Prevalence, sick leave, and health care use. Spine (Phila Pa 1976). 1998;23: Leboeuf-Yde C, Nielsen J, Kyvik KO, Fejer R, Hartvigsen J. Pain in the lumbar, thoracic or cervical regions: do age and gender matter? population-based study of 34,902 Danish twins years of age. MC Musculoskelet Disord. 2009; 10: Edmondston SJ, Singer KP. Thoracic spine: anatomical and biomechanical considerations for manual therapy. Man Ther. 1997;2: Moon SH. Ultrasound-guided intervention in lumbar spine. J Korean Orthop US Soc. 2013;2: Moon SH. Ultrasound-guided intervention in cervical spine. J Korean Orthop US Soc. 2014;1: Purcell-Jones G, Pither CE, Justins DM. Paravertebral somatic nerve block: a clinical, radiographic, and computed tomographic study in chronic pain patients. nesth nalg. 1989;68: Richardson J, Lönnqvist P. Thoracic paravertebral block. r J naesth. 1998;81: Davies RG, Myles PS, Graham JM. comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy: a systematic review and metaanalysis of randomized trials. r J naesth. 2006;96: Joshi GP, onnet F, Shah R, et al. systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. nesth nalg. 2008;107: Eason MJ, Wyatt R. Paravertebral thoracic block-a reappraisal. naesthesia. 1979;34: Lönnqvist P, MacKenzie J, Soni K, Conacher ID. Paravertebral blockade. Failure rate and complications. naesthesia. 1995;50: Cowie, McGlade D, Ivanusic J, arrington MJ. Ultrasoundguided thoracic paravertebral blockade: a cadaveric study. nesth nalg. 2010;110: Renes SH, ruhn J, Gielen MJ, Scheffer GJ, van Geffen GJ. In-plane ultrasound-guided thoracic paravertebral block: a preliminary report of 36 cases with radiologic confirmation of catheter position. Reg nesth Pain Med. 2010;35: O Riain SC, Donnell O, Cuffe T, Harmon DC, Fraher JP, Shorten G. Thoracic paravertebral block using real-time ultrasound guidance. nesth nalg. 2010;110: Shanti CM, Carlin M, Tyburski JG. Incidence of pneumothorax from intercostal nerve block for analgesia in rib fractures. J Trauma. 2001;51: Ozkan D, kkaya T, Karakoyunlu N, et al. Effect of ultrasound-guided intercostal nerve block on postoperative pain after percutaneous nephrolithotomy: prospective randomized controlled study. naesthesist. 2013;62: Manchikanti L, oswell MV, Singh V, Pampati V, Damron KS, eyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. MC Musculoskelet Disord. 2004;5: Manchikanti L, Singh V, Pampati V, eyer CD, Damron KS. Evaluation of the prevalence of facet joint pain in chronic thoracic pain. Pain Physician. 2002;5: Manchikanti L, Singh V, Falco FJ, Cash K, Pampati V, Fellows. Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial. Pain Physician. 2010;13: Dreyfuss P, Tibiletti C, Dreyer SJ. Thoracic zygapophyseal joint pain patterns. study in normal volunteers. Spine (Phila Pa 1976). 1994;19: Fukui S, Ohseto K, Shiotani M. Patterns of pain induced by distending the thoracic zygapophyseal joints. Reg nesth. 1997;22: tluri S, Datta S, Falco FJ, Lee M. Systematic review of diagnostic utility and therapeutic effectiveness of thoracic facet joint interventions. Pain Physician. 2008;11: Chua WH, ogduk N. The surgical anatomy of thoracic facet denervation. cta Neurochir (Wien). 1995;136:140-4.

13 105 Ultrasound-Guided Intervention in Thoracic Spine 24. Manchikanti L, Manchikanti KN, Manchukonda R, Pampati V, Cash K. Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up. Pain Physician. 2006;9: Stulc SM, Hurdle MF, Pingree MJ, rault JS, Porter C. Ultrasound-guided thoracic facet injections: description of a technique. J Ultrasound Med. 2011;30:

14 106 pissn : , eissn : Symposium J Korean Orthop ssoc Sang 2015; Ho 50: Moon, et al. 초음파를이용한척추중재술 흉추부초음파유도하중재술 문상호 이송 이재일 서울성심병원정형외과 흉추부통증은실제로요추나경추보다는유병률이적으나그래도 13% 에서 15% 까지보고하고있으며만성혹은극심한통증으로진행하는경우도드물지않다. 이러한환자들에게흉추부중재술이효과적인치료가될수있으나기흉을만들수있다는우려때문에쉽게시행하지못하고있는실정이다. 방사선투시기하시술이정확한방법이라지만기흉을막을수는없다. 최근에는그대안으로서흉추부초음파유도하중재술이시행되고있는데, 초음파는늑막에싸여있는폐를보면서시술할수있으며도플러를이용하여주요혈관구조물들의위치를관찰하면서폐와혈관을찌르지않고시행할수있다는중요한장점이있기때문이다. 방사선투시기와비교하여도초음파는금기적응증이없으며방사선피폭이없고신경혈관및연부조직을직접보면서실시간으로동영상하에서바늘이목표물까지삽입되기까지의모든경로를관찰할수있는안전하고효과적인술기이다. 그리하여저자들은실시간초음파유도하라는술기가흉추부중재술에서얼마나유용한가에대해분석하여기술하였다. 색인단어 : 흉추, 초음파, 중재술 접수일 2015 년 2 월 9 일수정일 2015 년 3 월 11 일게재확정일 2015 년 3 월 14 일책임저자문상호서울시동대문구왕산로 259, 서울성심병원정형외과 TEL , FX , msh124@paran.com 대한정형외과학회지 : 제 50 권제 2 호 2015 Copyright 2015 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

( ) Jkra076.hwp

( ) 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