Case Report J Korean Orthop Assoc 2011; 46: doi: /jkoa 자연소실된양측성견갑흉부점액낭염 Spontaneously Regressed Bilateral Scapul

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1 Case Report J Korean Orthop Assoc 2011; 46: doi: /jkoa Spontaneously Regressed Bilateral Scapulothoracic Bursitis 손강민 문동규 성창민 최필엽 * 박형빈경상대학교의학전문대학원정형외과학교실, * 진주고려병원영상의학과 견갑흉부점액낭염은견관절운동시통증과골성탄발음이특징적으로나타나는탄발성견갑증후군의원인으로알려져있다. 또한견관절불쾌감의한원인이기도하다. 견갑흉부점액낭염의원인은견갑골이나늑골의돌출과같은골성변화로인한견갑주위조직의만성반복적인기계적자극으로인한것으로생각되고있다. 보존적치료가우선시되며, 그결과는성공적인것으로알려져있으나, 통증, 과도한마찰, 기능부전등이동반될경우수술적치료가필요할수있으므로정확한진단이중요하다. 저자들은연부조직육종으로오인할수있는무통성으로탄발음의동반없이급속히커졌다가관찰도중 1예를경험하였기에이에대하여보고하는바이다. 색인단어 : 견갑흉부점액낭염 견갑흉부점액낭염은견갑흉부관절에발생하는동통성질환으 로견갑골운동시탄발음을동반하는것으로알려져있다. 1-5) 반 면, 탄발음의동반없이갑자기크기만증가하는견갑흉부점액낭 염의경우진행양상과예후에대해명확히알려져있지않다. 1,4) 크기가급속히증가하는견갑흉부점액낭염의경우종종연부조 직육종으로오인되어불필요한수술을시행하는경우가있다. 이들질환은예후에상당한차이가있고오진시불필요한수술 을야기할수있으므로두질환의감별이필요하다. 저자들은연 부조직육종으로오인할수있는무통성이고, 탄발음의동반없이 급속히커졌다가관찰도중자연소실된양측성견갑흉부점액낭 염 1 예를경험하였기에이에대하여보고하는바이다. 증례보고 67 세여자환자가양측견갑하각부위의종괴를주소로방문하 였다 (Fig. 1). 초진을본병원에서연부조직육종의심하에전원하 였다. 당뇨등과같은내과적병력은없었다. 문진상외상및미 접수일 2010 년 8 월 4 일게재확정일 2010 년 10 월 25 일교신저자박형빈경남진주시칠암동 90, 경상대학교의학전문대학원정형외과학교실 TEL , FAX hbinpark@gnu.ac.kr 세충격을줄수있는반복작업의과거력은없었으며, 양측종괴는단시간에급속히커지는양상이었다고하였다. 이학적검사상양측견갑하각부위에무통의경성종괴가촉지되었으나견관절운동시탄발음은관찰되지않았다. 단순방사선소견상연부조직의음영증가이외에다른특이적인소견은관찰되지않았다. 초음파검사를통하여낭종형태의종괴임을알수있었고, 자기공명영상소견상양측전거근과흉벽사이에위치한경계가명확한두개의낭종성종괴를확인할수있었다. 각각의크기는우측이 10 cm 5.l5 cm 4 cm였고, 좌측이 10 cm 4.0 cm 3.2 cm이었다. 자기공명영상검사상 T1 강조영상에서균일한저신호강도를보였고, T2강조영상에서는균일한고신호강도를보여낭종성종괴의전형적양상을나타내었다 (Fig. 2). 조영증강 T1 강조영상소견상낭종벽이조영증강되는소견을보였고, 낭종벽외에는고형종괴의존재를시사하는소견은없어낭종으로진단하였다. 우측종괴에서만진단적흡인술을시행하여혈액양상의낭액을흡인하였고 (Fig. 3), 흡인세포검사에서악성세포는발견되지않았다. 저자들은종괴를견갑흉부점액낭염으로진단하였고, 경과관찰 5개월후종괴는자연소실되었으며낭종소실후 3년간의추시에서재발은없었다. 고찰 견갑흉부관절에는 2 개의대점액낭과 4 개의소점액낭이위치하 대한정형외과학회지 : 제 46 권제 1 호 2011 Copyright 2011 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.

74 손강민 문동규 성창민외 2 인 고있으며견갑흉부점액낭은전거근과흉벽사이에있는전거근 공간에위치하는대점액낭중하나이다. 견갑흉부점액낭염의원인은견갑골이나늑골의돌출과같은 Figure 1.

골성변화로인한견갑주위조직의만성반복적인기계적자극으로인한것으로생각하고있다. 2,4) 그러나크기가급속히증가하는견갑흉부점액낭염의명확한발병원인및급속한진행을유발하는원인등에대해서는아직밝혀진바가없다.

Shackcloth 와 Page 7) 는점액낭이혈관분포가많은활액막으로둘러싸인섬유성결합조직임을보고하였고, 이같이증가된혈관분포가점액낭내출혈의원인이며조영증강자기공명영상소견에서점액낭벽의조영증강이일어나는원인이라고주장하였다.

급격한크기증가를보이는점액낭에서흡인검사를하였을때혈액이흡인되는것과점액낭의경과가자연적인소실을보인다는사실이점액낭내출혈설을뒷받침하며저자들의증례와도일치하는소견이라하겠다.

MR images demonstrate the well-circumscribed cystic masses located between the serratus anterior and the chest wall.

2 74 손강민 문동규 성창민외 2 인 고있으며견갑흉부점액낭은전거근과흉벽사이에있는전거근 공간에위치하는대점액낭중하나이다. 견갑흉부점액낭염의원인은견갑골이나늑골의돌출과같은 Figure 1. Clinical photograph shows the large bilateral masses below the inferior angles of both scapulae. 골성변화로인한견갑주위조직의만성반복적인기계적자극으로인한것으로생각하고있다. 2,4) 그러나크기가급속히증가하는견갑흉부점액낭염의명확한발병원인및급속한진행을유발하는원인등에대해서는아직밝혀진바가없다. Higuchi 등 6) 은최근연구에서크기가급격히증가한견갑흉부점액낭염모든예에서점액낭내출혈소견을관찰할수있었고, 그원인이점액낭내의갑작스러운출혈에기인한다고보고하였다. Shackcloth 와 Page 7) 는점액낭이혈관분포가많은활액막으로둘러싸인섬유성결합조직임을보고하였고, 이같이증가된혈관분포가점액낭내출혈의원인이며조영증강자기공명영상소견에서점액낭벽의조영증강이일어나는원인이라고주장하였다. 견갑흉부관절은기계적충격에쉽게노출되기때문에반복적인미세충격이견갑흉부점액낭에가해지면혈관분포가높은점액낭의출혈이발생하여점액낭이커지는것으로현재까지이해하고있다. 급격한크기증가를보이는점액낭에서흡인검사를하였을때혈액이흡인되는것과점액낭의경과가자연적인소실을보인다는사실이점액낭내출혈설을뒷받침하며저자들의증례와도일치하는소견이라하겠다. 크기가급속히증가하는견갑흉부점액낭은악성연부조직종양으로오인할수있으며, 이들질환은그예후및치료에현저한 Figure 2. MR images demonstrate the well-circumscribed cystic masses located between the serratus anterior and the chest wall. The right-side cystic mass, which measures approximately 10 cm x 5.5 cm x 4 cm, demonstrates homogeneous low signal intensity on T1- weighted images (A), and homogeneous high signal intensity on T2-weighted images (B). The left-side cystic mass, which measures 10 cm x 4 cm x 3.2 cm, demonstrates homogeneous low signal intensity on T1-weighted images (C), and homogeneous high signal intensity on T2- weighted images (D).

75 Figure 3. A diagnostic aspiration indicates that the cystic fluid is blood. 차이를보이기에감별이중요하다. 초음파, 조영증강컴퓨터단층촬영술등은견갑흉부점액낭염을진단하는데유용한검사방법으로알려져있으나, 점액낭내의출혈을쉽게감지할수있는자기공명영상이신생물과견갑흉부점액낭염을감별하는데가장유용한것으로알려져있다.

8,9) 견갑흉부점액낭염의자기공명영상이미지는 T2 강조영상에서고신호강도를 T1 강조영상에서는저신호강도를나타내며, 테두리음영이증가되는낭종의형태를보이나, 때로는격벽이나소엽성낭종의소견을보이는경우도있다.

3 75 Figure 3. A diagnostic aspiration indicates that the cystic fluid is blood. 차이를보이기에감별이중요하다. 초음파, 조영증강컴퓨터단층촬영술등은견갑흉부점액낭염을진단하는데유용한검사방법으로알려져있으나, 점액낭내의출혈을쉽게감지할수있는자기공명영상이신생물과견갑흉부점액낭염을감별하는데가장유용한것으로알려져있다. 6) 견갑흉부점액낭염의확진을위하여감별되어야할질환으로는탄력섬유종, 섬유육종, 지방육종등이있다. 최우선적으로감별하여야할질환으로는견갑흉부점액낭의호발부위인견갑하부위에서기원하는가성종양병변인탄력섬유종이며, 노인에게있어서흉벽에서흔히발생하는육종으로알려진지방육종및섬유육종의경우고령환자에게있어감별이필요하다. 8,9) 견갑흉부점액낭염의자기공명영상이미지는 T2 강조영상에서고신호강도를 T1 강조영상에서는저신호강도를나타내며, 테두리음영이증가되는낭종의형태를보이나, 때로는격벽이나소엽성낭종의소견을보이는경우도있다. 6) 반면, 탄력섬유종의경우는 T1 및 T2 강조영상에서근육의영상강도와유사한저신호강도내에고신호강도가산재해있는양상을보이며, 조영증강자기공명영상소견에서는조영증강의정도가일정하지않고강한조영증강을보이거나, 경도의조영증강을보여견갑흉부점액낭염의소견과는감별이가능하다. 10,11) 섬유육종은 T1 및 T2 강조영상에서균일혹은불균일한신호강도를모두나타낼수있으나, 대개 T1 강조영상에서는근육과동일한신호강도를, T2 강조영상에서는중등도내지고신호강도내에저신호강도가산재된불균일신호강도를보인다. 조영증강자기공명영상에서는대부분병변테두리의음영이증강된소견을보인다고알 려져두질환을감별하는데어려움은없다. 12) 지방육종은성인에게서발생하는악성연부조직육종중두번째로많은빈도를차지하는종양으로, 형태학적분류에따라자기공명영상소견에서차이를보인다. 고분화지방육종의경우종괴내의지방의비율이높아 T1 강조영상에서는고신호강도를, T2 강조영상에서는근육보다약간낮은저신호강도를보인다. 가장흔한형태인점액성지방육종은 T2 강조영상에서는불균일한고신호강도를, T1 강조영상에서는근육과동일한불균일한저신호강도를보이며, 조영증강자기공명영상에서는비조영영역을포함하는불균일한형태를보인다. 마지막으로다형성지방육종의경우자기공명영상소견에서괴사및출혈등을동반한전형적인불균일형태를보여견갑흉부점액낭염과감별이가능하다. 13) 양측성견갑흉부점액낭염은문헌고찰에따르면전세계적으로 1예만보고된매우드문증례로악성연부조직종양으로오인되어불필요한수술적치료가시행될수있으므로방사선검사를통한정확한진단이필요하며, 14) 수술적치료없이스스로소실될수있는질환이므로수술적치료를결정하기까지충분한경과관찰이요구된다고생각한다. 참고문헌 1. Kuhn JE, Plancher KD, Hawkins RJ. Symptomatic scapulothoracic crepitus and bursitis. J Am Acad Orthop Surg. 1998;6: Nicholson GP, Duckworth MA. Scapulothoracic bursectomy

4 76 손강민 문동규 성창민외 2 인 for snapping scapula syndrome. J Shoulder Elbow Surg. 2002;11: Ruland LJ 3rd, Ruland CM, Matthews LS. Scapulothoracic anatomy for the arthroscopist. Arthroscopy. 1995;11: Sisto DJ, Jobe FW. The operative treatment of scapulothoracic bursitis in professional pitchers. Am J Sports Med. 1986;14: Williams GR Jr, Shakil M, Klimkiewicz J, Iannotti JP. Anatomy of the scapulothoracic articulation. Clin Orthop Relat Res. 1999;359: Higuchi T, Ogose A, Hotta T, et al. Clinical and imaging features of distended scapulothoracic bursitis: spontaneously regressed pseudotumoral lesion. J Comput Assist Tomogr. 2004;28: Shackcloth MJ, Page RD. Scapular osteochondroma with reactive bursitis presenting as a chest wall tumour. Eur J Cardiothorac Surg. 2000;18: Gross JL, Younes RN, Haddad FJ, Deheinzelin D, Pinto CA, Costa ML. Soft-tissue sarcomas of the chest wall: prognostic factors. Chest. 2005;127: Zembsch A, Schick S, Trattnig S, Walter J, Amann G, Ritschl P. Elastofibroma dorsi. Study of two cases and magnetic resonance imaging findings. Clin Orthop Relat Res. 1999;364: Haykir R, Karakose S, Karabacakoglu A. Elastofibroma dorsi: typical radiological features. Australas Radiol. 2007;51 Spec No.:B Kourda J, Ayadi-Kaddour A, Merai S, Hantous S, Miled KB, Mezni FE. Bilateral elastofibroma dorsi. A case report and review of the literature. Orthop Traumatol Surg Res. 2009;95: Laffan EE, Ngan BY, Navarro OM. Pediatric soft-tissue tumors and pseudotumors: MR imaging features with pathologic correlation: part 2. Tumors of fibroblastic/myofibroblastic, socalled fibrohistiocytic, muscular, lymphomatous, neurogenic, hair matrix, and uncertain origin. Radiographics. 2009;29:e Arkun R, Memis A, Akalin T, Ustun EE, Sabah D, Kandiloglu G. Liposarcoma of soft tissue: MRI findings with pathologic correlation. Skeletal Radiol. 1997;26: Schiavon F, Ragazzi R. Bilateral scapulothoracic bursitis. Arthritis Rheum. 2008;58:585.

5 77 Spontaneously Regressed Bilateral Scapulothoracic Bursitis Kang Min Sohn, M.D., Dong Gyu Moon, M.D., Chang Min Sung, M.D., Pil Yeob Choi, M.D.*, and Hyung Bin Park, M.D., Ph.D. Department of Orthopaedic Surgery, School of Medicine and Hospital, Gyeongsang National University, *Department of Radiology, Korea General Hospital, Jinju, Korea Scapulothoracic bursitis causes snapping scapular syndrome, which is characterized by shoulder pain accompanying bony crepitation during shoulder motion, or as an isolated entity causing shoulder discomfort. The pathogenesis of scapulothoracic bursa formation is thought to be related to chronic repetitive mechanical stress on the periscapular tissue, usually from the result of a bone abnormality (a protrusion of the scapula or rib cage). Scapulothracic bursitis is treated with conservative management and the result can be successful. Accurate diagnosis is important because surgery is not necessary except for cases with pain, excessive friction, or dysfunction. We report a patient with rapidly developed bilateral scapulothoracic bursitis without pain and snapping, which can be confused with a soft tissue sarcoma. In this case, conservative management was used to treat the patient. Key word: scapulothoracic bursitis Received August 4, 2010 Accepted October 25, 2010 Correspondence to: Hyung Bin Park, M.D., Ph.D. Department of Orthopaedic Surgery, School of Medicine, Gyeongsang National University, 90, Chilamdong, Jinju , Korea TEL: FAX: hbinpark@gnu.ac.kr

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