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1 JKDSA 2014 ; 14(2) : Review Article 치과에서발생하는국소마취에의한신경손상 김현정 서울대학교치의학대학원치과마취과학교실 Peripheral Nerve Injuries Related to Local Anesthesia in the Dental Clinic Hyun Jeong Kim Department of Dental Anesthesiology and Dental Research Institute, School of Dentistry, Seoul National University Local anesthesia known as the safe and essential procedure to control pain in dentistry may cause sensory changes such as paresthesia or altered taste at the affected sites after even successful local anesthesia. Although the prognosis of the nerve injuries after local anesthesia is favorable, it might cause prolonged problems such as dysesthesia. The lingual nerve is a single fascicle at the level of the lingual among 1/3 of patients and more movable during regeneration compared to the inferior alveolar nerve after the injury. As a result, the lingual nerve is more vulnerable and has poorer outcomes. More vigilant clinical considerations are required to the lingual nerve injury after local anesthesia. Generally, more than 80% of cases are spontaneously resolved within 2 weeks after the local anesthesia even without any specific treatment. However, the patient having long lasting abnormal sensations more than 2 weeks needs specialists care for further assessment. In case of dysesthesia which is a symptom of neuropathic pain, immediate referral to specialists is mandatory. The exact mechanism, how to prevent its occurrence, or specific treatments of the nerve injury related to the local anesthesia have not been elucidated. To prepare clinical or medicolegal problems, many cautious considerations are given to the patients who complain sensory changes after local anesthesia. Key Words: Complications, Lingual nerve, Local anesthesia, Nerve injury, Neuropathic pain 서론 치과환자의통증을조절하기위하여시행되는국소마취는별다른부작용이나합병증없이매우안전하게시행되고있다. 그러나간혹성공적인국소마취후에도해당부위의감각의변화를호소하는환자들이있다. 일반적으로국소마취에의한신경손상의예후는양호하다고알려져있다 [1,2]. 신경병성통증으로진행되거나외과적처치가필요한경우가임플란트식립이나발치에의한신경손상의경우보다매우드물다 [3]. 그러나과거에비하여조직침습적인치과시술들이증가하였을뿐만아니라치과환자들의치료의질에대한요구가들어나면서국소마취의시행이증가하고그로인해발생하는감각변화등합병증을호소하는치과환자들이증가하고 있다 [4,5]. 이는환자들의치의학지식이늘어나면서치과분 쟁이문제가되고있다. 지난 2012 년우리나라에서치과분쟁 과관련된현대해상분석자료에의하면 [6] 임플란트, 발치, 국소마취등의시술과관련된신경손상이전체상담에서가 장많았다. 따라서, 국소마취와관련된신경손상의발생빈도, 원인, 증상, 치료법, 예후등을숙지하고있어야환자들의불편을 최소화하고환자와의신뢰를구축하고향후드물게발생할 수있는심각한합병증을조기발견하여그로인해발생할 수있는치과분쟁을최소화할수있을것이다. 이에본종설 Received: Revised: Accepted: Corresponding Author: Hyun Jeong Kim, Department of Dental Anesthesiology and Dental Research Institute, School of Dentistry, Seoul National University, 28 Yeongeon-dong, Jongno-gu, Seoul , Korea Tel: Fax: dentane@snu.ac.kr JOURNAL OF THE KOREAN DENTAL SOCIETY OF ANESTHESIOLOGY 2014 Jun ; 14(2) :

2 Hyun Jeong Kim : Peripheral Nerve Injuries Related to Local Anesthesia in the Dental Clinic 에서는치과마취과학의중요분야의하나인국소마취와관련하여발생한신경손상의최신지견을다루고자한다. 1. 국소마취와관련된신경손상발생빈도국소마취와관련된신경손상발생률은보고에따라다르다. 치과에서시행하는전제국소마취중 1/785,000 명으로매우드물다 [4]. 하치조신경전달마취인경우전제시술 1/160,571-1/26,762 명으로편차가크다 [7,8]. 이는술자의숙련도와신경손상발견의예민도에의존하기때문에발생률보고에차이가있다고생각된다. 2. 말초신경의구조와신경손상의분류말초신경은여러단위의막으로되어있다. 각각의신경축삭은신경내막 (endoneurium) 으로싸여있고, 신경다발들 (fascicles) 은신경다발막으로둘러싸여있으면설신경등의개별신경들은신경외막으로되어있다 (Fig. 1) [9]. 해부학적구조를기초로신경손상의정도에따라중증도를분류하게 되는데대표적으로사용되는분류법은 Seddon[10] 과 Sunderland 분류법 [11] 이며 (Table 1) 이를바탕으로손상된신경의결과를어느정도예측할수있다. 치과에서국소마취와관련된신경손상은주로설신경, 하치조신경, 턱신경, 설신경과같이주행하여미각을담당하는고실끝신경등에서발생하게되며가장흔한손상은설신경이나하치조신경에서발생한다 [4,5]. 3. 국소마취관련신경손상의기전신경손상의기전으로알려진가설은신경차단주사침에의한손상, 신경외막내혈종, 국소마취제에의한직접손상등이다 [12]. 국소마취도중주사침이신경축삭에직접적인자극을줄경우환자는전기에감전된것같은증상 (electrical shock like) 을보인다. 추적관찰에따르면이런중상을호소한환자의 15% 만이신경손상증상을호소하고, 대부분자연회복되며드물게영구적인신경손상으로진행된다. 더구나신경손상환자의오직 57% 만이국소마취도중전기에감전된것같은통증을경험한다 [13,14]. 때문에이러한신경자극증상이영구적인신경손상을의미하지는않는다. 그러나국소마취도중환자가갑자기놀라며 짜릿하다 고호소하면주사침위치와방향을변경하여추가로국소마취제를주사하여주사침에의한직접적인신경손상을예방한다. 4. 임상증상 Fig. 1. Cross sectional diagram of the peripheral nerve. 환자의임상증상은혀의앞쪽 2/3 부분의감각이상이나미각이상이발생하거나턱부분의감각이다. 간혹설신경과같이주행하는뇌신경 7번안면신경이지배하는턱밑샘이나설밑샘에서침색분비가감소하여구강건조증이발생할수도있다 (Fig. 2) [14,15]. Table 1. The classification of nerve injury and its outcomes Seddon Sunderland Injury Degeneration Regeneration Normal Normal Normal Normal Neuropraxia First degree Myelin sheath (M) Conduction block Complete recovery Axonotmesis Second degree M + Axon (A) Third degree M + A + Endoneurium (E) M + A + E + Perineurium Fourth degree Wallerian degeneration Neurotmesis (P) Incomplete recovery M + A + E + P + Fifth degree Epineurium 90 대한치과마취과학회지제 14 권제 2 호 89-94

김현정 : 치과에서발생하는국소마취에의한신경손상 신경손상과관련된환자의증상은국소마취를시행한쪽 의혀, 입술, 턱, 전정치은 (vestibular gum) 의체성감각이 나혀의미각의변화이다. 감각이상과관련하여감별진단해 야할것은무감각 (Anesthesia), 감각이상 (Paresthesia), 특 히불쾌감각 (Dysesthesia) 이다.

3 김현정 : 치과에서발생하는국소마취에의한신경손상 신경손상과관련된환자의증상은국소마취를시행한쪽 의혀, 입술, 턱, 전정치은 (vestibular gum) 의체성감각이 나혀의미각의변화이다. 감각이상과관련하여감별진단해 야할것은무감각 (Anesthesia), 감각이상 (Paresthesia), 특 히불쾌감각 (Dysesthesia) 이다. 신경손상의심각한합병증 인신경병성통증의증상은주로불쾌감각으로나타난다. 특징적으로특별한자극이없어도발생하는자발통, 가벼운 접촉에도통증을느끼는이질통 (allodynia), 또는통각의역 치가감소한통각과민 (hyperalgesia) 이나교감신경연관통 (sympathetic mediated pain), 무감각영역의통증을호소하 는무감각부위통증 (anesthesia dolorosa) 등이다 [2,16]. 불 쾌감각의발생빈도는수술 (8%) 과관련된신경손상보다국소 마취후발생하는신경손상 (34%) 에서많이발생하는것으로 보아신경손상이의심되는환자에서불쾌감각을포함한통증 의평가는매우중요하다 [16,17]. Fig. 2. Sensory innervation of the tongue which could show the sensory changes after local anesthesia. 혀와턱의감각의변화는 Fig. 3과같이도식화할수있다 [3]. V3 지역의감각이상이발생하는경우아래치조신경과턱끝신경의손상을확인하여야한다. V2 지역의감각이상이있는경우위치조신경의손상을의심해보아야한다. 반면혀와혀아래입바닥부위는위아래 3등분좌우로 3등분으로하여감각변화등의손상을확인하고각각부위에따라고려하는신경이달라질수있다. 5. 진단의심되는환자에서시행할수있는신경검사는다음과같다. 감각변화에대한진단을위해서는지속적인추적이필요하다. 만약 2주이상감각신경기능이상이의심되는경우감각신경기능을평가하기위해서는기계적, 열적, 화학적자극에대한반응을측정한다 [18,19]. 기계적자극으로는촉각, 압력, 통증자극이, 열자극으로는냉온자극등이이용된다 (Fig. 4) [20]. 통증을확인하는경우찌르기테스트 (pinprick test) 를시행하게되는데변화된부위의지도를그릴수있다. 본프레이의머리카락 (Von Frey s hairs) 역시압각에대한검사를위해시행할수있다. 기계적자극에는정적자극과동적자극을포함하여자극의위치파악및 2점분별자극 (2-point discrimination) 이사용된다. 2점분별자극의정상치는국소마취안한반대쪽과비교하여측정한다. 참고로입술인경우 5 mm 가정상치이다 [21,22]. 미각검사는단맛, 짠맛, 신맛, 쓴맛에대한검사를시행한다.[22,23] 국소마취후감각의변화를호소하는환자를진료할때중요한사항은향후치과분쟁이될수있으므로의무기록을법적증빙자료로활용할수있게정확히남겨야한다. (A) (B) (C) Fig. 3. Diagrams for neurosensory assessment. (A) face, (B) tongue, (C) tongue base. JOURNAL OF THE KOREAN DENTAL SOCIETY OF ANESTHESIOLOGY 2014 Jun ; 14(2) :

Hyun Jeong Kim : Peripheral Nerve Injuries Related to Local Anesthesia in the Dental Clinic Fig. 4.

(A) Thermal discrimination, (B) Pin pressure nociception, (C) Brush directional discrimination, (D) 2-point discrimination. 의무기록에포함되어야할사항은다음과같다.

통각과민유무확인 6. 치료현재까지국소마취관련신경손상의치료법은잘알려져있지않다. 대개약물적치료가사용되고그로인해성공적으로치료하는경우가보고되고있다 [24,25].

g.,lidocaine) 등을사용할수있다 [18,26]. 특히국소마취관련신경손상은수술적치료가필요한경우가극히드물다.

4 Hyun Jeong Kim : Peripheral Nerve Injuries Related to Local Anesthesia in the Dental Clinic Fig. 4. Sensory evaluation for the peripheral nerve injury. (A) Thermal discrimination, (B) Pin pressure nociception, (C) Brush directional discrimination, (D) 2-point discrimination. 의무기록에포함되어야할사항은다음과같다. 국소마취한날짜 신경손상으로가능한원인 시간경과에따른환자의증상 사용된약물이나시술, 이에따른효과 기능손상 : 발음이나저작기능저하, 혀나입술의씹기, 미각이상 정신과적문제등의기저질환 감각이상 : 무감각, 감각이상, 불쾌감각유무확인 신경병성통증 : 자발통, 이질통, 통각과민유무확인 6. 치료현재까지국소마취관련신경손상의치료법은잘알려져있지않다. 대개약물적치료가사용되고그로인해성공적으로치료하는경우가보고되고있다 [24,25]. 필요한경우소염진통제나스테로이드를사용할수있으며불쾌감각이있는경우신경병성통증치료제인항경련제 (carbamazepine, phenytoin, gabapentin, topiramate), 벤조디아제핀계약제, 항우울제, 근이완제 (e.g., baclofen), 마취제 (e.g.,lidocaine) 등을사용할수있다 [18,26]. 특히국소마취관련신경손상은수술적치료가필요한경우가극히드물다. 그러나마취후 2-3 개월간호전이없는경우, 이상감각이 4-6 개월동안적극적인약물적치료후에도호전이없는경우, 감각둔화가 2-3개월이상지속되는경우전문가의판단에따라수술적치료를할수있다 [24,27]. 그러나수술적방법이완전한회복을보장하지못하며어떤경우에는더나빠질수있는것을고려해야한다 [4]. 7. 예후환자의예후를예측하는것은매우중요하다. 보고에따르면감각이상을호소한 81% 이상의환자에서증상은 2 주이내에사라졌다.[27,28] 그러나증상이 2주이상지속된경우신경손상증상이영구적인고착될가능성이높으므로전문의에게의뢰해야한다 [7,29]. 신경손상증상중불쾌감각이발생한경우에는국소마취후 2주이내라도발견즉시통증의학전문의에게의뢰해야한다. 향후발생할수도있는치과분쟁의소지를최소화하기위해서는이런상황에익숙하고의사소통이순조로운전문의에게보내는것이좋겠다. 92 대한치과마취과학회지제 14 권제 2 호 89-94

5 김현정 : 치과에서발생하는국소마취에의한신경손상 결과적으로 8주이내에 85-94% 의환자에서아무런처치없이도완전한감각신경기능의회복이보고되었다 [8,16]. 그러나환자의감각이상증상이 8주이상지속되면예후가나쁘다고간주하고의학적법의학적으로적극적인대처가필요하겠다. 보고에따르면국소마취관련신경손상으로가장많이발생되는신경은가장많이행해지는하치조신경이아니라설신경이다 [7,16]. 그이유는혀돌기수준에서설신경은환자의 1/3 에서신경다발이하나로되어있기때문이다. 또한설신경이하지조신경보다예후가나쁘다 [7]. 손상된신경재생과정에서뼈속에안전에게고정되어있는하치조신경과는달리설신경은유동성이있기에신경재생에있어문제가발생하기쉽기때문이다. 결론치과진료에서국소마취를이용하는치과치료는흔하게진행되고있다. 그러나이는흔하지는않지만신경손상에의한일시적인감각의변화나심지어영구적인변화가발생할수있다. 그정확한기전이나예방법은알수없지만국소마취제에의한신경손상이일단발생하게되면환자에게기능적인이상뿐만아니라정신적인영향을줄수있고이는치과의사에게도마찬가지이다. 그러므로환자가국소마취한영역의감각의변화를호소할때신속한진단과임상적판단이필요하며그에적절한대처는중요하다. 국소마취제에의한신경손상은흔하게발생하진않지만예후는좋은편으로대개몇주안에호전된다. 그러나증상이계속지속되게되면예후는나빠진다. 말초신경손상과관련된합병증중가장심각한것은통증조절이쉽지않은신경병성통증의발현이다. 법학전문대학원에서배출되는변호사가많은미국에서는이미치과분쟁과관련된중요사항을보여주는온라인사이트가개설되어눈길을뜬다. 이사이트에서도신경병성통증이동반된신경손상이발생될경우실력있는변호사의선임이분쟁의결과에많은영향을미칠수있음을강조하고있다. 앞으로법학전문대학원에서해마다많은변호사배출이예상되는우리나라에서도시사하는바가크다. 그러므로이런종류의합병증발생에관하여지식을공유함으로써증상이발생했을때적절한치료와대처가 적절한시기에이루어질수있도록하는것이중요하겠다. 참고문헌 1. Campbell RL, Shamaskin RG, Harkins SW: Assessment of recovery from injury to inferior alveolar and mental nerves. Oral Surg Oral Med Oral Pathol 1987; 64(5): Nickel AA: A retrospective study of paresthesia of the dental alveolar nerves. Anesth Prog 1990; 37(1): Krafft TC, Hickel R: Clinical investigation into the incidence of direct damage to the lingual nerve caused by local anaesthesia. J Craniomaxillofac Surg 1994; 22(5): Haas DA, Lennon D: A 21 year retrospective study of reports of paresthesia following local anesthetic administration. J Can Dent Assoc 1995; 61(4): , 23-6, Lustig JP, Zusman SP: Immediate complications of local anesthetic administered to 1,007 consecutive patients. J Am Dent Assoc 1999; 130(4): Robinson PP, Loescher AR, Smith KG: A prospective, quantitative study on the clinical outcome of lingual nerve repair. Br J Oral Maxillofac Surg 2000; 38(4): Pogrel MA, Thamby S: The etiology of altered sensation in the inferior alveolar, lingual, and mental nerves as a result of dental treatment. J Calif Dent Assoc 1999; 27(7): 531, Assael LA: The nerve under the microscope. J Oral Maxillofac Surg 2002; 60(5): Sh S: Surgical disorders of the peripheral nerves. London, hurchill Livingstone Ss S: Nerve injuries and their repair. London, Churchill Livingstone Kirihara Y, Saito Y, Sakura S, Hashimoto K, Kishimoto T, Yasui Y: Comparative neurotoxicity of intrathecal and JOURNAL OF THE KOREAN DENTAL SOCIETY OF ANESTHESIOLOGY 2014 Jun ; 14(2) :

6 Hyun Jeong Kim : Peripheral Nerve Injuries Related to Local Anesthesia in the Dental Clinic epidural lidocaine in rats. Anesthesiology 2003; 99(4): Colin W, Donoff RB: Restoring sensation after trigeminal nerve injury: a review of current management. J Am Dent Assoc 1992; 123(12): Day RH: Diagnosis and treatment of trigeminal nerve injuries. J Calif Dent Assoc 1994; 22(6): 48-51, Hutchings ML: Nerve damage and nerve blocks. J Am Dent Assoc 1996; 127(1): Pogrel MA, Kaban LB: Injuries to the inferior alveolar and lingual nerves. J Calif Dent Assoc 1993; 21(1): Crean SJ, Powis A: Neurological complications of local anaesthetics in dentistry. Dent Update 1999; 26(8): Ruggiero SL: Trigeminal nerve injury and repair. N Y State Dent J 1996; 62(8): Gratt BM, Shetty V, Saiar M, Sickles EA: Electronic thermography for the assessment of inferior alveolar nerve deficit. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 80(2): Costa FW, Fontenele EH, Bezerra TP, Ribeiro TR, Carneiro BG, Soares EC: Correlation between radiographic signs of third molar proximity with inferior alveolar nerve and postoperative occurrence of neurosensory disorders: a prospective, double-blind study. Acta Cir Bras 2013; 28(3): Poort LJ, Van Neck JW, Van Der Wal KG: Sensory testing of inferior alveolar nerve injuries: a review of methods used in prospective studies. J Oral Maxillofac Surg 2009; 67(2): Takasugi Y, Furuya H, Moriya K, Okamoto Y: Clinical evaluation of inferior alveolar nerve block by injection into the pterygomandibular space anterior to the mandibular foramen. Anesth Prog 2000; 47(4): Haas DA, Lennon D: Local anesthetic use by dentists in Ontario. J Can Dent Assoc 1995; 61(4): Zuniga JR, Labanc JP: Advances in microsurgical nerve repair. J Oral Maxillofac Surg 1993; 51(1 Suppl 1): Robinson PP: Observations on the recovery of sensation following inferior alveolar nerve injuries. Br J Oral Maxillofac Surg 1988; 26(3): Pogrel MA, Bryan J, Regezi J: Nerve damage associated with inferior alveolar nerve blocks. J Am Dent Assoc 1995; 126(8): Pogrel MA: The results of microneurosurgery of the inferior alveolar and lingual nerve. J Oral Maxillofac Surg 2002; 60(5): Pogrel MA, Schmidt BL, Sambajon V, Jordan RC: Lingual nerve damage due to inferior alveolar nerve blocks: a possible explanation. J Am Dent Assoc 2003; 134(2): Pogrel MA, Thamby S: Permanent nerve involvement resulting from inferior alveolar nerve blocks. J Am Dent Assoc 2000; 131(7): 대한치과마취과학회지제 14 권제 2 호 89-94

제5회 가톨릭대학교 의과대학 마취통증의학교실 심포지엄 Program 1 ANESTHESIA (Room 2층 대강당) >> Session 4 Updates on PNB Techniques PNB Techniques for shoulder surgery: continuou

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