Korean J Pain Vol. 21, No. 1, 2008 대한통증학회지 2008; 21: 57 61 DOI:10.3344/kjp.2008.21.1.57 원저 초음파를활용한회전근개간격으로접근한견관절주사법 울산대학교의과대학강릉아산병원마취통증의학교실, * 을지대학교의과대학을지병원마취통증의학교실 임종범ㆍ김영기ㆍ김성우ㆍ성규완ㆍ정일ㆍ이청 * Ultrasound Guided Shoulder Joint Injection through Rotator Cuff Interval Jong Bum Lim, M.D., Young Ki Kim, M.D., Sung Woo Kim, M.D., Kyu Wan Sung, M.D., Il Jung, M.D., and Chung Lee, M.D.* Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, College of Medicine, Ulsan University, Gangneung, *Department of Anesthesiology and Pain Medicine, Eulji Hospital, College of Medicine, Eulji University, Daejeon, Korea Background: Shoulder joint injection is currently performed under fluoroscopic or computed tomography scan guidance. We performed this study to determine if an ultrasound guided shoulder joint injection through rotator cuff interval would have clinical usefulness. Methods: A total of 17 volunteers [12 women, 5 men; mean age 28 yr (23 32 yr)] received shoulder joint injection under multilinear ultrasound (5 10 MHz). Volunteers were positioned supinely on a table with their arm in a neutral position. The anterior shoulder region of the patient was sterilized using povidone iodine. A 24 gauge needle was introduced and directly visualized in real time as it passed obliquely from the skin surface to the inferior space of the biceps tendon. If there was little or no resistance to the injection, a contrast media (omnipaque) was injected and checked fluoroscopically. Results: Ultrasound guided shoulder joint injection through rotator cuff interval was successful in all cases. The average time taken for the procedure was 27.5 ± 16.5 sec. The vertical distance from skin to the inferior space of the biceps tendon was 1.6 ± 0.4 cm and the distance of needle from the skin to the inferior space of biceps tendon was 2.8 ± 0.6 cm. The procedure was well tolerated by all volunteers. Conclusions: Ultrasound guided shoulder joint injection through rotator cuff interval is an effective, rapid, and easy-to-perform injection technique. Ultrasound guided injection enables exact needle placement and avoids the use of both ionizing radiation and iodinated contrast material. (Korean J Pain 2008; 21: 57 61) Key Words: rotator cuff interval, shoulder joint injection, sonography. 서 견관절주사는견관절질환의평가를위한조영술과치료목적으로다양한방법으로시도되고있다. 기존에사용되고있는견관절주사는대표적으로전방접근법과후방접근법이있으나바늘에의한관절와 (glenoid) 나 접수일 :2007 년 10 월 23 일, 승인일 :2007 년 12 월 5 일책임저자 : 김영기, (210-711) 강원도강릉시사천면방동리 415 번지강릉아산병원마취통증의학과 Tel: 033-610-3409, Fax: 033-641-8180 E-mail: ykkim@gnah.co.kr 론 인대등주변조직의손상을야기할가능성이있으며맹목적으로시행하였을경우성공가능성이낮다고한다. 1,2) 또한, 방사선투시영상을이용한견관절조영술의경우적절한위치를확인하기위한조영제사용으로인하여관절외부로주사가되는경우가있으며방사선피폭을피할수없는단점이있다. 최근에는초음파를활용한견관절주사방법이보고되 Received October 23, 2007, Accepted December 5, 2007 Correspondence to: Young Ki Kim Department of Anesthesiology and Pain Medicine, Gangneung Asan Hospital, College of Medicine, Ulsan University, 415, Bangdong-ri, Sacheon-myeon, Gangneung 210-711, Korea Tel: +82-33-610-3409, Fax: +82-33-641-8180 E-mail: ykkim@gnah.co.kr
58 JB Lim, et al / Korean J Pain Vol. 21, No. 1, 2008 고있으며후방접근법과전방접근법이있으나전방접근법을이용할경우수직으로바늘이진입하여초음파영상상실시간확인이어려우며오구돌기 (coracoid process) 로인하여전방관절와 (anterior glenoid labrum) 를확인하기어려운단점으로후방접근법이사용된다. 3) 초음파를활용한회전근개간격 (rotator cuff interval) 에위치한관절낭으로견관절주사를시행하는접근법은바늘을깊이삽입하지않아도되며바늘이경사로진입하여실시간으로확인이되어시술이용이하고주변조직의손상을최소화할수있는좋은방법이라생각하여본실험을진행하게되었다. 대상및방법본연구는병원임상윤리위원회의승인을얻은뒤윤리규정에따라진행되었고실험에참여한사람에게는연구의방법과목적을설명한후서면동의하에연구를시행하였다. 연구에참여한인원은남녀 17명이었고약물에대한과민반응이나혈액응고이상의병력은없었고견관절의통증이나질환이없는건강한성인이었다. 모든술기는한명의마취통증의학과전문의가실시하였다. 실험참여자는수술대위에앙와위로자세를취한후가장좋은초음파영상을얻기위해시술측의상지는중립위또는어깨관절의외회전과신전을시켰다. 오구돌기와상완골의대결절을확인한후에환자의오구돌기부터상완골의대결절부위를 povidone iodine으로세번소독하였다. 소독포를덮은후소독비닐커버를덮은 초음파의소식자 (5 10 MHZ linear probe, Aloka, Prosound SSD-3500SV, Japan) 를이용하여사위축초음파조영사진 (oblique axial sonogram) 을얻었다 (Fig. 1). 상완이두근 (biceps tendon) 의힘줄과어깨밑힘줄 (subscapularis tendon), 가시위힘줄 (supraspinatus tendon) 이가장잘보이고상완이두근의힘줄이화면의중간에오도록소식자를조정한후영상을관찰하면서가장깊은부위에상완골두가고에코로나타나고그위로상완이두근의힘줄이타원형으로관찰되며상완이두근힘줄의외측으로가시위힘줄과내측으로는어깨밑힘줄이위치하도록하였다 (Fig. 2). 초음파소식자의내측에 1% 리도카인으로피부천자부위에피하주사한후 24 gauge, 8 cm의 spinal needle을소식자의장축을따라서상완이두근의힘줄아래로기울어진사선방향으로실시간으로초음파영상을확인하며진행시켰다 (Fig. 3, 4). 시험용량으로 0.5% 리도카인을 1 ml 주어저항감이있으면바늘의사단방향을바꾸거나조금씩바늘을진행시키거나후퇴시켜저항감이소실되면서주변조직이부풀어오르지않으면관절낭내주입으로보고방사선조영제 3 ml를투여한후방사선투시검사상전후영상을통하여견관절낭의방사선조영제확산을관찰하였다 (Fig. 5). 시술이끝난후 5분간시술부위를거즈로압박하였고상지의근력과활력징후를측정하였다. 피부천자후저항감이소실되는시간을기록하였고상완이두근힘줄의아래에위치한후바늘의방향이나깊이의조절에도저항감이소실되지않아 Fig. 1. Photograph shows 5 10 MHz multilinear transducer alignment. Image demonstrates the optimal positioning of the transducer over the anterior shoulder with the neutral position of ipsilateral arm. Fig. 2. Oblique axial sonogram demonstrates the normal rotator cuff interval. The boundaries of the interval are formed by the supraspinatus (SS) and subscapularis tendons (SubS). The rotator cuff interval contains the biceps tendon (B) and the superior glenohumeral (arrow) and coracohumeral ligaments (curved arrow). Asterisk: target site of needle. Delt: Deltoid muscle.
임종범외 5 인 : 초음파를활용한견관절낭주사법 59 바늘을다시삽입하는경우나방사선영상증강장치를이용한견관절조영술이확인되지않을경우는실패로간주하였다. 모든측정치의통계적처리는 SPSS 12.0을사용하였고측정치는평균 ± 표준편차로표기하였다. 결과연구에참여한인원은총 17명이었고평균연령은 28 세, 남자 5명, 여자 12명이었다. 남자의평균키는 172 cm, 몸무게는 79 kg이며여자는 158 cm, 62 kg이었다. 첫번째시도에서저항감이소실된경우는총 17명중 15명이었고실패한두명은바늘의자입점을바꾸어시도하였고두번째시도에모두성공하였다. 목표지점까지성공적으로도달한시간은평균 27.5 ± 16.5초였으며방사선영상증강장치를이용한견관절조영술에서는전원성공적으로확인되었다. 피부로부터목표지점까지삽입된거리는평균 2.8 ± 0.6 cm였고초음파상피부로부터목표지점까지의수직거리는평균 1.6 ± 0.4 cm였다 (Table 1). 시술후혈종이나피부발진등의부작용을보인사람은없었다. Fig. 3. Photograph shows introduction of needle. After skin antisepsis and local anesthetic infiltration, needle is introduced at skin surface just lateral to transducer and passed under real-time observation along imaging plane in oblique direction toward the inferior space of biceps tendon. Fig. 5. Glenohumeral arthrogram verifies the intraarticular distribution of the contrast material. Table 1. Results of Rotator Interval Injection under Sonographic Guidance Age (yr) 29.5 ± 3.6 Sex (M/F) 5/12 Results First trial success rate 15/17 (88%) Second trial success rate 2/17 (12%) *Vertical depth (cm) 1.6 ± 0.4 The depth of needle (cm) 2.8 ± 0.6 Time (sec) 27.5 ± 16.5 Success rate 100% Fig. 4. Axial oblique sonogram of rotator cuff interval shows preferred needle tip (arrowhead) location just below biceps tendon. Needle shaft (arrow) is also labeled. Data are mean ± SD or number of cases. *The vertical distance from skin to the inferior space of the biceps tendon, The distance of needle from the skin to the inferior space of biceps tendon, The time taken for the procedure.
60 JB Lim, et al / Korean J Pain Vol. 21, No. 1, 2008 고찰회전근개간격은가시위힘줄의전방부위와어깨밑힘줄의상방부위, 오구돌기의외측면, 상완이두근힘줄로이루어진삼각형모양이다. 견관절부위중인대가둘러싸여있지않아서외상에취약하며유착성관절낭염등의활액막질환에도이상소견이보이는곳이다. 회전근개간격내에는오구상완인대 (coracohumeral ligament) 와상관절와상완인대 (superior glenohumeral ligament), 관절낭 (joint capsule) 이있으며때때로중관절와상완인대 (middle glenohumeral ligament) 가있다. Jost 등은 4) 회전근개간격에대해자세한해부학적구조를보고하였는데내측으로는 2층으로구성되어있으며외측으로는 4층으로구성된다고하였다. 회전근개간격의내측으로표층부에는오구상완인대가있고심층부에는상관절와상완인대가위치하고있으며외측으로는표재오구상완인대가있고가시위힘줄과어깨밑힘줄이두번째층을구성하며깊은오구상완인대가세번째층을이루고마지막으로상관절와상완인대와관절낭이있다. 회전근개간격의기능은첫째, 견관절의과도한신전, 굴곡, 내전, 외회전을억제하며둘째, 상완골두의하방전위를억제하고마지막으로상완골두의후방전위를억제하는기능을한다. 특히오구상완인대가상완골두의하방전위와외회전을억제시켜견관절의안정화에기여한다. 5) 견관절주사법은유착성관절낭염, 류마티스관절염, 골관절염등의질환에자주사용된다. 골관절염은주로노인에흔하며청년기에는손상을받은다음에생길수있다. 증상은만성통증, 관절가동범위제한, 근력약화이다. 단순방사선검사가진단에도움이되지만임상증상과항상일치하지는않는다. 류마티스관절염은자가면역질환으로서관절윤활막염증이원인이고유착성관절낭염 (adhesive capsulitis) 은점진적으로견관절의수동적, 능동적운동이제한되는질환이며질환과연관된요인은여성, 40세이상의나이, 외상, 당뇨병, 갑상선질환, 심근경색, 자가면역질환등이있으며환자의 30% 에서반대편어깨에도질환이발생한다. Hazleman은 6) 유착성관절낭염의증상시작후 1달이내에견관절주사를시행하면평균 1.5 개월에회복되었으며 2 5개월의증상에는 8.1 개월, 6 18개월의증상이있었으면 14개월의치료기간이필요하다고하였다. 이는초기의주사요법이중요하다는점을시사하며유착성관절낭염의 초기에과혈관성윤활막증식 (hypervascular synovial hyperplasia) 이야기되면윤활막아래 (subsynovium) 와관절낭에섬유화가진행하므로관절낭내스테로이드주사는활액막염 (synovitis) 을감소시키며섬유화의진행을억제하는효과로추정된다. 7,8) 견관절주사요법은후방접근법과전방접근법이있다. 후방접근법은환자가앉은상태에서팔을내회전, 내전시킨후견봉 (acromion) 의뒤쪽면을촉지하고견봉의후방각으로부터아래로 1 cm, 내측으로 1 cm되는곳에서자입하여오구돌기방향으로시행하는방법이며, 전방접근법은팔을내회전시킨후오구돌기의외측하부에서자입하여견관절로향하는방법이다. 그러나맹목적접근법으로시행하였을경우견관절낭내주사는 42%, 견봉하활액낭으로의진입은 29% 의성공률을보이며주사의효과는정확한위치에약물이주입되었을경우더욱효과적이라고보고하였다. 1) 따라서, 컴퓨터단층촬영, 방사선영상증폭장치, 초음파등을이용한방법들이사용되고있다. 초음파유도하견관절강내주사는관절낭내로의진입을바로확인할수있는후방접근법이이용되고있으며전방접근법은오구돌기에의해전방관절와의확인이어려우며바늘이수직으로진입하게되어실시간으로바늘의위치를확인하기어려운단점이있다. 초음파를활용한회전근개간격으로접근한견관절주사법은삽입거리가짧아시술이용이하며시술부위에주된신경이나혈관이없다. 관절내로바늘이진입하지않아서다른술기에비해침습이적고오구돌기로인한영상의방해도없다는장점이있다. 또한, 통증크리닉외래에서자주진단되고견관절주사의적응증이되는유착성관절낭염의경우오구상완인대나상관절와상완인대의비후, 상완이두힘줄주위의수액저류를관찰할수도있어진단적가치도높다. 9,10) 본실험에서소요되는시간은평균 27.5 ± 16.5초였으나처음으로시도하는방법임을고려할때향후숙련도가증가하면더욱빠른시간에시술이가능할것으로생각되며가장좋은초음파영상의획득과바늘의진입이실시간으로확인될수있도록초음파소식자의수직방향의아래에위치시키는것이중요하였다. 회전근개간격으로접근한견관절주사법의단점은주사시견관절에약물이들어가는지바로확인이불가능하다는것이다. 본실험에서방사선영상증강장치를이용하여확인한결과전원에게견관절낭내조영제확산을관찰되었고바늘끝의위치가관절낭이아닐경우주사시약물이회전근개간격의가시위힘줄이나어깨밑힘줄등
임종범외 5 인 : 초음파를활용한견관절낭주사법 61 의주위조직으로퍼지는것을확인할수있다. 초음파를활용한회전근개간격으로접근한견관절주사법은방사선영상증강장치를사용하지않아방사선조사를피할수있고조영제에과민반응이있는환자에게시술할수도있으며혈관이나신경의손상을최소화하며정확한부위에빠르게주사하는장점과더불어질환의진단에중요한단서를얻을수있는좋은방법이라고생각한다. 본실험은건강한성인남녀를대상으로만진행하였고표본수도적은제한점이있으며, 이시술자체가관절낭내약물주입을바로알수없는단점을보완하는연구와유착성관절낭염환자등견관절질환환자에게시술하는추후연구가필요하다고생각한다. 참고문헌 1. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, Fitz- Gerald O: Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis 1997; 56: 59-63. 2. Chung CB, Dwek JR, Feng S, Resnick D: MR arthrography of the glenohumeral joint: a tailored approach. AJR Am J Roentgenol 2001; 177: 217-9. 3. Zwar RB, Read JW, Noakes JB: Sonographically guided glenohumeral joint injection. AJR Am J Roentgenol 2004; 183: 48-50. 4. Jost B, Koch PP, Gerber C: Anatomy and functional aspects of the rotator interval. J Shoulder Elbow Surg 2000; 9: 336-41. 5. Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992; 74: 53-66. 6. Hazleman BL: The painful stiff shoulder. Rheumatol Phys Med 1972; 11: 413-21. 7. Rizk TE, Pinals RS: Histocompatibility type and racial incidence in frozen shoulder. Arch Phys Med Rehabil 1984; 65: 33-4. 8. Steinbrocker O, Argyros TG: Frozen shoulder: treatment by local injections of depot corticosteroids. Arch Phys Med Rehabil 1974; 55: 209-13. 9. Homsi C, Bordalo-Rodrigues M, da Silva JJ, Stump XM: Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool? Skeletal Radiol 2006; 35: 673-8. 10. Lee JC, Sykes C, Saifuddin A, Connell D: Adhesive capsulitis: sonographic changes in the rotator cuff interval with arthroscopic correlation. Skeletal Radiol 2005; 34: 522-7.