Arthrosis management 흔한관절질환치료 1. Anatomy greater tuberosity lesser tuberosity bicipital groove biceps acromion clavicle coracoid process AC joint glen

흔한관절질환치료 1. Anatomy greater tuberosity lesser tuberosity bicipital groove biceps acromion clavicle coracoid process AC joint glenoid & labrum supraspinatus infraspinatus teres minor subscapularis * Joints of Shoulder 1) True joint (3) - glenohumeral joint - acromioclavicular joint - sternoclavicular joint 2) Functional joint (2) - scapulothoracic joint - subacromial space - Shoulder Hue Jung Park, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Seoul St. Mary s Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea 3. Treatment 1) Medication (NSAIDs, Codeine, etc.) 2) Physical rehabilitation 3) ESWT 4) IMS 5) Prolotherapy 6) Injection (LA, steroid) 7) Surgery *Intraarticular injection 환자에게손으로반대편어깨를잡도록한다. Acromion 바로아래에 probe 를횡으로바짝눌러위치시키면 deltoid 와 infraspinatus 아래로 humeral head 와 glenoid, 그리고 labrum 을확인한다. In-plane approach 로바늘을자입하여 tip 이 articular cartilage 와 labrum 사이에있는 joint space 에위치한다 (Fig. 1). 2. Differential Diagnosis - Rotator cuff disease - Biceps tendon disease - Calcific tendinitis - Instability Fig. 1. D: deltoid, InfraS: infraspinatus, H: humeral head, Gl: glenoid. 81

Bedside to Evidence, Evidence to Bedside 흔한관절질환치료 고관절치료 이상은 인제대학교의과대학마취통증의학과 The KorEan Society of AnesthesioLOgists 고관절 (hip joint) 통증은여러가지원인들로구성된흔한증상이다 (1). 60 세이상, 6596 명의성인연구에서최근 6 주간심한고관절통증을호소한경우가 14.3% 에해당된다. 고관절주위의점액낭염, 고관절염, 골절등이고관절통증을유발하는흔한원인들이다. 통증의위치와양상, 그리고통증을유발하는자세와움직임등을고려하면, 이원인들을구분하는데도움이된다. 고관절통증치료에서가장중요한것은고관절통증을정확하게진단하는것이며최근초음파의보급이증가하면서초음파를이용한치료에대해서간략히정리하였다. 해부학 고관절은골반골 (pelvis) 과태퇴골 (femur) 이만나는부위로, 골반의외측과대퇴골두 (femoral head) 가이루는구와관절 (ball and socket joint) 형태이며다양한방향으로운동이가능한관절이다. 대퇴골두와비구부 (acetabulum) 는연골로덮여있으며, 비구외측부에는관절와순 (labrum) 이비구와함께대퇴골두를덮고있다. 그외측으로관절낭 (joint capsule) 이비구부와대퇴경부 (femoral neck) 를함께감싸고있다. 대퇴골은공모양의대퇴골두, 대퇴경부, greater trochanter 와 lesser trochanter 사이를잇는부위로여러근육들이부착하는 intertrochanter 으로크게나누어진다. 대부분의골절은대퇴경부와 intertrochanter 에서발생한다. 대퇴경부의길이는약 8-10 cm 이고돌출부위가 2 군데있다. Greater trochanter 는외측에위치하며고관절의 abduction 을담당하는 gluteus medius 와 gluteus minimus 가붙는위치이다. Lesser trochanter 는내측에위치하며고관절의 flexion 을담당하는 iliopsoas tendon 이부착한다. 고관절의 extension 기능을하는 gluteus maximus 와 hamstrings 근육들은 greater trochanter 아래대퇴골에부착한다. 대퇴골두와대퇴경부로공급되는주요혈관은 medial femoral circumflex artery 이다. 만약대퇴경부골절이발생하면이혈관이손상되어대퇴골두괴사 (osteonecrosis) 가발생한다. 고관절주위에는대략 18 개의 bursa 가위치하는데, 이중에서 trochanteric bursa, iliopsoas bursa, ischiogluteal bursa 가자주임상적으로문제가된다. 고관절주위의 bursa 는활액막과비슷한구조의막으로이루어져있으며 iliopsoas bursa 는고관절과연결되어있는경우도있다. 고관절주위일차적병변은허리와무릎관절주위통증을일 으키고, 반대로요추혹은무릎관절병변은고관절주위에통증을유발하여고관절통증진단에주의를요한다. 원인및임상양상 고관절에서통증이가장많이호소하는증상이다. 대부분세밀한병력청취및이학적검사로아래의원인들을예상해볼수있다. 1. Pain patterns 통증의위치와특징은고관절통증진단에매우중요한요소이다. 고관절을움직이거나걸을때통증이심해지고밤에쉴때통증이완화되면관절의구조에문제가발생하는관절염 (osteoarthritis) 이의심된다. 이에반해서밤에지속적인통증이발생하면염증, 감염혹은종양에대한의심을해야한다. 2. Lateral hip pain 고관절외측부위통증은고관절이일차적인문제라기보다는고관절주위힘줄 (tendon) 과윤활낭 (bursa) 가원인일가능성이높다. 고관절외측부위통증이직접적으로누를때통증이악화되면 trochanteric bursitis 를의심해볼수있으며통증의강도는약간불편함부터걷지못하고잠을못잘정도로다양하다. 고관절외측부위통증이점점심해지지고압통에악화되고걸음을걷기힘들다면대퇴골의병변을고려하고만약환자가고령이고암에대한과거력이있다면전이암혹은골절의유무를영상학적검사를이용해확인해야한다. 3. Anterior hip or groin pain 고관절전방부와사태구니의통증은고관절자체가일차적인병변일가능성이높다. 고관절염은통증이서서히나타나고고관절움직임이제한되지만, 사태구니통증이갑자기나타나고걷기가힘들고체중이실리지않으면골괴사 (osteonecrosis), 골절, 급성윤활막염 (synovitis), 폐혈성관절염 (septic arthritis) 을감별진단해야한다. 고관절앞측통증이고관절의움직임과압박에의해악화되지않으면서혜부탈장, 요추병변의연관통 (referred pain) 을의심해야한다. 82 2015 대한마취통증의학회제 92 차종합학술대회

4. Posterior hip pain 고관절뒤쪽통증의원인이일차적으로고관절인경우는매우적고오히려대부분의원인들은엉치궁둥관절 (sacroiliac joint), 요추신경병증등이다. 고관절뒤쪽통증의원인을밝히는것은매우중요하고허리질환과고관절질환을구분하기위해서세심한이학적검사영상학적검사가필요하다. 감별진단 고관절부위통증은비교적흔한증상이지만여러원인이복합된경우가많아정확한치료를위해서는정확한진단이선행되어야한다. 일반적으로관절질환 (intra-articular lesions) 과관절외질환 (extra-articular lesions) 으로크게구분하며관절질환은관절의운동범위의제한으로추측할수있고서혜부통증으로주로나타난다. 고관절외측부의통증은대전자통증증후군 (greater trochanteric pain syndrome, GTPS), 넓다리감각이상증 (meralgia paresthetica), 장경인대증후군 (iliotibial band syndrome) 이나척추질환등을생각할수있다. 고관절뒷편의통증은척추질환이나엉치궁둥관절병변, 이상근 (piriformis) 이나슬괵근 (hamstring) 증후군등을생각하여야한다. 고관절에염증성관절염이발생하면환자는야간이나쉴때통증을호소하고퇴행성변화에의한경우는체중부하또는보행으로증상이악화된다. Snap 이들리거나 click 이만져지는것은심부뼈에대해 iliopsoas tendon 이나 fascia latae 가불안정해서나타난다. 고관절의바깥쪽의 tendinitis 또는 bursitis 등의이상에의한경우는어깨의회전근개질환처럼주로환부쪽으로잘때야간통이나타나는것이주증상일수있다. Greater trochanter 부위의국소적압통은 abductor muscle tendinitis 혹은 trochanteric bursitis 를의심할수있고, 만약무릎을펴고하지를 resisted abduction 을할때 trochanter 부위에통증이나타나면 trochanteric bursitis 보다 gluteus medius tendinophy 의가능성이더높다. 단순방사선사진으로고관절의뼈, 고관절, 엉치궁둥관절, 치골결합뿐아니라관절주위의석회침착을관찰할수있고 oblique view 가포함되도록검사하는것이좋다. 초음파는관절이나관절주위연부조직의병변확인이가능하고진단과동시에치료가가능하여최근에많이이용되고있다. 성인의고관절은연골성분이적고연부조직이두꺼워초음 파의흡수나산란이일어나서해상력이떨어지므로적응증이어깨처럼많지않다. 초음파는임상적으로고관절의외상, 관절액삼출, 윤활낭염, 종괴, 고관절치환후합병증, 근육파열, 힘줄염등의진단및치료에이용된다. 고관절에서초음파로주로검사하는부위를 Table 2 에정리하였다. 치료 국소마취제, 스테로이드, 히알루론산등의고관절내주사는고관절통증을경감시키는효과적인방법이다. 국소마취제고관절내주사는일시적으로통증을감소시켜통증위치를확인하고관절내병변의원인을규명하는데도움을주고스테로이드관절내주사는염증을감소시켜통증을줄인다. 히알루론산점성보충 (viscosupplementation) 은관절을부드럽게하고통증을감소시켜관절치환술을지연시키는장점이있다. 고관절은깊숙히위치하여고관절내주사가어렵고정확하지않으며, 신경혈관다발이가까이위치하여신경과혈관손상의위험이있다. 고관절전방에서주사하는것은대퇴신경의손상에주의하여야한다. Blind technique 은성공률은 50-80% 로보고되 Table 2. Main Structures for Hip Ultrasonography Location Structures Anterior Anterior joint recess Anterior thigh muscles and tendons Femoral nerve and vessels Anterior labrum Medial Iliopsoas tendon Adductor muscles Lateral Greater Trochanter Gltues minimus tendon Gluteus medius tendons Iliotibial band Posterior Ischial tuberosity Hamstring tendons Sciatic nerve Table 1. Causes of Pain Around the Hip joints Intra-Articular Extra-Articular Hip mimickers Laberal tears Iliopsoas tendinitis Athletic pubalgia Loose bodies Iliotibial band Sports hernia Femoroacetabular impingement Gluteus medius or minimus Osteitis pubis Capsular laxity Greater trochanter bursitis Ligamentum teres ruptures Stress fracture chondral damage Adductor strain Piriformis syndrome Sacroiliac joint pathology 83

Bedside to Evidence, Evidence to Bedside Fig. 2. Hip joint effusion. Ultrasound image shows anechoic anterior joint recess distension (arrowheads). The KorEan Society of AnesthesioLOgists Fig. 1. Anterior hip joint recess. (A), A sagittal oblique illustration through femoral head and neck. (B), An ultrasound image show the anterior layer of the joint capsule (arrows and the posterior layer (arrowheads). H, femoral head; N, femoral neck (Adaded from Fundamentals of Musculoskeletal Ultrasound. 2 nd edition). 며, 시술자와시술방법에따른차이가크다. 이러한이유로고관절치료에서영상유도장치가필요하다. 방사선투시장치를이용한고관절내주사는방사선에노출되는위험이있고, 연부조직과신경혈관구조물을확인할수없는단점이있다. 초음파는가볍고이동이쉽고, 방사선에노출이없는장점으로근골격계질환을진단하는역할을넘어치료를위한도구로사용되고있다. 1. Ultrasound-guided hip intra-articular injection 초음파유도고관절내주사는 anterior longitudinal approach 방법이선호되며환자를바로누운자세에서고관절을신전하고약간외전시킨후무릎아래에베개를받쳐고관절을이완시켜환자를편안하게하여시행한다. 선형배열탐촉자 (linear array transducer) 는표면의신경혈관구조물을확인하여고관절내주사시신경혈관손상을피하는데적합하지만, 비만한사람에게는투과력이높은저주파수의곡선형탐촉자 (curvilinear transducer) 가사용된다. 전상장골극 (anterior superior iliac spine) 과치골돌기 (pubic tubercle) 를잇는선상중간에서서혜부주름 (inguinal crease) 에걸쳐탐촉자 (probe) 를두고위아래로검사하며고관절은대퇴경부위에서장축 (longitudinal) 및 transverse oblique plane 으로가장잘관찰된다. 전방고관절관절낭에해당되는전방활막함입 (anterior synovial recess) 은장요근의심근막과대퇴경부의사이의공간이 Fig. 3. The needle can be seen entering the joint capsule at the base of the femoral head (Adaded from Arthroscopy. 2014 Jan;30(1):42-6). 며, 고관절내삼출액이없는경우납작해져두층의고에코선으로만관찰되고 (Fig. 1), 만약관절내삼출이있으면두에코선이벌어지고, 그사이저에코음영이확장되어나타난다 (Fig. 2). 베타딘혹은클로르헥시딘글루코네이트 (chlorhexidine gluconate) 으로소독한후, 탐촉자는소독비닐로감싸고, 소독젤을이용하여감염을위험을없애는것이중요하다. 고관절내주사는골두 (femoral head) 와대퇴경부 (femoral neck) 가만나는전방활막함입 (anterior synovial recess) 을목표점으로하기때문에충분한길이의바늘 (7-10 cm) 을사용하는것이필요하다 (Fig. 3). 치료를위한관절내주사용액은 10-15 ml 이고, MRI 혹은 CT 관절조영술을위한용액은 10-12 ml 이다. 2. Ultrasounded guided injection of the iliopsoas bursa Iliopsoas bursa 는 tendon 과관절낭사이에있으며근육의수축혹은관절의운동시 tendon 의마찰을줄이는것이고정상인에서는납작해져관찰할수없다. Iliopsoas bursitis 는고관절의통증과더불어대퇴신경의압박증상이있을수있으며정확한진단이중요하다. Iliopsoas bursa 는고관절과연결되어있고, 관절의삼출액이많은경우 bursa 내로관절액이저류되고, 내측의대퇴 84 2015 대한마취통증의학회제 92 차종합학술대회

혈관과외측의 iliopsoas muscle 사이에무에코의 iliopsoas bursa 를확인할수있다. Iliopsoas bursa 는대퇴신경혈관과인접하기때문에고관절위에서 transverse plane 으로인접구조물과 bursa 를확인한다. Probe 에평행이되도록대퇴부외측에서내측으로바늘을진입하고, bursa 내에바늘끝이위치하면국소마취제와스테로이드혼합액을주사한다. 3. Ultrasound guided injection of the greater trochanteric bursa Trochanter 부위의 bursitis 또는 tendinopathy 는고관절외측부위통증의주요원인이며, 임상소견으로구분하기어려우므로대전자부통증증후군 (greater trochanteric pain syndrome, GTPS) 으로부른다. 고관절의운동제한은없고환측으로눕거나또는체중을부하할때통증이나타난다. GTPS 에서초음파는고관절의회전근개파열이라고도불리는 gluteus medius 와 gluteus minimus 의 tendon 을검사는데매우유용하다. Tendinopathy 환자의대부분은 gluteus medius 앞쪽과뒤쪽에서비정상적인소견으로보이고 trochanteric bursa 내의 effusion 이동반될수있다. Trochanteric bursa 의이상소견은윤곽이뚜렷한초승달모양의저에코혹은무에코가 gluteus medius 의 tendon 의뒤쪽부착부의표층, 대전자의외측면, gluteus maximus 아래층에서보인다. 초음파유도로 bursa 내에또는이환된 tendon 가까이에국소마취제나스테로이드를 ( 예 ; 0.5% bupivacaine 3-5 ml + triamcinolone 10-40 mg) 주사하여치료할수있다. 참고문헌 1. Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd, WB Saunders, Philadelphia 1999. 2. Christmas C, Crespo CJ, Franckowiak SC, et al. How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey. J Fam Pract 2002; 51:345. 3. Bianchi S, Martinoli C. Ultrasound of the musculoskeletal system. Heidelberg, Springer. 2007, pp 551-610. 4. Shankar H, Simhan S. Ultrasound guided hip injections. In: Atlas of ultrasound-guided procedures in interventional pain management. Edited by Narouze SN. New York, Springer. 2011, pp 325-30. 5. Petterson JJ. Image-guided musculoskeletal intervention. Philadephia, Saunders Elsevier. 2008, pp 85-109. 6. Jacobson JA, Fundmental of musculoskeletal ultrasound. 2nd edition. Philadephia, Saunders Elsevier. 2013, pp 162-211. 7. Rowbotham EL, Grainger AJ. Ultrasound-guided intervention around the hip joint. AJR Am J Roentgenol 2011;197:W122-7. 8. Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy 2008;24:1407-21. 9. Freeman K, Dewitz A, Baker WE. Ultrasound-guided hip arthrocentesis in the ED. Am J Emerg Med 2007;25:80-6. 10. Lavelle W, Lavelle ED, Lavelle L. Intra-articular injections. Med Clin North Am 2007;91:241-50. 11. Strauss EJ, Nho SJ, Kelly BT. Greater trochanteric pain syndrome. Sports Med Arthrosc 2010;18:113-9. 12. Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain syndrome: a systematic review. Br Med Bull 2011. 13. Masala S, Fiori R, Bartolucci DA, Mammucari M, Angelopoulos G, Massari F et al. Diagnostic and therapeutic joint injections. Semin Intervent Radiol 2010;27:160-71. 14. Graif M. Ultrasound of the hip. Eur J Ultrasound 2001;14:35-43. 15. Nam WD, Nam SW, Han KY. Ultrasonographic Findings of Normal Hip Joint and Painful Hip due to Soft Tissue Problem. J Korean Orthop US Soc 2010;3: 38-46. 16. Atchia I, Kane D, Reed MR, Isaacs JD, Birrell F. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011;70:110-6. 17. El-Husseiny M, Patel S, Rayan F, Haddad F. Gluteus medius tears: an under-diagnosed pathology. Br J Hosp Med (Lond) 2011;72:12-6. 18. Byrd JW, Potts EA, Allison RK, Jones KS.Ultrasound-guided hip injections: a comparative study with fluoroscopy-guided injections. Arthroscopy. 2014 Jan;30(1):42-6. 85

Bedside to Evidence, Evidence to Bedside 흔한 관절질환 치료 Knee Joint 김웅모 전남대학교 의과대학 마취통증의학교실 Functional anatomy of the knee The KorEan Society of AnesthesioLOgists For accurate diagnosis and treatment of knee pain, the clinician must have a clear understanding of the functional anatomy of the knee. The knee is not just a simple hinge joint that flexes and extends. The largest joint in the body in terms of articular surface and joint volume, the knee is capable of amazingly complex movements that encompass highly coordinated flexion and extension. The knee joint is best thought of as a cam capable of locking in a stable position. Even the simplest movements of the knee involve an elegantly coordinated rolling and gliding movement of the femur on the tibia. Because of the complex nature of these movements, the knee is extremely susceptible to functional abnormalities with relatively minor alterations in the anatomy from arthritis or damage to the cartilage or ligaments. Although both clinicians and laypersons think of the knee Fig. 1. Anterior & posterior aspect of knee. Fig. 2. Medial & lateral aspect of knee. 86 2015 대한마취통증의학회 제92차 종합학술대회

joint as a single joint, from the viewpoint of understanding its functional anatomy, it is more helpful to think of the knee as two separate but interrelated joints: the femoral-tibial and the femoral-patellar joints. Both joints share a common synovial cavity, and dysfunction of one joint can easily affect the function of the other. The femoral-tibial joint is made up of the articulation of the femur and the tibia. Interposed between the two bones are two fibrocartilaginous structures known as the medial and lateral menisci. The menisci serve to help transmit the forces placed on the femur across the joint onto the tibia. They possess the property of plasticity in that they are able to change their shape in response to the variable forces placed on the joint through its complex range of motion. The medial and lateral menisci are relatively avascular and receive the bulk of their nourishment from the synovial fluid, which means that little potential for healing exists when these important structures are traumatized. The femoral-patellar joint's primary function is to use the patella, which is a large sesamoid bone embedded in the quadriceps tendon, to improve the mechanical advantage of the quadriceps muscle. The medial and lateral articular surfaces of the sesamoid interface with the articular groove of the femur. In extension, only the superior pole of the patella is in contact with the articular surface of the femur. As the knee flexes, the patella is drawn superiorly into the trochlear groove of the femur. Most of the knee joint's stability comes from the ligaments and muscles surrounding it, with little contribution from the bony elements. The main ligaments of the knee are the anterior and posterior cruciate ligaments, which provide much of the anteroposterior stability of the knee, and the medial and lateral collateral ligaments, which provide much of the valgus and varus stability. All of these ligaments also help prevent excessive rotation of the tibia in either direction. A number of secondary ligaments also add further stability to this inherently unstable joint. The main extensor of the knee is the quadriceps muscle, which attaches to the patella via the quadriceps tendon. Fibrotendinous expansions of the vastus medialis and vastus lateralis insert into the sides of the patella and are subject to strain and sprain. The hamstrings are the main flexors of the hip, along with help from the gastrocnemius, sartorius, and gracilis muscles. Medial rotation of the flexed knee is via the medial hamstring muscle, and lateral rotation of the knee is controlled by the biceps femoris Table 1. Classification of Painful Conditions That Affect the Knee Localized Bony or Joint Space Pathology Systemic Disease Fracture Rheumatoid arthritis Primary bone tumor Collagen vascular disease Primary synovial tissue tumor Reiter's syndrome Joint instability Gout Localized arthritis Other crystal arthropathies Osteophyte formation Charcot's neuropathic arthritis Joint space infection Hemarthrosis Sympathetically Mediated Pain Villonodular synovitis Causalgia Intra-articular foreign body Reflex sympathetic dystrophy Osgood-Schlatter disease Chronic dislocation of the patella From Other Body Areas Patellofemoral pain syndrome Lumbar plexopathy Patella alta Lumbar radiculopathy Lumbar spondylosis Periarticular Pathology Fibromyalgia Bursitis Myofascial pain syndromes Tendinitis Inguinal hernia Adhesive capsulitis Entrapment neuropathies Joint instability Intrapelvic tumors Muscle strain Retroperitoneal tumors Muscle sprain Periarticular infection not involving joint space 87

Bedside to Evidence, Evidence to Bedside muscle. The knee is well endowed with a variety of bursa to facilitate movement. Bursae are formed from synovial sacs whose purpose it is to allow easy sliding of muscles and tendons across one another at areas of repeated movement. These synovial sacs are lined with a synovial membrane that is invested with a network of blood vessels that secrete synovial fluid. Inflammation of the bursa results in an increase in the production of synovial fluid with swelling of the bursal sac. With overuse or misuse, these bursae may become inflamed, enlarged, and, on rare occasions, infected. Given that the knee shares a common synovial cavity, inflammation of one bursa can cause significant dysfunction and pain of the entire knee. Diagnosis of knee pain 1. Common painful conditions of the knee helpful. Although no classification of knee pain and dysfunction can be all inclusive or all exclusive because of the frequently overlapping and multifactorial nature of knee pathology, Table 1, 2 should help improve the diagnostic accuracy of the clinician confronted with the patient with knee pain and dysfunction and help the clinician avoid overlooking less common diagnoses. The list of disease processes in Table 1, 2 are by no means comprehensive, but it does aid the clinician in organizing the potential sources of pathology that manifest as knee pain and dysfunction. The most commonly missed categories of knee pain and the categories that most often result in misadventures in diagnosis and treatment are the last three categories. The knowledge of this potential pitfall should help the clinician keep these sometimes overlooked causes of knee pain and dysfunction in the differential diagnosis. 2. Approach to diagnosis The KorEan Society of AnesthesioLOgists The initial general physical examination of the knee guides the clinician in narrowing his or her differential diagnosis and helps suggest which specialized physical examination maneuvers and laboratory and radiographic testing will aid in confirming the cause of the patient's knee pain and dysfunction. For the clinician to make best use of the initial information gleaned from the general physical examination of the knee, a grouping of the common causes of knee pain and dysfunction is exceedingly A careful history is imperative for the accurate diagnosis of knee pain. The history should not be limited to the knee, because an evaluation of the hip and back may reveal patterns of referred pain. A review of systems should be performed, looking for systemic illness such as Lyme disease, lupus, and rheumatoid arthritis, as well as a sexual history for gonococcal arthritis. The temporal nature of the pain should be established. The pain may be either acute or chronic in nature. If acute, an injury should be suspected. Table 2. Common Causes of Knee Pain in Different Age Groups Cause Cause Intra-articular Periarticular Referred Childhood Juvenile chronic arthritis Osteomyelitis Perthes' disease (2-10 yrs) Osteochondritis dissecans Transient synovitis of the hip Septic arthritis Torn discoid lateral meniscus Adolescence Osteochondritis dissecans Osgood-Schlatter disease Slipped upper femoral (10-18 yrs) Torn meniscus Sinding-Larsen-Johansson disease epiphysis Anterior knee pain syndrome Osteomyelitis Patellar malalignment Tumors Early adulthood Torn meniscus Overuse syndromes Rare (18-30 yrs) Instability Bursitis Anterior knee pain syndrome Inflammatory conditions Adulthood Degenerate meniscal tears Bursitis Degenerative hip disease (30-50yrs) Early degeneration after injury Tendinitis from hip dysplasia or injury or meniscectomy Inflammatory arthropathies Older age Osteoarthritis Bursitis Osteoarthritis of the hip ( 50 yrs) Inflammatory arthropathies Tendinitis 88 2015 대한마취통증의학회제 92 차종합학술대회

Ligament tears often present with an acute hemarthrosis and instability that inhibit continued activity. If the pain is chronic, the initial onset of symptoms and cause of the pain should be investigated. An increase in activity levels, such as exercise or climbing stairs, can often lead to chronic patellofemoral pain. The location of the pain as well as specific complaints such as swelling, locking, giving out, instability, numbness, weakness, and pain should be determined. Meniscus pain is often localized at the joint line and may give a locking sensation to the knee. The physical examination begins with observation of the patient s gait and resting position. If the patient sits with the knee joint in extension, there may be an effusion. On inspection, the alignment of the knee should be noted, with 8 o to 12 o of a valgus Q-angle considered normal. The Q-angle is defined as the angle formed by a line drawn from the anterior superior iliac spine or top of the hip to the central patella and a second line drawn from the central patella to the tibial tubercle. Q-angles greater than 20 o increase the likelihood of patellofemoral pain syndromes. The patella should face anteriorly and both should be at the same level bilaterally. A medially positioned patella is associated with patellofemoral pain syndromes, as is atrophy of the vastus medialis oblique. Therefore, these pain syndromes warrant careful inspection of the quadriceps. The clinician should also inspect for an effusion, marked by the loss of soft tissue dimples at the knee. An enlargement of the insertion of the patellar tendon in adolescents may indicate Osgood-Schlatter disease. An inability to fully extend the knee indicates an intra-articular pathology such as meniscus tear, arthritis, loose body, or large effusion. Inability to walk in a squatting position, or a duck walk, may be due to a meniscal tear. Palpation of the knee can demonstrate an effusion as well as localize the pain symptoms. With a large effusion, a floating patella can be felt. Palpation for tenderness can help define the pathology. Pain on palpation of the superior pole of the patella is seen with quadriceps tendinitis. Prepatellar bursitis presents with warmth, erythema, and swelling upon palpation of the anterior patella. Tenderness over the medial or lateral retinaculum or medial and lateral facets of the patella is seen with patellar subluxation and patellofemoral pain syndrome. The patella should be checked for intrinsic stability by gently pushing it medially and laterally. Subluxation of more than 50% of the patella s width is abnormal. Tenderness on palpation of the joint line is indicative of a meniscal injury. Palpation of the medial and lateral aspect of the knee may illicit pain in a damaged MCL or LCL. The pes anserine complex should be palpated for tenderness from tendinitis or bursitis. The iliotibial band should be followed from the lateral thigh and knee to its insertion on the anterolateral aspect of the tibia. The Ober test can demonstrate iliotibial band tightness. With the patient in the lateral decubitus position with the painful knee up, the leg should be abducted as far as possible and then flexed at the knee to 90 o. The symptomatic leg is then released into adduction. If the iliotibial band is contracted, the thigh will remain in the abducted position when the leg is released. Palpation of the posterior aspect of the knee may demonstrate a popliteal, or Baker, cyst. The posterior tibial pulse should be palpated to rule out vascular damage in the event of multiplanar instability. Stability testing should be performed in the mediolateral, anteroposterior, and rotational planes. To test MCL stability, gentle valgus force is applied to the joint line in full extension and at 30 o of flexion. If there is instability in full extension, the MCL is likely torn. If there is instability at 30 o of flexion, a partial injury to the MCL is more likely. Applying varus forces to the extended and the 30 o flexed knee will evaluate the stability of the LCL. To assess the ACL and PCL, the anterior and posterior drawer tests are performed. With the knee flexed 90 o and the patient s foot neutrally aligned on the table, the knee is grasped and the tibia is pulled forward for the anterior drawer test and pushed posterior for the posterior drawer test. The amount of displacement as well as the character of the end-point are assessed. Lack of a clear end-point and increased displacement in comparison with the patient s other knee indicate damage to the ACL or PCL. In addition, the Lachman test may be performed for assessment of the ACL. The Lachman test is performed with the knee flexed to 20 o and the examiner stabilizing the thigh above the patella with one hand while grasping the proximal tibia in the other, pulling the tibia forward. Excessive displacement and lack of a clear endpoint are signs of an incompetent ACL. Rotational stability can be assessed by repeating the drawer tests with the foot rotated internally or externally. This allows testing of the secondary stabilizers of the knee as the lateral structures of the knee are tightened with internal rotation and the medial structures of the knee are tightened with external rotation of the foot. The provocation test for meniscus injury is the McMurray test. The McMurray test is performed with the knee in full flexion, and internal and external rotational forces are applied. The knee is then fully extended. A positive test is indicated by joint line pain or palpable click. Radiographic evaluation of the knee is almost always required to evaluate complaints of knee pain. A standing anteroposterior view of bilateral knees with a lateral view of the affected knee will elucidate most pathologies, including fractures, loose bodies, arthritis, osteochondritis dessicans, and chondrocalcinosis. When an ACL injury is suspected, a tunnel view may be useful to show small bone chips from the tibial spine. Sunrise views of the patella are helpful in the evaluation of patellofemoral tracking and subluxation. Evaluation of intra-articular soft tissue injuries, such as meniscus injuries or ACL and PCL injuries, can be visualized with magnetic resonance imaging (MRI). An MRI or a bone scan can confirm epiphyseal injuries, avascular necrosis lesions, stress fractures, and early osteochondritis. An arteriogram should be 89

Bedside to Evidence, Evidence to Bedside Table 3. Synovial Fluid Properties Appearance Viscosity Cells/mm 3 % PMNs Crystals Normal Transparent High <180 <10% None Osteoarthritis Transparent High 200-2,000 <10% None Rheumatoid arthritis Translucent Low 2,000-50,000 Variable None Psoriatic arthritis Translucent Low 2,000-50,000 Variable None Reactive arthritis Translucent Low 2,000-50,000 Variable None Gout Translucent to cloudy Low 2,000-50,000 >90% Needle-like - birefringence Pseudogout Translucent to cloudy Low 2,000-50,000 >90% Rhomboid-like + birefringence Septic arthritis Cloudy Variable 2,000-50,000+ >90% None Hemarthrosis Red Low 2,000-50,000 <10% None The KorEan Society of AnesthesioLOgists done in an acutely injured knee with multiplanar instability to access the competency of the vasculature. Knees with effusions should be aspirated and synovial fluid analyzed. Aspiration with an 18-gauge needle through the medial or lateral patellar retinaculum is easily performed. With the knee extended, the patella should be pressed into the trochlear groove and gently tapped. When a large effusion is present, the patella should bounce back. For a smaller effusion, the medial side of the patellar tendon can be milked; then the lateral retinaculum should be tapped while palpating for a fluid wave on the medial side. The fluid should be examined for crystals from gout or pseudogout. A cell count and differential as well as routine (Table 3) and gonococcal cultures should be done. Treatment Initial treatment of the pain and functional disability associated with arthritis of the knee should include a combination of the nonsteroidal anti-inflammatory agents or cyclooxygenase-2 inhibitors and physical therapy. The local application of heat and cold may also be beneficial. For patients who do not respond to these treatment modalities, an intra-articular injection of local anesthetic and steroid may be a reasonable next step 1. Intraarticular injection As a subcutaneous joint, the knee is relatively easy to aspirate through a medial retropatellar, lateral retropatellar, suprapatellar, or anterior approach. With the knee in extension, fluid accumulates in the suprapatellar pouch, where it can be aspirated. The knee should be placed into a comfortable position of extension before beginning. It is important that the patient be relaxed and not actively contracting the quadriceps muscle. Medially, the bulk of the medial quadriceps should be avoided, because transmuscular needle insertion is painful and can cause excessive bleeding and bruising. For the medial retropatellar approach, the needle is inserted below the vastus medialis bulk, between the medial femoral condyle and the midpoint of the patella. Directing the needle cephalad safely places it into the suprapatellar pouch with minimal risk of injuring the patellar or femoral cartilage. Many clinicians prefer the lateral retropatellar approach, because there is no muscle bulk to contend with: A 21 gauge needle is inserted laterally at the junction of the middle and upper thirds of the patella, midway between the patella and the femoral condyle. If a large effusion is present, the needle is directed medially at 90 o to the femur to access the suprapatellar pouch. If there is less fluid, the needle may need to be directed inferiorly and medially to enter the patellofemoral joint before fluid is encountered. Care should be taken to minimize trauma to the cartilage of the patella and femoral condyle by advancing the needle gently between the bone surfaces and redirecting it carefully if bone is encountered before fluid can be aspirated. A suprapatellar approach is indicated if there is a very large effusion expanding the suprapatellar pouch. The needle is introduced into the suprapatellar pouch, above and just lateral to the patella. In the anterior approach, direct access to the medial or lateral tibiofemoral joint can be obtained with the patient in a seated position and the knee flexed 90 o, preferably with the leg hanging over the end of the examining table to distract the joint by gravity as much as possible. The needle is inserted about one finger s breadth above the joint line and one finger s breadth lateral or medial to the patellar ligament. The needle is directed posteriorly and parallel to the line of the tibial plateau toward the midline, aiming for an imaginary point between the inferior aspects of the femoral condyles. The anterior approach is particularly indicated for patients with fixed kneeflexion deformity. 2. Bursal injection The prepatellar, deep infrapatellar, and anserine bursae can be aspirated and injected by placing the needle into the area of maximal fluctuance. Chronic bursitis can result in bursal loculation, which may preclude complete aspiration of fluid. The 90 2015 대한마취통증의학회제 92 차종합학술대회

prepatellar bursa is injected at the center of maximal fluctuance, usually over the lower part of the patella, with the needle at a 30 o angle. The deep infrapatellar bursa can be entered through a medial or lateral approach deep to the patellar ligament, proximal to its insertion into the tibial tuberosity. The anserine bursa is located over the anteromedial surface of the proximal tibia at the level of the tibial tuberosity. The needle is inserted into the area of maximal tenderness and fluctuance. A swollen popliteal bursa (cyst) is almost always caused by knee effusion with a communicating, fluid-distended medial gastrocnemiussemimembranosus bursa. Appropriate management consists of joint aspiration and treatment of the underlying knee pathology; direct aspiration or injection of a popliteal cyst is not recommended. In the iliotibial band friction syndrome, the most tender site over the lateral epicondyle, where the band slips over backward and forward during knee flexion and extension, is injected. 91

Bedside to Evidence, Evidence to Bedside 흔한관절질환치료 척추관절 서정훈 울산대학교의과대학서울아산병원마취통증의학과 The KorEan Society of AnesthesioLOgists 척추관절장애 척추관련통증은가장흔한통증질환중하나이며, 이중추간관절 (facet joint) 에의한통증도상당한유병률을가지는것으로알려져있다. 이러한추간관절관련질환에대해그병인이나기전, 진단법, 치료법등에대해상당히많은연구들이이루어졌다. 이모든부분에대해이번기회에모두언급할수없으므로최근 2-3 년간발표된여러문헌들의소개를중심으로설명하고자한다. 또한척추관절장애가경, 흉, 요추모두에서발생할수있으나흉추에있어서는흔하게발생하지않고, 그치료효과또한근거가높지않으므로경추와요추에대해다루도록하겠다. 추간관절은디스크와함께소위 three-joint complex 를형성한다. 이관절은척추를지지하고안정화하는역할을하며, 모든방향으로의동작을제한함으로써손상으로부터방지하는역할을한다. 추간관절의위치는부위에따라시상면과관상면에대해다른각도를가지게되는데, 이에따라각각서로다른과도한동작에대해보호하는기능을가지게된다. 경, 흉, 요추가모두다른각도를가짐을물론요추내에서도상부요추와하부요추사이의각도가다른것을볼수있다. 추간관절의신경지배는후지의내측지에의해이루어지며, 내측지의척수신경후지의가장큰분지로추간관절을지배하 는뿐만이아니라 multifidus muscle, interspinous muscle and ligaments 와 neural arch 의골막 (periosteum) 을지배한다 (Figure 1). 따라서이러한내측지는추간관절질환에있어중요한치료목표로제시되고있다. 이러한추간관절의장애에있어디스크의질환이중요한원인이되는데, 앞서언급한바와같이디스크와추간관절은 three joint complex 로함께협업하는구조물이다. 따라서어느하나의구조에이상이있을경우다른구조에영향을미치게됨은예상가능한결과일것이다. 실제로 degenerative disc disorder (DDD) 가있는환자에있어 facet arthosis 가함께발생함은많은연구에서밝혀진바와같고, 이중 DDD 가대체적으로선행하는것으로보여진다. 1 이외에도외상이나염증성질환같이많은원인에의해추간관절증이발생할수있다. 추간관절에의한통증을감별하기위해서는병력, 이학적검사, 이미지소견등을이용하게된다. 가장대표적인방법이환자의연관통의범위로문제가있는추간관절을유추하는방법인데, 대략적인연관통의위치는그림 2-4 와같다. 일부저자는디스크나추간공협착이없이도추간관절의이상으로인해 radiculopathy 가발생할수있다고주장하며이를 FOAR (facet joint osteoarthritis with radiculopathy) 라지칭하였는데, 2 이는 radiculopathy 가 facet joint origin 을배제할수없는요소임을시사하는것으로볼수있겠다. 이학적검사에있어서는 facet loading 을유발하는검사보다는 Fig. 1. Schematic drawing of the spinal cord and segmental spinal innervation (From Cohen SP et al. Anesthesiology. 2007;106:591-614). Fig. 2. Pain referral patterns from the cervical facet joints (From Bogduk N et al. Spine. 1988;13:615). 92 2015 대한마취통증의학회제 92 차종합학술대회

Fig. 3. Pain referral patterns from the thoracic facet joints From Dreyfuss P et al. Spine. 1994;19:809). paraspinal muscle tenderness 가보다신뢰성있는검사로제시되고있고, 이미지검사에있어서는 CT 나 MRI 가추간관절을평가함에있어유용한검사이나최근의문헌에서는초음파의유용성에대한내용들이많이보고되고있고, 진단및치료에대한초음파의적용에대한긍정적인결과들을제시하고있다. 3-7 또한 99mTcMDP SPECT/CT 의유용성에대한문헌들이보고되었는데, 최근의문헌에서는이러한검사소견과임상양상이잘부합하지않는다는보고가있어추가적인연구가필요할것으로보인다. 8 하지만추간관절증후군이단지이미지소견만으로는진단내리기쉽지않은데, Maataoui 등에 9 의하면 facet osteoarthritis 소견과 Oswestry Disability Index 사이에유의한상관관계가관찰되지않는것을보아이미지소견과임상증상과부합할때만진단을내릴수있다. Manchikanti 등의 10 systemic review 에따르면각부위별치료의장기적인효과에대한 evidence level 은다음과같았다. 경추와요추부의 radiofrequency neurotomy 및경, 흉, 요추의내측지차단술은 level II 의근거를가지며, 요추추간관절강내주사는 level III, 경추추간관절강내주사와흉추의 radiofrequency neurotomy 는 level IV 의근거를가진다. 미국의경우추간관절과관련한시술의시행빈도가 2000 년부터 2011 년사이에급격한증가를보임을표 1 을통해알수있는데, 이는질환에대한이해도가높아지면서진단률이증가한데기인하지않나싶다. 기타치료방법으로 shockwave 를이용한경우관절강내주사를시행한그룹과비슷한정도의장기적효과를나타내는것으로보고되고있다. 11 1. Cervical facet joint 경추부의추간관절은목통증의흔한원인으로알려져있으며 Fig. 4. Pain referral patterns from the lumbar facet joints. In descending order, the most common referral patterns extend from the darkest (low back) to the lightest regions (flank and foot). The following key is listed in order of affected frequency (i.e., low back to foot). The facet levels next to each location represent the zygapophyseal joints associated with pain in each region. Low back: L5-S1, L4-5, L3-4; buttock: L5-S1, L4-5, L3-4; lateral thigh area: L5-S1, L4-5, L3-4, L2-3; posterior thigh area: L5-S1, L4-5, L3-4; greater trochanter: L5-S1, L4-5, L3-4, L2-3; groin: L5-S1, L4-5, L3-4, L2-3, L1-2; anterior thigh area: L5-S1, L4-5, L3-4; lateral lower leg area: L5-S1, L4-5, L3-4; upper back area: L3-4, L2-3, L1-2; flank: L1-2, L2-3; foot: L5-S1, L4-5 (From Cohen SP et al. Anesthesiology. 2007; 106: 591-614). whiplash injury 와연관된만성목통증환자의 54-60% 의환자에서추간관절이중요한통증의원인인것으로생각되어지고있다. 12,13 경추의추간관절증은상부의경추에서보다흔하게발생하며, 60 세이상에서높은발생빈도를보인다. 14 Facet capsular ligament 는추간관절과같은척수분절로부터유래된 proprioceptive, nociceptive mechanoreceptor 로부터신경지배를받게된다. Facet capsule 이신장되게되면구심성신경의흥분횟수가증가하게되며, 이는척수로의신경절단을증가시켜장기적으로지속되는중추성감작을일으키게된다. 이로인해통각과민과작열통등이나타나게된다. 15 Crosby 등은 15 동물실험을통해이러한통각과민을일으키는척수후각의과흥분성과 spontaneous firing 의증가는손상후 6 시간에서 24 시간이내에발생함을보고하였고, 이는손상후 1 일이내에이러한감작을방지하기위한치료가시작되어야함을시사한다고하겠다. 같은저자들이시행한동물실험에서손상후즉시시행한 intraarticular bupivacaine 주입이 facet capsule 손상이후에발생하는척수의감작을차단하는데중요한소견을보임을제시하였다. 16 다른동물실험에서도경추추간관절의 distraction injury 이후 1 일과 7 일째후근신경절에서 PGE2 receptor 인 EP2 의발현이현저 93

Bedside to Evidence, Evidence to Bedside Table 1. Utilization rates (per 100,000 Medicare recipients) of various facet joint interventions in the Medicare population from 2000 to 2011 (from Manchikanti L et al. Pain Physician 2013;16:E365-E378) The KorEan Society of AnesthesioLOgists Table 2. Accuracy statistics with 95% CI for the Clinical Decision Guides (Adapted from Schneider GM et al. Arch Phys Med Rehab 2014;95:1695-701) 히늘어남을보고하였고, 17 척수에서도손상 1 일째 IL-1α 와 PGE2 가증가됨을보고하였다. 18 경추부추간관절증의임상진단에사용되는 manual spinal examination (MSE), palpation for segmental tenderness (PST), extention-rotation (ER) test 의진단적유용성은 Table 2 에표시된바와같다. 여러검사를함께시행할수록 likelihood ratio 가증가하는것을볼수있으며, 개별검사중에서는 PST 가가장민감도, 특이도가높은검사법으로생각된다. 경추의추간관절을검사함에있어누워서시행한 MRI 는 upright lateral radiograph 에비해시상면에서의 displacement 를잘반영하지못하는수가있다. 19 따라서 degenerative spondylolisthesis 가있는환자에서는 plain radiograph 를시행하는것이도움이된다. 또한경추의 MRI 소견으로비교하였을때 symptomatic subject 에서 asymptomatic subject 에비해 facet joint space thickness 와 volume 이모두감소되어있었고, 또한중립자세에서비트는자세로변경시에그값의변화차이도역시유의한차이가있었다. 20 따라서이러한 facet joint space thickness 및 volume 에대한고려가필요할것으로보인다. 경부내측지차단술의진단적인정확도는 level II 의근거를가지며. 21 치료에있어서도내측지차단술및 RF neurotomy 는앞서언급한바와같이 level II 의근거를가진다. 10 2. Lumbar facet joint 요통은가장흔한통증질환중하나이며, 여러원인에의해발생할수있으나추간관절증은매우흔하며, 적어도 50% 이상의인구에서이환되어있는것으로보여진다. 22 94 2015 대한마취통증의학회제 92 차종합학술대회

Fig. 5. FJ arthritis and FJ orientation. On the left side, sagittally oriented FJs at L2/3 and coronally oriented FJ at L5/S1 are associated with normal FJs at the lumbar spine. The right side illustrates inversely oriented FJs with arthritic FJs at the lumbar spine, namely, coronals oriented FJs at L2/3 and sagittally oriented FJs at L5/S1. 추간관절증은고령에서흔하며, 남녀의발생빈도의차이는없는것으로보이고, 상부요추에서보다관상면으로향한 (coronally oriented) 추간관절에서좀더발생하기쉬운것으로보인다. 23 또한다른연구에서는요추 4-5 번의추간관절에서는보다시상면으로향한 (sagitally oriented) 추간관절에서관절증이잘생기는것으로보고하고있다. 24 (Figure 5) 하지만다른연구에서는이러한추간관절의각도 (orientation) 보다 facet tropism 이더중요한요소라고주장하기도한다. 25 Facet tropism 이란좌측과우측의추간관절의각도가비대칭적인것을의미한다. Finite element model 을이용한연구에서 intervertebral disc 의 degeneration 에의해 facet arthosis 의위험도가증가함이제시되었고, 26 human lumbar spine 을이용하여 nucleotomy 를시행한후 facet joint 의부하를측정하였을때현저히증가함을관찰할수있고, 제거된 nucleus 와 facet 에미치는힘과의상관관계는분명치않았다. 27 즉소량의수핵제거로도추간관절에미치는 loading 을현저히증가시킬수있다고추론할수있겠다. 또한 low grade spondylolytic spondylolisthesis 가있는젊은성인에서그렇지않은성인에비해인접부위의추간관절의퇴행성변화가유의하게증가된다는연구결과도최근보고되었다. 28 요부내측지차단술의진단적인정확도는 level I 의근거를가지며, 21 치료적인내측지차단술및 RF neurotomy 는 level II 의근거를가진다. 10 Conventional RF 뿐만이아니라내측지에대해박동성고주파술 (prf) 을시행하는것이 bupivacaine 과 steroid 를투여하는것에비해통증의감소및기능의회복에더효과적이라는보고가있어이의임상적인적용을고려해볼만하다. 29 (Figure 6) 고주파열응고술은추간관절로인한요통의치료에 gold standard 로여겨지고있는데, 기존의방법들이시술의정확성을확인하기어려운단점이존재하므로 paravertebral muscle 의 compound muscle action potentials (CMAPs) 을모니터링하면보다객관적인신경파괴의지표를얻을수있을것으로제시하였다. 30 Joo 등은고주파열응고술에효과적이었던환자에서반복적인열응고술보다알콜을사용한신경파괴술이더효과적이라고보고하여, 이러한추간관절증후군에서화학적신경파괴술의사 Fig. 6. Analysis of proportion of patients who did not require analgesics in their follow-up visits are compared in a Logrank (Cox- Meier) test which was significantly different between PRF and steroid + bupivacaine (p=0.001) Adapted from Hashemi M et al. Eur Spine J 2014;23:1927-1932. 용가능성을제시하였다. 31 RF denervation 은추관절증후군에서효과적인치료법으로인정되고있으나관절강내주사는그효과에대해아직논란이있는실정이다. 하지만 Lakemeier 등은 32 관절강내스테로이드주사가 RF denervation 과비슷한통증감소및기능적회복을가져온다고주장하였다. Deriven 등은 lumbar facet joint 의 intra-articular injection 시 superior recess 를목표지점으로하는것이쉽고성공적인방법이라고제시하여기존의방법으로접근이어려운경우대안으로제시하였다. 33 또한 Freyhardt 등은 MR-guided facet joint injection 의방법도제시하였고, 34 정확하고안전한방법이나비용적인부분에있어고려가필요할것으로생각된다. 또다른치료방법으로 MR guided focused ultrasound (MRgFUS) 는비침습적으로열에너지를전달하여악성종양들을파괴하는치료법으로이를요추부추간관절에적용할수있을것으로전망하기도하였다. 35 맺음말 최근들어급격히증가한추간관절에대한시술의빈도에서보듯이추간관절질환에대한이해도가증대되었고, 이에따라조기치료에대한근거및기존의방법과다른치료방법들에대한연구들이계속보고되고있다. 이에따라추간관절질환에대한치료방침이점차변화될것으로예상되며이의적절한적용이환자의증상개선에큰도움을줄것으로보인다. 참고문헌 1. Fujiwara A, Tamai K, Yamato M, et al. The relationship between facet joint osteoarthritis and disc degeneration of the lumbar spine: an MRI study. European spine journal : official 95

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