49 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2015; 50: 49-54 http://dx.doi.org/10.4055/jkoa.2015.50.1.49 www.jkoa.org 극상건파열을동반한극상근근육내지방종 신동주 남승오 김태은 박기홍 대구파티마병원정형외과 Intramuscular Lipoma of the Supraspinatus Muscle with Supraspinatus Tendon Partial Tear Dong-Ju Shin, M.D., Seung-Oh Nam, M.D., Tae-Eun Kim, M.D., and Ki-Hong Park, M.D. Department of Orthopedic Surgery, Daegu Fatima Hospital, Daegu, Korea Infiltrating lipoma in supraspinatus muscle on the shoulder is very rare. We performed open excision and rotator cuff repair on a patient who had infiltrating lipoma in supraspinatus muscle with partial tear of the supraspinatus tendon. We achieved a satisfactory outcome on one-year follow-up magnetic resonance imaging. We report on the case with a review of the literature. Key words: shoulder joint, supraspinatus, intramuscular lipoma, impingement syndrome, rotator cuff tear 견관절의충돌증후군은견봉전하면, 견봉쇄골관절, 오구견봉 인대로이루어지는오구견봉궁과상완골두사이를지나는연 부조직에압박이가해짐으로써견관절에병변을일으키는질환 군으로견관절동통의가장큰원인중의하나로알려져있다. 1) 충돌증후군의원인으로는견관절의불안정성, 견봉골 (os acromiale), 활액막연골종증, 쇄골단의연골종, 활액막염, 견갑하근의 석회성건염및종물등여러가지원인에의하여발생할수있으 며, 근육내지방종역시그원인이될수있다. 1-4) 견관절에서의 근육내지방종은간간이보고된바있으나극상근내지방종은 국내에서는보고된바없으며국외논문에서도 2 예만이보고될 정도로극히드물다. 3,4) 저자들은극상건의부분파열이동반된극 상근내침윤성지방종환자에대해수술적제거및회전근개의 봉합술을시행하여만족스러운결과를얻어이에대한문헌고찰 과함께보고하고자한다. Received April 27, 2014 Revised June 20, 2014 Accepted July 15, 2014 Correspondence to: Seung-Oh Nam, M.D. Department of Orthopedic Surgery, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu 701-724, Korea TEL: +82-53-940-7320 FAX: +82-53-940-7417 E-mail: nso1020@naver.com 증례보고 73세남자환자로약 1년전부터발생한우측견관절주위동통을주소로내원하였다. 환자오른손잡이로특별한외상의과거력은없었으며, 내원전까지타병원에서통증을조절하기위한진통제를복용하였으나증상호전이보이지않았고, 지속적인통증으로정밀검사를위해본원으로전원되었다. 본원내원당시이학적소견상우측견관절부의경한압통이있었으며 Jobe test에서양성소견, 충돌증후군징후양성, 거상시동통 (visual analog scales [VAS] score 8) 과전방거상 150 o, 외회전 45 o, 내회전 T8로약간의견관절운동제한및견관절건측에비하여 4등급정도의근력의약화가있었다. 단순방사선사진에서는특별한이상소견이보이지않았으나, 자기공명영상소견에서극상건의관절내부분파열과동반하여극상근내에 6.4 2.7 2.4 cm 크기의종물이상견갑와에서견봉하공간에걸쳐진위치에서관찰되었다. 종물은 T1 강조영상에서고신호강도, T2 강조영상에서중등도의신호강도를, T2 지방억제영상에서저신호강도를나타내었으며, 조영제에의한조영증강을보이지않았다 (Fig. 1). 저자들은극상건관절내부분파열을동반한극상근내지방종으로진단하고수술적치료를시행하였다. 지방종의절제생검및관절경하회전근개봉합술을시행하기로하였다. 수술은전신마취하측 The Journal of the Korean Orthopaedic Association Volume 50 Number 1 2015 Copyright 2015 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
50 Dong-Ju Shin, et al Figure 1. Coronal section on T1 shows the lipoma (A), sagittal section on T1 shows the lipoma (B), coronal section on T2 fat suppression image shows the lipoma (C). (D) Coronal section on T2 fat suppression image shows the supraspinatus muscle tendon parial tear. Figure 2. (A) Intraoperative photograph shows the lipoma. (B) Gross photograph shows the lipoma. 와위자세에서견갑극에평행한피부절개창을통하여접근하였으며승모근을견갑극에서분리한후극상근을노출시켰다. 극상근을근육의결방향으로무딘박리를하여지방종괴를노출시켰으며비교적근육과의경계가불명확하여근육조직을일부포함하여제거하였다 (Fig. 2). 하지만종물은견봉하공간까지확장되어있었으므로이에대한접근에제한이있어이부위에대해서는관절경을이용하여최대한제거하였다. 이와동시에극상건의 관절측부분파열에대해서도봉합나사못을이용하여경건봉합을시행하였다 (Fig. 3). 수술 2일째부터수동적관절운동을시행하였고 6주간의외전보조기를착용하였다. 종물에대한병리조직학적검사에서성숙된지방세포로이루어진근육내침윤성지방종으로판명되었으며 (Fig. 4), 수술후 1년째추시에서통증은호전되었고 (VAS score 1), 전방거상 150 o, 외회전 45 o, 내회전 T8로견관절의운동범위는술전과비슷하였으나근력은정상으로회
51 Intramuscular Lipoma of the Supraspinatus Muscle with Supraspinatus Tendon Partial Tear Figure 3. (A) Arthroscopic photography shows the lipoma. (B) Arthroscopic photography shows that the lipomas was removed from the supraspinatus muscle. (C) Arthroscopic photography shows the supraspinatus tendon tear. (D) Arthroscopic photography shows that a foot print of the supraspinatus. (E) A torn cuff was repaired by the transcuff method. 되었으나개방성접근과관절경하접근이모두쉽지않았던견봉 쇄골관절아래의내측부에서일부남아있는소견이관찰되었다 (Fig. 5). 고찰 Figure 4. Histologic examination of a representative section of the mass shows a infiltrating lipoma characterized by mature adipocytes with muscle tissue (H&E, 40). 복되었고, Jobe test 에서음성소견, 충돌증후군징후음성소견 을보였다. 술후 1 년의추시자기공명영상에서봉합한극상건은 잘치유되었고, 극상근내지방종은상견갑와에서는완전히제거 지방종은성숙지방세포로이루어진종양으로양성간엽종양중가장많이발생한다. 특히비만환자에서잘발생하며발생원인및과정에대해서아직정확히알려져있지않다. 5) 지방종은지방이존재하는신체부위어디에서든발생가능한것으로알려져있으며, 주로피하층에발생하나드물게근육사이, 근육내, 골막, 골간막구조물에발생하기도한다. 그중에서근육내지방종은상하지의골격근, 그중에서도심부근육내에잘발생하며, 천천히자라고통증이없는것이일반적인특징이다. 6) 그러나드문경우에서빠른성장을보이거나근육의기능장애를일으키고신경압박으로신경학적증상을유발하기도한다. 7) 견관절에서극상근내근육내지방종은굉장히드물며, 국내에서는아직보고된바가없으며, 국외에서도 2예만이보고되어있다. 3,4) 국내에서는 Oh 등 7) 이견관절에서극관절와절흔근위부에지방종으로인한
52 Dong-Ju Shin, et al Figure 5. (A) Follow-up magnetic resonance imaging (MRI) (postoperative one-year later) coronal section shows that remaining lipoma tissue (arrow). (B) Follow-up MRI (postoperative one-year later), sagittal section shows that remaining lipoma tissue. (C) Follow-up MRI (postoperative one-year later) coronal section shows that rotator cuff was repaired. 상견갑신경하방분지의마비를보고한바있으나근육내지방종은아니었다. Ferrari 등 4) 이극상근의근육내지방종에의한견관절의충돌증후군을최초로보고하였는데비교적경계가명확하였고주로상견갑와에위치하여개방성절제술로치유하여좋은결과를보고하였다. 같은해 Egea Martínez와 Mena 3) 가주로견봉하에위치한극상근내지방종을보고하였고관절경을통하여절제하여만족스러운결과를얻었다고하였다. 본증례에환자의임상증상이앞서제시된증례처럼종물로발생한충돌증후군에의한것인지극상건의부분파열에의한것인지명확히구분할수는없겠으나두질환의이학적검사소견은모두양성소견이었다. 근력의약화는명확하지는않으나극상건의부분파열로인한통증으로인한근력의약화도있을수있으며지방종에의한근육이상으로인해근력의약화가발생할수있을것이다. 견관절의극상근내지방종에의한충돌증후군은종양으로인한증상이경미하며, 이학적검사상특이소견을발견하기가쉽지않고, 심부근육의경우만져지는종물을발견하기가어려울뿐아니라, 단순방사선상이상소견을발견할수없는경우가많아진단하기어렵다. 4) 또한회전근개질환의진단에흔히사용되는초음파로도위치상견봉과쇄골에의해가려져있어발견하기어렵다. 4) 자기공명영상은인접신경, 혈관, 골피질및연부조직, 회전근개와의관계도알수있을뿐아니라지방억제영상에서저신호강도를보이는특징을이용하여진단의정확성을높일수있어치료방침설정에중요하다. 8) 또한근육내침윤성지방종은지방육종 (liposarcoma), 양성지방모세포종증 (benign lipoblastomatosis), 근육내점액종 (intramuscular myxoma), 동면종 (hibernoma) 과방추상세포지방종 (spindle cell lipoma) 등과의감별을위해술전자기공명영상검사가반드시필요하다. 5) 자기공명영상검사에서지방종은 T1 강조영상에서고신호, T2 강조영상에서중등도혹은고신호를보이며, 종양의피질골부착부가 조영증가되거나, 지방종내에저신호의중격이보이는경우도있다. 8) 본증례에서도견관절의회전근개파열을동반한지방종으로회전근개파열의진단을위해시행한자기공명영상검사를통하여지방종을진단할수있었으며, 지방종의제거를추시자기공명영상검사를통하여확인할수있었다. 견관절의충돌증후군의치료방법으로는보존적치료와수술적치료가있으며대부분의경우보존적치료로잘치료된다. 9) 하지만극상근내지방종에의한충돌증후군의경우보존적치료에대한문헌보고는없었으며, 근육내침윤성지방종의경우침윤성으로인해잘분화된지방육종과의감별이어렵고, 악성변화의가능성이있기때문에발견즉시반드시제거해야한다. 8) Ferrari 등 4) 과 Egea Martínez와 Mena 3) 의수술적치료후각각수년후및 2년후의임상적설문에서결과는만족스러웠으나종물의제거범위나재발에대한방사선학적추시는이뤄지지않았다. 본증례의경우 1년추시의자기공명영상검사를시행하였는데견봉쇄골관절아래의내측부에서일부남아있는지방종조직을확인할수있었다. 이부위는개방적접근시견봉과쇄골에의해도달이쉽지않았고, 관절경적방법으로외측에서접근하여도깊은위치이기때문에도달이쉽지않아절제가충분히이루어지지못하였던것으로추정한다. 하지만좋은임상적결과를얻었으며, 충분하지못한절제가임상적결과에영향을끼치지는않았고, 향후이종물에대해서재발과악성변화에대하여지속적으로추시해나갈계획이다. 본증례는이학적검사상충돌증후군및회전근개파열이의심되는환자에서시행한자기공명영상검사로극상근의지방종과회전근개의파열을발견할수있었으며지방종의수술적제거와회전근개의봉합을통하여만족스러운임상적결과를얻을수있었다.
53 Intramuscular Lipoma of the Supraspinatus Muscle with Supraspinatus Tendon Partial Tear CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Neer CS 2nd. Impingement lesions. Clin Orthop Relat Res. 1983;173:70-7. 2. Relwani J, Ogufere W, Orakwe S. Subacromial lipoma causing impingement syndrome of the shoulder: a case report. J Shoulder Elbow Surg. 2003;12:202-3. 3. Egea Martínez JM, Mena JF. Lipoma of the supraspinatus muscle causing impingement syndrome: a case report. J Shoulder Elbow Surg. 2009;18:e3-5. 4. Ferrari L, Haynes P, Mack J, DiFelice GS. Intramuscular lipoma of the supraspinatus causing impingement syndrome. Orthopedics. 2009;32. pii: orthosupersite.com/view. asp?rid=41927. 5. Weiss SW. Lipomatous tumors. Monogr Pathol. 1996;38:207-39. 6. Sungur N, Kilinç H, Ozdemr R, Sensöz O. An infiltrating intramuscular lipoma of the brachioradialis muscle. Ann Plast Surg. 2001;46:353-4. 7. Oh JH, Gong HS, Kim HH. Paralysis of inferior branch of suprascapular nerve by a lipoma: a case report. J Korean Shoulder Elbow Soc. 2004;7:103-7. 8. Matsumoto K, Hukuda S, Ishizawa M, Chano T, Okabe H. MRI findings in intramuscular lipomas. Skeletal Radiol. 1999;28:145-52. 9. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am. 1996;78:1685-9.
54 pissn : 1226-2102, eissn : 2005-8918 Case Report J Korean Orthop Assoc 2015; 50: 49-54 http://dx.doi.org/10.4055/jkoa.2015.50.1.49 www.jkoa.org Dong-Ju Shin, et al 극상건파열을동반한극상근근육내지방종 신동주 남승오 김태은 박기홍 대구파티마병원정형외과 견관절의극상근내침윤성근육내지방종은극히드문증례로저자들은극상건의부분파열이동반된극상근내침윤성지방종환 자에대해수술적제거및회전근개의봉합술을시행하였고, 1 년추시자기공명영상결과상에서도만족스러운결과를얻어이에대 한문헌고찰과함께보고하고자한다. 색인단어 : 견관절, 극상근, 근육내지방종, 충돌증후군, 회전근개파열 접수일 2014 년 4 월 27 일수정일 2014 년 6 월 20 일게재확정일 2014 년 7 월 15 일책임저자남승오대구시동구아양로 99, 대구파티마병원정형외과 TEL 053-940-7320, FAX 053-940-7417, E-mail nso1020@naver.com 대한정형외과학회지 : 제 50 권제 1 호 2015 Copyright 2015 by The Korean Orthopaedic Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.