Symposium J Korean Orthop Assoc 2017; 52: 371-377 https://doi.org/10.4055/jkoa.2017.52.5.371 www.jkoa.org Superior Labrum Anterior to Posterior (SLAP) Lesion: Controversial Issue 371 임상적으로중요한 Superior Labrum Anterior to Posterior (SLAP) 병변은? 김정우 배규환 주민수 원광대학교의과대학정형외과학교실, 원광임상의과학연구소 pissn : 1226-2102, eissn : 2005-8918 Is There a Clinically Important Superior Labrum Anterior to Posterior (SLAP) Lesion? Jeong Woo Kim, M.D., Kyu Hwan Bae, M.D., and Min Su Joo, M.D. Department of Orthopedic Surgery, Wonkwang University School of Medicine, Institute of Wonkwang Medical Science, Iksan, Korea Superior labrum anterior to posterior (SLAP) lesion is a tear of the superior labrum, which starts posteriorly and extends anteriorly to include the anchor of the biceps tendon to the superior labrum. Symptoms of SLAP tear may include pain or instability. Recently, with the development of arthroscopy, the diagnosis and treatment of SLAP lesion have been made a lot. However, the diagnosis of clinically relevant SLAP tears remains challenging because of the lack of specific examination findings and the frequency of concomitant shoulder lesion. And there is still controversy regarding the treatment. Accordingly, proper treatment is important through accurate evaluation of whether or not it is a clinically important SLAP lesion. Key words: superior labrum anterior to posterior lesion, long head of biceps tendon 서론 1985 년 Andrews 등 1) 은야구선수에게서상완이두건의신장력으 로전상방관절와순의분리가일어날수있다고처음보고하였 으며, Snyder 등 2) 은관절경을통해상부관절와순이이두건부착 부후방에서전방으로파열되는양상을 superior labrum anterior to posterior (SLAP) 병변이라명명하고네가지유형으로분류하었 다. 최근관절경의발달과더불어병변에대한이해도가높아지 고, 진단과그에대한치료역시많이시행되고있다. Onyekwelu 등 3) 은 2002 년부터 2010 년까지관절경적 SLAP 복원술이 464% 증 Received May 30, 2015 Accepted July 28, 2015 Correspondence to: Jeong Woo Kim, M.D. Department of Orthopedic Surgery, Wonkwang University School of Medicine, 460 Iksan-daero, Iksan 54538, Korea TEL: +82-63-859-1360 FAX: +82-63-852-9329 E-mail: serina@wonkwang.ac.kr 가하였다고보고하였고, Kibler 4) 는 SLAP 병변에대한수술이 10 년동안전체견관절수술의 4% 에서 11% 로증가하였으며, 견관절에서두번째로흔하게시행되는관절경수술이라고하였다. 하지만몇몇의경험많은술자들은 SLAP 병변이과도하게진단 (overdiagnosis) 되거나오진 (misdiagnosis) 될수있으며, 이로인한부적절한치료또는과잉치료 (overtreatment) 가이루어질수있다는것을경계하고있다. 4) 이는 SLAP 병변이질병고유의증상을갖고있지않으며, 이학적검사역시특이한소견이없고동반질환을가지는경우가많아쉽게진단하기가어렵고, 치료에대해서도아직논란이있기때문이다. 이에임상적으로중요한 SLAP 병변인가에대한정확한평가를통해적절한치료를시행하는것이중요하다고할수있다. *This paper was supported by Wonkwang University in 2013. The Journal of the Korean Orthopaedic Association Volume 52 Number 5 2017 Copyright 2017 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/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
372 Jeong Woo Kim, et al. 본론 1. 해부학관절와순 (glenoid labrum) 은관절와의초자연골 (hyaline cartilage) 로부터섬유연골조직 (fibrous cartilage system) 을거쳐관절막의섬유조직과연결되는단단한섬유체로, 관절와의넓이및깊이를증가시켜견관절의안정성을증가시키고견관절에가해지는부하를분산시키는기능적인역할을하고있다. 5,6) 전방, 하방및후방관절와순은관절와에단단히부착되어있으나상완이두건장두의기시부역할을하는상부관절와순의 60% 정도에서는느슨하게부착된형태를하고있어반월판형관절와순 (meniscus-like labrum) 으로나타나기도한다. 그외에도관절순하공 (sublabral hole) 이나버포드복합체 (Buford complex), 중관절와상완인대 (middle glenohumeral ligament) 의정상적인해부학적변이등과의감별이필요하다. 2. 손상기전 SLAP 병변의손상기전에대한많은연구가보고되었으나아직까지는명확하지않다. 급성외상이있었던경우와만성적인반복손상이있는경우로나눌수있으며, 특히반복적인머리위운동 (overhead exercise) 이중요한원인이된다. Andrews 등 1) 은야구선수의투구동작에있어감속기 (deceleration phase) 와후속기 (follow-through phase) 에서발생하는상완이두건장두의신장력 (traction force) 으로인해전상방관절와순의분리가일어날수있다고처음보고하였다. 그후 Snyder 등 2) 은팔을뻗친상태에서넘어질때발생하는압박손상 (compression injury) 을, Jobe 7) 는내적충돌 (internal impingement) 을 SLAP 병변의손상기전으로제시하였다. Burkhart와 Morgan 8) 은박피기전 (peel back mechanism) 이 SLAP 병변의원인이라고보고하였으며, 견관절을외전및외회전시킬때상완이두건장두의기시부에염전력 (torsional force) 이발생한다고하였다. 그외에도직접적인가격에의한손상, 전단력 (shear force) 및말초혈류량감소에따른퇴행성변화등이원인이될수있다. 3. 분류 (classification) Snyder 등 2) 은 SLAP 병변을네가지로분류하였다. 제1형은상관절와순-이두건복합체 (biceps labral complex) 가상부관절와에단단히부착되어안정성이유지되고있는병변으로, 관절와순연 (labral margin) 의마모와세동 (fibrillation) 이심한상태이다. 주로머리위운동을하는젊은선수에게서관찰되며이는장년이상에서흔히관찰되는단순퇴행성변화와는구별되어야한다. 제2형은가장흔한병변으로상관절와순-이두건복합체가관절와로부터완전히분리되어불안정성을보이는병변이다. 제3형은양동이손잡이형파열 (bucket handle tear) 의양상을보이나복 합체의안정성은유지되어있는병변이다. 제 4 형은양동이손잡 이형파열이상완이두건장두까지연장된것으로복합체자체 가매우불안정하다. Morgan 등 9) 은제 2 형 SLAP 병변을전방, 후 방, 전후방으로나누었으며, Maffet 등 10) 은 Snyder 분류에세가지 형을추가하여제 5 형은전하방부의 Bankart 병변이상부로연장 된경우를, 제 6 형은제 2 형병변에불안정한부분관절와순파열 이동반된경우를, 그리고제 7 형은제 2 형병변이중관절와상완 인대로연장된경우라하였다. 최근에는전방형제 2 형병변이후 방으로확장된제 8 형, 제 2 형병변이전후방으로광범위하게연장 된제 9 형, 그리고제 2 형병변이회전근간격으로연장된제 10 형 등, 상관절와순 - 이두건복합체의병변외에, 파열의정도, 주위 조직의동반손상등에따라분류되고있다 (Table 1). 11) 4. 임상적으로중요한 SLAP 병변의진단 임상적으로중요한 SLAP 병변은상부관절와순의해부학적변 화가견관절의기능장애의원인이되는경우로, 정상적인해부 학적변이또는퇴행성변화와감별하는것이중요하다. 1) 병력 (patient history) 대부분 40 세이하젊은남자의우세수에서관찰되며, 주로외상 후또는수영선수나장기간투구운동을한경우에발생하게된 다. 환자는외회전을하거나거상기에통증을호소하며, 근력약 화와염발음 (clicking), 펑함 (popping) 등과같은관절내장애로인 한증상및마비상완징후 (dead arm sign) 를호소하기도한다. 이 러한증상은급작스럽게발생할수도있으나점진적으로악화되 는경우도있다. 2) 이학적검사 (physical examination) 현재까지많은이학적검사방법들이소개되었으나이학적검 Table 1. Definition of the Types of Superior Labrum Anterior to Posterior Lesions Type Type 1 Type 2 Type 3 Type 4 Type 5 Type 6 Type 7 Type 8 Type 9 Type 10 Fraying with intact biceps Definition Superior labral tear and biceps instability Bucket-handle tear of superior labrum and intact biceps Bucket-handle tear of superior labrum and biceps instability Bankart lesion and superior labral tear Unstable flap tear and biceps instability Superior labral tear and biceps instability/middle glenohumeral ligament tear Superior labral tear with postroinferior extension Pan-labral tear (extensive anterior and posterior extension) Superior labral tear with rotator interval extension
373 Is There a Clinically Important SLAP Lesion? 사만으로임상적으로중요한 SLAP 병변을진단하는것은쉽지않다. 이학적검사방법에는 speed test, Yergason test, Kibler test (anterior slide test), superior load and shift test, Whipple test, crank test, passive compression test, O Brien test (active compression test), compression rotation test, biceps load test I, biceps load test II, pain provocation test, resisted supination external rotation test, forced abduction test 등이있으며, 각검사법에대한다양한연구가이루어졌으나그결과에는많은차이가있다. 이는검사법의유용성평가시환자군선택의차이, 동반병변의유무, 병변의위치에따라결과가다르게나타날수있으며, 이학적검사의양성소견을통증으로보는지염발음으로보는지혹은둘다로보는지, 어느부위에증상이유발되는지를보는지에따라결과해석이달라질수있기때문이다. 12,13) Ben Kibler 등 14) 은 modified dynamic shear test 의임상적유용성을보고하였으며, 이검사의민감도는 0.72, 특이도는 0.98, 양성예측도 (positive predictive value) 는 0.97, 양성우도 비 (positive likelihood ratio) 는 31.57이었다고하였다. 하지만최근 Cook 등 15) 은 dynamic shear test가 SLAP 병변의진단에있어임상적으로유용하지않다고보고하기도하였다. Oh 등 13) 은민감도가높은이학적검사와특이도가높은이학적검사를함께시행하는것이 SLAP 병변을진단하는데있어효과적이라고하였다. 이처럼하나의이학적검사만으로 SLAP 병변을진단하는것은한계가있으나그럼에도불구하고임상적으로강력하게 SLAP 병변이의심되는경우병변의진단과정에있어도움이되는것은사실이다. 따라서자세한병력과함께정확하고본인에게익숙한이학적검사법을시행하는것은 SLAP 병변의진단에중요하다고할수있다. 3) 방사선검사 SLAP 병변의진단을위해자기공명영상 (magnetic resonance imaging) 이많이사용된다. 자기공명영상의경우약 93% 의민감도를보이며, 진단적가치를높이기위해자기공명영상조영술 (magnetic resonance angiography, MRA) 을시행할경우에는약 96% 의높은민감도를보인다. 13) 사관상면 (coronal oblique) 상에서잘관찰되며견관절의 abduction external rotation 위치는이두건을견인하여파열부위로조영제가쉽게흡수될수있도록도와준다 (Fig. 1). 14) 하지만 MRA는특이도가낮아위양성으로판독되는경우가많은단점이있으며, 14-16) 확진을위해서는관절경적검사가필요하다. Figure 1. Coronal T2-weighted magnetic resonance imaging scan of a left shoulder demonstrating the typical appearance of a type 2 superior labrum anterior to posterior tear, with high signal intensity under the superior labrum and extension of contrast dye between the superior glenoid and labrum. 4) 관절경소견임상적으로의미있는 SLAP 병변의관절경소견으로는첫째이두건부착부위의분리를동반한제2형또는제2형이상의 SLAP 병변, 둘째관절와의연골손상및연골연화가동반된경우, 셋째박피현상이발생하는경우, 넷째관절막의긴장도가감소된경우, 다섯째과도한후하방관절막의비후가관찰되는경우가있다. 3) 5. 치료 SLAP 병변은불확실한증상으로인해정확한진단이어려워진단과치료가늦어지는경우가많다. 머리위운동을하지않는경 A B Figure 2. (A) Arthroscopic photograph of a type 2 superior labrum anterior to posterior (SLAP) lesion. (B) Type II SLAP lesion was repaired with bio-suture anchor fixation.
374 Jeong Woo Kim, et al. 우증상이발현되지않아일상생활에서는큰불편을느끼지않기때문에휴식, 물리치료, 비스테로이드성소염제 (non-steroidal anti-inflammatory drug) 등의비수술적치료를시행할수있다. 17) 이때비수술적치료의목적은후관절낭의유연성회복과회전근개및견갑골근육의근력을회복시키는것이다. 최근재활치료등의비수술적치료로 50% 의환자에서증상호전을보였다는보고가있어충분한비수술적치료에도증상호전이없거나투구동작을하는경우, 젊은환자에서선택적으로수술적치료를고려해야하는것이추천된다. 3,18,19) 제1형의경우상관절와순-이두건복합체의안정성을유지하고있어변연절제술을시행한다. 20) 제2형의경우정상적인이두건의기능과상관절와순-이두건복합체의안정성을얻기위해상부관절와순을고정하여야한다 (Fig. 2). 21,22) 제3형의경우복합체의안정성은유지하고있어양동이형파열된부위만절제하면된다. 23) 하지만제3형의경우에도상관절와순-이두건복합체가쉽게관절와연에서분리된다면상부관절와순을고정해주는것이좋다. 제4형의경우연장된상완이두건장두의파열을절제하고, 복합체가불안정하기때문에상부관절와순을고정해준다. 하지만상완이두건파열이 50% 이상이거나너무심하게지저분한경우상부관절와순기시부에서단순건절단술 (simple tenotomy) 을시행하거나건고정술 (tenodesis) 을시행한다. 제5형에서제10형까지의 SLAP 병변은동반손상치료에주안점을두고, 제5형의경우전방관절와순과상부로연장된관절와순의파열부위의안정성을확인한후불안정할경우함께고정을하며, 상부관절와순이양동이손잡이형파열로복합체의안정성이유지될경우는전방관절순은고정하고, 상부관절순은절제한다. 6. 최신치료경향최근 SLAP 병변의치료경향에대한연구에서 2002년에서 2011 년까지 SLAP 병변만존재하는경우 SLAP 봉합술을시행한비율은 69.3% 에서 44.8% 로감소하였고, 이에반해건고정술및건절단술의비율은각각 1.9% 에서 18.8%, 0.4% 에서 1.7% 로증가하였다고보고하고있다. 또한 SLAP 병변과동반된회전근개파열이존재하는경우 SLAP 봉합술을시행한비율은 60.2% 에서 15.3% 로감소하였고, 건고정술및절단술의비율은 6.0% 에서 28.0% 로증가하였다. 24) 7. 치료및예후에영향을주는인자 1) 성별및나이 Zhang 등 25) 은남성이여성에비해 3배이상 SLAP 봉합술을시행받는다고보고하였으며, 나이가치료결과에미치는영향에대해서는아직까지논란이존재한다. Alpert 등 26) 은 40세이하의환자와 40세이상의환자에서모두좋은결과를보였다고보고하였으 나, 이에반해 Erickson 등 27) 은문헌고찰을통해 40세이상의환자에서나이가증가함에따라강직및재수술등의합병증이증가하며, 환자의만족도역시감소한다고하였다. Provencher 등 28) 은나이가유일한수술실패의원인이라고보고하였다. 2) 활동량 (activity level) 활동량은치료결과에중요한영향을미치며, 운동선수의경우비운동선수에비해만족도및결과가좋지않다고보고되고있다. 29-31) Neri 등 31) 은 23명의투수를대상으로한연구에서제2형 SLAP 봉합술후 57% 의환자만이이전의운동능력회복이가능하였다고보고하였다. 3) 동반병변 (1) 불안정성 (instability): 관절와상완관절의불안정성이동반된경우관절탈구및불안정성의재발을막기위해 SLAP 봉합술을시행하는것이선호된다. 32) (2) 관절와순낭종 (glenolabral cysts): 관절와순낭종이동반된경우젊은환자에서는 SLAP 봉합술을시행하며, 고령의퇴행성변화를동반한경우에는낭종에대한절제및천공을시행한다. 33) (3) 회전근개파열 (rotator cuff tear): Franceschi 등 34) 은회전근개파열을동반한 50세이상에서 SLAP 봉합술을시행하는것은이점이없으며회전근개봉합술과건절단술을시행하는것이좋은결과를보였다고하였고, Kim 등 35) 역시회전근개에대한봉합술과건절단술을시행한군에서회전근개봉합술과 SLAP 봉합술을시행한군과비교하여보다우수한결과를보였다고하였다. Neri 등 31) 은투수를대상으로한연구에서회전근개부분파열이동반된경우 SLAP 봉합술후오직 12.5% 만이이전의운동으로복귀가가능하였다고보고한바있다. 결론 SLAP 병변은비특이적인증상과이학적검사, 동반질환등으로인해정확한진단이어려우며, 치료에있어서도아직까지논란이있다. 이에자세한병력및이학적검사, 방사선검사등을통해임상적으로중요한 SLAP 병변에대한정확한진단및이에대한적절한치료를시행하는것이중요하다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum
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377 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop Is There Assoc a Clinically 2017; 52: Important 371-377 SLAP https://doi.org/10.4055/jkoa.2017.52.5.371 Lesion? www.jkoa.org Superior Labrum Anterior to Posterior (SLAP) 병변 : 쟁점 임상적으로중요한 Superior Labrum Anterior to Posterior (SLAP) 병변은? 김정우 배규환 주민수 원광대학교의과대학정형외과학교실, 원광임상의과학연구소 Superior labrum anterior to posterior (SLAP) 병변은상부관절와순의후방부에서전방부까지상완이두건장두의기시부를포함하여파열되는병변으로, 동통및불안정감등다양한증상을보이는질환이다. 최근관절경의발전과더불어 SLAP 병변의진단및치료가많이시행되고있다. 하지만질병고유의증상을갖고있지않으며, 이학적검사역시특이한소견이없다. 또한동반질환을가지는경우가많아쉽게진단하기가어려우며, 치료에있어서도아직논란이존재하는실정이다. 이에임상적으로중요한 SLAP 병변인가에대한정확한평가를통해적절한치료를시행하는것이중요하다고할수있다. 색인단어 : 상부관절와순병변, 상완이두건장두 접수일 2015 년 5 월 30 일게재확정일 2015 년 7 월 28 일책임저자김정우 54538, 익산시익산대로 460, 원광대학교의과대학정형외과학교실 TEL 063-859-1360, FAX 063-852-9329, E-mail serina@wonkwang.ac.kr * 이논문은 2013 학년도원광대학교의교비지원에의해수행됨. 대한정형외과학회지 : 제 52 권제 5 호 2017 Copyright 2017 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/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.