77 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop ssoc 2015; 50: 77-92 http://dx.doi.org/10.4055/jkoa.2015.50.2.77 www.jkoa.org Spine Intervention Using Ultrasound 경추부초음파유도하중재술 선승덕 장병권 * 문상호 * 선정형외과의원, * 서울성심병원정형외과 Ultrasound-Guided Intervention in ervical Spine Seung Deok Sun, M.D., yung Kwon hang, M.D.*, and Sang Ho Moon, M.D., Ph.D.* Sun's Orthopaedic linic, *Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, Seoul, Korea Interventional procedures around the cervical spine have been classically performed under the guidance of fluoroscopy with radiation hazards to patients and doctors. Even though under fluoroscopic guidance, vascular and nerve structures cannot be shown and there are actual risks for the patient. Nowadays, we can use high resolution image ultrasound around cervical spine procedures. Real time imaging is possible. ervical root block, medial branch block and many other interventions can be performed under ultrasound guidance. In outpatient clinics, ultrasound is very helpful in management of cervical problems in differentiating the origin of pain and treatment for the pain. Ultrasound is radiation free, easy to use and the imaging can be performed continuously while the injectant is visualized in real-time, increasing the precision of injection. Importantly, ultrasound enables visualization of major nerves and vessels and thus leads to improved safety of cervical interventions by decreasing the incidence of injury or injection into nearby vasculature. We therefore performed a review to investigate the feasibility of performing cervical interventions under real-time ultrasound guidance. Key words: cervical spine, ultrasound, intervention 서론 아직까지방사선투시하에서경추부중재술을시행하는것이표 준화된방법으로시행되고있다. 1) 척수는특이하게도혈관이척 추바깥쪽에서안쪽으로들어와혈액을공급하는양상을가지 고있는데이신경근동맥 (radicular artery) 의혈행방향이주사기 로약제를주입하는방향과일치하게된다. 따라서입자가큰 triamcinolone 같은제제를주입하다가예기치않게동맥내주사가 되면혈전을형성하여척수혹은소뇌등의경색을초래할수있 게되는것이다. 그러나방사선투시기로는연부조직, 특히신경 과혈관등의주요구조물들을볼수없다는큰단점이있다. 이로 Received March 9, 2015 Revised pril 2, 2015 ccepted pril 15, 2015 orrespondence to: Sang Ho Moon, M.D., Ph.D. Department of Orthopedic Surgery, Seoul Sacred Heart General Hospital, 259 Wangsan-ro, Dongdaemun-gu, Seoul 130-867, Korea TEL: +82-2-966-1616 FX: +82-2-968-2394 E-mail: msh124@paran.com 인하여특히방사선투시하경추간공 (transforaminal) 주사의경우혈관의위치를알수없으므로우연히동맥내주사가되어척수손상이라는심각한합병증을발생시킬수있으며실제이러한증례들이보고됨으로써방사선투시하시술의위험성이제기되고있다. 2-5) 비교적안전하다고생각되었던컴퓨터단층촬영유도하시술에서도소뇌와뇌간의경색이발생하는등 과연이러한위험성을무릅쓰고이시술을계속해야하느냐 라는회의론이나올정도로그안전성에대한논란이있는것이사실이다. 6) 이에비해초음파유도하경추부중재술은방사선투시기로볼수없는신경과혈관등주요구조물들을실시간으로보면서시술할수있고주사제가목표물주위로퍼져나가는정도와양상을동영상으로보면서주사할수있다는큰장점을가지고있다. 따라서주요신경과혈관등의구조물로주사되거나그조직을손상시키지않도록하고주사제가퍼지는영역을보면서조절할수있기때문에안전성과정확도를높일수있는방법인것이다. 더구나이러한시술과정을시술자나환자가방사선피폭이없 The Journal of the Korean Orthopaedic ssociation Volume 50 Number 2 2015 opyright 2015 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the reative ommons ttribution Non-ommercial 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.
78 Seung Deok Sun, et al. 이시행할수있다는큰장점도가지고있지만, 아직해상도가떨어지고시술자의숙련도에의해의존성이많은등의단점도있는것이사실이다. 앞으로초음파기기의발전및술기에대한연구로서이러한단점들이개선된다면경추부에서안전하고표준적인시술방법으로더욱부각될수있으리라생각한다. 이에저자들은저자가기존에보고한종설을기초로수정, 보완하여경추부중재술에있어서초음파의역할및술기에대하여기술하고자한다. 7) 초음파를위한경추부표면해부학 경추부의대부분이피부로부터깊은곳에위치하기때문에촉지로써전체적인윤곽을확인하는것은불가능하므로표면해부학을잘알아야하는데, 촉지로알수있는몇군데를먼저표시하고나서눈으로가상선을그려가면서다른중요구조물들의위치를예상하여야정확한영상을얻을수있다. 우선경추부후면의주요부위의위치와형태를알기위하여환자를엎드리게하는데상흉부전면에베개를받치게하고편하게엎드리게하면자연스럽게경추굴곡을유도할수있어촉지하기가쉽다. 우선후두부중앙원위부에돌기가정중앙선에서촉지되는데이것이외후두융기 (external occipital protuberance) 이다. 여기서정중앙선을따라원위부로촉지하며한손가락너비만큼이동하면작은돌기를만 질수있는데제2경추의극돌기이다. 더원위부로내려가면비교적육안으로도돌출되어있음을알수있을정도의큰돌기가만져지는데이부위가제7경추의극돌기가된다. 피하층이얇은환자에게서는그상부에있는제6경추의극돌기가먼저잘만져지기도한다. 정중앙선의제2경추극돌기와제7경추극돌기사이에서나머지 3, 4, 5, 6 극돌기가만져지는데피하층이두꺼운사람에게서는잘만져지지않는다. 이정중앙선으로부터 1수지너비 (one finger breadth) 만큼외측에정중앙선에평행하게선을그으면여기가후궁들이놓이게되는위치이고 2수지너비만큼외측에는후방관절들이위치하게된다. 여기서주의할것은환자의경추부는원통형이므로둥그런형태를따라수지를자연스럽게대고수지너비를표시하여야한다. 만약환자의관상면에대해수지너비를이동시키면너무외측이되므로주의해야한다. 외후두융기에서외측으로이동하면귀후면부위에서또하나의돌기를촉지할수있는데이곳은유양돌기 (mastoid process) 이다. 이두돌기들사이를촉지하면바로상항선 (superior nuchal line) 이위치하게된다. 상항선을 3등분한후내측 1/3과중앙 1/3이만나는지점에대후두신경 (greater occipital nerve) 이지나게된다 (Fig. 1). 경추부의전면을촉지하기위해환자를앙와위로눕게하면서하부경추부에서후면에베개를받치면자연스럽게경추부신전을얻게된다. 환자로하여금고개를검사하고자하는측에대하여반대쪽으로돌리게하고고개를약간들게하면흉쇄유돌기근이수축함으로써잘관찰되는데이근육의전면에기도, 식도, 경 Figure 1. Surface anatomy of the posterior neck region. fter dividing the line from external occipital protuberance to mastoid process into 3 sections, greater occipital nerve usually runs the point at the junction of its middle and medial thirds (white arrow). Drawing the line one finger breadth laterally from midline, there are laminae on this line (black arrows). Two finger breadths laterally, facet joints are on this line (arrowheads). E, external occipital protuberance; 2, spinous process of the 2nd cervical vertebra; 7, spinous process of the 7th cervical vertebra. Figure 2. Surface anatomy of the anterior neck region. elow the chin, hyoid bone (H) situated opposite the 3rd cervical vertebra can be easily palpated at midline. finger s breadth below, there is the laryngeal prominence of the thyroid cartilage (T). The outlines of the thyroid cartilage are readily palpated. elow its lower, anterior part of the cricoid cartilage () forms an important landmark on the front of the neck because it lies opposite the 6th cervical vertebra. rrow indicates sternocleidomastoid muscle.
79 Ultrasound-Guided Intervention in ervical Spine 동맥, 내경정맥, 갑상선등이위치하고후면에상완신경총, 사각근 (scalene muscle), 경추의횡돌기등이위치하게된다. 목의전면중앙부에서턱뼈밑부터촉지하여내려가면바로갑상선연골 (thyroid cartilage) 을만질수있는데표면이매끈하며제4, 5경추의높이에해당하게된다. 이연골의상연에서한손가락너비만큼상부로이동하여깊숙이촉지하면설골 (hyoid bone) 이만져진다. 제3경추의높이에해당하며갑상선연골의하방에서는반짇고리모양으로돌출된윤상연골 (cricoid cartilage) 을촉지할수있고제6경추의높이에해당하게된다 (Fig. 2). 경추부의측면을보기위해환자를옆으로뉘인후귀후방에있는유양돌기를만지고바로그원위부를검사자의검지로너무세지않게지긋이누르면손끝에서딱딱한돌기를촉지할수있는데여기가제1경추의횡돌기이다. 유양돌기와하악각 (angle of mandible) 을잇는선을가상으로긋고그선의중간지점에서약간후방으로깊숙이촉지하면흉쇄유돌기근바로후방에서작은돌 기가만져지는데이것이제2경추의 pillar에해당하고여기서직하방으로촉지하여내려가면다른하부경추의 pillar들을연속해서촉지할수있다. Pillar는요추에서의 pars interarticularis에해당하는부위로서상관절돌기와하관절돌기사이에위치하는기둥형태의골성구조물이다. 경부하방, 쇄골상부에서승모근의전방에손가락을전방에서후방으로, 외측에서내측으로넣어만지면제7경추의횡돌기가만져진다. 그하방으로약간외측에서더깊숙이만져보면편평한구조물인제1늑골이만져진다 (Fig. 3). 정상경추부의초음파소견 요추부는심부영상을필요로하기때문에곡선탐촉자 (convex probe) 를이용하는것이추천되지만경추부는상대적으로얕은위치에있으므로선형탐촉자 (linear probe) 를사용하는것이좋다. 환자를복와위로뉘인상태에서정중앙선에탐촉자를대고극돌기를검사하는데원위부의가장튀어나온곳이제7경추극돌기이다. 그보다약간작은제6경추극돌기가상부에서확인되고그로부터상부로올라가며제2경추극돌기까지확인할수있 Proximal Distal Figure 3. Surface anatomy of the lateral neck region. elow mastoid process (M), articular pillars (white arrows) can be palpated. t base of neck, transverse process of the 7th cervical vertebra (black arrow) can be palpated deeply at the anterior border of trapezius (arrowheads). Figure 5. () Ultrasonography on posterior longitudinal paravertebral sono gram shows laminae of cervical spines (arrows). () Position of probe for () on the artificial spine model. 7 Distal 6 5 Proximal Figure 4. () Ultrasonography on longitudinal scan at midline of the posterior cervical area shows the prominent 7th spinous process from which other cervical spinous processes can be counted upwards. () Position of probe (black bar) for () on the arti ficial spine model.
80 Seung Deok Sun, et al. 다. 경추부극돌기들은예외적으로곡선탐촉자하에서잘보이는 경우가많다. 외후두융기로부터하방으로탐촉자를이동하면제 일먼저나타나게되는제 2 경추극돌기를먼저찾은후아래로 이동하며 level 을확인해도된다 (Fig. 4). 종축영상을유지하면서 약간외측으로이동하면마치기왓장을포개놓은듯한후궁들이 관찰된다 (Fig. 5). Level 을확인하기위하여후방에서종축으로정 T T H Proximal Distal Proximal Distal Figure 6. () Ultrasonography on longitudinal scan at midline of the anterior cervical area shows thyroid cartilage (T) and distally, cricoid cartilage () which lies opposite the 6th cervical vertebra. () Proximally, hyoid bone (H) situated opposite the 3rd cervical vertebra is shown below the chin. Th Tr Th SM D IJV Th Tr Th L 6 Tr Figure 7. () Ultrasonography on anterior transverse scan at the level of cricoid cartilage shows thyroid gland (Th) in midline. () Position of probe for () on the artificial spine model. () y moving the ultrasound probe laterally until the carotid artery () can be seen, the 6th cervical transverse process (6 Tr), carotid artery, internal jugular vein (IJV), vagus nerve (arrow), longus colli (L) omohyoid (arrowheads) and sternocleidomastoid muscle (SM) are shown. (D) Esophagus (arrow) is seen behind the trachea (Tr).
81 Ultrasound-Guided Intervention in ervical Spine IJV Figure 8. () xial transverse image showing sharp anterior tubercle (white arrow) and posterior tubercle (black arrow) of 6 transverse process. sterisk indicates exiting nerve root. () Position of probe for () on the artificial spine model., carotid artery; IJV, internal jugular vein. SM nterior Posterior SM MSM Tr P F 7 Tr L S Figure 9. nterior scalene muscle (SM) is deep to sternocleidomastoid muscle (SM) and lateral to the internal jugular vein. Middle scalene (MSM) is found further postero-lateral. etween anterior and middle scalene muscle, visualize the roots or trunks of the brachial plexus (arrowheads) in the interscalene groove. These can appear as round or oval bundles with hypoechoic centers., carotid artery; 7 Tr, the 7th cervical transverse process. 중앙선에탐촉자를대어극돌기를먼저검사하는요추부와달리 경추부에서는후방에서극돌기부터검사하여 level 을확인하는 것은추천되지않는데, 이는극돌기들이크기가작고폭이얇아 서스캔하기가어려우며그들을확인하여 level 을정하는것보다 앙와위에서부터검사하는것이위치를확인하는데더용이하기 때문이다. 환자를앙와위로눕히고경부전면의중앙선상에종축영상을 이미촉지로써확인한갑상선연골부에서얻는다. 갑상선연골 상부에후방음향조영을동반하는설골이보이고하부에서마치 반짓고리모양의윤상연골을확인할수있는데연골이므로후 방음향조영은동반하지않는다 (Fig. 6). 윤상연골이제 6 경추높 이에해당하므로윤상연골을중앙에놓고탐촉자를 90 도로돌려 횡축영상을얻으면제 6 경추부횡축영상이된다. 중앙에윤상연 골이놓이고양측으로갑상선이보이는데여기서환자로하여금 고개를약간반대쪽으로돌리게한후탐촉자를외측으로이동 하며전방외측의영상을얻으면내측으로윤상연골과그바로 Figure 10. () ontinue to move the probe posterolaterally around the neck. Posterior tubercle of 6 transverse process (Tr), pedicle (P), facet joint (F), lamina (L) and spinous process (S) can be seen. () Position of probe for () on the artificial spine model. 외측에갑상선이보이고심부로식도가관찰된다 (Fig. 7). 식도임 을확인하려면환자에게침을삼켜보라고하고그때식도의수축 을영상에서확인할수있다. 식도의더심부외측으로척추체의 외측면을확인할수있고그전면에놓인근육이경장근 (longus colli) 이다. 더외측으로탐촉자를이동하면척추체로부터이행되 는횡돌기의전결절과후결절을각각확인할수있는데그사이 로제 6 경추신경이나오게된다 (Fig. 8). 탐촉자를약간씩상하방으로반복하여이동하면신경근이두 결절들사이로마치야구공이글러브에들어갔다가나오는양상 의영상을확인할수있다. 갑상선의외측으로두개의큰혈관이 보이는데탐촉자를표면에서압력을가하여눌러도사라지지않 고박동을관찰할수있는경동맥 (carotid artery) 이내측에있고탐 촉자를누름으로써혈관의내경이좁아지는내부경정맥 (internal jugular vein) 이그외측에놓인다. 두혈관사이에미주신경이관 찰된다. 혈관들의표층에는흉쇄유돌기근이관찰되며횡돌기결 절의표층, 그리고혈관들의외측에마치계란을비스듬이자른 듯한모양의전방사각근 (anterior scalene muscle) 과중간사각근 (middle scalene muscle) 이보이며그사이로상완신경총을이루
82 Seung Deok Sun, et al. 는신경근들이일렬로비스듬하게정렬되어있는양상이관찰되는데이는제7경추부에서더확실히나타난다 (Fig. 9). 더외측으로진행하면횡돌기로부터후방에있는골성구조물로서후방관절과후궁을관찰할수있다 (Fig. 10). 영상에서보이는척추구조물의 level이윤상돌기에대한횡축영상이라고해서꼭제6경추부라고는확정할수는없다. 경추간거리가요추에비해짧으므로윤상돌기에대한횡축이조금만 기울어져도다른 level의경추영상을얻게되기때문이다. 그래서다른방법으로꼭그 level을재확인하여야하는데, 횡축영상을유지하면서탐촉자를상하로움직이며그다음 level의횡돌기를관찰하여확인하는방법으로서각 level당구조물들의특성을이용한다. 즉제4경추부에서는경동맥이두개로분지되기시작하며제5경추부에서는갑상선의상부가관찰되고제6경추부에서는갑상선의하부가보이며여기까지는견갑설골근 (omohyoid) 이 Th Th 5 Tr 4 Tr D E Figure 11. () 4 transverse process (4 Tr) can be shown at the level of carotid artery bifurcation (arrows). () 5 transverse process (5 Tr) is located at the level of upper thyroid gland and has similar size tubercles. () 6 transverse process is located at the level of lower thyroid gland and has a sharp, tall anterior tubercle (white arrow). Open arrow indicates low, round posterior tubercle and asterisk is 6 root. (D) Transverse sonogram at 7 vertebral level shows 7 root (asterisk) between vertebral artery (white arrow) and posterior tubercle (black arrow). nterior tubercle is absent. Vertebral artery is confirmed by Doppler scan in the right side picture. (E) nterior tubercle is absent and vertebral artery is exposed (arrow) at 7 vertebral level of artificial spine model. Th, thyroid gland. 1 Proximal 2 Distal Figure 12. () longitudinal sonogram below the mastoid process (arrow) shows transverse processes of 1 (taller and wider) and 2. () Position of probe for () on the artificial spine model.
83 Ultrasound-Guided Intervention in ervical Spine Proximal Distal Figure 13. longitudinal sonogram at 2-3 level shows the 3rd occipital nerve (white arrow) crossing 2-3 joint and 3 medial branch (open arrow) at the waist of articular pillar. () Position of probe for () on the artificial spine model. 경동맥의내측에위치한다. 제7경추부에서는갑상선이사라지고횡돌기의전결절이없어지며상부경추에서는전결절로인해가려져있던추동맥 (vertebral artery) 이보이면서견갑설골근이경동맥표층을외측으로가로질러가는특징을가지게된다. 저자들은제6경추의전결절높이가후결절에비해높고가늘며뾰족하고, 이에대해후결절은낮고문득하게보이는특징이있는데비해제5경추는이런특징이없고두결절의높이와모양이비슷하다는점이제5경추와제6경추를감별하는점으로서제시될수있다고생각한다 (Fig. 11). 8,9) 또한제4경추의결절간간격은다른부위보다매우좁다. 결국윤상돌기에대한횡축영상을얻은후이영상이제6경추 level임을확인하려면하나아래 level( 제7경추 ) 의횡돌기를관찰하여돌기가하나이고그전방에 Doppler상추동맥이관찰된다면 level이맞음을확인하는것이간편하고정확한방법이다. 측면으로환자를눕힌후유양돌기의하방에종축으로탐촉자를대면제1경추와제2경추의횡돌기들의종축영상을얻을수있는데제1경추횡돌기가더크고바깥쪽까지돌출되어있다 (Fig. 12). 여기서약간후방으로탐촉자를이동한종축영상을보면후방관절들의종축영상을얻을수있는데 level을확인하려면근위부로탐촉자를이동하면서마치절벽모양의영상을우선확인하는것이필요하다. 이절벽의꼭대기에있는후방관절이제2, 3 경추간후방관절이되고이관절부의근위부로인접하여지나가는타원형의고에코구조물내로저에코의점들이관찰되는구조물이제3후두신경 (3rd occipital nerve) 이다. 탐촉자를서서히원위부로종축을유지한채이동하면언덕과골짜기가반복되며나타나는데언덕이후방관절들이며각내측분지는언덕들사이의잘룩하게들어간골짜기, 즉 waist 부위를지나게되는데예를들어제2, 3 후방관절과제3, 4 후방관절사이에종축영상에서보이는잘룩한 waist 부위로제3내측분지가지나게된다 (Fig. 13). Figure 14. Doctor should wear mask and sterile gloves, and then sterilize cervical area with bethadine solution. Probe is enveloped by sterile vinyl after coverage with gel to minimize the risk of infection. 경추부초음파유도하중재술 중재술에있어서시술후감염이가장심각한합병증중하나이 다. 이를최소화하기위하여저자들은마스크와소독장갑을착 용후시술부위에베타딘을이용한피부소독을철저히실시하 며탐촉자에겔을묻힌후소독된비닐을덮어서밀봉하고탐촉 자표면을덮고있는비닐표면에다시베타딘으로소독을한후 길이 6 cm, 굵기 23 G 주사바늘을주로이용하여시술에임하고 있으며아직까지저자들의시술증례들에서감염예는없다 (Fig. 14). 초음파가본격적으로경추부중재술에사용된것은비교적 최근으로서향후더연구되어야할분야이다. 현재대표적으로 시술되고있는항목들은다음과같다. 1. 신경근차단술 (root block) 선택적신경근차단술은원래경추부방사통의 level 을찾기위한 진단적목적으로사용되었으나최근방사통의감소, 두통, 견관 절부통증이나강직, 상지의통증조절등치료목적으로도사용
84 Seung Deok Sun, et al. SM SM Tr Tr Figure 15. The influence of head rotation. () In neutral position of head, sternocleidomastoid muscle (SM) overlay the root and plexus (arrows). () If the head is turned adequately to opposite side, the SM moves to the medial side and does not overlay the root and plexus (arrows)., carotid artery; Tr, transverse process. 되는술식이다. 10-12) 상기한바와같이혈관내주사는중추신경계의심각한합병증들을초래할수있기때문에실시간으로초음파유도하에서주요혈관과신경들을확인하여그들을피하면서시행하는것이보다안전하다고생각한다. 시술방법은우선환자를앙와위나측면으로눕힌자세로시행할수있는데저자들은측면자세를더선호한다. 이유는앙와위에서는시술중바닥에시술자의바늘을잡은손이닿을수있으나측면으로눕히고환자의뒤에시술자가앉아시술하면바늘이환자경부의후면에서전방을향해삽입되므로바닥에닿을염려가없고편하기때문이다. 또한이자세에서내측분지차단술까지한번에체위변경없이시행할수있다는장점이있다. 앙와위에서환자의등후면에베개를높이받쳐서시술자의손이바닥에닿지않도록하는것도가능하지만환자가베개의높이때문에불편해하는경우가많아저자들은선호하지않는다. 흉쇄유돌기근을바늘삽입경로에서피하기위해고개를환측의반대쪽으로돌려야하는데 (Fig. 15), 확실히돌리려면앙와위가좀더유리하지만측면에서도충분히가능하다. 제4경추신경에서제7경추신경까지는비교적쉽게시행할수있으며제3경추신경까지도 level을확인하는데주의한다면시행이가능하다. 상기한방법대로우선시술하고자하는경추의 level을확인한후탐촉자를횡축영상을얻을수있도록놓고 inplane 술기로서경추부후방에서전방으로삽입하여후결절에연해서나오는신경근부위를목표로하여주사한다 (Fig. 16). 일단후결절에바늘이닿을때까지접근한후저자들은미세하게바늘을다시후퇴시킨위치에서주사하고있다. 이유는너무횡돌기에접하여주사하면경막외혹은경막내주사가될수있고바늘이후결절을지나추간공쪽으로들어가면피질골로인해발생하는후방음향조영때문에바늘의위치확인이어려워지는데만약깊숙히삽입하게되면추동맥손상, 신경근동맥내주사등이발생할수있으므로후결절로부터약간외측으로떨어진부위인 P 신경근주위 (periradicular) 로주사되도록하는것이안전하기때 문이다. 이때 Doppler scan 을이용하여혈관의위치를확인후경 로에서피하여야하고주사직전흡인을통해혈액이나오는가를 확인하여야한다. 제 7 경추신경은특별히조심하여야하는데그 이유는전결절이없고, 추동맥이전결절이있어야할부위에노 출되어있기때문이다. 그러므로시간이걸리더라도바늘의전장 을잘추적하여후결절보다앞쪽으로가지않도록하는것이추 동맥손상등의합병증을막을수있는방법이다. Figure 16. Solid arrows point to the needle in place at the posterior aspect of root during ultrasound-guided selective nerve root block., anterior tubercle of 6 transverse process; P, posterior tubercle of 6 transverse process; sterisk, 6 root. Galiano 등 13) 은카데바경추신경근에초음파유도하차단술을 시행하여모두목표신경근으로부터 5 mm 이내에바늘이접근해 있는것을컴퓨터단층촬영을통해확인하였다. Narouze 등 9) 도초 음파유도하술기가신경근차단술에서정확함을투시기로확인
85 Ultrasound-Guided Intervention in ervical Spine Proximal Distal Figure 17. () oronal longitudinal sonogram at the level of articular pillars. branches (asterisks) are usually located at the deepest points between articulations. These points are target for out of plane technique. rrows indicate entries of facet articular joints. () Needle (arrow) is inserted into the deepest points between articulations by out of plane technique. Needle is shown as a white spot on the groove. () Position of probe for () on the artificial spine model. S I * P Tr P L D Figure 18. () Initially achieved transverse sonogram at the level of targeting facet joint. rrow indicates entry of joint. () Moving probe to slight distally and proximally to obtain images of articular pillars on which medial branches run (asterisk). () 23 G, 6 cm needle (arrowheads) is in troduced by use of real-time in-plane ultrasound guidance to target point for medial branch block. (D) Position of probe for () at artificial spine model. S, superior articular process of lower vertebra; I, inferior articular process of upper vertebra; P, articular pilla; L, lamina; Tr, transverse process.
86 Seung Deok Sun, et al. 하였다. Jee 등 14) 은무작위눈가림대조군연구를통하여차단술의정확도와효과에대해, 초음파군이투시기군에비하여차이가없다고증명하였고 Yamauchi 등 15) 은환자들과카데바를통한연구에서초음파를이용한신경근차단술이효과적이며정확하다고보고하였데, 기존의방사선투시하차단술보다초음파유도하시술은좀더말초에서주사가되는차이점이있으나주사할때발생하는정수압과주사제의삼투압으로인해신경섬유내부로퍼져나가고그방향이중추쪽이므로차단효과정도는비슷하다고주장하였다. 2. 내측분지차단술 (medial branch block) 후방관절은척추신경의후방분지에서갈라져나오는내측분지의신경지배를받는활막관절로서이분지를선택적으로차단하는치료가내측분지차단술이다. Manchikanti 등 16) 은이중눈가림무작위대조군 2년추시연구에서경추부내측분지차단술이후방관절에문제가있어발생한만성경추통에효과가있음을보고하였고 Siegenthaler 등 17) 은초음파유도하경추부내측분지차단술의정확도를투시기로평가하여제7경추내측분지를 제외한제3, 4, 5, 6 내측분지에대하여상당히정확한술기임을입증하였다. 상기한방법대로측면으로눕힌상태에서종축으로탐촉자를대고우선제2, 3경추간후방관절이그근위부에서심부로제2경추부가 drop-off되는절벽모양의특징적인소견이있으므로먼저찾는다. 그관절의원위부로잘룩하게들어가는골짜기모양으로생긴 pillar의 waist에제3경추내측분지가지나고다시그원위부에언덕이나타나는데제3, 4경추간후방관절이된다 (Fig. 13). 이러한모양이반복되므로제6경추내측분지까지위치를같은방법으로확인하여원하는위치의내측분지에주사하여차단술을시행하는데 Siegenthaler 등 17) 의방법처럼종축영상을유지하면서전방에서후방으로 out of plane 술기, 즉탐촉자에대하여 90도로바늘을삽입하여영상에서는한개의하얀점으로바늘이보이는술기로삽입하여주사할수있다 (Fig. 17). 이방법은여러 level을한영상하에서시행할수있고, 바늘의삽입방향을전방에서후방으로하기때문에주사제가후방을향해분사되므로상대적으로위험한구조물이많은전결절의전방으로약제가퍼짐을방지할수있다는장점이있다. 그러나삽입경로상전방구 SM MSM Figure 19. () In-plane approach from the posterior-lateral side of the probe for interscalene brachial plexus block. Needle (arrowheads) is inserted into interscalene groove at an angle of about 45 degrees to the skin surface. The needle tip is slowly advanced towards the plexus, avoiding any sensitive structures. ppropriate needle placement is confirmed by move ment of the plexus with the flow of in jectant and spread around the entire plexus. () Position of probe for (). rrow in dicates the direction of the needle. SM, an terior scalene muscle; MSM, middle scalene muscle. 1st rib Figure 20. () Needle (arrowheads) is inserted and slowly advanced using lateral-to-medial orientation towards the deep border of the plexus where it meets the subclavian artery in supraclavicular bra chial plexus block. () Position of probe for (). rrow indicates the direction of needle., subclavian artery;, brachial plexus.
87 Ultrasound-Guided Intervention in ervical Spine 조물들을지나야하고바늘을경추부의전방에찌르는것이후방에서찌르는것보다더환자에게공포심을유발할수있으며시술자에게도후방에서찌르는자세가전방보다더편하다는요소들을고려하여저자들은후방에서 in-plane으로시술하는방법을고안하여시행하고있다. 이술식은우선종축영상에서목표로하는후방관절의 level을확인한후 90도로탐촉자를돌려서해당후방관절에대한횡축영상을얻는다. 그원위부와근위부로각각조금씩탐촉자를이동하여관절부보다높이가낮아지며편평해지는 pillar 부위로바뀌어지는영상을얻은후후방으로부터전방으로바늘을 in-plane 술기로삽입하여 pillar에바늘이닿고나서주사함으로써약제가피질골을따라퍼지는양상을확인하는 과정들로이루어져있다 (Fig. 18). 후방관절의근위부 pillar를지나는내측분지와원위부 pillar를지나는내측분지를모두차단하는이유는제3경추에서제7경추까지의후방관절이바로그원위부및근위부를지나는각각의내측분지에의하여이중지배를받기때문이다. 예를들어제4, 5경추간후방관절은그관절의근위부 pillar를지나는제4 내측분지와원위부 pillar를지나는제 5 내측분지의이중지배를받으므로두군데의내측분지를차단하여야효과적인시술이되는것이다. 이런방식으로저자들은후방에서바늘을삽입하는것을더선호하며 in-plane 술기를통해실시간으로약제의퍼짐을주위깊게본다면전방구조물로의약제퍼짐은충분히방지할수있다고생각한다. 제7경추내측분 D Figure 21. () Ultrasound probe is placed in transverse plane at the level of the medial superior nuchal line. () Moving probe from medial to lateral until occipital artery (open arrow) is found. y in-plane technique, insert needle from lateral to medial near the artery (arrow). () Occipital artery can be confirmed by Doppler scan. (D) Position of probe for () at artificial spine model. 2 SP OI S SP Figure 22. () Oblique transverse scan between 2 spinous process and 1 transverse process. rrow indica tes greater occipital nerve in the inter muscular plane between obliquus capitis inferior and semispinalis capitis and the direction of the needle for block. Open arrow indicates the 3rd occipital nerve. () Po sition of probe for () at artificial spine model. OI, obliquus capitis inferior; S, semispinalis capitis; SP, splenius capitis; 2 SP, spinous process of axis.
88 Seung Deok Sun, et al. 지는하부경추의영상을보기위하여탐촉자를원위부로이동할때쇄골에의하여탐촉자가원위부로이동하는것이막혀영상을얻기가어렵고, 다른내측분지에비하여피부로부터상대적으로깊은위치에있어이러한술기는추천되지않는다. 3. 상완신경총차단술 (brachial plexus block) 여러부위에서상완신경총에대한차단이가능하지만경추부에서는사각근간 (interscalene) 및쇄골상부 (supraclavicular) 접근법이많이사용되고있고초음파유도하에서시술할수있다. 사각근간접근법은상기한방법대로제7경추 level에서얻은횡축영상을보면서전방사각근과중간사각근사이에약 45도각도로사면으로놓인일렬의둥근점들로관찰되는상완신경총의 trunk level을먼저확인하고이부위를 in-plane 술기로써바늘의전장을보고후방에서전방을향해깊은방향으로바늘을삽입하는것이다 (Fig. 19). 사각근간공간의지방량에따라초음파상에신경총이얼마나잘보이는가가결정되는데근육섬유들과혼동되기쉬우므로세심한관찰이필요하다. 쇄골상부에서는쇄골의 1에서 2 cm 상부의사각근간위치에서쇄골과평행하게횡축으로탐촉자를놓고쇄골하동맥을찾은 후그심부에있는제1늑골과흉막을확인한다. 쇄골하동맥보다표층및외측으로접하며포도송이모양으로있는 division level의신경총을찾은후탐촉자의외측에서내측으로바늘을삽입하여 in-plane 술기로신경총에도달한다 (Fig. 20). 저자들은쇄골상부를더선호하는데사각근간에서약제를주입하면드물지만전방으로약이흘러흉쇄유돌기근과내경정맥사이에있는횡격막신경 (phrenic nerve) 까지도달하여호흡곤란을일으킬수있기때문이다. 바늘은반드시신경총의깊은부위를향해주입되어야척골신경부위까지효과적인차단술이될수있다. 4. 대후두신경 (greater occipital nerve) 및제3후두신경 (3rd occipital nerve) 차단술경추성두통을유발하는질환들가운데대후두신경및제3후두신경의병변이있다. 대후두신경을차단하는기존의방법을기술하면, 대후두신경은상기한대로상항선을 3등분한후, 내측 1/3 과중앙 1/3이만나는부위를지나게되므로이부위에탐촉자를횡축으로대고 Doppler를이용하여후두동맥을찾고그내측으로신경이지나므로이지점을목표로하여바늘을탐촉자의내측에서외측으로삽입하여신경부위에주사하였다 (Fig. 21). Figure 23. () rrows indicate the direction of the needle by in-plane technique to enter facet joint in coronal longitudinal so nogram at the lateral aspect of neck. () Position of probe for () at artificial spine model. rrow indicates the direction of needle to enter facet joint. Figure 24. () Transverse scan of facet joint. rrow indicates the direction of the needle to enter facet joint. () Position of probe for () at artificial spine model. rrow indicates the direction of the needle to enter the facet joint.
89 Ultrasound-Guided Intervention in ervical Spine 7 R Figure 25. () Transverse scan at the base of neck. Transverse process of 7 and 1st rib (R) joins like a joint. This point can be a landmark to determine the facet joint level proximally. () Position of probe for (). 7, transverse process of 7. Figure 26. During stellate ganglion block, a small caliber probe like a Hockey stick probe is necessary. fter compression by probe, the gap between thyroid and carotid artery will be widened and the depth from skin to ganglion can be diminished to make it easier to reach stellate ganglion. Needle is inserted almost perpendicular to skin. 그러나 Greher 등 18) 은대후두신경이제 2 경추신경후방분지로 서환추후궁의아래경계에서후방으로출현하여내측상부로 이동하는동안하두사근 (obliquus capitis inferior) 의표면을따라 주행하는것을이용하여우선탐촉자를하두사근의위치대로맞 추려, 축추의극돌기와환추의횡돌기사이에대어약간경사진 횡축영상을얻고여기서축추후궁의표층에위치하는하두사근 과그표층에위치하는두반극근 (semispinalis capitis) 및두판상근 (splenius capitis) 근육층의사이에있는근막층에대후두신경이지 나가는것을확인하여탐촉자의외측에서내측을향해 in-plane 술기로써바늘을삽입하는방법을발표하였는데카데바에직접 두방법으로시술하여비교함으로써기존의방법에비해새로운 방법이더정확함을증명하였다 (Fig. 22). 기존의방법을시행하면머리카락이시술에방해가될뿐만아 니라이위치에서해부학적으로도대후두신경위치가일정치않 다는보고가있는데비하여이새로운방법이술기상더쉽고해 부학상으로도일정하게대후두신경이하두사근의위를지난다는장점이있으면서이근막층에제3후두신경도위치하므로근막층을따라주사액을흘려보내면두신경을한번에차단할수있는방법이될수있어서더권장할만하다고생각한다. 19) 제3후두신경은제3경추신경의후방분지가표층내측분지 (superficial medial branch) 와심부 (deep) 내측분지로나뉘는데, 그중표층내측분지이다. 심부분지는다른 level의내측분지들처럼제2, 3후방관절의원위부에있는 pillar를지나게된다. 이신경은특징적으로제2, 3후방관절의표면을관절의근위부에서지나므로이곳이목표가되는데, 이지점을지난후경추부와후두부의내측을따라상행한다. 그차단술의술기는상기한내측분지차단술에서의종축영상에서제2, 3경추간후방관절이그근위부에서심부로제2경추부를향해 drop-off되는부위를찾아서 level 을확인한후제2, 3경추간후방관절의표면, 그리고약간근위부를목표로 out of plane 술기로주사하면된다 (Fig. 13). 20) 그리고대후두신경처럼하두사근위에서대후두신경보다내측을지나는제3후두신경을찾아서 in-plane 술기로써바늘을삽입하는방법도가능하다. 5. 기타경추부중재술후방관절내차단술을시행하려면환자를측면으로눕히고내측분지차단술을할때와같은종축영상을얻은후, 이번엔 waist가아닌언덕부에서관절내로향하는 slit을찾아 in-plane 혹은 out of plane으로주사한다 (Fig. 23). 어깨에걸릴수있으므로 out of plane 술기가좀더권장된다. 목표로하는후방관절을종축영상의중심에놓고 90도회전하면그관절에대한횡축영상을얻게되는데여기에대하여 in-plane 술기로후방에서전방으로바늘을삽입할수도있다 (Fig. 24). 21) 이때횡축영상만으로 level을확인하는좀더쉬운방법으로저자들이사용하는방법이있다. 경부가장원위부측면에서횡축영상으로늑골을찾은후근위부로올라오면두개의산봉우리가접해있는양상의제7경추횡돌기와제1늑골이만나는, 마치관절을형성하는듯한지점을찾은후 (Fig. 25), 탐촉자를그대로횡축을유지한채근위부로이동하
90 Seung Deok Sun, et al. 면첫번째보이는후방관절이제6, 7경추간이된다. 거기서계속하여근위부로이동하며후방관절의 level을확인하면쉽게원하는 level을찾을수있다. Narouze와 Provenzano 20) 는복와위자세를취하고후방에서시행하는관절내차단술이여러 level이나양측으로할때유리하다고보고하였는데술기는다음과같다. 환자후면의정중앙에서종축영상을극돌기들에대하여얻은후외측으로탐촉자를이동하여톱니모양혹은기왓장을포개놓은듯한후방관절들의영상을얻는다. 여기서바늘을 in-plane 술기로원위부에서근위부를향해관절면으로삽입하는데관절면의방향과바늘의방향이일치하므로관절면을따라삽입이쉬운장점이있다. 성상신경절차단술 (stellate ganglion block) 은심한상지의통증이나복합부위통증증후군에서시도되는강력한차단술로하부경추및제1흉추교감신경절이별모양으로합쳐진부위를차단하는술기이다. 이신경절은제6경추에대한횡축영상에서경장근보다표층, 경동맥의심부에있는척추전근막 (prevertebral fascia) 의심부에위치하므로이부위를목표로경정맥을뚫고바늘을외측에서내측으로경사지게 in-plane 술기로삽입하여척추전근막을뚫자마자주사하거나하키스틱같은직경이작은탐촉자를이용하여압박을가해피부와신경절의간격을최소화하며갑상선과경동맥이약간벌어지게한후이사이간격으로피부에대해거의직각에가까운각도로탐촉자바로옆에서찔러서바늘을삽입하는방법이있다 (Fig. 26). 이외에도경추부에서는경신경총차단, 초음파유도하증식치료, 안면부의삼차신경분지들에대한차단술등아주다양한시술들을초음파를이용하여시행할수있다. 결론 경추부에서초음파유도하시술은방사선피폭없이실시간으로주요신경과혈관의위치를확인함으로써그구조물에대한손상혹은주사를방지하며척수손상등의심각한합병증을예방하면서효과적으로시행할수있는유용한치료방법이다. ONFLITS OF INTEREST The authors have nothing to disclose. REFERENES 1. Rathmell JP, prill, ogduk N. ervical transforaminal injection of steroids. nesthesiology. 2004;100:1595-600. 2. Tiso RL, utler T, atania J, Whalen K. dverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4:468-74. 3. aker R, Dreyfuss P, Mercer S, ogduk N. ervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003; 103:211-5. 4. Provenzano D, Fanciullo G. ervical transforaminal epidural steroid injections: should we be performing them? Reg nesth Pain Med. 2007;32:168. 5. Scanlon G, Moeller-ertram T, Romanowsky SM, Wallace MS. ervical transforaminal epidural steroid injections: more dangerous than we think? Spine (Phila Pa 1976). 2007; 32:1249-56. 6. Suresh S, erman J, onnell D. erebellar and brainstem in farction as a complication of T-guided transforaminal cervical nerve root block. Skeletal Radiol. 2007;36:449-52. 7. Moon SH. Ultrasound-guided intervention in cervical spine. J Korean Orthop US Soc. 2014;1:49-66. 8. Nakagawa M, Shinbori H, Ohseto K. Ultrasound-guided and fluoroscopy-assisted selective cervical nerve root blocks. Masui. 2009;58:1506-11. 9. Narouze SN, Vydyanathan, Kapural L, Sessler DI, Mekhail N. Ultrasound-guided cervical selective nerve root block: a fluoroscopy-controlled feasibility study. Reg nesth Pain Med. 2009;34:343-8. 10. Razzaq, O'rien D, Mathew, artlett R, Taylor D. Efficacy and durability of fluoroscopically guided cervical nerve root block. r J Neurosurg. 2007;21:365-9. 11. Martin D, Willis ML, Mullinax L, larke NL, Homburger J, erger IH. Pulsed radiofrequency application in the treatment of chronic pain. Pain Pract. 2007;7:31-5. 12. nderberg L, nnertz M, Rydholm U, randt L, Säveland H. Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine. Eur Spine J. 2006;15:794-801. 13. Galiano K, Obwegeser, odner G, et al. Ultrasound-guided periradicular injections in the middle to lower cervical spine: an imaging study of a new approach. Reg nesth Pain Med. 2005;30:391-6. 14. Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasoundguided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study. Skeletal Radiol. 2013;42:69-78. 15. Yamauchi M, Suzuki D, Niiya T, et al. Ultrasound-guided cer-
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92 pissn : 1226-2102, eissn : 2005-8918 Symposium J Korean Orthop ssoc Seung 2015; Deok 50: 77-92 Sun, et al. http://dx.doi.org/10.4055/jkoa.2015.50.2.77 www.jkoa.org 초음파를이용한척추중재술 경추부초음파유도하중재술 선승덕 장병권 * 문상호 * 선정형외과의원, * 서울성심병원정형외과 경추부에서전통적으로사용되고있는방사선투시하중재술은환자에게뿐만아니라시술하는의사에게도방사선의위험에노출이될수밖에없다. 더구나방사선투시하에서는혈관과신경을직접볼수없기때문에환자들에게도시술에대한위험성이높았던것이사실이다. 그런데최근해상도가높은초음파들이개발되어실시간동영상하에서연부조직의구조물들을확인하며시술할수있게되었다. 경추부신경근차단술, 후방분지차단술, 그리고여러가지중재술들이초음파유도하에서가능해진것이다. 이러한술기는외래에서도간편하게통증의원인을감별하고치료하는데있어서유용하게사용되고있다. 또한초음파는방사선이없고간편하며주사하는동안실시간으로계속영상을제공함으로써주사제가퍼져나가는양상을파악할수있어시술의정확도를높일수있는술기이다. 결국초음파유도하시술은주요신경과혈관의위치를확인하면서그에대한손상혹은주사를피할수있기때문에이러한구조물들의손상위험이높은경추부에서안전하게시행할수있다는중요한장점이있는술기이다. 그리하여저자는실시간초음파유도하라는술기가경추부중재술에서얼마나유용한가에대해분석하여기술하였다. 색인단어 : 경추, 초음파, 중재술 접수일 2015 년 3 월 9 일수정일 2015 년 4 월 2 일게재확정일 2015 년 4 월 15 일책임저자문상호서울시동대문구왕산로 259, 서울성심병원정형외과 TEL 02-966-1616, FX 02-968-2394, E-mail msh124@paran.com 대한정형외과학회지 : 제 50 권제 2 호 2015 opyright 2015 by The Korean Orthopaedic ssociation This is an Open ccess article distributed under the terms of the reative ommons ttribution Non-ommercial 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.