Original Article doi:http://dx.doi.org/10.5397/cise.2012.15.2.109 대한견 주관절학회지제15권제2호 Clinics in Shoulder and Elbow Volume 15, Number 2, December, 2012 주관절부척골신경병증에서의초음파소견및유용성 계명대학교의과대학동산의료원정형외과학교실 김동후 조철현 이경락 Ultrasonographic Findings and Usefulness in Ulnar Neuropathy at the Elbow Dong-Hu Kim, M.D., Chul-Hyun Cho, M.D., Ph.D., Kyung-Rak Lee, M.D. Department of Orthopedic Surgery, School of Medicine, Dongsan Medical Center, Keimyung University, Daegu, Korea Purpose: The aim of this study was to evaluate preoperative ultrasonographic findings and usefulness in ulnar neuropathy around elbow. Materials and Methods: Twenty-two patients with ulnar neuropathy were performed preoperative ultrasonogram. The route, location, thickness of the ulnar nerve and space occupying lesion through longitudinal scan were evaluated. Cross-sectional areas of the ulnar nerve were measured at the level of medial epicondyle and 3 cm proximal and distal to the medial epicondyle through axial scan. Correlations between swelling ratio of ulnar nerve and eletrophysiologic study and preoperative Dellon s assessment were checked. Results: In 21 cases (95.6%) of total 22 cases, diffuse swelling of the ulnar nerve around elbow were identified. 4 cases had space occupying lesions including 3 ganglionic cysts and 1 heterotopic ossification. Cross sectional areas at the level of medial epicondyle were significantly larger than at the level of 3 cm proximal and distal to the medial epicondyle (p<0.05). There were no statistically significant correlations between swelling ratio of ulnar nerve and eletrophysiologic study and preoperative clinical assessment (p>0.05). Conclusion: This study showed that ultrasonography was helpful to detect etiology of ulnar neuropathy around elbow such as space occupying lesion, morphological change or dislocation of ulnar nerve. It could be useful tool for diagnosis and treatment in patients with ulnar neuropathy at elbow. Key Words: Elbow, Ulnar nerve, Ultrasonography 통신저자 : 조철현대구광역시중구달성로 56 계명대학교의과대학동산의료원정형외과학교실 Tel: 053) 250-8160, Fax: 053) 250-7205, E-mail: oscho5362@dsmc.or.kr 접수일 : 2012 년 3 월 7 일, 1 차심사완료일 : 2012 년 5 월 21 일, 2 차심사완료일 : 2012 년 7 월 31 일, 3 차심사완료일 : 2012 년 8 월 28 일, 게재확정일 : 2012 년 9 월 15 일 109
대한견 주관절학회지제 15 권제 2 호 서 론 연구대상및방법 주관절부척골신경병증은상지에서두번째로흔한신경포착증후군 (nerve entrapment syndrome) 으로척골신경감각지배영역의이상감각과수부내재근과소지구근들의근력약화와근위축등을호소할수있다. 주관절부척골신경병증은자세한병력청취와진찰검사, 전기생리학적검사를통해진단되며, 보존적치료에반응이없거나근력약화가진행되는경우에는여러가지수술적요법을시행할수있다. 1) 척골신경병증의진단에있어서전기생리학적검사는확진을할수있는중요한검사이지만, 검사시통증, 부정확한위치, 위양성등에의해그민감도는 37~86% 까지보고되고있다. 2-6) 또한여러저자들에의해진찰검사및전기생리학적검사만으로는술전에척골신경병증의원인을파악하기에는한계가있음이지적되었다. 7) 1990 년이후지속적인초음파의발전과함께최근고해상도초음파및탐색자가개발되어신경포착증후군의새로운진단도구로서초음파가널리활용되고있다. 4,8) 주관절부척골신경병증에서의초음파검사는척골신경의주행및형태학적변화외에도종물또는골극등의주변조직의병변에대한확인이가능하여진단뿐만아니라그원인을아는데에도많은정보를제공한다는장점이있다. 9,10) 하지만수근관증후군다음으로흔한주관절부척골신경병증에대한초음파의유용성에대한연구는현재까지그리많지않은실정이다. 3-6,11) 이에저자들은주관절부척골신경병증에서술전에시행한초음파소견과그유용성에대하여알아보고자하였다. 2007년 5월부터 2011년 1월까지본원에내원하여진찰검사는전기생리학적검사로주관절부척골신경병증을진단받고수술적요법을계획하기전초음파검사를시행한 22예를대상으로후향적으로연구하였다. American Association of Electrodiagnostic Medicine 12) 에의거한전기생리학적검사상주관절부위에서척골신경의운동또는감각신경전달속도가 50.0 m/sec 이하인경우, 또는탈신경전위 (denervation potential) 의소견을보이는경우에양성으로판단하였다. 총 22 예중남자가 15 예, 여자가 7예였고평균연령은 56 (28~81) 세였다. 증상발현부터수술까지의기간은평균 12.3 (1~120) 개월이었고, 우세수가 15예, 비우세수가 7예였다. 평균추시기간은평균 27.5 (6~49) 개월이었다. 발병원인으로는특발성인경우가 8예였으며, 이차성으로발생한경우가 14 예로, 그중퇴행성관절염으로인한주관절구축이 10 예, 결절성낭종이 3예, 주관절탈구후발생한이소성골화가 1 예, 특발성인경우가 8예였다. 모든예에서전기생리학적검사를시행하였으며, Volpe s severity 분류법 4) 에따라경도, 중등도, 고도의 3단계로나누었다 (Table 1). 초음파검사는전예에서 IU22 (Philips Medical System, Bothell, WA, USA) 고해상도초음파에부착된 12-17MHz의선형탐색자를이용하였다. 모든검사는한명의방사선과전문의에의해시행되었으며, 반측와위자세에서주관절을신전한상태로시행되었다 (Fig. 1). 장축영상을통해척골신경의주행경로 Table 1. Volpe s severity classification 4) according to electrophysiologic study Severity Presence of one of the following Mild (1) reduced motor conduction velocity (MCV) > 10 m/s across the elbow (segment below-above elbow), compared with the more distal segment (wrist-below elbow), from the muscle I dorsal interosseus (IDI) or abductor digiti minimi (ADM), plus increase F-wave (compared with the unaffected side or normative value); (2) reduced amplitude of sensory nerve action potentials (SNAPs) at IV and/or V finger (compared with the unaffected side or normative value). Moderate (1) point 1 plus 2 of the previous grade; (2) motor conduction block from IDI or ADM at the elbow; (3) reduced amplitude of proximal compound muscle action potential (CMAP) across the elbow from IDI or ADM >20 but <50% and/or abnormal EMG of ulnar hand muscles (acute and chronic denervation potentials) and/or SNAPs absence. Severe (1) complete motor conduction block alone across the elbow from ID or ADM plus other abnormalities (point 3 of previous grade); (2) reduced amplitude of proximal CMAP across the elbow from IDI or ADM >50%; (3) severe axonal involvement of ulnar nerve with SNAPs abnormalities and abnormal EMG of ulnar hand muscles (acute and chronic denervation potentials) 110
김동후 : 주관절부척골신경병증에서의초음파소견및유용성 와위치, 신경의굵기를파악하고, 단축영상을통해내상과근위부 3 cm, 내상과후방부위, 내상과원위부 3 cm에서의척골신경의단면적 (cross sectional area) 을측정하였다. 척골신경부종비 (swelling ratio of ulnar nerve) 는내상과근위부척골신경의단면적을내상과후방부위의단면적으로나눈값으로 정의하였다. 또한척골신경의탈구, 아탈구, 결절성낭종과같은관절내공간점유병소및해부학적변이를확인하였다. 수술은모든예에서척골신경감압술및피하전방전위술을시행하였다. 술전환자의평가는이상감각, 진동감각, 근력약화, 근위축유무와주관절굴곡검사, 티넬증후의결과에따른 Dellon의 4단계분류법 13) ( 정상, 경도, 중등도, 고도 ) 을이용하였으며, 술후임상적평가는 Akahori s criteria 14) 를사용하여평가하였다. 통계학적인분석은성별, 근력약화유무, 골관절염의유무, 원인, 술전환자의평가와술후임상적평가와의상관관계를알아보기위해 t- 검정및나이및척골신경의부종비와술후임상적평가와의상관관계를알아보기위해 Kruskal-Wallis 검정법을이용하였으며, 통계적유의수준은 p값이 0.05 미만인경우로하였다. 결 과 Fig. 1. Ultrasonographic examination is performed at semi-lateral decubitus position with elbow extension. Dellon 분류법에의한술전임상적평가는경도가 4 예 (18.2%), 중등도가 6예 (27.3%), 고도가 12예 (54.5%) 였으며, 전기생리적검사결과는 Volpe s severity 분류법에따라경도가 8예 (36.4%), 중등도가 7예 (31.8%), 고도가 7예 (31.8%) 였다. Akahori s 분류법에따른술후임상적평가는우수가 8예 (36.4%), 양호가 10예 (45.5%), 보통이 3예 (13.6%), 불량이 1예 (4.5%) 였다 (Table 2). Del- A B C D E Fig. 2. Intraoperative photograph and corresponding ultrasonography. (A) Longitudinal image at elbow joint showed the ulnar nerve with segmental swelling (white arrows) at the elbow joint level. (B) Axial image at the level of 3cm proximal to the medial epicondyle (cross sectional area : 4.9 mm 2 ). (C) Axial image at the level of the medial epicondyle (cross sectional area : 23.5 mm 2 ). (D) Axial image at the level of 3cm distal to the medial epicondyle (cross sectional area : 6.8 mm2). (E) Intraoperative photograph demonstrated segmental swelling of the ulnar nerve at retrocondylar area. 111
대한견 주관절학회지제 15 권제 2 호 Table 2. Clinical data of 22 patients Case Age/Sex Cause Ultrasonographic findings CSA CSA CSA Swelling ratio Severity classification Preop* stage Postop* outcome above ME* at ME below ME of ulnar nerve* by EPS* (Dellon) (Akahori s) 1 59/M idiopathic diffuse nerve swelling 8.0 17.6 6.9 2.2 mild severe excellent 2 56/M osteoarthritis diffuse nerve swelling 3.6 18.8 6.8 5.2 severe severe good 3 39/M idiopathic 1.5 cm short segment nerve swelling 4.0 6.6 8.7 1.6 severe severe excellent 4 65/F ganglionic cyst multi-locular cystic mass 6.4 8.5 7.2 1.3 moderate mild excellent 5 58/F osteoarthritis diffuse nerve swelling 6.0 25.0 5.0 4.1 moderate severe good 6 41/F idiopathic minimal nerve swelling 4.0 6.6 4.5 1.6 moderate severe good 7 68/F osteoarthritis loss of normal fascicular pattern 6.0 21.0 7.0 3.5 severe severe fair 8 36/M idiopathic minimal nerve swelling 5.2 5.9 5.3 1.1 mild moderate poor 9 49/M idiopathic normal 9.0 7.0 6.0 0.7 mild severe excellent 10 55/M osteoarthritis fusiform nerve swelling 4.9 23.5 6.8 4.8 severe moderate fair 11 66/M osteoarthritis diffuse nerve swelling 5.0 13.0 6.0 2.6 moderate moderate excellent 12 54/M ganglionic cyst compression of nerve by cystic mass 4.0 11.8 5.9 2.9 moderate severe excellent 13 34/M trauma diffuse nerve swelling & dislocation 7.4 13.8 5.4 1.8 severe moderate good 14 50/M idiopathic diffuse nerve swelling 4.0 12.0 7.0 3.0 moderate severe good 15 64/M idiopathic diffuse nerve swelling 4.0 17.1 5.0 4.2 mild severe good 16 60/F osteoarthritis diffuse nerve swelling 7.0 15.0 7.0 2.1 mild mild good 17 63/M osteoarthritis diffuse nerve swelling 3.5 14.2 6.0 4.0 severe severe excellent 18 81/F ganglionic cyst compression of nerve by cystic mass 4.5 13.3 6.3 3.0 mild moderate good 19 61/F osteoarthritis diffuse nerve swelling 4.4 30.5 7.6 6.9 severe mild good 20 71/M osteoarthritis diffuse nerve swelling 5.7 20.7 4.5 3.6 moderate severe good 21 58/M osteoarthritis diffuse nerve swelling 8.3 17 5.5 2.1 mild mild fair 22 28/M idiopathic diffuse nerve swelling 5.1 13.2 8.3 2.6 mild moderate excellent CSA*: cross sectional area (mm 2 ), EPS*: electrophysiologic study, ME*: medial epicondyle, Preop*: Preoperative, Postop*: Postoperative, Swelling ratio of ulnar nerve*, ulnar nerve dimension ratio at medial epicondyle versus 3 cm above at medial epicondyle via ultrasonogram. 112
김동후 : 주관절부척골신경병증에서의초음파소견및유용성 lon 분류법및 Volpe s severity 분류법에따른술전평가는최종추시시임상적결과와통계학적유의성이없었다 (p>0.05). 수술전시행한초음파검사상총 22예중 21예 (95.5%) 에서주관절부척골신경의미만성부종 (diffuse swelling) 소견이관찰되었으며 (Fig. 2). 이중공간점유병소는 4예로, 결절성낭종에의한척골신경압박이 3예, 주관절탈구후발생한이소성골화및척골신경의탈구가 1예있었다. 내상과근위부 3 cm 에서의척골신경의평균단면적은 5.5±1.6 mm 2, 내상과후방부에서는 15.5±6.3 mm 2, 내상과원위부 3 cm 에서는 6.3±1.1 mm 2 였으며, 평균척골신경부종비는 3.0±1.5 였다 (Table 2). 내상과후방부척골신경의평균단면적이근위부및원위부의평균단면적보다통계학적으로유의하게컸다 (p<0.05). 발병원인 ( 특발성, 이차성 ) 과술전및술후임상적평가와는통계학적유의성은없었고 (p<0.05), 척골신경부종비와는통계학적차이가있었다 (p=0.049). 척골신경부종비는 Volpe s severity 분류법및 Dellon 분류법에따른결과와통계학적유의성을가지지않았다 (p>0.05). 초음파검사상공간점유병소가있었던 4예모두술후만족할만한결과를나타내었으나, 공간점유병소가있었던 4예와공간점유병소가없었던 18 예와의술후임상적결과에대한통계학적인유의성은없었다 (p>0.05). 또한나이, 성별, 우세수, 증상기간, 원인, 척골신경부종비와최종추시시임상적결과와의통계학적유의성은없었다 (p>0.05) (Table 3). 고찰주관절부척골신경병증의주요원인으로퇴행성관절염, 외상, 외반주같은주관절변형, 내상과의부정유합또는불유합, 주관절의불안정성, 주관내의골극이나골편, 종양, 근육의해부학적변이, 척골신경의탈구나아탈구등이있을수있다. 주관절부척골신경병증의진단에있어서전기생리학적검사는진단을위해필수적이라할수있지만, 민감도가낮으며단독검사만으로는술전에그원인을정확히파악이어려워확진검사에대한논란이있다. 2-6) 최근고해상도초음파가신경포착증후군의새로운진단도구로활용되고있으며, 특히말초신경의형태학적인흐름, 종양및구조적비정상, 여러해부학적변형등을확인할수있어그유용성이보고되고있다. 9,10) 초음파를이용한신경검사는검사자의경험에의존적이고주관적이란단점이있지만비침습적이고역동적영상을얻을수있으며, 자기공명영상에비해비용적및시간적측면에서도장점이있다. 2) Park 등 3) 은 13 예의척골신경병증환자에서주관절신전상태에서시행한초음파검사상내상과후방에서신경이압박될경우그근위부의신경부종이명확하고굴곡지대가두꺼워지는소견이관찰되며, 척골신경의형태학적변화및병변의범위를확인함으로주관절부척골신경병증의 screening 뿐만아니라추시관찰의도구로서의유용성을보고하였다. Okamoto 등 7) 은진찰검사및전기생리학적검사만으로는술전에척골신경병증의원인을파악하기에는 Table 3. Analysis between final clinical outcomes and variables Final clinical outcome according Akahori s criteria excellent good fair poor p-value Gender (%) male 7 (46.7) 5 (33.3) 2 (13.3) 1 (6.7) 0.317 female 1 (14.3) 5 (71.4) 1 (14.3) 0 (0.0) Side (%) non-dominant 2 (28.6) 3 (42.9) 1 (14.3) 1 (14.3) 0.709 dominant 6 (40.0) 7 (46.7) 2 (13.3) 0 (0.0) Sx. Duration < 1 year 6 (42.9) 6 (42.9) 1 (7.1) 1 (7.1) 0.726 1 year 2 (25.0) 4 (50.0) 2 (25.0) 0 Cause(%) ganglionic cyst 2 (66.7) 1 (33.3) 0 (0.0) 0 (0.0) 0.505 osteoarthritis 2 (20.0) 5 (50.0) 3 (30.0) 0 (0.0) trauma 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) idiopathic 4 (50.0) 3 (37.5) 0 (0.0) 1 (12.5) Space occupying no 6 (33.3) 8 (44.4) 3 (16.7) 1 (5.6) 1.000 lesion (%) yes 2 (50.0) 2 (50.0) 0 (0.0) 0 (0.0) Preop. Dellon (%) mild 1 (25.0) 2 (50.0) 1 (25.0) 0 (0.0) 0.765 moderate 2 (33.3) 2 (33.3) 1 (16.7) 1 (16.7) severe 5 (41.7) 6 (50.0) 1 (8.3) 0 (0.0) 113
대한견 주관절학회지제 15 권제 2 호 한계가있으며, 초음파검사를통하여신경압박부위의확인과함께골극, 종양, 해부학적이상, 이소성골화등의압박원인을알수있어술전초음파의유용성을강조하였다. 또한초음파소견을통해신병증의진행정도까지알수있음을보고하였다. 저자들의연구에서도수술전시행한초음파검사상총 22 예중 21 예 (95.5%) 에서주관절부척골신경의미만성부종소견이있었으며, 이중 4예에서결절성낭종또는이소성골화등의공간점유병소로인하여척골신경압박되는소견을관찰할수있었다. 또한내상과후방부척골신경의평균단면적이근위부및원위부의평균단면적보다통계학적으로유의하게컸음을확인할수있었다. 본연구결과에서나타나듯이술전초음파의민감도가 95.5% 로매우높았으며, 척골신경의형태학적변화를알수있을뿐만아니라공간점유병소또는신경탈구등의신경병증원인을파악하는데도움이되었던것으로보아주관절부척골신경병증의진단에있어서초음파의유용성을확인하였다할수있겠다. Volpe 등 4) 은척골신경병증의환자를대상으로내상과근위부 4 cm, 내상과, 내상과원위부 4 cm에서각각의척골신경의단면적을측정하여척골신경의부종의정도와전기생리학적검사와비교연구한결과초음파를주관증후군의진단뿐아니라척골신경병증의정도역시파악할수있었다고보고하였다. Yoon 등 6) 도초음파로측정한주관내척골신경의단면적과신경전도속도와의연관성이있음을보고하였다. Bayrak 등 11) 도역시주관증후군환자에서척골신경의부종정도를초음파하에확인하여그비를계산한결과민감도와특이도가 95% 와 85% 에달하였으며특히가장넓은단면적과전기생리검사학적검사와상관관계를확인하였으며주관증후군의진단적도구로초음파의유용성을보고하였다. 본연구에서는위저자들의보고와는달리척골신경의부종의정도를나타내는척골신경부종비는전기생리학적검사를바탕으로한 Volpe s severity 분류법및술전 Dellon 분류법에따른결과와통계학적유의성을가지지않는것으로나타나신경병증의정도와의연관성을입증하지못하였다. 이는척골신경병증에서초음파가민감도가높고원인을파악하는데많은도움이될수있지만, 신경병증의정도를알기에는초음파또한한계가있음으로해석할수있다. 그러나, 본연구는후향적연구이기때문에그결과를정확히판단하기에는제한점이있으므로, 향후전향적연구를통하여초음파소견과신경병증의정도와의연관성을알아보아야할것으로생각된다. 척골신경병증에서술후결과에영향을미치는요인으로는나이, 증상기간, 원인, 술전임상적상태등으 로알려져있다. 나이가많을수록, 증상기간이길수록, 술전임상적상태가심할수록술후임상적결과가좋지않다는보고가있는반면, 이러한요인들이술후임상적결과에영향을미치지않는다는보고도있다. 15-18) 본연구에서는나이, 성별, 우세수, 증상기간, 원인, 초음파상척골신경부종비등과최종추시시임상적결과와의통계학적유의성을보이지않았다. Kato 등 19) 은결절성낭종에의한척골신경병증은주로골관절염과연관이있고증상의발현이다른원인보다는급성으로나타난다고하였으며, 척골신경피하전방전위술로만족스러운결과를나타낸다고보고하였다. 본연구에서총 3예중 2예는증상기간이 1개월이었고 1예는 4개월로평균증상기간인 12.3개월보다짧은증상기간을보였으며, 모두만족할만한결과를나타내었다. 본연구는몇가지제한점이있다. 첫째, 표본수가적고후향적연구라는점이다. 둘째, 정상적인척골신경과의단면적비교가없었고, 전예가위축없이부종소견을보였다는점이다. 셋째, 수술후초음파를이용한추시관찰을시행하지않아척골신경부종의회복정도등을관찰하지못하였다는점이다. 향후대규모의증례를대상으로한전향적대조연구를통하여초음파의유용성을증명하는것이필요할것으로판단된다. 결 주관절부척골신경병증에서의초음파검사로신경의형태학적변화를알수있을뿐만아니라공간점유병소또는신경탈구등의원인을파악하는데도움이되었다. 초음파검사는전기생리학적검사와더불어척골신경병증의정확한진단및치료방법의선택에유용한방법으로판단된다. 론 REFERENCES 1) Macadam SA, Bezuhly M, Lefaivre KA. Outcomes measures used to assess results after surgery for cubital tunnel syndrome: a systematic review of the literature. J Hand Surg Am. 2009;34:1482-91. 2) Jeon IH, Lee SM, Choi JW, Kim PT. Dynamic morphologic study of the ulnar nerve around the elbow using ultrasonography. J Korean Shoulder Elbow Soc. 2007;10:99-105. 3) Park GY, Kim JM, Lee SM. The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow. Arch Phys Med Rehabil. 2004;85:1000-5. 4) Volpe A, Rossato G, Bottanelli M, et al. Ultrasound evaluation of ulnar neuropathy at the elbow: correlation with electrophysiological studies. Rheumatology. 114
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대한견 주관절학회지제 15 권제 2 호 초록 목적 : 주관절부척골신경병증에서술전에시행한초음파소견과그유용성에대하여알아보고자하였다. 대상및방법 : 척골신경병증을진단받고술전초음파검사를시행한 22 예를대상으로하였다. 장축영상을통해척골신경의주행경로, 위치, 굵기와신경주위공간점유병소등을확인하였고, 단축영상을통해내상과근위부 3 cm, 후방, 원위부 3 cm에서의단면적및척골신경부종비를측정하여전기생리학적검사및술전임상적평가와의연관성을파악하였다. 결과 : 초음파검사상총 22 예중 21 예 (95.5%) 에서주관절내상과후방부에척골신경의미만성부종소견이관찰되었다. 이중공간점유병소는 4예로, 결절성낭종이 3예, 이소성골화가 1예있었다. 내상과부위척골신경의평균단면적이근위부및원위부의평균단면적보다통계학적으로유의하게컸다 (p<0.05). 척골신경부종비는전기생리학적검사및술전임상적평가와통계학적유의성을가지지않았다 (p>0.05). 결론 : 주관절부척골신경병증에서의초음파검사로신경의형태학적변화를알수있을뿐만아니라공간점유병소또는신경탈구등의원인을파악하는데도움이되었다. 초음파검사는전기생리학적검사와더불어척골신경병증의정확한진단및치료방법의선택에유용한방법으로판단된다. 색인단어 : 주관절, 척골신경, 초음파 116