18-성창민/

대한견 주관절학회지제 13 권제 1 호 J. of Korean Shoulder and Elbow Society Volume 13, Number 1, June, 2010 극관절와결절성낭포의관절경적감압술및상부관절와순봉합술후잔존낭포의경과 - 증례보고 - 경상대학교의학전문대학원정형외과학교실 성창민 이상혁 박형빈 The Follow Up Results of Residual Spinoglenoid Ganglion Cyst after Arthroscopic Decompression and Superior Labral Repair - Cases Report - Chang-Meen Sung, M.D., Sang-hyuk Lee, M.D., Hyung Bin Park, M.D., Ph.D. Department of Orthopedic Surgery, School of Medicine, Gyeongsang National University, Jinju, Korea Purpose: There are many known treatment modalities for spinoglenoid ganglion cyst accompanied by suprascapular nerve palsy. However, to the author s knowledge, there is no report on the follow-up outcomes focused on remnant cysts. Materials and Methods: Six (n=6) patients with spinoglenoid ganglion cyst accompanied by suprascapular nerve palsy, with a mean follow-up of 15 months (12-23months) following arthroscopic cyst decompression and superior labral repair, were enrolled. Residual cyst was investigated by ultrasonography and MRI. Results: Immediate postoperative ultrasonography revealed complete remission of ganglion cyst in one patient and reduced ganglion cyst size in five patients. Three-month follow-up ultrasonography showed spontaneous complete remission of the residual cysts in all patients. No recurrence on MRI was seen at one-year follow-up. Conclusion: Residual spinoglenoid ganglion cyst remaining after arthroscopic decompression and superior labral repair tends to resolve spontaneously within 3 months of surgery. Key Words: Spinoglenoid ganglion cyst, Superior labral lesion, One-way check valve, Arthroscopic decompression 통신저자 : 박형빈경상남도진주시칠암동 90 번지경상대학교의학전문대학원정형외과학교실 Tel: 055) 750-8688, Fax: 055) 761-9477, E-mail: hbinpark@gnu.ac.kr 접수일 : 2010 년 3 월 23 일, 1 차심사완료일 : 2010 년 4 월 1 일, 2 차심사완료일 : 2010 년 4 월 26 일, 게재확정일 : 2010 년 5 월 7 일 111

대한견 주관절학회지제 13 권제 1 호 서론극관절와결절성낭포에의해견갑상신경마비까지동반하는경우는흔치않으며, 일반적으로상부관절와순전후방병변과동반된경우가많은것으로알려져있다 2,4). 여러가지치료방법이알려져있으나 7,10), 최근에는관절경적감압술및상부관절와순봉합술을흔히시행한다 3,9). 관절경적감압술및상부관절와순봉합술후임상적결과에관한보고는있지만 3,9), 술후잔존낭포의경과에관한보고는미미한실정이다. 저자들은관절경적감압술및상부관절와순봉합술을시행한 6 예의치료결과를잔존낭포의경과를중심으로보고하고자한다. 술전실시한자기공명영상소견상평균 3.9 5.6 3.3 cm (3-6/5.2-7/2.1-4) 크기의큰극관절와결절성낭포를확인할수있었고 (Fig. 2), 근전도검사로견갑상신경의마비를확진하였다. 증례보고 견갑상신경마비를동반한극관절와결절성낭포로진단된 6예 ( 남자 : 5예, 여자 : 1예 ) 를대상으로하였고, 평균나이는 45.2 (33~61) 세였다. 병변은모두우세수 ( 우측 : 5, 좌측 : 1예 ) 였으며, 평균추시기간은 15 (12~23) 개월이었다. 평균 9.6 (2~24) 개월전부터시작된견관절후방부의동통및견관절의근력약화를주소로내원하였으며, 외상이나수술을시행받은과거력은없었다. 신체검사상환측견관절의평균운동범위는전방거상 157 (150~160) 도, 외회전 49.1 (45~60) 도, 내회전 T6.17 (T5~T7), 외전 153.2 (150~160) 도로관절운동범위의제한은미미하였다. 시진으로쉽게관찰할수있을정도로극하근의위축이있었으며, 외회전근력이모두 Grade 4로약화되어있었다 (Fig. 1). Fig. 2. Preoperative MR images demonstrated the spinoglenoid ganglion cysts, which were placed closely near the superior glenoid labrum. Fig. 1. These clinical pictures demonstrate the atrophied right side infraspinatus muscle (arrows). 112

성창민 : 극관절와결절성낭포의관절경적감압술및상부관절와순봉합술후잔존낭포의경과 - 증례보고 - A B C Fig. 3. Three arthroscopic pictures show (A) The superior labral lesion, (B) Leakage of gelatinous liquid cystic material under superior labrum during decompression procedure, and (C) The status of superior labral repair. Table 1. The demographic, clinical, imaging and EMG data. Case Preoperative Postoperative F/U F/U No. Sex Age FF* IR ER ABD cyst size (cm) cyst size(cm) 3months 12months EMG** (MRI ) (US ) (US ) (MRI ) 1 M 33 160 T6 45 160 3 6 4 1.2 2 1.5 Remission Remission Full recovery 2 M 45 150 T7 50 160 6 5.5 4 3.3 3 1.7 Remission Remission Full recovery 3 M 33 150 T5 45 150 3 6.5 2.1 Remission Remission Remission Full recovery 4 M 54 160 T6 45 160 4.9 7 3.5 2.5 3 1.2 Remission Remission Full recovery 5 M 61 160 T6 50 140 3.4 5.2 2.6 1.9 2.7 0.9 Remission Remission Partial recovery Full recovery 6 F 53 160 T7 60 150 3.2 3.8 3.3 1.5 3.7 0.5 Remission Remission Mean 46.5 157 T6.17 49.1 153.2 3.9 5.6 3.3 2.1 2.9 1.2 *FF: Forward flexion. IR: Internal rotation. ER: External rotation. ABD: Abduction. MRI: Magnetic resonance image. US: Ultrasonography. **EMG: Electromyography. 113

대한견 주관절학회지제 13 권제 1 호 진단적관절경상전례에서상부관절와순전후방병변과낭포와관절사이에비정상적인연결을확인할수있었다 (Fig. 3A). 결정성낭포의감압술은탐촉자를이용하여관절과낭포의연결부를확장후낭포를압박하여시행하였으며, 이후상부관절와순봉합술을시행하였다 (Fig. 3B, 3C). 동일술자가수술직후와술후 3개월째초음파를이용하여장축영상 (long axis view) 에서측정한길이, 높이와단축영상 (transverse axis view) 에서측정한너비를이용하여잔존낭포의크기를측정하였다. 술후 1년째자기공명영상을이용하여재발여부를관찰하였다. 수술직후시행한초음파상 1예에서낭포가완전소실되었으나, 나머지 5예에서는평균 2.1 2.9 1.2 cm (1.2-3.3/2-3.7/0.7-1.7) 크기의낭포가잔존하였다 (Fig. 4A). 술후 3개월에시행한초음파상전례에서낭포가완전소실되었으며 (Fig. 4B), 술후 1년에시행한자기공명영상에서재발은없었다 (Fig. 5), (Table 1). 5예에서술후평균 11 개월 (9~13) 에극 하근의근력및근위축이건측과비교하여완전히회복되었다 (Fig. 6). 그러나 1예의경우, 술후 12 개월째술전과비교하여호전되었지만 Grade 5-로건측과비교하여여전히근력약화가있었다. 술후 1년에시행한근전도검사에서도 5예에서견갑상신경마비가완전회복되었지만, 1예에서는부분적인회복만을보였다. 고찰극관절와결절성낭포는흔히관절와순병변과동반되며, 영상의학적으로관절와순의병변이발견되지않는경우라도진단적관절경에서상부관절와순의병변과동반된경우가흔해몇몇저자들에의해두병변의관련성이보고된바있다 9,10). 극관절와결절성낭포의발생기전에대하여입증된명확한기전은없으나, 관절와순병변에의한한방향역행방지밸브 (one-way check valve) 효과에의해관절액이주위의조직으로유출되어발생하는것으로추론하고있다 2,10). A B Fig. 4. (A) The immediate postoperative ultrasonographies reveal the residual cysts with reduced size. (B) The residual ganglion cysts had been completely absorbed spontaneously demonstrated by the follow-up ultrasonography at 3 months after surgery. Fig. 5. The 1-year-follow-up MRI shows no recurrences of spinoglenoid ganglion cysts. Fig. 6. This figure demonstrated recovery of the atrophied infraspinatus muscle at 1 year after surgery. 114

성창민 : 극관절와결절성낭포의관절경적감압술및상부관절와순봉합술후잔존낭포의경과 - 증례보고 - 견갑상신경은경추 5번과 6번신경으로부터기시하여횡견갑인대밑으로견갑상절흔을통과한후극상근에지배분지를제공하고, 극와절흔을지나극하근을지배하는감각운동신경으로견갑상절흔과극와절흔부위에서흔히압박된다 8). 견갑상절흔에서압박된경우견관절통증, 극상근과극하근의근력약화및위축이나타나는반면, 극와절흔에서압박된경우는주로극하근에한정된증상만나타난다 4,8). 특징적인신체검사소견은견갑상신경압박에따른극하근의근력약화및위축이관찰되고, 극와절흔부압박시통증이유발되는경우이다. 확진은초음파, 자기공명영상, 진단적관절경으로가능하다 6). 비수술적치료방법으로흡인술이있으며, 수술적방법으로는개방적제거술, 관절경하낭포의감압술및상부관절와순봉합술, 상부관절와순단독봉합술등이있다 3,6,9,10). Piatt 등 6) 과 Antoniou 등 1) 은극관절와결절성낭포로유발된견갑상신경증에대한치료방법들의비교연구에서환자의만족도는수술적치료군이비수술적치료군보다높은만족도를보였다고하였고, 관절경을이용한감압술이개방적절제술과비교하여임상결과가비슷할뿐아니라, 관절내치료시동반병변의관찰이가능하고술후이환율이낮아관절경적수술을추천하였다. 많은후속연구들에서도관절경적감압술및관절와순봉합술이극관절와결정성낭포의치료법으로우수한결과를나타낸다고하여최근치료의대세를이루고있다 1,3,5,6,9). Schroder 등 9) 은낭포의감압없이관절와순병변의단독봉합만으로도추시결과낭포가소실되었다는보고를통해극관절와결절성낭포의발병원인으로한방향역행방지밸브효과가그기전이라는이론을지지하는근거를제시하였다. 본증례들에서도 6예중 5예에서수술직후시행한초음파에서는낭포가남아있었으나, 술후 3개월추시에서전례에서낭포가소실되었고, 술후 1년째재발이없었던것에근거하여잔존하는낭포는관절와순병변의봉합으로한방향역행방지밸브효과가제거됨으로써자연소실되었다고생각된다. 결론극관절와결절성낭포에대하여관절경적감압술및 상부관절와순봉합술로치료시, 낭포의완전한감압을시행하지않더라도잔존낭포는 3개월이내에자연소실되는경향이있었다. 하지만저자들의증례가적어명확한결론을위하여는보다많은증례연구가필요하다고생각한다. REFERENCE 1) Antoniou J, Tae SK, Williams GR, Bird S, Ramsey ML, Iannotti JP: Suprascapular neuropathy. Variability in the diagnosis, treatment, and outcome. Clin Orthop Relat Res, 386: 131-138, 2001. 2) Fehrman DA, Orwin JF, Jennings RM: Suprascapular nerve entrapment by ganglion cysts: a report of six cases with arthroscopic findings and review of the literature. Arthroscopy, 11: 727-734, 1995. 3) Iannotti JP, Ramsey ML: Arthroscopic decompression of a ganglion cyst causing suprascapular nerve compression. Arthroscopy, 12: 739-745, 1996. 4) Lee BC, Yegappan M, Thiagarajan P: Suprascapular nerve neuropathy secondary to spinoglenoid notch ganglion cyst: case reports and review of literature. Ann Acad Med Singapore, 36: 1032-1035, 2007. 5) Lichtenberg S, Magosch P, Habermeyer P: Compression of the suprascapular nerve by a ganglion cyst of the spinoglenoid notch: the arthroscopic solution. Knee Surg Sports Traumatol Arthrosc, 12: 72-79, 2004. 6) Piatt BE, Hawkins RJ, Fritz RC, Ho CP, Wolf E, Schickendantz M: Clinical evaluation and treatment of spinoglenoid notch ganglion cysts. J Shoulder Elbow Surg, 11: 600-604, 2002. 7) Rhee YG, Kim KI, Yang HS: Suprascapular Nerve Entrapment Neuropathy by Ganglion Cyst. J Korean Shoulder Elbow Soc, 2: 143-150, 1999. 8) Romeo AA, Rotenberg DD, Bach BR, Jr.: Suprascapular neuropathy. J Am Acad Orthop Surg, 7: 358-367, 1999. 9) Schroder CP, Skare O, Stiris M, Gjengedal E, Uppheim G, Brox JI: Treatment of labral tears with associated spinoglenoid cysts without cyst decompression. J Bone Joint Surg Am, 90: 523-530, 2008. 10) Youm T, Matthews PV, El Attrache NS: Treatment of patients with spinoglenoid cysts associated with superior labral tears without cyst aspiration, debridement, or excision. Arthroscopy, 22: 548-552, 2006. 115

대한견 주관절학회지제 13 권제 1 호 초록 서론 : 견갑상신경마비를유발하는극관절와결절성낭포에대하여여러가지치료방법이알려져있으나, 술후잔존하는낭포의경과에대한보고는미미한실정이다대상및방법 : 견갑상신경마비를동반한극관절와결절성낭포에대해관절경적감압술및상부관절와순봉합술시행후, 평균 15 (12~23) 개월추시가능하였던 6예를대상으로하였다. 술후, 초음파및자기공명영상으로극관절와결정성낭포의잔존여부를확인하였다. 결과 : 수술직후시행한초음파검사상 5예에서결절성낭포가잔존하고있었으며, 1예의경우완전소실되었다. 술후 3개월에시행한초음파검사상모든예에서잔여낭포가소실되었고, 술후 1년에시행한자기공명영상에서도재발된경우는없었다. 결론 : 극관절와결절성낭포의관절경적감압술및상부관절와순봉합술후잔존하는낭포는 3개월이내자연흡수되는경향이있는것으로판단한다. 색인단어 : 극관절와결절성낭포, 상부관절와순전후방병변, 한방향역행방지밸브, 관절경적감압술 116