Korean J Pain Vol. 21, No. 1, 2008 대한통증학회지 2008; 21: 1 10 DOI:10.3344/kjp.2008.21.1.1 종설 척추관절통증증후군 부산대학교의학전문대학원마취통증의학교실 김경훈 Spinal Joint Pain Syndrome Kyung Hoon Kim, M.D. Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea Spinal joint pain syndrome is composed of atlanto-occipital, atlanto-axial, facet, and sacro-iliac joints pain. The syndrome is characterized as referred pain which is originated from deep somatic tissues, which is quietly different from radicular pain with dermatomal distribution originated from nerve root ganglion. The prevalence of facet joint pain in patients with chronic spinal pain of cervical, thoracic, and lumbar regions has been known 56%, 42%, and 31% as in order. It is generally accepted in clinical practice that diagnostic blocks are the most reliable means for diagnosing spinal joints as pain generators. The sacroiliac joint has been shown to be a source of 10% to 27% of suspected cases with chronic low back pain utilizing controlled comparative local anesthetic blocks. The treatment of spinal joints ideally consists of a multimodal approach comprising conservative therapy, medical management, procedural interventions, and if indicated. (Korean J Pain 2008; 21: 1 10) Key Words: diagnosis, facet joint, pain, spine, treatment. 서론척추는후두-환추관절을통해두개골과천장관절을통해골반과연결된다. 앞쪽구조물인경추 2 3번에서부터요추 5 천추 1번사이의간의추간판을제외하고, 후두-환추관절, 환추-축추관절, 경추 2 3번부터요추 5 천추 1번에이르는후관절및천장관절등의척추관절통증증후군에관한해부, 흔한동반질환, 진단및치료에관해소개하고자한다. 본론척추통증을일으키는해부학적구조물은다음과같은 4가지특징을충족해야한다. 1) 그구조물은신경분 포를가지고있어야하고 (Fig. 1), 2) 정상지원자들에서임상적으로관찰할수있는비슷한통증을유발할수있어야하고, 3) 통증이있는질환과손상에감수성이있어야하며, 4) 신뢰성과타당성이있는진단적방법을이용하여그구조물이환자의통증의근원이된다는것을규명해야한다. 1) 척추후관절의경우활액낭에작은 C형통증섬유가둘러싸고있다. 뿐만아니라단백유전자산물 9.5 (protein gene product 9.5), substance P 및 calcitonin gene-related peptide 등에반응하는신경섬유가규명되어있고, 통증유발이가능하고, 후관절증후군이임상적으로존재하며, 진단적차단으로통증을차단할수있다. 2) 1. 후두-환추관절과환추-축추관절통증 1) 해부 : 상부경추의운동분절은하부경추와는다른특수한구조를가지고있다. 후두-환추관절은경추 1번 접수일 :2008 년 3 월 16 일, 승인일 :2008 년 3 월 28 일책임저자 : 김경훈, (602-739) 부산시서구아미동 1-10 부산대학교의학전문대학원마취통증의학교실 Tel: 051-240-7394, Fax: 051-242-7394 E-mail: pain@pusan.ac.kr Received March 16, 2008, Accepted March 28, 2008 Correspondence to: Kyung Hoon Kim Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, 1-10, Ami-dong, Seo-gu, Busan 602-739, Korea Tel: +82-51-240-7394, Fax: +82-51-242-7394 E-mail: pain@pusan.ac.kr
2 KH Kim / Korean J Pain Vol. 21, No. 1, 2008 Fig. 1. Average number of receptors (and standard deviation) on the nine spots of the dorsal aspect of the facet joint capsule. The asterisks indicate a significantly higher number of receptors at a particular spot. S = Spot. More A-δ receptors were found around Spot 3, which was on the dorsolateral aspect of the facet joint at the joint gap, where muscles were attached. More C-fiber receptors were found at Spot 9, which was located at the dorsolateral part of the capsule, at the caudal marginal region. (From Chen C, Lu Y, Kallakuri S, Patwardhan A, Cavanaugh JM: Distribution of A-delta and C-fiber receptors in the cervical facet joint capsule and their response to stretch. J Bone Joint Surg Am 2006; 88: 1807-16.) ( 환추 ) 의상관절면과후두가만나서생기며, 변형된후관절처럼보인다. 환추 (C1) 는추체가없으며, 후두 (C0) 와축추 (C2) 사이를연결해주는중심역할 (relay center) 을해주고있다 (Fig. 2A). 3) 축추 (C2) 의가장뚜렷한특징은치아돌기 (odontoid process, dens) 로서축추의골분절의앞쪽에서부터나와아스파라거스와같은모양으로돌출되어있고, 환추와머리가회전할때축의역할을한다 (Fig. 2B). 시상면에서좌우의양쪽으로볼록한외측의환추-축추관절은 1.4 3.2 mm 정도의두꺼운관절연골과관절내의반월연골에의해둘러싸여있다. 이관절을통해 굴곡, 신전, 회전및매우작은정도의측면굴절 (sidebending) 이가능하다 (Fig. 2C). 인대의통합성 (ligament integrity) 은뇌줄기와척수와인접하여상부경추의골성구조물사이에존재하므로필수적이다. 환추의횡인대 (transverse ligament of atlas) 는환추와축추의분리를막기위해치아돌기의뒤쪽에존재하는 lateral mass들사이를지난다. 이횡인대는경추의굴곡시에치아돌기가뇌줄기와척수방향으로뒤쪽으로끼이는것을막는다 (Fig. 2D). 환추의횡인대는치아돌기의중심위치를유지하기위해날개인대들 (alar ligaments) 에의해보조를받고있다. 길이가 11 13 mm 정도인좌우후두날개인대의가지들은모두각각치아돌기의뒤쪽꼭대기에서후두로달린다 (Fig. 2E). 환추-후두관절과환추-축추관절의해부학적위치, 가동범위및기능을 Table 1에정리하였다. 2) 경추인성두통 (cervicogenic headache): 목에서유래한통증이란의미의경추인성두통은 1983년 Sjaastad 가 목에서유래하는재발이잦고, 오래지속되는심한일측성두통 으로정의하였다 (Table 2). 4) 그이후 Sjaastad 의일부수정된내용, 세계두통학회 (International Headache Society) 및세계통증연구학회 (International Association for the Study of Pain) 등에서정의한내용은 Table 3과같다. 5) 필수적인증상들로적어도 2 3시간지속되는두통이외에어지럼증, 시각장애및현훈등을들수있다. 6) 상부경추신경근들들로부터감각입력이삼차신경핵 (trigeminal nucleus) 에수렴되면서경추인성두통을갖게되는기전을 Fig. 2F에서볼수있다. 7) 3) 환추-후두관절과환추-축추관절의관절내주사 : 상기시술에서가장주의할사항은척추동맥의주행이다 (Fig. 2G). 척추동맥은환추-축추관절의외측과환추- 후두관절의내측으로주행하므로, 환추-축추관절은관절의내측부에바늘을자입한다는느낌으로, 반면환추- 후두관절은관절의외측부에주입한다는느낌을가지면서바늘이작은점으로보일수있게만든다 (through the eye of the needle technique) (Fig. 2H). 8) 환자로부터시술직후후부부의두통이없어지는것은물론시력이갑자기좋아진느낌과귀가후이전에가졌던어지럼증과현훈이없어지거나현저히줄었다는말을다음추적관찰에서들을수있다. 시술전환추-후두관절과환추-축추관절의통증을연관통의분포로식별하기는어렵지만, 환추-축추관절
김경훈 : 척추관절통증증후군 3 Fig. 2. (A) The atlas (C1): 1 facet for the dens; 2 anterior tubercle; 3 posterior tubercle; 4 transverse foramen; 5 groove for the vertebra artery; 6 cartilage over superior articular facet. (B) The axis (C2), cranial (a) and sagittal (b) view: 1 dens or odontoid process; 2 superior articular facet; 3 spinous process; 4 groove for transverse ligament of atlas; 5 facet for anterior arch of the atlas; 6 transverse foramen. (C) Lateral atlantoaxial joint (C1-C2). Biconvexity in the sagittal plane. (D) The ligaments of the upper cervical spine: 1 occiput; 2 posterior arch of the atlas; 3 anterior arch of the atlas; 4 dens of the axis; 5 posterior arch of C2; 6 vertebral body of C3; 7 posterior atlanto-occipital membrane; 8 ligamentum flavum, C1C2; 9 ligamentum flavum, C2C3; 10 anterior longitudinal ligament; 11 anterior atlanto-occipital membrane; 12 apical ligament of the atlas; 13 tectorial membrane; 14 posterior longitudinal ligament; 15 transverse ligament of atlas; 16 Synovial compartment between the dens and the anterior arch of the atlas. (E) The alar ligaments (dorsal view): 1 left occipital alar ligament; 2 right occipital alar ligament; 3 left atlantal alar ligament; 4 right atlantal alar ligament; 5 occiput; 6 left C1; 7 right C1; 8 dens; 9 left C2; 10 right C2. (F) Convergence of sensory input from the upper cervical nerve roots into the trigeminal nucleus (cervicotrigeminal interneuronal relay). (G) Diagram of the placement of 25-gauge spinal needle into the anterior axial joint on the left (atlanto-axial) and the anterior occipital joint on the right (atlanto-occipital) as seen by "through the eye of the needle" technique. The spatial relationships of the needles with the vertebral arteries, foramen magnum, and spinal cord are shown. The circled dot is equivalent to "through the eye of the needle." 의통증은후두하부 (suboccipital area) 에국한되지만환추-후두관절통증은후두및후두하부에분산된형태의통증분포를보인다 (Fig. 2I). 병력으로흔히편타손상 (whiplash injury) 과같은외상, 퇴행성변화및류마티스관절염등을들수있다. 4) 제2경추신경의후신경절블록 : 후두통 (occipital headache) 을호소하는환자에서후두신경통이의심되면제2경추신경의후지인대후두신경혹은 Fig. 2J에서와같이후신경절을차단할수있다. 하지만관절에서유래한통증이라면그관절을목표로하는것이옳다.
4 KH Kim / Korean J Pain Vol. 21, No. 1, 2008 Fig. 2. Continued. (H) Atlantooccipital (a) and atlanto-axial (b) joint injections. (I) Referral zone of atlanto-occipital (a) and atlantoaxial (b) joint pain. (J) Right C2 ganglion block: (a) anteroposterior view, (b) lateral view.
김경훈 : 척추관절통증증후군 5 Table 1. Anatomy, Range of Motion, and Function of the Atlanto-occipital and the Atlanto-axial Joint Joint Anatomic position Passive range of motion Function Atlanto-occipital joint Atlanto-axial joint The joint between the C1 vertebra or "Atlas" and the skull The joint between the C1 vertebra or "atlas" and the C2 vertebra or "Axis" Flexion passive range of motion of about 10 degrees Extension passive range of motion of about 25 degrees Lateral rotation of about 70 degrees on either side with the movement occurring around the odontoid process Isolated flexion and extension of 5 degrees and 10 degrees, respectively, in and itself 50% of the flexion and extension in the neck Nodding the head to indicate: "yes" 50% of the side to side turning in the neck Shaking the head to indicate: "no" Table 2. Criteria to Include Cervicogenic Headache in Differential Diagnosis Typically, the headache: 1. Is recurrent, long-lasting and severe 2. Arises from the neck 3. Has a unilateral dominance (but can bilateral) 4. Is in the low occipital and temporal region (with possible radiation in the face, periorbital, frontal and parietal region and ipsilateral shoulder and arm) 5. Is accompanied with a reduced cervical spine range of motion 6. Can be precipitated 2. 후관절증후군 정상적인척추는추체와추간판과같은앞쪽구조물이체중을지탱하는구조물들인데비해, 경추, 흉추및요추의후관절은체중분배에서보조해주는역할을한다. 그러나앞쪽구조물이어떠한이유로그구실을하지못할경우후관절에무너지는힘이과다해지면후관절증후군의전제조건을갖는다 (Fig. 3A). 만성척추통증을호소하는환자의 56%, 42% 및 31% 가경추, 흉추및요추각부위의통증의원인으로후관절을지목하고있다 (Table 4). 9) 후관절은척추레벨에따라 Fig 3B와같이시상면과횡단면으로배열되어있다. 10) 1) 경추후관절증후군 : 경추후관절은만성경추통증을호소하는환자들에서가장먼저의심해볼만한구조물이다. 흔한경추후관절로부터발생하는질환으로근근막증후군, 추간판탈출증및편타손상등을열거할수있다 (Table 5). 저자의연구에서근근막증후군환자군이후관절증후군으로발전하여통증치료실을방문하는때까지의기간은나머지두질환군보다길고, 추간판 탈출증에서발전한후관절증상은후관절차단에대해가장효과가길게유지되었다. 2) 가장흔한경추후관절증후군의발병부위는경추 5 6과 6 7번사이이다. 경추 5 6 사이의후관절은어깨의상부, 견갑골의 spine 상부때로하부경추부위등에연관통을보이는반면, 견갑골전체특히 spine 하부로연관통을보이므로임상적으로큰차이를보인다 (Fig. 3C). 환자는언제나무거운것을지고있든지무언가올라타고있다는느낌을호소한다. 치료로는후관절차단 (Fig. 3D) 혹은후내측지차단을시행하고증상이반복될경우후내측지파괴술을시행한다. 대부분신경및관절차단의경우두관절이상을침범하므로제대로들어간바늘을필요한약물을투여후조금만뽑고그방향을참조하여반대편혹은상하관절에시행하는것이시술시간과노력을줄일수있다 (Fig. 3E). 관절차단과후관절분지신경인후내측지차단은각각의장단점이존재한다. 간접적인방법으로관절에분포하는신경인후내측지의신경차단으로통증을완화하는방법보다관절차단의경우통증을일으키는물질의직접적인염증경로의차단을볼수있는장점이있지만, 단점으로증상재발이되는경우후내측지차단이후파괴술이시행되어야하고관절낭의의인성파괴가일어날수있다. 2) 흉추후관절증후군 : 흉추후관절증후군은경흉추이행부를제외하면대부분악성혹은양성추체압박골절이발생할경우발생한다. 경흉추이행부는경추의원인과큰차이가없으며, 중간흉추는갑상선암, 폐암및유방암등의척추전이에흔하고, 흉요추이행부는골다공증에의한흔하다. 흉추는해부학적으로흉곽으로잘고정되어가동성보
6 KH Kim / Korean J Pain Vol. 21, No. 1, 2008 Table 3. Comparison of Diagnostic Criteria for Cervicogenic Headache Sjaastad et al. (1990) International Headache Society (1988) International Association for the Study of Pain (1994) 1. Unilateral headache triggered by head/neck movements or posture 2. Unilateral headache triggered by pressure on the neck 3. Unilateral headache spreading to the neck and homolateral shoulder/arm 4. Pain improvement after greater occipital nerve (GON)/C2 block 1. Pain localized to neck and occipital region. It may project to forehead, orbital region, temples, vertex or ears. 2. Pain is precipitated or aggravated by special neck movement or sustained neck pressure 3. At least one of the following: (1) Resistance to or limitation of passive neck movement (2) Changes in neck muscles contour, texture, tone or response to active and passive stretching and contraction (3) Abnormal tenderness of neck muscles 4. Radiological examination reveals at least one of the following: (1) Movement abnormalities in flexion/extension (2) Abnormal posture (3) Fractures, congenital abnormalities, bone tumors, rheumatoid arthritis or other distinct pathology (not spondylosis or osteochondrosis) Attacks of moderately severe unilateral head pain without change in side, ordinarily involving the whole hemicranium, usually starting in the neck or occipital area, and eventually involving the forehead and temporal areas, where the maximal pain is frequently located. The headache usually appears in episodes of varying duration in the early phase, but with time the headache frequently becomes more continuous, with exacerbation and remissions. Symptoms and signs such as mechanical precipitation of attacks imply involvement of the neck. A blockade of the greater occipital nerve, the minor occipital nerve, the so-called third occipital nerve, or the cervical roots on the symptomatic side 1/4 represents a diagnostic test. 다중요장기의보호역할을주로하고있기때문에경추와요추의연결부위의전만 (cervical and lumbar lordosis) 들과만나는부위에흔히역학적인요소에의한병변이흔히발생하기마련이다. 추체압박골절에따른체중부하로인한후관절증후군의동반은저자의연구에따르면 88% 정도이며, 11) 차단을시행하지않을경우추체성형술혹은후만성형술이후에도갈비뼈를따라경계가불분명한무거운느낌의통증과아침처음동작에서누워있다가일어날때큰불편을호소한다. 이학적검사에서도후관절부위에대부분심한압통을호소하면서갈비뼈를따라통증이재현되는경우가흔하다 (Fig. 3F). 후관절차단은반드시추체성형술혹은후만성형술이전에시행하는것이옳다. 그이유로첫째, 복와위에서참을수없는통증을호소하는환자에서후관절차단후추체성형술을시행할때후관절통증의제거로시술중자세에대한환자의협조를받을수있다. 둘째, 외래에서척추압박골절과후관절통증을감별하기힘들정도의심한통증으로복와위에서이학적검사를할수없을경우 fluoroscope하에서추체성형술전후관절차단만으로도전체통증이없어지고가시돌기부위의압통이발 견되지않을경우형태적으로압박골절이있지만통증이없어진추체에굳이추체성형술을시행할필요가없다. 셋째, 추체성형술시행후후관절차단을시행할경우먼저주입된추체의골시멘트에의해후관절을제대로관찰할수없어서후관절차단에어려움을겪게된다. 11) 관절내주사는전후상에서추경의 9시부터 12시사이의내상방에존재하는우측후관절혹은 12시에서 3시사이의좌측후관절을향하게된다 (Fig. 3G). 반대로후내측지차단및파괴술은사면상에서추경의추체의 9시부터 12시사이의내상방에존재하는좌측후관절혹은 12시에서 3시사이의우측후관절을향하게된다. 3) 요추후관절증후군 : 요추후관절증후군은요추전방전위증, 척추측만증, 척추유합술후상하, 상부요추의골다공증성압박골절및하부요추의암전이골분해성압박골절등에서흔히동반한다. 환자는아침에첫움직임이어렵고오후가되면다소완화된다는점에서흉추와차이가없으며, 엉치와다리쪽으로연관통을보이지만무릎이하로는통증이뻗치지는않는다. 이학적검사에서후관절주위의압통과함께옆구리와엉치쪽으로무겁고때로시린증상을재현할수있다.
김경훈: 척추관절통증증후군 7 Fig. 3. (A) Illustration of spinal loads and articular surface area across the lumbar spinal column. (B) Orientation of cervical, thoracic, and lumbar facet joint from the view of the sagittal and transverse plane. (C) The referral zone of cervical facet joint pain from C2-3 to C6-7. (D) Cervical facet joint injection on the right C6-7: (a) anteroposterior view, (b) lateral view. (E) The first lower needle is just removed from C6-7 facet joint. The second needle is approaching to the C5-6 facet joint with the guidance of the first one. (F) The referral zone of thoracic facet joint pain from the C7-T1 and T11-12. (G) The needle is placed at the superiomedial aspect of the left thoracic pedicle on the anteroposterior view. (H) The needle is placed at the superiomedial aspect of the lumbar pedicle on the oblique view. 관절 차단을 위해 사면상에서 관절을 잘 볼 수 있는 0.5 ml 이하로 하여 관절의 의인성 파괴의 기회를 줄인 방향으로 맞추고 가능하면 후관절의 하부 함몰(inferior 다(Fig. 3H). 후내측지 차단 및 파괴술 역시 흉추와 마찬 recess) 쪽으로 바늘을 삽입한다. 관절 내 조영제 투입은 가지로 추경의 외상방을 목표로 하고 감각과 운동신경
8 KH Kim / Korean J Pain Vol. 21, No. 1, 2008 Fig. 4. (A) Sacroiliac joint: (a) posterior view of the articulations and associated ligaments of the sacroiliac joint and surrounding structures and (b) anterior view of the articulations and associated ligaments of the sacroiliac joint and surrounding structures. (B) Commonly used physical test for sacroiliac joint pain. (C) Referral pain pattern of sacroiliac joints. (D) Sacroiliac joint block. (E) Direction of the needle for sacroiliac joint block. 자극을통해자극의수치가 3배이상차이가나면이상적이다. 3. 천장관절증후군 1) 해부와기능 : 천장관절은평균표면적이 17.5 cm 2 이나되는체내의가장큰축관절이며활액낭으로구성 되어있다. 그러나실제로천골과장골사이의앞쪽 1/3 만접해있고, 나머지는뒤쪽 2/3는인대로연결되어있다 (Fig. 4A). 12) 일부근육들특히대둔근, 이상근및대퇴이두근등이천장관절의인대와함께관절의유동성에조절한다. 뒤쪽천장관절의신경분포는요추 3번 천추 4번간
김경훈 : 척추관절통증증후군 9 Table 4. The Prevalence of Facet joint Pain in Patients with Chronic Spinal Pain Cervical Thoracic Lumbar spine spine spine Prevalence 56 (49 61) 42 (30 53) 31 (27 36) The false positive rate with single blocks 63 (54 72) 55 (39 78) 27 (22 32) with lidocaine Values are % values of mean (95% confidence interval). Table 5. Comparison of Myofascial Pain Syndrome (MPS), Herniated Nucleus Pulposus (HNP), and Whiplash Associated Disorder (WAD) Group History of Trauma radicular pain Imaging history on the shoulder diagnosis and arm MPS ( ) ( ) ( ) HNP ( ) (+) (+) WAD, grade II (+) ( ) (±) Table 6. Common Tests Utilized in Evaluation of Sacroiliac Joint Dysfunction Patrick's (FABERE) test With the patient supine on a level surface, the thigh is flexed and the ankle is placed above the patella of the opposite extended leg. With the knee depressed and the ankle maintaining its position above the opposite knee, the patient will complain of pain before the knee reaches the level obtained in normal persons. Gaenslen's (Pelvis torsion) test The patient lies supine, flexes the ipsilateral knee and hip with the thigh crowded against the abdomen with the aid of both the patient's hands clasped about the flexed knee. This brings the lumbar spine firmly in contact with the table and fixes both the pelvis and lumbar spine. The patient is then brought well to the side of the table, and the opposite thigh is slowly hyperextended with gradually increasing force by pressure of the examiner's hand on the top of the knee. With the opposite hand, the examiner assists the patient in fixing the lumbar spine and pelvis by pressure over the patient's clasped hands. The hyperextension of the hip exerts a rotating force on the corresponding half of the pelvis in the sagittal plane through the transverse axis of the sacroiliac joint. The rotating force causes abnormal mobility accompanied by pain, either local or referred on the side of the lesion. 후외측지가관여하고, 반면앞쪽천장관절은요추 2번 천추 2번간전지가관여한다고알려져있다. 고양이에서규명된신경생리검사에서대부분의기계적자극에민감한구심성신경들이관절낭에서발견되었고일부만근처근육에서발견되었다. 또대부분이침해성자극을받아들이는신경이며일부만고유감각에관여하였다. 이들신경들은뒤쪽천장관절근위부 1/3과중간 1/3에분포하고있다. 침해수용을하는신경의기계적역치는 70 g으로요추후관절의 6 g과앞쪽구조물인추간판의 241 g의중간정도로알려져있다. 기능적으로천장관절의기능은안정적으로하지에체간의무게를전달하고분산하며, x축회전을제한하고, 출산시도움을준다. 요추와비교하여내측으로주어지는힘에 6배잘견디지만, 반대로꼬임에대해서 1/2 정도와축방향의힘에대해서는 1/20 정도견디는힘이약하다. 손상기전으로축방향의부하와갑작스런회전을들고있다. 해부학적으로관절낭혹은활액의파괴, 관절낭 과인대의긴장, 과다혹은과소운동, 외부압박혹은전단력 (shearing force), 골절및연골연화, 연조직손상및염증등에서발생할수있다. 그외위험인자로서양쪽다리의길이가다른경우, 걸음의이상, 지속되는심한운동, 척추측만증및천공과의유합술등을들수있다. 그외임신시에도체중의증가, 과다한척추전만, 분만시기계적인손상및호르몬에기인한인대의느슨해짐등이천장관절의통증을일으키는위험요소가된다. 만성축방향의요통을호소하는환자의 15 25% 의환자가천장관절증후군을동반하고있음을알려져있다. 2) 진단 : 가장흔히이용되는이학적검사로는 Patrick's test와 Gaenslen's test가있다 (Table 6)(Fig. 4B). 핵의학검사는 13 44% 정도의민감성과 89.5 100% 의특이성을갖는다고알려져있다. 12) 연관통의분포는엉치 (94%), 하부요추부 (72%), 하지 (50%), 사타구니 (14%), 상부요추부 (6%) 및복부 (2%) 정도로알려져있어, 대부분요추 5번극돌기이하에서무릎위쪽허벅지까지로생각하는것이옳다 (Fig. 4C).
10 KH Kim / Korean J Pain Vol. 21, No. 1, 2008 3) 치료 : 관절내주사와고주파열응고술에의한신경파괴를시행할수있다. 관절내주사는불행히도하부끝부위에만바늘이주입되는경우가흔해, 조영제가관절의양면및위쪽까지잘묻었는지관찰을요한다 (Fig. 4D). 주입되는바늘의방향은 CT의영상에서추측할수있다 (Fig. 4E). 파괴술역시분포하는신경인요추 3번 천추 4번간후외측지를모두찾아파괴하는것은현실적으로불가능하며대안으로관절내들어와있는신경이라도모두파괴하는노출 (denudation) 방법 (Fig. 4D) 을사용하기도한다. 결 만성척추통증의가장흔한원인이되는후관절통증이임상적으로영상학적검사에서자주무시될수있으므로쉽게간과될수있으며가장좋은진단방법이자치료방법인작용기간이다른두가지국소마취제를사용하여이중차단법을시행하는것이유용하다. 임상적으로척추후관절의연관통그림과같은통증의재현보다그통증의감소가의미가있기때문이기도하다. 수많은관절로구성된척추의뒤쪽구조물인후관절에대한정확한진단은환자와의사의신뢰에도큰몫을할것으로생각한다. 론 참고문헌 1. Bogduk N: Clinical anatomy of the lumbar spine and sacrum. 3rd ed. New York, Churchill Livingstone. 1997, pp 187-214. 2. Kim KH, Choi SH, Kim TK, Shin SW, Kim CH, Kim JI: Cervical facet joint injections in the neck and shoulder pain. J Korean Med Sci 2005; 20: 659-62. 3. Sizer PS Jr, Phelps V, Azevedo E, Haye A, Vaught M: Diagnosis and management of cervicogenic headache. Pain Pract 2005; 5: 255-74. 4. Chou LH, Lenrow DA: Cervicogenic headache. Pain Physician 2002; 5: 215-25. 5. Leone M, D'Amico D, Grazzi L, Attanasio A, Bussone G: Cervicogenic headache: a critical review of the current diagnostic criteria. Pain 1998; 78: 1-5. 6. Antonaci F, Bono G, Mauri M, Drottning M, Buscone S: Concepts leading to the definition of the term cervicogenic headache: a historical overview. J Headache Pain 2005; 6: 462-6. 7. Haldeman S, Dagenais S: Cervicogenic headaches: a critical review. Spine J 2001; 1: 31-46. 8. Waldman SD: Interventional pain management. 2nd ed. Philadelphia, Saunders. 2008, p 301. 9. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD: Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord 2004; 5: 15. 10. Czerniecki JM, Goldstein B: General considerations of pain in the low back, hips, and lower extremities. In: Bonica's management of pain. 3rd ed. Edited by Loeser JD: Philadelphia, Lippincott Williams & Wilkins. 2001, p 1482. 11. Kim TK, Kim KH, Kim CH, Shin SW, Kwon JY, Kim HK, et al: Percutaneous vertebroplasty and facet joint block. J Korean Med Sci 2005; 20: 1023-8. 12. Cohen SP: Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005; 101: 1440-53.