15 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2017; 52: 15-24 https://doi.org/10.4055/jkoa.2017.52.1.15 www.jkoa.org 척골신경병증을동반한주관절퇴행성관절염에서최소절개척골신경감압술과동시에시행한관절경적변연절제술의효과 제갈믿음 * 유건웅 박성배 김종필 단국대학교의과대학정형외과학교실, *MS 재건병원정형외과 The Effectiveness of Arthroscopic Debridement with Mini-Open Ulnar Nerve Decompression in Primary Osteoarthritis of the Elbow with Ulnar Neuropathy Midum Jegal, M.D.*, Kun-Woong Yu, M.D., Sung-Bae Park, M.D., and Jong-Pil Kim, M.D. Department of Orthopaedic Surgery, Dankook University College of Medicine, Cheonan, *Department of Orthopaedic Surgery, MS Jaegeon Hospital, Daegu, Korea Purpose: The aim of this study was to determine the effectiveness of arthroscopic debridement with mini-open ulnar nerve decompression in primary osteoarthritis of the elbow with ulnar neuropathy. Materials and Methods: Between May of 2006 and July of 2014, a total of 43 patients who had undergone surgery for primary osteoarthritis of the elbow with ulnar neuropathy were included in this study. We divided the subjects into two groups according to the method of surgery: group 1 (n=18) received mini-open ulnar nerve decompression only, and group 2 (n=25) received arthroscopic debridement with mini-open ulnar nerve decompression. Patients were assessed for the following clinical outcomes: visual analogue scales (VAS) score, range of motion of the elbow joint, Mayo elbow performance score (MEPS), and disabilities of the arm, shoulder and hand (DASH) at the time before surgery and 6 months after surgery. We analyzed the recovery of the ulnar nerve by the McGowan grade and Bishop rating score preoperatively and at 6 months after the surgery. Results: The VAS score, range of motion of the elbow joint, MEPS, and DASH showed significant statistical difference after the surgery (p <0.05). However, between the 2 groups, there was no significant difference. For the McGowan grade, all cases of both groups except one case each group showed at least one grade improvement. Moreover, group 2 showed a greater significant difference than group 1 (p=0.001). At the final follow-up, according to the Bishop rating score, group 2 had a greater significant difference than group 1 (p=0.036). Conclusion: Arthroscopic debridement with mini-open ulnar nerve decompression in primary osteoarthritis of the elbow with ulnar neuropathy is a useful technique, which has several advantages, including the benefits associated with a minimally invasive surgery and also the improvement of elbow joint function and excellent recovery of the ulnar nerve. Key words: elbow, osteoarthritis, ulnar neuropathies, arthroscopy, decompression 서론 Received May 14, 2016 Revised August 2, 2016 Accepted August 29, 2016 Correspondence to: Jong-Pil Kim, M.D. Department of Orthopaedic Surgery, Dankook University Hospital, 201 Manghyangro Dongnam-gu, Cheonan 31116, Korea TEL: +82-41-550-3919 FAX: +82-41-556-0551 E-mail: kimjp@dankook.ac.kr 주관증후군은상지에서두번째로흔한압박신경병증으로병인 은대부분특발성이지만외상이나관절염또는골성변형에의 한주관증후군에서는척골신경을압박하는특정한병인을발견 The Journal of the Korean Orthopaedic Association Volume 52 Number 1 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.
16 Midum Jegal, et al. 할수있다. 1,2) 특히주관절의퇴행성관절염이있는환자에게주관증후군이동반된경우상완척골관절에골극이나결절종이생기면서주관이좁아지고척골신경에압박력이가해져서발생하는것이기때문에신경압박에대한개별적병인에대한수술적해결로증상의호전을도모할수있다. 3,4) 하지만이경우대부분의환자는저린감및감각저하, 그리고수지근력약화및내인근위축등의척골신경압박에의한증상뿐만아니라관절염에의한통증과운동제한을함께호소하게되며단순히척골신경에대한감압술만으로는환자의불편을완전히해소시키지못할수있다. 또한퇴행성관절염의진행정도와척골신경병증의진행정도는항상비례하지는않으며그관계에대해서아직명확하게밝혀진바가없기때문에주관절의퇴행성관절염과동반된척골신경병에대한적절한치료방침이제시되고있지않다. 주관절의퇴행성관절염에대한수술적접근은전통적인 Outerbridge-Kashiwagi 술식을비롯해 Morrey 5) 가이를수정하여발표한 triceps-sparing 접근법이나내측접근법을통한개방적골관절낭성형술식이소개되었고임상적결과도우수한것으로보고되었다. 6) 최근주관절의퇴행성관절염에대해널리시행되고있는관절경적변연절제술은개방적술식보다빠른회복을얻을수있으며특히비교적경증의관절염에서는개방적방법에비견할만한좋은임상적결과가보고되고있지만척골신경손상위험때문에주관절후내측으로의접근이다소제한된다는단점이있다. 7-9) 이를극복하기위해일부술자들은관절경적술식을시행하기전에후내측에개방적방법으로척골신경을먼저분리하여보호하면서관절경을시행하는방법을소개한바있다. 10) 본연구에서는주관절의퇴행성관절염이있으면서주관증후군이동반된경우퇴행성관절염에대한적극적처치가환자의관절기능회복뿐만아니라척골신경회복에도긍정적으로작용할수있다는가정하에척골신경감압술만시행한환자들과관절경적변연절제술과척골신경감압술을함께시행한환자들의임상적결과를비교하고자하였다. 대상및방법 1. 연구대상 2006년 5월부터 2014년 7월까지일차성주관절골관절염환자중척골신경병증이동반되어수술적치료를받은 43명을대상으로후향적조사를시행하였다. 남자 34명및여자 9명으로평균연령은 61.0세 (36-77세) 였다. 본연구의대상은주관절의지속적통증또는관절운동범위의제한이있으면서방사선사진상골극, 관절간격감소, 연골하경화증, 요골소두관절의아탈구등의퇴행성관절염소견이관찰된환자중제4 및 5 수지의저린감, 감각저하, 갈퀴손변형또는내인근의위축등의척골신경증상을호소하여신경감압술만을단독으로또는관절경적변연절제술을 함께시행받은환자들이다. 2006년 5월부터 2009년 10월까지는본병변에대하여최소절개신경감압술을단독으로시행하였고그이후는신경감압술과함께주관절염에대하여관절경적변연절제술을동시에시행하였다. 이는주관절골관절염과동반된척골신경병에대하여신경감압술만단독으로시행하였을때우수한신경회복에도불구하고통증성관절운동제한, Kissing sign 등지속적관절염증상으로술후결과평가에영향을미치는것으로판단되어, 2009년 10 월이후부터동일환자군에대하여관절경적변연절제술을동시에시행하여결과를비교하고자함이었다. 동일주관절의외상의과거력이있거나류마티스관절염과같은염증성관절염, 주관절의골성변형이있는환자들과주관절굴곡및신전시척골신경의아탈구또는탈구가관찰되는환자들은제외하였다. 모든수술은 6개월간의보존적치료 ( 비스테로이드성소염제, 물리치료, 활동제한 ) 에호전이없었던환자를대상으로하였으며숙련된단일정형외과전문의에의해시행되었다. 최소절개신경감압술만시행받은 18예의환자를 1군, 관절경적변연절제술과최소절개신경감압술을함께시행받은 25예를 2군으로나누어치료결과를비교분석하였다 (Table 1). 전체예에서전기생리학적검사상모두척골신경의압박으로인한중등도이상의신경전달속도의감소와탈신경전위가관찰되어주관증후군에합당한소견을보였고경추신경근증이동반된예는없었다. 2. 수술방법및술후재활최소절개신경감압술을단독으로시행하는경우다음과같은수술방법을사용하였다. 먼저전신마취혹은상완신경총마취후환자를앙와위로한뒤우측견관절을외전, 외회전시킨자세로상지테이블에상완을두고지혈대를설치하였다. 내상과와주두사이에 2 cm 길이의종절개를가하였다. 내측전완부피부신경에주의하면서피부와연부조직을견인한뒤척골신경을덮고있는근막층을노출시키고 Osborne 인대를절개하였다. 이인대의원위부에척수근굴근의양두사이의척골신경을덮고있는얕은층의막성연부조직 (aponeurotic tissue) 천장 (roof) 만열어주는방법으로감압을시행하였고, 필요한경우신경주행방향의원위부피부에추가적인소절개를가하여척골신경의운동가지를손상시키지않으면서충분한신경감압을하였다. 이후절개창을근위부로견인하면서 arcade of Struthers와내측근간격막으로접근하여척골신경에대한감압을시행하였다. 수술시척골신경보다심부에위치한주관절후내측의골극에대해서는추가적인박리를시행하지않았으며주변연부조직의보호를위해이비인후과용견인기 (nasal speculum) 와헤드라이트를적절히사용하면서시야를확보하였다. 최소절개신경감압술과관절경적변연절제술을함께시행
17 The Effectiveness of Arthroscopic Debridement with Mini-Open Ulnar Nerve Decompression Table 1. Case Analysis Variable Group 1 (n=18) Group 2 (n=25) p-value Age (yr) 61.61 (49 77) 60.56 (36 76) 0.902 Gender (male/female) 14/4 20/5 0.861 Employment 0.368 Heavy manual 6 12 Unemployed 3 3 Official worker 9 10 Dominant/nondominant arm 12/6 14/11 0.485 Symptom duration (mo) 9.72 (6 18) 11.04 (6 36) 0.310 Follow-up (mo) 20.84 (8.2 39.4) 15.81 (7.0 38.4) 0.087 Osteoarthritis classification 0.314 I 2 4 II 9 15 III 7 6 Osteophyte in the cubital tunnel 12 (66.7) 20 (80.0) 0.089 McGowan grade 0.365 I 0 1 II 3 6 III 15 18 Electrodiagnostic test 0.898 Mild 0 0 Moderate 9 13 Severe 9 12 Values are presented as median (range), number only, number (%). Group 1 received mini-open ulnar nerve decompression only. Group 2 received arthroscopic debridement with mini-open ulnar nerve decompression. Figure 1. Ulnar nerve is exposed following an incision of the overlying ligament of Osborne. 하는환자들에게는측와위에서일반적인주관절관절경을위한 자세를고정후지혈대를설치하고주관절을지지대에위치시킨 뒤앞서언급한동일한술식으로신경감압술을먼저시행하였다 (Fig. 1). 이후관절경술식으로전환하여측와위자세를유지하면서일반적인근위전내측및근위전외측관절경입구를만들고전방구역에서유리체를꺼내고활막을제거하였다. 구상돌기와와구상돌기의골극을충분히절제하여굴곡시충돌이일어나지않게하였다. 후방구역으로이동하여후방중앙및후방외측관절경입구를만들어활막과유리체를제거하고주두와와주두첨부의골극을충분히절제하였다. 후방구획의골극을충분히제거한뒤에도신전제한이남아있는경우다시전방구획으로이동하여전방관절막을제거하였다. 주관절의후내측골극제거시척골신경을조심스럽게견인하여척골신경이손상되지않도록주의하였다 (Fig. 2). 두군모두수술후하루동안장상지석고부목으로보호한뒤수술다음날부터적극적인능동적관절운동및주관절연속수동운동 (continuous passive motion) 을이용한수동적운동을시작하였다. 모든환자에게주관절관절운동방법에대한교육을시행하였고이를통해환자스스로가꾸준하게관절운동을할수
18 Midum Jegal, et al. A B Figure 2. (A) Ulnar nerve is identified and pulled gently using a vessel loop. (B) Care must be taken not to damage the ulnar nerve during posteromedial approach of the elbow. Table 2. McGowan Grade (Modified) Grade 0 No lesions Grade I Minimal lesions, with no detectable motor weakness of the hand Grade II Intermediated lesions Grade III Severe lesions, with paralysis of one or more of the ulnar intrinsic muscles Data from the article of McGowan (J Bone Joint Surg Br. 1950;32:293-301). 11) 있도록하였다. 3. 평가방법척골신경증상의호전정도를평가하기위해수술전과수술후 6개월의 McGowan grade 11) 를평가하여변화를기록하였다 (Table 2). 만일수술후추시에서척골신경증상이완전히호전된경우를보인다면 McGowan grade 0으로표시하여완전호전의정도를표시하였다. 수술후최소 6개월이후의추시에서최종적인척골신경의호전정도를잔존증상과직업복귀상태를평가할수있는 Bishop rating score 12) 를측정하였다 (Table 3). 최종적인점수에서 10-12점을 excellent, 7-9점을 good, 4-6점을 fair, 1-3점을 poor로분류하여비교하였다. 수술전퇴행성관절염의정도를 Rettig 등 13) 이제시한일차성주관절염분류 (primary elbow osteoarthritis classification) 로평가하였으며, 수술전삼차원전산화단층촬영 (3-dimensional computed tomography, 3D CT) 을실시하여척골신경구 (groove for ulnar nerve) 에서골극의위치를분석하였다. 환자들의임상적평가를위해수술전과수술후 6개월에통증점수, 관절운동범위, Mayo elbow performance score (MEPS), disabilities of the arm, shoulder and hand (DASH) score를측정하 였다. 통증점수는환자가주관절을움직일때경험하는통증을 0-10 사이의 visual analogue scale로측정하였고관절운동범위는주관절의능동적운동범위 (arc) 를 5도단위의각도계로측정하였다. 모든임상적평가는수술에참여하거나관여하지않았던정형외과전공의에의해측정되었으며방사선적분류와평가역시수술에참여하지않은독립된정형외과전문의에의해분석되었다. 통계분석은두군간의비교에서연속형변수 ( 나이, 증상발생기간 ) 에대해서는 Mann-Whitney U-test를시행하였고비연속형변수 ( 성별, 직업, 우세수, 관절염분류, 골극유무, McGowan grade, electrodiagnostic test grade) 에대해서는 chi-square test를시행하였다. 수술후의연속형변수 ( 통증점수, 관절운동범위, MEPS, DASH, Bishop rating system) 비교에대해서 Mann-Whitney U- test를시행하였고모든경우에서 p값이 0.05 미만인경우를통계적유의수준으로하였다. 결과 수술전대상환자의인구학적특징은 Table 1과같으며두군사이의통계적차이는없었다 (p>0.05). 수술전관절염분류에서
19 The Effectiveness of Arthroscopic Debridement with Mini-Open Ulnar Nerve Decompression Table 3. Bishop Rating Score Bishop rating system Number of points Satisfaction Satisfied 2 Satisfied with reservation 1 Dissatisfied 0 Improvement Better 2 Unchanged 1 Worse 0 Severity of residual symptoms (pain, paresthesia/dysesthesia, weakness, clumsiness) Symptomatic 3 Mild-occasional 2 Moderate 1 Severe 0 Work status Working or able to work at previous job 1 Not working secondary because of ulnar neuropathy Leisure activity Limited 1 Unlimited 0 Strength Both grasp and pinch strength (opposition) 80% or greater, compared with other hand 2 Either grasp or pinch (but not both) less than 80% 1 Both grasp and pinch less than 80% 0 Sensibility (static two-point discrimination) Normal ( 5 mm) 1 Abnormal (>5 mm) 0 Total 12 Data from the article of Kleinman and Bishop (J Hand Surg Am. 1989;14:972-9). 12) Table 4. Comparison of Clinical Outcomes Preoperatively Postoperatively (at 6 months) Group 1 Group 2 p-value Group 1 Group 2 p-value Pain VAS 3.61 (2 7) 3.60 (2 7) 0.980 1.00 (0 5) 1.28 (0 5) 0.226 ROM 102.83 (65 140) 97.72 (74 130) 0.490 103.28 (65 140 113.67 (90 140) 0.041* MEPS 55.89 (38 85) 63.00 (39 85) 0.085 85.06 (71 100) 83.32 (60 100) 0.755 DASH 79.72 (35 127) 87.40 (43 127) 0.375 50.67 (30 91) 59.24 (34 91) 0.111 Values are presented as median (range). Group 1 received mini-open ulnar nerve decompression only. Group 2 received arthroscopic debridement with mini-open ulnar nerve decompression. *There was no differences between preoperative and postoperative values of range of motion in group 1. VAS, visual analogue scale; ROM, range of motion; MEPS, Mayo elbow performance score; DASH, disabilities of the arm, shoulder and hand score.
20 Midum Jegal, et al. A 3 3 Group 1 12 B 3 Group 2 1 McGowan grade 2 1 1 2 McGowan grade 2 1 6 3 14 1 0 Preoperatively Postoperatively (at 6months) 0 Preoperatively Postoperatively (at 6months) Figure 3. (A) Postoperative outcome of the McGowan grade (group 1). The marked number beside the line reveals each number of patients. (B) Postoperative outcome of the McGowan grade (group 2). The marked number beside the line reveals each number of patients. Group 1 received miniopen ulnar nerve decompression only. Group 2 received arthroscopic debridement with mini-open ulnar nerve decompression. class I은 1군 2예및 2군 4예이고 class II는 1군 9예및 2군 15예였으며 class III는 1군 7예및 2군 6예였다. 3D CT에서척골신경이위치한주관 (cubital tunnel), 즉주관절후내측에골극이 1군 12예 (66.7%) 및 2군 20예 (80.0%) 에서관찰되었다. 수술전척골신경병증에대한 McGowan grade로 grade I은 1군 0명및 2군 1명이었고, grade II는 1군 3명및 2군 6명, 그리고 grade III는 1군 15명및 2군 18명이었으며내인근위축이보이는경우는두군모두 grade III 에서가장많았다. 수술후각군의평가항목을비교하였을때통증점수, 관절운동범위, MEPS, DASH 항목에서수술전에비하여모두통계적으로유의하게호전된결과를보였다 (p<0.05). 단, 척골신경에대한감압술만시행하였던 1군의관절운동범위는술전과술후의차이가나타나지않았다. 상기항목에서두군간의호전된결과를서로비교하였을때통계적으로유의한차이는관찰되지않았다 (Table 4). McGowan grade는 1군중에서 3명이수술전 grade III에서 grade I으로 2등급의호전을보였고 14명 (grade III 12명및 grade II 2명 ) 은각각 1등급의호전을보였으나 grade II 1명은수술전과차이가나지않았다. 2군에서는수술전 grade III 14명이수술후 2 등급의호전을보였고 10명 (grade III 3명, grade II 6명및 grade I 1 명 ) 이각각 1등급의호전을보였는데그중 grade I 1명은술후완전한증상의호전을보였다. 2군중에서 grade III 1명은수술전과차이가나지않았으나 McGowan grade가더악화된경우는없었다 (Fig. 3). 두군간의수술후최소 6개월의 McGowan grade를비교한결과두군모두척골신경의유의한회복을보여주었지만관절경적변연절제술을동시에시행했던 2군에서 1군보다통계적으로유의하게더나은결과를보여주었다 (p=0.001). 주관내에골극이관찰되는환자들간의 McGowan grade 비교 Group 1 에서도 2 군에서 1 군보다통계적으로유의하게더나은척골신경 회복을보여주었다 (p=0.003). 1 군 12 명중에서수술전, 후변화가 없었던 grade II 1 명을제외한 11 명 (grade III 9 명, grade II 2 명 ) 이 각각 1 등급의호전을보였다. 2 군 20 명중에서수술전, 후변화가 없었던 grade III 1 명을제외하고 grade III 10 명이 2 등급의호전을 보였고다른 9 명 (grade III 3 명, grade II 5 명, grade I 1 명 ) 이각각 1 등급의호전을보였다. 최소 6 개월이상의최종추시에서측정한 Bishop rating system 은 1 군에서 excellent 6 명, good 6 명, fair 6 명으로측정되었고 2 군 에서는 excellent 15 명, good 8 명, fair 2 명으로측정되었다. 척골신 경감압술과관절경적변연절제술을동시에시행했던 2 군에서 1 군보다통계적으로유의하게척골신경증상이더욱호전된결과 를보여주었다 (p=0.036; Fig. 4). 6 6 6 Bishop rating score * Fair Good Excellent Group 2 Figure 4. Postoperative outcome of the Bishop rating score (*p=0.036). 주관내에골극이관찰되는환자들간의 Bishop rating score 비 교에서도 2 군에서 1 군보다통계적으로유의하게더나은척골신 경회복을보여주었다 (p=0.024). 1 군 12 명중 excellent 4 명, good 4 명, 2 8 15
21 The Effectiveness of Arthroscopic Debridement with Mini-Open Ulnar Nerve Decompression fair 4명으로측정되었고 2군 20명중 excellent 12명, good 6명, fair 2명으로측정되었다. 전체예에서최소 6개월이상의최종추시까지수술로인한신경손상이나감염, 척골신경탈구등의합병증은관찰되지않았고증상이악화되어재수술이필요한경우도없었다. 고찰 일반적으로퇴행성관절염은반복적인사용과노화에의해관절연골이마모되는질환을의미하는것이지만주관절에서는축성하중의부담이적기때문에관절연골의마모가천천히진행되는반면골극으로인한충돌이나압박이증상을유발하는가장중요한요소이다. 14-17) 주관절의운동범위는골극이늘어남에따라점차적으로줄어들지만그진행속도가느린데다가정상범위와기능적범위간에 20도-30도정도의여유가있기때문에초기에는환자가활동에별불편함을느끼지않을수있다. 14,18) 또한통증도대부분굴곡과신전의마지막단계에서골극이서로충돌하면서발생하므로환자가실제로통증으로일상생활이나작업활동에서지장을느낄때는병변이상당히진행되고난이후이다. 14,18) 척골신경병증은이러한주관절의퇴행성관절염환자에서흔하게동반될수있으며그빈도는많게는 54% 까지로알려져있다. 19) Kurosawa 등 3) 에의하면주관절의퇴행성관절염환자에서주관증후군이발생하는가장주된원인은상완척골관절에발생된퇴행성골극에의한주관을통과하는척골신경의압박으로알려져있으며, 비록퇴행성관절염으로인한증상이경미하거나또는골극의크기가작은경우라도좁은주관절후내측에발생하거나혹은주관을침범하는경우에경증부터중증까지다양한정도의척골신경병증이생길수있다. 15,20) 그러나퇴행성관절염의진행정도와척골신경병증의진행정도간의뚜렷한관련성은아직까지알려진바가없다. 척골신경병이동반된주관절의퇴행성관절염환자대부분은척골신경병증이주증상이고퇴행성관절염으로인한증상은경미하여신경감압술만시행받는환자들이많다. 하지만척골신경병증은관절내충돌에의한증상은아니며주관내에서의압박이어느정도지속된후에제4 및 5 수지의이상감각등의초기증상을나타내게되므로본연구에서와같이환자대부분에서관절막의비후나인대조직의섬유화, 골극등의퇴행성관절염이적어도초기혹은중등도정도까지진행되어있다. 따라서본연구결과에서알수있듯이척골신경증상이점차로악화되면서진행되는경우비가역적인변화를피하기위해서는척골신경에대한충분한감압이필수적이라고생각되는데감압술뿐만아니라이미진행되어온퇴행성관절염에대한적극적조치가더해진다면좋은임상적결과를얻을수있다고판단된다. 척골신경병증이동반된퇴행성관절염환자에서수술방법을결정할때척골신경에대한감압이반드시필요한환자라면내측혹은후방접근법을이용한개방적변연절제술이일차적선택이될수있다. 21-23) 그러나관절경기술이발달함에따라관절경을이용한수술이점차보편화되고있는추세이며특히경증혹은중등도의퇴행성관절염에서관절경적변연절제술이개방적방법에비견할만한좋은결과를보고하고있으므로최소침습적장점을살리면서척골신경감압술을먼저시행한후관절경수술로전환하는방법도좋은선택이될수있을것으로판단된다. 7,24) 한편척골신경에대한술식은비전위감압술 ( 단순감압술 ), 전방이전술, 내측상과절제술등다양한치료가제시되고있다. 그중전방이전술은주관증후군에서보편적으로받아들여지고있는수술방법인데골극이나종양등척골신경을자극할수있는구조로부터척골신경을이전시켜비교적정상인조직에신경을위치시킬수있다. 뿐만아니라척골신경이주관절운동축의전방으로이전됨으로써주관절굴곡시척골신경이신연 (stretching) 되는정도를줄일수있다는장점이있다. 그러나최근전향적무작위연구에서척골신경의전방이전없이비전위감압술만으로도전방이전술과비견할만한성공적인결과를얻었다고보고하고있다. 25-27) 이는생역학적으로도척골신경증상이주관내에서의신연보다는압박 (compression) 이나전단 (shearing) 에의해더흔히발생할수있어단순감압에의한치료가더효율적일수있다는연구결과와도일치한다. 2,28) 비전위감압술이신경의아탈구를유발할수있는가능성은있으나실제아탈구가마찰신경염 (friction neuritis) 과직접적인연관이있다는연구결과는아직까지발표된바없으며, 본연구에서도비전위감압술후육안적으로신경아탈구또는탈구가관찰되거나이로인한신경염증상을호소한경우는없었다. 이는본연구에서시행된최소절개신경감압술이작은절개창으로척골신경이위치한바닥면을그대로유지한채척골신경을덮고있는 Osborne 인대를비롯한연부조직천장부분만을유리시키기때문에충분한신경감압뿐만아니라신경탈구의합병증이적기때문으로생각된다. 더구나본술식은척골신경을공급하는내인성및외인성혈류의장애를주지않기때문에수술에의해발생할수있는신경의이차적허혈성손상가능성을최소한으로피할수있다. 29) 다만비전위감압술에서도다른수술술식과같이술후신경주변의섬유화혹은잔여골극에의한이차적압박의가능성은여전히남아있으며이러한점이본연구에서두군의각각 1예에서수술전, 후척골신경의호전정도가차이가없었던원인일가능성이있다. Kurosawa 등 3) 은이전에퇴행성관절염에서척골신경병이동반된환자에서척골신경감압술뿐만아니라동일절개창에서관절의개방적변연절제술을동시에시행한후높은신경회복률을보고한바있다. 본연구에서도비전위감압술만을시행한 1군
22 Midum Jegal, et al. 보다최소절개척골신경감압술과관절경적변연절제술을동시에시행한 2군에서척골신경회복이높았던이유는신경의단순감압이외에관절내골극을제거함으로써이부위를주행하는척골신경에대하여보다완전한감압이된것이척골신경의회복에도움이되었을것으로생각된다. 30) 본연구결과를토대로판단한결과본저자들이시행하고있는관절경적술식과최소절개비전위감압술은관절운동회복과함께우수한신경회복을기대할수있는술식이라고판단된다. 하지만환자를측와위로해서관절경을시행하는경우최소절개신경감압술시다소시야확보가어렵기때문에의인성신경이나혈관손상을피하기위해서는척골신경과혈관뿐만아니라주변구조물에대한정확한해부학적지식이요구된다. 또한관절경적술식을위해서술자의숙련된기술을요하며전체적인수술시간이길어지고수술에필요한추가적인비용이늘어날수있다는점은고려해야한다. 본연구의제한점은첫째, 후향적연구로대상환자의수가적고추시기간이평균 17개월로비교적짧다는점이다. 일반적으로비전위감압술은주관절퇴행성관절염이동반된환자에게는표준적인치료방법이아니며재발의위험이높다고알려져있어이에대하여보다장기적추시가필요하다. 하지만모든환자에서최소 6개월이상추시하였고두군사이의최종추시기간에차이가없어단기적임상적결과를비교하는데무리는없을것으로생각된다. 둘째, 주관절관절염의분류로방사선적분류만사용했다는점이다. 관절운동범위나통증의정도를반영한분류체계를도입한다면퇴행성관절염의정도와척골신경병증간의관계를밝혀낼수있을것이라생각된다. 셋째, 척골신경의회복정도에대한평가시다수의관찰자가시행하였기때문에관찰자간신뢰도가다소떨어질수있다. 넷째, 치료결과평가시수술시점에따른단일술자의기술적숙련도를반영하지못했다는점이다. 결론 척골신경병이동반된주관절의퇴행성관절염에서최소절개척골신경감압술과동시에시행한관절경적변연절제술후단기적임상추시결과최소침습적수술의장점과더불어주관절의관절기능향상과우수한척골신경회복을기대할수있는유용한술식으로판단된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Szabo RM, Kwak C. Natural history and conservative management of cubital tunnel syndrome. Hand Clin. 2007;23:311-8, v-vi. 2. Tsujino A, Itoh Y, Hayashi K, Uzawa M. Cubital tunnel reconstruction for ulnar neuropathy in osteoarthritic elbows. J Bone Joint Surg Br. 1997;79:390-3. 3. Kurosawa H, Nakashita K, Nakashita H, Sasaki S. Pathogenesis and treatment of cubital tunnel syndrome caused by osteoarthrosis of the elbow joint. J Shoulder Elbow Surg. 1995;4:30-4. 4. Kato H, Hirayama T, Minami A, Iwasaki N, Hirachi K. Cubital tunnel syndrome associated with medial elbow Ganglia and osteoarthritis of the elbow. J Bone Joint Surg Am. 2002; 84:1413-9. 5. Morrey BF. Primary degenerative arthritis of the elbow. Treatment by ulnohumeral arthroplasty. J Bone Joint Surg Br. 1992;74:409-13. 6. Forster MC, Clark DI, Lunn PG. Elbow osteoarthritis: prognostic indicators in ulnohumeral debridement--the Outerbridge-Kashiwagi procedure. J Shoulder Elbow Surg. 2001;10: 557-60. 7. Adams JE, Wolff LH 3rd, Merten SM, Steinmann SP. Osteoarthritis of the elbow: results of arthroscopic osteophyte resection and capsulectomy. J Shoulder Elbow Surg. 2008;17:126-31. 8. Savoie FH 3rd, Nunley PD, Field LD. Arthroscopic management of the arthritic elbow: indications, technique, and results. J Shoulder Elbow Surg. 1999;8:214-9. 9. Lim TK, Koh KH, Lee HI, Shim JW, Park MJ. Arthroscopic débridement for primary osteoarthritis of the elbow: analysis of preoperative factors affecting outcome. J Shoulder Elbow Surg. 2014;23:1381-7. 10. Kelly EW, Morrey BF, O'Driscoll SW. Complications of elbow arthroscopy. J Bone Joint Surg Am. 2001;83:25-34. 11. McGowan AJ. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br. 1950;32: 293-301. 12. Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. 1989;14:972-9. 13. Rettig LA, Hastings H 2nd, Feinberg JR. Primary osteoarthritis of the elbow: lack of radiographic evidence for morphologic predisposition, results of operative debridement
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24 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2017; 52: 15-24 https://doi.org/10.4055/jkoa.2017.52.1.15 www.jkoa.org 척골신경병증을동반한주관절퇴행성관절염에서최소절개척골신경감압술과동시에시행한관절경적변연절제술의효과 제갈믿음 * 유건웅 박성배 김종필 단국대학교의과대학정형외과학교실, *MS 재건병원정형외과 목적 : 척골신경병이동반된주관절의퇴행성관절염에서최소절개척골신경감압술과동시시행한관절경적변연절제술의효과를알아보았다. 대상및방법 : 2006년 5월부터 2014년 7월까지 43명을대상으로최소절개신경감압술만시행받은 18예를 1군, 관절경적변연절제술과신경감압술을동시시행받은 25예를 2군으로나누어분석하였다. 술전과술후 6개월의통증점수, 관절운동범위, Mayo elbow performance score (MEPS), disabilities of the arm, shoulder and hand (DASH), McGowan grade, Bishop rating score 를분석하였다. 결과 : 두군간의통증점수, 관절운동범위, MEPS, DASH 호전정도는차이가없었다. McGowan grade 는각각 1예를제외하고모두 1등급이상의호전을보였으나 2군이유의하게더우수하였고 (p=0.001), Bishop rating score 도 2군이유의하게더우수하였다 (p=0.036). 결론 : 척골신경병이동반된주관절퇴행성관절염에대하여최소절개척골신경감압술과동시에시행한관절경적변연절제술은관절기능향상과척골신경회복에유용한술식이다. 색인단어 : 주관절, 퇴행성관절염, 척골신경병증, 관절경, 신경감압술 접수일 2016 년 5 월 14 일수정일 2016 년 8 월 2 일게재확정일 2016 년 8 월 29 일책임저자김종필 31116, 천안시동남구망향로 201, 단국대학교병원정형외과 TEL 041-550-3919, FAX 041-556-0551, E-mail kimjp@dankook.ac.kr 대한정형외과학회지 : 제 52 권제 1 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.