Original Article doi:http://dx.doi.org/10.5397/cise.2011.14.2.207 대한견 주관절학회지제14권제2호 Clinics in Shoulder and Elbow Volume 14, Number 2, December, 2011 주관증후군에서척골신경경근전방이동술의임상결과 충남대학교의학전문대학원정형외과 차수민 김경천 강동훈 신현대 Clinical Outcomes of Cubital Tunnel Syndrome after Transmuscular Anterior Transposition of the Ulnar Nerve Soo-Min Cha, M.D., Kyung-Cheon Kim, M.D.,Dong-Hun Kang, M.D., Hyun-Dae Shin, M.D. Department of Orthopedic Surgery, Chungnam National University School of Medicine, Daejeon, Korea Purpose: To retrospectively analyze the clinical results of the cubital tunnel syndrome after ulnar nerve transmuscular anterior transposition according to the severity of the disease. Materials and Methods: From January 2003 to December 2008, the 94 cases that underwent ulnar nerve anterior transposition using modified Mackinnon method after diagnosed as cubital tunnel syndrome were enrolled for this study. The severity of each cases was classified using McGowan classification before surgery, and were divided into grade I of 35 cases (group 1), grade II of 37 cases (group 2), and grade III of 22 cases (group 3). Results: All groups showed significant degree of pain improvement, and which was more statistically significant in group 1 and 2 compared to group 3. All groups showed significant degree of sensory function improvement. The degree showed no difference between group 1 and 2, and 2 and 3, however, group 1 showed higher degree of improvement compared to group 3. All groups showed significant degree of motor function improvement, and which showed no difference between group 1 and 2, and compared to group 3, group 1 and 2 showed significant improvement of disease severity (p<0.05). In evaluation using Akahori classification after surgery, 28 cases in group 1 (80%), 27 cases in group 2 (73%), and 13 cases in group 3 (59%) showed results of good or excellent. In the whole group, the age and Akahori classification after surgery showed significant negative correlation (p<0.05, r=-0.512). Conclusion: In the retrospective analysis regarding the cubital tunnel syndrome using modified Mackinnon method, postoperative pain, sensory, and motor function was improved compared to which before surgery, however, the degree of improvement decreased as the disease was more severe. Especially, as the age is older, the degree of improvement more decreases. Key Words: Ulnar nerve, Cubital tunnel syndrome, Transmuscular anterior transposition 통신저자 : 신현대대전광역시중구대사동 640 충남대학교의학전문대학원정형외과학교실 Tel: 042) 280-7349, Fax: 042) 252-7098, E-mail: hyunsd@cnu.ac.kr 접수일 : 2011 년 11 월 1 일, 1 차심사완료일 : 2011 년 11 월 8 일, 2 차심사완료일 : 2011 년 11 월 20 일, 3 차심사완료일 : 2011 년 11 월 24 일, 게재확정일 : 2011 년 11 월 24 일 207
대한견 주관절학회지제 14 권제 2 호 서론주관증후군은상지에서두번째로흔한압박성신경병증이며동통과신경증상으로일상생활과직장생활에큰불편을야기한다. 1) 증상이경미한경우는보존적치료를시도해보지만증상이지속또는악화되거나중등도이상의증상이있는경우에는대개수술적치료를하게된다. 주관증후군에대한많은연구보고가있지만중증도에따른정확한치료법이확립되어있지는않으며수술방법및저자들마다조금씩다른결과를보이고있다. 2-6) 주관증후군에대한수술적치료로는원위치감압술, 7) 피하전방이동술, 8,9) 근육하전방이동술, 10) 근육내전방이동술, 11) 내상과절제술 6,12) 등의방법이있다. 한편, Mackinnon 등 13) 에의해소개된경근전방이동술은술후임상결과에대해많이알려져있지않다. 이술식은이동된신경주변의어느방향에서도새로운압박의구조물이없으며신경주행거리를최소화시킬수있고, 내상과염이동반된경우에서도굴곡근-회내근의기시부에대한치료를병행할수있는장점이있다. 그러나, 주관감압후굴곡근-회내근위에척골신경을얹은후, 근막에 Z-성형술 ( 연장술 ) 을시행하는방법이나신경이놓이는구 (trough) 및근막성형이다소어려운술기이다. 이에저자들은내상과약 2 cm 원위에서근막박리후, 부채꼴모양의근막피판을만들어신경의전방이동후원래의위치보다근위에재봉합하는, 변형된 Mackinnon 술식을고안하였고, 주관증후군의중증도에따른 변형된 Mackinnon 술식 의후향적임상결과를보고하고자한다. 연구대상및방법연구대상 2003년 1월부터 2008년 12 월까지임상소견및근전도소견으로주관증후군진단후 Modified Mackinnon 술식으로척골신경의경근전방이동술을시행후최소 2년추시가가능했던 94 예를대상으로하였다. 주관증후군의첫증상발현이후 6개월정도의보존적치료를시도하여효과가없어근전도및신경전달속도검사후수술적치료를시행한예를대상으로하였다. 연구배제기준으로는 (1) 외상과관련된주관증후군, (2) 당뇨를포함한대사성질환, (3) 다발성신경병증, (4) 류마티스관절염, 결절종이나그밖의종양이존재하였던경우, (5) 내상과염으로인한경우, (6) 척골신경수술의과거력이있는경우로정하였다. 척골신경마비정도에따라 McGowan 등급으로분류하였으며, 이상감각을보이는경우를등급 I로, 골간근 (interosseous) 의약화를보이는경우를등급 II로, 확실한감각이상및골간근의위축과함께갈퀴손 (claw hand) 변형이관찰되는경우를등급 III 으로나누었다. McGowan 등급 I (1군 ) 35예, 등급 II (2군 ) 37예, 등급 III (3군) 22예였다. 각군의연령은 1군 44.4± 6.8세, 2군 47.1±5.4세, 3군 46.8±7.9세였고군별연령간차이는없었다 (p>0.05). 질병의이환기간은 1 군 17.6±2.8개월, 2군 19.2±4.1개월, 3군 22.4± 5.6 개월로 1군및 3군사이에서만통계적이환기간의차이가존재하였다 (p=0.027). 각군의성별및우세상지의비율등은세군에서통계학적차이가없었다 (p>0.05, Table 1). 수술방법전예에서전신마취를하였으며 변형된 Mackinnon 술식 의경근전방이동술은내상과직후방에서 6 cm 의피부종절개후, 피하조직을절개하면서내측전완피부신경 (medial antebrachial cutaneous nerve) 을가급적확인하고보존하였다. 척골신경을충분히유리시키기위해근위부로는내측근간격막 (medial intermuscular septum) 에서상완삼두근의내측기시부까지연장된근막및 arcade of Struthers를절개하고내측근간격막을절제하였으며, 원위부로는척수근굴근 (flexor carpi ulnaris) 의양두를연결하는근막을절개한후척수근굴근으로가는운동신경분지를보호하면서척수근굴근과천수지굴근사이의근간격막까지절개하여최종적으 Table 1. Demographic data Variable Group I Group II Group III P Number of patients 35 37 22 Patient characteristics Age at surgery (years) 44.4±6.8 47.1±5.4 46.8±7.9 > 0.05 Gender (male) 22 25 24 > 0.05 Duration of symptom (months) 17.6±2.8 19.2±4.1 22.4±5.6 0.027 (Group I and III) Affected side (dominant side) 28 26 24 > 0.05 208
차수민 : 주관증후군에서척골신경경근전방이동술의임상결과 A B C D Fig. 1. Modified Mackinnon method (transmuscular anterior transposition). (A, B) The ulnar nerve is completely released and decompressed proximally and distally, transposed anteriorly, on the trough made in the flexor-pronator muscle, without any tension. (C, D) The fan-shape fascia flap of the flexor-pronator was sutured loosely, at more proximal area than it s own origin. 로척골신경이충분히유리되도록하였다. 이때광범위한탈혈관화 (devascularization) 에의한허혈성손상을줄이기위해가능한신경주위의혈관들을같이이전하도록박리하였다. 내상과에서약 2 cm 원위방향으로굴곡근-회내근의근섬유방향과직각이되도록부채꼴모양의근막을박리하여피판을만들고전기소작기로폭 0.5 cm 가량의경로 (trough) 를만들어척골신경을전방으로완전히이동후경로 (trough) 에척골신경을안착시킨후근막을다시흡수성봉합사로굴곡근-회내근에봉합하였다 (Fig. 1). 이때, 근막을박리한굴곡근-회내근의원래부착부위보다근위부 ( 내상과측 ) 에재부착을하여술자의소지가관통할정도의느슨한봉합을 3~4 군데정도하여근막피판의과도한긴장이없도록하였다. 또한, 근섬유사이에존재하는섬유성격막을철저히소작하여척골신경이근육사이에서압박이받지않도록하였다. 철저한지혈후에피부봉합후, 주관절의중립위, 90 굴곡상태의석고부목고정을 2주간시행하였다. 평가방법한술자에의해동일한술식으로감압및전방이동술을시행하였으며, 최소 2년의추시를통해임상결과를파악하였다. 최종추시에서, 술전에비해통증의완화정도, 감각및운동기능의회복정도를 Gabel과 Amadio 등급 14) 을이용하여점수 (point) 화하였다 (Table 2). 또한, 각항목의호전정도에대해서군별비교를하였다. 최종추시에서의전반적기능평가는 Akahori 15) 분류를이용하여평가하였다 (Table 3). 수술전, 후의각항목에대한호전정도의비교는 Student t-test, 호전정도의군간비교, 전반적기능평가의군간비교는 ANOVA test로분석하였다. 한편, 연령, 이환기간에따른 Akahori 15) 분류와의연관여부는스피어만상관계수 (spearrman correlation coefficient) 을이용하여분석하였다. 209
대한견 주관절학회지제 14 권제 2 호 결과추시기간은 32.8±3.8개월이었고, Gabel과 Amadio 등급 14) 으로평가한술후통증의호전은 1군 2.3± 0.41, 2군 2.04±0.33, 3군 1.75±0.27이었다. 세군모두에서술후의미있는회복을보였으며 (p=0.034, 0.027, 0.043), 1군과 2군에서 3군에비해회복정도가유의하였다 (p=0.038, Fig. 2A). 감각기능의회복정 도는 1군 1.43±0.12, 2군 1.27±0.08, 3군 1.06± 0.22이었으며, 세군모두에서술후의미있는회복을보였고 (p=0.029, 0.032, 0.036), 1군과 2군의회복정도는차이가없었고 2군과 3군역시차이가없었으나 1군은 3군에비해유의하게회복정도가우수하였다 (p=0.026, Fig. 2B). 운동기능의회복정도는 1군 1.71±0.08, 2군 1.51±0.17, 3군 1.04±0.08이었다 (p=0.033, 0.035, 0.040). 세군모두에서술후의미 Table 2. Rating Scale 14) for Ulnar Neuropathy at Elbow Joint Score (Points) Pain Sensory Motor 0 Needs narcotics regularly Anesthesia Intrinsic paralysis with claw deformity 1 Intermittent medication Constant pain Constant numbness Obvious atrophy 2 Intermittent pain 2-point discrim: normal Weaker than opposite side Intermittent paresthesia 3 No pain No numbness No weakness 2-point discrimination of less than 6 mm is considered normal. Table 3. Akahori s Criteria 15) for Measuring Functional Recovery in the Hand Excellent Good Fair Poor Defined as normal; No motor weakness, Can include slight muscle atrophy, coldness in fingers, subtle hypoesthesia Muscle strength rated 4 or 5 MMT, and no residual deformity, some hypoesthesia that does not impair activities of daily living Clinical improvement, but the claw finger deformity, disability of small finger Adduction, and Froment s sign may remain; hypoesthesia that impairs activities of daily living No improvement or worsening Table 4. Postoperative Functional Recovery by Akahori s Criteria 15), at Final Follow-up Degeree Group I 35 cases Group II 37 cases Group III 22 cases p Excellent 18 19 9 0.028 (Group I and III) Good 10 8 4 Fair 5 6 6 Poor 2 4 3 A B Fig. 2. The comparisons of the improved clinical results between 3 groups. (A) All groups showed significant improvement of pain, and which was more statistically significant in group 1 and 2, compared to group 3 (p=0.038). (B) All groups showed significant improvement of sensory function, showed no difference between group 1 and 2, and 2 and 3, however, group 1 showed significant degree of improvement, compared to group 3 (p=0.026). (C) All groups showed significant improvement of motor function, and which showed no difference between group 1 and 2, group 1 and 2 showed significant degree of improvement, compared to group 3 (p=0.028). C 210
차수민 : 주관증후군에서척골신경경근전방이동술의임상결과 있는회복을보였고, 1군과 2군사이에는회복정도의차이는없었으며 3군과의비교에서의미있는회복정도관찰할수있었다 (p=0.028, Fig. 2C). 술후 Akahori 분류 15) 를이용한평가에서 1군의 28 예 (80%), 2군의 27 예 (73%), 3군의 13 예 (59%) 에서양호및우수의결과를나타내었다. 양호및우수의결과가효과가있는것으로판단할경우 1군이 3군에비해효과가우수하였다 (p=0.028, Table 4). 전체대상군에서연령에따른술후 Akahori 등급 15) 은두변수간유의한음의상관관계가있는것으로나타났다 (p=0.021, r=- 0.512). 또한, 이환기간과술후 Akahori 15) 분류역시두변수간유의하면서, 음의상관관계가있는것으로나타났다 (p=0.019, r=-0.607). 즉, 연령이많을수록, 이환기간이길수록술후전반적임상결과는불량한것으로나타났다. 반면, 성별과우세측여부에따른임상결과는통계학적유의성이없었다. 고찰주관증후군의치료에있어증상의중증도에따라어느술식이가장적합한가에대해서는객관적기준이나지침이없다. 문헌고찰결과각술자의연구결과를근거로장단점이보고되고있으며이에따라적절한술식을선정하고있다. 3,5-8,10) 현재까지대체적으로받아들여지는견해는중등도이상의척골신경압박증인경우에는비수술적치료는전혀효과적이지못했으며, 3,4,9) 수술방법으로는근육하전방이동술이가장좋은결과를보였고가장낮은재발율을보였다고하였다. 3,10,16,17) Vogel 등 16) 은전방피하이동술후실패한18예의주관증후군환자들을전방근하이동술로재수술하여좋은임상결과를보고한바있다. Mowlavi 등 18) 은경도의예에서는모든수술방법이비슷하게좋은결과를보였지만내상과절제술이가장좋은결과를, 피하전방이동술이가장좋지않은결과를나타내었다고보고하였다. 또한, 중증의예에서는모든수술방법이일관되게효과적인결과를나타내지못하였지만내상과절제술이가장불량하였다고보고하였다. 반면에, 비교적쉽고간단한피하전방이동술도중등도및고도의예에서근육하전방이동술에못지않게우수하다는보고도있다. 3,17,19-21) 저자들이시행한경근이동술은, Mackinnon에의해소개된후, 다른술식과의비교연구등은보고되지않았으나최소 2년추시에서편측주관증후군에서 75%, 양측의주관증후군에서는 68% 의정상에가까운호전이보고되었다. 22) 이술식의특징은척골신경이내상과를기준으로근위및원위어느부위에서도긴장 (tension) 을받지않으며, 척골신경의주행경로가직선화 되어짧아지면서주관절의어느운동범위에서도횡으로 (transverse) 신경이놓이게되어철저한감압만전제된다면다시압박을받을가능성은거의없는것이특징이다. 또내상과기시부의굴곡근-회내근의대부분은보존을하기때문에술후근력의감소를최소화할수있을것으로기대되는술식이다. 저자들의변형된방법은굴곡근-회내근의근막절제를굳이연장 (lengthening) 의방법을쓰지않고내상과를기준으로 2 cm 원위의방향으로부채꼴모양의피판 (flap) 을만들었으며, 전기소작기를이용해신경이놓일수있는공간 (trough) 을만드는, 기존의 Mackinnon 술식에비해간단한방법이다. 근막의피판은원래부착부위보다내상과측에느슨하게봉합하여근막피판에의해다시신경이압박되지않도록하였다. 다른보고된연구들과마찬가지로동일한군내에서이동술의효과는명백히존재하였고, 다만중증도가심한경우회복의정도가경증의군에비해적었다. 특히, 술후 Akahori 분류 15) 를이용한평가에서양호이상의결과는중증도가심함에따라반비례양상을보였다. 중증도에따른결과및연령에따른결과의차이도확인할수있었다. 특히, 대상군들에대한연령의차이가없어, 순수한중증도에따른술후결과파악할수있었으며, 역시중증도와무관하게연령에따른술후결과를따로파악할수있었다. 이번연구의장점은첫째, 많은증례에대한한술자의동일술식으로시행한연구라는점이며, 둘째로는국내외문헌상경근전방이동술 (transmuscular anterior transposition) 에대한연구가많지않은상태에서, 중증의주관증후군에서도효과가있음을알수있었다는점이다. 본연구의한계점으로는, 후향적연구이며다른술식과의비교연구가아니라는점이다. 또한술전, 후평가의방법에있어점수체계가다소단순하여통증의파악, 감각의회복정도에있어세분화된평가어려웠다는점이다. 추후다른술기와의비교연구등을통해주관증후군에서중증도에따른임상결과에대한추가적연구가필요할것으로생각된다. 결론변형된 Mackinnon 술식을이용한주관증후군에대한후향적연구에서술전에비해술후통증, 감각및운동기능이호전되었으나호전정도는중증도가심할수록감소하는양상이었다. 특히, 연령이증가할수록, 질환의이환기간이길수록호전되는정도가감소하므로질환의경과초기에수술적치료를고려해야할것으로생각된다. 211
대한견 주관절학회지제 14 권제 2 호 REFERENCES 1) Fernandez E, Pallini R, Lauretti L, Scogna A, La Marca F. Neurosurgery of the peripheral nervous system: Cubital tunnel syndrome. Surg Neurol. 1998;50: 83-5. 2) Bednar MS, Blair SJ, Light TR. Complications of the treatment of cubital tunnel syndrome. Hand Clin. 1994;10:83-92. 3) Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg Am. 1989;14: 688-700. 4) Mitsionis GI, Manoudis GN, Paschos NK, Korompilias AV, Beris AE. Comparative study of surgical treatment of ulnar nerve compression at the elbow. J Shoulder Elbow Surg. 2010;19:513-9. 5) Pyun YS, Jeon HS, Bae KC, Yeo KK. Anterior Subcutaneous Ulnar Nerve Transposition for Cubital Tunnel Syndrome. J Korean Shoulder Elbow Soc. 2005;8: 36-42. 6) Chung MS, Baek GH, Kim SL, Park YC. Medial Epicondylectomy for the Treatment of Cubital Tunnel Syndrome. J Korean Shoulder Elbow Soc. 1998;1:100-8. 7) Gellman H, Campion DS. Modified in situ decompression of the ulnar nerve at the elbow. Hand Clinics. 1996;12:665-77. 8) Osterman AL, Davis CA. Subcutaneous transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Hand Clinics. 1996;12:421-33. 9) Hamidreza A, Saeid A, Mohammadreza D, Zohreh Z, Mehdi S. Anterior subcutaneous transposition of ulnar nerve with fascial flap and complete excision of medial intermuscular septum in cubital tunnel syndrome: a prospective patient cohort. Clin Neurol Neurosurg. 2011;113:631-4. 10) Siegel DB. Submuscular transposition of the ulnar nerve. Hand Clinics. 1996;12:421-33. 11) Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. 1989;14:972-9. 12) Kuschner SH. Cubital tunnel syndrome: Treatment by medial epicondylectomy. Hand Clinics. 1996;12:421-33. 13) Lowe JB 3rd, Novak CB, Mackinnon SE. Current approach to cubital tunnel syndrome. Neurosurg Clin N Am. 2001;12:267-84. 14) Gabel GT, Amadio PC. Reoperation for failed decompression of the ulnar nerve at the elbow. J Bone Joint Surg Am. 1990;72:213-9. 15) Akahori O. Cubital tunnel syndrome: grade of palsy and prognosis, and selection of operation. Orthop Surg Traumatol. 1986;29:1745-51. 16) Vogel RB, Nossaman BC, Rayan GM. Revision anterior submuscular transposition of the ulnar nerve for failed subcutaneous transposition. Br J Plast Surg. 2004;57:311-6. 17) Stuffer M, Jungwirth W, Hussl H, Schmutzhardt E. Subcutaneous or submuscular anterior transposition of the ulnar nerve?. J Hand surgery Am. 1992;17:248-50. 18) Mowlavi A, Andrews K, Lille S, Verhulst S, Zook E, Milner S. The management of cubital tunnel syndrome: A meta-analysis of clinical studies. Plast Reconstr Surg. 2000;106:327-34. 19) Sreedharan S, Yam AK, Tay SC. Self-reported outcome following anterior transposition of ulnar nerve in the elderly. Hand Surg. 2010;15:169-72. 20) Eaton GJ, Crowe JF, Parkes JC. Anterior transposition of the ulnar nerve using a noncompressing fasciodermal sling. J Bone Joint Surg Am. 1980;62:820-5. 21) Osterman AL, Davis CA. Subcutaneous transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Hand Clinics. 1996;12:421-33. 22) Novak CB, Mackinnon SE, Stuebe AM. Patient Self- Reported Outcome After Ulnar Nerve Transposition. Ann Plast Surg. 2002;48:274-80. 212
차수민 : 주관증후군에서척골신경경근전방이동술의임상결과 초록 목적 : 주관증후군진단후질환중증도에따른척골신경경근전방이동술의임상결과를후향적으로분석하였다. 대상및방법 : 2003년 1월부터 2008년 12 월까지주관증후군진단후변형된 Mackinnon 술식으로척골신경의경근전방이동술을시행한 94 예를대상으로하였다. 술전중증도는 McGowan 등급으로파악하였고등급 I (1군) 35예, 등급 II (2군) 37예, 등급 III (3군) 22예였다. 결과 : 술후통증은세군모두에서술후의미있게호전되었고, 1군과 2군에서 3군에비해회복정도가유의하였다. 감각기능은세군모두에서술후의미있는회복을보였고, 1군은 3군에비해유의하게회복정도가우수하였다. 운동기능의회복정도역시, 세군모두에서술후의미있는회복을보였고, 3군과의비교에서의미있는회복정도관찰할수있었다 (p<0.05). 술후 Akahori 분류를이용한평가에서 1군의 80%, 2군의 73%, 3군의 59% 에서 양호 또는 우수 의결과를나타내었다. 결론 : 변형된 Mackinnon 술식으로치료한주관증후군에대한후향적연구에서술전에비해술후통증, 감각및운동기능이호전되었으나호전정도는중증도가심할수록감소하는양상이었다. 색인단어 : 척골신경, 주관증후군, 경근전방이동술 213