Original Article pissn 1738-2637 / eissn 2288-2928 J Korean Soc Radiol 2015;72(3):164-170 http://dx.doi.org/10.3348/jksr.2015.72.3.164 The Value of MRI in Idiopathic Tarsal Tunnel Syndrome by Measuring the Cross-Sectional Area of Tarsal Tunnel 1 족근관의횡단면적측정을통한특발성족근관증후군의진단에있어 MRI 의가치 1 Min Jung Kim, MD 1, Yu Mi Jeong, MD 1, Sheen-Woo Lee, MD 1, Seung Joon Choi, MD 1, Jeong Ho Kim, MD 1, Hong Gi Park, MD 2 Departments of 1 Radiology, 2 Orthopedic Surgery, Gachon University, Gil Hospital, Incheon, Korea Purpose: The purpose of this study was to evaluate the use of MRI as a diagnostic test in tarsal tunnel syndrome. There are no published reports with this aim and no diagnostic standard for idiopathic tarsal tunnel syndrome (TTS) using imaging modalities. Materials and Methods: We retrospectively searched our Picture Archiving and Communication System data and medical records to identify patients who were clinically and electomyographically diagnosed with idiopathic TTS without space-occupying lesion on MRI. Twenty five patients were included in the patient group. Another twenty-five patients who underwent ankle MRI for Achilles tendon disease were selected and included in the control group. Cross-sectional areas (CSA) of tarsal tunnel were manually measured independently by two radiologists who were blinded to clinical and surgical results, using three-dimensional reconstruction software in our hospital. Measurements were done on axial images at three levels (level 1, tibiotalar joint level; level 2, medial malleolar tip level; level 3, sustentaculum tali level). Patient and control group data were statistically analyzed by the Mann-Whitney test. Results: The mean values of CSA at levels 1, 2, and 3 of the tarsal tunnel were 87.8 mm 2, 98.2 mm 2, and 105.2 mm 2, respectively in the patient group; and 100.0 mm 2, 113.8 mm 2, and 127.9 mm 2 in the control group, respectively, in reader 1; and 86.2 mm 2, 97.6 mm 2, 105.2 mm 2, respectively in the patient group; and 99.7 mm 2, 112.3 mm 2, 124.4 mm 2, respectively, in the control group, in reader 2. The mean CSA in the patient group was significantly less than that of the control group at all three levels (p < 0.05). Intra-class correlation coefficient value between reader 1 and reader 2 were 0.98 in group 1, and 0.97 in group 2, respectively. Conclusion: MRI can be helpful in the assessment of idiopathic tarsal tunnel syndrome. CSA measurements of tarsal tunnel at each level may predict TTS even though there are no space occupying lesions in the tarsal tunnel on MRI. Index terms Idiopathic Tarsal Tunnel Syndrome Cross-Sectional Areas MRI Received July 8, 2014; Accepted October 29, 2014 Corresponding author: Yu Mi Jeong, MD Department of Radiology, Gachon University, Gil Hospital, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 405-760, Korea. Tel. 82-32-460-3060 Fax. 82-32-460-3065 E-mail: youme34@gilhospital.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 서론 족근관 (tarsal tunnel) 은섬유골공간 (fibro-osseous space) 으로경골의내측과 (medial malleolus), 굽힘근지지띠 (flexor retinaculum) 및거골 (talus) 의내측면과종골 (calcaneus) 로경계지어진다 (1, 2). 이공간으로후경골동맥 (posterior tibial artery) 및정맥 (vein) 과경골신경 (tibial nerve), 장무지굴건 (flexor halluces longus tendon), 장지굴건 (flexor digitorum longus tendon) 및후경골건 (tibialis posterior tendon) 이통과한다. 족근관증후군 (tarsal tunnel syndrome) 은경골신경 (tibial nerve) 혹은그가지 (branches) 의포착신경병증 (entrapment neuropathy) 으로정의 (2) 되는데, 주행경로인족근관이여러이유로좁아지면서경골신경이눌리게되어신경병증이발생하게된다. 현재까지알려진족근관증후근의원인은족근관내의종괴 (tumor), 결절종 (ganglion cyst), 정맥류 (varicosities), 부근육 (accessory muscles) 등이있다. 그외에이전외상이나수술로형성 164 Copyrights 2015 The Korean Society of Radiology
김민정외 된섬유조직에의한신경의압박, 그리고내반족 / 외반족 (hindfoot valgus/varus), 편평족 (pes planus), 족근골융합 (tarsal coalition) 등과같은발기형 (foot deformity) 이원인으로알려져있다 (1, 3, 4). 환자들이겪는증상은전형적으로발목과발꿈치의저린감각 (tingling sensation), 타는듯한감각 (burning sensation), 무감각 (numbness), 통증등의감각이상이고, 후기합병증으로움직임결손 (motor deficit) 이나근육의 denervation 을초래하기도한다 (3). 그러나약 60% 정도의증례에서만신경병증 (neuropathy) 을일으킬수있는병변이발견되고, 그외의경우에서는원인을찾지못한다는보고가있다 (3). 이러한경우를특발성족근관증후군 (idiopathic tarsal tunnel syndrome) 이라고정의할수있으며 (5), 보존적인치료에도반응이없는특발성족근관증후군의경우에도수술적감압술로증상의호전이있다고보고되어있다 (5, 6). 자기공명영상은연부조직의대조도가좋으며, 세부해부학적구조를잘볼수있어족근관주변에서경골신경포착 (tibial nerve entrapment) 을일으킬만한원인을찾는데가장좋은검사이다 (3, 7). 그러나특발성족근관증후군으로진단된환자에있어서자기공명영상 (MRI) 의유용성에대해연구, 보고된바는없다. 저자들은족근관면적자체가협소한경우내부해부학적구조들의과밀에의하여특발성족근관증후군이생길수있다는가설하에, 이를진단하는데있어자기공명영상의유용성을평가하고자하였다. 대상과방법 2007 년 3월에서 2013 년 5월까지발의통증을주소로내원한환자중, 임상적및신경전도검사상족근관증후군이의심되어발목자기공명영상을시행한환자들을후향적으로분석하였다. 이들중, 촬영된자기공명영상에서경골신경 (tibial nerve) 의포착을유발하는족근관내부혹은근처의종괴, 부근육, 정맥류와같은공간점유병소 (space-occupying lesion) 가발견된환자들은제외하였으며, 이중족근관의수술적감압술후증상이호전된환자들만을환자군에포함시켰다. 수술은한명의족부정형외과의사에의해시행되었으며, 환자들의의무기록을통해내원당시의증상, 신경전도검사결과, 수술기록및증상호전유무에대한정보를얻었다. 대조군으로는 Picture Archiving and Communication System 데이터를검색하여아킬레스건의손상혹은염증으로자기공명영상을촬영한환자들중의무기록을통해족근관증후군의증상이없는환자들로선정하였다. 환자군에는총 25 명 ( 여성 13 명, 남성 12 명 ) 이포함되었고, 평균나이는47.6세 (range, 16~72) 였다. 대조군역시 25 명 ( 여성 15명, 남성 10명 ) 으로구성되었으며, 평균나이는 37.6세 (range, 19~69) 였다. Independent sample t test 상 p value 가나이에대해 0.07, 성별은 0.08 이었고, 모두 0.05 이상으로각그룹에서나이나성별에의미있는차이를보이지않았다. 자기공명영상검사는 3-T 기기 (Skyra or Verio, Siemens Medical Systems, Erlangen, Germany) 를이용하여시행되었다. 본원에서시행하는표준발목검사프로토콜은다음과같다. Axial and sagittal fat-suppressed turbo spine-echo T2- weighted images [repetition time ( 이하 TR)/echo time ( 이하 TE), 4520~8000/90~104 ms], coronal turbo spin-echo T2-weighted imaging (TR/TE, 3000~4000/74~80 ms), axial, sagittal and coronal spin-echo T1-weighted imaging (TR/TE, 513/16 ms), axial proton density-weighted imaging (TR/TE, 3500~3920/10~24 ms). Slice thickness 3 mm, gap 은 0.9 mm 였고, matrix 는 384 346 또는 384 208 이었으며, sagittal/coronal/axial sequence 의 field of view 는차례로 220 220/50 200/60 170 mm 였다. 2008 년도 Sora 등 (8) 에시행된해부학연구 (anatomic study) 에서는족근관의축상면을기준으로하여위 / 중간 / 아래 (superior: level 1, middle: level 2, inferior: level 3) 의세부분을정하였는데 level 1은정강목말관절높이, level 2는내측복사과의 tip 높이, 그리고 level 3는종골의재거돌기높이이다 (Fig. 1). 이에따라저자들은자기공명영상중 axial proton density-weighted 영상에서 three-dimensional software (TeraRecon Aquarius Workstation, San Mateo, CA, USA) 를사용하여각 level 에서의단면적을수작업으로측정하였다. 측정은두명의영상의학과의사가환자군및대조군여부를모르는상태에서각각독립적으로시행하였다. 단면적측정시후경골건, 장지굴건, 장족무지굴건및근육은면적측정에서제외하였고, 각각의높이에서굴건및근육의경계, 경골, 거골및종골의후내측경계및굽힘근지지띠를따라선을그어수작업으로단면적을지정하여면적을측정하는방식으로진행하였다. 모든통계적분석은 SPSS (13.0 for Windows, SPSS Inc., Chicago, IL, USA) 를사용하여수행하였다. 환자군및대조군의자료비교를위해 Mann-Whitney test 를사용하였고, p- value 0.05 미만을통계적으로유의한것으로정하였다. 신뢰도검증을위하여 intra-class correlation coefficient 분석을시행하였다. 결과 Reader 1 에의해측정된환자군에서의족근관단면적평균 jksronline.org 대한영상의학회지 2015;72(3):164-170 165
족근관의횡단면적측정을통한특발성족근관증후군의진단에있어 MRI 의가치 A B C Fig. 1. The three axial levels of the tarsal tunnel at which the cross-sectional area were measured. A. Cross section of ankle at level of tibiotalar joint. B. Cross section of ankle at level of medial malleolar tip. C. Cross section of ankle at level of sustentaculum tali. Table 1. The Comparison of Mean CSA of Tarsal Tunnel CSA (Group 1, mm 2 ) CSA (Group 2, mm 2 ) Asymp. Sig. (2-Tailed) Reader 1 Level 1* 87.8 100.0 p = 0.035 Level 2* 98.2 113.8 p = 0.026 Level 3* 105.2 127.9 p = 0.013 Reader 2 Level 1 86.2 99.7 p = 0.023 Level 2 97.6 112.3 p = 0.025 Level 3 105.2 124.4 p = 0.024 Note. *Level 1: tibiotalar joint level, Level 2: medial malleolar tip level, Level 3: sustentaculum tali level. CSA = cross-sectional area 값은 level 1, level 2, level 3에서각각 87.8 mm 2, 98.2 mm 2, 105.2 mm 2 였고, 대조군의단면적평균값은각각 100.0 mm 2, 113.8 mm 2, 127.9 mm 2 였다. Reader 2에서의단면적평균값은환자군에서각각 86.2 mm 2, 97.6 mm 2, 105.2 mm 2, 대조군에서각각 99.7 mm 2, 112.3 mm 2, 124.4 mm 2 였다. Mann- Whitney test 로각그룹의단면적측정값을비교한결과 reader 1과 reader 2 모두에서 p-value 가 0.05 미만으로환자군의족근관단면적이대조군의족근관단면적과비교하여통계적으로유의하게작다는결과를얻었다 (Table 1, Figs. 2, 3). 또한환자군에서는, 단면적의형태가대체적으로전후상방으로길쭉하고너비는납작한형태를보였다 (Fig. 2). Reader 1과 2의측정값에대한신뢰도검증은 intra-class correlation coefficient 로분석하였고, 환자군과대조군에대해각각 0.98, 0.97 로, 상당한일치도를보임을확인하였다. 환자군에포함된 25 명의환자들은모두족근관의수술적감압술을시행받았으며, 술후모두증상의호전을보였고, 감염 이나신경손상등의합병증은발생하지않았다. 고찰 족근관증후군은족근관내부에서경골신경이나그분지신경의압박으로인하여생기는신경병증으로, 대부분임상적증상과이학적검사, 신경전도검사결과를종합하여진단된다. 전형적인족근관증후군의증상은발과발가락의바닥쪽에발생하는타는듯한통증과감각이상이며, 활동에의해악화되는특징을갖는다. 특히진단에도움이되는것은발바닥부분의감각이상과족근관부분의 Tinel 징후양성이다 (3). 또한신경전도검사를시행하여신경병증유무를확인하면진단에더욱도움을받을수있다. 족근관증후군의원인으로종괴, 정맥류, 부근육등의공간점유병소가알려져있고, 이에의한신경의직접적인압박이증상을유발하는것으로생각되고있다. 또한굽힘근지지띠의과증 166 대한영상의학회지 2015;72(3):164-170 jksronline.org
김민정외 Fig. 2. MR axial image of 59/M with idiopathic tarsal tunnel syndrome, right ankle. Some of the patient group showed flattened appearance of fibro-osseous tunnel on the transverse images. Fig. 3. MR axial image of 31/M. Right ankle MRI for postoperative follow-up 2 years after Achilles tendon repair. 식이나굴건의건초염 (tenosynovitis), 족근골융합이나편평족등의족부기형도족근관증후군의원인으로열거할수있다. 족근관내에공간점유병소가있는경우수술적치료가필요하기때문에초음파 (5, 9, 10) 나자기공명영상과같은영상검사를시행하게된다 (7, 11, 12). 특히자기공명영상의경우높은연부조직대조도로수술전공간점유병소또는액체저류등의병변을정확히진단할수있기때문에술전검사로선호되고있다. 그러나문헌에따라약 20~40% 정도에서족근관내의공간점유병소나골병변없이도족근관증후군이생기는것으로보고하고있는데 (3), 이를특발성족근관증후군으로말할수있다 (6). 최근보고에따르면, 특발성족근관증후군의경우에도수술적감압술을시행하였을때증상의호전을보이는경우가 있다 (6). 말초신경 (peripheral nerve) 의포착에의해발생하는신경병증중가장흔한것은중년여성에서호발하는수근관증후군 (carpal tunnel syndrome) 이다 (13, 14). 수근관은손목에서굽힘근지지띠에의해경계지어진제한된공간으로내부로굴건및정중신경이지난다. 족근관증후군과유사하게, 수근관증후군도공간점유병소나건초염, 굽힘근지지띠의과증식등다양한원인에의하여정중신경이압박을받아생기는질환이다 (15, 16). 그러나역시이러한병소없이도수근관증후군이생길수있으며, 수근관의단면적이나정중신경의단면적이특발성수근관증후근을예측할수있다는여러보고들이있다 (17). 초음파나자기공명영상을이용하여정중신경의단면적을측정함으로 jksronline.org 대한영상의학회지 2015;72(3):164-170 167
족근관의횡단면적측정을통한특발성족근관증후군의진단에있어 MRI 의가치 써높은특이도와민감도로수근관증후군을진단할수있다는여러보고가있으며 (13, 14, 18), 자기공명영상에서수근관의단면적이수근관증후군환자군에서건강한지원자들보다유의하게작다고보고된연구도있다 (16). 이러한연구들로미루어볼때족근관증후군에서도초음파나자기공명영상검사등의영상의학적검사를통하여족근관의단면적이나경골신경의단면적을측정하는것이특발성족근관증후군을진단하는데도움이될수도있을것이라생각할수있다. 문헌고찰에의하면, 경골신경의단면적을측정함에있어초음파가높은신뢰도를보이며, 경골신경의신경병증이있는경우신경의단면적이정상보다증가되어있다는연구들이있다 (19-21). 그러나수근관내에서비교적일정하게보이는정중신경과는달리경골신경의경우족근관상방이나족근관내에서내측및외측족저신경 (medial and lateral plantar nerves) 으로분지하며, 분지하는위치도사람마다각기차이가있기때문에 (22) 분지된이후의신경단면적을일정하게측정하기가어렵다. 따라서저자들은경골신경의단면적을측정하기보다는족근관자체의단면적을측정하는것이좀더신뢰도있는결과를얻을수있을것이라는가설하에족근관자체의단면적을측정하였고, 통계적으로유의한결과를얻을수있었다. 족근관증후군의치료는초기비스테로이드성진통소염제나보조기, 그리고스테로이드국소투여등의보존적인방법을시행하며, 증상호전이없는경우수술적치료를시행한다 (23). 그러나특발성족근관증후군의경우에도수술적감압술이도움이된다는연구가있으며 (6), 자기공명영상에서족근관의단면적이작은경우조기에수술적치료를결정하는데도움이될것이라생각한다. 본연구는후향적인정보수집방법으로수행되었기때문에몇가지제한점을갖는다. 우선, 환자의신체적인특징, 특히발목의크기가고려되지않았다는점이다. 다음으로, 비교적적은표본을대상으로하였다는점에서일반화에제한을가지고있고, 환자군과정상군을구분지을수있는기준점 (cut-off value) 을제시할수없었다는점이다. 또한아킬레스건에외상이나질병을갖는환자들을대조군으로지정하였기때문에, 건강한자원자들의값과차이가있을수도있다. 그리고자기공명영상검사시, 일반적인경우발목을중립자세에서시행하게되지만, 환자의통증등으로인하여중립자세가아닌상태에서검사를했을경우도배제할수없고, 이에의한단면적의변화가고려되지않았기에후향적연구의제한점이라하겠다. 마지막으로수작업에의해단면적의경계를그렸기때문에이로인한오차가있을수있겠다. 이러한제한점을고려한 prospective study 가향후이루어진 다면, 족근관증후군을진단하는데있어, 자기공명영상은족근관내부 / 외부병변의유무를찾는것뿐만아니라, 이러한원인없이발생하는특발성족근관증후군에서족근관의단면적을측정하는방법으로, 보존적치료혹은수술적치료를결정하는데있어도움을줄수있을것으로기대한다. REFERENCES 1. Erickson SJ, Quinn SF, Kneeland JB, Smith JW, Johnson JE, Carrera GF, et al. MR imaging of the tarsal tunnel and related spaces: normal and abnormal findings with anatomic correlation. AJR Am J Roentgenol 1990;155:323-328 2. Narváez JA, Narváez J, Ortega R, Aguilera C, Sánchez A, Andía E. Painful heel: MR imaging findings. Radiographics 2000;20:333-352 3. Donovan A, Rosenberg ZS, Cavalcanti CF. MR imaging of entrapment neuropathies of the lower extremity. Part 2. The knee, leg, ankle, and foot. Radiographics 2010;30: 1001-1019 4. Trepman E, Kadel NJ, Chisholm K, Razzano L. Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot Ankle Int 1999;20:721-726 5. El Shazly O, El Shazly A, Desouky A, El Zohiery AK, Sakr HM. Anatomical bases of endoscopic tarsal tunnel release: anatomical and ultra-sonographic study with a preliminary clinical report. Surg Radiol Anat 2011;33:929-936 6. Kohno M, Takahashi H, Segawa H, Sano K. Neurovascular decompression for idiopathic tarsal tunnel syndrome: technical note. J Neurol Neurosurg Psychiatry 2000;69:87-90 7. Jung HJ, Lee SW, Jeong YM, Choi HY, Kim HS, Park HG, et al. The usefulness of the preoperative magnetic resonance imaging findings in the evaluation of tarsal tunnel syndrome. J Korean Soc Radiol 2012;66:183-192 8. Sora MC, Jilavu R, Grübl A, Genser-Strobl B, Staykov D, Seicean A. The posteromedial neurovascular bundle of the ankle: an anatomic study using plastinated cross sections. Arthroscopy 2008;24:258-263.e1 9. Martinoli C, Bianchi S, Gandolfo N, Valle M, Simonetti S, Derchi LE. US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs. Radiographics 2000;20 Spec No:S199-S213; discussion S213-S217 10. Peer S, Kiechl G, Bonder G. Nerve compression syndromes. 168 대한영상의학회지 2015;72(3):164-170 jksronline.org
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족근관의횡단면적측정을통한특발성족근관증후군의진단에있어 MRI 의가치 족근관의횡단면적측정을통한특발성족근관증후군의진단에있어 MRI 의가치 1 김민정 1 정유미 1 이신우 1 최승준 1 김정호 1 박홍기 2 목적 : 본연구의목적은특발성족근관증후군 (tarsal tunnel syndrome) 을진단하는데있어자기공명영상 (magnetic resonance imaging) 의유용성을평가하는데있다. 대상과방법 : 영상데이터와전자의무기록을검토하여, 임상적및신경전도검사상족근관증후군이의심되어발목자기공명영상을시행한환자들중특발성족근관증후군으로진단된총 25 명의환자를후향적으로분석하였다. 마찬가지의방법으로아킬레스건의손상혹은염증으로자기공명영상을촬영한환자들중의무기록을통해족근관증후군의증상이없는환자들로대조군을선정하였다. 족근관의횡단면적 (cross-sectional areas) 측정은두명의영상의학과의사가임상적정보와수술결과에대해모르는상태에서독립적으로수행하였다. 횡단면적은정강목말관절높이 (tibiotalar joint level, level 1), 내측복사과의 tip 높이 (medial malleolar tip level, level 2), 그리고종골 (calcaneus, level 3) 의재거돌기높이 (sustentaculum tali level) 에서측정되었다. 모든통계적분석은 SPSS (13.0 for Windows, SPSS Inc., Chicago, IL, USA) 를사용하여수행하였으며, 환자군및대조군의자료비교를위해 independent sample t test 와 Mann-Whitney test 를사용하였고, p-value 0.05 미만을통계적으로유의한것으로정하였다. 결과 : Reader 1에의해측정된환자군에서의족근관단면적평균값은 level 1, level 2, level 3에서각각 87.8 mm 2, 98.2 mm 2, 105.2 mm 2 였고, 대조군의단면적평균값은각각 100.0 mm 2, 113.8 mm 2, 127.9 mm 2 였다. Reader 2에서의단면적평균값은환자군에서각각 86.2 mm 2, 97.6 mm 2, 105.2 mm 2, 대조군에서각각 99.7 mm 2, 112.3 mm 2, 124.4 mm 2 였다. Mann-Whitney test 로각그룹의단면적측정값을비교한결과 reader 1과 reader 2 모두에서 p-value 가 0.05 미만으로환자군의족근관단면적이대조군의족근관단면적과비교하여통계적으로유의하게작다는결과를얻었다. 신뢰도검증은 intra-class correlation coefficient 로분석하였고, 환자군과대조군에대해각각 0.98, 0.97 로확인하였다. 결론 : 족근관내부와외부에병변이없는특발성족근관증후군을진단하는데있어, 자기공명영상을이용한족근관의단면적측정법은보존적치료혹은수술적치료를결정하는데있어도움을줄수있을것으로기대한다. 가천대학교길병원 1 영상의학과, 2 정형외과 170 대한영상의학회지 2015;72(3):164-170 jksronline.org