350 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2018; 53: 350-357 https://doi.org/10.4055/jkoa.2018.53.4.350 www.jkoa.org 초음파를이용한요추부내측분지차단술시부위별바늘삽입각도및깊이계측 : 자기공명영상과비교를통한유용성평가 김창수 심대무 * 이석중 우영하 백사무엘 정학순 고신대학교복음병원정형외과, * 원광대학교의과대학정형외과학교실, 계명대학교의과대학정형외과학교실, 부산부민병원정형외과 Measuring Needle Angle and Depth for Lumbar Medial Branch Block Using Ultrasonography: An Evaluation of Efficiency Compared with Magnetic Resonance Imaging Changsu Kim, M.D., Daemoo Shim, M.D.*, Seokjoong Lee, M.D., Youngha Woo, M.D., Samuel Baek, M.D., and Haksun Chung, M.D. Department of Orthopedic Surgery, Kosin University Gospel Hospital, Busan, *Department of Orthopedic Surgery, Wonkwang University School of Medicine, Iksan, Department of Orthopedic Surgery, Keimyung University School of Medicine, Daegu, Department of Orthopedic Surgery, Bumin Hospital Busan, Busan, Korea Purpose: The purpose of this study was to compare accuracy of proper needle insertion angle between magnetic resonance imaging (MRI) and ultrasonography during lumbar medial branch nerve block procedure. Materials and Methods: Between January 2015 and June 2016, 80 people who underwent MRI in the past 3 months with improved lumbar pain after sono-guided medial branch nerve block were enrolled for analysis (male, 39; female, 41; average age, 63.3 years). The insertion angle and depth between the spinous process and needle at each target points were measured at various levels (superior, inferior segment of each facet joints from L2-3 to L5-S1). The needle was positioned 1 cm apart from both lateral sides of the probe, locating spinous process in the middle. A comparative analysis was performed between an ultrasonography and an MRI. We determined the statistical correlation between the two methods. Results: The average differences with respect to the distance between each level on a sono-guided medial branch nerve block were 1.28±1.07 mm in L2 (7 cases), 1.27±4.26 mm in L3 (25 cases), 1.63±5.89 mm in L4 (93 cases), 1.99±4.12 mm in L5 (141 cases), and 1.51±3.87 mm in S1 (66 cases). The average differences regarding the angle of each level were 1.69 ±1.34 in L2 (7 cases), 2.03 ±5.35 in L3 (25 cases), 1.49 ±3.42 in L4 (93 cases), -1.55 ±3.67 in L5 (141 cases), and 1.86 ±4.83 in S1 (66 cases). All measurements followed a normal distribution (p>0.05), showing statistical correlation without significant difference (p>0.05). Conclusion: After measuring each level using an MRI prior to performing the procedure, a sono-guided lumbar medial branch nerve block can be performed with greater safety and efficacy, especially for beginners. Key words: spine, facet joint, ultrasonography, magnetic resonance imaging Received June 24, 2016 Revised September 10, 2016 Accepted July 4, 2017 Correspondence to: Changsu Kim, M.D. Department of Orthopedic Surgery, Kosin University Gospel Hospital, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea TEL: +82-51-990-6467 FAX: +82-51-990-3071 E-mail: mewha98@naver.com ORCID: https://orcid.org/0000-0002-4660-7794 The Journal of the Korean Orthopaedic Association Volume 53 Number 4 2018 Copyright 2018 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.
351 Measuring Needle Angle and Depth for Lumbar Medial Branch Block 서론 1976 년 Mooney 와 Robertson 1) 이후관절증후군을보고한이래후 관절증후군이요통의중요한원인의하나로여겨지고있으며만성요통의 10%-15% 가후관절에서기인하는것으로보고되고있다. 2) 이러한외래요통환자의주요원인질환으로추정이되는후관절증후군의치료방법으로후관절내로직접약물을주입하는후관절차단술및후관절을지배하는내측분지를선택적으로차단하는내측분지차단술이대표적이며이전에는컴퓨터단층촬영 (computed tomography, CT) 이나방사선투시장치를이용한후관절내관절강약물주입술, 혹은내측신경의선택적차단술에대한문헌보고가많다. 3-5) 하지만이런시술은상대적으로높은가격과제한된이동성, 시술자와환자모두방사능에노출되는단점을가지고있다. 또한이러한시술을하기위해서는환자가투시방사선실, 수술실등으로이동하여야하며이동후대기를해야하는등의불편함이있다. 최근초음파기구의발달로정형외과영역에서초음파의진단적기구로서의비중이점차높아지고있으며정형외과외래에비치되어있어상대적으로접근성이뛰어난초음파를이용하여후관절차단술및내측분지차단술의빈도가빈번해졌으며좋은결과를보고하였다. 6-8) 그러나초음파를이용한술기의경우 CT나방사선투시장치를이용한술기보다초심자가시술하기어려우며시술하는술자의숙련상태에따라결과가많이달라질수있는문제가있고요추부의경우환자의체형에따라상당한변이를보이므로비만한환자의경우정확한시술이이루어지기어려운경우가많다. 이에저자는척추질환이있는환자의경우과거에비하여자기공명영상 (magnetic resonance imaging, MRI) 촬영을하는경우가빈번하므로 MRI를이용하여주사침의깊이, 각도를미리계측한후이를초음파를이용한요추부후관절내측분지차단술시부위별주사침의깊이, 각도를계측하여비교함으로써시술시 MRI의계측을청사진으로사용하여시술할수있는방법을제시하고자하였다. Table 1. Area of Evoking Pain and Number of Needle Insertion at Each Level Level (case) Site of symptom Left Right Both Total* L2/3 (n=5) 2 1 2 7 L3/4 (n=12) 3 3 6 18 L4/5 (n=47) 7 12 28 75 L5/S1 (n=35) 8 6 21 66 Values are presented as number only. For 1 facet joint block, inserting the needle at the upper, lower, and medial branches of the facet joint. *Left+right+both 2. 대상및방법 본연구는고신대학교복음병원윤리위원회의승인을받아후향적연구로시행되었다 ( 승인번호 : 2018-04-010). 2015년 1월에서 2016 년 6월까지요추부통증을주소로내원하여초음파를이용한후관절내측분지차단술을시행받은환자군중호전이있었으며이중 3개월이내에요추부 MRI 검사를시행받은적이있는환자 80명을대상으로하였다 ( 남자 39명, 여자 41명, 평균연령 63.3세 ). 이전요추부수술을받았던환자, 요추부의퇴행성측만증및후만변화를보이는환자는제외하였다. 이중통증을일으키는부위가 L2-3 3명, L3-4 9명, L4-5 29명, L5-S1 21명이었고 L2-3과 L4-5 2명, L3-4와 L4-5 2명, L4-5와 L5-S1 13명, L3-4, L4-5, L5-S1 1명이었으며, 좌측증상만있는경우는 16명, 우측증상만있는경우는 17명, 양측증상이있는경우는 47명이었다 (Table 1). 후관절내측분지차단술시행분절의선택은환자의증상 ( 요통과신전시악화되는통증 ) 과이학적검사 ( 압통 ) 에근거하여후관절의퇴행성변화를보이는 MRI 결과와일치하는분절로하였고, 환자의증상과이학적검사결과가영상소견과일치되는지확인을위한진단적목적으로도의심되는분절에시행하였다. 시술은환자를복와위로하여요추만곡을상쇄시킨다음환자등에극돌기와후방장골능선을촉지하여표시한후제4-5요추위치를확인하고타원형프루브 ( 탐촉자 ) (C2-6IC, Application: Abdomen, Obstetric, Gynecology, field of view: 58.1, 길이 : 70 mm) 를이용하여세로축상에서후관절이보이도록하였다. 그리고극돌기의후관절연결과천골의상연에서부터후관절을머리쪽으로세어가면서정확한위치를정하였으며탐촉자를 90 회전하여가로축상영상을얻은후후관절과횡돌기를확인하고횡돌기와상관절돌기가만나는부분을목표점으로하여해당후관절의위, 아래지점에주사침을삽입하였다. 저자가설정한각부위별 ( 제2-3요추에서제5요추-제1천추까지 ) 주사침의삽입지표는극돌기를따라그은정중선을종축으로하고, 해당부위에위치한탐촉자의중심이극돌기에오게했을때탐촉자의양끝점에서 1 cm 떨어진지점을주사침의삽입점으로하였다 (Fig. 1). 각부위별지표를통해주사침을삽입하였고내측분지차단술에따른목표점에닿았으며주사침을통해뼈에닿는느낌 (bone touch) 이느껴졌을때의주사침의깊이및극돌기와주사침이이루는각도를측정하였다 (Fig. 2). MRI에서주사침의길이와각도는각부위별횡돌기와상관절돌기가만나는부분이보이는컷에서미리측정하여놓은탐촉자의양끝거리에 2 cm를연장하여의료영상저장전송시스템 (picture archiving and communication system) 상에서극돌기의중심에탐촉자길이의중심이오도록하여삽입점을표시한후삽입점에서부터목표점까지선을그어선의길이및극돌기와선이이루는각도를측정하
352 Changsu Kim, et al. L4/5 A-1 A-3 A-2 S F L5/S1 Facet joint L4/5 Facet joint L3/4 Facet joint F T T B-1 B-2 Figure 1. (A) When longitudinal axis is a line along the spinous process (A-1) and center of probe is on the spinous process (A-2), entrance points of the needle are 1 cm from both lateral sides of the probe (A-3). (B) Facet joint seen at a longitudinal view; the exact point is set by counting the interface between spinous process and facet joint and upper portion of sacrum (B-1) facet joint and spinous process are checked after rotating the probe 90 for a horizontal view (B-2). S, spinous process; F, facet; T, transverse process. Spinous process Needle Figure 2. Needle is inserted through the index at each level, needle s depth and angle between the needle and spinous process are measured when the needle touches the target point of the medial branch block. 였다(Fig. 3). 부위별로 실제로 초음파에서 측정한 주사침의 깊이 및 삽입각 과 MRI에서 측정한 선의 길이 및 삽입각의 차를 구하여 정규 분 포를 이루는지 여부를 평가하였으며 차의 평균값이 0에 수렴하 는지 평가하였고 상관계수를 구하였다. 저자들이 사용한 MRI는 Philips 1.5 Tesla scanner (Gyroscan;
353 Measuring Needle Angle and Depth for Lumbar Medial Branch Block 10.1 340.9 67.16 mm Table 3. Mean of Needle Depth and Angle in Using Ultrasonography for Medial Branch Level (case) Depth (mm) Angle ( ) L2 (n=7) 54.29 38.19 L3 (n=25) 53.73 37.31 L4 (n=93) 57.76 34.42 L5 (n=141) 52.31 26.97 S1 (n=66) 50.30 28.23 45.00 mm Figure 3. On a magnetic resonance imaging, the length (depth) and angle of the needle at each level are measured using the distance between the entrance point of needle insertion and the target point when interface between the transverse process and superior articular process is observed on the axial view. Philips, Amsterdam, Netherlands) 를이용하였으며, 초음파는 AC- CUVIX XG (Samsung Medison, Hongcheon, Korea) 를이용하였고, 검사자간의오차를줄이기위하여한명의정형외과전문의에의해서시행및계측되었다. 영상은 2차원으로얻어서측정하였다. 결과에관한통계처리는 SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA) 상에서정규성검정은 Sapiro-Wilks test를이용하였고평균값이 0에수렴하는지는 paired t-test를이용하였으며, 상관계수는 Pearson correlation coefficient를이용하여통계처리하였다. 이에서 p-value가 0.05 이하인것을통계적으로유의한차이가있는것으로평가하였다. 결과 45.01 mm 56.56 mm Table 2. Mean of Needle Depth and Angle in Using Magnetic Resonance Imaging Level (case) Depth (mm) Angle ( ) L2 (n=7) 53.01 36.50 L3 (n=25) 52.46 35.28 L4 (n=93) 56.13 32.93 L5 (n=141) 50.32 28.52 S1 (n=66) 48.79 26.37 MRI에서측정된주사침의깊이 (mm) 와각도 ( ) 는각각제2요추에서 53.01 mm, 36.50, 제3요추에서 52.46 mm, 35.28, 제4요추에서 56.13 mm, 32.93, 제5요추에서 50.32 mm, 28.52, 제1천추에서 48.79 mm, 26.37 로측정되었다 (Table 2). 초음파에서측정된주사침의깊이 (mm) 와각도 ( ) 는각각제2 Table 4. Difference of Needle Depth and Angle between the Use of Ultrasonography for Medial Branch and Magnetic Resonance Imaging* Level (case) Depth (mm) p-value Angle ( ) p-value L2 (n=7) 1.28±1.07 0.214 1.69±1.34 0.189 L3 (n=25) 1.27±4.26 0.176 2.03±5.35 0.199 L4 (n=93) 1.63±5.89 0.183 1.49±3.42 0.198 L5 (n=141) 1.99±4.12 0.206-1.55±3.67 0.172 S1 (n=66) 1.51±3.87 0.143 1.86±4.83 0.207 Values are presented as mean±standard deviation. *SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA); paired t-test. 요추에서 54.29 mm, 38.19, 제3요추에서 53.73 mm, 37.31, 제4요추에서 57.76 mm, 34.42, 제5요추에서 52.31 mm, 26.97, 제1천추에서 50.30 mm, 28.23 로측정되었다 (Table 3). 초음파는복와위로시술하여요추만곡을상쇄시키지만 MRI 는앙와위로촬영하여요추만곡이좀더과장되는자세의차이와타원형초음파탐촉자의측정오차가발생할수있음에도초음파를이용한후관절의내측분지차단술에서부위별주사침깊이 (mm) 와 MRI에서측정한주사침의길이 (mm) 의차평균값은제2요추 (7예) 에서 1.28±1.07 mm, 제3요추 (25예) 에서 1.27±4.26 mm, 제4요추 (93예) 에서 1.63±5.89 mm, 제5요추 (141예) 에서 1.99 ±4.12 mm, 제1 천추 (66 예 ) 에서 1.51±3.87 mm 로측정되었다. 부위별삽입각 ( ) 차의평균값은제2요추 (7예) 에서 1.69 ±1.34, 제3 요추 (25예) 에서 2.03 ±5.35, 제4요추 (93예) 에서 1.49 ±3.42, 제5 요추 (141예) 에서 -1.55 ±3.67, 제1천추 (66예) 에서 1.86 ±4.83 로측정되었으며이는각부위별로정규분포를따랐으나 (p=0.247, p>0.05) 유의한차이없이통계적으로일치함을보였다 (p>0.05) (Table 4). 길이 (mm) 의차의평균의상관계수 r값은제2요추에서 0.62, 제 3요추에서 0.57, 제4요추에서 0.76, 제5요추에서 0.63, 제1천추에서 0.55로측정되었으며부위별삽입각 ( ) 차의평균의상관계수 r값은제2요추에서 0.55, 제3요추에서 0.52, 제4요추에서 0.66, 제5요추에서 0.69, 제1천추에서 0.59로측정되었고뚜렷한양적상관관계가있는것으로나타났다 (p<0.05) (Table 5).
354 Changsu Kim, et al. Table 5. Correlation Coefficient of Needle Depth and Angle between Ultrasonography for Medial Branch and Magnetic Resonance Imaging* Level (case) Depth Angle L2 (n=7) r 0.62 0.55 p-value 0.001 0.002 L3 (n=25) r 0.57 0.52 p-value 0.002 0.001 L4 (n=93) r 0.76 0.66 p-value 0.001 0.001 L5 (n=141) r 0.63 0.69 p-value 0.001 0.002 S1 (n=66) r 0.55 0.59 p-value 0.001 0.001 *Pearson correlation test. 초음파와 MRI 모두에서삽입된주사침의깊이는제 4 요추에서 가장길게측정되었고, 제2요추, 제3요추, 제5요추, 제1천추순으로길게측정되었으며, 각도는 MRI에서제2요추, 제3요추, 제4요추, 제5요추, 제1천추순으로뒤로갈수록작게측정되었으며초음파에서는제2요추, 제3요추, 제4요추, 제1천추, 제5요추순으로측정되었다. 부위가아래로내려갈수록일반적으로삽입각이작아져야함을알수있었다. 고찰 1956년 Pedersen 등 9) 이동척추신경에대한보고에서후관절이요통의원인이된다고주장하였고 1976년 Mooney와 Robertson 1) 이후관절증후군을명명한이래후관절이하부요통및좌골신경통의원인으로생각되어많은연구가이루어졌다. Hirsch 등 10) 과 Kellgren 11) 은후관절에고농도생리식염수를이용한동통유발을통해이증후군을증명하고자하였고, 1983년 Mooney 12) 는일종의기계적요통군이분절간동요에의한통증으로생각하여이의확진과치료를위하여관절강내주사법을시행하는것이바람직하다고주장하였다. 이외에후관절을지배하는신경에대해 Rees 13) 는절단술, Shealy 14) 는전기감작술 (radiofrequency cautery techniques), Silvers 15) 는 10% phenol을이용한탈감작을각각시도하였다. 이와같이많은연구자들이후관절에서기인하는요통을치료하고자여러가지방법을시도해왔고진단및치료목적으로스테로이드및국소마취제의후관절내투여를시도하여왔다. 후관절을차단하는방법으로는후관절내혹은주위관절낭에직접약제를주사하는것도치료방법이지만 Alhelail 등 16) 은신경차단술이직접적인병변주사보다더효과적이라고보고하였는데, 직접주사방법은더많은양의약제를투여해야하므로부작용의우려가있고, 넓은부위를주사하는과정에서정상조직의훼손이발생할수있으므로보다더선택적이고덜파괴적인신경차단술이우수한결과를보인다고하였다. 또한후관절에대한직접적인주입은주사바늘에의한관절연골의손상및주위관절낭의파괴를초래할수있다. Birkenmaier 등 17) 도후관절낭주위차단술보다내측분지차단술이더우수하다고보고함으로써이러한주장들을뒷받침하고있다. 특히퇴행성변화가진행함에따라후관절의골관절염이진행되고, 이에따른활액막의비후와연관되어관절이불안정해지며신경을압박하여발생하는경우 18) 내측분지차단술을우선해야할것으로생각되며이때술기의기준이되는주사침의각도및깊이를제시한다면술기의안정성및정확성에도움이될수있을것이라고생각하였다. 방사선투시기하시술하는것이그동안표준화된방법이었지만방사선피폭을피할수없고투시기기의크기가크므로일정공간이필요하다는단점들때문에그대안으로서, 또한최근초음파기구의발달로정형외과영역에서진단적기구로서의비중이점차높아지고있어초음파유도하시술이제시되고있다. 19) 초음파유도의정확성에대한보고들을보면, Greher 등 20) 은 28 예의초음파유도하내측분지차단술중 25예에서정확한부위에주사를하였다고보고하였고, Shim 등 8) 은초음파시술후방사선투시기로위치가정확한지확인하여 95% 의성공률을보고하였다. Galiano 등 21) 은 CT로위치를확인하여 94% 의정확도를보고하는등초음파유도만으로도상당히효과적으로내측분지차단술시행이가능한것으로많은문헌에서알려져있다. 또한선택적요추신경차단술과달리요추부후관절차단술이나후관절신경차단술은초음파를이용시횡돌기나후관절이잘구분이되기때문에이를표지자로쉽게접근할수있는장점이있다. 그러나초음파는 CT나방사선투시하시술에비하여어려워숙련도에따라같은시술이라도그결과가상이하게나타난다. 특히요추부인경우체형에따라바늘침이들어가는깊이및각도가매우달라지게되므로개개인의 MRI를이용하여시술부위의주사침의깊이와각도를미리계측하여청사진을만들어놓는다면초심자의경우시술전주사침의삽입점으로부터어떤각도와깊이로삽입해야할지예상할수있어시술의부담을덜수있을것으로생각된다. 또한이러한계측방법은초음파시술을받는본인의 MRI를이용하기때문에시술전환자시술부위의해부학적구조물위치를미리확인하여볼수있고 MRI상보이는지방의두께등을확인하여비만한환자에서도당황하지않고비교적정확한술기를시
355 Measuring Needle Angle and Depth for Lumbar Medial Branch Block 행할수있는장점이있다. 가장유의하게주사삽입각이작게계측된부위는제5요추-제 1천추간내측분지로서, 바늘이외측에서내측으로경사지게삽입하는경로의각도를너무적게주게되면제5요추의횡돌기하연과후상장골극사이공간으로바늘이삽입되기어려워목표점에도달하지못하게된다. 그러므로이부위에서는삽입각도를거의평행에가깝게해야만도달할수있었기때문에이러한계측결과를보인것으로생각된다. 또한이때바늘의진행방향이이루는각도가초음파의주행방향에비해평행에가까워지므로바늘이잘안보이게된다. 이럴때저자의바늘위치확인방법은바늘이들어가면서주변연부조직들의움직임이있으므로이를통해경로를확인하면서삽입한후, 뼈에닿는느낌이들면약제를아주소량주입하여제5요추-제1천추간후관절과천추외측부피질이교차하는부위로부터천추외측부피질을따라외측방향으로약제가퍼지는것을우선확인하였으며, 이러한현상이관찰되면정확한위치로판단하고약제를주사하였다. 본연구의한계점으로는 MRI 검사와시술시의자세의차이, 타원형프로브를사용함으로생기는오차등을들수있으나반대로 MRI만있다면초음파에숙련되지않은시술자라도환자의체형에관계없이짧은시간내에탐촉자의길이만으로청사진을, 그리고바로초음파차단술을시행할수있는방법을제시하였다는점에서의의가있다고생각된다. 결론 MRI상의계측된수치와초음파를통한요추부후관절내측분지차단술시측정된수치가통계적으로유의한상관관계를보이므로먼저 MRI를이용하여환자별부위계측을시행한후이를청사진으로삼아내측분지차단술을시행한다면체형에상관없이주사침이부적절한각도로깊게들어가서발생하는요추구조물의의인성손상을줄일수있으므로보다정확하고안전한술기에도움이될것으로생각된다. 이러한방법은초음파에숙련되지않은초심자들도쉽게내측분지차단술을시행할수있게도와주어향후요추부후관절질환의진단및치료에있어많은도움이될것으로생각된다. CONFLICTS OF INTEREST The authors have nothing to disclose. REFERENCES 1. Mooney V, Robertson J. The facet syndrome. Clin Orthop Relat Res. 1976;115:149-56. 2. Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988;318:291-300. 3. Bogduk N. International spinal injection society guidelines for the performance of spinal injection procedures. Part 1: zygapophysial joint blocks. Clin J Pain. 1997;13:285-302. 4. Gangi A, Dietemann JL, Mortazavi R, Pfleger D, Kauff C, Roy C. CT-guided interventional procedures for pain management in the lumbosacral spine. Radiographics. 1998;18:621-33. 5. Saal JS. General principles of diagnostic testing as related to painful lumbar spine disorders: a critical appraisal of current diagnostic techniques. Spine (Phila Pa 1976). 2002;27:2538-45; discussion 2546. 6. Saranteas T, Paraskeuopoulos T, Anagnostopoulou S, Kanellopoulos I, Mastoris M, Kostopanagiotou G. Ultrasound anatomy of the cervical paravertebral space: a preliminary study. Surg Radiol Anat. 2010;32:617-22. 7. Ha DH, Shim DM, Kim TK, Kim YM, Choi SS. Comparison of ultrasonography- and fluoroscopy-guided facet joint block in the lumbar spine. Asian Spine J. 2010;4:15-22. 8. Shim JK, Moon JC, Yoon KB, Kim WO, Yoon DM. Ultrasound-guided lumbar medial-branch block: a clinical study with fluoroscopy control. Reg Anesth Pain Med. 2006;31:451-4. 9. Pedersen HE, Blunck CF, Gardner E. The anatomy of lumbosacral posterior rami and meningeal branches of spinal nerve (sinu-vertebral nerves); with an experimental study of their functions. J Bone Joint Surg Am. 1956;38:377-91. 10. Hirsch C, Ingelmark BE, Miller M. The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand. 1963;33:1-17. 11. Kellgren JH. Referred pains from muscle. Br Med J. 1938;1:325-7. 12. Mooney V. The syndromes of low back disease. Orthop Clin North Am. 1983;14:505-15. 13. Rees WS. Rhysolysis of the nerves of the zygoapophyseal joints. Spine (Phila Pa 1976). 1983;8:118-20. 14. Shealy CN. Facet denervation in the management of back and sciatic pain. Clin Orthop Relat Res. 1976;115:157-64. 15. Silvers HR. Lumbar percutaneous facet rhizotomy. Spine (Phila Pa 1976). 1990;15:36-40. 16. Alhelail M, Al-Salamah M, Al-Mulhim M, Al-Hamid S.
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357 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2018; 53: 350-357 https://doi.org/10.4055/jkoa.2018.53.4.350 www.jkoa.org 초음파를이용한요추부내측분지차단술시부위별바늘삽입각도및깊이계측 : 자기공명영상과비교를통한유용성평가 김창수 심대무 * 이석중 우영하 백사무엘 정학순 고신대학교복음병원정형외과, * 원광대학교의과대학정형외과학교실, 계명대학교의과대학정형외과학교실, 부산부민병원정형외과 목적 : 초음파를통한요추부내측분지차단술시초음파기기의탐촉자를이용하여바늘삽입점의지표를설정한후부위별주사침 의각도, 깊이를계측한후자기공명영상결과와비교하여정확성을알아보고자하였다. 대상및방법 : 2015 년 1 월에서 2016 년 6 월까지요추부통증을주소로내원하여초음파를이용한내측분지차단술후호전있는환 자중최근 3개월이내에요추부자기공명영상검사를시행받은 80명을대상으로하였다 ( 남자 39명, 여자 41명, 평균연령 63.3세 ). 각부위별 ( 제2-3요추에서제5요추-제1천추까지, 해당후관절의위, 아래분절 ) 초음파기기의탐촉자의중앙이극돌기에오도록위치시킨뒤탐촉자의양끝점에서 1 cm 떨어진지점에서주사침을삽입하였고각목표점에닿았을때의극돌기와주사침이이루는각도및깊이를측정하였다. 각해당값이정규분포를이루는지여부를평가하였으며내측분지차단술시부위별로계측한깊이및각도와자기공명영상계측값이통계적으로유의한일치를보이는지비교분석하였다. 결과 : 초음파를이용한후관절의내측분지차단술에서부위별길이 (mm) 차의평균값은제2요추 (7예) 1.28±1.07 mm, 제3요추 (25 예 ) 1.27±4.26 mm, 제4요추 (93예) 1.63±5.89 mm, 제5요추 (141예) 1.99±4.12 mm, 제1천추 (66예) 1.51±3.87 mm로측정되었으며부위별삽입각 ( ) 차의평균값은제2요추 1.69 ±1.34, 제3요추 2.03 ±5.35, 제4요추 1.49 ±3.42, 제5요추 -1.55 ±3.67, 제1천추 1.86 ±4.83 로측정되었으며이는각부위별로정규분포를따랐으나 (p>0.05) 유의한차이없이통계적으로일치함을보였다 (p>0.05). 결론 : 자기공명영상촬영을시행한환자의경우각환자별로의료영상저장전송시스템 (picture archiving and communication system) 상에서미리부위별계측을한다음초음파를이용한요추부내측분지차단술시계측한깊이및각도를이용하여주사침삽입을한다면초음파를처음접하는시술자들에게보다안전하고효과적인술기가되는데도움이될것으로생각된다. 색인단어 : 척추, 후관절, 초음파, 자기공명영상 접수일 2016 년 6 월 24 일수정일 2016 년 9 월 10 일게재확정일 2017 년 7 월 4 일책임저자김창수 49267, 부산시서구감천로 262, 고신대학교복음병원정형외과 TEL 051-990-6467, FAX 051-990-3071, E-mail mewha98@naver.com, ORCID https://orcid.org/0000-0002-4660-7794 대한정형외과학회지 : 제 53권제 4호 2018 Copyright 2018 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.