대한족부족관절학회지 : 제 11 권제 2 호 2007 J Korean Foot Ankle Soc. Vol. 11. No. 2. pp.187-191, 2007 을지대학교의과대학정형외과학교실 Surgical Treatment of Tarsal Tunnel Syndrome Jae-Hoon Ahn, M.D., Kap-Jung Kim, M.D., Ha-Yong Kim, M.D., Won-Sik Choy, M.D., Dae-Suk Yang, M.D. Department of Orthopaedic Surgery Eulji University College of Medicine, Daejeon, Korea =Abstract= Purpose: The authors intended to analyze the operative results of tarsal tunnel syndrome. Materials and Methods: Twenty-one patients with tarsal tunnel syndrome were followed for more than 1 year after operation. The mean age was 44 years, and the mean follow up period was 2 years and 9 months. Clinically preoperative and postoperative AOFAS ankle-hindfoot score and visual analogue scale for pain were analyzed. Radiologically the cause of disease was investigated, and the size of mass was measured, if possible. The duration of symptom, the presence of space occupying lesion (SOL), the effect of epineurolysis were statistically analyzed to see the relation with the operative results. Results: Operative release of tarsal tunnel was done in all cases, and epineurolysis was done in 11 cases. The causes of the disease were 10 soft tissue masses, 7 talocalcaneal coalitions, 1 nonunion of medial talar process fracture, and 1 pes planovalgus, and 3 idiopathic cases. The masses were subdivided into 7 ganglions, 2 neurilemmomas, and 1 lipoma. There was 1 case of combined talocalcaneal coalition and ganglion. Clinically AOFAS ankle-hindfoot score was increased from 62.7 points preoperatively to 84.3 points postoperatively. Visual analogue scale was improved from 6.5 preoperatively to 2.2 postoperatively. Two cases were graded as unsatisfactory. One was severe pes planovalgus, and the other was idiopathic case. The duration of symptom and the epineurolysis were not related with the results. However the presence of space occupying lesion was significantly related with the good results. Conclusion: Early operative release of tarsal tunnel appears to be important for the improvement of symptom. However the prognosis is limited in case that there is no SOL. Key Words: Tarsal tunnel, Tarsal tunnel syndrome, Space occupying lesion 서 론 족근관증후군은족근관내에서경골신경이나그분지 의압박으로인한신경병증을의미하는비교적드문질환 으로후족부및족저부의동통, 감각장애등을주증상으로 Address for correspondence Jae-Hoon Ahn, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, 1306 Dunsan-dong, Seo-gu, Daejeon, 302-799, Korea Tel: +82-42-611-3279, 3280 Fax: +82-42-259-1289 E-mail: jhahn@eulji.ac.kr 하며그원인으로는크게종괴, 외상및염증등이열거되고있다 3,4,6,8,11,17). 신경의경로를따른 Tinel 징후의존재가진단에중요한역할을하게되는데방사선학적으로는자기공명영상검사가종괴의종류나외상후의진단에도움을주게된다 3,19). 한편족근관증후군의치료로는조기에수술 - 187 -
(A) Figure 1. (A) Ankle MRI of a 44 year-old female shows multilocualr cyst adjacent to tibial nerve. (B) I ntraoperative photograph shows large ganglion which compresses tibial nerve. (B) (A) Figure 2. (A) 3D CT of a 24 year-old male shows large talocalcaneal beak prot ruding post eromed ial l y. (B) I ntrao perat iv e photograph shows close relationship of the talocalcaneal beak an d t ib ial n erve. (B) 적감압술을시행하는것이효과가있는것으로알려지고있다 5,16,18). 저자들은증상이심한족근관증후군에대하여수술적감압술을시행하고그결과를분석함으로써수술시주의할점과수술후예후에영향을미치는인자들을알아보고자하였다. 대상및방법 1. 연구대상 1999년 6월부터 2006 년 5월까지 7년동안본원에서족근관증후군으로진단받고수술적으로치료한환자중 1년이상추시가가능하였던 21명, 21예를대상으로하였다. 환 자의성별은남자 14예, 여자 7예였고, 연령은평균 44세, 추시기간은최소 12개월에서최대 8년으로평균 2년 9개월이었다. 2. 수술방법및수술후처치수술은족관절내과의후하부를따라곡선절개를가한후족근관을유리하고필요한경우종괴의제거및신경박리술등을시행하였다 (Fig. 1, 2). 3. 방사선학적및임상적평가임상적으로미국정형외과족부족관절학회 ankle-hindfoot score 9) 를술전, 술후그리고최종추시시에측정하여비 - 188 -
교하였고, 동통의호전정도는 visual analogue scale 을이용하여평가하였다. 방사선학적으로컴퓨터단층촬영이나자기공명영상검사를이용하여원인질환을알아보고자하였으며종괴가있는경우그종류및크기를분석하였다. 그외증상의지속기간, 종괴의유무, 신경박리술의시행유무, 재수술여부등이수술결과에미치는영향을통계학적으로분석하였다. 결과수술은모든예에서족근관감압술을시행하였으며신경박리술은 11예에서시행하였다. 원인질환으로는연부조직종양 10예, 거종골간결합 7예, 거골내측골절의불유합 1예, 심한편평족 1예였으며그외확실한원인이발견되지않은경우가 3예있었다. 종양의경우조직학적검사상결절종 7예, 신경초종 2예, 지방종 1예로확인되었으며, 1예에서는결절종과거종골간결합이동반되었다. 특수검사로는 19예에서자기공명영상검사를, 5예에서는컴퓨터단층촬영검사를각각시행하였다. 근전도검사는 9예에서시행하였다. 임상적으로미국정형외과족부족관절학회평가는술전평균 62.7 점에서술후 84.3 점으로증가하였으며, visual analogue scale 은술전평균 6.5에서술후평균 2.2로호전되었다. 자기공명영상검사소견상종양의직경은 1 cm에서 2.5 cm으로평균 1.7 cm이었다. 수술결과의분석에서 21예중 2예가증상의호전이없어불만족으로분류되었으며그중 1예는심한편평족으로인한경우였고다른 1예는원인질환이없이증상을나타내었던경우였다. 임상적인여러인자와수술결과와의상관관계를분석한결과우선증상의지속기간에대해서는그기간이 1년이하였던 12예에서모두증상의호전을보였으나, 1년이상이었던 9예중 2예에서증상의호전이없어그결과가좋지않았으나통계학적으로유의한차이는보이지않았다 (p>0.05). 공간점유병소의유무에대해서는종괴가있는 17예에서수술후모두증상의호전을보였으나, 종괴가없는경우는 4예중 2예에서증상의호전이관찰되지않았으며이는통계학적으로도유의한차이를보였다 (p<0.05). 신경박리술을시행한경우는 11예중 1예에서증상의호전이없었으며, 시행하지않은경우는 10예중역시 1예에서증상의호전이없어신경박리술은수술의결과에유의한영향을미치지않았다 (p>0.05). 다른병원에서수술후재발한경우가본연구에서 3예포함되었으나모두증상의호전이관찰되어일차수술을시행한경우와비교하여그결 과에통계학적으로유의한차이는없었다 (p>0.05). 술후합병증으로는증상이호전되지않아불만족스러운경우가 2예있었으며그외에술후창상부위에누공형성이발생한경우가결절종이동반된 1예에서관찰되었으나국소적인창상처치후치유되었다. 감염이나신경손상등의합병증은발생하지않았다. 고 찰 족근관증후군은 1962 년 Keck 과 Lam 이별개의연구에서각각사용한용어로서족관절내측의굴건지대안에서경골신경및그분지들이포착되어발생하는신경병증을의미하며그병인으로는공간점유병소에의한직접적인압박이나외상후혹은염증에의한유착, 그리고그외에특발성인경우등이열거되고있다 3,5). 환자들은종종족부의한부분의감각이상과국소적또는방사하는동통, 작열감등을호소하게되며증상의시작은대개서서히발생하게되는것이특징이다. 족근관증후군의진단을위해서는이학적검진과병력청취가중요한데특히경골신경의주행을따라 Tinel 징후가관찰되는경우가보통이다. 특수검사로서신경전도검사가필요하나신경전도검사상정상으로나오는신경병증의경우도드물지않게보고되고있다 3). 자기공명영상검사중특히 T2 강조영상은연부조직종양등의공간점유병소, 액체저류및염증상태의구별에매우유용하다고알려져있으며술전검사를통해병변범위를정확히파악하고또한신경과원인인자와의유착여부를판단하여감압술시주의를기울임으로써의인성신경손상을방지할수있다 3). 또한술후증상이남아있는경우에시행하여굴건지대의잔존여부및재수술의필요성을결정하는데도움이된다는보고도발표되고있다 15). Takakura 등 19) 은결절종이동반된거종골결합에의한족근관증후군 7예를보고하고골성결합의형태와범위를보는데는컴퓨터단층촬영이도움이되었으며결절종을진단하는데는자기공명영상이유용하다고하였다. 본연구에서는 21예중 19예에서자기공명영상을촬영하였고거종골결합등의골성병변이의심되었던경우는그중 5예에서컴퓨터단층촬영검사를시행하여병변의정확한위치와범위등을파악함으로써술전계획수립및수술시도움을받을수있었다. 족근관증후군에대한문헌고찰상대체로전체의 60-80% 에서구체적인원인이발견된다고하며, 구체적으로외적요인과내적요인으로대별되는데외적요인으로는거골, 종골및경골후방의전위된골절편, 보조장족지굴근, - 189 -
후족부의외반변형, 인접한건들의건초염이나결절종또는강직성척추염이나류마토이드관절염환자에서의염증반응등이있고내적요인으로는정맥류, 신경주위의섬유화, 신경초종등이있으나정확한원인을모를경우도많다고한다 4,6,8,11,17). 본연구에서족근관증후군의발생원인으로는연부조직종양이 10예로가장많았으며, 그외거종골간결합 7예, 거골내측골절의불유합 1예등총 17예에서공간점유병소가발견되어전체의 81% 에서구체적인원인이밝혀질수있었다. 비정상적인족부의회내전혹은심한후족부외반으로인한족근관증후군의발생여부에대해서는논란의여지가있으나후경골건파열과동반된증예에대한보고가있다 1,2). 본연구에서 1예가공간점유병소없이심한편평족과동반되어족근관증후군이발생한경우이었으며족근관유리술, 신경박리술및종골의내측전위절골술을시행한후에도지속적인증상을호소하여불만족으로분류되었다. 한편족근관증후군과감별해야할질환으로는족저근막염, 지간신경종등이있으며, 특히요천추신경근방사통에대한감별이중요하다고알려져있다 14). 이러한감별은신경전도검사를통해이루어질수있지만제 5 요추나제 1 천추신경근의전방분지만이침범된경우는감별이힘들수있다고하며 Kaplan 과 Kernahan 7) 은족근관증후군으로추정되어의뢰되었으나신경전도검사상비특이적인소견이관찰된환자 45명이제 1 천추신경의병변으로인한방사통으로밝혀졌다고보고한바있다. 본연구에서는술후증상이지속된경우에서도다른질환으로인한신경의이상이의심되는소견은찾아볼수없었다. 족근관증후군의치료는초기에는비스테로이드성진통소염제, 보조기그리고스테로이드국소투여등의보존적치료가행해질수도있지만대부분의경우수술적치료가보다확실한증상의호전을가져오는것으로알려져있다 5,18,20). Sammarco 와 Chang 16) 은술전증상이 1년이내인경우가장기간경과된경우보다수술로인한결과가더좋았다고발표한바있다. 반면 Turan 등 20) 은평균 60개월이상경과된족근관증후군의경우에도대부분에서좋은결과를얻을수있었다고보고하였다. 본연구에서는대부분의환자에서보존적치료후도증상의호전이없어내원한경우로서진단이확인된이후바로수술적감압술을시행하였다. 또한증상의지속기간에따른비교에서증상의호전이없었던 2예가모두 1년이상증상을호소한경우였으나 1년이하의경우에비교하여그차이가통계학적으로유의하지는않았다 (p>0.05). 문헌보고상수술적감압술의실패율은 10-20% 로보고 되고있는데그이유로첫째잘못된진단, 둘째진단은맞았으나신경의압박이굴건지대이외의곳에서발생한경우, 셋째정확히진단하였으나굴건지대를불충분하게유리한경우, 넷째신경박리술을시행한신경의주변으로유착이발생한경우등이보고되고있다 3,15). Pfeiffer와 Cracchiolo 13) 는술후불만족소견을보인환자의분석결과신경주위의정맥류, 과거외상에대한수술에서비롯한신경단열, 단단한굴근지대, 반흔조직에의한신경포착등이있는경우가많았으며, 반대로수술결과에만족한경우는신경주위의이차적인종괴를같이제거한경우가대부분이었다고하였다. Nagaoka와 Satou 12) 는결절종으로인한족근관증후군에대해수술을시행한 29예를분석하고모든예에서만족할만한결과를얻었다고발표한바있다. 본연구에서도공간점유병소가있는 17예에서는모두증상의호전이있었으나그렇지않은 4예중 2예에서증상의호전이없었으며이는통계학적으로도유의한차이를나타내었다. 재발된족근관증후군의경우는일차수술에비하여그수술결과가좋지않다고알려져있다 10,15). 본연구에서는전체 21예중 3예가재수술을시행한증례였으나모두증상의호전을보여일차수술과비교하여그결과에유의한차이는관찰되지않았는데이는재발된경우라도대부분일차수술시에불충분한족근관유리혹은종괴제거로인한재발의경우로서유착성신경염등은심하지않았던것이원인으로생각된다. 또한이는재수술의경우라도확실한질환의원인이발견되는경우에는그원인인자의제거로인하여증상의호전을기대할수있다는것을보여주고있다. 결 론 족근관증후군의경우조기의수술적감압술이증상의호전에중요한것으로사료되며특히특별한종괴가없이발생한경우예후가제한적임을알수있었다. REFERENCES 1. Bracilovic A, Nihal A, Houston VL, Beattie AC, Rosenberg ZS and Trepman E: Effect of foot and ankle position on tarsal tunnel compartment volume. Foot Ankle Int, 27: 431-437, 2006 2. Francis H, March L, Terenty T and Webb J: Benign joint hypermobility with neuropathy: documentation and mechanism of tarsal tunnel syndrome. J Rheumatol, 14: 577-581, 1987. 3. Franson J and Baravarian B: Tarsal tunnel syndrome: a compression neuropathy involving four distinct tunnels. - 190 -
Clin Podiatr Med Surg, 23: 597-609, 2006. 4. Fujita I, Matsumoto K, Minami T, Kizaki T, Akisue T and Yamamoto T: Tarsal tunnel syndrome caused by epineural ganglion of the posterior tibial nerve: report of 2 cases and review of the literature. J Foot Ankle Surg, 43: 185-190, 2004. 5. Gondring WH, Shields B and Wenger S: An outcomes analysis of surgical treatment of tarsal tunnel syndrome. Foot Ankle Int, 24: 545-550, 2003. 6. Ho VW, Peterfy C and Helms CA: Tarsal tunnel syndrome caused by strain of an anomalous muscle: an MRI-specific diagnosis. J Comput Assist Tomogr, 17: 822-823, 1993. 7. Kaplan PE and Kernahan WT: Tarsal tunnel syndrome: an electrodiagnostic surgical correlation. J Bone Joint Surg, 63-A: 96-99, 1981. 8. Kinoshita M, Okuda R, Morikawa J and Abe M: Tarsal tunnel syndrome associated with an accessory muscle. Foot Ankle Int, 24: 132-136, 2003. 9. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS and Sanders M: Clinical rating systems for the ankle-hindfoot, midfoot, hallux and lesser toes, Foot Ankle Int, 15: 349-353, 1994. 10. Kohno M, Takahashi H, Segawa H and Sano K: Neurovascular decompression for idiopathic tarsal tunnel syndrome: technical note. J Neurol Neurosurg Psychiatry, 69: 87-90, 2000. 11. Miranpuri S, Snook E, Vang D, Yong RM and Chagares WE: Neurilemmoma of the posterior tibial nerve and tarsal tunnel syndrome. J Am Podiatr Med Assoc, 97: 148-150, 2007. 12. Nagaoka M and Satou K: Tarsal tunnel syndrome caused by ganglion. J Bone Joint Surg, 81-B: 607-610, 1999. 13. Pfeiffer WH and Cracchiolo A 3rd: Clinical results after tarsal tunnel decompression. J Bone Joint Surg, 76-A: 1222-1230, 1994. 14. Pickard JD, Robinson AH and Bearcroft PW: Posterior tarsal tunnel syndrome: an unusual unrelated cause of late pain after lumbar spine surgery. Br J Neurosurg, 20: 331-332, 2006. 15. Raikin SM and Minnich JM: Failed tarsal tunnel syndrome surgery. Foot Ankle Clin, 8: 159-174, 2003. 16. Sammarco GJ and Chang L: Outcome of surgical treatment of tarsal tunnel syndrome. Foot Ankle Int, 24: 125-131, 2003. 17. Spinner RJ, Dellon AL, Rosson GD, Anderson SR and Amrami KK: Tibial intraneural ganglia in the tarsal tunnel: Is there a joint connection? J Foot Ankle Surg, 46: 27-31, 2007. 18. Suh JT, Park BG and Yoo CI: Surgical decompression of tarsal tunnel syndrome. J Korean Orthop Assoc, 34: 547-552, 1999. 19. Takakura Y, Kumai T, Takaoka T and Tamai S: Tarsal tunnel syndrome caused by coalition associated with a ganglion. J Bone Joint Surg, 80-B: 130-133, 1998. 20. Turan I, Rivero-Melian C, Guntner P and Rolf C: Tarsal tunnel syndrome. Outcome of surgery in longstanding cases. Clin Orthop Relat Res, 343: 151-156, 1997. - 191 -