대한영상의학회지 2008;59:429-434 상완골대결절의낭성병변 : 회전근개파열과나이와의연관성 1 김강득 오정택 2 목적 : 상완골대결절에생기는낭성병변의위치를알아보고회전근개파열과나이와의연관성을알아보고자한다. 대상과방법 : 어깨통증으로자기공명관절조영술을시행하고관절경이나개방적수술을시행한 19-82세 ( 평균 51세 ) 의환자 78명을대상으로하였다. 낭성병변의위치는극상근만부착되는부위를 A, 극하근만부착되는부위를 C, 극상근과극하근이중첩되어부착되는부위를 B, 이두근구후방에있는부위를 BG, 상완골경부의노출부에있는경우를 P로나누었다. 자기공명관절조영술에서낭성병변의위치와극상근과극하근파열여부를조사하였고카이제곱검정과로지스틱회귀분석으로분석하였다. 결과 : BG 부위와 A 부위의낭성병변은극상근파열과, C 부위의낭성병변은극하근파열과, B 부위의낭성병변은극상근과극하근파열모두와관계가있었다 (p < 0.05). P 부위의낭성병변은회전근개파열과연관성이없었다. 나이에따라모든낭성병변의발생은증가하였으나통계적으로연관성은없었다. 결론 : 극상근과극하근부착부위의낭성병변은위치에따라각각의회전근개파열을예측할수있는유용한소견이다. 그러나모든상완골대결절의낭성병변은나이와연관성이없었다. 견관절충돌증후군은견관절통증을초래하는흔한원인으로 95% 이상에서회전근개파열을가져오는소인이라알려져대상과방법있다 (1). 충돌증후군을일으키는원인을조기에알아내적절한치료를함으로증상완화와회전근개파열을막을수있다. 2004년 5월부터 2008년 5월까지어깨통증이나불안정성으회전근개파열과관련된충돌증후군의소견은견봉의모양, 퇴로 MRA를시행하고관절경이나개방적수술을시행한환자행성견쇄관절염, 오구견봉인대비후, 근비대등오구견봉궁중견관절수술병력이없고견관절탈구나외상에의한골절, 의공간을감소시키는모든경우와상완골대결절의퇴행성변심한퇴행성관절염이없는환자 78명을대상으로하였다. 이화가있다 (2). 중 46명은갑작스러운충격, 낙상, 사고등외부에서어깨에상완골대결절의퇴행성변화는골의증식, 편평화, 경화, 피과도한힘이가해진병력이있었고 32명은외상의과거력없질골의불규칙화와낭성병변이있는데낭성병변의회전근개이만성적인통증을호소하였다. 파열과나이와의연관성에는다양한논란이있다 (2-7). 저자환자의평균연령은 51(19-82) 세, 남자가 57명, 여자가 21 들은자기공명영상관절조영술 (MR arthrography, MRA) 에명, 우측이 53명, 좌측이 25명이었다. MRA와관절경및수술서상완골대결절에생기는낭성병변의위치를알아보고회전은평균 26(1-263) 일의간격으로시행하였다. 근개파열과나이와의연관성을알아보고자한다. 관절내조영제주입은비이온성조영제 (Omnipaque 350, 35% isohexol, GE Healthcare, Cork, Ireland) 7-10 ml, 0.1 ml of gadopentetate dimeglumine (Magnevist, Schering, Berlin, Germany), 무균의생리식염수 10-13 1 원광대학교의과대학영상의학과 ml와 Epinephrine 0.3 ml 혼합액을천자부위피부를소독 2 원광대학교의과대학외과한후투시유도하에서 5-17 ml( 평균 12 ml) 를주입하였다. 이논문은 2007년도원광대학교교비지원에의해서시행됨. 이논문은 2008년 6월 25일접수하여 2008년 9월 30일에채택되었음. 자기공명영상기기는 1.0-T magnet(signa Horizon, GE 429
김강득외 : 상완골대결절의낭성병변 medial system, Milwaukee, U.S.A.) 와 1.5-T Achieva (Philips Medical Systems, Best, Netherlands) 를사용하였다. 자기공명영상은조영제주입후 20분내에횡단면, 시상사면과관상사면의지방억제스핀에코 T1 강조영상 (TR/TE=550-614/14-20 msec) MRA를시행하였고추가로고속스핀에코 T2 강조영상 (TR/TE=3500/70-80 msec) 이나양자밀도강조영상 (TR/TE=1362-2003/15 msec) 의횡단면, 시상사면과관상사면영상을얻었다. 영상영역 (FOV) 는 15-18 cm, 행렬수는 256 192-253, 절편두께 / 간격은 3 mm/0.3-1 mm로시행하였다. 견관절전용코일을사용하여앙와위에서중립자세나약간의외회전상태에서검사를시행하였다. 상완골대결절은상부, 중간부, 하부세개의면 (facet) 이있는데상부면은극상근만부착되고중간부면의전반 1/2에는극상근과극하근이중첩되어부착되며중간부면의후반 1/2 에극하근만부착되고, 각각의길이는평균 12.6 mm, 9.9 mm, 12.9 mm이다 (8). 이를기준으로낭성병변의위치를시상사면영상에서대결절의극상근만부착되는부위를 A, 극하근만부착되는부위를 C, 중첩되는부위를 B 세부분으로나누고, 이두근구후방에연해서있는부위를 BG, 상완골두해부학적경부의노출부 (bare area) 를 P로나누어서관찰하였다 (Fig. 1-3). 낭성병변은상완골대결절의피질이나피질하에직경 2 mm 이상의원형또는난원형의병변으로정의하였다. 이를 MRA에서조영제가유입된낭성병변과조영제유입이없었으나추가영상인 T2 강조영상에서관절액과비슷하게높은신호강도를보이거나양자밀도강조영상에서확실한저신호강도의테두리가있는경우를조영제유입이없는낭성병변으로구분하였다. MRA와추가 MR 영상에서극상근과극하근의파열여부를완전파열이나부분파열에관계없이파열과정상둘로나누어후향적으로분석하였다. MRA와수술소견간에불일치를보인 2예는수술결과에따랐다. 상완골대결절의낭성병변에대한회전근개파열과의연관성에대하여카이제곱검정을하였고, 나이와낭성병변및회전근개파열과의연관성은로지스틱회귀분석을이용하였으며유의수준은 p 값이 0.05 이하이면통계적으로유의성이있다고분석하였다. Fig. 1. On fat-suppressed T1-weighted oblique sagittal MRA, location of cystic lesions of humeral greater tuberosity. Cysts involve the subcortical or cortical margin at the superior facet A, anterior half of the middle facet B, posterior half of the middle facet C and posterior to the bicipital groove BG. Dotted line = insertion site of supraspinatus tendon. Solid line = insertion site of infraspinatus tendon. The infraspinatus tendon covers the posterior half of the supraspinatus tendon at the site of B. 결과상완골대결절의낭성병변은 78명의환자중 71명에서한부위이상총 123개있었고, 이두근구후방에연해서있는부위 BG에 23예 (30%), 대결절의극상근만부착되는부위 A에 11예 (14%), 극하근만부착되는부위 C에 13예 (17%), 극상근과극하근이중첩되는부위 B에 18예 (23%), 상완골두해부 Fig. 2. Cystic lesion at the bare area of the humeral head (P). Both fat-suppressed T1-weighted axial MRA (A) and fat-suppressed T1-weighted oblique coronal MRA (B) show cystic lesion (arrows) within the bare area of humerus. A B 430
대한영상의학회지 2008;59:429-434 학적경부의노출부 P에 58예 (74%), 없는경우가 7예 (9%) 였다. 123개낭성병변중조영제의유입이있는경우는 62명의환자에서 111예였고조영제의유입이없는경우는 9명의환자에서 12예 (10%) 였다. 5명의환자에서는조영제의유입이있는낭성병변과조영제의유입이없는낭성병변이같이있었다. 회전근개파열은 78명의환자중 44명에서 64예가있었고극상근파열은 41예 (53%), 극하근파열은 23예 (30%) 였다. 이중 20명은극상근과극하근파열이모두있었다 (Table 1). 조영제의유입이있는모든낭성병변의 50%(55/111) 와조영제의유입이없는낭성병변의 67%(8/12) 에서회전근개파열이있었다. 그러나조영제유입이없는군의표본수가적고대부분 (7/9) 조영제유입이있는낭성병변이같이있어서조영제유입유무와회전근개파열사이의관계를찾기는어려웠다. BG 부위의낭성병변은극상근파열시 11예 (48%) 로가장많았고, A 부위의낭성병변은극상근파열시 7예 (64%), B 부위와 C 부위의낭성병변은극상근과극하근파열이동시에있을때각각 11예 (61%) 와 8예 (62%), P 부위의낭성병변은회전근개파열이없을때 25예 (43%) 로가장많았다 (Table 2). 다섯부위전체의낭성병변과극상근, 극하근파열과의관계는통계학적으로유의하였다 (p = 0.04). 그러나 P 부위의낭성병변과극상근 (p = 1.00) 및극하근 (p = 0.16) 파열과의관계는통계적으로유의성이없었다. P 부위의낭성병변을제외한 BG 부위와 A 부위의낭성병변은극상근파열과, C 부위의낭성병변은극하근파열과, B 부위의낭성병변은극상근과극하근파열모두와관계가있었다 (p < 0.05). 특히 A Table 2. Numbers of Cystic lesions at the Greater Tuberosity of the Humerus and Rotator Cuff Tears RC Tear Cyst BG A B C P No SSP (n=21) 11 07 05 01 13 1 ISP (n=3) 00 00 01 02 02 0 SSP+ISP (n=20) 07 04 11 08 18 0 No (n=34) 05 00 01 02 25 6 Total 23 11 18 13 58 7 Note Data are numbers of patients. The location of the cystic lesions: BG, posterior to the bicipital groove; A, supraspinatus insertion site; B, both supraspinatus and infraspinatus insertion site; C, infraspinatus insertion site; P, bare area of the humeral head. RC; Rotator cuff, SSP; Supraspinatus tendon, ISP; Infraspinatus tendon. Table 1. Numbers of Cystic lesions at the Greater Tuberosity of the Humerus and Rotator Cuff Tears according to the Age of Patients Age Cyst RC Tear BG A B C P No SSP ISP SSP + ISP No < 40 (n=18) 03 00 01 04 11 3 01 1 01 15 41-60 (n=42) 12 07 11 05 32 4 12 2 09 19 > 61 (n=18) 08 04 06 04 15 0 08 0 10 00 Total 23 11 18 13 58 7 21 3 20 34 Note Data are numbers of patients. The location of the cystic lesions: BG, posterior to the bicipital groove; A, supraspinatus insertion site; B, both supraspinatus and infraspinatus insertion site; C, infraspinatus insertion site; P, bare area of the humeral head. RC; Rotator cuff, SSP; Supraspinatus tendon, ISP; Infraspinatus tendon. A B C Fig. 3. Cystic lesion posterior to the bicipital groove (BG) of the humeral head. On fat-suppressed T1-weighted axial MRA (A), fatsuppressed T1-weighted oblique sagittal MRA (B) and fat-suppressed T1-weighted oblique coronal MRA (C), high signal intensity of contrast material fills cystic lesion (arrowheads) posterior to the bicipital groove (arrows). 431
김강득외 : 상완골대결절의낭성병변 부위와 B 부위는극상근파열과, B 부위와 C 부위는극하근파열에매우밀접한관계가있었다 (p 0.001) (Fig. 4, 5). 외부에서어깨에과도한힘이가해진병력이있는군은위의결과와동일하게나왔으나, 특별한원인이없는군은 B 부위에있는낭성병변만이극하근파열과유의한관계가있었다 (p = 0.001). 나이가증가함에따라모든낭성병변의발생빈도는증가는하였으나통계적으로유의한관계는없었고, 회전근개파열역시증가하였으나극하근파열만통계적으로유의하였다 (p = 0.005) (Table 1). 외부에서어깨에과도한힘이가해진병력이있는군은 C 부위의낭성병변과극하근파열이나이증가에따라유의하게증가하였으나 (p < 0.05), 특별한원인이없는군은나이에따른낭성병변의발생과회전근개파열과의연관성은없었다. 고찰이연구에서상완골대결절에있는낭성병변은각각의위치에따라특이한회전근개파열을보였다. 즉극상근과극하근건의부착부위에있는상완골대결절의낭성병변은각각의해부학적위치에따라회전근개파열과연관성을보였다 (p < 0.05). 그러나상완골두해부학적경부의노출부에있는낭성병변은회전근개파열과관계가없었다 (p > 0.5). 상완골대결절의낭성병변에대한일반적인의견은 Fritz 등 (3) 의주장처럼대결절전반부의낭성변화는회전근개파열과밀접한연관이있으나나이와는연관성이없고, 극하근부착부주위의후반부낭성변화는전반부낭성변화보다흔하지만회전근개파열이나나이와의연관성은없다고한다 (3, A B C Fig. 4. Fat-suppressed T1-weighted axial MRA (A), fat-suppressed T1-weighted oblique sagittal MRA (B) and fat-suppressed T1- weighted oblique coronal MRA (C) show cystic lesion (arrowheads) within the superior facet of humeral greater tuberosity in a 41- year-old male patient with full-thickness tear of supraspinatus tendon. Overlying high signal intensity gap created by tear of supraspinatus tendon (arrows). Another high signal cystic lesion involves posterior to the bicipital groove (BG, open arrowheads). A B C Fig. 5. Fat-suppressed T1-weighted oblique sagittal MRA (A), fat-suppressed T1-weighted oblique coronal MRA (B) and (C) show cystic lesions (arrowheads) within the superior facet and anterior half of the middle facet of humeral greater tuberosity in a 53- year-old male patient with partial-thickness tear of supraspinatus (arrows) and infraspinatus (open arrows) tendons. 432
대한영상의학회지 2008;59:429-434 4). Williams 등 (7) 은증상이없는환자에게서도대결절후반부의낭성변화는회전근개파열이나나이와무관하다고하였다. 그러나상완골대결절낭성병변의위치를전반부와후반부로만분류하면극상근과극하근과의관계를정확하게알기어렵다. 이연구의결과에서상완골두해부학적경부의노출부에있는낭성병변은회전근개파열과관계가없으나다른논문 (3, 7) 의대결절후반부에해당하는대결절중간부 (middle facet) 의낭성병변은극상근과극하근의부착부위에따라밀접한관계를보였다. 따라서대결절낭성병변의위치를극상근이나극하근의부착부위와상완골경부의노출부로구분할필요가있고 (Fig. 1, 2) 이번연구결과를통해서회전근개부착부위의낭성병변은회전근개파열을예측할수있는유용한소견이라생각한다. 상완골대결절낭성병변의발생기전은위치에따라크게전반부와후반부로나누어설명한다. Fritz 등 (3) 은손상이없는극상근건은뼈에단단히붙어있어서활액에대한장벽으로작용하여낭성병변의형성을막아주나건의열상이있으면활액이대결절로누출되어활액막과육아조직이안으로자라게되어낭성병변이발생한다고하였다. 그래서전반부낭성병변이극상근의관절측부분파열이있을때점액낭측부분파열에서보다많다고한다. 이연구에서외부에서어깨에과도한힘이가해진병력이있는군의낭성병변은위치에따라각각극상근파열과극하근파열에매우밀접한관계가있었다 (p 0.001). 그러나갑작스런외부의충격등특별한원인이없는경우는극상근과극하근이중첩되어부착되는부위 (Fig. 1B) 의낭성병변이극하근파열과관계가있는것외에는회전근개파열과연관성이없었다. 이는회전근개에과도한장력 (tensile force) 이가해질때대결절피질골의미세한견열골절 (avulsion fracture) 이나건의열상으로인해낭성병변이발생하는것으로생각된다. 후반부낭성병변의발생기전에대해서는많은주장이있다. 나이에따라증가하므로퇴행성변화라고하나나이에관계없이높은유병률 (56.7%) 을보여설명이어렵다는반론이있고 (2, 6), 피질골이관절연골에의해보호되지않는노출부에서발생하므로대퇴경부에생기는 herniation pit과유사한골내활액낭이라고도하고 (9), 대결절의후반부는외전과외회전시관절와상부에충돌하므로후상방충돌의결과로생긴다는주장도있다 (3). 이외에도확장된혈관통로나골내정맥류 (10) 또는정상변이 (11) 라는주장이있다. 이연구에서상완골두해부학적경부의노출부에있는낭성병변은회전근개부착부위에서약간떨어져있고회전근개파열과연관성이없었고관절내와연결되어있는경우가많아서정상변이나대퇴경부에생기는 herniation pit와유사한골내활액낭등으로설명할수있다. 그러나극하근부착부위대결절의낭성병변은극하근파열과밀접한관계가있어서전반부낭성병변과같은기전에의해발생하는것으로생각된다. Resnick 등 (12) 은다양한원인으로고관절에발생하는연 433 골하낭종중골관절염으로발생하는연골하낭종은노출된뼈의결함부위로관절액이침습되거나골좌상에의해발생하고대부분관절강과연결이있다고하였다. 이는회전근개부착부위의낭성병변이건의열상부위를통해활액이상완골대결절로누출되어발생한다 (3) 는점과유사하고이연구대부분의낭성병변도관절강과연결된조영제유입이있는낭성병변이었다. 또한, 일부는관절강과연결이있는연골하낭종을섬유성조직이막거나골좌상으로골괴사부위에낭종이발생할때관절강과연결이없는데이연구의조영제유입이없는낭성병변도이같은경우로생각한다. 이두근구후방에있는낭성병변도회전근개부착부위에서약간떨어져있고이두근구를통해서관절내와연결되어있는경우가많아서상완골경부의노출부에있는낭성병변과같은성질의낭성병변으로생각할수도있다 (Fig. 3). 그러나이부위의낭성병변은극상근파열과연관성이있는데 (p = 0.04) 극상근부착부위와약간의거리가있지만직하방에있으므로극상근에가해지는장력에의한것인지정상변이나골내활액낭인지좀더연구가필요하다. 이연구는몇가지제한점이있는데다른방사선학적소견과임상병력을아는한명의영상의학과전문의가판독하여판독자간의차이를평가하지못하여객관성이부족할수있고, 환자군에외상병력이있는환자가많아서 (59%, 46/78) 전체적인결론이유도되었을수도있으며극상근과극하근이중첩되는부위의낭성병변은 2% 이하로드물다고보고되었으나 (3, 7) 23%(18/78) 로유난히많았다. 결론적으로극상근과극하근건의부착부위에있는상완골대결절의낭성병변은각각의해부학적위치에따라회전근개파열을예측할수있는유용한소견이며특히외상병력이있는경우는가능성이매우크다. 그러나상완골두해부학적경부의노출부에있는낭성병변은회전근개파열과관계가없는정상변이나골내활액낭으로생각된다. 나이와상완골대결절의낭성병변사이의연관성은없었다. 참고문헌 1. Neer CS 2nd. Impingement lesions. Clin Orthop 1983;173:70-77 2. Huang LF, Rubin DA, Britton CA. Greater tuberosity changes as revealed by radiography: lack of clinical usefulness in patients with rotator cuff disease. AJR Am J Roentgenol 1999;172:1381-1388 3. Fritz LB, Ouellette HA, O Hanley TA, Kassarjian A, Palmer WE. Cystic changes at supraspinatus and infraspinatus tendon insertion sites: association with age and rotator cuff disorders in 238 ptients. Radiology 2007;244:239-248 4. Sano A, Itoi E, Konno N, Kido T, Urayama M, Sato K. Cystic changes of the humeral head on MR imaging. Acta Orthop Scand 1998;69:397-400 5. Jiang Y, Zhao J, van Holsbeeck MT, Flynn MJ, Ouyang X, Genant HK. Trabecular microstructure and surface changes in the greater tuberosity in rotator cuff tears. Skeletal Radiol 2002;31:522-528 6. Needell SD, Zlatkin MB, Sher JS, Murphy BJ, Uribe JW. MR imaging of the rotator cuff: peritendinous and bone abnormalities in an asymptomatic poplution. AJR Am J Roentgenol 1996;166:863-867
김강득외 : 상완골대결절의낭성병변 7. Williams M, Lambert RGW, Jhangri GS, Grace M, Zelaso J, Wong B, et al. Humeral head cysts and rotator cuff tears: an MR arthrographic study. Skeletal Radiol 2006;35:909-914 8. Minagawa H, Itoi E, Konno N, Kido T, Sano A, Urayama M, et al. Humeral attachment of the supraspinatus and infraspinatus tendons: an anatomic study. Arthroscopy 1998;14:302-306 9. Pitt MJ, Graham AR, Shipman JF, Birkby W. Herniation pit of the femoral neck. AJR Am J Roentgenol 1982;138:1115-1121 10. Anderson SE, Steinbach LS, Hertel R. Normal variant or degenerative cyst? Recognizing dorsolateral vascular channels to the proximal humeral epiphysis. 2000 RSNA. Oak Brook, IL: Radiological Society of North America, 2000:529 11. Jin W, Ryu KN, Park YK, Lee WK, Ko SH, Yang DM. Cystic lesions in the posterosuperior portion of the humeral head on MR arthrography: correlations with gross and histologic findings in cadavers. AJR Am J Roentgenol 2005;184:1211-1215 12. Resnick D, Niwayama G, Coutts RD. Subchondral cysts (geodes) in arthritic disorders: pathologic and radiographic appearance of the hip joint. AJR Am J Roentgenol 1977;128:799-806 J Korean Radiol Soc 2008;59:429-434 Cystic Lesions in the Greater Tuberosity of the Humerus: The Relation to Rotator Cuff Tears and Age 1 Gang-Deuk Kim, M.D., Jung-Taek Oh, M.D. 2 1 Department of Diagnostic Radiology, Wonkwang University Hospital 2 Department of General Surgery, Wonkwang University Hospital Purpose: This study was designed to investigate the location of cystic lesions in the greater tuberosity of the humerus and the relationship to rotator cuff tears and age. Materials and Methods: A total of 78 patients (age range, 19-82 years; mean age, 51 years) who underwent arthroscopy or open surgery after MR arthrography (MRA) for a painful shoulder were enrolled in the study. The location of the cystic lesions were classified as A for a supraspinatus insertion site, as C for an infraspinatus insertion site, as B for both a supraspinatus and infraspinatus insertion site, as BG for a site posterior to the bicipital groove and as P for a site at the bare area of the humeral head. The location of cystic lesions and supraspinatus and infraspinatus tears were evaluated on MRA. Statistical analyses used the chi-squared test and logistic regression. Results: BG and A cystic lesions were related to the presence of a supraspinatus tear, C cystic lesions were related to the presence of an infraspinatus tear and B cystic lesions were related to the presence of both supraspinatus and infraspinatus tears (p < 0.05). P cystic lesions were not related to the presence of rotator cuff tears. The incidence of cystic lesions increased with age, but with no statistical correlation. Conclusion: Cystic lesions at the supraspinatus and infraspinatus insertion sites are useful to predict the presence of a rotator cuff tear, but cystic lesions were not age related. Index words : Shoulder joint Magnetic resonance (MR) Arthrography Cysts Rotator cuff Age factor Address reprint requests to : Gang-Deuk Kim, M.D., Department of Diagnostic Radiology, Wonkwang University Hospital 344-2 Shinyong-dong, Iksan, Chonbuk 570-711, Korea Tel. 82-63-472-5243 Fax. 82-63-851-4749 E-mail: gdkim@wonkwang.ac.kr 434