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Chicago Jaseng Center - Acupuncture 자생한방병원 시카고 분원Chicago Jaseng Center - Acupuncture 자생한방병원 시카고 분원
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오늘 환자를 보면서 읽은 내용들에 대하여 잠시 정리

 

 

이 글의 내용들 중 많은 부분은 문형철 원장님이 관리하시는 치료적 맞춤운동 연구소(http://cafe.daum.net/panicbird)

공유 되어 있는 정보를 바탕으로 정리한 것 입니다. 추후에 계속 보강을 할 예정입니다.

이미 아는 분도 많으시지만, 관심 있는 분들은 까페에 한 번 방문해 보세요^^ 

 

 

 

 

정중 신경 포착 증후군 Carpal tunnel syndrome

 

엊그제 지인의 소개로 멀리 안산에서부터 찾아와 입원한 환자분이 있습니다.

 

최근 문원장님과 함께 일하면서 배운 여러가지 중에 하나는 지금까지의 공부가 "발생 기전(왜 아픈가!)"을 이해하거나 "치료 기전(어떻게 낫는가? 침은 어떤 기전으로 왜 효과가 있는가? 또는 효과가 없는가?? )를 고민하는 고생스러운 과정이었다면, 임상의로서 필요하기도 하고, 더 재밌기도 한 요즘 하고 있는 고민은 "어떻게 효율적으로 빨리 낫게 할 것인가?" 입니다.   

 

 

 

수근관 증후군, 손목 터널 증후군, 정중신경 포착 증후군 등 여러가지 이름으로 불리는 이 질환은

특히 손을 많이 사용하는 주부들에게서 흔히 나타납니다.

 

수근관 증후군은 손목에 있는 정중신경(median nerve)의 포착으로 인해 발생하며, 미국에서는 매년 인구의 1%에서 나타나는 비교적 흔한 질병입니다.

 

 

아래의 그림에서 보면 노란색의 신경 주행을 볼 수 있는데,

이 때문에 특징적으로 엄지 손가락부터 4번째 손가락 반절 정도만 저리고 시린 등의 감각 이상을 쉽게 보입니다.

 

 

 

 

 

그 외에 상지에서의 압박 증후군은 아래와 같은 것들이 있습니다.

(참고 문헌 :  Entrapment_neuropathies_of_the_upper_extremity.pdf)

 

In the upper limbs, ulnar nerve and posterior interosseous branch of the radial nerve can also be entrapped leading to cubital tunnel syndrome (CuTS) and radial tunnel syndrome (RTS) respectively. Other entrapment neuropathies have been recognized in the upper extremity, involving the superficial sensory radial nerve, the anterior interosseous nerve, the median nerve in the elbow region (e.g. pronator syndrome), the ulnar nerve at the base of the palm (Guyon’s canal), the palmar cutaneous branch of the median nerve, and various components of the brachial plexus (neurogenic thoracic outlet syndrome). 

Anatomical variations, a hypertrophied subscapularis muscle may lead to entrapment of the suprascapular nerve [10, 11].

Detailed anatomical studies have been performed to clarify the basic mechanical aspects of these syndromes. Yet, there is still discussion regarding the best methods for eval‍uating patients both initially and in follow-up, and the most appropriate treatment. 

 

This review focuses on most common upper extremity entrapment neuropathies which are the CTS, CuTS, RTS and neurogenic thoracic outlet syndrome. Anatomical considerations, patient eval‍uation, indications for conservative treatment and surgical intervention, outcomes, and complications are discussed.

 

 

 

 

수근관 증후군의 원인은 다음과 같은 것들을 생각해 볼수 있습니다. (참고 문헌 :

 

 

The three leading theories of causation of CTS are: 

1) repeated compression leading to ischemia, edema formation in the subendoneurial space and the synovium and eventually fibrosis [28], 


2) tethering of the nerve due to scar tissue leading to reduced nerve gliding and ischemia [29–31], and 


3) localized mechanical pressure from structures such as the FR causing local nerve damage [32]. These theories may overlap, e.g., an increase in extraneurial pressure may push the nerve against a stiff tissue and lead to a localized injury due to mechanical pressure.

 

 

검사법

 

Patient Eval‍uation

Clinical assessment includes Phalen’s test (appearance or worsening of paresthesia with maximal passive wrist

flexion for one minute) and Tinel’s sign (paresthesia in the median territory elicited by gentle tapping over the carpal tunnel). Tinel’s sign has a sensitivity of 60% and a specificity of 67%; the corresponding values for Phalen’s test are 75% and 47% [43, 44]. When conducted in the proper setting, these tests can provide useful information. In a clinical setting, an assessment of strength, sensory loss, and pain is sufficient to monitor the progress of the syndrome. 


Electrodiagnostic testing should be carried out in most cases. Sensory fibers are used to measure the nerve

conduction velocity from the finger or palm to the wrist and motor conduction velocity from the wrist to the thenar muscles. 

 

 

 

 

 

아래의 논문 참고 :

Treatment_of_carpal_tunnel_syndrome.pdf

 

 

 

 

 

 

The clinical presentation
usually is consistent with numbness and tingling in the median distribution of the hand.
Sometimes the symptoms will be present only in one finger while in other cases the patient will complain of pain in the whole hand. In chronic cases symptoms are present above the carpal tunnel and may reach the cervical spine region. Thorough examination, including electrophysiology testing, of both the cervical spine and the wrist may reveal the presence of a double crush syndrome, involving compression of both the ipsilateral lower cervical nerve roots and the median nerve at the wrist (Butler, 1991, 2000; Akalin et al., 2002; Maitland, 2001; Shacklock, 1995
x400). The literature on double crush pathology is rather confusing with some researchers denying the
existence of this disorder (Bednarik et al., 1999) and others who support it (Golovchinsky, 1998; Butler, 1991, 2000; Elvey, 1997; Shacklock, 1995). Golovchinsky in his retrospective analysis of results of electromyography and nerve conduction velocity studies in 169 patients with lower back pain, identified peripheral entrapment of nerves (tarsal
tunnel syndrome and anterior tarsal tunnel syndrome) in 5.3% of patients, signs of acute or chronic partial muscle denervation of corresponding muscles of lower extremities in 21.8% of patients, and abnormally prolonged F-wave latency in 12.5% of patients. Statistical analysis of his data showed significantly higher than random overlap of peripheral entrapment syndromes and signs of proximal nerve damage of the corresponding nerves. This higher than random coincidence of the two conditions strongly suggests cause-and-effect relationship of damage of the proximal stretch of motor nerve fibers and development of peripheral entrapment syndromes in the same nerves rather than a random coincidence of two independent pathologies (Golovchinsky, 1998).

 

 

 

Treatment
Patients with long-lasting moderate or severe symptoms of CTS, especially when muscle weakness
and atrophy are present, undergo carpal tunnel release. In some cases steroid injections into the
carpal canal may offer temporary symptom relief. Marshall et al. (2002) in an extensive review of the
literature concerning injections in the carpal tunnel found that local corticosteroid injections
provide greater clinical improvement in symptoms 1 month after injection compared to placebo.
Symptom relief beyond 1 month compared to placebo has not been demonstrated. However,
local corticosteroid injection provides significantly greater clinical improvement compared to oral
steroid up to 3 months after treatment. Marshall et al. (2002) and O’Connor et al. (2003) searched
the literature for studies in order to evaluate the effectiveness of non-surgical treatment (other than
steroid injection) for carpal tunnel syndrome versus a placebo or other non-surgical, control interventions
in improving clinical outcome. They found that current evidence shows significant short-term

benefit from oral steroids, splinting, ultrasound, yoga and mobilization techniques of the carpal
bones (O’Connor et al., 2003). A recent randomized controlled study reported significant decrease of
CTS symptoms after the application of red-beam laser (continuous wave, 15mW, 632.8 nm) on
shallow acupuncture points on the affected hand,
infrared laser (pulsed, 9.4W, 904 nm) on deeper points on upper extremity and cervical paraspinal
areas, and microamps TENS on the affected wrist (Naeser et al., 2002). The effectiveness of nerve
gliding (neuro-mobilization) treatments for CTS still remains controversial (Akalin et al., 2002;
Jabre, 1994; Totten and Hunter, 1991).

 

 

 

 Nerve neurodynamic test

 

The author of this article utilizes the following suggested sequencing for the most commonly used
median nerve neurodynamic test (see Figs. 2–5):

 

(i) Glenohumeral abduction.
(ii) Wrist extension.
(iii) Supination.
(iv) Glenohumeral lateral rotation.
(v) Elbow extension.
(vi) Neck lateral bending to opposite side.

 

This neurodynamic test can be considered positive if:
(i) It produces the patient’s symptoms (pain, numbness, tingling).
(ii) There is asymmetry when testing right and left sides (limitation in range of motion, resistance
in the movement, production of symptoms during movement).
(iii) Test responses altered by movement of distant body parts (neck)

 

 

 

 

 

 

CASE REPORT

 

제 환자분은

o/s 2010 년부터 (2년전)

c/c 좌측손저림 (1-4지),  

p.i. 로컬 정형외과에서 불규칙하게 물리치료 받았으나 호전 악화 반복(별무차도)

     류마티스성 다발성 근육염 때문에 서울대 병원에서 올 초까지 외래치료 (소론도 정 드심) 받으시면서, 

     손 저림 증상 관련하여 근전도, 신경전도 검사 받고 Dx. CTS.  

     올해 3월에 서울대병원에서 주사 치료 받으면서 서서히 손저림 완화됨.

     약 3개월 전부터 손 저림 악화양상 보임

     3주 전부터 특별한 이유 없이 증상 호전되어 안정시에는 손저림 심하지 않고, 손끝만 저림.

 

p/e 경추 굴곡신전, spurling test - non. phalen's test - non (예전에는 손목을 꺽기만 해도 저렸었다함)

      사각근 압박- none  대흉근 압박 - none

      thenar muscle atrophy - none

 

r/o carpal tunnel syndrome

 

p.

2일간 손목사용 최대한 금지 (avoid aggravation factor)

교찰마사지 20회 이후 얼음팩

얼음팩 40분 하루 2회

신경 스트레칭 (3초, 10회, 3세트)

완관절 대릉혈 습부항

정중신경 침마취

봉약침 0.2cc

 

상기 치료 3일 반복 하면서 경과 관찰.

--------------------------------------------------------------------------------------

 

###치료 1일 후

-약간의 호전 반응

처음에는 서울대 병원만 찾으면서 반신반의하던 환자가 손목이 한결 부드러워 졌다고 하면서 치료에 순응을 보임.

여러가지 운동법을 노트에 적어가면서 배워가려고 하는 모습 보임.

-C-spine X-ray 상 C4-5 narrowing intervetebral space. -> double crush?

-완관절 gliding 시 거친느낌 ? -> joint mobilization?

 

 

 

 

 

 

 

 

이 글의 내용들 중 많은 부분은 문형철 원장님이 관리하시는 치료적 맞춤운동 연구소(http://cafe.daum.net/panicbird)에 공유 되어 있는 정보를 바탕으로 정리한 것 입니다. 추후에 계속 보강을 할 예정입니다. 이미 아는 분도 많으시지만, 근골격계의 치료법에 관심 있는 분들은 문형철 원장님의 까페에 한 번 방문해 보세요^^ 

 

저작자 표시 비영리 변경 금지
Posted by 착한 한의사 Dr. Ilwha Kim

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