§≈‘π‘°ª√‘»π“
* °≈ÿà¡ß“π√—ß ’«‘∑¬“ ‚√ß欓∫“≈æ√–ª°‡°≈â“ ®—ßÀ«—¥®—π∑∫ÿ√’
™≈‘µ ®‘µ‡®◊Õ®ÿπ æ.∫.*
√Ÿª∑’Ë 1 ¢
ºŸâªÉ«¬ 3 √“¬ ¡’Õ“°“√ª«¥∫√‘‡«≥À—«‰À≈à¢â“ߢ«“ ·æ∑¬å ‰¥â∑”°“√µ√«®·≈â« ß —¬«à“®–¡’§«“¡º‘¥ª°µ‘¢Õß rotator cuff ®÷߉¥â àßµ√«®¥â«¬ MR imaging ‰¥âº≈¥—ß√Ÿª 1-3
√Ÿª∑’Ë 1 °
ºŸâªÉ«¬ √“¬∑’Ë 1 µ√«® MR imaging ¥â«¬
conventional (1 °) ·≈– fat-saturated (1 ¢) T2- weighted spin echo coronal MR images (2700/70
[TR/TE]) ∫√‘‡«≥ supraspinous tendon æ∫ low signal µ≈Õ¥ tendinous portion ¢Õß Rotator cuff
‰¡à‡ÀÁπ√Õ¬©’°¢“¥
[TR/TE]) ∫√‘‡«≥ supraspinous tendon æ∫«à“∫“ß à«π¢Õß rotator cuff ¡’ bright signal (À—«≈Ÿ°»√)
∫√‘‡«≥¥â“π„µâ¢Õß cuff µ‘¥°—∫ joint surface
√Ÿª∑’Ë 2 ¢
√Ÿª∑’Ë 2 °
ºŸâªÉ«¬√“¬∑’Ë 2 µ√«® MR imaging ¥â«¬
conventional (2 °.) ·≈– fat-saturated (2 ¢) T2- weighted spin-echo coronal MR images (2700/70
√Ÿª∑’Ë 3 ° √Ÿª∑’Ë 3 ¢
ºŸâªÉ«¬√“¬∑’Ë 3 µ√«® MR imaging ¥â«¬
conventional (3 °.) ·≈– fat saturated (3 ¢.) T2- weighted spin-echo coronal MR images (2700/70 [TR/TE]) ∫√‘‡«≥ supraspinous tendon æ∫ bright
signal µ≈Õ¥§«“¡Àπ“¢Õß rotator cuff (À—«≈Ÿ°»√)
§”∂“¡
®“°¿“æ MR imagings ®ß„Àâ°“√«‘π‘®©—¬ºŸâ ªÉ«¬∑—Èß 3 √“¬
§”µÕ∫
√“¬∑’Ë 1 Normal rotator cuff
√“¬∑’Ë 2 Partial thickness tear of rotator cuff
√“¬∑’Ë 3 Full thickness tear of rotator cuff
∫∑«‘®“√≥å
“¡“√∂µ√«®À“§«“¡º‘¥ª°µ‘¢Õß rotator cuff
‰¥â 3 «‘∏’ §◊Õ arthrography, sonography ·≈– MR imaging1-10 °“√µ√«®¥â«¬ MR imaging ∂÷ß·¡â®–‡ ’¬
§à“„™â®à“¬§àÕπ¢â“ß Ÿß ·µà°Á‡ªìπ«‘∏’∑’Ë¡’ª√–‚¬™πå·≈–‡ªìπ∑’Ë
¬Õ¡√—∫ „π°“√À“欓∏‘ ¿“æ¢Õß shoulder ‡æ√“–®–
‡ÀÁπ√“¬≈–‡Õ’¬¥¢Õß rotator cuff, glenoid labrum, marrow, soft tissue ·≈– bursae ¢Õß shoulder11-15
¡’À≈“¬°“√»÷°…“∑’Ëæ∫«à“ conventional spin- echo MR imaging ¡’ª√–‚¬™πå¡“°„π°“√«‘π‘®©—¬
moderate to large full thickness rotator cuff tears11,13,16,17
·µàº≈¢Õß°“√µ√«®À“ partial thickness tears ¬—߉¡à‡ªìπ∑’Ëπà“æ÷ßæÕ„®π—°11-13,18 fat saturation technique ®–™à«¬„Àâ‡ÀÁππÈ”„π T2-weighted images
‰¥â™—¥¢÷Èπ ·≈–™à«¬≈¥ signal ®“° adipose tissue ∑’Ë Õ“®®–∑”„À⇰‘¥§«“¡ —∫ π„π°“√·ª√º≈‰¥â19,20 ®“°∑’Ë
°≈à“«¡“°Á‡™◊ËÕ‰¥â«à“ fat saturation technique ®–‡æ‘Ë¡
§«“¡‰«„π°“√«‘π‘®©—¬ rotator cuff tears ®“° MR images ‰¥â¡“°¢÷Èπ ‚¥¬‡©æ“–∂Ⓡªìπ small partial thickness tear
«‘∏’°“√∑” §◊Õ √â“ß¿“æ coronal oblique T1-weighted (400/18 [TR/TE]) ·≈– coronal oblique T2-weighted dual echo (2200/20,70) spin echo sequences with frequency-selective presaturation of fat ·≈– axial gradient echo (300/15, 30o flip angle) sequence. Coronal oblique section „™â§«“¡
Àπ“ 4 ¡‘≈≈‘‡¡µ√·≈–™àÕß«à“ß √–À«à“ß section 0.5
¡‘≈≈‘‡¡µ√ ‚¥¬ coronal oblique π—Èπ ®—¥„Àâ·π«¢Õß¿“æ
¢π“π°—∫·°πµ“¡¬“«¢Õß supraspinous tendon „™â field of view 16 ‡´πµ‘‡¡µ√
‡°≥±å „π°“√«‘π‘®©—¬æ¬“∏‘ ¿“æ¢Õß rotator cuff ¡’¥—ßπ’È
Intact rotator cuff tendon ®–æ∫«à“ tendon
¡’ low signal intensity on all sequence √Ÿª√à“ߪ°µ‘
‰¡à‡ÀÁπ√àÕß√Õ¬©’°¢“¥ tendon ∑’˪°µ‘∫“ß√“¬Õ“®æ∫
focal area of increased signal on proton density- weighted images ·µà ‰¡à increased signal on T2- weighted images (√Ÿª 1 °, ¢)
Partial thickness tear of the rotator cuff
®–æ∫¡’ focus of high signal intensity on T2-weighted images ∫√‘‡«≥ bursal À√◊Õ joint surface ¢Õß tendon
·µà ‰¡à‡ªìπµ≈Õ¥§«“¡Àπ“¢Õß cuff (√Ÿª 2 °, ¢) Full thickness tear of rotator cuff ®–‡ÀÁπ focal À√◊Õ diffuse high signal intensity on T2- weighted images ‡√‘Ë¡®“° bursal À√◊Õ joint surface
¢Õß tendon À√◊Õ‡¡◊ËÕ¡Õ߉¡à‡ÀÁπ à«π tendon ¢Õß cuff πÕ°®“°π’Ȭ—ßÕ“®®–‡ÀÁπ medial retraction ¢Õß musculotendinous junction Õ’°¥â«¬ (√Ÿª 3 °, ¢)
ªí®®ÿ∫—π ¡’°“√„™â MR imaging Õ¬à“ß·æ√àÀ≈“¬
‡æ◊ËÕ«‘π‘®©—¬À“ tears of the rotator cuff ¡’À≈“¬
√“¬ß“π∑’Ëæ∫«à“ conventional spin-echo imaging “¡“√∂µ√«®À“ full thickness tears of rotator cuff
‚¥¬¡’§«“¡‰«∂÷ß√âÕ¬≈– 80-9711,13,16,17
William R.
Reinus ·≈–§≥–21 æ∫«à“∂â“„™â conventional imaging technique ‡æ◊ËÕÀ“ full thickness tears ®–¡’
§«“¡‰«ª√–¡“≥ √âÕ¬≈– 80 ·µà∂â“„™â fat saturation technique ·≈â«®–¡’§«“¡‰«‡æ‘Ë¡¢÷Èπ‡ªìπ√âÕ¬≈– 100
‡≈¬∑’‡¥’¬« °“√«‘π‘®©—¬ normal rotator cuff ¡’§«“¡
®”‡æ“–‡æ‘Ë¡¡“°¢÷Èπ¥â«¬ ‡æ√“– fat saturated image
®–∑”„Àâ signal ∑’˺‘¥ª°µ‘„π rotator cuff π—Èπ ‡ÀÁπ‰¥â ßà“¬¢÷È𠧫“¡‰«„π°“√«‘π‘®©—¬ partial tear ‡æ‘Ë¡¡“°¢÷Èπ
¥â«¬‡™àπ‡¥’¬«°—π ®“°√âÕ¬≈– 15 ‡ªìπ√âÕ¬≈– 3521 ∂÷ß
·¡â«à“®–‡æ‘Ë¡¢÷Èπ°«à“‡∑à“µ—« ·µà°Á¬—߉¡à‡ªìπ∑’Ëπà“æÕ„®
πÕ°®“°π’È MR imaging ¬—߉¡à “¡“√∂∑”𓬫à“
partial tear ¢Õß rotator cuff Õ¬Ÿà∑’Ë bursal À√◊Õ joint surface ‡æ√“–æ∫«à“∫Õ°‰¥â∂Ÿ°µâÕßπâÕ¬°«à“ √âÕ¬≈– 50
‡ ’¬Õ’°21 ®–‡ÀÁπ‰¥â«à“‰¡à ‰¥â¥’ ‰ª°«à“°“√‡¥“‡≈¬ ¥—ßπ—Èπ∂â“
¡’°“√·ª√º≈®“° MR imaging «à“ partial tear Õ¬Ÿà
¥â“π„¥·≈â«Õ“®º‘¥‰¥â∂÷ߧ√÷ËßÀπ÷Ë߇≈¬∑’‡¥’¬« ºŸâÕà“πÕ“®®–
¡’§”∂“¡«à“ fat saturation technique ¡’§«“¡‰«
¡“° ‡æ√“–‡ÀÁπ欓∏‘ ¿“扥⥒¢÷Èπ ®–∑”„Àâ¡’º≈∫«°
≈«ß‡æ‘Ë¡¡“°¢÷Èπ¥â«¬À√◊Õ‰¡à ‚¥¬‡©æ“–∂Ⓡª√’¬∫‡∑’¬∫
proton density weighted imaging without fat suppression °—∫ T2-weighted fast spin-echo imaging with fat suppression ‡æ√“–µâÕ߇¢â“„®°àÕπ
«à“«‘∏’°“√√—°…“ºŸâªÉ«¬∑’Ë¡’Õ“°“√ª«¥∫√‘‡«≥À—«‰À≈àπ—Èπ
·µ°µà“ß°—π‰ª §◊Õ ∂â“¡’ intact rotator cuff À√◊Õ«à“
‡ªìπ‡æ’¬ß partial tear π—Èπ „Àâ°“√√—°…“‡À¡◊Õπ°—π §◊Õ
√—°…“·∫∫ª√–§—∫ª√–§Õß (conservative treatment)22,23
·µà∂âⓇªìπ full thickness tear Õ“®®–µâÕß√—°…“‚¥¬
°“√ºà“µ—¥ ®“°°“√»÷°…“¢Õß Singson RD æ∫«à“ fat suppression technique ‰¡à ‰¥â∑”„Àâ°“√«‘π‘®©—¬ partial tear À√◊Õ full thickness tear ¡’º≈∫«°≈«ß‡æ‘Ë¡¢÷Èπ
‡≈¬24 ºŸâªÉ«¬∫“ß√“¬‰¥â√—∫°“√µ√«® MR imaging ·≈â«
«‘π‘®©—¬«à“‡ªìπ full thickness tear ·µàº≈ºà“µ—¥æ∫
«à“‡ªìπ partial thickness tear π—Èπ ·∑â®√‘ß·≈â« MR imaging Õ“®«‘π‘®©—¬ full thickness tear ‰¥â∂Ÿ°µâÕß
·≈â«°Á ‰¥â ‡æ√“–√–¬–‡«≈“√–À«à“ß°“√µ√«® MR imaging °—∫°“√√Õºà“µ—¥Õ¬Ÿàπ—Èπ Õ“®¡’°“√‡ª≈’ˬπ·ª≈ß æ¬“∏‘ ¿“æ¢Õß rotator cuff ‰ª„π∑“ß∑’Ë¥’¢÷ÈπÀ√◊Õ·¬à
≈ß°Á‰¥â ´÷Ëß®–¡’º≈µàÕ°“√‡ª√’¬∫‡∑’¬∫º≈°“√ºà“µ—¥°—∫º≈
MR imaging. Palten ·≈–§≥– ·π–«à“§«√„™â oblique sagittal imaging √à«¡¥â«¬ ®–™à«¬„Àâ¡’§«“¡‰«·≈–
§«“¡®”‡æ“–¢Õß°“√«‘π‘®©—¬ rotator cuff tear ‡æ‘Ë¡
¡“°¢÷Èπ25
°“√∑’Ë fat suppression technique “¡“√∂
™à«¬«‘π‘®©—¬ partial tear ‰¥â ‰«°«à“°“√„™â conventional spin-echo imaging ‡æ√“– soft tissue contrast
‡ÀÁπ™—¥¢÷Èπ ·≈– fluid °Á‡ÀÁπ‰¥âßà“¬¢÷Èπ àߺ≈„Àâ¡’§«“¡
‰«„π°“√À“欓∏‘ ¿“æ‡æ‘Ë¡¡“°¢÷Èπ πÕ°®“°π’È surface coil √ÿàπ„À¡à ®–¡’ spatial resolution ‡æ‘Ë¡¡“°
¢÷Èπ ‡ÀÁ𧫓¡º‘¥ª°µ‘∫√‘‡«≥¢Õ∫¢Õß rotator cuff ‰¥â
™—¥‡®π¢÷Èπ ∂â“∫√‘‡«≥欓∏‘ ¿“æ¢Õß rotator cuff ¡’
signal intensity „°≈⇧’¬ß°—∫πÈ” ·≈–√Õ¬©’°¢“¥Õ¬Ÿà
∫√‘‡«≥ tendon surface ¥â«¬·≈â« ®– “¡“√∂„Àâ°“√
«‘π‘®©—¬ partial tear ‰¥âÕ¬à“ß∂Ÿ°µâÕß ·µà∂â“√Õ¬©’°¢“¥
π—ÈπÕ¬Ÿà„π tendon °Á®–«‘π‘®©—¬‰¥â¬“°°«à“ °“√·¬°√–À«à“ß partial tear ·≈– degeneration (æ∫√Õ¬¢√ÿ¢√–∫√‘‡«≥
cuff margin À√◊Õ attenuation ‰¡à ¡Ë”‡ ¡Õ) ¡—°∑”‰¥â
¬“°·µà∂â“„™â fat suppression technique °Á®–™à«¬„Àâ
·¬°‰¥âßà“¬¢÷Èπ
°“√µ√«® rotator cuff „™â arthroscopy ‡ªìπ
‡°≥±å¡“µ√∞“π (gold standard) ·µà°Á¬—ß¡’§«“¡º‘¥
æ≈“¥‡°‘¥¢÷Èπ‰¥â arthroscopy Õ“®®–‡ÀÁπ rotator cuff tear ‰¥âπâÕ¬°«à“§«“¡‡ªìπ®√‘ß °“√«‘π‘®©—¬ full thickness tear ¥â«¬ arthroscopy Õ“»—¬À≈—°∑’Ë«à“ ‡ÀÁπ compartment Ωíòßµ√ߢⓡ°—∫µ”·Àπàß compartment ∑’Ë arthroscope Õ¥‡¢â“‰ª ‚¥¬ºà“π√Õ¬©’°¢“¥¢Õß tendon ·µàºŸâªÉ«¬
∫“ß√“¬ small full thickness tear ∑’Ë¡’√Õ¬©’°¢“¥‡ªìπ À¬—° Ê Õ“®®–∑”„ÀâÀ—«µ√«® (probe) Õ¥‡¢â“‰ª‰¥â ‰¡à ÿ¥ „π°√≥’‡™àππ’È°Á®–«‘π‘®©—¬ full thickness tear º‘¥«à“
‡ªìπ partial thickness tear ·µà∂⓺Ÿâµ√«® µ√«®¥Ÿ bursal
·≈– joint surface „À⥒·≈â«°Á¡’‚Õ°“ º‘¥æ≈“¥πâÕ¬
∫∑ √ÿª
°“√„™â fat saturated T2-weignted spin- echo MR imaging ®–™à«¬«‘π‘®©—¬ ∑—Èß full thickness
·≈– partial thickness tear ¢Õß rotator cuff ‰¥â¥’¢÷Èπ
‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√„™â standard spin-echo imaging technique ‚¥¬‰¡à∑”„Àâ partial À√◊Õ full thickness tendon tear ¡’º≈∫«°≈«ß‡æ‘Ë¡¡“°¢÷Èπ fat saturation ¬—߇æ‘Ë¡§«“¡®”‡æ“–„π°“√«‘π‘®©—¬ intact rotator cuff Õ’°¥â«¬ ®÷ߢշπ–«à“ °“√µ√«® rotator cuff
¥â«¬ MR imaging µâÕß„™â fat saturation technique
¥â«¬‡ ¡Õ ·µàÕ¬à“߉√°Áµ“¡ MR imaging ¬—߉¡à “¡“√∂√–∫ÿµ”·Àπàß partial rotator cuff tear «à“‡ªìπ bursal À√◊Õ joint surface ‡æ√“–‚Õ°“ ∂Ÿ°π—Èπ¡’‡æ’¬ß
√âÕ¬≈– 50 ‡∑à“π—Èπ
‡Õ° “√Õâ“ßÕ‘ß
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