Neurologic deficit of endoscopic complications

최우진 , 전기현 , 김현성 , 김관태

허리사랑병원

Case data ( N= 1023 4yrs. 2004 – 2007)

허리사랑병원

PELD & PEID

L1-2 4

L2-3 24

L3-4 95

L4-5 518

L5-S1 387

total 1023

Direct Neural Injury

upper level disc & far lateral disc & interlaminar approach 에서 발생될 수 있다 .

초창기엔 scope view 없이 large forcep 사용에서 위험성이 높았다 .

dura tear 나 small forcep 에 의한 some root leaflet 의 손상이 수술중 발생한다면 일단

수술은 끝까지 마치고 판단한다 . Unexperienced period

Disc 5-1 Rt inferior PEID like transdural approach

Point: axillar 접근시엔 channel oblique tip 의 위치가 caudal-medial 방향으로 접근해야 함

far lateral disc 3-4, 5-1 Lt

Point: oblique channel 이 round 보다 디스크제거가 더 용이하나 bleeding으로 view 가 덜 좋고 Scope 시야내에 root 가 있을 수 있으므로 더

주의해야한다 .

Interlaminar axillar trial of recurred disc L5-S1 Lt

Point: wide laminectomy 의 revision 은 bone margin 따라 shoulder 로 접근해야한다 .

Trial interlaminar app: Disc L4-5 Rt

inferior sequestrated

Trial interlaminar app Recurred 4-5 Rt after open surgery

Packing lateral exiting zone, medial pedicle

Trial to L3-4 PEID

1st 36/M, disc 3-4 Lt inferior PEID

preop postop

2nd 69/M, 3-4 Rt inferior PEID

preop postop

3rd Foot drop after PEID L3-4 Rt

65/F Rt thigh pain & gait disturbance

agg 1 weeks

Dx: disc 3-4 rt inferior

spinal stenosis 3-4-5

spondylolisthesis 3-4

Parkinson & DM medication 중임

X-ray & CT

MRI

Clinical course Postop: Subside severe rt leg pain POD #1

Rt ankle dorsiflex GO

Rt knee flex GIV

MRI 후 observation POD #4

open decompression L3-4-5 두달입원하며 Walker 잡고 보행할정도

호전됬으나 foot drop 은 dense 하게 지속됨

Preop postop#1 postop#4

Endoscopic view : L3-4 Rt

왜 neurologic deficit 발생했나 ?

Ischemia - pressure injury for root traction   >> direct root inrury

Initial traction point – rupture site Initial disc space decompression fail Oblique channel tip – compression Long continuous traction time Indication fail : stenosis & listhesis

Parkinson & DM

Risk of traction ischemia in PEID Combined stenosis Old age Upper level Adhesive root Initial shoulder approach than axillar Long continous traction without decompression Preop. weakness or severe pain Hard, thick disc Root 밑으로 빵빵하고 pulsation 없을때 특히 주위

Prevention of traction injury in PEID

Intermittent traction Initial decompression without channel traction

  ( probe, RF, punch, forcep 만 넣어서 먼저제거함 )

More upper site traction if possible Initial axillar decompression if possible Wide opening of lig flavum Upper level L3-4 이상은 bone 작업없이

자제

Neurologic deficit of endoscopic lumbar discectomy

Risk: 1. upper level disc

2. far lateral disc

3. severe compression disc

Cause: Pressure injury > direct

Method: pressure 가 전혀 없는 곳부터 channel & scope 보면서 target 를 피해서 접근해 들어가initial decompression 후 root pressure 풀어

놓고 channel 접근하면 안전함 .

 

Further trial of Endoscopic spine surgery is

effective bone work & fusion

감사합니다 .