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Neurologic deficit of endoscopic complications

Neurologic deficit of endoscopic complications. 최우진 , 전기현 , 김현성 , 김관태 허리사랑병원. Case data ( N= 1023 4yrs. 2004 – 2007 ). 허리사랑병원. Direct Neural Injury. upper level disc & far lateral disc & interlaminar approach 에서 발생될 수 있다 . 초창기엔 scope view 없이 large forcep 사용에서 위험성이 높았다 .

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Neurologic deficit of endoscopic complications

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  1. Neurologic deficit of endoscopic complications 최우진, 전기현, 김현성, 김관태 허리사랑병원

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

  3. Direct Neural Injury • upper level disc & far lateral disc & interlaminar approach에서 발생될 수 있다. • 초창기엔 scope view없이 large forcep 사용에서 위험성이높았다. • dura tear 나 small forcep에 의한 some root leaflet의 손상이 수술중 발생한다면 일단 수술은 끝까지 마치고 판단한다. • Unexperienced period

  4. Disc5-1 Rt inferior PEID like transdural approach • Point: axillar 접근시엔 channel oblique tip의 위치가 caudal-medial방향으로 접근해야함

  5. far lateral disc 3-4, 5-1 Lt Point: oblique channel이 round보다디스크제거가 더 용이하나 bleeding으로 view가 덜 좋고 Scope시야내에 root가있을 수 있으므로 더 주의해야한다.

  6. Interlaminar axillar trial of recurred disc L5-S1 Lt Point: widelaminectomy의 revision은 bone margin따라 shoulder로 접근해야한다.

  7. Trial interlaminar app: Disc L4-5 Rt inferior sequestrated

  8. Trial interlaminar app Recurred 4-5 Rt after opensurgery Packing lateral exiting zone, medial pedicle

  9. Trial to L3-4 PEID

  10. 1st 36/M, disc 3-4 Lt inferior PEID preop postop

  11. 2nd 69/M, 3-4 Rt inferior PEID preop postop

  12. 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 medication중임

  13. X-ray & CT

  14. MRI

  15. Clinical course • Postop: Subside severe rt leg pain • POD #1 Rt ankle dorsiflex GO Rt knee flex GIV MRI후 observation • POD #4 open decompression L3-4-5 • 두달입원하며 Walker잡고 보행할정도 호전됬으나 footdrop은 dense하게 지속됨

  16. Preop postop#1 postop#4

  17. Endoscopic view : L3-4 Rt

  18. 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

  19. 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

  20. Prevention oftraction injury in PEID • Intermittent traction • Initial decompression without channel traction   ( probe, RF, punch, forcep만 넣어서 먼저 제거함) • More upper site traction if possible • Initial axillar decompressionif possible • Wide opening of lig flavum • Upper level L3-4 이상은 bone작업없이 자제

  21. Neurologic deficit of endoscopic lumbar discectomy Risk: 1. upper level disc 2. far lateral disc 3. severe compression disc Cause: Pressure injury > direct Method: pressure가 전혀 없는 곳부터 channel & scope보면서 target를 피해서 접근해 들어가 initial decompression후 root pressure 풀어 놓고 channel접근하면 안전함.

  22. Furthertrial of Endoscopic spine surgery is effective bone work & fusion감사합니다.

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