Journal of Korean Society of Spine Surgery Indirect Repair with Surgicel and Fibrin Glue for Postoperative Cerebrospinal Fluid Leakage after Cervical

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Journal of Korean Society of Spine Surgery Indirect Repair with Surgicel and Fibrin Glue for Postoperative Cerebrospinal Fluid Leakage after Cervical Anterior Foraminotomy - A Case Report - Dong-Hyuk

1 Journal of Korean Society of Spine Surgery Indirect Repair with Surgicel and Fibrin Glue for Postoperative Cerebrospinal Fluid Leakage after Cervical Anterior Foraminotomy - A Case Report - Dong-Hyuk Choi, M.D., Ji-Won Lee, M.D., Chel-Hwan Kim, M.D., Yong-Soo Choi, M.D. J Korean Soc Spine Surg 2016 Sep;23(3): Originally published online September 30, 2016; Korean Society of Spine Surgery Department of Orthopedic Surgery, Gangnam Severance Spine Hospital, Yonsei University College of Medicine, 211 Eunju-ro, Gangnam-gu, Seoul, 06273, Korea Tel: Fax: Copyright 2016 Korean Society of Spine Surgery pissn eissn The online version of this article, along with updated information and services, is located on the World Wide Web at: This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Case Report J Korean Soc Spine Surg Sep;23(3): Indirect Repair with Surgicel and Fibrin Glue for Postoperative Cerebrospinal Fluid Leakage after Cervical Anterior Foraminotomy - A Case Report - Dong-Hyuk Choi, M.D., Ji-Won Lee, M.D., Chel-Hwan Kim, M.D., Yong-Soo Choi, M.D. Department of Orthopaedic Surgery, Kwangju Christian Hospital, Gwangju, Korea Study Design: A case report. Objectives: To report a case of indirect repair of cerebrospinal fluid (CSF) leakage after cervical anterior foraminotomy using Surgicel and fibrin glue. Summary of Literature Review: There is no single modality that is best practice for this type of case because it is difficult to apply primary repair for a case of CSF leakage after cervical anterior decompression. Materials and Methods: A 49-year-old female patient was diagnosed with CSF leakage on the second day after cervical anterior foraminotomy. We performed coverage with Surgicel and fibrin glue at the CSF leak site. Results: The patient was treated with indirect repair of CSF leakage without any complications. The clinical and radiological outcomes were excellent upon follow-up 1 year postoperatively. Conclusions: Indirect repair using Surgicel and fibrin glue is an effective treatment for postoperative CSF leakage after cervical anterior foraminotomy. Key words: Cervical spine, Anterior decompression, CSF leakage 서론 경추전방추간판절제술과유합술의수술후합병증은혈종및연하곤란, 신경손상등이보고되고있으나수술후뇌척수액누출은드문합병증이다. 경추수술에서뇌척수액누출의합병증은후방접근경추수술및후종인대골화증으로인한전방접근경추수술후보고되고있으나경추전방추간판제거및유합술후발생은 % 정도로드물게보고되고있다. 1) 경추전방감압수술후발생한뇌척수액누출의치료에보존적치료가우선되며, 보존적치료에실패한경우수술적봉합술이원칙이나요추수술과달리경추전방감압수술부위에발생한뇌척수액누출은공간협소와척수가가까이위치하여천공부의봉합이어려워치료방법이확립되어있지않다. 이에저자들은경추전방추간공감압술후발생한뇌척수액누출을경험하고 Surgicel (Ethicon, Cornelia, GA) 과 fibrin glue 를이용한누출부간접봉합을하였고합병증없이치료되어문헌고찰과함께보고하는바이다. 증례보고 49 세여자환자가내원약 4 년전부터시작된경추부통증및 우측수부방사통으로내원하였다. 지속적인약물치료및수차 례경추신경차단술등보존적치료를시행하였으나증상호전 보이지않았고이학적검사상우측경부, 승모근부위에통증및 우측수부에심한방사통이지속되었다. 심부건반사및신경학 적이상소견은관찰되지않았다. 단순방사선영상에서제 5-6 경추간추간판협소및경추간구상돌기비후로인해우측추간 Received: February 18, 2016 Revised: February 25, 2016 Accepted: August 8, 2016 Published Online: September 30, 2016 Corresponding author: Yong-Soo Choi, M.D., Ph.D. Department of Orthopaedic Surgery, Kwangju Christian Hospital, 37, Yangrimro, Nam-gu, Gwangju, Korea TEL: , FAX: stemcellchoi@gmail.com Copyright 2016 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 171

Dong-Hyuk Choi et al Volume 23 Number 3 September 2016 공협착관찰되며, 자기공명검사에서제 5-6경추우측추간판탈출및구상돌기비후로인한추간공협착증, 제 6-7번추간판탈출증관찰되었다 (Fig. 1).

제 6-7 경추추간판탈출증에대해서는전방추간판절제술후인공추간판치환술을시행하였다 (Fig. 2). 수술후상지방사통이개선되었으나수술후 2일째두통과수술부위에발적을동반한부종이발생하였다. 배액관으로시간당 10cc 정도의뇌척수액이배액되었으며뇌척수액누출에따른신경증상은보이지않았다.

A preoperative magnetic resonance image showed C5-6 foraminal stenosis and C6-7 herniated nucleus pulposus. A B Fig. 2.

3 Dong-Hyuk Choi et al Volume 23 Number 3 September 2016 공협착관찰되며, 자기공명검사에서제 5-6경추우측추간판탈출및구상돌기비후로인한추간공협착증, 제 6-7번추간판탈출증관찰되었다 (Fig. 1). 이에제 5-6경추추간공협착증에대해서는전방추간판절제술을시행하고우측추간공협착에 대해구상돌기내측부를절삭기로절삭한후케리손론저로내측 1/3를절제하여볼팁가이드를이용하여추간공감압상태를확인한후케이지를이용한추체간유합술시행하였다. 제 6-7 경추추간판탈출증에대해서는전방추간판절제술후인공추간판치환술을시행하였다 (Fig. 2). 수술후상지방사통이개선되었으나수술후 2일째두통과수술부위에발적을동반한부종이발생하였다. 배액관으로시간당 10cc 정도의뇌척수액이배액되었으며뇌척수액누출에따른신경증상은보이지않았다. 24시간 30도두부거상침상안정과배액관음압을제거하였으나다음날에도지속적으로뇌척수액이배액되고, 컴퓨터단층 Fig. 1. A preoperative magnetic resonance image showed C5-6 foraminal stenosis and C6-7 herniated nucleus pulposus. A B Fig. 2. A postoperative radiograph showed interbody fusion with a cage at C5-6, total disc replacement (TDR) at C6-7, and notably, extensive pretracheal space widening (arrow). Fig. 3. (A) Erythematous swelling occurred at the neck. (B) Postoperative computed tomography revealed a cm fluid collection (white arrow) at the prevertebral area. *Hemovac line (block arrow)

Journal of Korean Society of Spine Surgery CSF Leakage After Cervical Anterior Foraminotomy 촬영검사상제 4경추부터제 1흉추까지이어지는연부조직내뇌척수액저류가관찰되었다 (Fig. 3).

재수술소견에서뇌척수액이수술환부에미만성으로젖어있었으나제 5-6경추케이지고정옆추체간사강부에척수액이고여있었고, 1차수술에서추간공감압을위한구상돌기절제술을시행부위와같은부위로누출예상분절은제 5-6경추추간공감압술을시행한분절로판단하였다.

4 Journal of Korean Society of Spine Surgery CSF Leakage After Cervical Anterior Foraminotomy 촬영검사상제 4경추부터제 1흉추까지이어지는연부조직내뇌척수액저류가관찰되었다 (Fig. 3). 경추수술후발생한뇌척수액누출이 48시간보존적치료에도척수액배액이지속되고, 수술부위발적에따른창상감염위험성증가와누출부확인에대한척수조영술이환자의조영제과민반응병력으로재수술에대한설명에환자동의하여수술적치료를결정하였다. 재수술소견에서뇌척수액이수술환부에미만성으로젖어있었으나제 5-6경추케이지고정옆추체간사강부에척수액이고여있었고, 1차수술에서추간공감압을위한구상돌기절제술을시행부위와같은부위로누출예상분절은제 5-6경추추간공감압술을시행한분절로판단하였다. 케이지제거를한수술부위소견상추간공부위저명한경막파열부위는확인되지않았으나건조된시트를추간공에위치시킨결과뇌척수액누액으로시트가젖어드는것을확인할수있어누출부위로진단하였다. 추간공부위경막손상이수술시야에서확인되지않아경막손상부확인을위한추가적인추간공감압술을고려하였으나추가적인감압술을시행하더라도공간의협소로천공부직접봉합이어렵다고판단되어, 추간공누출부를 Surgicel 로밀봉하고 fibrin glue를이용하여도포하여간접봉합하였다 (Fig. 4). 제 5-6경추추간공간접봉합후발사바법에도뇌척수액이더이상누출되지않는것을확인하였고, 케이지를다시고정하고수술을마쳤다. 수술후뇌척수액은배액되지않았으며, 환부의부종이나발적없이창상치료가되었으며, 뇌척수액누액의재발여부를위한추적컴퓨터단층촬영검사상액체저류현상등누액재발소견은관찰되지않았다 (Fig 5). 수술후 1년추적방사선상제 5-6경추추체간유합이성공적인결과를얻었으며, 제 6-7 경추인공관절치환술분절은양호한소견이유지되었다. 임상 적결과또한증상이개선되어우수한결과를얻었다. A B Fig. 4. No CSF leakage was detectable after coverage with Surgicel and fibrin glue at C5-6 (arrow). Fig. 5. (A) A lateral radiograph on postoperative day 10 shows improvement of the pretracheal space widening (arrow). (B) No specific fluid collection was visible at the prevertebral area on the second postoperative computed tomogram

5 Dong-Hyuk Choi et al Volume 23 Number 3 September 2016 고찰 후종인대골화증을제외한경추전방감압술후발생하는뇌척수액누출은 Fountas 등이경막내탈출된추간판제거에따른 1예를제외하고누액의이유가불명한예기치않은발생으로보고되었다. 2-8) 저자들의증례는경추전방추간공감압술당시뇌척수액누출을확인하지못하였고, 수술후 2일째배액관을통한뇌척수액누출을진단하였다. 이전보고에따르면수술중매우작은천공이발생하더라도지주막이유지되어있어수술중실제누액이확인되지않을수있다고보고된바 9) 가있으며, 본증례가이경우로사료된다. 경추전방감압술후발생한뇌척수액누액에대한문헌고찰에따른치료 2-8) 는일차수술에서모두누액에대한봉합을시도하였으나수술후누액이발생하였다. 수술후누액에대한치료를위해 Tharvarajah 등 8) 의증례는일차봉합과 fibrin glue 도포후경추신경압박에따른신경학적증상으로재수술을시행하였고, Hart 와 Apfelbaum 7) 의증례는뇌척수액만성누관에따른전방척수의묶임 (tethering) 으로누관봉합을위한추체절제와요추배액관설치를하였다. 다른증례보고는재수술을통한다양한봉합방법이성공적이었으나일차봉합이실패한이유는분명치않다. 대부분의재수술은추가적인골감압술을시행하고 Gelfoam (Pfizer) 과 fibrin glue 를도포하는간접봉합을시행하였다. 2-8) Syre 등 9) 은누출부위의공간이협소하고척수가인접하며, 경막상태가건강치않아일차봉합시도는경막누출부가커질수있는위험등이있어천공경막의일차봉합은기술적으로어렵다고보고하였다. 따라서 Gelfoam (Pfizer), Surgicel (Ethicon, Cornelia, GA), 인공경막대체제 ( 예 : DuraGen; Integra Lifesciences) 를 fibrin glue 와병용또는분무형경막밀봉제 ( 예 : DuraSeal; Coviden, Waltham, MA) 또는상기두제형을혼합병용하는간접봉합을시행하였고, 척수압박이되지않는간접봉합이중요하다지적하였다. 그리고경추전방추간판절제술과유합술후발생한뇌척수액누출 13예에대해성공적인치료결과를얻은다양한치료방법을보고하였는데치료방법의적은증례가제한점이나경추수술후뇌척수액누출에대한치료알고리즘을구체적으로제시하였다. 수술후확인된뇌척수액누출은일단침상안정및 30도두부거상등보존적치료를먼저시행하고, 이에따른두통은크리스탈로이드 1회분과카페인주사로좋은결과를기대할수있으며, 다음단계로요추부단락배액술을 ml/hr 로 3일간배액하며창상부뇌척수액저류여부를관찰하도록하였다. 이후에도뇌척수액누출이 지속되면수술적치료를위한재수술을결정하게되며, 이때누출부확인또는다분절수술에서수술부위결정을위해척수조영술이선택될수있다. 재수술에서시행하는봉합은자가근육, Gelfoam (Pfizer), Surgicel, 인공경막등과 fibrin glue 또는분무형밀봉제를병용하여간접봉합한다. 이후에도지속되면두부컴퓨터단층촬영을시행하여지속적인척수액배액을위한뇌실복강간단락술를고려해야한다. 저자들의경우재수술전요추부단락배액술및척수강조영술을통한누출부확인이고려될수있었으나뇌척수액배액술은뇌척수액의누출을우회시키는것으로경막내부와경막내부공간사이의뇌척수액의압력을감소시켜경막누액치료가될수있지만두통, 수막염, 상처감염, 일시적인신경근자극증상등의합병증발생가능성과뇌척수액배액술에도누액의합병증지속시추가적수술적치료필요성설명에환자가이차적창상탐색술을통한수술적치료를선택하였으며, 과거조영제과민반응이있어환자동의하여재수술의치료방법을결정하였다. 경추후방감압술등시야와공간이확보되는경막파열은일차봉합술을시행할수있으나경추전방감압술후뇌척수액누출에서는공간협소및척수와인접하여봉합술이어려워 Surgicel 로누출부를밀봉하고 fibrin glue 를이용한도포의간접봉합이좋은방법이될수있다. Surgicel 은국소출혈방지용흡수성지혈제로서, 식물성재질로질병전파가능성이없고수술시모세혈관, 정맥및소동맥의출혈에대해결찰등의다른방법이효과적이지않을때사용하는지혈보조제로서 fibrin glue 와함께사용시효과가좋은것으로알려졌다. 10) Fibrin glue 는인위적으로섬유소응괴를형성하도록하는물질로합성트롬빈, 섬유소원이섞이면섬유소로변화하며, 이때변환된섬유소가조직사이에서접합제역할을하게된다. Fibrin glue 는자가혈액보다섬유소응괴형성이빠르고, 공기나액체누출을막는효과가탁월하다. 저자들은드물게발생하는경추전방추간공감압술후뇌척수액누출을경험하였고, 이에대해 Surgicel 과 fibrin glue 를이용한간접봉합으로합병증없이치료되어문헌고찰과함께보고하는바이며, 경추전방감압술의뇌척수액누출간접봉합술은누출부위의공간이협소하고척수가인접하며, 경막상태가건강치않아일차봉합이기술적으로어려운경우또는추간공부위누출부시야가확보되지않은경우에서무리한일차봉합시도는경막누출부가커질수있는위험이있어간접봉합이선택될수있으리라사료된다

6 Journal of Korean Society of Spine Surgery CSF Leakage After Cervical Anterior Foraminotomy REFERENCES 1) Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976). 2007;32: ) Fountas KN, Kapsalaki EZ, Johnston KW. Cerebrospinal fluid fistula secondary to dural tear in anterior cervical discectomy and fusion: case report. Spine (Phila Pa 1976). 2005;30:E ) Spennato P, Rapana A, Sannino E, et al. Retropharyngeal cerebrospinal fluid collection as a cause of postoperative dysphagia after anterior cervical discectomy. Surg Neurol. 2007;67: ) Schaberg MR, Altman JI, Shapshay SM, et al. Cerebrospinal fluid leak after anterior cervical disc fusion: an unusual cause of dysphagia and neck mass. Laryngoscope. 2007;117: ) Penberthy A, Roberts N. Recurrent acute upper airway obstruction after anterior cervical fusion. Anaesth Intensive Care. 1998;26: ) Hannallah D, Lee J, Khan M, et al. Cerebrospinal fluid leaks following cervical spine surgery. J Bone Joint Surg Am. 2008;90: ) Hart DJ, Apfelbaum RI. Anterior cervical spinal cord tethering after anterior spinal surgery: case report. Neurosurgery. 2005;56:E414. 8) Thavarajah D, De Lacy P, Hussain R, et al. Postoperative cervical cord compression induced by hydrogel (DuraSeal): a possible complication. Spine (Phila Pa 1976). 2010;35:E ) Syre P, Bohman LE, Baltuch G, et al. Cerebrospinal fluid leaks and their management after anterior cervical discectomy and fusion: a report of 13 cases and a review of the literature. Spine (Phila Pa 1976). 2014;39:E ) Sawamura Y, Asaoka K, Terasaka S, Tada M, Uchida T. Evaluation of application techniques of fibrin sealant to prevent cerebrospinal fluid leakage: a new device for the application of aerosolized fibrin glue. Neurosurgery. 1999;44:

7 Case Report J Korean Soc Spine Surg Sep;23(3): 경추전방추간공감압수술후뇌척수액누출의 Surgicel 과 Fibrin glue 를이용한간접봉합 - 증례보고 - 최동혁 이지원 김철환 최용수 광주기독병원정형외과 연구계획 : 증례보고목적 : 경추전방추간공감압술후뇌척수액누출의 Surgicel 과 fibrin glue를이용한간접봉합의치험사례를보고한다. 선행문헌의요약 : 경추전방감압수술후발생한뇌척수액누출에치료방법이확립되어있지않다. 대상및방법 : 49세여자환자의제 5-6경추추간공감압술후 2일째수술부위에발적을동반한부종과배액관에뇌척수액이배액되어뇌척수액누출이진단되었고, 추간공누출부에 Surgicel 과 fibrin glue를도포하여치료하였다. 결과 : 뇌척수액누출의간접봉합후합병증없이치료되었고, 1년추시임상적및방사선학적결과우수하였다. 결론 : Surgicel 과 fibrin glue를이용한간접봉합은경추전방추간공감압술후뇌척수액누출에대한치료의하나로사료된다. 색인단어 : 경추, 전방감압술, 뇌척수액누출 약칭제목 : 경추전방감압술후뇌척수액누출 접수일 : 2016년 2월 18일 수정일 : 2016년 2월 25일 게재확정일 : 2016년 8월 8일 교신저자 : 최용수 광주광역시남구양림로 37 광주기독병원정형외과 TEL: FAX: stemcellchoi@gmail.com 176 Copyright 2016 Korean Society of Spine Surgery Journal of Korean Society of Spine Surgery. pissn eissn This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Lumbar spine

Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical