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Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure of C7 for Intradural Tumor Excision - A Case Report - Sung Shik Kang, M.D., Seong Hwan Moon, M.D., Hwan Mo Lee, M.D. J Korean Soc Spine Surg 2015 Mar;22(1):20-25.

Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2015 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this

1 Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure of C7 for Intradural Tumor Excision - A Case Report - Sung Shik Kang, M.D., Seong Hwan Moon, M.D., Hwan Mo Lee, M.D. J Korean Soc Spine Surg 2015 Mar;22(1): Originally published online March 31, 2015; Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, , Korea Tel: Fax: Copyright 2015 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/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Case Report pissn eissn J Korean Soc Spine Surg Mar;22(1): Laminoplasty and Recapping Procedure of C7 for Intradural Tumor Excision - A Case Report - Sung Shik Kang, M.D., Seong Hwan Moon, M.D.*, Hwan Mo Lee, M.D.* Department of Orthopaedic Surgery, Pusan National University, School of Medicine and Pusan National University Yangsan Hospital, Yangsan, Korea / Graduate School, Yonsei University College of Medicine, Seoul, Korea Department of Orthopaedic Surgery, Yonsei University, College of Medicine, Seoul, Korea* Study Design: A case report. Objectives: To report laminoplasty and recapping procedure of C7 for intradural tumor excision Summary of Literature Review: Various surgical techniques have been attempted to decrease postoperative axial neck pain. Material and Methods: Kurokawa laminoplasty of C7 was performed. Autogenous bone graft material was harvested from partial T1 laminectomy. Intradural tumor was removed without any complications. Four mini plates were applied at hinge sites of laminoplasty and one lag screw was fixed at the longitudinally splitted lamina of C7. Results: Early range of motion without braces was possible following laminoplasty and recapping procedure. Solid union was achieved at the hinge sites of laminoplasty at the 3-month postoperative follow-up. No instability was observed at the 2-year postoperative followup. The visual analog scale of axial neck pain at the 2-year postoperative follow-up was 2. Conclusions: Laminoplasty and recapping procedure might be a good option for intradural tumor excision to facilitate early range of motion and decrease postoperative axial neck pain. Key Words: C7, Laminoplasty, Recapping, Intradural tumor 경막내종양 (intradural tumor) 은인구백만명당남자는 3명, 여자는 5명정도로빈도로보고되고있다. 1) 경막내종양을제거하기위해서는골성구조물이나근육손상이불가피한경우가많다. 이로인해, 축성통증, 불안정증, 운동제한, 후만변형의부작용이발생할수있으며, 이를줄이기위해여러가지노력들이시도되고있다. 2-8) 저자들은제 7경추에 Kurokawa 후궁성형술을시행한뒤경막을노출시켜종양을제거하였고, 견고한고정을통한재부착술을시행하였으며, 술후보조기착용없이조기운동을가능하게하여축성경부통증을줄이고자하였다. 술후 2년추시에서별다른부작용없이우수한결과를나타내어문헌고찰과조우하여증례를보고하는바이다. (tandem gait) 이불가능하였던것과하지의심부건반사항진이외에는다른특이소견은없었다. 복와위에서제 7경추와제 1흉추부위의후방에정중앙피부절개를시행하였다. 제 7경추와제 1흉추에부착된근육을박리한뒤, 좌우로견인하였다. 수술술기에대한모식도는 Fig. 2에나타내었다. 나중에제 7경추후궁나사 (laminar screw) 를삽입할위치에미리천공을해두었다. 제 6경추와제 7경추사이그리고제 7경추와제 1흉추사이의극돌기간인대 (interspinous ligament) 를제거하였다. 제 1흉추후궁의상부 4분의 1 정도를절골기 (osteotome) 를이용하여일괄부분후궁절제술 (en bloc 대상및방법 60세여자가보행장애를주소로내원하였다. 자기공명영상에서제 7경추와제 1흉추부에걸친가로 12 mm, 세로 11 mm, 높이 24 mm의경막내수질외종양 (intradural extramedullary tumor) 이관찰되었다. T1, T2 강조영상에서모두척수와비슷한강도를보였고, 조영증강촬영에서균질하게조영증강되면서 경막꼬리징후 (dural tail sign) 가관찰되었다 (Fig. 1). 일자보행 Received: September 4, 2014 Revised: November 7, 2014 Accepted: March 11, 2015 Published Online: March 31, 2015 Corresponding author: Hwan Mo Lee, M.D. Department of Orthopaedic Surgery, Yonsei University, College of Medicine 250 Seongsanno, Sedaemun-gu, Seoul, Korea TEL: , FAX: hwanlee@yuhs.ac 본연구는 2014 년도양산부산대학교병원임상연구비지원으로이루어졌음 20 Copyright 2015 Korean Society of Spine Surgery

Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure Fig. 1. Gadolinium-enhanced magnetic resonance images show an intradural extramedullary tumor at C7-T1 level. Fig. 2.

, Utsunomiya, Japan) 을이용하여제 7경추를정중앙에서종으로절단한뒤 (Fig. 3A), 좌측과우측모두후궁의외측과외측괴 (lateral mass) 의경계부위에 3 mm 고속연마기 (high speed burr) 를이용하여근위부피질골만갈아내어경첩 (hinge) 을만드는 Kurokawa 후궁성형술을시행하였다.

3 Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure Fig. 1. Gadolinium-enhanced magnetic resonance images show an intradural extramedullary tumor at C7-T1 level. Fig. 2. A 3-dimensionally reconstructed image shows the bony procedures of our technique. partial laminectomy) 을시행후이를보관하였다. 이후다이아몬드나사선상톱 (diamond threaded saw)(t-saw TM, Mani Inc., Utsunomiya, Japan) 을이용하여제 7경추를정중앙에서종으로절단한뒤 (Fig. 3A), 좌측과우측모두후궁의외측과외측괴 (lateral mass) 의경계부위에 3 mm 고속연마기 (high speed burr) 를이용하여근위부피질골만갈아내어경첩 (hinge) 을만드는 Kurokawa 후궁성형술을시행하였다. 종으로절단된후궁을좌우로벌린뒤, 후궁나사 (laminar screw) 삽입을위해미리천공해둔구멍에봉합사를통과시켜좌우의근육에각각묶어서보다넓은시야를확보하고, 종양제거도중후궁의닫힘현상 (reclosure) 을방지하였다. 황색인대제거후경막을절개한뒤, 경막내수질외 (intradural extramedullary) 공간에위치한종양을조심스럽게박리한뒤 (Fig. 3B), 이를부작용없이제거하였다 (Fig. 3C). 경막봉합후경막밀폐제 (dural sealant)(duraseal TM, Covidien Inc., Massachusetts, USA) 를뿌려뇌척수액의유출을재차방지하였다. 철저한지혈후, 개문형후궁성형술 (open door laminoplasty) 시행도중경첩골절 (hinge fracture) 이발생하였을때사용되는경첩금속판 (Hinge plate, Centerpiece plate system TM, Medtronic Inc., Tennessee, USA) 과수부골절에사용되는미니금속판 (Leibinger universal plate TM, Stryker Inc., Freiburg, Germany) 을양측에각각 1개씩고정하였다 (Fig. 3D). 외측괴 (lateral mass) 에미니금속판 (mini plate) 을추가로고정할공간을 21

(C) Intradural extramedullary tumor was successfully removed.

4 Sung Shik Kang et al Volume 22 Number 1 March 2015 A B C D Fig. 3. Intraoperative photographs are shown. (A) Lamina was longitudinally splitted with T-saw TM. (B) Intradural extramedullary tumor was dissected. (C) Intradural extramedullary tumor was successfully removed. (D) The longitudinally splitted lamina was reattached with a cortical lag screw and each hinge site of Kurokawa laminoplasty was fixed with Hinge plate TM, and mini plate. Fig. 4. A computed tomograghy taken at 3 months after the operation shows solid union of osteomized and hinge site (black arrows). 22

Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure Fig. 5. A plain X-ray taken after 2 years after surgery shows good alignment without any metal failure.

5 Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure Fig. 5. A plain X-ray taken after 2 years after surgery shows good alignment without any metal failure. 확보하기위해, 경첩금속판 (Hinge plate) 을원래고안된좌우방향을반대로고정하였다. 후궁에미리천공해둔구멍에 3.5 mm 피질골지연나사 (cortical lag screw) 를삽입하였다. 견고한고정이된것을확인한후, 제 1흉추에서얻은자가골에서연부조직을제거한뒤, 양측경첩부위에얹어골이식을시행하였다. 배액관을삽입한뒤, 근육과근막을해부학적으로봉합하였다. 술후신경학적이상은관찰되지않았으며, 조직검사결과에서수막종 (meningioma) 으로진단되었다. 술후 2일째배액관을제거하였고, 보행장애가많이호전되어보조기착용없이보행을장려하였다. 술후 3개월째촬영한전산화단층촬영에서경첩부위와절골부위에각각견고한골유합이이루어졌음을확인할수있었다 (Fig. 4). 술후 2년까지종양의재발없이금속고정물은잘유지되고있었고, 경추부의후만변형이나불안정증과같은부작용은관찰되지않았다 (Fig. 5). 10점만점의시각동통등급 (visual analogue scale) 상 2점의경미한정도의통증을호소하였고, 운동제한소견은관찰되지않았다. 고찰 경추후방수술후축성경부통증을줄이기위해 1) 가능한제 2, 7경추에부착된신전근을보존하고, 2) 조기운동을장려하 며, 3) 절제한극돌기의재부착술 (recapping osteomized spinous process) 이시도되고있다. 2-8) 본증례는제 7경추와제 1흉추에걸친척수내종양으로제 7경추에붙는신전근손상이불가피하였다. 그리고제 7경추에부착된신전근의근육양은상당히많아서 (bulky), 절골술시행후신전근을보존하면서재부착 (musclepreserving recapping) 을하면골유합을얻기전에신전근에의한장력때문에금속고정물의파단또는이탈될확률이매우높다. 9) 이에저자들은제 7경추부근의척수내종양제거에있어신전근손상은불가피하다고보고, 절골된극돌기의재부착만을시도하였다. 절골시킨뒤재부착할경우혈류공급 (blood supply) 이완전히차단되어추후불유합의가능성이높아질것을우려하여, 절골술대신 Kurokawa 후궁성형술후재부착술을시행하였다. 저자들은비슷한경추척수내종양증례에서, 극돌기를종으로절개할때고속연마기 (high speed burr) 를사용하였더니골손실이많아서추후해부학적인재부착술이불가능하였던경험을하였고, 경첩부위에경첩금속판을좌우에각각 1개씩고정하였더니견고한고정력을얻을수없었던경험도하였다. 그이후로는척추관을확장하기위한기존의 Kurokawa 후궁성형술과는다르게, 극돌기를다이아몬드나사선상톱을이용하여골손실을최소화시키면서종으로절골하여재부착이가능하도록하였다. 경첩부위의고정을위해상품화된경첩금속판 23

6 Sung Shik Kang et al Volume 22 Number 1 March 2015 (Hinge plate, Centerpiece plate system TM, Medtronic Inc., Tennessee, USA) 을원래고안된방향대로고정할경우, 추가로다른금속판을고정할공간이나오지않으므로, 금속판의좌우방향을반대로고정해야, 경첩금속판 (Hinge plate) 아래에미니금속판을추가로고정할수있었다. 후궁에미리천공해둔구멍에피질골지연나사를추가로삽입하여조기운동이가능할정도의충분한고정력을얻을수있었다. 이후에제 1흉추에서얻은자가골을경첩부위에얹어골유합이잘이루어지도록하였다. 술후 3개월에견고한골유합을얻을수있었으며, 2년추시에서불안정증이나금속판의파단등은관찰되지않았다. 본환자의경우술후심한축성통증을호소하지않았는데, 본증례만으로속단하기에는무리가있으나, 1) 신전근손상은불가피했지만, 후궁을절제하지않고재부착하였고, 2) 견고한고정이가능하여조기운동이가능했던점과 3) 환자자신도본인의후궁이절제된것이아니라재부착되었다는심리적안정감이영향을미쳤을수있다. 2-8) Kurokawa 후궁성형술을시행한뒤절골된극돌기를좌우로벌려양옆연부조직에임시봉합을해두면, 척수내종양을제거하는데필요한공간이충분히확보되어, 종양의크기가상당히큰경우를제외하고대부분의경추척수내종양제거시적용할수있으며, 척추경나사 (pedicle screw) 나외측괴나사 (lateral mass screw) 의고정이나후외방유합의과정이필요없어이에따르는부작용을줄일수있을것으로사료된다. 2-8,10) REFERENCES 1. Wiemels J, Wrensch M, Claus EB. Epidemiology and etiology of meningioma. J Neurooncol. 2010;99: Lee GW, Kang SS, Padua MRA, et al. C2 en bloc hemilaminectomy and recapping using laminar screws: A new approach to preserve the C2 extensor muscle during intradural tumor resection at the C2 level. J Korean Orthop Assoc. 2012;47: Xie T, Qian J, Wu X, et al. Unilateral, multilevel, interlaminar fenestration in the removal of a multisegment cervical intramedullary ependymoma. Spine J. 2013;13: Sivaraman A, Bhadra AK, Altaf F, et al. Skip laminectomy and laminoplasty for cervical spondylotic myelopathy. J Spinal Disord Tech. 2010;23: Dehcordi SR, Marzi S, Ricci A, et al. Less invasive approaches for the treatment of cervical schwannomas: our experience. Eur Spine J. 2012;21: Shiraishi T, Kato M, Yato Y, et al. New Techniques for Exposure of Posterior Cervical Spine Through Intermuscular Planes and Their Surgical Application. Spine (Phila Pa 1976). 2012;37:E Miyakoshi N, Hongo M, Kasukawa Y, et al. Huge thoracolumbar extradural arachnoid cyst excised by recapping T-saw laminoplasty. Spine J. 2010;10:E Hida S, Naito M, Arimizu J, et al. The transverse placement laminoplasty using titanium miniplates for the reconstruction of the laminae in the thoracic and lumbar lesion. Eur Spine J. 2006;15: Vasavada AN, Li S, Delp SL. Influence of muscle morphometry and moment arms on the moment-generating capacity of human neck muscles. Spine (Phila Pa 1976). 1998;23: Iplikcioqlu AC, Hatiboqlu MA, Ozek E, et al. Surgical removal of spinal mass with open door laminoplsty. 2010;71:

7 Journal of Korean Society of Spine Surgery Laminoplasty and Recapping Procedure 경막내종양절제를위한제 7 경추후궁성형술및재부착술 - 증례보고 - 강성식 문성환 * 이환모 * 부산대학교의과대학양산부산대학교병원정형외과학교실 / 연세대학교의학대학원연세대학교의과대학정형외과외과학교실 * 연구계획 : 증례보고목적 : 제 7경추에후궁성형술을시행하여경막내종양을절제한후, 재부착술을시행한증례에대하여보고하고자한다. 선행문헌의요약 : 경추후방수술후축성경부통증을줄이기위해다양한노력들이시도되고있다. 대상및방법 : 제 7경추에대해 Kurokawa 후궁성형술을시행하였다. 제 1흉추의부분후궁절제술로얻은자가골은경첩부위의골이식재료로보관해두었다. 부작용없이경막내종양을제거하였고, 4개의미니금속판을후궁성형술의경첩부위에고정하였고, 1개의지연나사 (lag screw) 를이용하여종으로절골된후궁을고정하였다. 결과 : 술후보조기착용없이경추운동을시작하였고, 술후 3개월째견고한골유합을얻었으며, 2년추시상불안정증은관찰되지않았다. 술후 2년째시각동통등급은 2점이었다. 결론 : 경추부경막내종양절제를위한후궁성형술및재부착술은술후조기운동을용이하게해주며, 술후축성경부통증을줄일수있는술기로사료된다. 색인단어 : 제 7 경추, 후궁성형술, 재부착술, 경막내종양 약칭제목 : 후궁성형술및재부착술 25

375 pissn : , eissn : Original Article J Korean Orthop Assoc 2013; 48:

375 pissn : , eissn : Original Article J Korean Orthop Assoc 2013; 48: 375 pissn : 1226-2102, eissn : 2005-8918 Original Article J Korean Orthop Assoc 2013; 48: 375-381 http://dx.doi.org/10.4055/jkoa.2013.48.5.375 www.jkoa.org 경추척수증에서후궁확장형성술의수술중, 수술후합병증에따른임상적결과비교 안재성 이준규