Postoperative Spinal Epidural Hematoma: The Danger Caused by the Misuse of Thrombin- Containing Local Hemostatics

안동기,신원식,김고위,구기혁 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.6

Study Design: Retrospective case-control study. Purpose: To examine the hypothesis that the misuse of thrombin-containing local hemostatics (TCLH) increases the risk of postoperative spinal epidural hematoma (POSEH). Overview of Literature: Many studies have focused on hypocoagulability as a risk factor for POSEH. However, there are no prior reports on the increased risk of POSEH in hypercoagulable states. Methods: Posterior instrumented lumbar spine surgery cases over 2 consecutive years were divided into two groups: a study group (98 patients in whom TCLH was used) and a control group (176 patients in whom TCLH was not used). The excess TCLH matrix that was not associated with blood clot was not removed from the patients in the study group. The senior author decided whether to use TCLH or not. Suction drains were used in all patients. The demographics, coagulation-related factors, and intraoperative factors of the patients in the two groups were analyzed. The development of POSEH was compared between the two groups. Results: The two groups were homogenous in demographics (age and sex), coagulation-related factors (platelet count, prothrombin time, activated partial thromboplastin time, and platelet function analysis), and surgical factors (total blood loss, operation time, blood loss/10 minutes, number of fusion segments, posterolateral fusion/posterior lumbar interbody fusion, and virgin or revision surgery). POSEH developed more frequently in the patients in the study group than in those in the control group (14/98 patients, 14.3% vs. 3/176 patients, 1.7%, respectively; p =0.001; odds ratio, 17.1). Conclusions: TCLH causes blood clot not only at the edge of damaged vessels but also at the site of extravascular blood. Excess TCLH matrix not associated with blood clot at the epidural space can enhance POSEH development because early clotted hematomas do not drain through suction drains.

Prognostic Factors of Neurological Complications in Spinal Surgeries

신원식,안동기,이정수,구기혁,유인선 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.4

Study Design: Retrospective study. Purpose: To determine prognostic factors of neurological complications (NCs) of posterior thoracolumbar surgeries. Overview of Literature: There have been few reports on the prognosis of NCs according to the causes and treatment methods. Methods: The subjects were 65 patients who had NCs for 19 years (1995–2013) after posterior thoracolumbar surgeries in Seoul Sacred Heart General Hospital. The degree of neurological injury was assessed using numeric scales as follows: G1, increased leg pain or sensory loss; G2, hemiparesis; G3, paraparesis; G4, cauda equine syndrome; and G5, complete paraplegia. The relative degree of neurological recovery was evaluated using four numeric scales as follows: Gr1, complete recovery; Gr2, almost complete recovery with residual sensory loss or numbness; Gr3, partial recovery with apparent neurological deficit; and Gr4, no recovery. The prognostic factors were investigated in terms of demographic and surgical variables that were available in a retrospective review. Results: The causes were as follows: epidural hematoma (EH), 25 patients (38.5%); insufficient decompression and fusion, 14 patients (21.5%); mechanical injury, 11 patients (16.9%); insufficient discectomy, four patients (6.2%); and unknown, 11 patients (23.1%). The grade of neurological injury was as follows: G1, 11 patients (16.9%); G2, 34 patients (52.3%); G3, 15 patients (23.1%); G4, three patients (4.6%); and G5, two patients (3.1%). Thirteen patients received conservative treatment, and 52 underwent revision surgeries. Neurological recovery was as follows: Gr1, 21 patients (32.3%); Gr2, 17 patients (26.2%); Gr3, 20 patients (30.8%); and Gr4, seven patients (10.8%). The prognosis depended on the causes (p=0.041). The subgroup analysis of the revision group revealed a significant correlation between the degree of neurological recovery and the timing of revision, irrespective of causes (r=0.413, p=0.002). Conclusions: The prognosis of NC depended on the causes. EH was the best and unknown was the worst prognostic factor. Revision should be performed as soon as possible for a better prognosis.

후방 척추 수술의 신경학적 합병증 발생률과 임상적 특성

신원식,안동기,이정수,이승민,구기혁 대한척추외과학회 2018 대한척추외과학회지 Vol.25 No.1

Study design: Retrospective study. Objectives: To identify clinical features and risk factors helpful for the prevention and early diagnosis of neurological complications. Overview of Literature: Previous studies have investigated postoperative complications only for specific disease entities and did not present distinctive clinical features. Materials and Methods: This was an observational study of patients who underwent posterior thoracolumbar spinal surgery in the orthopedic department of a single hospital over the course of 19 years (1995-2013). The incidence, cause, onset time, and risk factors of complications were investigated. Neurological deterioration was graded on a 5-point numeric scale: G1, increased leg pain or sensory loss, G2, unilateral motor weakness; G3, bilateral motor weakness; G4, cauda equina syndrome; and G5, complete paraplegia. Results: Sixty-five cases out of 6574 (0.989%) developed neurological complications due to the following causes: epidural hematoma, 0.380%; instrumentation with inadequate decompression, 0.213%; mechanical injury, 0.167%; inadequate discectomy, 0.061%; and unknown cause, 0.167% (p=0.000). The grade of neurological deterioration was G1 in 0.167% of patients, G2 in 0.517%, G3 in 0.228%, G4 in 0.046%, and G5 in 0.030%. Neurological deterioration was most severe in patients who experienced epidural hematoma, followed by those in whom complications occurred due to instrumentation with inadequate decompression, unknown causes, mechanical injury, and inadequate discectomy, in order (p=0.009). Revision surgery was a significant risk factor (p=0.000; odds ratio, 2.741). The time that elapsed until symptom development was as follows, in order: unknown cause, 0.6 hours; epidural hematoma, 5.4 hours; mechanical injury, 6.6 hours; inadequate discectomy, 18.0 hours; and instrumentation with insufficient decompression, 36.0 hours (p=0.001). Conclusions: The incidence of neurological complications in our cohort was 1%. Revision surgery increased the risk by 3 times. Severe cases (cauda equina syndrome or complete paraplegia) rarely developed, occurring in 0.08% of patients. The major causes of neurological decline were epidural hematoma and instrumentation with inadequate decompression. Close observation in the early period was important for the diagnosis because most patients developed symptoms within 12 hours. Delayed diagnosis was most common in complications caused by instrumentation with inadequate decompression. 연구 계획: 후향적 연구목적: 신경학적 합병증의 예방 및 조기 진단에 유용한 위험인자와 원인 별 특징들을 알아보고자 한다. 선행 문헌 요약: 이전의 연구들은 특정 질병 군에 국한되어 있고 원인별로 다양한 임상적 특성을 언급하지 않았다. 대상 및 방법: 1995년부터 2013년까지 19년 동안 단일 병원 정형외과에서 후방 흉-요추부 수술을 받은 환자를 대상으로 하였다. 발생률, 원인, 발병 시간 및 위험 인자를 조사하였다. 신경 증상의 정도는 5등급의 순위척도를 다음과 같이 정의하여 측정하였다. 1등급 증가된 하지 통증이나 감각 손실, 2등급 일측 하지 근력약화 3등급 양측 하지 근력약화, 4등급 마미 증후군, 5등급 완전 마비. 결과: 전체 6,574명 중 65명의 환자에게서 신경 합병증이 발생했다(0.989%). 원인에 따른 발병은 다음과 같다. 경막 외 혈종 0.380%, 불충분한 감압술과고정술 0.213%, 기계적 손상 0.167%, 불충분한 수핵 제거 0.061%, 그리고 원인미상 0.167% 이었다(p=0.000). 신경증상의 등급은 1등급 0.167%, 2등급 0.517%, 3등급 0.228%, 4등급 0.046%, 그리고 5등급 0.030% 이었다. 원인별 증상의 정도는 경막 외 혈종에서 가장 심했고, 불충분한 감압술과 고정술, 원인미상, 기계적 손상, 불충분한 수핵 제거 순이었다(p=0.009). 재수술은 유의한 위험 인자였다(p=0.000, OR=2.741). 증상이 발현하기까지 경과된 시간의 순서는 다음과 같다. 경막 외 혈종 5.4 시간, 기계적 손상 6.6시간, 불충분한 수핵 제거 18.0 시간, 그리고 불충분한 감압술과 고정술 36.0 시간(p=0.001). 결론: 본 저자들의 코호트 연구에서 신경학적 합병증 발생률은 1% 였다. 재수술은 위험률이 3배 증가되었다. 마미 증후군보다 심한 증상의 경우는0.08%로 매우 드물게 나타났다. 주된 원인은 경막 외 혈종과 불충분한 감압술과 고정술 이었다. 대부분의 경우 12시간 이내에 증상이 나타나기 때문에초기에 면밀히 관찰하는 것이 진단에 중요하였다. 뒤늦게 진단된 경우는 불충분한 감압술과 고정술이 가장 많았다. 약칭 제목: 척추 수술의 신경학적 합병증

한국인에서 시행한 가동성 슬관절 단일 구획 치환술의 합병증

김경태(Kyung Tae Kim),이송(Song Lee),김지형(Jeehyung Kim),강민수(Min Su Kang),구기혁(Ki Hyuk Koo) 대한정형외과학회 2017 대한정형외과학회지 Vol.52 No.4

목적: 한국인에서 시행한 가동형 슬관절 단일 구획 치환술 후 발생한 발생한 합병증의 원인, 종류 및 양상 등을 분석하고 이를 외국에서 발표된 기존 논문들과 비교하여 한국인에서 시행한 가동형 슬관절 단일 구획 치환술의 적합성 여부를 알아보고자하 였다. 대상 및 방법: 2002년 1월부터 2015년 12월까지 본원 정형외과에서 가동형 치환물을 사용하여 내측 슬관절 단일 구획 치환술을 시행하고 1년 이상 추시가 가능했던 1,325명(1,560예)을 대상으로 하였다. 정기적 추시를 통해 임상적 평가 및 방사선적 평가를 시행하고자 하였고 추시 중 합병증이 발생한 예들을 후향적으로 분석하여 합병증의 원인을 조사하고 확인하였으며 수술 후 합병증이 발생한 기간을 측정하고 시행한 치료 방법을 분석하였다. 결과: 총 1,560예의 가동형 슬관절 단일 구획 치환술 후 101예(6.5%)에서 합병증이 발생하였다. 가동성 삽입물의 단독 탈구가 52예(3.3%)로 가장 많았으며 전체 합병증 중 절반 이상(51.5%)을 차지하였다. 그 외 합병증으로 치환물의 해리 16예(1.0%), 반대측 구획으로의 관절염의 진행 9예(0.6%), 폴리에틸렌 삽입물의 마모 및 파손 5예(0.3%), 치환물 주위 골절 4예(0.3%), 치환물의 충돌 3예(0.2%), 내측 인대 손상 2예(0.1%), 관절 강직 1예(0.1%) 및 원인을 알 수 없는 통증으로 인한 실패가 1예(0.1%) 등이 있었으며 감염으로 인한 실패는 8예(0.5%)였다. 가동형 슬관절 단일 구획 치환술 후 합병증이 발생할 때까지의 기간은 평균 5.2년이었고 그 중 가동성 삽입물의 단독 탈구는 수술 후 평균 4.3년, 치환물의 해리는 수술 후 평균 6.5년, 반대측 구획으로의 관절염으로 인한 실패는 수술후 평균 11.2년에 발생하였다. 총 101예의 합병증 중 68예는 전치환술로, 1예는 단일 구획 치환술로 재치환술을 시행하여 치료하였으며, 23예는 단순 가동성 삽입물의 교환으로 치료하였다. 그 외 관절경술 3예, 내측 인대 봉합술 2예, 관혈적 정복술 및 내고정술 2예, 도수정복술 및 내고정술 1예, 도수 조작술 1예 등을 시행하였다 결론: 한국인에서 시행한 가동형 슬관절 단일 구획 치환술 후 발생한 합병증을 분석한 결과 가동성 삽입물의 탈구가 특히 많이 발생함을 알 수 있었으며 반대측 구획으로의 관절염의 진행 또는 폴리에틸렌 삽입물의 마모로 인한 실패는 상대적으로 적었다. 따라서 한국인에서 가동형 슬관절 단일 구획 치환술을 시행할 경우 가동성 삽입물의 탈구에 대한 충분한 대비와 함께 환자에 대한 사전 설명과 교육이 필요할 것으로 생각된다. Purpose: To evaluate the causes and modes of complications after unicompartmental knee arthroplasty (UKA) in Korean patients, and to identify the adaptability of mobile-bearing UKA for Korean patients by analyzing its complications. Materials and Methods: Between January 2002 and December 2015, a total of 1,325 patients (1,560 cases) who underwent mobile-bearing medial UKA and were followed-up for more than 1 year were included in this study. We analyzed the complications of UKA retrospectively, and investigated the mode of complications, mean time to reoperation, and method of treatment. Results: We observed a total of 101 complications (6.5%) after mobile-bearing UKA. The most prevalent complication was dislocation of mobile-bearing (n=52, 3.3%), accounting for more than half of the complications. Other complications include component loosening (n=16, 1.0%), progression of arthritis in lateral compartment (n=9, 0.6%), polyethylene wear and breakage (n=5, 0.3%), periprosthetic fracture (n=4, 0.3%), impingement (n=3, 0.2%), medial collateral ligament (MCL) injury (n=2, 0.1%), arthrofibrosis (n=1, 0.1%), unexplained pain (n=1, 0.1%) and infection (n=8, 0.5%). At a mean of 5.2 years post-UKA, complications occurred in our patients. The mean time interval from UKA to the development of mobile-bearing dislocation, component loosening, and progression of arthritis to the lateral compartment was a 4.3 years, 6.5 years, and 11.2 years, respectively. Complications were treated with a conversion to total knee arthroplasty in 68 cases, revision UKA in 1 case, and simple bearing change in 23 cases. Remaining complications were treated with arthroscopic management (n=3), MCL repair (n=2), open reduction and internal fixation (n=2), closed reduction and internal fixation (n=1), and manipulation (n=1). Conclusion: The incidence of mobile-bearing dislocation after mobile-bearing UKA was especially higher in Korean patients. However, the progression of arthritis in the lateral compartment and polyethylene wear were relatively lower compared with Western counterparts. Therefore, it is encouraged that Korean patients are provided with sufficient preparation for mobile-bearing dislocation and education prior to surgery when performing mobile-bearing UKA.