Download Retroperitoneal Hematoma Secondary to Terminal Branch of

J Korean Neurosurg Soc 36 : 246-248, 2004
KISEP
Case Report
Retroperitoneal Hematoma Secondary to
Terminal Branch of Segmental Artery Injury
during Intertransverse Discectomy through
Paramedian Muscle Splitting Approach
Woo-Jong Lee, M.D., Jong-Pil Eun, M.D.,
Ha-Young Choi, M.D., Jung-Chung Lee, M.D.
Department of Neurosurgery, Research Institute for Clinical Medicine, Chonbuk National University Medical
School and Hospital, Jeonju, Korea
A 47-year-old man underwent the surgery of intertransverse discectomy through paramedian muscle splitting due to
extraforaminal type of far lateral disc herniation at 4th-5th interspace of lumbar vertebrae. The authors encountered
the terminal branch of the segmental artery that traversed the extruded disc around the dorsal root ganglion during
the sugery. We coagulated the artery by a bipolar coagulator and cut the artery for the discectomy. There was no
active bleeding during the surgery. However, the patient suffered from abdominal, right leg and flank pain at the first
postoperative day. The follow-up magnetic resonance imaging revealed a retroperitoneal hematoma at the operation
site. The patient underwent removal of the retroperitoneal hematoma. We identified the cause of bleeding as the
rupture of coagulated terminal branch of the segmental artery around the dorsal root ganglion. The retroperitoneal
hematoma was evacuated completely. The ruptured artery was clipped by a small metal clip, and his symptoms
subsequently were resolved.
KEY WORDS : Far lateral disc herniation∙Paramedian muscle splitting approach∙Retroperitoneal
hematoma.
Introduction
L
umbar lateral (extraforaminal) disc herniation constitutes
from 2.6% to 11.7% of all lumbar disc herniations2).
According to Benini1), any disc herniation lateral to the medial
wall of the pedicle is classified as a lateral disc herniation. There
are several surgical approaches used in the management of far
lateral lumbar disc herniation. In the management of the pure
extraforaminal type of far lateral disc herniations, intertransverse
discectomy through paramedian muscle splitting is best used. This
approach can provide not only sufficient space for operation but
minimal invasive surgery. Nho, et al.6), reported two cases
surgically treated via the paramedian muscle splitting approach
for pure extraforaminal type of far lateral disc herniations.
We experienced a case of retroperitoneal hematoma secondary
�Received：April 27, 2004 �Accepted：May 27, 2004
�Address for reprints： Jong-Pil Eun, M.D., Department of
Neurosurgery, Research Institute for Clinical Medicine, Chonbuk
National University Medical School and Hospital, 634-18,
Geumam-dong, Deokjin-gu, Jeonju 561-712, Korea
Tel：063) 250-1580, Fax：063)277-3273
E-mail：[email protected]
246 J Korean Neurosurg Soc 36
to the rupture of the coagulated terminal branch of segmental
artery around the affected dorsal root ganglion, which developed
after intertransverse discectomy through paramedian muscle
splitting. The retroperitoneal hematoma was evacuated, and the
arterial bleeding was suceessfully controlled by metal clips.
Case Report
A
47-year-old man presented with a right L4 radiculopathy
aggravated by walking, secondary to a right L4-5
extraforaminal
type of far lateral
disc herniation.
His chief complaints were pain, numbness, tingling
sensation and weakness in the right
lower extremity.
The laboratory Fig. 1. Transaxial T1-weighted magnetic
resonance image shows a large right extraexaminations we- foraminal type of far lateral disc herniation
re unremarkable, (arrows) at the L4-5 level.
WJ Lee, et al.
and his medical
history showed
no previous trauma. Physical examination demonstrated a positive
straight leg raising sign at 70 degrees in the right
Fig. 2. Postoperative transaxial T2-weighted
magnetic resonance image reveals a retropside. He had objeritoneal hematoma (arrows) on the operation
ective weakness
site.
of the right tibialis anterior and
the ankle extensors graded as a
4/5. The patient
had normal right
great toe strength
in dorsiflexion.
The patellar reflex
was significantly
decreased on the
right side. The
patient had no
fasciculations,
muscle atrophy
or upper motor
neuron signs.
A magnetic reFig. 3. Postoperative coronal magnetic
sonance image of
resonance image reveals a retroperitoneal
the lumbar spine
hematoma on the previous operation site.
revealed findings
consistent with his symptoms. This test demonstrated a large
extruded far lateral disc herniation at L4-5 (Fig. 1). This was
accompanied by rightward, superior, axillary migration of a large
free fragment, and compressed right L4 root ganglion. Surgical
discectomy was recommended. He underwent surgery of
intertransverse discectomy through paramedian muscle splitting.
The operation was done under general anesthesia. A skin incision
of 3cm length and about 4-5cm lateral to the midline was made.
After the paramedian muscles(Longissimus, Multifidus) were
gently splitting using fingers, the intertransverse ligament was
removed. We encountered the terminal branch of segmental
artery that traversed the extruded disc around dorsal root ganglion
during the surgery. We tried to mobilize the artery to the cranial or
caudal direction, but we could not. We coagulated the artery by a
bipolar coagulator and cut the artery for the discectomy. There
was no active bleeding during the surgery. The extruded disc
Medial Intertransverse m.
Superior Articular Facet
Erector Spinae m.
Medial Branch of the
Posterior Primary Ramus
Extreme Lateral Lumbar
Disc Herniation
� HEAD
Terminal Branch of the
Segmental Arteryⓐ
Lateral Branch of the
Posterior Primary Ramus
Terminal Branch of the
Segmental Arteryⓑ
Lateral Intertransverse m.
Transverse Processs
Ventral Nerve Root
Intertransverse Ligament
Dorsal Root Ganglion
Fig. 4. Postoperative coronal magnetic resonance image reveals a
retroperitoneal hematoma on the previous operation site.
materials were easily extirpated and the nerve root was free all
around. The surgical findings were consistent with what were
seen on magnetic resonance imaging. However the patient
suffered from abdominal, right leg and flank pain in the first
postoperative day. He also complained of right leg pain and
weakness. The follow-up magnetic resonance imaging revealed a
retroperitoneal hematoma on the operation site (Fig. 2, 3). The
patient underwent evacuation of the retroperitoneal hematoma.
We identified the cause of bleeding as the rupture of coagulated
terminal branch of segmental artery around the L4 dorsal root
ganglion. The retroperitoneal hematoma was evacuated
completely. The coagulated artery was clipped by small metal
clips, and his symptoms subsequently were resolved.
Discussion
P
ostoperative spinal hematomas are mostly spinal epidural
hematoma. Spinal epidural hematoma is an uncommon
complication of spinal surgery occurring at a rate of 0.1~0.22% in
some series3). Until now, there has been no reported case of
retroperitoneal hematoma related with an operation of far lateral
lumbar disc herniation in english medical literature.
The incidence of postsurgical spinal epidural hematomas that
result in neurologic deficts are extremely rare. Lawton, et al.5),
reported the incidence rate to be 0.1%. Uribe, et al.9), reported the
incidence rate to be 0.22%, and they reported delayed
postoperative spinal epidural hematomas as a cause of clinical
deterioration after an asymptomatic postoperative period of at
least 3 days.
According to O’Brien, et al.7), the dorsal root ganglion is found
within the intervertebral foramen just medial to the lateral border
of the pars interarticularis. The ventral nerve root cross the disc
space obliquely in a caudal and ventral direction in proximity to
the rostrolateral aspect of the caudal pedicle. The posterior
VOLUME 36
September, 2004
247
Retroperitoneal Hematoma
primary ramus courses in a caudal and dorsal direction. The
segmental vessels are identified at the inferior edge of the rostral
pedicle, lateral to the existing nerve root(Fig. 4). These consistently
divide into five easily identifiable branches : 1) a branch to the
under surface of the transverse process, 2) a dorsally directed
branch in the waist of the pars, 3) a more laterally directed branch
that entered the space between the multifidus and longissimus, 4) a
branch into the midlateral aspect of the erector spinae and 5) a
terminal branch that traveled with the lateral branch of the posterior
primary ramus. Generally, the terminal branch accompanying the
lateral branch of the posterior primary ramus creates the most
substantial neurovascular cord in the area6).
Most surgical procedures involving the spine will develop a
small, clinically insignificant epidural hematoma3,8). In the risk
factor of postoperative spinal hematoma, Kou, et al.4), reported the
multilevel procedure and the presence of a preoperative
coagulopathy. O’Brien et al, previous surgery with attendant
scarring that results in impairment of clot resorption may be a
contributing factor in the development of the delayed spinal
epidural hematomas7). In our case, there was no coagulopathy.
There are no compressing soft tissues, such as muscles in the
intertransverse space where the neurovascular bundles are located.
We assumed that this may be a contributing factor for the
retroperitoneal hematoma were formation in our case. We clipped
the ruptured arterial branches using metal clip after evacuation of
the hematoma. His symptoms subsequently were resolved after
the second operation.
Conclusion
W
e think that, in case of the sacrifice of the terminal branch
of segmental artery during intertransverse discectomy
248 J Korean Neurosurg Soc 36
through paramedian muscle splitting approach, it would be better
clipping rather than coagulating the artery to prevent a
postoperative hematoma.
References
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Beispiel einer Hernie L4/5. Operat Orthop Traumatol 10 : 103-116,
1998
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