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대 한 방 사 선 의 학 회 지 1992; 28 (5) : 763~765 Journal of Korean Radiological Society, September, 1992
Massive Retroperitoneal Hemorrhage Due to a T earing of Common Iliac Vein Complicating Lumbar Diskectomy: A Case Report
Eun Kyung Kim, M.D. , Jae Hee Oh, M.D. , Young Sook Kim, M.D. , Young Chul Kim , M.D.
Departrneηt 0/ Diagnostic Radiology, College 0/ Medicine, Chosuη University
- Abstract-
Injury to major retroperitoneal vessels is a recognized life-threatening compJication of lumbar diskectomy.
CT can depict vessel tearing and consequent retroperitoneal hemorrhage
We report a case 0 1' retroperitoneal hemorrhage due to right common iliac vein injury during lumbar
diskectomy with a brief review of the Jiteratu re
Index Words: Diskectomy, compJication of surgery
Retroperitoneum , CT 87. 1211
Retroperi toneum , hemorrhage 87 .4134
Lu m bar disc surgery is a common su rgical
procedure in m ost hospitals. Since first reported
in 1945 by Linton and White( l ) a t the
M assachussetts General Hospit혀 , major vascular
lnJury occu rrin g durin g opera tion fo r lumbar disk disease has become recognized as an unusual
but well-described complication of the surgery.
CASE REPORT
A 35-year old m an underwent laminectom y
and d iskectom y at the level of the 4th lumbar
intervertebral disk . Twelve hors aft er the opera
tion , the patien t became hypotensive. On suspi
cion of vascular injury , CT ofthe abdomen was
done . C T scan showed diffuse low densities in
dicating hematoma in both retroperitoneal spaces
a nd leakage of con trast media from small , ir
regular shaped right common iliac vein (Fig. 1a).
After one month pe riod of close observation , there was no cha nge in the hematoma locula ted
in the left peri to neal space. Superimposed infec -
tion ensu ed and operation to evacu ate the
hem a toma was performed (Fig . 1b) . Postoper
a tive recovery was satisfactory
DISCUSSION
Lumbar disc surgery is now a common
surgical procedure in most hospitals. Although
rare, the exact incidence of vascula r injury oc
curing durin g laminectomy is unknown . The
L. 4-5 disc space is the m ost common site for a
herniated nucleus pulposus (Fig. 1c)
Major vascular lllJuries may occur during
lumbar diskectomy when the surgical rongeur
or other instrument penetrates beyond the
anterior longitudinalligamen t. In the presence
of a weakened or distorted anterio r longitudinal
ligam ent , or during an aggressive explora tion of
di sc space , re troperitoneal or intraabdominal
structures m ay be included in the j aws of the
rongeur . Wi th penetration an terior to the disc
space , lllJury to re troperitoneal or intraab-
이 논문은 1992년 3월 3일 접수하여 1992년 7월 22일에 채택되었음.
Received March 3, Accepted July 22 , 1992
- 763 -
Journal of Korean Radiological Society 1992 ; 28 (5) : 763~ 765
a
c
dominal structures is likely , particul a rl y if the
operator is unaware of thc cxact locat ion 0 1‘ hi s
mstrument
Trauma to m ajor vessels may result in tear
in g or laceration of the vessels( 2), form a tion of
an arter iovenou s fistul a (3 ,4) , or fa lse a neurysm
(5 ,6). I solated in띠lJUI따11"따‘
severe retro이peritone al bleeding and will present
early manifestations of hy povolemia a nd
h ypotension. Profuse bleeding through the disc
space and rap id development of hemorrh agic
shock may occur. If vascular inJury occurs
simul taneously to both arte ry and ve in , form a
tion of an arterivenous fistu la is likely , as the path
of least resistance for arteríal bleeding is into the
low-pressure venous circui t. A th ird possible and
least frequent sequela of vascular trauma secon
dary to disc surgery is form ation of a false
aneu rysm. Most often , there may be early false
b
Fig. 1. a. Enh anced CT scan at the level of l cm caudal to the bifurcation ofIVC. Diffu se lower densities in both retro peritoneal space due to hematoma and leakage (arrow) of contrast media from small irregular shaped right common iliac vein indicate a tearing 0 1' the ve in ‘
b. Unenhanced CT scan at the level of distal IVC. Multiple gas bubbles within locul ated hematoma in left retroperitoneal space suggest superimposed infection c. CT scan of lumber spines . Herniated intervertebral disk on ri ght posterolateral side is seen at the level of L4-5 .
fo rm at ion with ex pa nsion or rupture occurring
within days . In rare insta nce , however , a well
con tained fa lse a neurysm m ay remain c1 inical
ly silent for years, fin aJ ly a ppcaring as a pul sat ile
abdomin a l m ass
CT scan shows not onl y the amount and ex
ten t of Ja rge retroperitoneaJ hemorrhage but also
th e type dnd locati o n o f vascu la r injury (4 ,6-8)
The focal con tinu ity 0 1' the hem atom a with the
ves~e l a nd cxt ravasat ion 0 1' contrast med ia fro m
the vesse l in our case suggest th is vessel is the
source o f the hem o rrhage ‘
W e think radi oJogists shouJd be aware of the
potentia lJ y Ji fe -th reatcnin g vascuJa r IHJuries
which m ay complica tc lumba r di skec tomy . CT
in ou r pat ien t provcd helpf'u J in co nfïrmin g the
clini cal d iagnos is , show ing th c ex tent of hemor
rhage , a nd demostrat in g the typc a nd Jocation
of the vascul a r inju ry
- 764
Eun Kyung Kim. et al : Mass ive Retroperitoneal Hemorrhage Due to a Tearing 01 Common lIiac Vein Complicating Lumbar Diskectomy
REFERENCES
1. Linton RR , White PD. Arteriovenous fi stul a
between the right common iliac and the inferior
vena cava: R eport of a case of its occurrence
following and operation for a ruptured in
te rvertebral disk with cure by operation. Arch
2. Surg 1945;50:6-13
Hidreth DH , Turcke ]R. Postlaminectomy
arterovenous fi stula. Surge ry 1977 ;81: 512-520
3. ]ustfer BS , Rich NM . The ch all enge of
arterivenous fi stula form a tion following disk
surgery: A collect ive review. ] Trauma 1976;
16:726
4. Hw a n g ]W , P a rk HW , Chang UH.
〈국문 요약〉
Arteriovenous fistul a followin g lumbar laminc
tomy.] Korean R adiol Society 1988;24:369-399
5. Brewster DC , M ay ARL , D arling R C , et al.
V ariable manifestation of vascular injury dur
ing lumbar disk surge ry. Arch Surg 1979 ;
114 :1026
6. Kim H] , Chung SH. M assive retrope ritoneal
hemorrhage with a fal se aneurysm of left com
mon iliac artery complicatin g lumbar diskec
tomy.] Korean R adiol Society 1990;26:985-988
7. Staple TW , Fri ed e nberg M]. lli o ili ac
arteriovenous fistul a following intervertebral disk
surgery. Clin Radiol 1965;16:248-250
8. K elly ]] , R euter KL, Waite R]. V ascular in
jury complicating lumbar diskectomy: CT
diagnosis. A]R 1989;153:1233- 1234
요추 추간판 절제술후에 생긴 총장골 정맥 손상에 의한 후복막강 출혈 : I 예 보고
조선대학교 의과대학 진단방사선과학교실
검은경·오재희·김 영숙·김 영 철
요추 추간판 절제술후 후복막강혈관의 손상으로 인한 후복막강출혈은 드물게 발생하지만 대단히 위험한 합병증중
의 하나이다. 찢겨진 혈관과 후복막강출혈의 진단에 있어서 전산화단층촬영은 많은 도움을 준다.
저자들은 요추 추간판 절제술후에 우측 총장골정맥의 손상에 의한 심한 후복막강 출혈이 있었던 환자에서, 한달간
의 관찰후 대부분의 후복막강 출혈은 홉수되었으나 골반강과 좌측 후복막강에 국한된 혈종 및 이차감염으로 수술후
완치된 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다.
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