腰部脊柱管狭窄症手術における術中硬膜損傷に対する対策

抄録

  Inadvertent dural tears are not uncommon in spinal surgery. It is not too difficult to fix dural tears in a normal setting, but they can prove problematic especially under minimally invasive surgery. We report a case of dural tear under a narrow operative field, and explain how to deal with such a case.

  An 83-year-old man presented with intermittent claudication, and felt discomfort in his thigh. An MR imaging study showed canal stenosis at the L3-5 level. During an operation at another hospital, a punch coused a dural tear and his cauda equina prolapsed from this small hole. This prolapsed cauda equina remgined herniated, and this patient was ther referred to our hospital. He could not move or even get up due to severe lumbago. Two weeks after the first operation, a second operation was performed at our hospital. When the laminectomy was enlarged from the L3 to L5 level, the dural sac tension of the dural sac was decompressed. The prolapsed cauda equina was carefully repositioned into dural sac. The patient recovered well neurologically soon after the operation. Imaging studies showed that the dural sac was decompressed sufficiently as well.

  In this case, the most important technical point was to gain enough decompression of the dural sac by enlarging the laminectomy space. The more common minimally invasive surgery becomes, the more frequently difficult cases to deal are encountered. In order to minimize iatrogenic complications, we have to carefully consider the 3D anatomical architecture of the spinal process, laminar arch, pedicle, yellow ligament, articular process and so on before each operation.