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

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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

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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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