뇌기저부수술(자480-1)에 대하여

<A name="[문서의 처음]"></A> 뇌기저부수술(자480-1)에 대하여 ■ 청구내역    0 상병명 : 머리뼈 및 얼굴뼈 상세불명 부위의 뼈 및 관절연골의 악성 신생물, 기타 세균성 수막염    0 주요청구내역       자480-1나  뇌기저부수술(중두개와) x 1       자480-1가  뇌기저부수술(전두개와) x 0.5       자49-1가   척추후궁절제술(경추) x 1       자46나(1)   척추후방고정술(경추) x 0.5       자31 골편절채술 x 1 ■ 진료내역   전년 12.20 C/C) dysarthria, neck pain            Hx) 8월경부터 post neck pain develop 되어 local에서 neck sprain 진단받고 conservative care 받던 중 12.11경 갑자기 dysarthria, 혀가 마비되는 증세 있고, 12월부터 neck pain 심해져서 시행한 brain MRI상 clivus chordoma(사대부 척색종) 의심되어 입원함.            imp) clivus chordoma   금년 1.10      - 수술전․후 진단명) chordoma, clivus                         Fracture, second cervical vertebra, closed     - 수술명) Subfrontal, transbasal approach and gross total removal of brain tumor     - 수술방법)        ① Bicoronal scalp incision was marked on the scalp.        ② Before sclap incision, a transverse incision was made on lateral to umbilicus for fat harvest. Using the coagulator, fat tissue was obtained.        ③ Subgaleal dissection with the Bovie coagulator especially muscle attached area. Muscle was carefully dissected sparing its facia layer. Periosteum was dissected using the Periosteum elevator. The Legend electronic drill drilled a small holes on frontal bone. The Craniotome made a free bone flap above frontal sinus level.        ④ Subfrontal dissection had been performed. At the cribiform plate, olfactory nerves dissected. The Frontal lobe was retracted posteriorly. Anterior to dorsul sella and posterior to cribriform plate, Drilling was started.        ⑤ Gray-bluish tumor tissue was exposed in the drilling field.        ⑥ Frontal bone was cut in the level of frontal sinus and superior orbital wall. Left orbital wall was opened and fat tissue was bulging out.        ⑦ Drilling, coagulation, hemostasis and removal of tumor was repeated.        ⑧ Odontoid process was exposed and it was easily removed because of tumor invasion.        ⑨ C1 arch and C2 vertebral body was removed by drilling.        ⑩ Harvested fat was grafted on sphenoid and ethmoid sinus and dead space. The Periosteal flap covered anterior skull base.        ⑪ On the frontal area, Tacocomb was applied.        ⑫ The bone flap was fixed with the osteomeds.        ⑬ Then position was changed in the prone position without extension and flextion of neck.        ⑭ Midline linear incision was made on posterior neck from inion to T1 level. After dissection of neck muscles, C1 and C2 laminar was exposed.        ⑮ After removal of tumor, the Spine surgeon had started fusion of occipit and C1-2-3-4 with screw and rod. ■ 참고    ○ 건강보험요양급여행위및그상대가치점수 제9장 처치 및 수술료 [산정지침] (6)항    ○ 신경외과학 제2판, 대한신경외과학회, 2004; P239, 258 ■ 심의내용    사대부 척색종(chordoma, clivus) 상병에 Subfrontal, transbasal approach and gross total removal of brain tumor를 시행한 동 건은 전두개와 접근방법으로 중두개와를 지나 후두개와에 위치한 종양을 제거한 경우로 중두개와는 주요구조물제거가 확인되지 아니하고 통로로만 이용 되었고, 종양이 후두개와에 위치하고 주요시술이 이루어진 부위가 후두개와이므로 『자480-1나 뇌기저부수술(중두개와) x 100%, 자480-1가 뇌기저부수술(전두개와) x 50%』는 『자480-1다 뇌기저부수술(후두개와) x 100%』로 인정함. 또한 종양이 경추부위까지 침범해 있어 체위변경후 별도의 절개하에 시행된 경추후궁절제술 및 경추고정술은 인정함.   [2006.9.11 진료심사평가위원회]