A사례 |
■ 청구내역 (남/17세)
0 상병명 : 뇌하수체의 행동양식 불명 또는 미상의 신생물
0 주요청구내역
[수술료]
자480-1(가) 뇌기저부수술[경막을 이용한 이식포함] - 전두개와 1x1
* 바2 전신마취 12시간 30분
■ 진료내역
O C/C) known tumor(craniopharyngioma)
O P/I) 2년전.9월 갑자기 Lt.eye visual disturbance develop 되어 시행한 brain MRI 검사상 상기병명 진단받고 4차례 수술 받은 환자로 최근 Lt. side homonomous hemianopsia가 다시 develop되어 recurr
의심하에 수술위해 내원
O Imp) panhypopituitarysm, craniopharyngioma
0 Progress note
동년.6.15 수술시행
․Pre Op Dx : craniopharyngioma
․Op name : craniotomy & mass removal(bifrontal craniotomy, interhemispheric approach)
․Op finding & procedure
① supine position에서 head를 약간 extension 시킨 후 Head fixator를 이용하여 position 취함.
② 기존의 operation scar 따라서 bicoronal skin incision 시행.
③ Scalp retraction 시키면서 bone exposure 시킴.
④ 기존의 craniotomy 하였던 plate와 screw 제거. Bone flap 제거하자 Dura에서 bleeding 심함.
⑤ 양쪽으로 midline과 평행하게 dura incision 한 후에 flax cerebri 양쪽으로 frontal lobe의 base로 dissection 해 나갔음.
⑥ Falx cerebri의 adhesion된 곳을 찾아 bone과 박리한 후에 sup. sagittal sinus를 ligation 하였음.
⑦ Frontal lobe를 retraction하면서 mass에 접근하였음.
⑧ 먼저 양쪽 olfactory nerve를 확인한 후에 optic nerve와 양쪽 ICA 확인함.
⑨ Optic chiasm 아래로 mass 확인하였으며, 조심스럽게 optic nerve를 피하여 mass를 제거하기 시작함.
⑩ cystic portion은 1cc syringe로 약 3cc정도 aspiration 시행함.
⑪ Aspiration 하자 mass는 shrink되었으며, 그 다음에 tumor forcep 이용하여 mass 제거함.
⑫ Mass는 다소 calcified 되었으며, 주변과 adhesion은 심하지 않았음.
⑬ Grossly total remove 시행 후에 Surgicel, Gelfoam으로 bleeding control 하였으며 dura suture 시행.
⑭ Greenplast로 sealing 시행한 후에 Dura tenting시행 후 bone flap을 microplate와 craniofix로 고정함.
⑮ Muscle, subcutaneous, skin을 layer by layer로 suture 후 op 종료함.
B사례 |
■ 청구내역 (남/47세)
0 상병명 : 뇌막의 양성 신생물
0 주요청구내역
[수술료]
자480-1(나) 뇌기저부수술[경막을 이용한 이식포함] - 중두개와 1x1
* 바2 전신마취(개두술마취) 7시간
■ 진료내역
O Imp) ACP(ant.clinoid process) meningioma, Lt.
* 4 vessel angiography(동년.2.24) : Lt. ECA middle meningeal artery에서 origin된 accessory meningeal
artery에서 blood supply 받는 2x2cm size 의 Lt. side ACP meningioma
0 Progress note
동년.2.26 수술시행
․Pre Op Dx: ACP(ant.clinoid process) meningioma, Lt.
→ 병리조직상 meningothelial meningioma 확인
․Op name : osteoplastic craniotomy in Lt. frontoparietotemporal area(Lt. pterional approach)
zygomatic osteotomy, grossly total removal of tumor
․Op finding & procedure
① supine position with the Lt.shoulder up position.
② The head was fixed to the three-pins Mayfield headrest with lidocaine injection, rotated to Rt. side for Lt. pterional approach, and elevated about 10 degree for the venous drainage, thus left malar area was positioned on top. Then the entire scalp was prepared and drapped as usual aseptic manner.
③ a curvilinear scalp incision was made on Lt. frontotemporal area, from the midline to the Lt. zygomatic arch within the patient's hairline, about 15cm in length.
④ bleedings from the subcutaneous tissue.
⑤ subcutaneous tissue was dissected with care to avoid dividing the frontalis branch of facial nerve and the superficial temporal artery.
⑥ The muscular layer was incised with monopolar units and dissected from the periosteum (interfascial
approach technique)
⑦ subcutaneous tissue and muscular flaps were reflected inferiorly with scalp hooks in interfascial approach technique. one burrholes were made, key hole on the Lt. frontozygomatic junction and the others in the frontotemporal area.
⑧ The bone flap was removed out with Midas craniotome.
⑨ zygomatic osteotomy was done.
⑩ The lesser wing of the sphenoid bone was rongeured and grinded for more visualizing skull base and minimal brain retraction and to avoid inadvertent dural tearing. during grinding the sphenoid ridge, the anterior clinoid process was opened. it was coated with bone wax.
⑪ multiple dural tack-up sutures were done along the craniotomy margin.
⑫ Then Zeiss surgical microscope equiped with Greenberg-self-retaining retractors was applied to the operation field. following control of the bone bleeding with bone wax, the duramater was incised in semilunar fashion after bipolar cauterization. the dural leaflet was reflected with stay sutures.
⑬ The frontal lobe was slightly retracted at the anterior side of the Sylvian vein and the Sylvian fissure was opened carefully with arachnoid dissector.
⑭ The tumor was noted between clinoidal triangle. whitish and soft tumor beneath the 3rd nerve and optic nerve. careful dissection was started from the medial aspect of the Lt. anterior clinoid process. dural adhesion to tumor was carefully dissected. using tumor holding forceps and Malis bipolar coagulator, the tumor was removed to be small particles.
⑮ tumor was removed through clinoidal triangle. after grossly total removal of tumor, minor bleeding from tumor bed was controlled with Surgicels and Avitenes.(이하생략)
■ 의사소견서
동 환자는 전상돌기(ant. clinoid process)에서 발생한 수막종이 있어 종양의 제거과정를 보면, 종양이 해면정맥동 외측벽까지 침습되어 있어 관골절개술(zygomatic osteotomy)후 중두개와 접근법을 통해 종양에 접근하여 해면정맥동의 외측 상측벽을 노출하여 종양을 박리하였음.
경동맥과 중대뇌동맥, 그리고 그 가지들이 종양에 둘러싸여 있었기에 혈관손상없이 종양을 제거하기 위해서는 전두개와 접근법으로 불가능하였으며 전상상돌기에 붙어있는 종양제거시 주의의 2,3,4,5 뇌신경의 손상을 방지하기 위하여 그리고 후상상돌기(post.clinoid process) 후방과 천막(tentorium)으로 자라나는 종양을 제거하기 위해서는 중두개와 뇌기저부수술을 할 수 밖에 없는 상황이었음.
C사례 |
■ 청구내역 (남/25세)
0 상병명 : 뇌신경의 양성 신생물
0 주요청구내역
[수술료]
자480-1(다) 뇌기저부수술[경막을 이용한 이식포함] - 후두개와 1x1
* 바2 전신마취(개두술마취) 9시간 30분
■ 진료내역
O C/C) dizziness, Lt.hearing difficult, tinnitus
O P/I) 1년전 상기증상 발생하였으나 medication만 시행. 2주전부터 nausea & vomiting 심해져 타병원 경유하여 본원 외래 통해 입원
O Imp) Lt. vestibular schwannoma
0 Progress note
동년.8.9 수술 시행
․Pre Op Dx: Lt. vestibular schwannoma
․Op name: Rt. RMSOC(retromastoid suboccipital craniotomy) and tumor removal
․Op finding & procedure
① supine, HR to Lt.80 degree and skeletal fixation(+)
② "lagged-S" shaped incision superior to sup.nuchal line behind pina to posterior to mastoid tip, along the hair-line. muscle splitting layer by layer.
③ burr hole at asterion, retromastoid suboccipital craniotomy done to show the Lt. transverse sinus and sigmoid sinus
④ CSF was drained at cerebellomedullary cistern after dura incision. after brain relaxation, dura opening was completed.
⑤ with retraction of Lt.cerebellar hemisphere, we could find the cystic mass and would puncture and aspirate it. yellowish fluid was gush out about 10cc.
⑥ tumor was composed of cystic half superior portion and solid half inferior portion. cystic portion was decompressed first with opening their membranes. the membrane was like arachnoid membrane component. But deep portion of cystic membrane was not pilled-up because of attachment to brainstem.
⑦ solid portion was removed from lateral and lower pole to superior pole and then anterior to posterior. mass was moderately vascular and soft so that easily removable with CUSA. frozen biopsy was reported as schwannoma without pleomorphism, mitosis.
⑧ after thorough internal debulking capsulotomy was done from lower pole to upper pole. at superior part petrosal vein bleeding was profuse but controlled with avitene and surgicel.
⑨ fascial nerve was found from brainstem REZ and it goes to superior direction at medial of mass and the inferior to reach the porus. Anatomically preserved with islands of mass attached on it.
⑩ some of mass was remained because difficulties encountered to dissect from brainstem.
⑪ meatal portion was small and totally removed with ring curette without unroofing.
⑫ after all the mass was removed radical-subtotally, meticulous bleeding control and cerebellar condition was good. mastoid air cell was packed with bone wax.
⑬ dura closed water-tightly and bone flap was closed with mini-plate.
⑭ closed layer by layer. H-vac was placed at sub-muscular space.
■ 참고
○ 석세일 「척추외과학」 개정신판 최신의학사 2004년
․ 두개인두종(Craniopharyngioma) p208-210
․ 청신경초종 p198-199
○ 이비인후과학 두경부외과학 대한 이비인후과학회편 2002년. 등.
․ 수막종 p867
■ 심의내용
뇌기저부 수술(자480-1)은 기존 수술에 비해 해부학적으로 중요한 여러 구조들이 위치하고 있어 고도의 난이도 수술 수기가 요구되며 기존 수술 접근법이나 수술 수기로는 소기의 목적을 달성할 수 없어 뇌손상을 최소화하는 두개저 접근방법을 시행한 경우로 수술명, 수술접근방법, op procedure상 skull base 제거여부 및 범위 등을 고려하여 인정함이 타당함. 따라서 각 사례는 아래와 같이 결정함.
- 아 래 -
․A사례 : craniopharyngioma 상병으로 bifrontal craniotomy & mass removal(interhemispheric approach)를 실시하고 자480-1(가) 뇌기저부수술(전두개와)로 산정된 동 건은 수술기록지 및 x-ray film 등 참조할 때 approach 및 op procedure 상 skull base 수술로 확인되지 아니한 바 수기료는 자463가 종양절제를 위한 개두술(천막상부)로 인정함이 타당함.
․B사례 : Lt. anterior clinoid process meningioma상병으로 Lt pterional approach 하에 osteoplastic craniotomy in Lt frontoparietotemporal area, zygomatic osteotomy, grossly total removal of tumor를 실시한 동 건은 MRI 사진 및 수술기록지 참조할 때 종양이 해면정맥동의 위쪽과 외측벽까지 침범되어 있고 pterional approach & zygomatic osteotomy를 실시한 바 수기료는 「자480-1(나) 뇌기저부수술(중두개와)」 수술로 인정함이 타당함.
․C사례 : Lt. vestibular schwannoma 상병으로 Rt retromastoid suboccipital craniotomy and tumor removal을 실시하고 자480-1(다) 뇌기저부수술(후두개와)로 산정된 동건은 approach 및 Op procedure 참조할 때 수기료는 자463나 종양절제를 위한 개두술(천막하부)로 인정함이 타당함.
[ 2005.3.10 진료심사평가위원회 ]