Surgical anatomy of the presacral area

  • Mustafa Güvençer
  • Sedat Dalbayrak
  • Hamid Tayefi
  • Süleyman Tetik
  • Mesut Yılmaz
  • Ufuk Erginoğlu
  • Özdil Baksan
  • Salih Güran
  • Sait Naderi
Original Article



L5–S1 instabilities can be fixated using minimally invasive presacral approach. The close relationship between the sacrum and neurovascular as well as intestinal structures may complicate the procedure during this approach. This requires knowledge regarding the normal anatomy of the presacral area to avoid the iatrogenic injuries. The aim of this study was to measure the distance between the sacrum and the structures anterior to it.

Materials and methods

The measurements were performed on ten cadavers fixed with formaldehyde and ten MR imaging studies on individuals without any pathology in the presacral area. The distances between the sacrum and the presacral structures (i.e., middle and lateral sacral arteries, sympathetic trunks, internal iliac arteries and veins, and colon/rectum) were measured.


Cadaver study showed that the middle sacral artery was located on the right side in 55.0%, on the left side in 31.7%, and on the midline in the 13.3% of cases. The distance between the sacral midline and middle sacral artery was found to be 8.0 ± 5.4, 9.0 ± 4.9, 8.7 ± 6.0, 8.6 ± 6.4, and 4.7 ± 5.0 mm at the levels of S1–2, S2–3, S3–4, S4–5, and S5–coccyx, respectively. The distance between the sacral midline and the sympathetic trunk ranged between 22.4 ± 5.8 and 9.5 ± 3.2 mm in different levels between S1 and coccygeal level. The study also showed that the distance between the posterior wall of the intestine (colon/rectum) and the ventral surface of the sacrum can be as close as 11.44 ± 7.69 mm on MR images.


This study showed that there was close distance between the sacral midline and the structures anterior to it. The close relationships, as well as the potential for anatomical variations, require the use of sacral and presacral imaging before presacral approach.


Middle sacral artery Presacral anatomy Presacral approach Sympathetic trunk 


  1. 1.
    Anouble S, Hoste D, Donkersloot P, Liquois F, Basso Y, Huec JCL (2006) Video-assisted ALIF with cage and anterior plate fixation for L5–S1 spondylolisthesis. J Spinal Disord Tech 19(7):471–476CrossRefGoogle Scholar
  2. 2.
    Baque P, Karimdjee B, Iannelli A, Benizri E, Rahili A, Benchimol D, Bernard JL, Sejor E, Bailleux S, de Peretti F, Bourgeon A (2004) Anatomy of the presacral venous plexus: implications for rectal surgery. Surg Radiol Anat 26:355–358PubMedGoogle Scholar
  3. 3.
    Bleich AT, Rahn DD, Wieslander CK, Wai CY, Roshanravan SM, Corton MM (2007) Posterior division of the internal iliac artery: anatomic variations and clinical applications. Am J Obstet Gynecol 197:658.e1–658.e5CrossRefGoogle Scholar
  4. 4.
    Brau SA, Delamarter RB, Schiffman ML, Williams LA, Watkins RG (2004) Vascular injury during anterior lumbar surgery. Spine J 4:409–412PubMedCrossRefGoogle Scholar
  5. 5.
    Cardinot TM, Aragao AH, Babinski MA, Favorito LA (2006) Rare variation in course and affluence of internal iliac vein due to its anatomical and surgical significance. Surg Radiol Anat 28:422–425PubMedCrossRefGoogle Scholar
  6. 6.
    Cragg A, Carl A, Casteneda F, Dickman C, Guterman L, Olivera C (2004) New percutaneous access method for minimally invasive anterior lumbosacral surgery. J Spinal Disord Tech 17:21–28PubMedCrossRefGoogle Scholar
  7. 7.
    Datta JC, Janssen ME, Beckham R, Ponce C (2007) The use of computed tomography angiography to define the prevertebral vascular anatomy prior to anterior lumbar procedures Spine 32:113–119Google Scholar
  8. 8.
    Diop M, Parratte B, Tatu L, Vuillier F, Brunelle S, Monnier G (2003) Mesorectum: the surgical value of an anatomical approach. Surg Radiol Anat 25:290–304PubMedCrossRefGoogle Scholar
  9. 9.
    Eck JC, Hodges S, Humphreys SC (2007) Minimal invasive lumbar spinal fusion. J Am Acad Orthop Surg 6:321–329Google Scholar
  10. 10.
    Fantini GA, Pappou IP, Girardi FP, Sandhu HS, Cammisa FP (2007) Major vascular injury during anterior lumbar spinal surgery: incidence, risk factors and management. Spine 32:2751–2758PubMedCrossRefGoogle Scholar
  11. 11.
    Flynn MK, Romero AA, Amundsen CL, Weidner AC (2005) Vascular anatomy of the presacral space: a fresh tissue cadaver dissection. Am J Obstet Gynecol 192:1501–1505PubMedCrossRefGoogle Scholar
  12. 12.
    Gallia GL, Sciubba DM, Bydon A, Suk I, Wolinsky JP, Gökaslan ZL, Witham TF (2007) Total L-5 spondylectomy and reconstruction of the lumbosacral junction. J Neurosurg Spine 7:103–111PubMedCrossRefGoogle Scholar
  13. 13.
    Inamasu J, Guiot BH (2006) Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien) 148:375–387CrossRefGoogle Scholar
  14. 14.
    Kaiser AM, Ortega AE (2002) Anorectal anatomy. Surg Clin N Am 82:1125–1138PubMedCrossRefGoogle Scholar
  15. 15.
    Kulkarni SS, Lowerly GL, Ross RE, Sankar KR, Lykomitros V (2003) Arterial complications following anterior lumbar interbody fusion: report of eight cases. Eur Spine J 12:48–54PubMedGoogle Scholar
  16. 16.
    Marotta N, Coşar M, Pimenta L, Khoo LT (2006) A novel minimally invasive presacral approach and instrumentation technique for anterior L5–S1 intervertebral discectomy and fusion. Neurosurg Focus 20(1):E9PubMedCrossRefGoogle Scholar
  17. 17.
    Muntean V (1999) The surgical anatomy of the fasciae and the fascial spaces related to the rectum. Surg Radiol Anat 21:319–324PubMedCrossRefGoogle Scholar
  18. 18.
    Oto A, Peynircioğlu B, Eryılmaz M, Besim A, Sürücü HS, Çelik HH (2004) Determination of the width of the presacral space on magnetic resonance imaging. Clin Anat 17:14–16PubMedCrossRefGoogle Scholar
  19. 19.
    Pirro N, Ciampi D, Champsaur P, Di Marino V (2005) The anatomical relationship of the iliocava junction to the lumbosacral spine and the aortic bifurcation. Surg Radiol Anat 27:137–141PubMedCrossRefGoogle Scholar
  20. 20.
    Regan JJ, Yuan H, McAfee PC (1999) Laparoscopic fusion of the lumbar spine: minimally invasive spine surgery. A prospective multicenter study evaluating open and laparascopic lumbar fusion. Spine 24(4):402–411PubMedCrossRefGoogle Scholar
  21. 21.
    Sasso RC, Best NM, Mummaneni PV, Reilly TM, Hussain SM (2005) Analysis of operative complications in a series of 471 anterior lumbar interbody fusion procedures. Spine 30:670–674PubMedCrossRefGoogle Scholar
  22. 22.
    Sasso RC, Kenneth Burkus J, LeHuec JC (2003) Retrograde ejaculation after anterior lumbar interbody fusion. Transperitoneal versus retroperitoneal exposure. Spine 28(10):1023–1026PubMedCrossRefGoogle Scholar
  23. 23.
    Shen FH, Samartzis D, Khanna AJ, Anderson DG (2007) Minimally invasive techniques for lumbar interbody fusions. Orthop Clin N Am 38:373–386CrossRefGoogle Scholar
  24. 24.
    Sürücü HS, Erbil KM, Tastan C, Yener N (2001) Anomalous veins of the retroperitoneum: clinical considerations. Surg Radiol Anat 23(6):443–445PubMedCrossRefGoogle Scholar
  25. 25.
    Tribus CB, Blander T (2001) The vascular anatomy anterior to the L5–S1 disc space. Spine 26:1205–1208PubMedCrossRefGoogle Scholar
  26. 26.
    Yuan PS, Day TF, Albert TJ, Morrison WB, Pimenta L, Cragg A, Weinstein M (2006) Anatomy of the percutaneous presacral space for a novel fusion technique. J Spinal Disord Tech 19:237–241PubMedCrossRefGoogle Scholar
  27. 27.
    Weiner BK, Walker M, Fraser RD (2001) Vascular anatomy anterior to lumbosacral transitional vertebrae and implications for anterior lumbar interbody fusion. Spine J 1:442–444PubMedCrossRefGoogle Scholar
  28. 28.
    Wieslander CK, Rahn DD, McIntire DD, Marinis SI, Wai CY, Schaffer JI, Corton MM (2006) Vascular anatomy of the presacral space in unembalmed female cadavers. Am J Obstet Gynecol 195:1736–1741PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  • Mustafa Güvençer
    • 1
  • Sedat Dalbayrak
    • 2
  • Hamid Tayefi
    • 1
  • Süleyman Tetik
    • 1
  • Mesut Yılmaz
    • 2
  • Ufuk Erginoğlu
    • 2
  • Özdil Baksan
    • 3
  • Salih Güran
    • 3
  • Sait Naderi
    • 4
  1. 1.Department of Anatomy, School of MedicineDokuz Eylül UniversityBalçovaTurkey
  2. 2.The First Department of NeurosurgeryDr Lütfü Kırdar Research HospitalIstanbulTurkey
  3. 3.Sonomed Radiodiagnostic CenterIstanbulTurkey
  4. 4.Department of NeurosurgeryÜmraniye Education and Research HospitalIstanbulTurkey

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