Abstract
Extreme/direct lateral interbody fusion (X/DLIF) has been used to treat various lumbar diseases. However, it involves risks to injure the lumbar plexus and abdominal large vessels when it gains access to the lumbar spine via lateral approach that passes through the retroperitoneal fat and psoas major muscle. This study was aimed to determine the distribution of psoas major and abdominal large vessels at lumbar intervertebral spaces in order to select an appropriate X/DLIF approach to avoid nerve and large vessels injury. Magnetic resonance imaging scanning on lumbar intervertebral spaces was performed in 48 patients (24 males, 24 females, 54.2 years on average). According to Moro’s method, lumbar intervertebral space was divided into six zones A, I, II, III, IV and P. Thickness of psoas major was measured and distribution of abdominal large vessels was surveyed at each zone. The results show vena cava migrate from the right of zone A to the right of zone I at L1/2–L4/5; abdominal aorta was located mostly to the left of zone A at L1/2–L3/4 and divided into bilateral iliac arteries at L4/5; Psoas major was tenuous and dorsal at L1/2 and L2/3, large and ventral at L3/4 and L4/5. Combined with the distribution of nerve roots reported by Moro, X/DLIF approach is safe via zones II–III at L1/2 and L2/3, and via zone II at L3/4. At L4/5, it is safe via zones I–II in left and via zone II in right side, respectively.
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References
Obenchain TG (1991) Laparoscopic lumbar discectomy: case report. J Laparoendosc Surg 1:145–149
Regan JJ, Aronoff RJ, Ohnmeiss DD, Sengupta DK (1999) Laparoscopic approach to L4–L5 for interbody fusion using BAK cages: experience in the first 58 cases. Spine (Phila Pa 1976) 24:2171–2174
Lieberman IH, Willsher PC, DE Litwin, Salo PT, Kraetschmer BG (2000) Transperitoneal laparoscopic exposure for lumbar interbody fusion. Spine (Phila Pa 1976) 25:509–514 (discussion 515)
Olsen D, McCord D, Law M (1996) Laparoscopic discectomy with anterior interbody fusion of L5–S1. Surg Endosc 10:1158–1163
Zdeblick TA, David SM (2000) A prospective comparison of surgical approach for anterior L4–L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine (Phila Pa 1976) 25:2682–2687
Zucherman JF, Zdeblick TA, Bailey SA, Mahvi D, Hsu KY, Kohrs D (1995) Instrumented laparoscopic spinal fusion. Preliminary results. Spine (Phila Pa 1976) 20:2029–2034 (discussion 2034–2025)
Mayer HM (1997) A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine (Phila Pa 1976) 22:691–699 (discussion 700)
McAfee PC (1994) Complications of anterior approaches to the thoracolumbar spine. Emphasis on Kaneda instrumentation. Clin Orthop Relat Res 306:110–119
McAfee PC, Regan JJ, Geis WP, Fedder IL (1998) Minimally invasive anterior retroperitoneal approach to the lumbar spine. Emphasis on the lateral BAK. Spine (Phila Pa 1976) 23:1476–1484
McAfee PC, Regan JR, Zdeblick T, Zuckerman J, Picetti 3rd GD, Heim S, Geis WP, Fedder IL (1995) The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases. Spine (Phila Pa 1976) 20:1624–1632
Olinger A, Hildebrandt U, Mutschler W, Menger MD (1999) First clinical experience with an endoscopic retroperitoneal approach for anterior fusion of lumbar spine fractures from levels T12 to L5. Surg Endosc 13:1215–1219
Regan JJ, Guyer RD (1997) Endoscopic techniques in spinal surgery. Clin Orthop Relat Res 335:122–139
Regan JJ, McAfee PC, Guyer RD, Aronoff RJ (1996) Laparoscopic fusion of the lumbar spine in a multicenter series of the first 34 consecutive patients. Surg Laparosc Endosc 6:459–468
Regan JJ, Yuan H, McCullen G (1997) Minimally invasive approaches to the spine. Instr Course Lect 46:127–141
Regan JJ, Yuan H, McAfee PC (1999) Laparoscopic fusion of the lumbar spine: minimally invasive spine surgery: a prospective multicenter study evaluating open and laparoscopic lumbar fusion. Spine (Phila Pa 1976) 24:402–411
Baker JK, Reardon PR, Reardon MJ, Heggeness MH (1993) Vascular injury in anterior lumbar surgery. Spine (Phila Pa 1976) 18:2227–2230
Christensen FB, Bunger CE (1997) Retrograde ejaculation after retroperitoneal lower lumbar interbody fusion. Int Orthop 21:176–180
Ozgur BM, Aryan HE, Pimenta L, Taylor WR (2006) Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:435–443
Knight RQ, Schwaegler P, Hanscom D, Roh J (2009) Direct lateral lumbar interbody fusion for degenerative conditions: early complication profile. J Spinal Disord Tech 22:34–37
Moro T, Kikuchi S, Konno S, Yaginuma H (2003) An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine (Phila Pa 1976) 28:423–428 (discussion 427–428)
Benglis DM, Vanni S, Levi AD (2009) An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine 10:139–144
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Hu, WK., He, SS., Zhang, SC. et al. An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach. Eur Spine J 20, 557–562 (2011). https://doi.org/10.1007/s00586-010-1609-1
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DOI: https://doi.org/10.1007/s00586-010-1609-1