Avulsion of ascending lumbar and iliolumbar veins in anterior spinal surgery: An anatomical study

Abstract

To expose the disc between the 4th and 5th lumbar vertebrae in anterior spinal surgery, left to right retraction of inferior vena cava and aorta is required. This manoeuvre can be complicated by venous haemorrhage that, in most cases, is due to avulsion of the left ascending lumbar vein (ALV) or the left iliolumbar vein (ILV). We dissected 23 embalmed cadavers to assess the factors that contribute to the risk of tearing these two veins during retraction. We describe a triangular region that should help surgeons in identifying the ALV and ILV. This triangle is defined by the lateral border of the common iliac vein, the medial border of the psoas major muscle, and the superior end-plate of the L5 vertebral body. We observed that 3 cm between the termination of the left ALV, or a common stem with the ILV, and the termination of the common iliac vein is the critical distance, less than which the risk of venous avulsion is highest. Although the sample considered is small, our study seems to suggest that male patients tend to have a higher risk of venous avulsion than female patients.

Anatomical variations of the iliolumbar vein with application to the anterior retroperitoneal approach to the lumbar spine: A cadaver study

“…One previous study suggests that the only significant difference between right and left ILVs is that the distance of the ILV to the IVC confluence on the left tends to be farther away from the IVC than those on the right (Kiray et al, 2004;Hamid et al, 2007). A separate study has shown no significant difference between the two sides (Sivakumar et al, 2007). Our study confirms the former.…”

“…They felt that the male venous structures may be more susceptible to avulsion upon retraction to the right side as four of five avulsions that occurred in their study were in male cadavers, but they also admitted that this was too small of a sample size to make any firm conclusions (Sivakumar et al, 2007). All other differences in their comparison of male and female cadavers were not statistically significant.…”

“…One previous study found a statistically significant difference between males and females in the mean distance between the IVC confluence and the ILV trunk (Sivakumar et al, 2007). They felt that the male venous structures may be more susceptible to avulsion upon retraction to the right side as four of five avulsions that occurred in their study were in male cadavers, but they also admitted that this was too small of a sample size to make any firm conclusions (Sivakumar et al, 2007).…”

“…Previously, there have been a total of six ILV and ALV drainage patterns described, and they are as follows (Arthornthurasook and Gaew-Im, 1987;Jasani and Jaffray, 2002;Kiray et al, 2004;Sivakumar et al, 2007):…”

“…With large blood loss or even death documented following laceration of the iliolumbar vein intraoperatively, an understanding of the paraspinal venous variation is critical. Research attempting to clarify these anatomical variations has been limited and incongruous (Arthornthurasook and Gaew-Im, 1987;Jasani and Jaffray, 2002;Kiray et al, 2004;Hamid et al, 2007;Sivakumar et al, 2007). Collectively, a total of five separate variations have been described.…”