Lumbar Plexus Anatomy within the Psoas Muscle: Implications for the Transpsoas Lateral Approach to the L4-L5 Disc

Davis, Timothy T.; Bae, Hyun; Mok, Ji Oh; Rasouli, Alexandre; Delamarter, Rick B.

doi:10.2106/jbjs.j.00962

Cited by 110 publications

(49 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…15,21 There is also risk of injury to the lumbar plexus with this approach due to the anatomical course of the lumbar plexus through the psoas muscle. 2,3,11,12,31 Another disadvantage to this approach is the inability to access the L5-S1 disc space due to the large overlap of the iliac crest and density of neural and vascular structures. 27 Intraoperative neurological monitoring is often used to assess proximity to neural structures and in an attempt to decrease neural injury; however, neurological monitoring is not a substitute for careful dissection and surgical skill.…”

Section: 1019mentioning

confidence: 99%

“…14,21,33 The transpsoas approach does, however, pose risk to neural structures of the lumbar plexus as they course through the psoas. 2,12,13,15,21 The large muscle belly of the psoas and overlap of the iliac crest make access to the L4-5 disc difficult and eliminate access to the L5-S1 disc. 2,3,8,10,15 Access to the L4-5 disc in a lateral transpsoas approach often requires a table break or jack-knifed table position to lower the ipsilateral iliac crest.…”

mentioning

confidence: 99%

See 1 more Smart Citation

Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study

Davis

Hynes²,

Fung

et al. 2014

SPI

162

145

View full text Add to dashboard Cite

Object Access to the intervertebral discs from L2–S1 in one surgical position can be challenging. The transpsoas minimally invasive surgical (MIS) approach is preferred by many surgeons, but this approach poses potential risk to neural structures of the lumbar plexus as they course through the psoas. The lumbar plexus and iliac crest often restrict the L4–5 disc access, and the L5–S1 level has not been a viable option from a direct lateral approach. The purpose of the present study was to investigate an MIS oblique corridor to the L2–S1 intervertebral disc space in cadaveric specimens while keeping the specimens in a lateral decubitus position with minimal disruption of the psoas and lumbar plexus. Methods Twenty fresh-frozen full-torso cadaveric specimens were dissected, and an oblique anatomical corridor to access the L2–S1 discs was examined. Measurements were taken in a static state and with mild retraction of the psoas. The access corridor was defined at L2–5 as the left lateral border of the aorta (or iliac artery) and the anterior medial border of the psoas. The L5–S1 corridor of access was defined transversely from the midsagittal line of the inferior endplate of L-5 to the medial border of the left common iliac vessel and vertically to the first vascular structure that crosses midline. Results The mean access corridor diameters in the static state and with mild psoas retraction, respectively, were as follows: at L2–3, 18.60 mm and 25.50 mm; at L3–4, 19.25 mm and 27.05 mm; and at L4–5, 15.00 mm and 24.45 mm. The L5–S1 corridor mean values were 14.75 mm transversely, from midline to the left common iliac vessel and 23.85 mm from the inferior endplate of L-5 cephalad to the first midline vessel. Conclusions The oblique corridor allows access to the L2–S1 discs while keeping the patient in a lateral decubitus position without a break in the table. Minimal psoas retraction without significant tendon disruption allowed for a generous corridor to the disc space. The L5–S1 disc space can be accessed from an oblique angle consistently with gentle retraction of the iliac vessels. This study supports the potential of an MIS oblique retroperitoneal approach to the L2–S1 discs.

show abstract

Section: 1019mentioning

confidence: 99%

mentioning

confidence: 99%

Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study

Davis

Hynes²,

Fung

et al. 2014

SPI

162

145

View full text Add to dashboard Cite

show abstract

“…Duration of surgery (odds ratio 1.01, 95 % confidence interval (CI) 1.01-1.01, p = 0.009) was the only risk factor for lumbar plexusrelated deficits and, in addition to female sex (odds ratio 3.86, 95 % CI 1.10-13.50, p = 0.034), was also a risk factor for psoas mechanical flexion deficits. Patient positioning has also been implicated in iatrogenic nerve injury; L4 neuropraxia may occur from excessive side bending of the patient during lateral positioning as a result of increased psoas tension and reduced nerve root perfusion [57].…”

Section: Anteriormentioning

confidence: 99%

Neurological complications in adult spinal deformity surgery

Iorio

Reid

Kim

2016

Curr Rev Musculoskelet Med

View full text Add to dashboard Cite

The number of surgeries performed for adult spinal deformity (ASD) has been increasing due to an aging population, longer life expectancy, and studies supporting an improvement in health-related quality of life scores after operative intervention. However, medical and surgical complication rates remain high, and neurological complications such as spinal cord injury and motor deficits can be especially debilitating to patients. Several independent factors potentially influence the likelihood of neurological complications including surgical approach (anterior, lateral, or posterior), use of osteotomies, thoracic hyperkyphosis, spinal region, patient characteristics, and revision surgery status. The majority of ASD surgeries are performed by a posterior approach to the thoracic and/or lumbar spine, but anterior and lateral approaches are commonly performed and are associated with unique neural complications such as femoral nerve palsy and lumbar plexus injuries. Spinal morphology, such as that of hyperkyphosis, has been reported to be a risk factor for complications in addition to three-column osteotomies, which are often utilized to correct large deformities. Additionally, revision surgeries are common in ASD and these patients are at an increased risk of procedure-related complications and nervous system injury. Patient selection, surgical technique, and use of intraoperative neuromonitoring may reduce the incidence of complications and optimize outcomes.

show abstract

“…Neuro-monitoring is essential and the L4/5 level can be difficult because of iliac crest obstruction or an anterior plexus position (4)(5)(6). Sensory disturbances and thigh weakness are common complications (7)(8)(9)(10)). An oblique approach, with the patient in a lateral position passes anterior to the iliac crest, remains retroperitoneal, and eliminates the need for neuro-monitoring by staying entirely anterior to psoas.…”

Section: Introductionmentioning

confidence: 99%

Anterior to psoas (ATP) fusion of the lumbar spine: evolution of a technique facilitated by changes in equipment

Gragnaniello

Seex

2016

J. Spine Surg.

View full text Add to dashboard Cite

Background: Lateral interbody cages have been proven useful in spinal fusions. Spanning both lateral cortical rims while sparing the Anterior Longitudinal Ligament, the lateral interbody cages restore and maintain disc height while adding stability prior to supplemental fixation. The standard approach for their insertion is by a 90-degree lateral transpsoas method. This is relatively bloodless compared to other techniques although has its limitations, requiring neuro-monitoring and being, at times, very difficult at L4/5 due to iliac crest obstruction or an anterior plexus position. An oblique approach, with the patient in lateral decubitus, passes anterior to the iliac crest, retroperitoneal, and being anterior to psoas, eliminates the need for neuro-monitoring.Methods: Twenty-one consecutive patients underwent surgery for a total of 32 levels instrumented with the ATP technique. Mean age at the time of surgery was 62.4±7.4 years. There was a 6 months minimum clinical follow up, with imaging to assess fusion, at 6 and 12 months. Indications included symptomatic degenerative lumbar spondylosis +/− spondylolisthesis, leg and back pain. All patients were assessed with the Oswestry Disability Index (ODI), Visual Analog Scale 100 mm for back pain (VASb) and for leg pain (VASl) preoperatively, at 3, 6 and 12 months. Last follow-up was at 12 months for 9 patients and the rest had 6 months follow up.Results: Statistical analysis showed significance for the results in ODI, VASb and VASl with improvement in all components except for one patient with worsening VASl. Eight patients had complications related to surgery which were still present at last follow-up including moderate weakness of hip flexion and EHL weakness. Lateral cutaneous nerve (LCN) palsy on the side of the approach was also seen as well as sympathectomy effect related to the mobilization of the sympathetic trunk. One patient, who also suffered from multiple sclerosis, experienced psoas abscess 3 months post op that required drainage. Conclusions:The left sided anterior to psoas approach offers the most natural corridor to the disc space.The novel instruments and method described here allows insertion of large lateral cages between L2 to L5, without the problems associated with the transpsoas approach, particularly at L4/5.

show abstract

Lumbar Plexus Anatomy within the Psoas Muscle: Implications for the Transpsoas Lateral Approach to the L4-L5 Disc

Cited by 110 publications

References 16 publications

Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study

Retroperitoneal oblique corridor to the L2–S1 intervertebral discs in the lateral position: an anatomic study

Neurological complications in adult spinal deformity surgery

Anterior to psoas (ATP) fusion of the lumbar spine: evolution of a technique facilitated by changes in equipment

Contact Info

Product

Resources

About