Movement of abdominal structures on magnetic resonance imaging during positioning changes related to lateral lumbar spine surgery: a morphometric study

Clinical article

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Object

The minimally invasive lateral interbody fusion of the lumbar spine through a retroperitoneal transpsoas approach has become increasingly used. Although preoperative imaging is performed supine, the procedure is performed with the patient in the lateral decubitus position. The authors measured the changes in location of the psoas muscle, aorta, inferior vena cava (IVC), iliac vessels, and kidneys with regard to the fixed lumbar spine when moving from a supine to a lateral decubitus position.

Methods

Unenhanced lumbar MRI scans were performed using a 3T magnet in 10 skeletally mature volunteers in the supine, left lateral decubitus (LLD), and right lateral decubitus (RLD) positions. Positional changes in the aorta, IVC, iliac vessels, and kidneys were then analyzed at all lumbar levels when moving from supine to RLD and supine to LLD. Values are presented as group means.

Results

When the position was changed from supine to RLD, both the aorta and the IVC moved up to 6 mm to the right, with increased movement caudally at L3–4. The aorta was displaced 2 mm anteriorly at L1–2, and the IVC moved 3 mm anteriorly at L1–2 and L2–3 and 1 mm posteriorly at L3–4. The left kidney moved 22 mm anteriorly and 15 mm caudally, while the right kidney moved 9 mm rostrally.

When the position was changed from supine to LLD, the aorta moved 1.5 mm to the left at all levels, with very minimal anterior/posterior displacement. The IVC moved up to 10 mm to the left and 12 mm anteriorly, with increased movement rostrally at L1–2. The left kidney moved 3 mm anteriorly and 1 mm rostrally, while the right kidney moved 20 mm anteriorly and 5 mm caudally.

The bifurcation of the aorta was an average of 18 mm above the L4–5 disc space, while the convergence of the iliac veins to form the IVC was at the level of the disc space. The iliopsoas did not move in any quantifiable direction when the position was changed from supine to lateral; its shape, however, may change to become more flat or rounded. When the position was changed from supine to RLD, the right iliac vein moved posteriorly an average of 1.5 mm behind the anterior vertebral body (VB) line (a horizontal line drawn on an axial image at the anterior VB), while the other vessels stayed predominantly anterior to the disc space. When the position was changed from supine to LLD, the right iliac vein moved to a position 1.4 mm anterior to the anterior VB line. There was negligible movement of the other vessels in this position.

Conclusions

The authors showed that the aorta, IVC, and kidneys moved a significant distance away from the surgical corridor with changes in position. At the L4–5 level, a left-sided approach may be riskier because the right common iliac vein trends posteriorly and into the surgical corridor, whereas in a right-sided approach it trends anteriorly.

Abbreviations used in this paper:DICOM = Digital Imaging and Communications in Medicine; IVC = inferior vena cava; LIF = lateral interbody fusion; LLD = left lateral decubitus; RLD = right lateral decubitus; VB = vertebral body.

Article Information

Address correspondence to: Armen R. Deukmedjian, M.D., Department of Neurosurgery and Brain Repair, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, Florida 33606. email: armendeuk@gmail.com.

Please include this information when citing this paper: published online March 30, 2012; DOI: 10.3171/2012.3.SPINE1210.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Aorta/IVC measurement method. Axial T2-weighted MR image obtained in the supine position at the level of the L1–2 disc space demonstrating the method of measurement of both the aorta and the IVC in the medial-lateral and anterior-posterior planes. Distance in the medial-lateral plane was measured from the midspinous process–VB line for the IVC (IVC-x) and aorta (A–x). Distance in the anterior-posterior plane was measured from the anterior VB line for the IVC (IVC-y) and aorta (A–y). These measurements were compared with those obtained at the same disc space level in the LLD and RLD positions.

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    Kidney measurement method. Coronal T2-weighted image obtained in the LLD position demonstrating the method of measuring cranial and caudal kidney movement. A horizontal line was drawn across the superior endplate of L-4, and the distance from each inferior kidney pole was recorded in the supine, LLD, and RLD positions.

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    Aorta movement. Graphs depicting aorta movement when position is changed from supine to LLD and supine to RLD in the anterior-posterior (upper) and medial-lateral (lower) directions at L1–2, L2–3, and L3–4. Upper: Anterior movement of the aorta is depicted with a positive value while posterior movement is depicted with a negative value. At L1–2 in the RLD position, the aorta moves 1.9 mm anteriorly (p = 0.015). All other movements in this plane are less than 1 mm and not statistically significant. Lower: Aorta movement to the right is depicted with a positive value, while movement to the left is depicted with a negative value. When the position is changed from supine to RLD, the aorta moves to the right 2.5 mm at L1–2 (p = 0.01), 5.4 mm at L2–3 (p = 0.001), and 5.6 mm at L3–4 (p < 0.001). When the position is changed from supine to LLD, the aorta moves less than 2 mm to the left. Data are given as mean values for 10 volunteers.

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    Inferior vena cava movement. Graphs depicting IVC movement when the position is changed from supine to LLD and from supine to RLD in the anterior-posterior (upper) and medial-lateral (lower) directions at L1–2, L2–3, and L3–4. Upper: Anterior movement of the IVC is depicted with a positive value while posterior movement is depicted with a negative value. When the position is changed from supine to LLD, the IVC moves anteriorly 12.4 mm at L1–2 (p = 0.001), 4.7 mm at L2–3 (p = 0.005), and 1.1 mm at L3–4 (p = 0.037). The IVC movements when the position was changed from supine to RLD were not statistically significant, but it is interesting to note the posterior movement of 1.1 mm at L3–4. Lower: The IVC movement to the right is depicted with a positive value, while movement to the left is depicted with a negative value. All values are statistically significant.

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    Aorta bifurcation and IVC convergence. Graph depicting distance from the L4–5 disc space of the bifurcation of the aorta into the right and left common iliac arteries and the convergence of the right and left common iliac veins into the IVC. These are shown in the supine, RLD, and LLD positions. (A positive value indicates cranial direction, while a negative value indicates caudal direction.) In all positions the aorta bifurcation was on average 18 mm cranial to the L4–5 disc space, while the common iliac veins converged to form the IVC at the level of the disc space.

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    Right common iliac vein measurement method. Axial T2-weighted image obtained in the RLD position at the L4–5 disc space depicting the right common iliac vein 3 mm posterior to the anterior border of the disc space.

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    Kidney movement. Graphs depicting left and right kidney movement when changing from the supine to the LLD position and from the supine to the RLD position in the anterior-posterior (upper) and cranial-caudal (lower) directions. Upper: Anterior kidney movement is depicted with a positive value, while posterior movement is depicted with a negative value. The kidney on the side of the approach moves anteriorly 20 mm and 22 mm (p = 0.001). Lower: Cranial kidney movement is depicted with a positive value, while posterior movement is depicted with a negative value. Of note, the left kidney moves caudally 15 mm when the position is changed from supine to RLD (p = 0.001).

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    Axial T2-weighted MR images obtained at the L4–5 disc space in the LLD (left) and RLD (right) positions (insets demonstrate patient positioning). Note the right common iliac vein (RCIV) anterior movement in a right-sided approach and posterior movement in a left-sided approach.

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    Axial T2-weighted MR images obtained in the LLD position at L1–2 (A), L2–3 (B), and L3–4 (C). The arrows demonstrate the direction of movement of the aorta (A), IVC (I), and the right and left kidneys (RK and LK). The insets show the patient positioning. Note that all structures moved anteriorly at all levels, except for the aorta at L3–4, where it moved slightly posteriorly (0.04 mm).

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    Axial T2-weighted MR images obtained in the RLD position at L1–2 (A), L2–3 (B), and L3–4 (C). The arrows demonstrate the direction of movement of the aorta, IVC, and the right and left kidneys. The insets show the patient positioning. Note that all structures moved anteriorly at all levels except for the IVC at L3–4, where it moved slightly posteriorly (1.1 mm).

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