An evaluation of vascular anatomy for minilaparotomic anterior L4–5 procedures

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Object

The complexity of the vascular anatomy pertinent to the L4–5 intervertebral disc space has led to difficulties when performing the anterior approach to the lumbar spine. The purpose of the present study was to evaluate the variations of the great vessels to match the imaging-documented axial anatomy with the surgical exposure.

Methods

The authors analyzed data obtained in 223 patients who had undergone mini–open anterior lumbar surgery involving the L4–5 disc. The preoperative magnetic resonance images or computed tomography scans were evaluated by examiners blinded to the surgical approach to determine the vascular configuration. All complications of the procedures were described.

Two major variations of the vascular configuration were delineated according to the location of the bifurcation of the inferior vena cava. On images showing the lower margin of the L-4 vertebra, the anatomy in 182 patients (81%) was classified as Type A because the inferior vena cava (IVC) was not bifurcated; in 38 patients (17%) it was classified as Type B because the IVC was bifurcated. Type A could be subdivided into Types A1 and A2 according to whether the aorta was bifurcated (A2) or not (A1) on the same image. The surgical exposure used was above the bifurcations (in Type A) and below the bifurcations (in Type B). The major complications were three venous injuries, and the leading complication was sympathetic dysfunction in 14 patients, which in most cases resolved spontaneously.

Conclusions

Careful preoperative evaluation of the vascular anatomy is essential to conducting successful anterior lumbar surgery. The determination of an appropriate approach can contribute to a reduction of unnecessary vascular retraction and a consequent decrease in vascular complications.

Abbreviations used in this paper:CT = computed tomography; IVC = inferior vena cava; MR = magnetic resonance.

Article Information

Address reprint requests to: Sang-Ho Lee, M.D., Ph.D., 47-4 Chungdam-Dong Gangnam-Gu, Wooridul Spine Hospital, Seoul, Korea 135-100.email: grussin@empal.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A and B: Axial MR images of Type A1 (A) and A2 (B) configurations. C: Schematic diagram showing the approach from above the bifurcations of the great vessels. A = aorta; a = iliac artery; V = IVC.

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    A: Axial MR image of configuration Type B. B: Schematic diagram showing the approach from below the bifurcations of the great vessels. v = iliac vein.

  • View in gallery

    Axial CT scans. A: Severe calcification of the aorta. B: Calcification of the left iliac artery with double contour. C: Aortic aneurysm; the transverse diameter is 4 cm in this case.

References

1

Aljabri BMacDonald PSSatin RStein LSObrand DISteinmetz OK: Incidence of major venous anomalies relevant to aortoiliac surgery as demonstrated by computed tomography. Ann Vasc Surg 15:6156182001

2

Anda SAakhus SSkaanes KOSande ESchrader H: Anterior perforations in lumbar discectomies. A report of four cases of vascular complications and a CT study of the prevertebral lumbar anatomy. Spine 16:54601991

3

Baker JKReardon PRReardon MJHeggeness MH: Vascular injury in anterior lumbar surgery. Spine 18:222722301993

4

Bianchi CBallard JLAbou-Zamzam AMTeruya THAbu-Assal ML: Anterior retroperitoneal lumbosacral exposure: operative technique and results. Ann Vasc Surg 17:1371422003

5

Brau SA: Miniopen approach to the spine for anterior lumbar interbody fusion: description of the procedure, results and complications. Spine J 2:2162232002

6

Capellades JPellise FRovira AGrive EPedraza SVillanueva C: Magnetic resonance anatomic study of iliocava junction and left iliac vein positions related to L5–S1 disc. Spine 25:169517002000

7

Carpenter N: Spondylolisthesis. Br J Surg 19:3743861932

8

Castro FP JrHartz RSFrigon VWhitecloud TS III: Aortic thrombosis after lumbar spine surgery. J Spinal Disord 13:5385402000

9

Chithriki MJaibaji MSteele R: The anatomical relationship of the aortic bifurcation to the lumbar vertebrae: a MRI study. Surg Radiol Anat 24:3083122002

10

Dewald CJMillikan KWHammerberg KWDoolas ADewald RL: An open, minimally invasive approach to the lumbar spine. Am Surg 65:61681999

11

Faciszewski TWinter RBLonstein JEDenis FJohnson L: The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. A review of 1223 procedures. Spine 20:159215991995

12

Flynn JCPrice CT: Sexual complications of anterior fusion of the lumbar spine. Spine 9:4894921984

13

Fraser RDGogan WJ: A modified muscle-splitting approach to the lumbosacral spine. Spine 17:9439481992

14

Inamasu JKim DHLogan L: Three-dimensional computed tomographic anatomy of the abdominal great vessels pertinent to L4–L5 anterior lumbar interbody fusion. Minim Invasive Neurosurg 48:1271312005

15

Katkhouda NCampos GMMavor EMason RJHume MTing A: Is laparoscopic approach to lumbar spine fusion worthwhile?. Am J Surg 178:4584611999

16

Kawahara NTomita KBaba HToribatake YFujita TMizuno K: Cadaveric vascular anatomy for total en bloc spondylectomy in malignant vertebral tumors. Spine 21:140114071996

17

Kleeman TJAhn UMClutterbuck WBCampbell CJTalbot Kleeman A: Laparoscopic anterior lumbar interbody fusion at L4–L5: an anatomic evaluation and approach classification. Spine 27:139013952002

18

Kulkarni SSLowery GLRoss RERavi Sankar KLykomitros V: Arterial complications following anterior lumbar interbody fusion: report of eight cases. Eur Spine J 12:48542003

19

Kuslich SDUlstrom CLGriffith SLAhern JWDowdle JD: The Bagby and Kuslich method of lumbar interbody fusion. History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial. Spine 23:126712791998

20

Lieberman IHWillsher PCLitwin DESalo PTKraetschmer BG: Transperitoneal laparoscopic exposure for lumbar interbody fusion. Spine 25:5095152000

21

Mahvi DMZdeblick TA: A prospective study of laparoscopic spinal fusion. Technique and operative complications. Ann Surg 224:85901996

22

Mayer HM: A new microsurgical technique for minimally invasive anterior lumbar interbody fusion. Spine 22:6917001997

23

McAffee PCRegan JRZdeblick TZuckerman JPicetti GD IIIHeim S: The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases. Spine 20:162416321995

24

Obenchain TG: Laparoscopic lumbar discectomy: case report. J Laparoendosc Surg 1:1451491991

25

Onimus MPapin PGangloff S: Extraperitoneal approach to the lumbar spine with video assistance. Spine 21:249124941996

26

Oskouian RJ JrJohnson JP: Vascular complications in anterior thoracolumbar spinal reconstruction. J Neurosurg 96:1 Suppl152002

27

Parke WWWhalen JLVan Demark REKambin P: The infraaortic arteries of the spine: their variability and clinical significance. Spine 19:161994

28

Penta MFraser RD: Anterior lumbar interbody fusion. A minimum 10-year follow-up. Spine 22:242924341997

29

Rajaraman VVingan RRoth PHeary RFConklin LJacobs GB: Visceral and vascular complications resulting from anterior lumbar interbody fusion. J Neurosurg 91:1 Suppl60641999

30

Raskas DSDelamarter RB: Occlusion of the left iliac artery after retroperitoneal exposure of the spine. Clin Orthop Relat Res 338:86891997

31

Regan JJAronoff RJOhnmeiss DDSengupta DK: Laparoscopic approach to L4-L5 for interbody fusion using BAK cages: experience in the first 58 cases. Spine 24:217121741999

32

Regan JJYuan HMcAfee PC: Laparoscopic fusion of the lumbar spine: minimally invasive spine surgery. A prospective multicenter study evaluating open and laparoscopic lumbar fusion. Spine 24:4024111999

33

Saraph VLerch CWalochnik NBach CMKrismer MWimmer C: Comparison of conventional versus minimally invasive extraperitoneal approach for anterior lumbar interbody fusion. Eur Spine J 13:4254312004

34

Sasso RCBurkus JKLeHuec JC: Retrograde ejaculation after anterior lumbar interbody fusion: transperitoneal versus retroperitoneal exposure. Spine 28:102310262003

35

Slosar PJReynolds JBSchofferman JGoldthwaite NWhite AHKeaney D: Patient satisfaction after circumferential lumbar fusion. Spine 25:7227262000

36

Stauffer RNCoventry MB: Anterior interbody lumbar spine fusion. Analysis of Mayo Clinic Series. J Bone Joint Surg Am 54:7567681972

37

Thalgott JSChin AKAmeriks JAJordan FTDaubs MDGiuffre JM: Gasless endoscopic anterior lumbar interbody fusion utilizing the B.E.R.G. approach. Surg Endosc 14:5465522000

38

Tiusanen HSeitsalo SOsterman KSoini J: Retrograde ejaculation after anterior lumbar interbody fusion. Eur Spine J 4:3393421995

39

Tribus CBBelanger T: The vascular anatomy anterior to the L5–S1 disk space. Spine 26:120512082001

40

Vraney RTPhillips FMWetzel FTBrustein M: Peridiscal vascular anatomy of the lower lumbar spine. An endoscopic perspecive. Spine 24:218321871999

41

Watkins R: Anterior lumbar interbody fusion surgical complications. Clin Orthop Relat Res 284:47531992

42

Westfall SHAkbarnia BAMerenda JTNaunheim KSConnors RHKaminski DL: Exposure of the anterior spine. Technique, complications, and results in 85 patients. Am J Surg 154:7007041987

43

Zdeblick TADavid SM: A prospective comparison of surgical approach for anterior L4-l5 fusion: laparoscopic versus mini anterior lumbar interbody fusion. Spine 25:268226872000

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