Complications during anterior surgery of the lumbar spine: an anatomically based study and review

Abstract

Procedures involving anterior surgical decompression and fusion are being performed with increasing frequency for the treatment of a variety of pathological processes of the spine including trauma, deformity, infection, degenerative disease, failed-back syndrome, discogenic pain, metastases, and primary spinal neoplasms. Because these operations involve anatomy that is often unfamiliar to many neurological and orthopedic surgeons, a significant proportion of the associated complications are not related to the actual decompressive or fusion procedure but instead to the actual exposure itself. To understand the nature of these injuries, a detailed anatomical study and dissection was undertaken in six cadaveric specimens. Critical structures at risk in the abdomen and retroperitoneum were identified, and their anatomical relationships were categorized and photographed. These structures included the psoas muscle, kidneys, ureters, diaphragm and crura, esophageal hiatus, thoracic duct, greater splanchnic nerves, phrenic nerves, sympathetic chains, medial arcuate ligament, superior and inferior hypogastric plexus, segmental and radicular vertebral vessels, aorta, vena cava, median sacral artery, common iliac vessels, iliolumbar veins, lumbosacral plexus, and presacral hypogastric plexus. Based on these dissections and an extensive review of the literature, the authors provide a detailed anatomically based discussion of the complications associated with anterior lumbar surgery.

Mini-open lateral retroperitoneal lumbar spine approach using psoas muscle retraction technique. Technical report and initial results on six patients

“…There are several advantages of this technique over anterior and posterior fusion techniques. It gives a surgeon the ability to place relatively large cages which decrease the possibility of subsidence [5]. The cages are rested at the apophyseal rings providing stability in the coronal plane.…”

The iliolumbar artery—Anatomic considerations and details on the common iliac artery trifurcation

“…Because these procedures involve anatomy that is often unfamiliar to many neurological and orthopedic surgeons, a significant proportion of the associated complications are not related to the actual procedure but instead to the actual exposure itself (Samudrala et al, 1999). A good knowledge of the arterial blood supply of the coxal bone is helpful in the course of radiological embolization for minimizing the risk of postoperative osteonecrosis (Yiming et al, 2002); hemorrhage from branches of the IIA requiring embolization occurs in 7-11% of patients with pelvic fractures; the most commonly injured arteries are the superior gluteal, iliolumbar, lateral sacral, internal pudendal, and obturator arteries.…”

The kinesthetic Buddha, human form and function—Part 1: Breathing Torso

“…The cause-and-effect relationship arising from structural contiguity is exemplified by malignant tumors burrowing in and out of the psoas muscle and causing ipsilateral hip flexion, impingement of the lumbosacral plexus, and great pain (Agar et al, 2004) or by anterior surgical procedures requiring the optimum flexion at the hip joint 'to relax the psoas (and thus)yprevent traction on the lumbosacral plexus, which is located within its substance' (Samudrala et al, 1999). An elegant example of structural causation is the cessation of piriformislike syndrome by inserting a Goretex patch between the looping anomaly of the inferior gluteal artery and the impinged sciatic nerve (Merlo et al, 1997) and is corroborated by viewing an inflamed piriformis muscle exactly proximal to the 'hyperintensity' or enlargement of the sciatic nerve (Filler et al, 2005).…”