The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach

Abstract

We observed some differences concerning the safe working zone in comparison with other cadaveric studies. The small number of cadaveric specimens used in anatomical studies probably explains theses differences. The minimally invasive transpsoas lateral approach was initially developed to reduce the complications associated with the traditional procedure. The anatomical relationships between the lumbar plexus and the intervertebral disc make this technique particularly risky a L4L5. Alternative techniques, such as transforaminal interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF) or anterior interbody fusion (ALIF) should be used at this level.

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

“…At lower levels, especially at L4-5, there is no safe working window anterior to all nerves. Guerin et al [3] performed an anatomical study on the safe working zones inside the psoas muscle and found that at L3-4 and L4-5 levels, the ''safest'' zone is always posterior to genitofemoral nerve. Anterior lumbar interbody fusion is another alternative to XLIF [8][9][10][11][12][13][14][15][16][17][18][19].…”

“…It is based on lateral retroperitoneal transpsoas approach and electrophysiological navigation inside the psoas major muscle to avoid damaging the lumbar plexus. Studies on nerve distribution along the lateral side of the lumbar vertebral column, inside the psoas muscle, showed relatively safe working ''windows'' to access the disc spaces from L1-2 to L4-5 [3,4]. However, given the patient-and level-related variations, no standard surgical strategy can be used to access all levels.…”

Lateral Lumbar Interbody Fusion

“…Preoperative magnetic resonance imaging can be helpful to identify the position of the psoas and the approximate locations of the lumbar plexus and vascular structures, although the operative position (lateral decubitus with hips and knees flexed) is quite different than the supine position [1,[4][5][6][7].…”

“…Furthermore, biomechanical studies show that LLIF implants provide a greater reduction in range of motion during flexion, extension, lateral bending, and axial rotation when compared to those of anterior lumbar interbody fusion and TLIF implants [15,16]. The most common complication is anterior thigh pain and numbness, which result from irritating the psoas muscle or transient irritation of the genitofemoral nerve [1,4,5,8]. Pumberger et al [17] examined 181 patients at our institute.…”

Bloqueo simpático lumbar

“…El primero se dirige al plexo solar, el segundo al plexo intermesentérico, el tercero se sitúa delante de los vasos iliacos primitivos para llegar al plexo hipogástrico, y el cuarto nervio viene del ganglio simpático lumbar inferior situándose detrás de los vasos iliacos primitivos, para dirigirse a la pelvis, aunque da fibras a la porción inferior del plexo hipogástrico superior (9)(10)(11).…”