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Lumbar plexus nervous distortion in XLIF® approach: an anatomic study

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Abstract

Purpose

XLIF® is a widely used minimally invasive technique to treat different spine pathologies. The aim of this study was to quantify nerve distortion of lumbar plexus during XLIF® approach and to correlate it with morphometric data.

Methods

Nine fresh frozen cadaveric specimens were used. All specimens were subjected to the same dissection procedure cored on a left XLIF® approach at L2/L3 and L4/L5 levels. Distortion of cutaneous superficial nerves, femoral nerve (FN) at L4/L5 and genitofemoral nerve (GN) at L2/L3 and L4/L5 while opening the retractor were assessed and analyzed with respect to psoas muscle features.

Results

Superficial nerves were slightly displaced but never stretched. FN, as well as GN at L4/L5 level, could be displaced and stretched by the blades. Statistically significant correlation between FN distortion and the amount of psoas fibers interposed between the posterior blade of the retractor and the nerve itself (TCK) was found. GN distortion was found to be related to its clock position on an axial section of psoas muscle seen from cranially at L4/L5.

Conclusion

FN was in close connection with the deep psoas muscle fibers and it is subjected to anterior translation that correlates with TCK. This mechanism may partly explain the rate of femoral nerve palsy that occurs despite neuromonitoring and safe entry zones respect. The GN location at L4/L5 should be considered not only for its projection in Zone I, but also for its clock position on the psoas muscle surface, since it affects its distortion.

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References

  1. Pimenta L (2001) Lateral endoscopic transpsoas retroperitoneal approach for lumbar spine surgery. In: VIII Brazilian Spine Society Meeting. Belo Horizonte, Minas Gerais, Brazil

  2. Ozgur BM, Aryan HE, Pimenta L, Taylor WR (2006) Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J Off J North Am Spine Soc 6:435–443. doi:10.1016/j.spinee.2005.08.012

    Article  Google Scholar 

  3. Berjano P, Lamartina C (2013) Far lateral approaches (XLIF) in adult scoliosis. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Section Cervical Spine Res Soc 22(Suppl 2):S242–S253. doi:10.1007/s00586-012-2426-5

    Article  Google Scholar 

  4. Caputo AM, Michael KW, Chapman TM, Jennings JM, Hubbard EW, Isaacs RE, Brown CR (2013) Extreme lateral interbody fusion for the treatment of adult degenerative scoliosis. J Clin Neurosci Off J Neurosurgery Soc Austral 20:1558–1563. doi:10.1016/j.jocn.2012.12.024

    Google Scholar 

  5. Paulino CPA, Carrer A (2010) Anatomical considerations for the extreme lateral (XLIF) approach. Curr Orthop Pract 21:7

    Article  Google Scholar 

  6. Ozgur BM, Agarwal V, Nail E, Pimenta L (2010) Two-year clinical and radiographic success of minimally invasive lateral transpsoas approach for the treatment of degenerative lumbar conditions. SAS J 4:41–46. doi:10.1016/j.esas.2010.03.005

    Article  PubMed  PubMed Central  Google Scholar 

  7. Dakwar E, Vale FL, Uribe JS (2011) Trajectory of the main sensory and motor branches of the lumbar plexus outside the psoas muscle related to the lateral retroperitoneal transpsoas approach. J Neurosurg Spine 14:290–295. doi:10.3171/2010.10.SPINE10395

    Article  PubMed  Google Scholar 

  8. Uribe JS, Arredondo N, Dakwar E, Vale FL (2010) Defining the safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: an anatomical study. J Neurosurg Spine 13:260–266. doi:10.3171/2010.3.SPINE09766

    Article  PubMed  Google Scholar 

  9. Moro T, Kikuchi S, Konno S, Yaginuma H (2003) An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine 28:423–428. doi:10.1097/01.BRS.0000049226.87064.3B (discussion 427–428)

  10. Regev GJ, Chen L, Dhawan M, Lee YP, Garfin SR, Kim CW (2009) Morphometric analysis of the ventral nerve roots and retroperitoneal vessels with respect to the minimally invasive lateral approach in normal and deformed spines. Spine 34:1330–1335. doi:10.1097/BRS.0b013e3181a029e1

    Article  PubMed  Google Scholar 

  11. Benglis DM, Vanni S, Levi AD (2009) An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. J Neurosurg Spine 10:139–144. doi:10.3171/2008.10.SPI08479

    Article  PubMed  Google Scholar 

  12. Park DK, Lee MJ, Lin EL, Singh K, An HS, Phillips FM (2010) The relationship of intrapsoas nerves during a transpsoas approach to the lumbar spine: anatomic study. J Spinal Disorders Techniq 23:223–228. doi:10.1097/BSD.0b013e3181a9d540

    Article  Google Scholar 

  13. Banagan K, Gelb D, Poelstra K, Ludwig S (2011) Anatomic mapping of lumbar nerve roots during a direct lateral transpsoas approach to the spine: a cadaveric study. Spine 36:E687–E691. doi:10.1097/BRS.0b013e3181ec5911

    Article  PubMed  Google Scholar 

  14. Davis TT, Bae HW, Mok JM, Rasouli A, Delamarter RB (2011) Lumbar plexus anatomy within the psoas muscle: implications for the transpsoas lateral approach to the L4–L5 disc. J Bone Joint Surg Am 93:1482–1487. doi:10.2106/JBJS.J.00962

    Article  PubMed  Google Scholar 

  15. Guerin P, Obeid I, Gille O, Bourghli A, Luc S, Pointillart V, Cursolle JC, Vital JM (2011) Safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: a morphometric study. Surg Radiol Anat SRA 33:665–671. doi:10.1007/s00276-011-0798-6

    Article  PubMed  Google Scholar 

  16. Lu S, Chang S, Zhang YZ, Ding ZH, Xu XM, Xu YQ (2011) Clinical anatomy and 3D virtual reconstruction of the lumbar plexus with respect to lumbar surgery. BMC Musculoskel Disorders 12:76. doi:10.1186/1471-2474-12-76

    Article  Google Scholar 

  17. Guerin P, Obeid I, Bourghli A, Masquefa T, Luc S, Gille O, Pointillart V, Vital JM (2012) The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach. Surg Radiol Anat SRA 34:151–157. doi:10.1007/s00276-011-0881-z

    Article  PubMed  Google Scholar 

  18. Yusof MI, Nadarajan E, Abdullah MS (2014) The morphometric study of l3-L4 and L4-L5 lumbar spine in Asian population using magnetic resonance imaging: feasibility analysis for transpsoas lumbar interbody fusion. Spine 39:E811–E816. doi:10.1097/BRS.0000000000000368

    Article  PubMed  Google Scholar 

  19. Rodgers WB, Gerber EJ, Patterson J (2011) Intraoperative and early postoperative complications in extreme lateral interbody fusion: an analysis of 600 cases. Spine 36:26–32. doi:10.1097/BRS.0b013e3181e1040a

    Article  PubMed  Google Scholar 

  20. Ahmadian A, Deukmedjian AR, Abel N, Dakwar E, Uribe JS (2013) Analysis of lumbar plexopathies and nerve injury after lateral retroperitoneal transpsoas approach: diagnostic standardization. J Neurosurg Spine 18:289–297. doi:10.3171/2012.11.SPINE12755

    Article  PubMed  Google Scholar 

  21. Houten JK, Alexandre LC, Nasser R, Wollowick AL (2011) Nerve injury during the transpsoas approach for lumbar fusion. J Neurosurg Spine 15:280–284. doi:10.3171/2011.4.SPINE1127

    Article  PubMed  Google Scholar 

  22. Lehmen JA, Gerber EJ (2015) MIS lateral spine surgery: a systematic literature review of complications, outcomes, and economics. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Section Cervical Spine Res Soc 24(Suppl 3):287–313. doi:10.1007/s00586-015-3886-1

    Article  Google Scholar 

  23. Grimm BD, Leas DP, Poletti SC, Johnson DR 2nd (2014) Postoperative Complications Within the First Year After Extreme Lateral Interbody Fusion: Experience of the First 108 Patients. J Spinal Disorders Techn. doi:10.1097/BSD.0000000000000121

    Google Scholar 

  24. O’Brien J, Haines C, Dooley ZA, Turner AW, Jackson D (2014) Femoral nerve strain at L4–L5 is minimized by hip flexion and increased by table break when performing lateral interbody fusion. Spine 39:33–38. doi:10.1097/BRS.0000000000000039

    Article  PubMed  Google Scholar 

  25. Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M, Wehrenberg U (2015) Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia. Hernia J Hernias Abdominal Wall Surg 19:539–548. doi:10.1007/s10029-015-1396-z

    Article  CAS  Google Scholar 

  26. Geh N, Schultz M, Yang L, Zeller J (2015) Retroperitoneal course of iliohypogastric, ilioinguinal, and genitofemoral nerves: a study to improve identification and excision during triple neurectomy. Clin Anat 28:903–909. doi:10.1002/ca.22592

    Article  PubMed  Google Scholar 

  27. Buric J (2015) Relationship between psoas muscle dimensions and post operative thigh pain. A possible preoperative evaluation factor. International journal of spine surgery 9:27. doi:10.14444/2027

  28. He L, Kang Z, Tang WJ, Rong LM (2015) A MRI study of lumbar plexus with respect to the lateral transpsoas approach to the lumbar spine. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Section Cervical Spine Res Soc. doi:10.1007/s00586-015-3847-8

    Google Scholar 

  29. Bendersky M, Sola C, Muntadas J, Gruenberg M, Calligaris S, Mereles M, Valacco M, Bassani J, Nicolas M (2015) Monitoring lumbar plexus integrity in extreme lateral transpsoas approaches to the lumbar spine: a new protocol with anatomical bases. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Section Cervical Spine Res Soc 24:1051–1057. doi:10.1007/s00586-015-3801-9

    Article  Google Scholar 

  30. Uribe JS, Isaacs RE, Youssef JA, Khajavi K, Balzer JR, Kanter AS, Kuelling FA, Peterson MD, Group SDS (2015) Can triggered electromyography monitoring throughout retraction predict postoperative symptomatic neuropraxia after XLIF? Results from a prospective multicenter trial. Euro Spine J Off Publ Euro Spine Soc Euro Spinal Deform Soc Euro Section Cervical Spine Res Soc 24(Suppl 3):378–385. doi:10.1007/s00586-015-3871-8

    Google Scholar 

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Acknowledgments

The authors of this work thank Dr Enrico Mandelli (M.S.) for his statistical support.

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Authors and Affiliations

  1. Department of Neurosurgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy

    Carlo Mandelli, Elena Virginia Colombo, Giovanni Marco Sicuri & Pietro Mortini

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  1. Carlo Mandelli
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  2. Elena Virginia Colombo
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  3. Giovanni Marco Sicuri
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  4. Pietro Mortini
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Corresponding author

Correspondence to Carlo Mandelli.

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The authors declare that they have no conflict of interest.

Funding

NuVasive Inc. funded the study providing the cadavers and the laboratory facilities.

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Mandelli, C., Colombo, E.V., Sicuri, G.M. et al. Lumbar plexus nervous distortion in XLIF® approach: an anatomic study. Eur Spine J 25, 4155–4163 (2016). https://doi.org/10.1007/s00586-016-4617-y

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  • DOI: https://doi.org/10.1007/s00586-016-4617-y

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