Three-Dimensional Computed Tomographic Anatomy of the Abdominal Great Vessels Pertinent to L4-L5 Anterior Lumbar Interbody Fusion

Abstract

A recent accumulation of surgical and radiological literature has helped spine surgeons to better understand the anatomy and establish surgical trajectories to the anterior L4-L5 disc space. However, the preoperative display of anatomic data in individual subjects in the three-dimensional (3-D) mode has rarely been attempted. The objective of this study was to acquire 3-D images of the abdominal great vessels pertinent to the L4-L5 anterior lumbar interbody fusion (ALIF), and to better define the radiological vascular anatomy. The 3-D images of 100 subjects with non-spinal diseases, generated from abdominal computed tomography angiography (CTA), were analyzed retrospectively. The anatomy of the great vessels pertinent to the L4-L5 ALIF procedure was investigated by measuring the level of the abdominal aorta (AA) bifurcation and that of the inferior vena cava (IVC) confluence in relation to the lumbar vertebral body. These two complexes were segmented into upper or lower parts, or disc level. The visibility of the middle sacral artery (MSA) and the left L4 lumbar artery on the 3-D images was also assessed. The AA bifurcation level was above L4 in 4, at L4 in 55, at L4-L5 in 23, and at L5 in 18 subjects. The IVC confluence level was at L4 in 17, at L4-L5 in 14, at L5 in 68 and below L5 in 1 subject. Levels of the bifurcation of the AA/IVC as combined data showed that the AA bifurcation was usually located 1 - 2 segments above the IVC confluence. The MSA and L4 segmental artery were identified in 79 and 83 subjects, respectively. The 3-D images of the abdominal great vessels together with the lumbar spinal column were reliably depicted. Anatomic data obtained from this study are in accordance with those obtained from conventional 2-D studies, and the 3-D images can serve as a versatile tool for preoperative evaluation for the ALIF candidates and can contribute to the reduction of surgical time and perioperative vascular complications.

Abdominal aorta - inferior vena cava - three-dimensional (3-D) - L4-L5 anterior lumbar interbody fusion - vascular anatomy - complication

References

• 1 Boos N, Kalberer F, Schoeb O. Retroperitoneal endoscopically assisted minilaparotomy for anterior lumbar interbody fusion: technical feasibility and complications.  Spine. 2001;  26 E1-E6
• 2 Kaiser M G, Haid Jr R W, Subach B R, Miller J S, Smith C D, Rodts Jr G E. Comparison of the mini-open versus laparoscopic approach for anterior lumbar interbody fusion: a retrospective review.  Neurosurgery. 2002;  5 97-103
• 3 Kim D H, Jaikumar S, Kam A C. Minimally invasive spine instrumentation.  Neurosurgery. 2002;  51 (5 Suppl) 15-25
• 4 Kleeman T J, Michael Ahn D, Clutterbuck W B, Campbell C J, Talbot-Kleeman A. Laparoscopic anterior lumbar interbody fusion at L4-L5: an anatomic evaluation and approach classification.  Spine. 2002;  1 1390-1395
• 5 Regan J J, Aronoff R J, Ohnmeiss D D, Sengupta D K. Laparoscopic approach to L4-L5 for interbody fusion using BAK cages: experience in the first 58 cases.  Spine. 1999;  24 2171-2174
• 6 Zdeblick T A, David S M. A prospective comparison of surgical approach for anterior L4-L5 fusion: laparoscopic versus mini anterior lumbar interbody fusion.  Spine. 2000;  25 2682-2687
• 7 Kulkarni S S, Lowery G L, Ross R E, Ravi Sankar K, Lykomitros V. Arterial complications following anterior lumbar interbody fusion: report of eight cases.  Eur Spine J. 2003;  12 48-54
• 8 Oskouian Jr R J, Johnson J P. Vascular complications in anterior thoracolumbar spinal reconstruction.  J Neurosurg. 2002;  96 (1 Suppl) 1-5
• 9 Rajaraman V, Vingan R, Roth P, Heary R F, Conklin L, Jacobs G B. Visceral and vascular complications resulting from anterior lumbar interbody fusion.  J Neurosurg. 1999;  91 (1 Suppl) 60-64
• 10 Bianchi C, Ballard J L, Abou-Zamzam A M, Teruya T H, Abu-AssaI M L. Anterior retroperitoneal lumbosacral spine exposure: operative technique and results.  Ann Vasc Surg. 2003;  17 137-142
• 11 Capellades J, Pellise F, Rovira A, Grive E, Pedraza S, Villanueva C. Magnetic resonance anatomic study of iliocava junction and left iliac vein positions related to L5-S1 disc.  Spine. 2000;  25 1695-1700
• 12 Chithriki M, Jaibaji M, Steele R D. The anatomical relationship of the aortic bifurcation to the lumbar vertebrae: an MRI study.  Surg Radiol Anat. 2002;  24 308-312
• 13 Tribus C B, Belanger T. The vascular anatomy anterior to the L5-S1 disk space.  Spine. 2001;  26 1205-1208
• 14 Vraney R T, Phillips F M, Wetzel F T, Brustein M. Peridiscal vascular anatomy of the lower lumbar spine. An endoscopic perspective.  Spine. 1999;  24 2183-2187
• 15 Kornreich L, Hadar H, Sulkes J, Gomish M, Ackerman J, Gadoth N. Effect of normal ageing on the sites of aortic bifurcation and inferior vena cava confluence: a CT study.  Surg Radiol Anat. 1998;  20 63-68