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Anatomy of the Percutaneous Presacral Space for a Novel Fusion Technique

Yuan, Philip S. MD*; Day, Thomas F. BS; Albert, Todd J. MD; Morrison, William B. MD; Pimenta, Luiz MD§; Cragg, Andrew MD; Weinstein, Michael MD

Journal of Spinal Disorders & Techniques: June 2006 - Volume 19 - Issue 4 - p 237-241
doi: 10.1097/01.bsd.0000187979.22668.c7
Original Articles

Objectives Lumbar fusion has been widely used to treat unstable spinal disorders. Methods are evolving from open procedures to less invasive methods to avoid soft tissue trauma. Recently, a soft tissue sparing method to access the axial lumbosacral spine has been developed. It is crucial to determine structures potentially at risk for injury during this fusion technique. The anatomy of the presacral space and safety of the paracoccygeal approach were evaluated through cadaveric dissection and radiographic studies. The objective was to evaluate the safety of a paracoccygeal approach to the axial lumbosacral spine and determine structures that could potentially be injured.

Methods The paracoccygeal approach was performed on two cadavers, followed by dissection. Distances from the midline trajectory of the approach to surrounding vascular structures were determined. Similar distances were also measured on computed tomography (CT) and magnetic resonance imaging (MRI) of 12 patients, as well as CT images of two additional patients. A “safe zone” was determined using the sagittal length of the presacral space and the distance between the most medial internal iliac vessel on the right and left, respectively.

Results The coronal safe zone averaged 6.9 and 6.0 cm on MRI and CT, respectively. The mean distance from the anterior sacral margin to the rectum at the S3–S4 level was 1.2 and 1.3 cm on MRI and CT, respectively.

Conclusion In this study, we defined the “coronal safe zone” within the presacral space. This “safe zone” may guide surgeons when utilizing the percutaneous paracoccygeal approach.

*Memorial Orthopaedic Surgical Group, Long Beach, CA

Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Rothman Institute, Philadelphia, PA

Division of Diagnostic and Musculoskeletal Radiology, Thomas Jefferson University Hospital, Philadelphia, PA

§Santa Rita Hospital, Sao Paulo, Brazil

Department of Radiology, University of Minnesota, and Interventional Radiology, Minneapolis Vascular Institute, Edina, MN

Department of Surgery, Thomas Jefferson University Medical College, Philadelphia, PA

Received for publication May 24, 2005; accepted September 9, 2005

Reprints: Dr. T. J. Albert, Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Rothman Institute, 925 Chestnut St., Philadelphia, PA 19107 (e-mail:

© 2006 Lippincott Williams & Wilkins, Inc.