To determine if lumbarized sacra at the L5-6 level (functional L4-5) are a contraindication to a lateral transpsoas approach.
Transitional vertebrae at the lumbosacral junction present mechanical and morphologic changes, though these changes have not been characterized with respect to the feasibility of a lateral transpsoas approach.
Three hundred fifty-one patients were scheduled for lumbar interbody fusion using a mini-open lateral transpsoas approach (XLIF) at L4-5 from 2004 to 2008 at a single institution. In patients with 6 lumbar vertebrae, accessibility, based on neuromonitoring, of the L5-6 level (functional L4-5) was reviewed. Qualitative assessments using axial magnetic resonance imaging (MRI) were performed and compared with a sample of patients with normal anatomy treated at L4-5.
Of the 351 patients scheduled for treatment at L4-5, 10 (2.8%) were determined to have 6 lumbar vertebrae with the symptomatic level at L5-6. Of those 10, 2 (20%) could be treated using a lateral transpsoas approach, and 8 (80%) were converted to another approach after a corridor through the psoas muscle was not found, based on neuromonitoring feedback. Review of axial MRI showed a teardrop-shaped psoas detached from the lateral border of the disc space in patients with transitional anatomy unapproachable at L5-6, resemblant of L5-S1 in normal anatomy. In the 2 patients who could be safely approached, the psoas anatomy at L5-6 was similar to a normal L4-5 level, with a domed/helmet shape, attached laterally to the disc space.
Treating the L5-6 level using a lateral transpsoas approach in individuals with lumbarized sacra can be challenging due to anatomy more similar to the L5-S1 level in normal patients. Preoperative planning using axial MRI and intraoperative adherence to advanced neuromonitoring can aid in identifying and avoiding injury in these rare patients.
*Western Regional Center for Brain and Spine Surgery
†University Medical Center
‡NNI Research Foundation, Las Vegas, NV
§Durango Orthopedic Associates, P.C./Spine Colorado, Durango, CO
∥South Florida Spine Institute, Miami Beach, FL
Sources of support or funding (including NIH, Wellcome Trust, Howard Hughes Medical Institute, and others): None.
Reprints: William D. Smith, MD, Neurosurgery, University Medical Center, 1800 W. Charleston, Las Vegas, NV 89102 (e-mail: firstname.lastname@example.org).
Received February 7, 2011
Accepted April 5, 2011