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Chapter 12

Surgical Exposure/Anatomy of
the Lateral Lumbar Spine and Plexus
Seth B. Hayes and Allan D. Levi*
Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida, USA.
*Corresponding author: e-mail: ALevi@med.miami.edu

INTRODUCTION the abdominal musculature fascia develops into the anterior


and posterior rectus sheath. Deep to the muscular layer is
The retroperitoneal space provides access to the lumbar the transversalis fascia and retroperitoneal space. In the pos-
plexus, origin and course of peripheral nerves, and the lateral terior abdominal wall, the psoas major muscle lies directly
lumbar spine as well as the ventrolateral spinal canal. Surgical along the lumbar spine. Lateral to the psoas major is the
approaches to this region have evolved over time, minimizing quadratus laborum and the iliacus muscle inferiorly (Lee,
tissue destruction and utilizing neurophysiological monitoring Ravinutala, & Garfin, 2011).
in order to decrease the risk of nerve injury. The lateral retro-
peritoneal transpsoas approach to the lumbar spine has become
an acceptable and at times preferred approach for a variety of Retroperitoneum
operative indications requiring access to the anterolateral The retroperitoneum is part of the extraperitoneal com-
lumbar spinal column. The development of this technique partment between the diaphragm and subperitoneal pelvic
has advanced clinically relevant anatomical knowledge. This space. It is located between the parietal peritoneum and
pathway offers several advantages when compared to tradi- muscular fascia. This extraperitoneal space actually sur-
tional open anterolateral approaches including the avoidance rounds the abdominal cavity circumferentially. Along the
of dissection around major retroperitoneal vessels, most vis- posterior abdominal wall, the retroperitoneal space is bor-
ceral abdominal structures, and it minimizes soft tissue dered by the fascia of the diaphragm (superiorly), psoas,
destruction. These favorable conditions allow the procedure quadratus lumborum (posteriorly), and transversalis fascia
to be performed without an approach surgeon. The major risk (laterally). The extraperitoneal space extends anteriorly as
is injury to the lumbar plexus—its branches both in the intra- the preperitoneal space, which is located between the par-
and extrapsoas compartments. In order to safely incorporate tietal peritoneum and transversalis fascia. The retroperi-
the lateral retroperitoneal approach into one’s surgical arsenal, toneal can be compartmentalized into three zones. The
the clinical anatomy of the lumbar spine and plexus, and their borders, vascular, and visceral contents of these zones
relationship to key structures, must be mastered. In this can be found in Table 12.1 (Mirilas & Skandalakis, 2010a).
chapter, we review the anatomy and critical relationships of
this surgical corridor with an emphasis on minimally invasive
lateral approaches. Following the anatomical discussion, sur- Lumbar Plexus and Lateral Spine
gical techniques will be reviewed. The lumbar plexus originates from the anterior divisions of
the first four lumbar nerve roots and may have contributions
from T12 (subcostal nerve). It is located in the retroperi-
CLINICAL ANATOMY OF THE LATERAL toneum traveling in the posterior portion of the psoas major
LUMBAR SPINE AND LUMBAR PLEXUS muscle, anterior to the transverse processes. The plexus
gives rise to six peripheral nerves and direct muscular
Abdominal Wall branches to the psoas major, qudratum labordum, illiacus,
The lateral abdominal wall consists of the skin, subcuta- and lumbar intertransverse muscles. The nerves of the
neous fascia, and muscular layers. The three muscular lumbar plexus include the illiohypogastric, illioinguinal,
layers are composed of the external oblique, internal genitofemoral, lateral femoral cutaneous, obturator, and
oblique, and transversus abdominis muscles. Medially, femoral. The first lumbar nerve root (ventral) receives a

Nerves and Nerve Injuries, Vol. 2. http://dx.doi.org/10.1016/B978-0-12-802653-3.00061-0


© 2015 Elsevier Ltd. All rights reserved. 169
170 PART II Surgical Exposure of the Peripheral Nerves

TABLE 12.1 Retroperitoneal Zones

Zone I (Central) II (Lateral: Right/Left Flank) III (Pelvic)


Borders Upper: diaphragm, aortic, Upper: diaphragm Anterior: retropubic space
esophageal entry Lower: iliac crest Posterior: sacrum
Lower: sacral promontory Lateral: lateral abdominal wall Lateral: bony pelvis
Lateral: psoas Medial: psoas
Contents Abdominal aorta, inferior vena Kidney (vascular structures, ureters), hepatic and Pelvic wall, illiac vessels,
cava, iliac vessels, pancreas, splenic flexure of ascending and descending colon, retrosigmoid colon, part of
partial duodenum respectively; lumbar plexus and nerves urogenital organs

branch from the subcostal nerve (T12) and then bifurcates internal and external oblique muscles and fascia providing
into an upper branch, which further divides into the illiohy- sensory branches to the anterolateral gluteal region. The
pogastric and illioinguinal nerves, and a lower branch that anterior cutaneous branch runs between the two oblique
joins the L2 ventral ramus forming the genitofemoral nerve. muscles from approximately 2-3 cm medial to the anterior
Ventral rami from L2 to L4 combine to form an anterior superior iliac spine (ASIS) until it exits above the super-
branch, the obturator nerve, and a larger posterior branch ficial inguinal ring to supply the skin overlying the pubis.
that gives rise to the larger femoral nerve. Smaller posterior
branches from L2 to L3 give rise to the lateral femoral cuta-
neous nerve (Figure 12.1) (Mirilas & Skandalakis, 2010b). Illioinguinal Nerve (L1)
Course: In a similar but inferior path, this nerve exits the
Iliohypogastric Nerve (T12, L1, or L1 Only) lateral psoas and travels obliquely along the quadratus
Course: This nerve exits the upper lateral border psoas laborum muscle piercing the transversalis fascia at the
running obliquely along the quadratus laborum behind anterior iliac crest. It may give branches to the transversus
the lower pole of the kidney. It then penetrates the transver- abdominis and internal oblique muscles on its way to enter
salis fascia above the iliac crest. The nerve passes between the inguinal canal. The nerve then exits the superficial
the transversus muscle and internal oblique (innervating inguinal ring innervating the scrotum and root of the penis
both) and branches into anterior and lateral cutaneous in males or mons pubis and labia majoris in females
branches. The lateral cutaneous branch traverses the

Genitofemoral Nerve (L1, L2)


Course: Following its formation in the psoas muscle, this
nerve exits through the anterior surface of the psoas muscle
near its medial border (L3 or L4 vertebral body level). The
nerve then travels along the psoas dividing into the genital
and femoral branch.
Genital branch: Enters the inguinal canal and gives off
branches to part of the scrotum and cremasteric muscle.
Femoral branch: Passes under the inguinal ligament,
enters the femoral sheath, and provides cutaneous branches
to the femoral triangle.

Lateral Femoral Cutaneous Nerve (L2, L3)


Course: At approximately the level of the L4 vertebra, this
nerve exits lateral to the psoas muscle running obliquely
FIGURE 12.1 Artist’s diagram demonstrating a 3D appearance of the across the iliacus muscle toward the ASIS. The nerve passes
lumbosacral plexus with red indicating the nerves and their location, which
under or traverses the inguinal ligament approximately
are at risk with lateral approaches to the retroperitoneum, including open
and minimally invasive approaches. (a) Subcostal, (b) illiohypogastric, 1 cm medial to the ASIS. It then penetrates or crosses
(c) illioinguinal, (d) lateral femoral cutaneous, (e) genitofemoral, and anterior to the sartorius muscle giving sensory branches
(f) femoral nerve. to the anterolateral thigh.
Lateral Lumbar Spine and Plexus Chapter 12 171

Obturator Nerve (L2, L3, L4 Anterior Divisions) at risk of injury using the minimally invasive lateral
Course: After traveling with the muscle, this nerve exits the approach to the spine include the subcostal, iliohypogastric,
medial psoas as it enters the pelvis. Along its path to the illioinguinal, genitofemoral, lateral femoral cutaneous
obturator foramen, the nerve passes behind the common nerves, and femoral nerves (Figure 12.1). This is consistent
iliac and lateral to the internal iliac vessels. It continues with the previous anatomical review of the nerves of the
through the obturator foramen with obturator vessels and lumbar plexus, as the iliogypogastric, ilioinguinal, and
innervates the obturator externus, pectineus, adductor lateral femoral cutaneous nerves course within the muscle
longus, adductor magnus, and gracilis. Sensory branches of the abdominal wall, and the lateral femoral cutaneous
supply the medial thigh, hip, and knee joints. Its course is nerve passes along the posterior abdominal wall. In addition,
such that it is not at risk with the minimally invasive lateral this study recognizes the subcostal nerve (T12) as a critical
approach. structure within the abdominal wall, its anatomical course,
and clinical significance. The subcostal nerve courses
below the twelfth rib, crosses the superior quadratus labo-
Femoral Nerve (L2, L3, L4 Posterior Divisions) rum, pierces the transversalis fascia, and courses within
Course: After coursing within the medial portion of the the abdominal musculature to the rectus abdominis muscle.
psoas muscle, this nerve emerges laterally coursing Along its course, the subcostal nerve innervates the external
between the psoas and iliacus muscles. The nerve then oblique and rectus abdominis muscles, while giving off
enters the femoral canal within the femoral sheath just cutaneous branches supplying the lateral and anterior
lateral to the femoral artery. The femoral nerve then inner- abdominal wall. When performing a lateral retroperitoneal
vates the iliopsoas, all segments of the quadriceps (femoris) approach to the lumbar spine, the authors recommend using
muscle, the sartorius, and pectineus muscles; sensory blunt dissection through the abdominal musculature and
branches supply the anterior and medial thigh, medial leg retroperitoneal space with the intention of identifying and/
(saphenous nerve), and hip/knee joints. or avoiding these traversing nerves at risk. Within the
Refer to Table 12.2 for the origin and distribution of the retroperitoneal space they recommend manipulation from
nerves of the lumbar plexus. posterior to anterior and superior to inferior until the
Although the lumbar plexus and nerves within the psoas transverse process and psoas muscle are identified.
muscle are known to be at risk when approaching the lateral When approaching the retroperitoneal space in the
lumbar spine, the risk of extrapsoas injury to these nerves lateral decubitus position, the layer of adipose tissue above
must also be recognized. Several authors have described the psoas muscle is bordered by the diaphragm superiorly,
nerves that are at risk of injury (Benglis, Vanni, & Levi, the pelvic retroperitoneal space inferiorly, the quadratus
2009; Dakwar, Vale, & Uribe, 2011) using a cadaveric laborum and illiacus posteriorly, and the peritoneum and
model by dissecting the nerves of the lateral and posterior abdominal contents anteriorly. Identification of the neural
abdominal wall in the lateral decubitus position. The nerves elements of the lumbar nerve roots, plexus, and peripheral

TABLE 12.2 Nerves of the Lumbar Plexus

Nerve Origin Motor Innervation Sensory Distribution


Illiohypogastric T12, L1 Transversus abdominus, internal oblique Anterolateral gluteal, pubis
Illioinguinal L1 Transversus abdominus, internal oblique Scrotum/root penis (males); mons pubis/labia
majora (females)
Genitofemoral L2, L3 Cremaster (males) Genital branch: scrotum; femoral branch:
inguinal (above femoral triangle)
Lateral femoral L2, L3 None Anterolateral thigh
cutaneous
Obturator L2, L3, L4 Obturator externus, pectineus, adductor Medial thigh, hip, and knee joints
longus, adductor magnus, gracilis

Femoral L2, L3, L4 Iliopsoas, quadriceps femoris, sartorius, and Anterior and medial thigh, medial leg
pectineus muscles (saphenous nerve), and hip/knee joints

Direct T12-L4 Psoas major, quadratus lumborum, iliacus, None


muscular lumbar intertransverse
branches
172 PART II Surgical Exposure of the Peripheral Nerves

nerves can be extraordinarily difficult in this position. midpoint of zone III (middle posterior quarter) except the
Special consideration must be taken to identify reliable genitofemoral nerve and intrinsic muscular branches to
landmarks and relationships. the psoas at L2-L3, L3-L4, and L4-L5. They further iden-
Numerous cadaveric and radiographic studies have been tified the location of the nerves of the lumbar plexus with
performed in order to better define anatomic relationships respect to the four-zone model. The sensory nerves
and safe entry points in order to avoid neural elements including the illiohypogastric (L1), illioinguinal (L1), and
during surgical approaches. Utilizing cross-sectional ana- lateral femoral cutaneous nerve (L2, L3) remain in zone
tomical and 3D models in cadavers, Lu et al. described per- IV, exiting the psoas muscle posterolaterally and obliquely
tinent anatomical findings. In their study, axial cuts at traversing the retroperitoneal space along the quadratum
sequential levels of the lumbar spine showed that the labordum and illiacus, reaching the iliac crest. However,
lumbar plexus was consistently located in the posterior third the genitofemoral nerve (L1, L2) passes anterior obliquely
of the psoas major muscle from L2 to L5. They also found in zone II at the L2-L3 disc space and is located in zone I
that the angle of the exiting nerve root increased in a des- at the L3-L4 and L4-L5 spaces. The femoral and obturator
cending fashion, from 20.4  4.1 at L1 to 32.9  4.4 nerves (L2-L4) were located in zones III and IV at the
at L5. The authors concluded that by entering the psoas L4-L5 disc space, never crossing the marker at the midpoint
muscle at the junction of the anterior and middle one-third, of zone III. Additionally, no major vascular structures
lumbar plexus injury may be avoided (Lu et al., 2011). were located in zones I-IV. In conclusion, the authors
In an attempt to better define safe working corridors and recommend mid-zone III entry at the L1-L2, L2-L3, and
prevent neural element injury, a cadaveric study was per- L3-L4 disc spaces, and entry at the junction of zones
formed in order to identify the relationship of the lumbar II-III (mid-vertebral body) at the L4-L5 space. These
plexus and distal nerves at each disc space. Benglis et al. entry points attempt to avoid the dorsal nerve roots,
(2009) used radiopaque wires and lateral fluoroscopy in plexus, and branches, while remaining posterior to the
combination with anatomical dissections in the lateral decu- genitofemoral nerve.
bitus position to identify the lumbar plexus and safe entry MRI studies have been performed in an attempt to
points at each disc space from L1 to L5. The authors calcu- confirm these findings and identify possible anatomical
lated the ratio of the distance of the lumbar plexus from the variations. Kepler, Bogner, Herzog, and Huang (2011) ret-
posterior vertebral body wall to the entire length of the disc. rospectively reviewed 43 lumbosacral MRIs in order to
The ratios at descending levels were 0 (L1-L2), 0.11 evaluate the neurovascular relationships to the lumbar disc
(L2-L3), 0.18 (L3-L4), and 0.28 (L4-L5). This finding spaces from L1 to L5. The study was designed to identify
showed that as the lumbar plexus descends along the lumbar neurovascular structures located within 20 mm of the
vertebral bodies it migrates anteriorly. In this anatomical anterior aspect of the vertebral body. Axial MRIs were eval-
study, the lumbar plexus and major femoral nerve con- uated at each level and the location of the psoas muscle,
tributor, on average, were behind the 30-yard line or pos- lumbar plexus, femoral nerve, inferior vena cava, and right
terior to the anterior 70% of the entire disc space length; iliac vein were recorded in relation to the anterior vertebral
however, this represents an average distance or percentage line (anterior or posterior). Based on this model, they found
and at times they may reside even more anteriorly. This that at the L4-L5 level 44% of patients would require some
study concluded that the posterior placement of a dilator retraction of neurovascular structures with a right-sided
or retractor may increase the likelihood of injury to the approach and 21% of patients with a left-sided approach.
lumbar plexus. This is largely due to the posterior location of the right iliac
In a similar cadaveric study, Uribe, Arredondo, Dakwar, vein. In addition, three patients (7%) had a femoral nerve
and Vale (2010) combined an anatomical dissection with located less than 20 mm from the anterior vertebral line
lateral fluoroscopy and radiopaque markers in the lateral at the L4-L5 level. While this does not predict iatrogenic
decubitus position, attempting to verify safe disc space injury based on the need for retraction alone, it points out
entry points from L1 to L5. The authors divided the ver- the importance of evaluating individual patient anatomy
tebral body into four equal zones from anterior (zone I) and the theoretic utility of clinical adjuncts (e.g., neuro-
to posterior (zone IV). Radiographic markers were placed physiological monitoring) when approaching the lateral
demarcating each zone border. The psoas muscle, nerve spine and plexus.
roots, lumbar plexus, and peripheral nerves were dissected In a continuation of the previous study, Deukmedjian,
and the zones (I-IV) was recorded. They reported several Le, Dakwar, Martinez, and Uribe (2012) used similar
important findings. While slight anterior migration of the MRI methodology to measure the movement of the aorta,
plexus was noted as it descends the to L4-L5 interspace, IVC, iliac vessels, psoas muscle, and kidney in the right
the lumbar plexus remained in zone IV (posterior one- lateral decubitus (RLD) and left lateral decubitus (LLD)
quarter). The nerves pass obliquely traversing the psoas position. In regard to the minimally invasive lateral retro-
muscle. No neural element was identified anterior to the peritoneal approach, current industry recommendations
Lateral Lumbar Spine and Plexus Chapter 12 173

are to perform the surgery in the RLD position (left-sided In an attempt to capitalize on the advantages of mini-
approach). Various rationales have been described mally invasive surgery, avoid complications of the anterior
including right-handed surgeon preference, avoidance of lumbar approach, and reduce the necessity of an approach
the liver, and safer manipulation of arterial rather than surgeon, the lateral interbody fusion (trade names include
venous structures. This study intended to quantify XLIF (eXtreme Lateral Interbody Fusion) and DLIF (Direct
movement of critical structures during lateral positioning Lateral Interbody Fusion)) procedure was first described in
and determine if this may lead to safer access when com- 2006 (Ozgur, Aryan, Pimenta, & Taylor, 2006). Initially
paring the RLD vs. LLD position. They found that all struc- described for discectomy and interbody fusion, this lateral
tures moved anteriorly and out of the lateral surgical retroperitoneal, transpsoas approach has been modified and
corridor at the L1-L2 and L2-L3 disc spaces in both posi- utilized for a wide variety of surgical pathology including
tions. At the L3-L4 disc space, the IVC moved 1.1 mm pos- corpectomies for tumors and trauma (Arnold, Anderson,
terior along the vertebral body in the RLD position. At the & McGuire, 2012). The traditional open lateral approach
L4-L5 disc space, the right common iliac vein moved and less invasive techniques to access the lateral retroperi-
1.5 cm posteriorly in the RLD position and moved slightly toneal corridor, lumbar plexus, and lateral lumbar spine will
anterior in the LLD position. The kidneys move at least be discussed. Through various techniques, these approaches
2 cm anterior in both positions and the psoas muscle provide a corridor through the retroperitoneal space, pro-
remained fixed. Consistent with previous findings, the viding access to numerous pathologies of the lumbar plexus
psoas muscle increased in size and moves slightly anterior and spine.
from L1 to L5 (Hu et al., 2011). Because the aorta, IVC, and
kidneys move anterior and away from the surgical corridor
at the L1-L2 and L2-L3 disc space, the authors conclude ANTEROLATERAL RETROPERITONEAL
that the location of structures allows surgical preference APPROACH: OPEN
at these levels. Based on the trends of the posterior dis-
Preoperative Considerations
placement of the IVC at L3-L4 and right common iliac vein
at L4-L5 in the RLD position, the authors suggest that a The approach provides broad access to the psoas muscle,
right-sided approach (LLD) should be considered. lumbar plexus, and all lumbar vertebrae; however, the iliac
Multiple factors must be taken into account in each crest, vessels and the bulky girth of the psoas muscle limit
patient with regard to the laterality of patient position access to the lateral L5 vertebral body. Relative contra-
including the anatomy of the iliac crest, visceral organs, indications to this approach include prior retroperitoneal
location of the vessels, and coronal deformity. While surgery, infection, surgical site irradiation, morbid
these anatomical studies provide valuable quantitative obesity, abdominal aortic calcification, and retroperi-
data allowing for safer and less invasive access to the toneal fibrosis.
lumbar plexus and lateral spine, each patient must be
analyzed individually in order to recognize anatomical
variations, prevent iatrogenic injury, and optimize Technique
outcome. Positioning and Preparation
Under general anesthesia, the patient is placed in the RLD
position (left side up). A right axillary roll is placed along
SURGICAL APPROACH TO THE LATERAL with padding of all bony prominences, including pillows
LUMBAR SPINE AND PLEXUS between the legs. The left arm is extended and resting on
a pillow, paralleling the right arm. Taping or strapping
Traditionally, surgical access to the anterolateral lumbar
the torso above the costal margin and the iliac crest or
spine was performed through an open anterolateral, trans-
femoral head caudally then secures the position.
peritoneal, or retroperitoneal approach. Major complica-
tions occurring are related to the anatomical structures
traversed with these approaches, including bowel, uro- Incision
genital (ureteral, hypogastric plexus), and vascular injury. The appropriate level is identified with lateral fluo-
Technological advancements have led to the development roscopy, and the transverse or oblique incision is utilized
of less invasive lateral retroperitoneal approaches; however, depending on the target level and pathology. The posterior
the risk of serious morbidity inherent to this surgical cor- extent of the incision generally begins at the posterior
ridor remains (Baker, Reardon, Reardon, & Heggeness, axillary line. At the L1-L2 level, the incision starts approx-
1993; Flouzat-Lachaniette, Delblond, Poignard, & Allain, imately two levels cranial to the target level and is con-
2013; Quraishi et al., 2013; Rajaraman et al., 1999; tinued obliquely in the direction of the rib. The incision
Youssef et al., 2010). terminates at the lateral border of the rectus sheath above
174 PART II Surgical Exposure of the Peripheral Nerves

the midpoint of the umbilicus and costal margin. To LATERAL RETROPERITONEAL APPROACH:
expose the L2-L5 levels, a more inferior incision is uti- MINIMALLY INVASIVE LATERAL
lized from the posterior axillary line to the lateral rectus
RETROPERITONEAL TRANSPSOAS
sheath, between the costal margin and iliac crest. The
incision terminates between the costal margin and umbi- Preoperative Considerations
licus for L2-L3, at the umbilicus for L3-L4, and between
the umbilicus and iliac crest for L4-L5. Initiating the pos- This approach provides access from the thoracolumbar
terior extent of the incision superolateral to the ASIS and junction to the L4-L5 disc space. One can also grain access
remaining rostral and parallel to the iliac crest and inguinal through the retropleural space to the thoracic spine. The
ligament until reaching the lateral rectus sheath exposes psoas muscle, lumbar plexus, lumbar vertebral bodies,
the lumbosacral junction. and disc spaces are accessible utilizing these techniques.
A wide spectrum of pathological conditions can be
addressed, including a variety of lumbar degenerative dis-
Retroperitoneal Access/Approach eases, neoplasms, trauma, and infections (Arnold et al.,
The abdominal wall is first traversed to enter the retroper- 2012). In addition, a variety of procedures can be per-
itoneal space. A muscle-splitting approach involves formed, including but not limited to a biopsy, tumor
splitting the external oblique, internal oblique, and trans- resection, corpectomy, discectomy, or interbody graft
versals muscles along anatomical planes with blunt dis- placement. The approach to the L4-L5 level is the most
section. Anatomical dissection of the internal oblique challenging. The iliac crest may limit the ability to approach
limits exposure and may not be feasible depending on the this level, and risk of femoral nerve injury is greatest at this
pathology and surgical goals. Although usually not feasible level (Cahill, Martinez, Wang, Vanni, & Levi, 2012). A
during an open approach, the muscle-splitting approach subcostal nerve injury (Cahill et al., 2012) is more common
should be utilized when possible in an attempt to avoid with approaches at the upper lumbar disc space levels.
denervation, reduce pain, and promote healing. The flank Access is provided to the psoas muscle and its neural con-
approach follows the anatomical planes of the external tents, the lumbar vertebral bodies, and the disc spaces and
oblique and transversalis muscles, but transects the internal anterolateral canal.
oblique muscle in order to maximize exposure. The trans-
versals fascia is then identified and opened laterally at a
point where the peritoneum is thicker and less likely to Technique
be adherent. Retroperitoneal adipose tissue should be Position and Preparation (Figure 12.2)
apparent. Peritoneum is transparent gray and, if entered,
Under general endotracheal anesthesia, the patient is placed
should be immediately repaired primarily with nonab-
in the RLD position (left side up) with an axillary roll. Elec-
sorbable suture.
tromyography (EMG) leads are appropriately placed in both
The retroperitoneal plane is bluntly dissected
lower extremities. The left knee is flexed to minimize
approaching the lateral lumbar spine between the quad-
tension of the psoas muscle and lumbar plexus. The table
ratus laborum and psoas muscles posteriorly and the renal
can be slightly flexed and a bump/roll may be placed under
fascia anteriorly. A Deaver blade padded with a lap sponge
the flank in an attempt to increase the distance between the
can be used to retract the kidney anteriorly and a Buck-
walter retractor for craniocaudal retraction. Caution
should be taken to avoid retracting the genitofemoral
nerve, which exits the psoas muscle anteromedially at
the L3 level. Injury manifests as genital and inguinal dys-
esthesias. Additionally, the ureter should be retracted with
the retroperitoneal fat. The ureter can be identified with
visible peristalsis following gentle manipulation (Kelly’s
sign). During exposure of the upper lumbar spine,
resection of the T11 and T12 rib may be necessary to
access the L1 vertebral body. If the rostral L1 or caudal
T12 vertebral body are targeted, the diaphragmatic crus
may be divided from the anterior longitudinal ligament
and L1 transverse process. To prevent phrenic nerve injury
(arises medially), the diaphragm should be transected FIGURE 12.2 Lateral decubitus position (left side up). Positioning is
within 2 cm of the lateral margin (Harkey, Wiebe, & secured at the chest and illiac crest. Lateral fluoroscopy is utilized to
Schenk, 2006). outline the vertebral body of interest.
Lateral Lumbar Spine and Plexus Chapter 12 175

lower ribs and the iliac crest. At this point, a cross table retroperitoneal contents from the posterior abdominal wall.
anterior-posterior (AP) image confirms a true 90 position. Continuing the blunt dissection toward the lateral lumbar
The patient is then secured with a strap/tape across the rib spine, the psoas muscle is identified.
cage and femoral head. A radiopaque marker is placed on
the lateral abdominal wall and used to identify the planned Transpsoas Access
target at the appropriate level and anterior-posterior
Two-Incision Technique (Indirect)
position. The lateral skin incision is marked at this point.
The key to proceeding blindly through the psoas muscle is
the availability of stimulating serial dilators and EMG mon-
Retroperitoneal Access
itoring. The first dilator separates the psoas muscle fibers
Two-Incision Technique until reaching the desired disc space or vertebral body.
In the same plane as the direct lateral skin mark, a second While the lumbar plexus and femoral nerve are usually
horizontal incision (large enough to insert the surgeon’s located in the posterior one-third of the psoas muscle, the
index finger) is made posteriorly between the erector spinae entry varies slightly depending on the lumbar level. While
muscles and abdominal obliques. Blunt dissection using a continuing to monitor for evoked EMG responses, the
finger and scissors is used to gently penetrate the muscle dilators are sequentially placed until the maximal diameter
and fascia into the retroperitoneal space. Finger dissection is reached. At this point, a retractor is placed over the final
is used to sweep the peritoneum anteriorly and palpate the dilator and AP/lateral fluoroscopy is performed to confirm
psoas muscle posteriorly. At this point, the index finger that the retractor is abutting the lateral spine and perpendic-
should sweep up toward the direct lateral incision. The ularly seated. Under direct visualization and direct stimu-
direct lateral skin incision is made and a dilator is used to lation of the area exposed and adjacent areas, the retractor
penetrate the lateral abdominal wall. The index finger is gently expanded in a craniocaudal and anterior-posterior
guides the dilator through the retroperitoneal space to the direction if desired (Figures 12.4 and 12.5).
surface of the psoas muscle.
Mini-Open (Direct)
Mini-Open Technique (Figure 12.3) As with the two-incision technique, serial dilator with elec-
A 3-5 cm horizontal or oblique incision is made (depending trophysiological monitoring is performed. However, the
on the number of levels accessed) at the appropriate level psoas muscle and entry point can be directly visualized.
following the radiographically planned trajectory. The
abdominal wall musculature is split utilizing the same tech- Suprapsoas Docking
niques previously described under direct visualization. The
The retractor is docked along the surface of the psoas
transversalis fascia is then penetrated and the retroperi-
muscle. The psoas muscle is directly visualized and split
toneal space identified. At this point, the retroperitoneal
longitudinally using a Penfield 4. At this point, a small
adipose tissue is gently mobilized anterior, separating the
retractor is placed along the vertebral body in the medial-
lateral direction. Acosta, Drazin, and Liu (2013) described

FIGURE 12.4 Example of an expanded three blade retractor. One blade


is located posteriorly and the additional two blades are open in the cranio-
FIGURE 12.3 Mini-open incision and lateral abdominal wall dissection. caudal direction. The retractor is secured to a fixed arm attached to the
The retroperitoneal space is entered under direct vision. surgical bed.
176 PART II Surgical Exposure of the Peripheral Nerves

and peritoneal injury must be anticipated and avoided.


New postoperative sensory disturbances are common and
have been described in up to 60% of patients
(Cummock, Vanni, Levi, Yu, & Wang, 2011), with the
vast majority improving after a year (5.5% of patients with
residual thigh pain; all paresthesias resolved). Postoper-
ative abdominal flank bulging, also referred to as pseudo-
hernia, may occur if the subcostal nerve (T12) is injured
while traversing or closing the abdominal wall. In large
series, the risk has been reported to be between 1% and
4% (Ahmadian, Deukmedjian, Abel, Dakwar, & Uribe,
2013; Cahill et al., 2012; Dakwar, Le, et al., 2011;
Lykissas et al., 2014). Motor nerve injuries of the lumbar
plexus can lead to serious patient morbidity. While direct
FIGURE 12.5 Lateral fluoroscopy confirming the appropriate location injury to the psoas muscle is common and manifests as
and perpendicular orientation of the retractor system. transient hip flexion pain and weakness, femoral nerve
injury has been reported to occur in between 1% and
5% of cases (Cahill et al., 2012; Lykissas et al., 2014;
a small cohort of patients utilizing this technique. They Rodgers, Gerber, & Patterson, 2011). The risk of femoral
hypothesize that inadvertent injury to the peritoneum, nerve injury increases as lower lumbar levels are surgically
ureter, psoas, and lumbar plexus may be minimized by exposed. In addition to strategic entry points identified by
suprapsoas docking. anatomical studies, intraoperative EMG monitoring is uti-
lized in order to minimize motor nerve injury. It should be
noted that motor nerve injuries have been described in the
Modified Technique: Anterolateral Psoas absence of intraoperative monitoring signal abnormalities
Retraction (Houten, Alexandre, Nasser, & Wollowick, 2011;
Figures 12.6 and 12.7).
In an attempt to minimize lumbar plexus injury associated
with the transpsoas technique, an additional technique has
been described that utilizes a slightly anterior and oblique
approach. The incision is slightly anterior when compared
to the other minimally invasive approaches described. The
same techniques for retroperitoneal access are utilized; No pain
however, the entry point to the lateral lumbar spine is at
the anterior border of the psoas muscle, between the sym-
pathetic chain and anterior border of the psoas. The psoas
muscle is then dissected and retracted laterally along the
vertebral body creating a more oblique trajectory
through the disc space. At this time, only a small series
of patients has been described utilizing this novel tech-
nique (Aghayev & Vrionis, 2013). While preliminary data
support the theory of avoiding lumbar plexus injury,
inguinal pain and hip flexion weakness are commonly
reported secondary to psoas dissection. A larger number Left Left Right
Right
of patients and longer follow-up must be obtained before
the risk and value of this modified approach can be appro-
priately analyzed.

COMPLICATIONS
Any anatomical structure located in the lateral surgical
corridor is at risk during the traditional open and less
invasive procedures. Although injuries to neural elements FIGURE 12.6 Numbness in distribution of lateral femoral cutaneous
are well described, vascular, visceral (e.g., kidney, ureter), nerve in a postoperative patient after a minimally invasive lateral approach.
Lateral Lumbar Spine and Plexus Chapter 12 177

Dakwar, E., Le, T.V., Baaj, A.A., Le, A.X., Smith, W.D., Akbarnia, B.A.,
Uribe, J.S., 2011. Abdominal wall paresis as a complication of
minimally invasive lateral transpsoas interbody fusion. Neurosurgical
Focus 31 (4), E18.
Dakwar, E., Vale, F.L., Uribe, J.S., 2011. Trajectory of the main sensory
and motor branches of the lumbar plexus outside the psoas muscle
related to the lateral retroperitoneal transpsoas approach. Journal of
Neurosurgery: Spine 14 (2), 290–295.
Deukmedjian, A.R., Le, T.V., Dakwar, E., Martinez, C.R., Uribe, J.S.,
2012. Movement of abdominal structures on magnetic resonance
imaging during positioning changes related to lateral lumbar spine
surgery: A morphometric study: Clinical article. Journal of Neuro-
surgery: Spine 16 (6), 615–623.
Flouzat-Lachaniette, C.H., Delblond, W., Poignard, A., Allain, J., 2013.
Analysis of intraoperative difficulties and management of operative
complications in revision anterior exposure of the lumbar spine: A
report of 25 consecutive cases. European Spine Journal 22 (4),
766–774.
Harkey III, L.H., Wiebe, T.M., Schenk, M.P., 2006. Anterolateral
retroperitoneal approach to the lumbosacral spine. In: Fessler, R.G.,
Sekhar, L.N. (Eds.), Atlas of neurosurgical techniques: Spine and
peripheral nerves. Thieme Medical Publishers Inc., New York,
pp. 604–611.
Houten, J.K., Alexandre, L.C., Nasser, R., Wollowick, A.L., 2011. Nerve
FIGURE 12.7 Numbness in distribution of genitofemoral nerve in a dif- injury during the transpsoas approach for lumbar fusion. Journal of
ferent postoperative patient after a minimally invasive lateral approach. Neurosurgery: Spine 15 (3), 280–284.
Hu, W.K., He, S.S., Zhang, S.C., Liu, Y.B., Li, M., Hou, T.S., et al., 2011.
An MRI study of psoas major and abdominal large vessels with
respect to the X/DLIF approach. European Spine Journal 20 (4),
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Kepler, C.K., Bogner, E.A., Herzog, R.J., Huang, R.C., 2011. Anatomy of
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