Morphometric Analysis of the Ventral Nerve Roots and Retroperitoneal Vessels with Respect to the Minimally Invasive Lateral Approach in Normal and Deformed Spines

Study Design: A morphometric analysis, using magnetic resonance imaging (MRI) studies of the lumbar spine.

Objective: To identify the anatomic position of the ventral root and the retroperitoneal vessels in relation to the vertebral body in normally aligned and deformed spines.

Summary Of Background Data: The lateral approach to the lumbar spine is a relatively new method for performing interbody fusions. In contrast to the standard open anterior approach with direct vision of the operative field, the lateral approach uses expandable retractors that are positioned under fluoroscopic guidance. Risks of this technique include injury to the exiting nerve root and retroperitoneal vessels.

Methods: One hundred lumbar spine MRI studies were reviewed from patients treated for various spinal pathologies. The measured intervertebral segments were divided into 3 groups: group 1 (n = 247), normally aligned vertebrae and disc spaces; group 2 (n = 18), degenerative spondylolisthetic segments; and group 3 (n = 19), segments from the apex of degenerative lumbar scoliosis. Axial MR images were used to measure: the vertebral endplate anterior-posterior (AP) diameter, the overlap between the ventral root and the posterior margin of the vertebra, and the overlap between the retroperitoneal large vessels and the anterior edge of the vertebra.

Results: The overlap between the adjacent neuro-vascular structures and the vertebral body endplate gradually increased from L1-L2 to L4-L5. The maximal overlap, at the L4-L5 level reached 87% resulting in a relatively narrow corridor for performing the operative procedure. Alteration in the anatomic location of the nerve root and the retroperitoneal vessels, in Group 3 (scoliosis) further decreased the safe corridor.

Conclusion: The safe corridor for performing the discectomy and inserting the intervertebral cage narrows from L1-L2 to the L4-L5 level. This corridor is further narrowed with rotatory deformity of the spine. Using the preoperative MRI to assess the relative position of the adjacent neuro-vascular structures in relation to the lower vertebra's endplate at each level is recommended.