Summary
Anterior lumbar spine approaches may be indicated for fusion in degenerative lumbar spine disorders or to fill discal and bone gaps after fracture reduction. We present an anterior extraperitoneal approach applicable to any discal and vertebral levels from T12 to S1. The anatomic study, based on 25 cadavers, highlights retroperitoneal dissection principles for easy kidney and duodenopancreatic mobilisation and direct left anterior access to the entire lumbar spine. We established a precise description of the lumbar veins and the anastomoses between the left renal vein and hemiazygos system, in order to define different topographic and anatomic factors related to safe and easily reproducible approaches for cage or graft implementation. Independent of the level and previous intraperitoneal surgery, lumbar spine access with this approach safeguards the kidney, ureter, spleen, hypogastric plexus and duodenopancreatic system. Regarding operating time, bloodloss and possibilities for freshening and grafting, this technique seems an effective counterbalance to the difficulties and complex technology of endoscopic approaches. The clinical study includes our first 42 cases in traumatic and degenerative lesions. Avoiding the neurologic or hemorrhagic risk inherent in classical posterior lumbar interbody fusion (PLIF) techniques, it can be considered as a reasonable and valid alternative. This technique could be used in the near future for mini invasive discal prosthesis insertion.
Résumé
Les abords antérieurs du rachis lombaire sont pratiqués pour l'obtention d'une fusion dans les cas de rachis dégénératif mais également pour combler des pertes de substance osseuse ou des vides discaux après les réductions de fracture. Nous présentons un abord antérieur extra-péritonéal applicable pour n'importe lequel des niveaux discaux et vertébraux de T12 à S1. L'étude anatomique basée sur 25 cadavres met en évidence les principes de la dissection rétropéritonéale pour une mobilisaion facile du rein et du bloc duodéno-pancréatique et un abord direct antéro-latéral gauche du rachis. Nous avons établi une description précise des veines lombaires et des anastomoses entre la veine rénale gauche et le système hémi-azygos dans l'optique de définir les différents facteurs topographiques et anatomiques indispensables à connaître pour un abord simple sécurisé et reproductible, et pour l'introduction de cages ou de greffes intersomatiques. Indépendamment du niveau à atteindre et des antécédents de chirurgie intra-péritonéale préalable, l'abord du rachis lombaire par cette technique ne pose pas de problème concernant le rein, l'uretère, la rate, le plexus hypogastrique et l'ensemble duodéno-pancréatique. Pour ce qui concerne la durée opératoire, le saignement et les possibilités d'avivement et de greffe, cette technique semble contrebalancer sérieusement les difficultés et la technologie complexe des abords endoscopiques. L'étude clinique rapporte nos 42 premiers cas de pathologie traumatique et dégénérative. Evitant le risque neurologique ou hémorragique inhérent aux techniques classiques de fusion intersomatique lombaire par voie postérieure, cet abord peut être considéré comme une alternative raisonnable et efficace. Cette technique pourrait être utilisée dans le futur proche pour l'insertion “mini-invasive” des prothèses discales.
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Lazennec, J.Y., Pouzet, B., Ramare, S. et al. Anatomic basis of minimal anterior extraperitoneal approach to the lumbar spine. Surg Radiol Anat 21, 7–15 (1999). https://doi.org/10.1007/BF01635046
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DOI: https://doi.org/10.1007/BF01635046