Lumbar Plexus Anatomy within the Psoas Muscle: Implications for the Transpsoas Lateral Approach to the L4-L5 Disc

2011 ◽  
Vol 93 (16) ◽  
pp. 1482-1487 ◽  
Author(s):  
Timothy T Davis ◽  
Hyun W Bae ◽  
MAJ James M Mok ◽  
Alexandre Rasouli ◽  
Rick B Delamarter
Keyword(s):  
Psoas Muscle ◽  
Lateral Approach ◽  
Lumbar Plexus ◽  
Transpsoas Lateral Approach

Minimally Invasive Lateral Retroperitoneal Approach for Resection of Extraforaminal Lumbar Plexus Schwannomas: Operative Techniques and Literature Review

2018 ◽  
Vol 15 (5) ◽  
pp. 516-521 ◽  
Author(s):  
Michael M Safaee ◽  
Christopher P Ames ◽  
Vedat Deviren ◽  
Aaron J Clark
Keyword(s):  
Minimally Invasive ◽  
Good Condition ◽  
Tumor Resection ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Lumbar Plexus ◽  
Retroperitoneal Approach ◽  
Transpsoas Approach ◽  
Lateral Interbody ◽  
Traditional Approaches

Abstract BACKGROUND Traditional approaches for retroperitoneal lumbar plexus schwannomas involve anterior open or laparoscopic resection. For select tumors, the lateral retroperitoneal approach provides a minimally invasive alternative. OBJECTIVE To describe a minimally invasive lateral transpsoas approach for the resection of retroperitoneal schwannomas. METHODS A lateral retroperitoneal transpsoas approach was used to resect a 3.1 × 2.7 × 4.1 cm schwannoma embedded within the psoas muscle. A minimally invasive retractor system allows for appropriate visualization and complete resection with the aid of the microscope. The patient tolerated the procedure without complication and was discharged on postoperative day 2 in good condition at her neurological baseline. RESULTS The lateral retroperitoneal approach provides a minimally invasive alternative for select retroperitoneal schwannomas. In theory, this procedure allows for faster recovery and less blood loss compared to traditional open anterior approaches. For a subset of tumors, anterior laparoscopy may provide better access, but the lateral approach is well known to most neurosurgeons who perform lateral interbody fusions and can be easily tailored to extraforaminal tumor resection. CONCLUSION Retroperitoneal schwannomas pose a challenge due to their deep location. The lateral retroperitoneal approach provides a useful alternative for resection of a subset of retroperitoneal schwannomas.

scholarly journals COMPARATIVE STUDY OF LUMBAR PLEXUS PATH ON THE LEFT AND RIGHT SIDES THROUGH THE PSOAS MUSCLE

2018 ◽  
Vol 17 (4) ◽  
pp. 262-265
Author(s):  
Emiliano Neves Vialle ◽  
Luiz Roberto Gomes Vialle ◽  
Letícia Cardoso Ern ◽  
Luis Miguel Duchén Rodríguez ◽  
Grover Coaquira Huayta ◽  
...  
Keyword(s):  
Psoas Muscle ◽  
Transverse Process ◽  
Lateral Approach ◽  
Anatomical Landmark ◽  
Wilcoxon Test ◽  
Lumbar Plexus ◽  
Level Of Evidence ◽  
Left And Right ◽  
The Mean ◽  
The Right

ABSTRACT Objective: Spine surgery with a minimally invasive lateral approach and validate possible anatomical differences between the right and left sides. Methods: Four measurements (cm) were taken on 38 cadavers: the distance between the lumbar plexus and the transverse process (L4-L5) and the distance between the lumbar plexus and the midline of the lumbar spine, both on the right and left sides. Results: The mean distance between the lumbar plexus and the transverse process of L4-L5 was 1.03 cm and the distance to the midline was 3.99 cm for the right side. The averages of the left side were 1.13 cm and 3.38 cm, respectively. There is statistical difference between the sides (p<0.05) using the non-parametric Wilcoxon test. Conclusions: The authors suggest that the transverse process might be used as an anatomical landmark to define the surgical approach through the psoas muscle. Level of Evidence IV; Cadaveric study.

Trajectory of the main sensory and motor branches of the lumbar plexus outside the psoas muscle related to the lateral retroperitoneal transpsoas approach

2011 ◽  
Vol 14 (2) ◽  
pp. 290-295 ◽  
Author(s):  
Elias Dakwar ◽  
Fernando L. Vale ◽  
Juan S. Uribe
Keyword(s):  
Minimally Invasive ◽  
Abdominal Wall ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Retroperitoneal Space ◽  
Lumbar Plexus ◽  
Pelvic Cavity ◽  
Abdominal Muscles ◽  
Transpsoas Approach ◽  
Risk Of Injury

Object The minimally invasive lateral retroperitoneal transpsoas approach is increasingly used to treat various spinal disorders. Accessing the retroperitoneal space and traversing the abdominal wall poses a risk of injury to the major nervous structures and adds significant morbidity to the procedure. Most of the current literature focuses on the anatomy of the lumbar plexus within the substance of the psoas muscle. However, there is sparse knowledge regarding the trajectory of the lumbar plexus nerves that travel along the retroperitoneum and abdominal wall muscles in relation to the lateral approach to the spine. The objective of this study is to define the anatomical trajectories of the major motor and sensory branches of the lumbar plexus that are located outside the psoas muscle. Methods Six adult fresh frozen cadaveric specimens were dissected and studied (12 sides). The relationship between the retroperitoneum, abdominal wall muscles, and the lumbar plexus nerves was analyzed in reference to the minimally invasive lateral retroperitoneal approach. Special attention was given to the lumbar plexus nerves that run outside of psoas muscle in the retroperitoneal cavity and within the abdominal muscle wall. Results The skin and muscles of the abdominal wall and the retroperitoneal cavity were dissected and analyzed with respect to the major motor and sensory branches of the lumbar plexus. The authors identified 4 nerves at risk during the lateral approach to the spine: subcostal, iliohypogastric, ilioinguinal, and lateral femoral cutaneous nerves. The anatomical trajectory of each of these nerves is described starting from the spinal column until their termination or exit from the pelvic cavity. Conclusions There is risk of direct injury to the main motor/sensory nerves that supply the anterior abdominal muscles during the early stages of the lateral retroperitoneal transpsoas approach while obtaining access to the retroperitoneum. There is also a risk of injury to the ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves in the retroperitoneal space where they travel obliquely during the blunt retroperitoneal dissection. Moreover, there is a latent possibility of lesioning these nerves with the retractor blades against the anterior iliac crest.

Inguinal Paravascular (Lumbar Plexus) Neurolytic Block—Description of a Catheter Technique: Case Report

1998 ◽  
Vol 23 (2) ◽  
pp. 214-218
Author(s):  
Abdullah M. Kaki ◽  
Geraint W. Lewis
Keyword(s):  
Case Report ◽  
Guide Wire ◽  
Femoral Nerve ◽  
Psoas Muscle ◽  
Pathologic Fracture ◽  
Sensory Block ◽  
Lumbar Plexus ◽  
Catheter Technique ◽  
Neurolytic Block ◽  
The Right

Background and ObjectivesWe provided care for a 47-year-old female with a history of lung carcinoma and bony metastases who sustained a pathologic fracture of the right acetabulum causing severe and uncontrolled pain in the right groin. Her pain was rated as 8-10 on a 10-point visual analog scale (VAS). Her terminal disease and poor surgical risk precluded therapeutic operative intervention. Consequently, a neurolytic block of the lumbar plexus was performed as a palliative measure.MethodsA modified inguinal paravascular (lumbar plexus) block technique was used. A 17-gauge Tuohy needle was inserted in the groin area just lateral to femoral artery and 1 cm below the inguinal ligament. A guide wire was threaded through the needle and subsequently an angiogram catheter was introduced over the wire into the psoas muscle. Radiographic confirmation of the position was obtained, and the catheter was secured in place. A prognostic block using an infusion of 0.25% bupivacaine at 5 mL/h was initiated for the first 2 days. On the third day a neurolytic block with 6% phenol was performed.ResultsMarked pain relief was experienced by the patient (VAS: 0-1). Sensory block in the femoral, lateral femoral cutaneous, and obturator nerve distributions was elicited. Motor weakness in the femoral nerve was demonstrated. Narcotic use was markedly reduced, and the patient was discharged to home in a pain-free state.ConclusionsThis case report supports the feasibility of placing a catheter via a modified anterior inguinal paravascular block technique and its subsequent use for both local anesthetic infusion and neurolytic block of the lumbar plexus.

Genitofemoral Nerve Protection During the Lateral Retroperitoneal Transpsoas Approach

2013 ◽  
Vol 73 (2) ◽  
pp. ons192-ons197 ◽  
Author(s):  
Gabriel C. Tender ◽  
Daniel Serban
Keyword(s):  
Length Of Stay ◽  
Blood Loss ◽  
Minimally Invasive ◽  
Operative Time ◽  
Femoral Nerve ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Direct Visualization ◽  
Genitofemoral Nerve ◽  
Estimated Blood Loss

Abstract BACKGROUND: The minimally invasive lateral retroperitoneal approach for lumbar fusions is a novel technique with good results, but also with significant sensory and motor complications. OBJECTIVE: To present the early results of a modified surgical technique, in which the psoas muscle is dissected under direct visualization. METHODS: Thirteen consecutive patients with L4-5 or L3-4 pathology were prospectively followed after being treated using a minimally invasive lateral approach with direct exposure of the psoas muscle before dissection. There were 7 woman and 6 men with a mean age of 52.3 years. Perioperative parameters like operative time, estimated blood loss, and length of stay, were noted. Pain, paresthesia, and motor weakness, as well as any other complications, were evaluated at 2 weeks and 3 months postoperatively. RESULTS: The mean operative time, estimated blood loss, and length of stay were 163 minutes, 126 mL, and 3 days, respectively. One patient exhibited anterior thigh pain and paresthesia at 2 weeks, both of which resolved by 3 months. Two patients experienced superficial wound infections that healed with antibiotics. The genitofemoral nerve was identified and protected in 7 patients; in 4 patients, it had a more posterior anatomic location than expected. The femoral nerve was not exposed or detected in the operative field by neuromonitoring, nor were there any symptoms related to a femoral nerve injury in any patient. CONCLUSION: Dissection of the psoas muscle under direct visualization during the minimally invasive lateral approach may provide increased safety to the genitofemoral and femoral nerves.

The rising psoas sign: an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4–5

2014 ◽  
Vol 20 (5) ◽  
pp. 531-537 ◽  
Author(s):  
Jean-Marc Voyadzis ◽  
Daniel Felbaum ◽  
Jay Rhee
Keyword(s):  
Minimally Invasive ◽  
Preoperative Evaluation ◽  
Femoral Nerve ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Preoperative Imaging ◽  
Disc Disease ◽  
Disc Space ◽  
Imaging Characteristics ◽  
Lateral Interbody

Minimally invasive lateral interbody fusion for the treatment of degenerative disc disease, spondylolisthesis, or scoliosis is becoming increasingly popular. The approach at L4–5 carries the highest risk of nerve injury given the proximity of the lumbar plexus and femoral nerve. The authors present 3 cases that were aborted during the approach because of pervasive electromyography responses throughout the L4–5 disc space. Preoperative imaging characteristics of psoas muscle anatomy in all 3 cases are analyzed and discussed. In all cases, the psoas muscle on axial views was rising away from the vertebral column as opposed to its typical location lateral to it. Preoperative evaluation of psoas muscle anatomy is important. A rising psoas muscle at L4–5 on axial imaging may complicate a lateral approach.

scholarly journals Resolution of the more anteriorly positioned psoas muscle following correction of spinal sagittal alignment from spondylolisthesis: case report

2017 ◽  
Vol 26 (4) ◽  
pp. 441-447 ◽  
Author(s):  
Hasan R. Syed ◽  
Kurt Yaeger ◽  
Faheem A. Sandhu
Keyword(s):  
Back Pain ◽  
Sagittal Alignment ◽  
Morphological Changes ◽  
Psoas Muscle ◽  
Lateral Approach ◽  
Neurological Injury ◽  
Direct Result ◽  
Low Back ◽  
Dynamic Nature ◽  
Spinal Sagittal Alignment

Several studies have described the radiographic, histological, and morphological changes to the paraspinal muscle in patients with chronic low-back pain due to degenerative diseases of the spine. Gross anatomical illustrations have shown that the psoas muscle lies lateral to the L4–5 vertebrae and subsequently thins and dissociates from the vertebral body at L5–S1 in a ventrolateral course. A “rising psoas” may influence the location of the lumbar plexus and result in transient neurological injury on lateral approach to the spine. It is postulated that axial back pain may be exacerbated by anatomical changes of paraspinal musculature as a direct result of degenerative spine conditions. To their knowledge, the authors present the first reported case of a more anteriorly positioned psoas muscle and its resolution following correction of spondylolisthesis in a 62-year-old woman. This case highlights the dynamic nature of degenerative spinal disorders and illustrates that psoas muscle position can be affected by sagittal balance. Normal anatomical positioning can be restored following correction of spinal alignment.

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