An MRI study of lateral vascular safety zones in oblique lumbar interbody fusion surgery_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

GAO Fei ¹ , DUAN Hongkai ² , QIN Daxian ¹ , WANG Hongwei ¹ , WANG Qingyun ¹ , LI Xian ² ,  ZHANG Yu ³

1. Department of Orthopaedics, Dongguan Tungwah Hospital, Dongguan Guangdong, 523413, P. R. China;
2. Department of Orthopaedics, Dongguan Songshan Lake Tungwah Hospital, Dongguan Guangdong, 523808, P. R. China;
3. Department of Orthopaedics, General Hospital of Southern Theater Command of Chinese PLA, Guangzhou Guangdong, 510010, P. R. China;

Corresponding author：

ZHANG Yu, Email: gz_zhangyu1980cmu@126.com

Keywords：

Oblique lateral interbody fusion; segmental vessels; MRI; radiological evaluation

DOI：

10.7507/1002-1892.202305077

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Objective To study the anatomical characteristics of blood vessels in the lateral segment of the vertebral body through the surgical approach of oblique lumbar interbody fusion (OLIF) using MRI imaging, and evaluate its potential vascular safety zone. Methods The lumbar MRI data of 107 patients with low back and leg pain who met the selection criteria between October 2019 and November 2022 were retrospectively analyzed. The vascular emanation angles, vascular travel angles, and the length of vessels in the lateral segments of the left vertebral body of L₁-L₅, as well as the distance between the segmental vessels in different Moro junctions of the vertebral body and their distances from the edges of the vertebrae in the same sequence (bottom marked as I, top as S) were measured. The gap between the large abdominal vessels and the lateral vessels of the vertebral body was set as the lateral vascular safe zones of the lumbar spine, and the extent of the safe zones (namely the area between the vessels) was measured. The anterior 1/3 of the lumbar intervertebral disc was taken as the simulated puncture center, and the area with a diameter of 22 mm around it as the simulated channel area. The proportion of vessels in the channel was further counted. In addition, the proportions of segmental vessels at L₅ without a clear travel and with an emanation angel less than 90° were calculated. Results Except for the differences in the vascular emanation angles between L₄ and L₅, the vascular travel angles between L₁, L₂ and L₄, L₅, and the length of vessels in the lateral segments of the vertebral body among L₁-L₄ were not significant (P>0.05), the differences in the vascular emanation angles, vascular travel angles, and the length of vessels between the rest segments were all significant (P<0.05). There was no significant difference in the distance between vessels of L₁, L₂ and L₂, L₃ at Moro Ⅰ-Ⅳ junctions (P>0.05), in L₃, L₄ and L₄, L₅ at Ⅱ and Ⅲ junction (P>0.05). There was no significant difference in the vascular distance of L₂, L₃ between Ⅱ, Ⅲ junction and Ⅲ, Ⅳ junction, and the vascular distance of L₃, L₄ between Ⅰ, Ⅱ junction and Ⅲ, Ⅳ junction (P>0.05). The vascular distance of the other adjacent vertebral bodies was significant different between different Moro junctions (P<0.05). Except that there was no significant difference in the distance between L₂I and L₃S at Ⅰ, Ⅱ junction, L₃I and L₄S at Ⅱ, Ⅲ junction, and L₂I and L₃S at Ⅲ, Ⅳ junction (P>0.05), there was significant difference of the vascular distance between the bottom of one segment and the top of the next in the other segments (P<0.05). Comparison between junctions: Except for the L₃S between Ⅰ, Ⅱ junction and Ⅱ, Ⅲ junction, and L₅S between Ⅰ, Ⅱ junction and Ⅱ, Ⅲ and Ⅲ, Ⅳ junctions had no significant difference (P>0.05), there were significant differences in the distance between the other segmental vessels and the vertebral edge of the same sequence in different Moro junctions (P<0.05). The overall proportion of vessels in the simulated channels was 40.19% (43/107), and the proportion of vessels in L₁ (41.12%, 44/107) and L₅ (18.69%, 20/107) was higher than that in the other segments. The proportion of vessels in the channel of Moro zone Ⅰ (46.73%, 50/107) and zone Ⅱ (32.71%, 35/107) was higher than that in the zone Ⅲ, while no segmental vessels in L₁ and L₂ were found in the channel of zone Ⅲ (χ²=74.950, P<0.001). Moreover, 26.17% (28/107) of the segmental vessels of lateral L₅ showed no movement, and 27.10% (29/107) vascular emanation angles of lateral L₅ were less than 90°. Conclusion L₁ and L₅ segmental vessels are most likely to be injured in Moro zones Ⅰ and Ⅱ, and the placement of OLIF channels in L_{4, 5} at Ⅲ, Ⅳ junction should be avoided. It is usually safe to place fixation pins at the vertebral body edge on the cephalic side of the intervertebral space, but it is safer to place them on the caudal side in L_{1, 2} (Ⅰ, Ⅱ junction), L_{3, 4} (Ⅲ, Ⅳ junction), and L_{4, 5} (Ⅱ, Ⅲ, Ⅳ junctions).

Citation： GAO Fei, DUAN Hongkai, QIN Daxian, WANG Hongwei, WANG Qingyun, LI Xian, ZHANG Yu. An MRI study of lateral vascular safety zones in oblique lumbar interbody fusion surgery. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(9): 1119-1126. doi: 10.7507/1002-1892.202305077 Copy

1.	张宇轩, 王洪立, 马晓生, 等. 斜外侧腰椎椎间融合术并发症的研究进展. 中华骨科杂志, 2019, 39(19): 1222-1228.
2.	魏晋鹏, 常峰. 斜外侧入路腰椎椎间融合术临床应用研究进展. 脊柱外科杂志, 2023, 21(1): 50-56.
3.	王朝杨, 曾建成, 杨志强. 影像学评估在斜外侧腰椎椎间融合术中的指导作用. 中国修复重建外科杂志, 2019, 33(12): 1572-1577.
4.	Moro T, Kikuchi S, Konno S, et al. An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine (Phila Pa 1976), 2003, 28(5): 423-428.
5.	Grasso G. Avoiding lumbar segmental arteries injury in oblique lateral interbody fusion procedure. World Neurosurg, 2020, 139: 57-59.
6.	Aguirre AO, Soliman MAR, Azmy S, et al. Incidence of major and minor vascular injuries during lateral access lumbar interbody fusion procedures: a retrospective comparative study and systematic literature review. Neurosurg Rev, 2022, 45(2): 1275-1289.
7.	Huang W, Zhou P, Xie L, et al. The trajectory characteristics and clinical significance of the left-sided lumbar segmental artery: a prospective cross-sectional radio-anatomical study. Quant Imaging Med Surg, 2022, 12(3): 1977-1987.
8.	Jang JS, Ko MJ, Lee YS, et al. Importance of surgical order for minimizing vascular injury during the L₅-S₁ approach in multilevel oblique lateral interbody fusion surgery. Korean J Neurotrauma, 2022, 18(2): 287-295.
9.	Han ML, He WH, He ZY, et al. Anatomical characteristics affecting the surgical approach of oblique lateral lumbar interbody fusion: an MR-based observational study. J Orthop Surg Res, 2022, 17(1): 426.
10.	Zhu HF, Fang XQ, Zhao FD, et al. Anteroinferior psoas technique for oblique lateral lumbar interbody fusion. Orthop Surg, 2021, 13(4): 1458-1461.
11.	Degulmadi D, Parmar V, Dave B, et al. A comparative morphometric analysis of operative windows for performing OLIF among normal and deformity group in lower lumbar spine. Spine Deform, 2023, 11(2): 455-462.
12.	Deng D, Liao X, Wu R, et al. Surgical safe zones for oblique lumbar interbody fusion of L_1-5: A cadaveric study. Clin Anat, 2022, 35(2): 178-185.
13.	Wang H, Zhang Y, Ma X, et al. Radiographic study of lumbar sympathetic trunk in oblique lateral interbody fusion surgery. World Neurosurg, 2018, 116: e380-e385.
14.	Razzouk J, Ramos O, Mehta S, et al. CT-based analysis of oblique lateral interbody fusion from L₁ to L₅: location of incision, feasibility of safe corridor approach, and influencing factors. Eur Spine J, 2023, 32(6): 1947-1952.
15.	Julian Li JX, Mobbs RJ, Phan K. Morphometric MRI imaging study of the corridor for the oblique lumbar interbody fusion technique at L₁-L₅. World Neurosurg, 2018, 111: e678-e685.
16.	Shimizu S, Tanaka R, Kan S, et al. Origins of the segmental arteries in the aorta: an anatomic study for selective catheterization with spinal arteriography. AJNR Am J Neuroradiol, 2005, 26(4): 922-928.
17.	易西南, 沈民仁, 罗刚, 等. 腰椎侧面节段血管神经的应用解剖. 中国临床解剖学杂志, 2005, 23(5): 470-473.
18.	Orita S, Inage K, Sainoh T, et al. Lower lumbar segmental arteries can intersect over the intervertebral disc in the oblique lateral interbody fusion approach with a risk for arterial injury: Radiological analysis of lumbar segmental arteries by using magnetic resonance imaging. Spine (Phila Pa 1976), 2017, 42(3): 135-142.
19.	Wu T, Xiao L, Liu C, et al. Anatomical study of the lumbar segmental arteries in relation to the oblique lateral interbody fusion approach. World Neurosurg, 2020, 138: e778-e786.
20.	Molinares DM, Davis TT, Fung DA. Retroperitoneal oblique corridor to the L₂-S₁ intervertebral discs: an MRI study. J Neurosurg Spine, 2016, 24(2): 248-255.
21.	Vaccaro AR, Kepler CK, Rihn JA, et al. Anatomical relationships of the anterior blood vessels to the lower lumbar intervertebral discs: analysis based on magnetic resonance imaging of patients in the prone position. J Bone Joint Surg (Am), 2012, 94(12): 1088-1094.
22.	Chithriki M, Jaibaji M, Steele RD. The anatomical relationship of the aortic bifurcation to the lumbar vertebrae: a MRI study. Surg Radiol Anat, 2002, 24(5): 308-312.
23.	Garg B, Mehta N, Vijayakumar V, et al. Defining a safe working zone for lateral lumbar interbody fusion: a radiographic, cross-sectional study. Eur Spine J, 2021, 30(1): 164-172.
24.	Li R, Li X, Zhou H, et al. Development and application of oblique lumbar interbody fusion. Orthop Surg, 2020, 12(2): 355-365.
25.	宋永兴, 俞伟, 张建乔, 等. 斜外侧腰椎融合技术并发血管损伤的原因分析和预防策略. 中国骨伤, 2020, 33(12): 1142-1147.

1. 张宇轩, 王洪立, 马晓生, 等. 斜外侧腰椎椎间融合术并发症的研究进展. 中华骨科杂志, 2019, 39(19): 1222-1228.
2. 魏晋鹏, 常峰. 斜外侧入路腰椎椎间融合术临床应用研究进展. 脊柱外科杂志, 2023, 21(1): 50-56.
3. 王朝杨, 曾建成, 杨志强. 影像学评估在斜外侧腰椎椎间融合术中的指导作用. 中国修复重建外科杂志, 2019, 33(12): 1572-1577.
4. Moro T, Kikuchi S, Konno S, et al. An anatomic study of the lumbar plexus with respect to retroperitoneal endoscopic surgery. Spine (Phila Pa 1976), 2003, 28(5): 423-428.
5. Grasso G. Avoiding lumbar segmental arteries injury in oblique lateral interbody fusion procedure. World Neurosurg, 2020, 139: 57-59.
6. Aguirre AO, Soliman MAR, Azmy S, et al. Incidence of major and minor vascular injuries during lateral access lumbar interbody fusion procedures: a retrospective comparative study and systematic literature review. Neurosurg Rev, 2022, 45(2): 1275-1289.
7. Huang W, Zhou P, Xie L, et al. The trajectory characteristics and clinical significance of the left-sided lumbar segmental artery: a prospective cross-sectional radio-anatomical study. Quant Imaging Med Surg, 2022, 12(3): 1977-1987.
8. Jang JS, Ko MJ, Lee YS, et al. Importance of surgical order for minimizing vascular injury during the L₅-S₁ approach in multilevel oblique lateral interbody fusion surgery. Korean J Neurotrauma, 2022, 18(2): 287-295.
9. Han ML, He WH, He ZY, et al. Anatomical characteristics affecting the surgical approach of oblique lateral lumbar interbody fusion: an MR-based observational study. J Orthop Surg Res, 2022, 17(1): 426.
10. Zhu HF, Fang XQ, Zhao FD, et al. Anteroinferior psoas technique for oblique lateral lumbar interbody fusion. Orthop Surg, 2021, 13(4): 1458-1461.
11. Degulmadi D, Parmar V, Dave B, et al. A comparative morphometric analysis of operative windows for performing OLIF among normal and deformity group in lower lumbar spine. Spine Deform, 2023, 11(2): 455-462.
12. Deng D, Liao X, Wu R, et al. Surgical safe zones for oblique lumbar interbody fusion of L_1-5: A cadaveric study. Clin Anat, 2022, 35(2): 178-185.
13. Wang H, Zhang Y, Ma X, et al. Radiographic study of lumbar sympathetic trunk in oblique lateral interbody fusion surgery. World Neurosurg, 2018, 116: e380-e385.
14. Razzouk J, Ramos O, Mehta S, et al. CT-based analysis of oblique lateral interbody fusion from L₁ to L₅: location of incision, feasibility of safe corridor approach, and influencing factors. Eur Spine J, 2023, 32(6): 1947-1952.
15. Julian Li JX, Mobbs RJ, Phan K. Morphometric MRI imaging study of the corridor for the oblique lumbar interbody fusion technique at L₁-L₅. World Neurosurg, 2018, 111: e678-e685.
16. Shimizu S, Tanaka R, Kan S, et al. Origins of the segmental arteries in the aorta: an anatomic study for selective catheterization with spinal arteriography. AJNR Am J Neuroradiol, 2005, 26(4): 922-928.
17. 易西南, 沈民仁, 罗刚, 等. 腰椎侧面节段血管神经的应用解剖. 中国临床解剖学杂志, 2005, 23(5): 470-473.
18. Orita S, Inage K, Sainoh T, et al. Lower lumbar segmental arteries can intersect over the intervertebral disc in the oblique lateral interbody fusion approach with a risk for arterial injury: Radiological analysis of lumbar segmental arteries by using magnetic resonance imaging. Spine (Phila Pa 1976), 2017, 42(3): 135-142.
19. Wu T, Xiao L, Liu C, et al. Anatomical study of the lumbar segmental arteries in relation to the oblique lateral interbody fusion approach. World Neurosurg, 2020, 138: e778-e786.
20. Molinares DM, Davis TT, Fung DA. Retroperitoneal oblique corridor to the L₂-S₁ intervertebral discs: an MRI study. J Neurosurg Spine, 2016, 24(2): 248-255.
21. Vaccaro AR, Kepler CK, Rihn JA, et al. Anatomical relationships of the anterior blood vessels to the lower lumbar intervertebral discs: analysis based on magnetic resonance imaging of patients in the prone position. J Bone Joint Surg (Am), 2012, 94(12): 1088-1094.
22. Chithriki M, Jaibaji M, Steele RD. The anatomical relationship of the aortic bifurcation to the lumbar vertebrae: a MRI study. Surg Radiol Anat, 2002, 24(5): 308-312.
23. Garg B, Mehta N, Vijayakumar V, et al. Defining a safe working zone for lateral lumbar interbody fusion: a radiographic, cross-sectional study. Eur Spine J, 2021, 30(1): 164-172.
24. Li R, Li X, Zhou H, et al. Development and application of oblique lumbar interbody fusion. Orthop Surg, 2020, 12(2): 355-365.
25. 宋永兴, 俞伟, 张建乔, 等. 斜外侧腰椎融合技术并发血管损伤的原因分析和预防策略. 中国骨伤, 2020, 33(12): 1142-1147.

Chinese Journal of Reparative and Reconstructive Surgery

An MRI study of lateral vascular safety zones in oblique lumbar interbody fusion surgery

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