The Oblique Corridor at L4-L5 A Radiographic-Anatomical Study Into the Feasibility for Lateral Interbody Fusion

Study Design. Cross-sectional radioanatomical study. Objective. The aim of this study was to analyze the prevalence, size, and location of the oblique corridor (OC), and the morphology of the psoas muscle at the L4-L5 disc level. Summary of Background Data. Lateral lumbar interbody fusion via the OC has the advantage of avoiding injury to the psoas muscle and lumbar plexus. However, the varying anatomy of major vascular structures and the iliopsoas may preclude a safe oblique access to the L4-L5 level. Methods. Five hundred axial magnetic resonance images of the L4-L5 disc level were shortlisted. OCs were categorized into four grades: Grade 0 = no corridor, Grade 1 = small corridor (<= 1 cm), Grade 2 = moderate corridor (1-2 cm) and Grade 3 = large corridor (>2 cm). OC location was labeled as antero-oblique, oblique, or oblique-lateral. Psoas morphology was categorized based on a modified Moro's classification, where the anterior section was further subdivided into types AI-AIV. Oblique approach was considered nonviable either when there was no corridor due to vascular obstruction (Grade 0) or when the psoas was high-rising (Types AII-AIV). Results. 10.5% of the selected 449 patients had no measurable OC (grade 0) at the L4-L5 level. There were 35% and 37.2% patients with a grade 1and 2 OC, respectively. The location of the OC was anterior oblique, oblique, and oblique lateral in 3.7%, 89.6%, and 6.7%, respectively. According to the modified Moro's classification, 19.4% had a high-rising psoas. Predominantly, psoas was either in line with the disc (Type I; 30.7%) or low-rising (Type AI; 47.4%). Conclusion. Twenty-five percent of the patients did not have an accessible OC either due to obstruction by vascular structures or due to a high-rising psoas. Hence, proper evaluation of the relevant anatomy preoperatively is recommended for early adopters of this technique, as varying anatomy precludes universal suitability of oblique lateral interbody fusion for the L4-L5 level.