The lumbosacral plexus: anatomic considerations for minimally invasive retroperitoneal transpsoas approach

The minimally invasive transpsoas approach can be employed to treat various spinal disorders, such as disc degeneration, deformity, and lateral disc herniation. With this technique, visualization is limited in comparison with the open procedure and the proximity of the lumbar plexus to the surgical pathway is one limitation of this technique. Precise knowledge of the regional anatomy of the lumbar plexus is required for safe passage through the psoas muscle. The primary objective of this study was to determine the anatomic position of the lumbar plexus branches and sympathetic chain in relation to the intervertebral disc and to define a safe working zone. The second objective was to compare our observations with previous anatomical studies concerning the transpsoas approach. A total of 60 lumbar plexus in 8 fresh cadavers from the Department of Anatomy were analyzed in this study. Coronal and lateral X-Ray images were obtained before dissection in order to eliminate spine deformity or fracture. All cadavers were placed in a lateral decubitus position with a lateral bolster. Dissection of the lumbar plexus was performed. All nerve branches and sympathetic chain were identified. Intervertebral disc space from L1L2 to L4L5 was divided into four zones. Zone 1 being the anterior quarter of the disc, zone 2 being the middle anterior quarter, zone 3 the posterior middle quarter and zone 4 the posterior quarter. Crossing of each nervous branch with the disc was reported and a safe working zone was determined for L1L2 to L4L5 disc levels. A safe working zone was defined by the absence of crossing of a lumbar plexus branch. No anatomical variation was found during blunt dissection. As described previously, the lumbar plexus is composed of the ventral divisions of the first four lumbar nerves and from contributions of the sub costal nerve from T12. The safe working zone includes zones 2 and 3 at level L1L2, zone 3 at level L2L3, zone 3 at level L3L4, and zone 2 at level L4L5. No difference was observed between right and left sides as regards the relationships between the lumbar plexus and the intervertebral disc. We observed some differences concerning the safe working zone in comparison with other cadaveric studies. The small number of cadaveric specimens used in anatomical studies probably explains theses differences. The minimally invasive transpsoas lateral approach was initially developed to reduce the complications associated with the traditional procedure. The anatomical relationships between the lumbar plexus and the intervertebral disc make this technique particularly risky a L4L5. Alternative techniques, such as transforaminal interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF) or anterior interbody fusion (ALIF) should be used at this level.