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Vascular anatomy anterior to lumbosacral transitional vertebrae and implications for anterior lumbar interbody fusion
Authors:Bradley K Weiner MD  Matthew Walker MD  Robert D Fraser MD  FRCS
Institution:1. Department of Orthopaedic Surgery, Spine Unit, Northeastern Ohio Universities College of Medicine and Summa Health Systems, Akron, OH 44310, USA;2. Orthopaedic Resident, Summa Health Systems, Akron, OH 44310 USA;3. Spine Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia 5000;1. Department of Orthopedics, University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands;2. Department of Radiology, Wilhelmina Children''s Hospital (WKZ), University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands;3. Intensive Care Unit, Wilhelmina Children''s Hospital (WKZ), University Medical Center Utrecht, Heidelberglaan 100 3584 CX, Utrecht, the Netherlands;1. Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA;2. UCLA Comprehensive Spine Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA;1. Department of Orthopaedic Surgery, Tufts Medical Center, Boston, Massachusetts, U.S.A;2. Tufts University School of Medicine, Boston, Boston, Massachusetts, U.S.A;3. Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
Abstract:Background context: Anterior approaches to the lumbosacral spine afford the ideal window to the disc for interbody fusion. Vascular injuries represent the most feared complications of such approaches. Unfortunately, the combination of more procedures being performed, more surgeons at the beginning of the learning curve and less invasive techniques of approach combine to increase the risk of vascular injury in the face of altered vascular anatomy.Purpose: To assess cases in which vascular anatomy significantly altered the surgical approach to the lumbosacral junction. Study design/setting: Chart review of operative reports. Patient sample: All patients undergoing anterior lumbar interbody fusion between 1994 and 1997 at one large center. Methods: We reviewed all cases of anterior lumbar interbody fusion performed between 1994 and 1997 to discover cases requiring significant alteration in approach because of vascular variation. Results: One hundred seven consecutive cases were reviewed. Of these, 11 required significant alteration of the approach secondary to vascular variation. All 11 were in cases at the functional lumbosacral junction above a fixed transitional level. In only one case of transition was a usual approach able to be used. Conclusions: A consistent pattern of altered vascular anatomy anterior to the functional lumbosacral junction was found. This pattern is depicted and the surgical alterations required discussed. Such alteration in surgical approach was required in nearly all cases with transitional vertebrae and represented about 10% of cases overall. If anterior lumbar surgery is to be performed at the functional lumbosacral junction in the presence of transitional vertebrae, it is vital that close attention be paid to the vascular anatomy and more open techniques of approach should be considered.
Keywords:Transitional vertebrae  Iliac veins  Anterior lumbar interbody fusion  Cages
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