Basic parameters of retroperitional access for total prosthetics of intervertebral discs of the lumbar spine

OBJECTIVE: To study the main parameters of retroperitoneal access for total prosthetics of the intervertebral discs in the lumbar spine to reduce the risk of complications and the morbidity of surgical access, taking into account surgical risk areas.

MATERIAL AND METHODS. The study included 110 patients operated on from 2017 to 2020 (72 men, 38 women) in the neurosurgical department of FGKU «1586 VKG» of the Ministry of Defense of Russia. The average age of the patients was 44,9 ± 15,4 years. According to the localization of access to the lumbar spine, patients were divided as follows: LIII–LIV — 8 (7,3 %), LIV–LV — 46 (41,7 %), LV–SI — 56 (51 %). Using special tools (protractor, ruler, caliper — compass, compass gauge, device for installing cages in the lumbar spine), the main parameters of retroperitoneal access were determined intraoperatively. The anthropometric parameters of the studied patients were determined. The morphometric characteristics of the location of the veins (inferior vena cava, left common iliac veins) in relation to the intervertebral discs were studied.

RESULTS. The main parameters of retroperitoneal access for prosthetics of the intervertebral disc in the lumbar spine were studied for each operated level. In particular, for the LIV–LV level, the length of the skin incision was 100 (80; 120), the length of the surgical wound was 95 (80; 100), the thickness of the subcutaneous fat layer was 37.5 (30; 45), and the depth of the wound to the spine was 110 (80; 130), the depth of the wound to the spinal canal is 142.5 (125; 172), the angle of surgical action in the horizontal plane at the level of the spine is 50 (44; 54). Based on the anthropometric data of the studied patients, the optimal skin incisions were determined to perform retroperitoneal access. A study was made of the location of the inferior hollow, left common iliac veins with respect to the intervertebral discs, taking into account these anatomical differences, a classification system was developed.

CONCLUSIONS. The obtained data can be used in planning retroperitoneal access to the lumbar spine in order to reduce the morbidity of the operation.

1. Кремер Ю. Заболевания межпозвонковых дисков/ Ю. Кремер.; пер. с англ.; под общ. ред. проф. В. А. Широкова. — 2-е изд. — М.: МЕДпресс-информ, 2015. — 472 с. ил.

2. Митбрейт И.М., Глазырин Д. И. Передний спондилодез В. Д. Чаклина // Хирургия позвоночника 2017. Т. 14 No 1. С. 91–99.

3. Nalbandian M.M., Hoashi J. S., Errico T. J. Variations in the iliolumbar vein during the anterior approach for spinal procedures. Spine (Phila Pa 1976). 2013;38(8): E445-E450. doi:10.1097/BRS.0b013e31828972ac.

4. Busardò F.P., Frati P., Carbone I., Pugnetti P., Fineschi V. Iatrogenic left common iliac artery and vein perforation during lumbar discec- tomy: a fatal case. Forensic Sci Int. 2015;246: e7-e11. doi:10.1016/j.forsciint.2014.11.006.

5. Lazennec J.Y., Pouzet B., Ramare S., et al. Anatomic basis of minimal anterior extraperitoneal approach to the lumbar spine. Surg Radiol Anat. 1999;21(1):7–15. doi:10.1007/BF01635046.

6. Lucas F., Emery E., Dudoit T., Berger L. Influence of Obesity on Access-Related Complications During Anterior Lumbar Spine Interbody Fusion. World Neurosurg. 2016;92:229–233. doi:10.1016/j.wneu.2015.12.104.

7. Ким Х. Д. Позвоночник. Хирургическая анатомия и хирургиче- ская техника/ Д. Х. Ким, А. Р. Ваккаро, К. А. Дикман и др.; пер. с англ. под ред. Ю. А. Щербука. — М.: Издательство Панфилова, 2016. — 848 с. ил.

8. Smoljanovic T., Bicanic G., Bojanic I. Re: Kleeman T. J., Ahn UM, Talbot-Kleeman A. Laparoscopic anterior lumbar interbody fusion with rhBMP-2: a prospective study of clinical and radiographic outcomes. Spine 2001;26:2751–6. Spine (Phila Pa 1976). 2010;35(20): E1013. doi:10.1097/BRS.0b013e3181edf48a.

9. Ефимов, А. Н. Топографо-анатомические аспекты сравнительной оценки оперативных доступов к позвоночнику: автореф. дис. … канд. мед. наук.: 14.03.01 / Ефимов Андрей Николаевич. — Санкт-Петербург, 2011. — 20 с.

10. Molloy S., Butler J. S., Benton A., Malhotra K., Selvadurai S., Agu O. A new extensile anterolateral retroperitoneal approach for lumbar interbody fusion from L1 to S1: a prospective series with clinical outcomes. Spine J. 2016;16(6):786–791. doi:10.1016/j.spinee.2016.03.044.

11. Булыщенко, Г. Г. Эндоскопическая трансфораминальная дискэктомия в лечении больных с дегенеративно-дистрофическими заболеваниями поясничного отдела позвоночника: автореф. дис. … канд. мед. наук.: 14.03.01 / Булыщенко Геннадий Геннадьевич. — Санкт-Петербург, 2018. — 22 с.

12. Кравцов, М.Н. 2020 Чрезкожная видеоэндоскопическая хирургия в комплексном лечении дегенеративно-дистрофических заболеваний позвоночника: автореф. дис. … д-ра. мед. наук.: 14.01.18 / Кравцов Максим Николаевич. — Санкт-Петербург, 2019. — 49 с.

13. Корж А.А., Талышинский Р. Р., Хвисюк Н. И. Оперативные доступы к грудным и поясничным позвонкам (анатомо-хирургическое обоснование). — М.: Медицина. — 1968. — 204 с.

14. Lakchayapakorn K., Siriprakarn Y. Anatomical variations of the

15. position of the aortic bifurcation, iliocava junction and iliac veins in relation to the lumbar vertebra // J. Med. Assoc. Thai. — 2008. — V.91. — N.10. — P. 1564–1570.

16. Gstöttner M., Glodny B., Petersen J., Thaler M., Bach C. M. CT angiography for anterior lumbar spine access: high radiation exposure and low clinical relevance. Clin Orthop Relat Res. 2011;469(3):819– 824. doi:10.1007/s11999-010-1520-4.