A comprehensive review of the sub-axial ligaments of the vertebral column: part I anatomy and function

Deferent Anatomical Presentations of Iliolumbar Ligament: A Cadaveric Study

This work was carried out to describe the detailed gross anatomy of the iliolumbar ligaments in human cadavers and to shed more light on these disputes regarding the configuration and direction of these ligaments. Twenty partially dissected human formalin-preserved cadavers originating from North America and Europe were investigated in this study. Blunt dissection was made through the ventral and dorsal aspects of the pelvic area of the cadavers. According to the current study, the anterior and posterior portions of the iliolumbar ligament most frequently attached to the 5th lumbar vertebra’s transverse process (70% and 80%, respectively). The body of the 4th lumbar vertebra with the 5th lumbar vertebra’ transverse process was the attachment of the anterior part (30%). The attachment of the posterior part was the body of the 5th lumbar vertebra (20%). The anterior and posterior parts of the iliolumbar ligament were inserted into the anterior tip of the iliac crest. There is an obvious variation in the morphological appearance of the iliolumbar ligament distinguished in attachments, length, width, thickness, number of bands, and the presence of accessory bands in the anterior part of the ligament. In addition, a new attachment for the anterior band was revealed in one-third of the specimens (body of the 4th lumbar vertebra) which have not been described before. Also, in one-fifth of the specimens, there was a new attachment for the posterior band (body of the 5th lumbar vertebra).

Anterior Longitudinal Ligament Flap Technique: Description of Anterior Longitudinal Ligament Opening During Anterior Lumbar Spine Surgery and Review of Vascular Complications in 189 Patients

BACKGROUND

One of the main concerns of anterior lumbar spine approaches are vascular complications. The aim of our study is to provide technical details about a flap technique using the anterior longitudinal ligament (ALL) when approaching the lumbar spine via an anterior corridor. This can help decrease complications by protecting the adjacent vascular structures. We also include a retrospective cohort review.

METHODS

This is a retrospective bicentric study: 189 patients with a mean age of 44.2 years underwent anterior lumbar spine surgery using the ALL flap technique. Patients were diagnosed with degenerative pathologies. We treated 239 lumbar levels primarily at the L4-5 and L5-S1: 88 single-level anterior lumbar interbody fusions, 9 two-level ALIFs, 51 total disk replacements (TDR), and 41 hybrid constructs (i.e., ALIF L5S1 and TDR L4L5). Anterior approaches were performed by two senior spine surgeons. The ALL flap technique was utilized in all of these cases, by carefully dissecting the ALL, with the flap suspended using sutures. As such, this ALL flap provided a "safe corridor" to avoid any potential vascular laceration.

RESULTS

The operative and early surgical complication rate was 3.2%. There was no arterial injury. There were only 2 minor venous lacerations (1.05%). No blood transfusion was required. Neither lacerations happened during disk space preparation.

CONCLUSIONS

Here, we provide technical details about a simple and reproducible technique using the ALL as a flap, which may help spine surgeons minimize vascular injuries during ALIF or even TDR surgeries.