Preoperative phlebography in anterior L4-L5 disc approach. Clinical experience about 63 cases

Iliocava junction to L4-L5 disc anatomical relationship in L5-S1 isthmic spondylolisthesis

BACKGROUND

Anterior lumbar interbody fusion finds a place in L5-S1 isthmic spondylolisthesis (ISPL) treatment. Extension of this arthrodesis at L4-L5 level is sometimes required. Anterior approach of the L4L5 disc is considered difficult due to the anatomical relationship between the iliocava junction (ICJ) and the spine.

HYPOTHESIS

Does the lumbosacral deformation induced by ISPL allows anterior approach of L4-L5 disc between the iliac?

STUDY DESIGN

Retrospective radiographic analysis of consecutive patients.

METHODS

This retrospective imaging study of a continuous series of 97 patients treated for an L5-S1 ISPL involved radiological parameters specific to ISPL and pelvic-sagittal balance. The distance between the ICJ and the L4 lower endplate was measured in millimeters. The factors influencing this distance were sought in order to identify a predictive model of high ICJ.

RESULTS

The ICJ took a cranial position with respect to the L4-L5 disc with an average distance of 1.8mm±16.4. This distance was statistically higher in the case of high-grade ISPL (p<0.01). The high ICJ position was correlated with a high Taillard index (r=0.39; CI_95% [0.13; 0.61]; p<.001) and a low lumbar-sacral angle (LSA) (r=-0.33; CI_95% [-0.56; -0.06]; p<0.01). Among the parameters specific to spino-pelvic statics, pelvic incidence, pelvic tilt and lumbar lordosis had similar correlations (r>0.30).

CONCLUSION

ISPL induces a geometric deformation of the lumbosacral hinge which modifies its anatomical relations with the ICJ. The anterior approach technique of L4-L5 disc in the presence of an L5-S1 ISPL is possible between the iliac veins for the large displacement and low LSA forms.

LEVEL OF EVIDENCE

IV, retrospective analysis.