Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.
Department of Orthopaedic Surgery, University of Southern California, Los Angeles, CA.
Spine (Phila Pa 1976). 2023 Nov 15;48(22):1606-1610. doi: 10.1097/BRS.0000000000004541. Epub 2022 Nov 14.
Retrospective chart review.
Identify demographic and sagittal alignment parameters that are independently associated with femoral nerve position at the L4-L5 disk space.
Iatrogenic femoral nerve or lumbar plexus injury during lateral lumbar interbody fusion (LLIF) can result in neurological complications. The LLIF "safe zone" is the anterior half to two third of the disk space. However, femoral nerve position varies and is inconsistently identifiable on magnetic resonance imaging. The safe zone is also narrowest at L4-L5.
An analysis of patients with symptomatic lumbar spine pathology and magnetic resonance imaging with a visibly identifiable femoral nerve evaluated at a single large academic spine center from January 1, 2017, to January 8, 2020, was performed. Exclusion criteria were transitional anatomy, severe hip osteoarthritis, coronal deformity with cobb >10 degrees, > grade 1 spondylolisthesis at L4-L5 and anterior migration of the psoas.Standing and supine lumbar lordosis (LL) and its proximal (L1-L4) and distal (L4-S1) components were measured. Femoral nerve position on sagittal imaging was then measured as a percentage of the L4 inferior endplate. A stepwise multivariate linear regression of sagittal alignment and LL parameters was then performed. Data are written as estimate, 95% CI.
Mean patient age was 58.2±14.7 years, 25 (34.2%) were female and 26 (35.6%) had a grade 1 spondylolisthesis. Mean femoral nerve position was 26.6±10.3% from the posterior border of L4. Female sex (-6.6, -11.1 to -2.1) and supine proximal lumbar lordosis (0.4, 0.1-0.7) were independently associated with femoral nerve position.
Patient sex and proximal LL can serve as early indicators of the size of the femoral nerve safe zone during a transpsoas LLIF approach at L4-L5.
回顾性图表审查。
确定与 L4-L5 椎间盘水平股神经位置相关的人口统计学和矢状位对齐参数。
在侧方腰椎椎间融合术（LLIF）过程中，医源性股神经或腰丛损伤可导致神经并发症。LLIF“安全区”是椎间盘空间的前半到三分之二。然而，股神经的位置不同，在磁共振成像上也不一致。安全区在 L4-L5 处最窄。
对 2017 年 1 月 1 日至 2020 年 1 月 8 日期间在一家大型学术脊柱中心接受治疗且有明显可识别股神经的症状性腰椎病理和磁共振成像的患者进行了分析。排除标准为过渡解剖、严重髋关节骨关节炎、冠状面畸形 Cobb 角＞10 度、L4-L5 级 1 以上脊椎滑脱和腰大肌向前迁移。测量站立位和仰卧位腰椎前凸（LL）及其近端（L1-L4）和远端（L4-S1）组成部分。然后，在矢状面图像上测量股神经位置，以 L4 下终板的百分比表示。然后进行矢状位对齐和 LL 参数的逐步多元线性回归。数据以估计值和 95%置信区间表示。
患者平均年龄为 58.2±14.7 岁，25 例（34.2%）为女性，26 例（35.6%）为 1 级脊椎滑脱。股神经的平均位置为 L4 后缘的 26.6±10.3%。女性性别（-6.6，-11.1 至-2.1）和仰卧位近端腰椎前凸（0.4，0.1-0.7）与股神经位置独立相关。
患者性别和近端 LL 可作为经腰大肌前路 L4-L5 腰椎椎间融合术时股神经安全区大小的早期指标。
