Surface landmarks for anterior lumbar access: is fluoroscopy necessary?

Abstract

Background context: Anterior lumbar fusion surgery is increasing by an estimated 24% annually in the United States. There is a paucity of precise anatomic guidelines to help surgeons determine the appropriate anterior access incision site.

Purpose: The purpose of this study is to compare the available anterior surface landmarks for the L4/L5 and L5/S1 disk levels to the disk levels determined by fluoroscopy, with the goal of creating a guide for surgical incision sites in anterior lumbar access surgery.

Study design: A prospective, observational cohort study of consecutive patients undergoing anterior lumbar spinal exposure for anterior lumbar interbody fusion (ALIF), total disk replacement (TDR), or a combination of the two procedures at levels L4/L5 and/or L5/S1.

Patient sample: All patients (n=183) undergoing primary ALIF and/or TDR surgery from June 2018 to April 2021 at the study sites were assessed for inclusion, and 18 patients were excluded. The remaining 165 patients were included in the study, and a total of 208 surgical levels were exposed.

Outcome measures: Mean, standard deviation, and 95% confidence interval (CI) were calculated. At each level, the distance from the symphysis pubis to the target disk level (SD distance) and the distance from the symphysis pubis to the umbilicus (SU distance) were measured, and the SD/SU ratio was calculated. Paired 2-tailed t tests were used to assess significant differences (p<.05). An R2 (coefficient of determination) test was used to assess variability of the SD distance, SU distance, and SD/SU ratio at each level.

Methods: All physiologic and anatomic measures were collected prospectively by the investigators, including intraoperative measurements of SD and SU. Demographic and previous health history data were collected at the time of study enrollment.

Results: The mean age of the 165 study participants was 48±14 years (range 18-80 years), and 97 (61%) were male. A total of 208 disk levels were exposed: 140 at L5/S1 and 68 at L4/L5. For the L5/S1, the SD ranged from 0 to 12.5 cm, with a mean of 5.2±1.9 cm (95% CI 4.88-5.52). For the L4/L5 level, the SD ranged from 6 to 15.5 cm, with a mean of 10.7±2.3 cm (95% CI 10.2-11.2). SD/SU ratios at both levels were lower in overweight (body mass index [BMI] 25-29.9) and obese (BMI 30-34.9) groups than in normal body mass index groups. There was no significant difference in SD/SU ratios between females and males at either L5/S1 (p=.39) or L4/L5 (p=.66).

Conclusion: Clinically important variability in SD distances (≥9.5 cm) was observed for both the L5/S1 and L4/L5 disk levels. SD/SU ratios provided more consistent estimates of disk location than SD distance alone, but they still displayed substantial variability. Thus, intraoperative fluoroscopy remains mandatory to accurately plan the surgical incision for anterior lumbar access surgery.