A Crucial But Neglected Anatomical Factor Underneath Psoas Muscle and Its Clinical Value in Lateral Lumbar Interbody Fusion—The Cleft of Psoas Major (CPM)

• Published in: Orthopaedic surgery Vol. 14; no. 2; pp. 323 - 330
• Main Authors: Ji, Jianfei, Li, Fangcai, Chen, Qixin
• Format: Journal Article
• Language: English
• Published: Melbourne John Wiley & Sons Australia, Ltd 01-02-2022; John Wiley & Sons, Inc; Wiley
• Subjects: Cadavers; Cleft of psoas major; Clinical; Connective tissue; Extreme lateral lumbar interbody fusion; Femoral Nerve - anatomy & histology; Humans; Lateral lumbar interbody fusion; Lumbar Vertebrae - anatomy & histology; Lumbar Vertebrae - surgery; Lumbosacral Region - surgery; Oblique lateral lumbar interbody fusion; Psoas Muscles - anatomy & histology; Safe zone; Spinal Fusion - adverse effects; Spinal Fusion - methods; Surgery; Veins & arteries; Vertebrae; Extreme lateral lumbar interbody fusion; Safe zone; Lateral lumbar interbody fusion; Oblique lateral lumbar interbody fusion; Cleft of psoas major
• ISSN: 1757-7853; 1757-7861
• DOI: 10.1111/os.13180

Objective
To describe the anatomical feature positioned beneath the psoas muscle at the lateral aspect of the lower lumbar, and to create a new location system to identify the risk factors of lateral lumbar interbody fusion.
Methods
Six cadavers were dissected and analyzed. The anatomy and neurovascular distribution beneath the psoas major from L3 to S1 was observed and recorded, with particular focus on the L4/5 disc and below. The psoas major surface was divided homogeneously into four parts, from the anterior border of psoas major to the transverse process. The cranial‐to‐caudal division was from the lower edge of the psoas muscle attachment on the L4 vertebrae to the upper part of the S1 vertebrae, and was divided into five segments. Then a grid system was used to create 20 grids on the psoas major surface, from the anterior border of the muscle to the transverse process and from L4 to superior S1, which was used to determine the anatomical structures' distribution and relationship beneath the psoas major.
Results
A cleft was identified beneath the psoas major, from the level of L4/5 downwards. It was filled with loose connective tissue and neurovascular structures. We termed it the cleft of psoas major (CPM). The sympathetic trunk, ascending lumbar vein, iliolumbar vessels, obturator nerve, femoral nerve and occasionally the great vessels are contained within the CPM, although there is significant interpersonal variation. The grid system on the psoas major surface helped to identify the anatomical structures in CPM. There was a considerably lower frequency of occurrence of neurovascular structures in the grids of I/II at the L4/5 level where can be considered the “safe zones” for the lateral lumbar interbody fusion. In contrast, the distribution of neurovascular structures at the L5S1 level is dense, where the operation risk is high.
Conclusion
The CPM exists lateral to the vertebral surface from L4 and below. Although the occurrence and distribution of neurovascular structures within the CPM is complex and varies greatly, it can provide a potential cavity for visualization during lateral lumbar interbody fusion. Using psoas major as a reference, this novel grid system can be used to identify the risk factors in CPM and thus identify a safe entry point for surgery.
Although the occurrence and distribution of neurovascular structures within the CPM is complex and varies greatly, it can provide a potential cavity for visualization during LLIF. Using psoas major as a reference, this novel grid system can be used to identify the CPM beneath the psoas muscle and thus identify a safe entry point for surgery.