title: Diffusion-weighted magnetic resonance (DW-MR) neurography of the lumbar plexus in the preoperative planning of lateral access lumbar surgery.
abstract: OBJECTIVE
  Magnetic resonance (MR) neurography has been used to evaluate entire nerves and nerve bundles by providing better contrast between the nerves and the surrounding tissues. The purpose of the study was to validate diffusion-weighted MR (DW-MR) neurography in visualizing the lumbar plexus during preoperative planning of lateral transpsoas surgery.
  
  
  METHODS
  Ninety-four (188 lumbar plexuses) spine patients underwent a DW-MR examination of the lumbar plexus in relation to the L3-4 and L4-5 disc spaces and superior third of the L5 vertebral body. Images were reconstructed in the axial plane using high-resolution Maximum Intensity projection (MIP) overlay templates at the disc space and L3-4 and L4-5 interspaces. 10 and 22 mm MIP templates were chosen to mimic the working zone of standard lateral access retractors. The positions of the L4 nerve root and femoral nerve were analyzed relative to the L4-5 disc in axial and sagittal planes. Third-party radiologists and a senior spine surgeon performed the evaluations, with inter- and intraobserver testing performed.
  
  
  RESULTS
  In all subjects, the plexus was successfully mapped. At L3-4, in all but one case, the components of the plexus (except the genitofemoral nerve) were located in the most posterior quadrant (zone IV). The L3 and L4 roots coalesced into the femoral nerve below the L4-5 disc space in all subjects. Side-to-side variation was noted, with the plexus occurring in zone IV in 86.2 % right and only 78.7 % of left sides. At the superior third of L5, the plexus was found in zone III in 27.7 % of right and 36.2 % of left sides; and in zone II in 4.3 % right and 2.1 % left sides. Significant inter- and intraobserver agreement was found.
  
  
  CONCLUSIONS
  By providing the surgeon with a preoperative roadmap of the lumbar plexus, DW-MR may improve the safety profile of lateral access procedures.
authors.affiliation: Serviço de Cirurgia de Coluna, Hospital Ortopédico/Lifecenter and Hospital São Francisco de Assis, Belo Horizonte, Brazil, cristianomenezes@icloud.com.
authors.forename: Cristiano Magalhães
authors.initials: CM
authors.lastname: Menezes
authors.forename: Luciene Mota
authors.initials: LM
authors.lastname: de Andrade
authors.forename: Carlos Fernando Pereira da Silva
authors.initials: CF
authors.lastname: Herrero
authors.forename: Helton Luiz
authors.initials: HL
authors.lastname: Defino
authors.forename: Marcos Antonio
authors.initials: MA
authors.lastname: Ferreira Júnior
authors.forename: William Blake
authors.initials: WB
authors.lastname: Rodgers
authors.forename: Marcello Henrique
authors.initials: MH
authors.lastname: Nogueira-Barbosa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D038524:Diffusion Magnetic Resonance Imaging / Q000379:methods*; D004576:Electromyography; D005260:Female; D006801:Humans; D007403:Intervertebral Disc / Q000601:surgery*; D016015:Logistic Models; D017116:Low Back Pain / Q000175:diagnosis* / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery*; D008160:Lumbosacral Plexus / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D011300:Preoperative Care; D011446:Prospective Studies; D016658:Psoas Muscles / Q000601:surgery*; D013123:Spinal Fusion / Q000379:methods*