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Aberrant Iliac Artery: Far Lateral Lumbosacral Surgical Anatomy

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Aberrant Iliac Artery: Far Lateral Lumbosacral Surgical Anatomy ■ Case Report Aberrant Iliac Artery: Far Lateral Lumbosacral Surgical Anatomy LAWRENCE A. DELASOTTA, MD, MPH; KRIS RADCLIFF, MD; MARCOS A. SONAGLI, MD; LUCIANO MILLER, MD abstract Full article available online at ORTHOSuperSite.com. Search: 20120123-28 A 44-year-old man presented after 3 weeks of progressively worsening atraumatic on- set pain in the right anteromedial thigh. The pain was sharp and radiated to the antero- medial shin and medial foot. The patient had no associated weakness, numbness, or bowel/bladder dysfunction. Nonsteroidal anti-infl ammatory, pain, and neuropathic- relieving drugs had limited effect. He underwent interlaminar injections, which pro- vided transient relief of his shin symptoms. After conservative management failed, a spine surgeon (not affi liated with our prac- tice) recommended an anterior lumbar interbody fusion via far lateral approach. The patient presented to our spine clinic for a second opinion. Closed magnetic resonance imaging revealed an aberrant iliac artery impinging on the lumbar plexus and a fo- raminal herniation at L4-L5 on the right, an orientation more lateral than expected or seen on the contralateral side. We recommended physical therapy that focused Figure: Sagittal magnetic resonance image show- on core strength and adequate stretching prior to considering surgery. The patient’s ing the abdominal aorta anterior to the L2 vertebral symptoms have since resolved. Common iliac artery anomalies are rare. No known in- body (arrow). cidence exists. The fi nding in this case was incidental and, if missed, could have led to vascular compromise. To prevent such an injury during minimally invasive (transpsoas lateral approach) spine surgery, we recommend careful examination of radiographs for aberrant vessels. Dr Delasotta is from the Department of Surgery, Temple University, and Dr Radcliff is from Thomas Jefferson University, Philadelphia, Pennsylvania; Dr Sonagli is from the Spine and Orthopedic Department, Hospital de Clinicas Universidade Federal do Parana, Curitiba, and Dr Miller is from the Department of Orthopaedics, Faculdade de Medicina do ABC, Sao Paulo, Brazil. Drs Delasotta, Radcliff, Sonagli, and Miller have no relevant fi nancial relationships to disclose. Correspondence should be addressed to: Lawrence Delasotta, MD, MPH, 3401 N Broad St, Parkin- son Pavilion, Ste 400, Philadelphia, PA 19140 ([email protected]). doi: 10.3928/01477447-20120123-28 e294 ORTHOPEDICS | ORTHOSuperSite.com ABERRANT ILIAC ARTERY | DELASOTTA ET AL ascular anomalies around gressively worsen- the lumbar spine, such as ing atraumatic on- those of the iliac arteries, set pain in the right Vare rare.1-4 Index Medicus anteromedial thigh literature searches failed to reveal an in- that was sharp and cidence for such anomalies. The course radiated to the an- of the common iliac artery begins at the teromedial shin and distal portion of the abdominal aorta and medial foot. The extends inferolaterally for approximately patient had no as- 4 cm from the L4 vertebra to alongside sociated weakness, the medial aspect of the psoas muscle, numbness, or bowel/ 1 where it typically bifurcates anterior to bladder dysfunction. Figure 1: Axial magnetic resonance image at L3-L4. Abdominal aorta the sacroiliac joint of the pelvis. The Nonsteroidal anti- branches into common iliac arteries (arrows). Left common iliac courses in internal iliac artery (lateral to the lum- infl ammatory, pain, its normal distribution (left arrow). The aberrant right iliac is lateral to the bosacral junction and medial to exter- and neuropathic re- L3-L4 disk (right arrow). nal iliac vein) traverses the upper sacral lieving drugs had regions. It is the primary arterial supply limited effect. to the pelvis, where it provides blood to Open magnetic the viscera and most of the musculoskel- resonance imag- etal anatomy,5 whereas the external iliac ing (MRI) revealed becomes the femoral artery and supplies a right foraminal blood to the lower limbs. disk herniation at The most commonly reported iliac ar- L4-L5. Interlaminar tery anomaly is congenital hypoplasia/atre- injections provided sia.1-4,6,7 Sonneveld et al8 reported an aber- transient relief of rant iliac artery coursing posterior to the his shin symptoms. 2 psoas and quadratus lumborum muscles. Mild degenerative Figure 2: Axial magnetic resonance image at L4-L5. Right internal iliac re- Vohra and Leiberman9 reported a retro- scoliosis was also mains between the psoas muscle and vertebral body (right arrow). psoas iliac artery that presented clinically noted. After conser- as iliac stenosis with an intermittent clau- vative management dication; whereas Benny et al10 reported failed, a spine surgeon (not affi liated with iliac artery located directly adjacent to that vascular radiculopathies (including our practice) recommended an anterior the lumbar plexus that coursed through a but not limited to epidural spinal hema- lumbar interbody fusion via far lateral ap- potential far lateral (transpsoas) surgical toma, subdural spinal hematoma, spinal proach. approach for anterior lumbar interbody arteriovenous malformation, vertebral The patient then presented to our spine fusion, an approach that is gaining popu- hemangioma, spinal epidural cavernous clinic. Closed MRI revealed an aberrant larity throughout the United States. The hemangioma, vertebral artery anomalies iliac artery impinging on the lumbar plex- fi nding was incidental and, if missed, [tortuosity and dissection], aortic aneu- us and a foraminal herniation at L4-L5 on could have led to a vascular complica- rysm, hemorrhagic synovial cysts, liga- the right, an orientation more lateral than tion.15-21 mentum fl avum hematoma, and venous expected or seen on the contralateral side The initial MRI was inadequate to varices) in the lumbar spine occurred at an (Figures 1-4). We recommended physi- inspect vessel morphology. We ordered incidence of approximately 0.015%.11 cal therapy that focused on core strength additional testing and appreciated the lo- This article describes an aberrant iliac and adequate stretching prior to consider- cation of the aberrant right iliac artery. In artery that could have complicated access ing surgery. The patient’s symptoms have our patient, the common iliac arteries like- to the lumbar disk during a far lateral sur- since resolved. ly branched from the aorta at L3-L4; how- gical approach. ever, on the right at the L3-L4 disk space, DISCUSSION the iliac artery was found between the CASE REPORT Although anomalous iliac and iliolum- psoas major and vertebral body. Whether A 44-year-old man presented to an- bar arteries have been reported,7-9,12-14 we the arterial anomaly is congenital or due other spine clinic after 3 weeks of pro- are the fi rst to report an aberrant common to a degenerative process is unknown; FEBRUARY 2012 | Volume 35 • Number 2 e295 ■ Case Report 4. Kawashima T, Sato K, Sasaki H. A human case of hypoplastic external iliac artery and its collateral pathways. Folia Morphologica (Warsz). 2006; 65(2):157-160. 5. Moore KL, Dalley AF. Clinically Oriented Anatomy. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. 6. Link DP, Garza AS, Monsky WL. Congenital single, pelvic iliac artery: a case report. J Vasc Interv Radiol. 2009; 20(9):1231- 1234. 7. Tamisier D, Melki JP, Cormier JM. Congenital anomalies of the external iliac ar- tery: case report and review of the literature. Ann Vasc Surg. 1990; 4(5):510-514. 8. Sonneveld DJ, Van Dop HR, Van der Tol 4 A. Anomalous retro-psoas iliac artery in a 3 patient with an abdominal aortic aneurysm. Figure 3: Sagittal magnetic resonance image Figure 4: Sagittal magnetic resonance image Eur J Vasc Endovasc Surg. 1998; 16(1):85- showing the abdominal aorta anterior to the L2 showing right common iliac artery abnormally 86. coursing to the lateral aspect of L3 (arrow). vertebral body (arrow). 9. Vohra R, Leiberman DP. An anomalous right iliac artery presenting as iliac stenosis. Eur J Vasc Surgery. 1991; 5(2):209-211. however, the mild degenerative scolio- avoided due to the high risk of inadver- 10. Benny BV, Nagpal AS, Singh P, Smuck M. sis was unlikely to cause such a unique tent vascular injection. A far lateral (trans- Vascular causes of radiculopathy: a literature course. Furthermore, the common iliac psoas) surgical approach would have been review. Spine J. 2011; 11(1):73-85. artery becomes the internal iliac artery, high risk. Fortunately, the radiculopathy 11. Kleiner JB, Donaldson WF III, Curd JG, Thorne RP. Extraspinal causes of lumbosa- which branches into anterior and posterior subsided, and the patient reported signifi - cral radiculopathy. J Bone Joint Surg Am. branches at the superior edge of the great- cant improvement during conservative man- 1991; 73(6):817. er sciatic foramen. The typical anterolat- agement; the radiculopathy was most likely 12. Jain A, Patil VP, Horton P, et al. Common eral course for the common iliac artery due to the L4-L5 disk herniation because the iliac artery lying posterior to psoas major identifi ed during kidney transplantation. is seen on the left side (Figures 1-4). To vascular anomaly posed no reported trouble Transplantation. 2008; 86(4):623-624. our knowledge, we are the fi rst to report a throughout the patient’s lifetime. 13. Harrington JF Jr. Far lateral disc excision common iliac artery anomaly that courses at L5-S1 complicated by iliolumbar artery ONCLUSION incursion: case report. Neurosurgery. 2001; through a potential far lateral (transpsoas) C 48(6):1377-1379. surgical approach.22,23 This case is a reminder that although 14. Ebraheim NA, Lu J, Biyani A, Yang H. Harrington13 reported a case of ilio- anomalous abdominal vasculature is rare, Anatomic considerations of the principal lumbar artery incursion during a far lat- it occurs. The fi nding in this case was in- nutrient foramen and artery on internal sur- face of the ilium. Surg Radiol Anat. 1997; eral lumbar disk excision. While using a cidental and, if missed, could have led to 19(4):237-239.
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