Case Report
L U M B A R A R T E R I E S W I T H U N C O M M O N P A T T E R N S O F O R I G I N
J a s n a G ü r b ü z , P h . D . / M e h t a p Y ü k s e l , P h . D . / A y m e l e k Y a l ı n , P h . D .
D e p a r t m e n t o f A n a t o m y , S c h o o l o f M e d i c i n e , M a r m a r a U n i v e r s i t y , İ s t a n b u l , T u r k e y .
A B S T R A C T
M ultiple variations of the origin the lum bar arteries were observed during the dissection of the abdominal aorta in a 44 year old male cadaver.
A total of four pairs of the lum bar arteries were present. The 1st and 2nd pairs emerged from the poste rio r a sp e ct of the abdom ina l aorta separately, while the 3 rd pair emerged via a common trunk. The 4th right lum bar artery arose from the lateral aspect of the aorta 1.3 mm above aortic bifurcation w hile the left one arose 0.3 mm above bifurcation via a long com m on trunk with the median sacral artery.
The variant origin and/or course of lum bar arteries could increase the risk of vascular injury, during the surgical and diagnostic procedures within the retroperitoneal region.
S ignificance of lu m b a r a rte rie s and th e ir variations will be discussed from both clinical and embriological standpoint.
K e y W o r d s : Lum bar artery, com m on trunk, variation
IN T R O D U C T IO N
Lumbar arteries are small, segm ental vessels that arise in series from the back of the aorta. There are usually four pairs of the lum bar arteries
and the fifth pair occasionally originates from the median sacral artery if present (1).
The m ain tru n k of each lu m b a r a rte ry is approxim ately 2.5 cm long and divides into dorsal and spinal bra n ch e s. The dorsal branches proceed laterally and dorsally to supply the m uscles of the posterior and lateral abdominal wall (psoas major, quadratus lum borum and p o ste rio r a p o n e u ro sis of the tra n sve rsu s abdom inis), the skin of the back and the lum bar plexus. Each spinal branch enters the vertebral canal to supply its contents and the adjacent ve rte b ra . C lin ic a lly Im p o rta n t the arte ria ra d icu la ris m agna (A d a m kie w icz) usually o rig in a te s from one of the lo w e r p o ste rio r intercostal or upper lum bar arteries, generally on the left side (2).
Variations of origin or course of the lum bar arteries are not uncom m on. Baniel et al. (3) found in 15% and Ratcliff (4) reported in 26.3% of cases a short, single, m idline artery that gave origin to the fourth lum bar arteries. In 5.3% the third lum bar arteries em erged also via a midline artery (4).
Caes et al. (5) com pared the incidence of single bifurcating lum bar arteries at the fourth and fifth lum bar vertebrae am ong the patients with aortic hypoplasia and healthy individuals. The result of their study showed the Incidence In patients with aortic h yp o p la sia to be as high as 54%, com pared with only 25% in the control group. The variations of lum bar arteries could increase the possibility of vascular Injury.
(A c c e p te d 16 S ep tem be r, 1999)
8 8
Lumbar arteries with uncommon pattern of origin
Although the lum bar arteries may be injured during many surgical and diagnostic procedures in the retroperitoneum , reports in the literature have been rare (6). Kim et al. (7) reported m assive retroperitoneal hemorrhage from the first left lum bar artery as a complication of a percutaneous renal biopsy. Injury of the fourth right lum bar artery was also reported during lum bar d e co m p re ssio n lam inectom y and foram inotom y (8). Hemorrhage of the lumbar arteries associated with lum bar spinal fractures can cause life-threatening conditions (6).
C ASE R E P O R T
The current case concerns the third and fourth pairs of lum bar arteries of uncommon pattern of origin and their clinical implications.
During the dissection of the abdominal aorta, of a 44 year old male cadaver (Fig. 1). Multiple variations of origins of the lumbar arteries were encountered.
The first and second pairs did not show any abnorm ality. The third pair emerged via a short
common trunk (0.4 cm) from the posterior aspect of the aorta which subsequently branched to both sides. The fourth right lumbar artery emerged from the lateral aspect of the aorta, 1.3 cm above the aortic bifurcation while the left one emerged together with a median sacral artery 0.3 cm above bifurcation via a long common trunk (1.2 cm). There was no significant difference between the thickness of the lum bar arteries in the present case.
D IS C U S S IO N
During the fifth w eek of em bryonic life the early vascularisation of the spinal cord is furnished by the segmental vessels. They aries from the dorsal aortae, while it is still in its primitive paired
condition, and retain th e ir own paired
arrangem ent after the two aortae have fused to form a single main trunk (9).
Origin of the lum bar arteries via a common trunk could be explained by overfusion of the dorsal primitive aortae in the fourth w eek of embryonic life (5, 10).
F i g . l • : Cadaveric appearance of the lower part of the abdominal aorta and the lumbar arteries in the case. 1. abdominal aorta; 2. first left lumbar artery; 3. second left lumbar artery; 4. third pair of lumbar artery; 5. fourth right lumbar artery; 6. common trunk; 7. median sacral artery; 8. fourth left lumbar artery; 9. left common iliac artery.
Jasna Gürbüz, et al
The single bifurcating lum bar arteries (common trunk) are more frequently seen in lower pairs probably due to later vascularisation of the caudal part of the spinal cord. Hence, any causal agent has a greater length of time in which to act (9).
There are also genetic and local haem odynam ic influences such as rate and direction of flow and pressure of the blood which are concerned in the establishm ent of the final vascular pattern (11) making an explanation of mentioned variations even more complex.
Injuries of the lum bar arteries, especially those of variable origin can occur as a result of laceration, com pression or traction (12). Reported vascular injuries include com plete laceration, partial laceration or sim ultaneous rents in artery and vein with a resultant arteriovenous fistula (8).
The origins of the lum bar arteries from the posterior aspect of the aorta could be accepted as a m echanism of protection. The lum bar artery that em erges from the lateral aspect of the aorta, as in our case, is particularly prone to injury, especially during antero-lateral approaches to the lumbar spine.
Sometimes the lum bar arteries are the major blood supply of retroperitoneal soft-tissue tumors and neoplasms of the lum bar spine and bony pelvis. In th e se in sta n ce s tra n sca th e te r embolization through the lum bar vessels has successfully been em ployed in order to control hemorrage, alleviate pain, decrease tum or bulk and faciliate surgery. Due to possibility of variant lumbar arteries and inconstant origin of artery of Adamkiewicz, it is m andatory to perform an a n giog ra phy p rio r to tra n s c a th e te r arterial em bolization (2).
Massive retroperitoneal hem orrhage is the most w orrisom e, life -th re a te n in g com p lica tio n and although injury of the lum bar artery is not frequently seen, prom pt intervention is required to prevent a fatal outcom e (8).
S uccessful m anagem e nt of these injuries
depends on early diagnosis and im m ediate vascular reconstruction (12).
Therefore, it is of significant clinical importance to be aware of regular and irregular patterns of
lu m b a r arte rie s, d u rin g any surgical (8), therapeutic (6) or diagnostic (7) procedures in the retroperitoneum .
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