Direct anterior decompression of L4 and L5 nerve root in sacral fractures using the pararectus approach: a technical note

Arch Orthop Trauma Surg. 2020 Mar;140(3):343-351. doi: 10.1007/s00402-019-03276-7. Epub 2019 Sep 13.


Purpose: To describe a new surgical technique for neurolysis and decompression of L4 and L5 nerve root entrapment after vertical sacral fractures via the pararectus approach for acetabular fractures, and to present four case examples.

Patients and methods: We retrospectively evaluated four patients suffering radiculopathy from entrapment of the L4 or L5 nerve root in vertical sacral fractures between January and December 2016. The mean follow-up period after surgery was 18 (range 7-27) months. All patients underwent direct decompression and neurolysis of the L4 and L5 nerve roots via the single-incision, intrapelvic, extraperitoneal pararectus approach.

Results: In all patients, the L4 and L5 nerve root was successfully visualized and decompressed, proving feasibility of the pararectus approach for this indication. No patient presented with a neural tear. Complete neurologic recovery was present in one patient at last follow-up; two patients had incomplete recovery of their radiculopathy; and one patient had no improvement after nerve root decompression.

Conclusions: The pararectus approach allows for sufficient visualisation and direct decompression and neurolysis of the L4 and L5 nerve root entrapped in vertical sacral fractures. Although neurologic recovery was not achieved in all patients in this small case series, the approach may be a suitable alternative to posterior approaches and other anterior approaches such as the lateral window of the ilioinguinal approach.

Keywords: Anterior approach lumbar plexus; L4-nerve root injury; L5 nerve root injury; Nerve root entrapment; Neurolysis; Pararectus approach; Radiculopathy; Vertical sacral fractures.

MeSH terms

  • Decompression, Surgical / methods*
  • Humans
  • Lumbar Vertebrae* / innervation
  • Lumbar Vertebrae* / surgery
  • Nerve Compression Syndromes / surgery
  • Retrospective Studies
  • Sacrum* / injuries
  • Sacrum* / surgery
  • Spinal Fractures / surgery*
  • Spinal Nerve Roots / surgery*