The Great Escape
Interfascial Decompression Planes of the Retroperitoneum
Richard M. Gore1,
Dennis M. Balfe2,
Robert I. Aizenstein3 and
Paul M. Silverman4
1
Department of Radiology, Evanston Hospital-Northwestern University, 2650 Ridge
Ave., Evanston, IL 60201.
2
Department of Diagnostic Radiology, Mallinckrodt Institute of Radiology,
Washington University School of Medicine, 510 S. Kingshighway, St. Louis, MO
63110.
3
Department of Radiology, University of Illinois Medical Center, 1740 W.
Taylor, Chicago, IL 60612.
4
Department of Radiology, M. D. Anderson Cancer Center, Department of
Radiology, Box 057, 1515 Holcomb Blvd., Houston, TX 77030.
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Fig. 1. —Retroperitoneal and interfascial planes. Drawing at level of renal
hila shows that renal and lateroconal fasciae are laminated planes composed of
apposed layers of embryonic mesentery. Thickness of interfascial planes is
exaggerated to illustrate their potentially expansile nature. Note that
perinephric spaces (PRS) are closed medially. Retromesenteric space is
continuous across midline. Retromesenteric anterior interfascial space (RMP),
retrorenal posterior interfascial space (RRS), and lateroconal plane
communicate at fascial trifurcation (arrows). A = aorta, APS =
anterior pararenal space, ARF = anterior renal fascia, DPS = dorsal pleural
sinus, IVC = inferior vena cava, LCF = lateroconal fascia, PP = parietal
peritoneum, PPS = posterior pararenal space, PRF = posterior renal fascia, TF
= transversalis fascia, asterisk = posterior peritoneal recess.
(Reprinted from [3])
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Fig. 2A. —Perinephric space bridging septa. Drawing of perinephric space at
level of mid pole of kidney shows that perinephric space contains rich network
of bridging septa (open arrows), lymphatics (solid arrow),
arteries, and veins (arrowhead). Note that perirenal lymphatics
communicate with small lymph nodes at renal hilum, and that these, in turn,
connect with periaortic and pericaval lymph nodes. This lymphatic network
provides potential route of spread for metastatic tumor into perinephric
space. (Reprinted from [3])
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Fig. 2B. —Perinephric space bridging septa. T1-weighted (B) and
T2-weighted fat-suppressed (C) MR images in 47-year-old man with
left-sided pyelonephritis reveal fluid-filled bridging perinephric septa
(arrows).
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Fig. 2C. —Perinephric space bridging septa. T1-weighted (B) and
T2-weighted fat-suppressed (C) MR images in 47-year-old man with
left-sided pyelonephritis reveal fluid-filled bridging perinephric septa
(arrows).
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Fig. 3. —52-year-old woman with aortic bleeding. CT scan at level of lower
poles of kidneys shows hemorrhage in anterior interfascial plane (straight
open arrow), posterior interfascial plane (curved solid arrow),
and lateroconal interfascial plane (curved open arrow). These
collections meet at fascial trifurcation (straight solid arrow).
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Fig. 4. —59-year-old man with fulminant ulcerative colitis in whom incomplete
fusion of fascial planes has permitted retromesenteric and retrorenal
extension of peritoneal fluid. CT scan shows that ascending (A) and descending
(D) mesocolons have not completely fused with renal fascia, permitting ascites
(straight arrows) to enter anterior interfascial retromesenteric
plane. Posterior renal fascia has also not fused, allowing peritoneal fluid to
extend into retrorenal posterior interfascial planes (curved arrows).
These anterior interfascial planes are easily surgically dissected during
hemicolectomy. Posterior interfascial planes are readily dissected during
nephrectomy.
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Fig. 5. —45-year-old woman with interfascial fluid spread in acute
pancreatitis and retrorenal dissection of fluid in lumbar triangle. Note fluid
in left anterior interfascial space (straight open arrow),
lateroconal interfascial space (curved open arrow), and posterior
interfascial space (curved solid arrow). Fluid extends to and
thickens transversalis fascia (straight solid arrow), dissecting
quadratus lumborum muscles and posterior pararenal fat (arrowhead).
This is source of Grey Turner's sign of pancreatitis.
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Fig. 6. —58-year-old man with pancreatitis and inflammatory fluid spread into
interfascial planes. CT scan shows fluid extending into anterior interfascial
space (open arrow), right fascial trifurcation (solid
arrow), and subsequently lateroconal and posterior interfascial spaces.
Note that fat in anterior pararenal space adjacent to ascending colon (AC) is
spared.
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Fig. 7A. —65-year-old man with spontaneous subcapsular renal hemorrhage
decompressing along perinephric bridging septa and retroperitoneal
interfascial planes. CT scan at level of mid kidney shows both subcapsular and
perinephric hemorrhage. Note thickened perinephric bridging septa
(arrows).
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Fig. 7B. —65-year-old man with spontaneous subcapsular renal hemorrhage
decompressing along perinephric bridging septa and retroperitoneal
interfascial planes. CT scan at level slightly lower than that of A
shows perinephric blood decompressing in anterior (open arrow) and
posterior (curved arrow) interfascial planes. Note that descending
colon (straight solid arrow) and fat in anterior pararenal space are
uninvolved.
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Fig. 7C. —65-year-old man with spontaneous subcapsular renal hemorrhage
decompressing along perinephric bridging septa and retroperitoneal
interfascial planes. CT scan at level of iliac crest shows that blood
extending down anterior and posterior interfascial planes lies in caudal
continuation of these structures—the combined interfascial plane
(arrows).
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Fig. 8. —Ruptured calyceal fornix with urine decompressing into anterior and
posterior (curved arrow) interfascial spaces in 60-year-old woman
with obstructive uropathy caused by adenopathy resulting from stage IV
cervical cancer. CT scan at level of mid pole of right kidney shows
hydronephrosis and urine dissecting into bridging perinephric septa. Multiple
calcified gallstones are present. Note posterior perinephric (Zuckerkandl's
body) fascia (straight arrow) is separated from posterior pararenal
space by this urinoma.
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Fig. 9. —Interfascial dissection of gas. CT scan shows ERCP-related duodenal
perforation resulting in dissection of gas in anterior interfascial plane
(straight arrow) in 63-year-old man. Scan also shows gas and fluid in
posterior interfascial plane (curved arrow).
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Fig. 10. —Intraperitoneal and retroperitoneal gas is present on this CT scan
of 61-year-old man with chronic obstructive pulmonary disease, pneumothorax,
and retroperitoneal and peritoneal extension of air. Note how gas has easily
dissected anterior (straight arrow) and posterior (curved
arrow) interfascial planes. Intramural dissection of gas has also
occurred in colon.
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Fig. 11. —CT scan of 57-year-old man with schemic colitis shows edema
extending into anterior interfascial plane (open arrow), fascial
trifurcation (solid arrow), and pericolic fat in anterior pararenal
space. Note marked colonic mural thickening and submucosal edema.
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Fig. 12. —CT scan of 49-year-old man with pseudomembranous colitis shows mural
thickening of ascending (AC) and descending (DC) colons. Note inflammation of
fat of anterior pararenal spaces bilaterally. Also note that fluid has
extended in anterior (straight arrow) and posterior (curved
arrows) interfascial spaces bilaterally.
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Fig. 13. —Aortic aneurysm rupture with interfascial spread of retroperitoneal
hematoma (straight arrows) in 73-year-old man. CT scan obtained at
level of lower pole of left kidney reveals hyperdense hematoma extending
across midline in anterior interfascial (retromesenteric) plane bilaterally.
On right, hematoma also decompresses in posterior interfascial plane
(curved arrow).
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Fig. 14. —Metastases to perinephric and interfascial spaces from carcinoma of
pancreas in 70-year-old woman. CT scan shows marked retroperitoneal
lymphadenopathy (curved arrow) with tumor spread into anterior
interfascial plane (open arrow). Tumor has also infiltrated
perinephric lymphatics (straight solid arrow).
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Copyright © 2000 by the American Roentgen Ray Society.
