The anterior approach at L5-S1 has many advantages, however, vascular complications are challenging for spinal surgeons who may not be familiar with the variability of vascular anatomy. There are three different anterior approaches (intra-bifurcation approach and extra-bifurcation: left-, and right-sided pre-psoas approaches) described in previous studies to respond to the variability of anterior vascular anatomy for reduction in vascular injury, while no guidance for the choice of approach preoperatively.To analyze the anatomical feasibility of three anterior approaches to access the L5-S1 disk space according to a practical framework.Retrospective study.Lumbar magnetic resonance imaging (MRI) from patients who visited our outpatient clinic were reviewed, with 150 cases meeting the inclusion criteria.The following radiographic parameters were measured on axial T2-weighted MRI at the lower endplate of L5 and the upper endplate of S1: width of the vascular corridor, position of the left and right common iliac vein (CIV), and presence of perivascular adipose tissue (PAT). Moreover, we designed a safe line to evaluate the feasibility of left-, and right-sided pre-psoas approaches. Cases of lumbosacral transitional vertebrae were identified.The feasibility of the intra-bifurcation approach was determined by the width of the vascular corridor, presence of PAT, and the position of the CIV. The feasibility of the pre-psoas approach was determined by the relative position of the CIV to the safe line, presence of PAT, and the intersection point of the CIV and vertebral body.68%, 64.7%, and 75.3% cases allowed the intra-bifurcation, left-, and right-sided pre-psoas approach to L5-S1, respectively. The cases in this study had at least one of three anterior approaches to access L5-S1 disk space, and 74% of cases had more than one anatomical feasibility of anterior approach. The right-sided pre-psoas approach was feasible in the majority of cases because of the vertical course of the right CIV with a significantly higher proportion of presence of PAT. Patients with lumbosacral transitional vertebrae (24 cases) may prefer the pre-psoas approaches, and only six cases (25.0%) were determined to be feasible for the intra-bifurcation approach.Our study proposes a practical framework to determine whether the three different anterior approaches are feasible access at L5-S1. According to the framework, all cases had the anatomical feasibility of using an anterior approach to access L5-S1, and three-fourths of cases had a replaceable anterior approach when encountering intraoperative difficulties.Copyright © 2023. Published by Elsevier Inc.