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http://dx.doi.org/10.3340/jkns.2018.0091

Evaluation of Dimensions of Kambin's Triangle to Calculate Maximum Permissible Cannula Diameter for Percutaneous Endoscopic Lumbar Discectomy : A 3-Dimensional Magnetic Resonance Imaging Based Study  

Pairaiturkar, Pradyumna Purushottam (Department of Spine, Deenanath Mangeshkar Hospital)
Sudame, Onkar Shekhar (Department of Spine, Deenanath Mangeshkar Hospital)
Pophale, Chetan Shashikant (Department of Spine, Deenanath Mangeshkar Hospital)
Publication Information
Journal of Korean Neurosurgical Society / v.62, no.4, 2019 , pp. 414-421 More about this Journal
Abstract
Objective : To evaluate 3-dimensional magnetic resonance imaging (MRI) of Kambin's safe zone to calculate maximum cannula diameter permissible for safe percutaneous endoscopic lumbar discectomy. Methods : Fifty 3D MRIs of 19 males and 31 females (mean, 47 years) were analysed. Oblique, axial and sagittal views were used for image analysis. Three authors calculated the inscribed circle (cannula diameter) individually, within the neural (original) and bony Kambin's triangle in oblique views, disc heights on sagittal views and root to facet distances at upper and lower end plate levels on axial views and their averages were taken. Results : The mean root to facet distances at upper end plate level measured on axial sections increased from $3.42{\pm}3.01mm$ at L12 level to $4.57{\pm}2.49mm$ at L5S1 level. The mean root to facet distances at lower end plate level measured on axial sections also increased from $6.07{\pm}1.13mm$ at L12 level to $12.9{\pm}2.83mm$ at L5S1 level. Mean maximum cannula diameter permissible through the neural Kambin's triangle increased from $5.67{\pm}1.38mm$ at L12 level to $9.7{\pm}3.82mm$ at L5S1 level. The mean maximum cannula diameter permissible through the bony Kambin's triangle also increased from $4.03{\pm}1.08mm$ at L12 level to $6.11{\pm}1mm$ at L5S1 level. Only 2% of the 427 bony Kambin's triangles could accommodate a cannula diameter of 8mm. The base of the bony Kambin's triangle taken in oblique view (3D MRI) was significantly higher than the root to facet distance at lower end plate level taken in axial view. Conclusion : The largest mean diameter of endoscopic cannula passable through "bony" Kambin's triangle was distinctively smaller than the largest mean diameter of endoscopic cannula passable through "neural" Kambin's triangle at all levels. Although proximity of exiting root to the facet joint is always taken into consideration before PELD procedure, our 3D MRI based anatomical study is the first to provide actual maximum cannula dimensions permissible in this region.
Keywords
MRI scan; Regional anatomy; Intervertebral disk; Lumbosacral regions; Endoscopic surgical procedure;
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1 Ahn Y, Lee SH, Park WM, Lee HY, Shin SW, Kang HY : Percutaneous endoscopic lumbar discectomy for recurrent disc herniation: surgical technique, outcome, and prognostic factors of 43 consecutive cases. Spine (Phila Pa 1976) 29 : E326-E332, 2004   DOI
2 Arslan M, Comert A, Acar HI, Ozdemir M, Elhan A, Tekdemir I, et al. : Nerve root to lumbar disc relationships at the intervertebral foramen from a surgical viewpoint: an anatomical study. Clin Anat 25 : 218-223, 2012   DOI
3 Choi G, Lee SH, Bhanot A, Raiturker PP, Chae YS : Percutaneous endoscopic discectomy for extraforaminal lumbar disc herniations: extraforaminal targeted fragmentectomy technique using working channel endoscope. Spine (Phila Pa 1976) 32 : E93-E99, 2007   DOI
4 Choi G, Lee SH, Lokhande P, Kong BJ, Shim CS, Jung B, et al. : Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine (Phila Pa 1976) 33 : E508-E515, 2008   DOI
5 Choi I, Ahn JO, So WS, Lee SJ, Choi IJ, Kim H : Exiting root injury in transforaminal endoscopic discectomy: preoperative image considerations for safety. Eur Spine J 22 : 2481-2487, 2013   DOI
6 Civelek E, Solmaz I, Cansever T, Onal B, Kabatas S, Bolukbasi N, et al. : Radiological analysis of the triangular working zone during transforaminal endoscopic lumbar discectomy. Asian Spine J 6 : 98-104, 2012   DOI
7 Kambin P, Gellman H : Percutaneous lateral discectomy of the lumbar spine a preliminary report. Clin Orthop Relat Res 174 : 127-132, 1983
8 Guvencer M, Naderi S, Kiray A, Yilmaz HS, Tetik S : The relation between the lumbar vertebrae and the spinal nerves for far lateral lumbar spinal approaches. J Clin Neurosci 15 : 192-197, 2008   DOI
9 Hoshide R, Feldman E, Taylor W : Cadaveric analysis of the Kambin's triangle. Cureus 8 : e475, 2016
10 Hurday Y, Xu B, Guo L, Cao Y, Wan Y, Jiang H, et al. : Radiographic measurement for transforaminal percutaneous endoscopic approach (PELD). Eur Spine J 26 : 635-645, 2017   DOI
11 Kendir S, Acar HI, Comert A, Ozdemir M, Kahilogullari G, Elhan A, et al. : Window anatomy for neurosurgical approaches. Laboratory investigation. J Neurosurg 111 : 365-370, 2009   DOI
12 Lee SH, Kang BU, Ahn Y, Choi G, Choi YG, Ahn KU, et al. : Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 cases. Spine (Phila Pa 1976) 31 : E285-E290, 2006   DOI
13 Lertudomphonwanit T, Keorochana G, Kraiwattanapong C, Chanplakorn P, Leelapattana P, Wajanavisit W : Anatomic considerations of intervertebral disc perspective in lumbar posterolateral approach via Kambin's triangle: cadaveric study. Asian Spine J 10 : 821-827, 2016   DOI
14 Loukas M, Louis RG Jr, Childs RS : Anatomical examination of the recurrent artery of Heubner. Clin Anat 19 : 25-31, 2006   DOI
15 Min JH, Kang SH, Lee JB, Cho TH, Suh JK, Rhyu IJ : Morphometric analysis of the working zone for endoscopic lumbar discectomy. J Spinal Disord Tech 18 : 132-135, 2005   DOI
16 Yeung AT, Tsou PM : Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976) 27 : 722-731, 2002   DOI
17 Mirkovic SR, Schwartz DG, Glazier KD : Anatomic considerations in lumbar posterolateral percutaneous procedures. Spine (Phila Pa 1976) 20 : 1965-1971, 1995   DOI
18 Quester R, Schroder R : The shrinkage of the human brain stem during formalin fixation and embedding in paraffin. J Neurosci Methods 75 : 81-89, 1997   DOI
19 Ruetten S, Komp M, Merk H, Godolias G : Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976) 33 : 931-939, 2008   DOI
20 Ahn Y, Lee SH, Lee JH, Kim JU, Liu WC : Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration. Acta Neurochir (Wien) 151 : 199-206, 2009   DOI