Kambin's triangle and the position of the dorsal nerve root in the lumbar neural foramen

König, Anya; Joseph, Febin; Rensburg, Charl Janse van; Myburgh, Jolandie; Keough, Natalie

doi:10.1002/ca.23565

Cited by 9 publications

(5 citation statements)

References 39 publications

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“…On the one hand, transforaminal ligaments in the lumbar intervertebral foramen, such as the superior and inferior costotransverse ligaments, which are mostly distributed in the L5-S1 neuroforamen, may influence the L5 nerve root during the reduction process [ 24 ]. On the other hand, extra-foraminal motion of the L5 nerve root during patient positioning could also contribute to a stretch injury of the L5 nerve root due to nerve excursion and displacement of intrathecal nerve roots [ 2 , 12 , 18 ]. Osteophytes arising from the lower L5 and upper S1 may also contribute to the development of postoperative L5 palsy [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

A novel anatomo-physiologic high-grade spondylolisthesis model to evaluate L5 nerve stretch injury after spondylolisthesis reduction

et al. 2021

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L5 nerve palsy is a well-known complication following reduction of high-grade spondylolisthesis. While several mechanisms for its occurrence have been proposed, the hypothesis of L5 nerve root strain or displacement secondary to mechanical reduction remains poorly studied. The aim of this cadaveric study is to determine changes in morphologic parameters of the L5 nerve root during simulated intraoperative reduction of high-grade spondylolisthesis. A standard posterior approach to the lumbosacral junction was performed in eight fresh-frozen cadavers with lumbosacral or lumbopelvic screw fixation. Wide decompressions of the spinal canal and L5 nerve roots with complete facetectomies were accomplished with full exposure of the L5 nerve roots. A 100% translational slip was provoked by release of the iliolumbar ligaments and cutting the disc with the attached anterior longitudinal ligament. To evaluate the path of the L5 nerves during reduction maneuvers, metal bars were inserted bilaterally at the inferomedial aspects of the L5 pedicle at a distance of 10 mm from the midpoint of the L5 pedicle screws. There was no measurable change in length of the L5 nerve roots after 50% and 100% reduction of spondylolisthesis. Mechanical strain or displacement during reduction is an unlikely cause of L5 nerve root injury. Further anatomical or physiological studies are necessary to explore alternative mechanisms of L5 nerve palsy in the setting of high-grade spondylolisthesis correction, and surgeons should favor extensive surgical decompression of the L5 nerve roots when feasible.

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Section: Discussionmentioning

confidence: 99%

A novel anatomo-physiologic high-grade spondylolisthesis model to evaluate L5 nerve stretch injury after spondylolisthesis reduction

et al. 2021

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“…König et al examined L1-5 levels in 20 cadavers and found that L2-3 was larger than L3-4 (181.2 mm 2 vs 172.2 mm 2 ). 4 Additionally, in Hardenbrook et al's analysis of 8 cadavers, L1-2 (175 mm 2 ) was larger than both L2-3 (172 mm 2 ) and L3-4 (171 mm 2 ). 11 On the other side, Lertudomphonwanit et al found that L1-2 (100.23 mm 2 ) was larger than L2-3 (98.73 mm 2 ).…”

Section: Area Of Kambin's Trianglementioning

confidence: 94%

“…For this reason, there have been differences regarding the exact definition, sizes, and anatomical limits of Kambin's triangle. [4][5][6][7][8][9][10][11][12] ABBREVIATIONS ENR = exiting nerve root; MISS = minimally invasive spine surgery; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SAP = superior articular process.…”

mentioning

confidence: 99%

How dimensions can guide surgical planning and training: a systematic review of Kambin’s triangle

Kouam

Tabarestani

Sykes

et al. 2023

Neurosurgical Focus

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OBJECTIVE The authors sought to analyze the current literature to determine dimensional trends across the lumbar levels of Kambin’s triangle, clarify the role of imaging techniques for preoperative planning, and understand the effect of inclusion of the superior articular process (SAP). This compiled knowledge of the triangle is needed to perform successful procedures, reduce nerve root injuries, and help guide surgeons in training. METHODS The authors performed a search of multiple databases using combinations of keywords: Kambin’s triangle, size, measurement, safe triangle, and bony triangle. Articles were included if their main findings included measurement of Kambin’s triangle. The PubMed, Scopus, Ovid, Cochrane, Embase, and Medline databases were systematically searched for English-language articles with no time frame restrictions through July 2022. RESULTS Eight studies comprising 132 patients or cadavers were included in the study. The mean ± SD age was 66.69 ± 9.6 years, and 53% of patients were male. Overall, the size of Kambin’s triangle increased in area moving down vertebral levels, with L5–S1 being the largest (133.59 ± 4.36 mm2). This trend followed a linear regression model when SAP was kept (p = 0.008) and removed (p = 0.003). There was also a considerable increase in the size of Kambin’s triangle if the SAP was removed. CONCLUSIONS Here, the authors have provided the first reported systematic review of the literature of Kambin’s triangle, its measurements at each lumbar level, and key areas of debate related to the definition of the working safe zone. These findings indicate that CT is heavily utilized for imaging of the safe zone, the area of Kambin’s triangle tends to increase caudally, and variation exists between patients. Future studies should focus on using advanced imaging techniques for preoperative planning and establishing guidelines for surgeons.

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“…Finally, the size and shape of the inferior triangle are known to be highly variable and sensitive to adjacent spinal pathology such as facet hypertrophy, disk herniation, and loss of disk height. [45][46][47] In some patients, the inferior triangle may be no more than a theoretical space, without any appreciable surface area between the exiting nerve root, the superior endplate of the adjacent vertebral body, and the facet joint. 45 Thus, successful TFESI via the inferior triangle may impair epidural contrast spread and present additional technical challenges above and beyond the safe triangle approach, while not necessarily obviating intravascular injection.…”

Section: Anesthesia and Analgesiamentioning

confidence: 99%

Pro-Con Debate: Superior Versus Inferior Triangle Needle Placement in Transforaminal Epidural Injections

Doshi,

Engle,

Przybysz

et al. 2023

Anesthesia &Amp; Analgesia

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Although transforaminal epidural injections have long been used for radicular pain, there is no universal standard injection approach to the neural foramen. The intervertebral foramen and its surrounding structures comprise an anatomically sensitive area that includes bone and joint structures, the intervertebral disk, blood vessels (in particular, the radicular arteries), the epidural sheath, and the spinal nerve root. Given the relatively high risk of inadvertent injury or injection to these nearby structures, image guidance for transforaminal epidural steroid injections (TFESIs) is standard of care. However, there is a lack of consensus regarding the optimal approach to the neural foramen: from the traditional superior (“safe”) triangle or from the inferior (Kambin’s) triangle. In this Pro-Con commentary article, we discuss the relative advantages and disadvantages of each approach for TFESIs.

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Kambin's triangle and the position of the dorsal nerve root in the lumbar neural foramen

Cited by 9 publications

References 39 publications

A novel anatomo-physiologic high-grade spondylolisthesis model to evaluate L5 nerve stretch injury after spondylolisthesis reduction

A novel anatomo-physiologic high-grade spondylolisthesis model to evaluate L5 nerve stretch injury after spondylolisthesis reduction

How dimensions can guide surgical planning and training: a systematic review of Kambin’s triangle

Pro-Con Debate: Superior Versus Inferior Triangle Needle Placement in Transforaminal Epidural Injections

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