Radiographic measurement for transforaminal percutaneous endoscopic approach (PELD)

Hurday, Yuvraj; Xu, Baoshan; Guo, Lin; Cao, Yi; Wan, Yong; Jiang, Hongfeng; Liu, Yue; Yang, Qian; Ma, Xinlong

doi:10.1007/s00586-016-4454-z

Cited by 36 publications

(49 citation statements)

References 26 publications

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“…Our group measured the distance from the nerve root to the lateral border of the superior facet on the MRI axis in the superior and inferior margins of the intervertebral disc. From the L 2‐3 level to the L 5 S 1 level, the maximum value is 6.41 mm. In this study, the distance from the exiting nerve root to the facet joint surface, which is equivalent to the removal of the entire superior articular process during surgery, on the CT axis was larger on the inferior margins of the disc.…”

Section: Discussionmentioning

confidence: 53%

CT‐based Morphometric Analysis of Approach of Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion

Zhang

et al. 2019

Orthopaedic Surgery

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Objectives A radiographic study was designed to measure the relationship of the exiting nerve root and its surroundings to the corresponding intervertebral disc for percutaneous transforaminal endoscopic lumbar interbody fusion to better understand the regional anatomy and to improve clinical applications. Methods A retrospective study from January 2017 to October 2017 was conducted at Tianjin Hospital. CT images were obtained from patients presenting low back pain (110 patients), and analysis was performed bilaterally from L2‐3 to L5S1. In the rotating coronal plane we analyzed: the nerve root–dural sac distance at the superior and inferior margins of the disc (Js, Ji); the nerve root–pedicle distance at the medial, middle, and lateral borders of the pedicle (Pa, Pb, Pc); the pedicle width (W); and the safe working zone, defined as a trapezoid bounded by the inferior pedicle and the exiting nerve root (S). In the transverse plane, the nerve root‐articular process and the shortest distance for the nerve root‐articular process joint surface were analyzed at the superior and inferior margins of the disc (Gs, Gi), respectively. The groups were analyzed using ANOVA, and paired t‐tests were used to compare the left and right sides. Results From L2‐3 to L5S1, the distance of the nerve root to the dural sac was larger at the inferior margin of the disc. From L2‐3 to L5S1, each segment of the vertebral nerve root‐pedicle distance gradually decreased from medial to lateral. From L2‐3 to L5S1, the distance from the exiting nerve root to the middle and lateral margins of the pedicle gradually decreased, with L5S1 being the minimum. Some significant differences were observed between the left and right sides for L4‐5 and L5S1. The pedicle width of the vertebral body and the mean area for the safe working zone gradually increased from L2‐3 to L5S1. In the axial plane, the shortest distance between the nerve root and articular process joint surface at the inferior margin of the disc was greater than the distance for the nerve root to the articular process at the superior margin of the disc from L2‐3 to L5S1. There were no significant differences between the two sides. Conclusions It is more difficult to implant a cage with a width of 10 mm above the L3‐4 level. By removing part of the superior articular process, the safe working area can be expanded, and damage to the nerve or other structures can be avoided when implanting a cage.

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Section: Discussionmentioning

confidence: 53%

CT‐based Morphometric Analysis of Approach of Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion

Zhang

et al. 2019

Orthopaedic Surgery

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“…Previous reports documented attempts at evaluating the triangular working zone on transverse, sagittal, and coronal MR images. 6,9,10,27 Examinations of nerve root branching angles in MR coronal images showed that the intervertebral disk angles are smaller in the lower spinal column intervertebral spaces. 10 Further, some studies evaluated distances between SAPs and exiting nerves and measured these distances on MR transverse images at the inferior intervertebral disk margins.…”

Section: Discussionmentioning

confidence: 99%

“…10 Further, some studies evaluated distances between SAPs and exiting nerves and measured these distances on MR transverse images at the inferior intervertebral disk margins. 8,10,27 These values may make it possible to determine the increased surgical risk in patients with small triangular working zones, although there are a limited number of reports on clinical outcomes in patients who were considered to be at low risk. 6 However, in all of these studies, the authors revealed that because the triangular working zone is a 3D structure, there are limitations to evaluating it on 2D images.…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcomes Based on Preoperative Kambin's Triangular Working Zone Measurements on 3D CT/MR Fusion Imaging to Determine Optimal Approaches to Transforaminal Endoscopic Lumbar Diskectomy

Hirayama¹,

Hashimoto²,

Sakamoto³

2020

J Neurol Surg A Cent Eur Neurosurg

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Background Transforaminal endoscopic lumbar diskectomy (TELD) is a widely used minimally invasive surgical procedure to treat herniated disks. Postoperative dysesthesia (POD) is a significant complication that affects patient satisfaction. Several anatomical and magnetic resonance (MR) imaging studies of the intervertebral foramina showed that TELD should be avoided in patients with small Kambin's triangular working zones. Recently, some reports indicated the usefulness of three-dimensional (3D) computed tomography/magnetic resonance (CT/MR) fusion images. To date, no articles have been published in the English literature regarding the use of 3D CT/MR fusion images before TELD to evaluate Kambin's triangular working zone. Our objective was to examine clinical outcomes when preoperative Kambin's triangular working zone measurements from 3D CT/MR fusion images were used to determine the approach to TELD. Patients and Methods We included 31 patients who underwent TELD. We rotated the 3D CT/MR fusion images from the posteroanterior view on the approach side to the angle at which Kambin's triangular working zone appeared the largest. This was used to determine the intraoperative insertion angle for the working cannula. When the perpendicular line extending from the exiting nerve at the intervertebral disk level to the upper margin of the superior articular process (exiting nerve-superior articular process distance [ESD]) was less than or equal to 7 mm, an approach that combined foraminoplasty with an outside-in technique (F + outside-in) was used. We compared ESD and clinical outcomes, such as POD, between the approaches. Results Surgical plans were based on ESD values from 22 patients. ESD was 7 mm in 21 patients, all of whom underwent F + outside-in. The inside-out approach was used in eight of nine patients who did not have ESD measurements. Of these, five patients had retrospective ESD measurements of 7 mm. The mean ESD was 6.3 ± 1.0 mm when inside-out was used and 4.4 ± 1.6 mm when F + outside-in was used, a significant difference. Significant improvements were observed in the visual analog scale scores for low back pain, lower limb pain, and lower limb paresthesia. There were no incidences of POD or intraoperative complications. Conclusion Based on preoperative Kambin's triangular working zone measurements from 3D CT/MR fusion images, F + outside-in should be selected when the working zone is smaller than the cannula diameter. This method successfully avoided POD in our study. Preoperative Kambin's triangular working zone measurements from 3D CT/MR fusion imaging can enhance patient safety during TELD.

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“…Since the body sizes of individual patients are different, the puncture and localization procedures mainly rely on the experience of the operators, making it one of the most difficult steps for beginners in performing PELD (13). The existing preoperative measuring methods mainly rely on 2-dimensional (2D) X-ray images or MRI cross-sections (14). Because the bony structure and the trajectory are 3-dimensional (3D), the relationship between the anatomical lumbar structure and the working channel cannot be evaluated precisely.…”

Section: Virtual Trajectory Placement and Measurementmentioning

confidence: 99%

Quantitative 3D Trajectory Measurement for Percutaneous Endoscopic Lumbar Discectomy

2018

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Background: Percutaneous endoscopic lumbar discectomy (PELD) has become an increasingly popular minimally invasive spinal surgery. Due to the technical evolution of PELD, the focus of decompression has shifted from the central nucleus to the subannular-protruded disc herniation, which allows direct neural decompression. Surgical entry into the spinal canal leads to the greater possibility of bony structure obstruction, thus the location and direction of the working channel are crucial. The existing preoperative measuring methods mainly rely on 2-dimensional (2D) x-ray images or MRI cross-sections. Because the bony structure and the trajectory are 3-dimensional (3D), the relationship between the anatomical lumbar structure and the working channel cannot be precisely evaluated. Objectives: To investigate a 3D method and quantitatively evaluate the trajectory for percutaneous endoscopic lumbar discectomy (PELD). Study Design: Technical note. Setting: Pain medicine center of a university hospital. Methods: Twenty patients suffering from L4/5 disc herniation were enrolled in this study. After reconstructing the preoperative CT images, the virtual trajectory was placed into the intervertebral foramen through gradient-changing angulations in relation to the coronal and transverse planes. The overlapping portion of the virtual trajectory and the lumbar vertebrae was evaluated. In addition, the probability of atypical structure involvement was calculated. Results: As cephalad angulation (CA) increased, the intersection volume of the L4 inferior articular process increased, while the total intersection volume, the intersection volume of the L5 superior articular process, the intersection volume of the facet joint, and the volume proportion of L5 superior articular process intersection in the facet joint all decreased. As coronal plane angulation (CPA) increased, the total intersection volume, the intersection volume of the L4 inferior articular process, and the intersection volume of the facet joint all increased, while the volume proportion of the L5 superior articular process intersection in the facet joint decreased. When CA increased to 15°-20°, there was a high probability of atypical structure involvement, whereas such a probability in the groups of CA 0° (CPA 15°, 20°, and 25°), CA 5° and CA 10° was low. Limitations: Only patients with L4/5 herniation were evaluated in this study. Conclusions: In terms of the regularity, the ideal angulation for L4/L5 PELD is CPA 5°-10° and CA 5°-10°, which can lead to a relatively low level of total damage to the bony structure, minimal damage to the facet joint, and negligible involvement of atypical structures. Key words: Lumbar disc herniation, percutaneous endoscopic lumbar discectomy (PELD), transforaminal, trajectory, 3D method, quantitative measurement, angulation, bony structure obstruction

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Radiographic measurement for transforaminal percutaneous endoscopic approach (PELD)

Abstract: At lower lumbar levels the exiting nerve root is at risks of injury. Hence, it is advised to enlarge the foramen for safe passage of endoscopic instruments and to minimize the possibility of nerve injury.

Cited by 36 publications

References 26 publications

CT‐based Morphometric Analysis of Approach of Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion

CT‐based Morphometric Analysis of Approach of Percutaneous Transforaminal Endoscopic Lumbar Interbody Fusion

Clinical Outcomes Based on Preoperative Kambin's Triangular Working Zone Measurements on 3D CT/MR Fusion Imaging to Determine Optimal Approaches to Transforaminal Endoscopic Lumbar Diskectomy

Quantitative 3D Trajectory Measurement for Percutaneous Endoscopic Lumbar Discectomy

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