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Mitchell Hardenbrook, Sergio Lombardo, Miles C. Wilson and Albert E. Telfeian

I n 1972, Kambin described a lumbar transforaminal discectomy via the posterolateral approach and defined Kambin's triangle as the site to approach the intervertebral disc. 2 , 3 Kambin's triangle is defined as a right triangle over the dorsolateral disc: the hypotenuse is the exiting nerve root, the base (width) is the superior border of the caudal vertebra, and the height is the traversing nerve root. 2 , 3 Advances in endoscopic visualization and instrumentation, as well as increased patient demand for more minimally invasive procedures, have led to

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Michael Y. Wang and Jay Grossman

to moderate sedation. No narcotic medications are given and no spinal, epidural, or regional analgesia is used. This method has the advantage of offering the surgeon live feedback if there is any contact or tension with the neural structures as the patient will respond to this painful stimulus. In addition, this method reduces the side effects of general anesthesia, such as nausea, dysphagia, and memory loss. Surgical Technique Patients were positioned prone on a Jackson Table. The procedure was begun by accessing Kambin's triangle on the side and level of

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Laxmaiah Manchikanti, Sairam Atluri, Alan David Kaye and Joshua A. Hirsch

one method superior to the other? . Korean J Pain 28 : 11 – 21 , 2015 15 Park JW , Nam HS , Cho SK , Jung HJ , Lee BJ , Park Y : Kambin's triangle approach of lumbar transforaminal epidural injection with spinal stenosis . Ann Rehabil Med 35 : 833 – 843 , 2011 16 Park KD , Lee J , Jee H , Park Y : Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain . Am J Phys Med Rehabil 91 : 1039 – 1050 , 2012 17 Tan LA , Kasliwal MK , Deutsch H : Complications associated with epidural

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Albert E. Telfeian, Anand Veeravagu, Adetokunbo A. Oyelese and Ziya L. Gokaslan

origin, the technique showed promising results: Kambin and Gellman reported a 72% success rate in 136 patients with their percutaneous technique in 1983, but it has been difficult to quantify the impact of such results because they were not matched with nonoperative controls. 28 Thus, percutaneous endoscopic discectomy represented what is only an indirect spinal decompression, but a direct and very powerful new surgical approach to spinal pathology. Kambin's Triangle In 1990, Parvis Kambin described a triangular safe zone bordered by the exiting root anteriorly

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Hormoz Sheikh, Karen Zakharian, Ramiro Perez De La Torre, Christopher Facek, Adrian Vasquez, G. Rasul Chaudhry, David Svinarich and Mick J. Perez-Cruet

the disc segment of interest. The overlying skin was first anesthetized with 0.75% bupivacaine, and a 16-gauge needle was then advanced into the disc space through the Kambin triangle, starting ~ 3 cm off the midline at the level of interest. To guide needle placement, AP and lateral fluoroscopic imaging were used ( Fig. 1 ). The needle was advanced until fluoroscopic confirmation showed the needle tip to be in the center of the disc. Needle punctures of 2 adjacent discs at L2–3 (Group B) and L3–4 (Group C) experimental groups were performed to induce disc

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without written permission from JNSPG. 2016 Introduction: One of the goals of minimally invasive surgery (MIS) has been to speed the recovery following surgery. In this cases series we utilized an endoscopic technique for interbody fusion combined with percutaneous screws to obviate the need for complete general anesthesia. Methods: The first 10 consecutive patients treated with minimum one-year follow-up were included in this series. The patients were all treated using endoscopic access through Kambin's triangle to allow for neural decompression

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Karthik Madhavan, Lee Onn Chieng, Christoph P. Hofstetter and Michael Y. Wang

fractional curve. B: Postoperative dynamic flexion-extension radiographs show spondylolisthesis but no significant movement or worsening of the L5–S1. Operation The patient underwent a left-sided L5/S1 transforaminal endoscopic discectomy with intraoperative discography. The patient was positioned prone under monitored anesthesia care. Using fluoroscopy, the L5–S1 disc space was accessed through Kambin's triangle using successive dilators and reamers through a 7-mm left flank incision. The herniated disc was removed and a foraminal enlargement was achieved with

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Albert E. Telfeian, Gabriele P. Jasper, Adetokunbo A. Oyelese and Ziya L. Gokaslan

the surgeon throughout the procedure. The joimax TESSYS endoscopic system was used for the procedure. Percutaneous entry was established, entering through the skin 5–8 cm lateral to the midline. Using intermittent fluoroscopic guidance, alternating between a lateral and anteroposterior (AP) view, a 25-cm 18-gauge needle was advanced and placed in the disc space through Kambin's triangle, between the exiting and traversing nerves. An AP fluoroscopic view was used to assure that the disc space was entered before the needle was past the middle of pedicle. Sequential

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Ralf Wagner, Menno Iprenburg and Albert E. Telfeian

fluoroscopic guidance, alternating between lateral and anteroposterior views, a 25-cm 18-gauge needle was advanced and placed in the disc space through Kambin's triangle, between the exiting and traversing nerves. An anteroposterior fluoroscopic view was used to ensure that the disc space was entered before the needle was inserted beyond the medial wall of the pedicle. Sequential reamers were used to enlarge the neural foramen by removing the ventral aspect of the superior articulating process ( Fig. 2 ). Resection of the bone fragment and decompression of the neural

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Lynn B. McGrath Jr., Karthik Madhavan, Lee Onn Chieng, Michael Y. Wang and Christoph P. Hofstetter

in foraminal stenosis (asterisk) . B: Sagittal T1-weighted MRI study depicts an additional foraminal disc bulge (arrow) , which further aggravates foraminal stenosis. FIG. 2. Endoscopic foraminotomy. A: During the initial phase of the foraminotomy the Kambin's triangle is exposed. Asterisk indicates the superior articulating process. The arrow points toward the foraminal disc protrusion. B: An articulating bur has been used to resect the anterior aspect of the superior articulating process, including the tip of the process (asterisk) . The