Three-dimensional architecture of the neurovascular and adipose zones of the upper and lower lumbar intervertebral foramina: an epoxy sheet plastination study

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OBJECTIVE

Kambin’s triangle and the safe triangle are common posterolateral approaches for lumbar transforaminal endoscopic surgery and epidural injection. To date, no consensus has been reached on the optimal transforaminal approach, in particular its underlying anatomical mechanism. The aim of this study was to investigate the 3D architecture of the neurovascular and adipose zones in the upper and lower lumbar intervertebral foramina (IVFs).

METHODS

Using the epoxy sheet plastination technology, 22 cadaveric lumbar spines (12 female and 10 male, age range 46–89 years) were prepared as a series of transverse (11 sets), sagittal (8 sets), and coronal (3 sets) slices with a thickness of 0.25 mm (6 sets) or 2.5 mm (16 sets). The high-resolution images of the slices were scanned and analyzed. The height, area, and volume of 30 IVFs from T12–L1 to L4–5 were estimated and compared. This study was performed in accord with the authors’ institutional ethical guidelines and approved by the institutional ethics committees.

RESULTS

The findings were as follows. 1) The 3D boundaries of the lumbar IVF and its subdivisions were precisely defined. 2) The 3D configuration of the neurovascular and adipose zones was different between the upper and lower lumbar IVFs; zoning in the upper lumbar IVFs was much more complex than that in the lower lumbar IVFs. 3) In general, the infraneural adipose zone gradually tapered and rotated from the inferoposterolateral aspect to the superoanteromedial aspect. 4) The average height, area, and volume of the IVF gradually increased from the upper to the lower lumbar spine. Within a lumbar IVF, the volumes below and above the inferior border of the dorsal root ganglia were similar.

CONCLUSIONS

This study highlights differences of fine 3D architecture of neurovascular and adipose tissues between the upper and lower lumbar IVFs, with related effects on the transforaminal approaches. The findings may contribute to optimization of the surgical approaches to and through the IVF at different lumbar spinal levels and also may help to shorten the learning curve for the transforminal techniques.

ABBREVIATIONS DRG = dorsal root ganglion; IVD = intervertebral disc; IVF = intervertebral foramen; IVJ = intervertebral joint; PA = posteroanterior; SAP = superior articular process; TFB = transforaminal fibrous bundle.
Article Information

Contributor Notes

Correspondence Ming Zhang: University of Otago, Dunedin, New Zealand. ming.zhang@anatomy.otago.ac.nz.INCLUDE WHEN CITING Published online January 10, 2020; DOI: 10.3171/2019.10.SPINE191164.

Z.X. and G.L. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Cho PGJi GYShin DAHa YYoon DHKim KN: An effect comparison of teriparatide and bisphosphonate on posterior lumbar interbody fusion in patients with osteoporosis: a prospective cohort study and preliminary data. Eur Spine J 26:6916972017

    • Search Google Scholar
    • Export Citation
  • 2

    Choi GPophale CSPatel BUniyal P: Endoscopic spine surgery. J Korean Neurosurg Soc 60:4854972017

  • 3

    Depauw PRAMGadjradj PSSoria van Hoeve JSHarhangi BS: How I do it: percutaneous transforaminal endoscopic discectomy for lumbar disk herniation. Acta Neurochir (Wien) 160:247324772018

    • Search Google Scholar
    • Export Citation
  • 4

    Derby RKine GSaal JAReynolds JGoldthwaite NWhite AH: Response to steroid and duration of radicular pain as predictors of surgical outcome. Spine (Phila Pa 1976) 17 (6 Suppl):S176S1831992

    • Search Google Scholar
    • Export Citation
  • 5

    Fujiwara AAn HSLim THHaughton VM: Morphologic changes in the lumbar intervertebral foramen due to flexion-extension, lateral bending, and axial rotation: an in vitro anatomic and biomechanical study. Spine (Phila Pa 1976) 26:8768822001

    • Search Google Scholar
    • Export Citation
  • 6

    Glaser SEShah RV: Root cause analysis of paraplegia following transforaminal epidural steroid injections: the ‘unsafe’ triangle. Pain Physician 13:2372442010

    • Search Google Scholar
    • Export Citation
  • 7

    Hardenbrook MLombardo SWilson MCTelfeian AE: The anatomic rationale for transforaminal endoscopic interbody fusion: a cadaveric analysis. Neurosurg Focus 40(2):E122016

    • Search Google Scholar
    • Export Citation
  • 8

    Hasegawa TAn HSHaughton VMNowicki BH: Lumbar foraminal stenosis: critical heights of the intervertebral discs and foramina. A cryomicrotome study in cadavera. J Bone Joint Surg Am 77:32381995

    • Search Google Scholar
    • Export Citation
  • 9

    Hoogland TSchubert MMiklitz BRamirez A: Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain: a prospective randomized study in 280 consecutive cases. Spine (Phila Pa 1976) 31:E890E8972006

    • Search Google Scholar
    • Export Citation
  • 10

    Hurday YXu BGuo LCao YWan YJiang H: Radiographic measurement for transforaminal percutaneous endoscopic approach (PELD). Eur Spine J 26:6356452017

    • Search Google Scholar
    • Export Citation
  • 11

    Inufusa AAn HSLim THHasegawa THaughton VMNowicki BH: Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement. Spine (Phila Pa 1976) 21:241224201996

    • Search Google Scholar
    • Export Citation
  • 12

    Jacquot FGastambide D: Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it? Int Orthop 37:150715102013

    • Search Google Scholar
    • Export Citation
  • 13

    Kambin P: Arthroscopic microdiscectomy. Arthroscopy 8:2872951992

  • 14

    Kambin PBrager MD: Percutaneous posterolateral discectomy. Anatomy and mechanism. Clin Orthop Relat Res (223):1451541987

  • 15

    Kambin PCasey KO’Brien EZhou L: Transforaminal arthroscopic decompression of lateral recess stenosis. J Neurosurg 84:4624671996

    • Search Google Scholar
    • Export Citation
  • 16

    Kambin PGellman H: Percutaneous lateral discectomy of the lumbar spine. A preliminary report. Clin Orthop Relat Res (174):1271321983

    • Search Google Scholar
    • Export Citation
  • 17

    Karaman HKavak GOTüfek AYldrm ZB: The complications of transforaminal lumbar epidural steroid injections. Spine (Phila Pa 1976) 36:E819E8242011

    • Search Google Scholar
    • Export Citation
  • 18

    Khiami FAziria SARagot SPascal-Moussellard HRicher JPScepi M: Reliability and validity of a new measurement of lumbar foraminal volume using a computed tomography. Surg Radiol Anat 37:93992015

    • Search Google Scholar
    • Export Citation
  • 19

    Kim MKim HSOh SWAdsul NMSingh RKashlan ON: Evolution of spinal endoscopic surgery. Neurospine 16:6142019

  • 20

    Lee CKRauschning WGlenn W: Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine (Phila Pa 1976) 13:3133201988

    • Search Google Scholar
    • Export Citation
  • 21

    Lew SMMehalic TFFagone KL: Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral and foraminal lumbar disc herniations. J Neurosurg 94 (2 Suppl):2162202001

    • Search Google Scholar
    • Export Citation
  • 22

    Masharawi YSalame KMirovsky YPeleg SDar GSteinberg N: Vertebral body shape variation in the thoracic and lumbar spine: characterization of its asymmetry and wedging. Clin Anat 21:46542008

    • Search Google Scholar
    • Export Citation
  • 23

    Mayer HMBrock M: Percutaneous endoscopic discectomy: surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg 78:2162251993

    • Search Google Scholar
    • Export Citation
  • 24

    Min JHKang SHLee JBCho THSuh JG: Anatomic analysis of the transforaminal ligament in the lumbar intervertebral foramen. Neurosurgery 57 (1 Suppl):37412005

    • Search Google Scholar
    • Export Citation
  • 25

    Mirkovic SRSchwartz DGGlazier KD: Anatomic considerations in lumbar posterolateral percutaneous procedures. Spine (Phila Pa 1976) 20:196519711995

    • Search Google Scholar
    • Export Citation
  • 26

    Nash LNicholson HDZhang M: Does the investing layer of the deep cervical fascia exist? Anesthesiology 103:9629682005

  • 27

    Park JWNam HSCho SKJung HJLee BJPark Y: Kambin’s triangle approach of lumbar transforaminal epidural injection with spinal stenosis. Ann Rehabil Med 35:8338432011

    • Search Google Scholar
    • Export Citation
  • 28

    Park KDLee JJee HPark Y: Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain. Am J Phys Med Rehabil 91:103910502012

    • Search Google Scholar
    • Export Citation
  • 29

    Rivera CE: Lumbar epidural steroid injections. Phys Med Rehabil Clin N Am 29:73922018

  • 30

    Ruetten SKomp MGodolias G: An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approach—technique and prospective results of 463 patients. Spine (Phila Pa 1976) 30:257025782005

    • Search Google Scholar
    • Export Citation
  • 31

    Standring SAdams MA: Gray’s Anatomy: The Anatomical Basis of Clinical Practice ed 41. St. Louis, MO: Elsevier2016

  • 32

    Tumialán LMMadhavan KGodzik JWang MY: The history of and controversy over Kambin’s triangle: a historical analysis of the lumbar transforaminal corridor for endoscopic and surgical approaches. World Neurosurg 123:4024082019

    • Search Google Scholar
    • Export Citation
  • 33

    Wiese MKrämer JBernsmann KErnst Willburger R: The related outcome and complication rate in primary lumbar microscopic disc surgery depending on the surgeon’s experience: comparative studies. Spine J 4:5505562004

    • Search Google Scholar
    • Export Citation
  • 34

    Xu XYYan ZJMa QChen LKe ZYChen F: Clinical application of the paraspinal erector approach for spinal canal decompression in upper lumber burst fractures. J Orthop Surg Res 9:1052014

    • Search Google Scholar
    • Export Citation
  • 35

    Xu ZTu LZheng YMa XZhang HZhang M: Fine architecture of the fascial planes around the lateral femoral cutaneous nerve at its pelvic exit: an epoxy sheet plastination and confocal microscopy study. J Neurosurg [epub ahead of print December 7 2018. DOI: 10.3171/2018.7.JNS181596]

    • Search Google Scholar
    • Export Citation
  • 36

    Yeung ATTsou PM: Posterolateral endoscopic excision for lumbar disc herniation: surgical technique, outcome, and complications in 307 consecutive cases. Spine (Phila Pa 1976) 27:7227312002

    • Search Google Scholar
    • Export Citation
  • 37

    Zhang KHZhang WHXu BSDong XMGuo LDu LL: CT-based morphometric analysis of approach of percutaneous transforaminal endoscopic lumbar interbody fusion. Orthop Surg 11:2122202019

    • Search Google Scholar
    • Export Citation
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