Kambin’s triangle: definition and new classification schema

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Kambin’s triangle is an anatomical corridor used to access critical structures in a variety of spinal procedures. It is considered a safe space because it is devoid of vascular and neural structures of importance. Nonetheless, there is currently significant variation in the literature regarding the exact dimensions and anatomical borders of Kambin’s triangle. This confusion was originally caused by leaving the superior articular process (SAP) unassigned in the description of the working triangle, despite Kambin identifying that structure in his original report. The SAP is the most relevant structure to consider when accessing the transforaminal corridor. Leaving the SAP unassigned has led to an open-handed application of the term “Kambin’s triangle.” That single eponym currently has two potential meanings, one meaning for endoscopic surgeons working through a corridor in the intact spine and a second meaning for surgeons accessing the disc space after a complete or partial facetectomy. Nevertheless, an anatomical corridor should have one consistent definition to clearly communicate techniques and use of instrumentation performed through that space. As such, the authors propose a new surgically relevant classification of this corridor. Assigning the SAP a border requires adding another dimension to the triangle, thereby transforming it into a prism. The term “Kambin’s prism” indicates the assignment of a border to all relevant anatomical structures, allowing for a uniform definition of the 3D space. From there, the classification scheme considers the expansion of the corridor and the extent of bone removal, with a particular focus on the SAP.

ABBREVIATIONS IAP = inferior articular process; IDET = intradiscal electrothermal therapy; PLIF = posterior lumbar interbody fusion; SAP = superior articular process; TLIF = transforaminal lumbar interbody fusion.
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Contributor Notes

Correspondence Michael Y. Wang: Lois Pope Life Center, Miami, FL. mwang2@med.miami.edu.INCLUDE WHEN CITING Published online November 29, 2019; DOI: 10.3171/2019.8.SPINE181475.Disclosures Dr. Tumialán reports being a consultant for Medtronic and having direct stock ownership in LessRay. Dr. Wang reports being a consultant for DePuy Synthes Spine, Stryker, K2M, and Spineology; being a patent holder in DePuy Synthes Spine; and having direct stock ownership in ISD and Medical Device Partners.
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References
  • 1

    Ahn Y: Transforaminal percutaneous endoscopic lumbar discectomy: technical tips to prevent complications. Expert Rev Med Devices 9:3613662012

    • Search Google Scholar
    • Export Citation
  • 2

    Alamin TMalek FCarragee EKim MJ: The functional anaesthetic discogram: description of a novel diagnostic technique and report of 3 cases. SAS J 2:1071132008

    • Search Google Scholar
    • Export Citation
  • 3

    Amankulor NMXu RIorgulescu JBChapman TReiner ASRiedel E: The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors. Spine J 14:185018592014

    • Search Google Scholar
    • Export Citation
  • 4

    Botanlıoğlu HAydıngöz ÖKantarcı FKaynak GGüven MFErtan S: Positional alterations of the Kambin’s triangle and foraminal areas in the lumbosacral region. Acta Orthop Traumatol Turc 49:30362015

    • Search Google Scholar
    • Export Citation
  • 5

    Botwin KPGruber RDBouchlas CGTorres-Ramos FMSanelli JTFreeman ED: Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil 81:8989052002

    • Search Google Scholar
    • Export Citation
  • 6

    Epstein NE: More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: a review. Surg Neurol Int 7 (Suppl 3):S83S952016

    • Search Google Scholar
    • Export Citation
  • 7

    Fanous AALipinski LJKrishna CRoger EPSiddiqui AHLevy EI: The impact of preoperative angiographic identification of the artery of Adamkiewicz on surgical decision making in patients undergoing thoracolumbar corpectomy. Spine (Phila Pa 1976) 40:119411992015

    • Search Google Scholar
    • Export Citation
  • 8

    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
  • 9

    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
  • 10

    Harms JGJeszenszky D: Die posteriore, lumbale, interkorporelle Fusion in unilateraler transforaminaler Technik. Oper Orthop Traumatol 10:901021998

    • Search Google Scholar
    • Export Citation
  • 11

    Hoshide RFeldman ETaylor W: Cadaveric analysis of the Kambin’s triangle. Cureus 8:e4752016

  • 12

    Kambin P: Arthroscopic microdiskectomy. Mt Sinai J Med 58:1591641991

  • 13

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

  • 14

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

    • Search Google Scholar
    • Export Citation
  • 15

    Kambin PGennarelli THermantin F: Minimally invasive techniques in spinal surgery: current practice. Neurosurg Focus 4(2):e81998

  • 16

    Kambin PSampson S: Posterolateral percutaneous suction-excision of herniated lumbar intervertebral discs. Report of interim results. Clin Orthop Relat Res (207):37431986

    • Search Google Scholar
    • Export Citation
  • 17

    Kambin PSavitz MH: Arthroscopic microdiscectomy: an alternative to open disc surgery. Mt Sinai J Med 67:2832872000

  • 18

    Kambin PSchaffer JL: Percutaneous lumbar discectomy. Review of 100 patients and current practice. Clin Orthop Relat Res (238):24341989

    • Search Google Scholar
    • Export Citation
  • 19

    Kambin PZhou L: History and current status of percutaneous arthroscopic disc surgery. Spine (Phila Pa 1976) 21 (24 Suppl):57S61S1996

    • Search Google Scholar
    • Export Citation
  • 20

    Lertudomphonwanit TKeorochana GKraiwattanapong CChanplakorn PLeelapattana PWajanavisit W: Anatomic considerations of intervertebral disc perspective in lumbar posterolateral approach via Kambin’s triangle: cadaveric study. Asian Spine J 10:8218272016

    • Search Google Scholar
    • Export Citation
  • 21

    Manchikanti LCash KAPampati VDamron KSMcManus CD: Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report. Pain Physician 7:2172232004

    • Search Google Scholar
    • Export Citation
  • 22

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

    • Search Google Scholar
    • Export Citation
  • 23

    McGrath LB JrMadhavan KChieng LOWang MYHofstetter CP: Early experience with endoscopic revision of lumbar spinal fusions. Neurosurg Focus 40(2):E102016

    • Search Google Scholar
    • Export Citation
  • 24

    Min JHKang SHLee JBCho THSuh JKRhyu IJ: Morphometric analysis of the working zone for endoscopic lumbar discectomy. J Spinal Disord Tech 18:1321352005

    • 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

    Murthy NSMaus TPBehrns CL: Intraforaminal location of the great anterior radiculomedullary artery (artery of Adamkiewicz): a retrospective review. Pain Med 11:175617642010

    • Search Google Scholar
    • Export Citation
  • 27

    Ozer AFSuzer TCan HFalsafi MAydin MSasani M: Anatomic assessment of variations in Kambin’s triangle: a surgical and cadaver study. World Neurosurg 100:4985032017

    • Search Google Scholar
    • Export Citation
  • 28

    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
  • 29

    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
  • 30

    Sairyo KMatsuura THigashino KSakai TTakata YGoda Y: Surgery related complications in percutaneous endoscopic lumbar discectomy under local anesthesia. J Med Invest 61:2642692014

    • Search Google Scholar
    • Export Citation
  • 31

    Sasani MOzer AFOktenoglu TCanbulat NSarioglu AC: Percutaneous endoscopic discectomy for far lateral lumbar disc herniations: prospective study and outcome of 66 patients. Minim Invasive Neurosurg 50:91972007

    • Search Google Scholar
    • Export Citation
  • 32

    Slipman CWChow DW: Therapeutic spinal corticosteroid injections for the management of radiculopathies. Phys Med Rehabil Clin N Am 13:6977112002

    • Search Google Scholar
    • Export Citation
  • 33

    Trinh KHGharibo CGAydin SM: Inadvertent intradiscal injection with TFESI utilizing Kambin’s retrodiscal approach in the treatment of acute lumbar radiculopathy. Pain Pract 16:E70E732016

    • Search Google Scholar
    • Export Citation
  • 34

    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
  • 35

    Wang MYGrossman J: Endoscopic minimally invasive transforaminal interbody fusion without general anesthesia: initial clinical experience with 1-year follow-up. Neurosurg Focus 40(2):E132016

    • Search Google Scholar
    • Export Citation
  • 36

    Wimmer CMaurer H: Anatomic consideration for lumbar percutaneous interbody fusion. Clin Orthop Relat Res (379):2362412000

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