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To compare the short-term effect and advantage of transforaminal epidural steroid injection TFESI performed using the Kambin's triangle and subpedicular approaches. Forty-two patients with radicular pain from lumbar spinal stenosis were enrolled. Subjects were randomly assigned to one of two groups.
All procedures were performed using C-arm KMC The frequency of complications during the procedure and the effect of TFESI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual numeric scale VNS and a five-grade scale.
Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors Kambin's triangle or subpedicular approach, age, duration of symptoms and sex and the therapeutic effect. VNS was improved 2 weeks after the injection and continued to improve until 4 weeks in both groups.
There were no statistical differences in changes of VNS, effectiveness and contrast spread pattern between these two groups. No correlation was found between the other variables tested and therapeutic effect. The Kambin's triangle approach is as efficacious as the subpedicular approach for short-term effect and offers considerable advantages i. The Kambin's triangle approach maybe an alternative method for transforaminal epidural steroid injection in cases where needle tip positioning in the anterior epidural space is difficult.
Lumbar spinal stenosis may induce radiating pain in the lower limbs through narrowed intervertebral foramen by a herniated intervertebral disc due to degenerative changes and thickening of the ligamentum flavum, zygapophysial joint and surrounding soft tissues.
Suggested causes include inflammatory changes around nerve root, venous congestion and hematogenous disability. In this method, the injection needle is progressed towards the safe triangle under the inferior surface of the pedicle to locate the superolateral spinal nerve related to symptoms.
The risk of damaging dura mater is decreased, as the injection needle goes through the border of the lateral upper intervertebral foramen. In , Kambin introduced endoscopic intervertebral discectomy by posterolateral approach, defining the Kambin's triangle as the site to approach the intervetebral disc. According to Murthy et al. In this context, the purpose of this study was to compare the subpedicular approach and the approach using Kambin's triangle in transforaminal epidural block performed in patients with spinal stenosis complaining of lumbar radicular pain, and to investigate the short-term effects and possible complications during injection.
The subjects of this study were patients who visited the Department of Rehabilitation Medicine for lumbar nerve root pain between July 1 and June 31 The sex ratio, duration of pain, body mass index BMI , nerve root as cause and period of prevalence are presented in Table 1. Patients showing no therapeutic effects at the 2-week follow-up after the first procedure patient satisfaction index 0 were excluded from the final analysis; those with partial effects i.
Kambin's triangle is defined as a right triangle over the dorsolateral disc. The canal is divided into the entrance, middle and exit zone.
The space occupied by the spinal nerve outside the exit zone is called the far lateral zone. Schematic description of the "Kambin's triangle". The triangle is defined by the hypotenuse, base, and height. The hypotenuse is the exiting nerve; the base is the caudad vertebral body; and the height is the traversing nerve root.
In the subpedicular approach, the agents are injected at the exit zone as the distal site of the nerve root canal; occasionally the agents cannot be delivered into retrodiscal area, as the entrance zone or proximal area is passing through the stenosis area. In the preganglionic approach, it is possible to inject agents at the entrance and middle zone as the main areas of nerve entrapment by injecting at the retrodiscal area of the entrance zone, as proximal area of the targeted nerve root e.
Such approaches may damage the intervertebral disc because the injection is adjacent to the posterior segment of the intervertebral disc. Thus, in this study, the final target site of injection was determined to be the posterior inferior at the lateral view Fig.
Schematic description for transforaminal epidural steroid injection with the Kambin's triangle versus the subpedicular approach target L5 nerve root. A Anterior-posteior view of the lumbar spine, with superimposed line 1 bisecting the pedicle. This line was drawn halfway between the farthest medial 2 and farthest lateral 3 points on the pedicle.
B Lateral view of the lumbar spine, with the quadrant system superimposed. First, a line was drawn tangent to the curve of the spine at the level of interest along the posterior vertebral line. Next, two lines perpendicular to lines 1 and 2 were drawn at the superior and inferior margins of the foramen 3 and 4, respectively.
Finally, line 5 was drawn bisecting 1 and 2, and, likewise, line 6 bisecting 3 and 4. This divided the foramen into four quadrants Arrow: needle position. Patients were placed in the prone position and were supported by pillows under the abdomen to reduce lumbar lordosis. The X ray projection was focused on the epiphyseal plate of the upper and lower vertebral body by controlling the cranial-caudal angle of the C-arm KMC KOMED, Kwangju, Korea , and the right and left angle of the C-arm was rotated by degrees toward the region, so that the superior articular process could be seen at the middle of the intervertebral disc.
Then, the needle was located medially in the 5 o'clock direction of the upper pedicle at the anteroposterior view, without further advancement and in the posteroinferior of the intervertebral foramen at lateral view. After the final location of the needle was secured, 1 cc of non-ionic contrast agent was administered to observe diffusion location and scope of the contrast agent, and then 2 cc of the prepared agent 0.
Kambin's triangle approach of the L5 nerve root. A In the oblique view, the needle tip is advanced slowly and cautiously past the superior articular process lateral surface. B The anterior-posterior view will most often demonstrate the tip in the interpedicular line. C The lateral radiography should also be used while advancing past the SAP to minimize the risk of the penetration until the needle tip is at the posterior and inferior aspect of intervertebral neural foramen.
D A small amount of contrast is used to confirm epidural spread. All patients were in the prone position and were supported by pillows under the abdomen to reduce lumbar lordosis.
The relevant lumbar part was identified by using the Scotty dog shadow oblique view. The lower endplate of the spine for the C-arm was adjusted for accordance and rotated by degrees in the oblique view to visualize the Scotty dog shadow. After the site was disinfected, 3. When the tip of the needle reached the inferolateral border, the C-arm was rotated to the lateral view, and the needle was gradually progressed toward the anterior and superior aspects of the intervertebral foramen.
When the needle reached the final location, an aspiration text test was conducted to check for blood detection, and 1 cc of non-ionic contrast agent was administered under real-time fluoroscopy, to identify whether the agent was injected into the anterior epidural space.
All procedures were done by the same author; photographs were taken before and after administration of the contrast agent and 2 cc of the agent 0. Subpedicular approach of the L5 nerve root. A In oblique view, needle tip lies directly inferior to the pedicle and inferolateral to the pars interarticularis.
B The anterior-posterior view showing the proper location of the needle at the base of pedicle. C The lateral radiography should also be used while the needle is advanced until the needle tip is at the anterior and superior aspect of intervertebral neural foramen.
All events were recorded during and after injections. The merits and flaws of the two methods were compared by observing diffusion location and scope of the contrast agents, and the discomfort produced by injection.
When the agent diffused into the epidural space, the agent diffusing from the injected vertebral body by blocking the needle in the cranial-caudal direction and diffusion to the anterior or posterior epidural space was analyzed on the lateral view.
The spinal levels of diffusion of the contrast agent in the epidural space were measured in the cranial-caudal direction and recorded at the upper endplate, middle of the vertebral body and low endplate of the vertebral body. Cases when the agent reached the superior low endplate were contained in the vertebral body below the area, whereas cases when the agent reached the middle vertebral body and the upper endplate were contained in the vertebral body of the area.
Similarly, cases when the agent reached the superior endplate and the middle of the vertebral body were contained in the vertebral body above the area, whereas cases when the agent reached the low endplate were contained in the vertebral body of the area. Pain was assessed before treatment and 2 and 4 weeks after treatment, to compare the short-term therapeutic effects of the two approaches.
After 4 weeks, the patient satisfaction index was measured on a 5-point scale, as follows: 0 no effects , 1 poor , 2 normal , 3 good and 4 excellent. Gender, BMI, period of prevalence, age, targeted nerve root and diffusion of the contrast agent were compared between the two groups using the chi-square test, Fisher's exact test, and Mann-Whitney U method.
Comparisons between the two groups in complications and discomfort that could occur during injection were conducted by Fisher's exact test. Comparison of the numeric rating scale NRS between the two groups was conducted by repeated measures analysis of variance ANOVA , and Bonferroni's correction was applied post-hoc. By using logistic regression, correlations between success of treatment and several variables method of injection, age, gender and period of prevalence were analyzed.
SAS Enterprise Guide 4. We investigated a total of 52 patients, and six were excluded because after applying our exclusion criteria. One patient from the subpedicular approach and one from the Kambin's triangle approach were excluded because medication was used during the research period.
Other two patients were excluded because it was difficult for them to visit the hospital regularly. The short-term treatment effects significantly declined in both groups at 2 and 4 weeks after the procedure.
However, there was no significant difference between the two groups in initial pain, pain after 2 weeks and pain changes after 4 weeks Table 2.
Nerve root pricking during injection showed significant differences: five cases were reported in the subpedicular approach, whereas no case was found in the Kambin's triangle approach. As for intravascular injection, four cases were found in the conventional subpedicular approach and three cases were found in the Kambin's triangle approach, with no significant difference between the two Table 3.
Both groups did not present nerve root damage as a complication, and injection into the intervertebral disc was found in two cases of the subpedicular approach. Other severe complications were not shown. Patients with dizziness and temporary muscular weakness were moved to the recovery room for observation, and all symptoms were absent at discharge. The five patients with nerve root pricking did not show nerve root damage at the 2-week follow-up visit.
In the subpedicular approach, on lateral view, the contrast agent diffused only to the anterior epidural space in 18 patients In total, the contrast agent diffused into the anterior epidural space in 21 In the Kambin's triangle approach, 12 In the subpedicular approach, on anteroposterior epidural contrast, the contrast agent diffused by 1.
In the Kambin's triangle approach, the contrast agent diffused by 1. There was no statistically significant difference between the two groups Table 4. No correlations were found between the success rate and several investigated factors, such as injection method, age, gender and prevalence period Table 5.
Spinal stenosis is a condition produced by compression of the nerve root due to narrowness of the spinal canal and nervous canal following spine fracture, thickness of zygapophysial joint and ligamentum flavum and ossification of posterior longitudinal ligament. In addition, increased permeability of the cell membrane produced by nutritional disorder and inflammatory mediators may induce edema in the nerve root, leading to pain and numbness in the hips and lower limbs.
As for the effects of epidural nerve blockage, Delport et al. In a prospective, double-blind, randomly-assigned study, Riew et al. Thus, epidural steroid injections for spinal stenosis had clinical effects, and the transforaminal approach, when compared to others, was effective in improving symptoms with smaller amount of agents, because the agents could easily reach the targeted nerve root, dorsal root ganglion and the anterior of epidural space.
Such reports required reexamination of the transforaminal approach through the safe triangle. As for the lumbar spinal nerve, there is a triangle area in which the nerve leaves the intervertebral foramen obliquely to form the hypotenuse, the connected line to the lower part of the pedicle is the bottom side, and the line forming a right angle against the exterior of the pedicle is the vertical plate.
This area is called "the safe triangle," because the space mainly contains only the spinal nerve and vessels.
Anatomical relationship between Kambin’s triangle and exiting nerve root
To compare the short-term effect and advantage of transforaminal epidural steroid injection TFESI performed using the Kambin's triangle and subpedicular approaches. Forty-two patients with radicular pain from lumbar spinal stenosis were enrolled. Subjects were randomly assigned to one of two groups. All procedures were performed using C-arm KMC The frequency of complications during the procedure and the effect of TFESI at 2 and 4 weeks after the procedure between the two groups were compared. Short-term outcomes were measured using a visual numeric scale VNS and a five-grade scale. Multiple logistic regression analyses were performed to evaluate the relationship between possible outcome predictors Kambin's triangle or subpedicular approach, age, duration of symptoms and sex and the therapeutic effect.
Kambin’s triangle: definition and new classification schema
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Kambinâs Triangle Approach to Transforaminal Epidural Injections
Lumbar spinal stenosis affects more than , adults in the United States yearly, resulting in substantial pain and disability. Pain is partially caused by physical compression from degenerative changes and thickening of the ligamentum flavum, zygapophysial joint, and surrounding soft tissues; however, no unifying theory explains the exact etiology of the pain in lumbar spinal stenosis. One of the mainstays of interventional treatment is an epidural steroid injection ESI. Steroids interrupt the synthesis of prostaglandins, block conduction of nociceptive fibers, and decrease edema around the nerve root, thereby potentially decreasing pain. The transforaminal approach has shown excellent clinical efficacy, with improved pain scores, improved ability to complete activities of daily living, and decreased pain-related anxiety and depression. The transforaminal approach, although proven to have better clinical efficacy, has the potential for significant complications, including air emboli, cerebral thrombosis, epidural hematoma, nerve root injury, vascular transection, and vasospasm. However, the most devastating complications are cord ischemia or vascular injury from needle trauma or intravascular injection of particulate matter.