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Sakane Anatomical relationship between Kambin’s triangle and ENR

Figure 2: Partial fecetectomy to widen transforaminal space. An Figure 3: Walking technique. A guide needle is place on the
area of partial fecetectomy is colored by blue superior facet (X1). Then surgeon moves needle on the X2, X3, and
X4 point to avoid touching the exiting nerve root
describe about the type of anesthesia used during the
surgery. Magnetic resonance imaging (MRI) revealed the efficacy of fully endoscopic interlaminar L5-S1
that patients sustaining ENR injuries had a shorter discectomy in 72 patients with axillary, ventral, or
distance between the ENR and the lower facet. They shoulder types/locations of disc herniation. They used
recommended that measuring this distance during postoperative MRI to confirm the extent of resection.
preoperative MRI studies may allow surgeons to Complications included 1 disc recurrence, but there
choose more optimal approaches. Recently, the were no nerve root injuries and infections.
diffusion tensor imaging technique has been used for
the structural and functional diagnosis of lumbar nerve DISCUSSION
damage before and after surgery. [19-23]
PELD has the advantages of shorter hospital stay
Regarding surgical procedures, Cho et al. and a lower risk of infection compared with standard
[24]
demonstrated that their floating technique reduces surgical procedures, such as open or micro discectomy
complications during PELD. In their series of 154 for lumbar disc herniation. [27]
patients, none had ENR injury. They recommended
that the guide needle should be attached to the lateral However, the large spine patient outcomes research
aspect of the superior facet for the insertion of dilators trial conducted by Desai et al. showed the frequency
[28]
and cannula before accessing the annulus. of nerve root injury following an open discectomy
ranged from 0.13% to 0.25%. For open laminectomy
Sairyo et al. [25] have reported on their initial 100 cases or stenosis with or without fusion, it was 0% and
of PELD under local anesthesia. In this series, 2 for open laminectomy or stenosis or degenerative
patients (2%) complained of leg pain and dysesthesia spondylolisthesis with or without fusion it was 2%.
2 days after surgery, although the pain disappeared
within 3 months after conservative treatment. They Most minimal invasive surgeries for lumbar disc
proposed 2 etiologies of POD, direct exiting nerve herniation have higher frequencies of radiculitis and/
injury with the needle and/or cannula insertion or nerve root injuries compared with conventional
and irritation of the dorsal root ganglion due to open surgery. ENR injury is the most devastating
compression by the cannula. They also emphasized complication of transforaminal PELD, and rates of
that the guide needle should touch a caudal pedicle injury up to 20% have been reported.
before needling Kambin’s triangle, as this “walking
technique” prevents POD [Figure 3]. ENR injury causes POD and motor weakness and
reduces physical function and overall satisfaction of
Using a surgical bur through the working portal of the patient. Therefore, the prevention of ENR injury is
the endoscope, full endoscopic partial laminectomy important for achieving a higher rate of clinical success.
has been performed more frequently. Converting
from a translaminar to an interlaminar approach is Under fluoroscopy, surgeons are not able to see
a reasonable option. In 2015, Li et al. evaluated one border of ENR in Kambin’s triangle. Careful
[26]
Mini-invasive Surgery ¦ Volume 1 ¦ September 30 101