Ann Rehabil Med.  2012 Aug;36(4):480-487. 10.5535/arm.2012.36.4.480.

Injectate Volumes Needed to Reach Specific Landmarks and Contrast Pattern in Kambin's Triangle Approach with Spinal Stenosis

• Park KD
• Lee JH
• Park Y

• KMID: 2266718
• DOI: http://doi.org/10.5535/arm.2012.36.4.480

Abstract

OBJECTIVE
To identify the volumes of contrast material needed to reach the specific landmarks and contrast pattern during Kambin's triangle approach (KB-A) in lumbar spinal stenosis. METHOD: Sixty patients undergoing KB-A were investigated. Fifty-six patients were included in this study. KB-A were performed with the use of contrast-enhanced fluoroscopic visualization. After confirming the appropriate spinal needle position, a slow injection of up to 5.0 ml of nonionic contrast material was carried out. Under intermittent fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: ipsilateral inferior or superior neural foramen.
RESULTS
After 2.0 ml of contrast was injected, 93.2% of KB-A cases spread to the medial aspect of the inferior pedicle of the corresponding level of injection and 86.3% of KB-A spread to the medial aspect of the superior pedicle of the corresponding level of injection. After 3 ml of contrast was injected, 95.3% of KB-A spread to cover both the medial aspect of the inferior pedicle and the superior pedicle of the corresponding level of injection. A volume of 2 ml of injectate reaches the anterior epidural space 100% of the time.
CONCLUSION
This study demonstrates injectate volumes needed to reach the specific anatomic landmarks in KB-A. A volume of 3.0 ml of injectate reaches both the medial aspect of theinferior pedicle and the superior pedicle 94.6% of the time. Therefore, Interventionalists may consider a 1-level instead of a 2-level injection for patients with a bleeding risk or for 2 level central pathology.

Keyword

Contrast; Volume; Pattern; Lumbar injection; Spinal stenosis

MeSH Terms

Anatomic Landmarks
Epidural Space
Hemorrhage
Humans
Needles
Spinal Stenosis

Figure

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  Fig. 1 Schematic description of the Kambin's triangle. The hypotenuse is the exiting nerve; the base is the caudad vertebral body; and the height is the traversing nerve root.

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  Fig. 2 (A) The anterior-posterior view of the lumbar spine, with the superimposed line (1) bisecting the pedicle. This line was drawn halfway between the farthest medial (2) and the farthest lateral (3) points on the pedicle. (B) The lateral view of the lumbar spine with the quadrant system superimposed. A line was drawn tangent to the curve of the spine at the level of interest along the posterior vertebral line. (1) A second line (2) was drawn parallel to the third line at the posterior margin of the foramen. Next, two lines perpendicular to lines 1 and 2 were drawn at the superior and inferior margins of the foramen (lines 3 and 4, respectively). Finally, line 5 was drawn bisecting lines 1 and 2, and line 6 was drawn bisecting lines 3 and 4. These lines divided the foramen into four quadrants. Arrow: needle position.

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  Fig. 3 (A) The anteroposterior view of a needle placed for a Kambin's triangle approach of the L5 nerve root demonstrating the landmarks used for this investigation. Note the contrast flowing along the most medial aspect of the inferior pedicle (PED). (B) The lateral view of a needle placed for a Kambin's triangle approach of the L5 nerve root demonstrating the landmarks used for this investigation. Note the contrast flowing anterior epidural space.

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