Narrative Review Medicine ®

An overview of lumbar anatomy with an emphasis

on unilateral biportal endoscopic techniques
A review
Qiang Zhang, MMa, Yongan Wei, MMa, Li Wen, MMa, Chang Tan, MMa, Xinzhi Li, MDa,* , Bo Li, MMa,*

Abstract
Unilateral biportal endoscopy (UBE) is a major surgical technique used to treat degenerative lumbar diseases. The UBE technique
has the advantages of flexible operation, high efficiency, and a large observation and operation space. However, as a typical
representative of minimally invasive techniques, UBE still needs to complete a wide range of decompression and tissue resection
in a narrow working space, resulting in many surgery-associated injuries. Therefore, it is necessary to reduce complications by
familiarity with the anatomy of the lumbar spine. Based on the UBE technique, this review article provides historical and current
information on the anatomical structures of the lumbar vertebrae, such as the articular process, pedicle, lamina, ligamentum
flavum, nerve root, intervertebral disc, and artery supply.
Abbreviation: UBE = unilateral biportal endoscopy.
Keywords: lumbar spine, spinal nerve, unilateral biportal endoscopy

1. Introduction Unilateral biportal endoscopy (UBE) has recently become

popular. Compared with the traditional open technique, unilat-
Lumbar degenerative diseases are among the most common eral 2-channel endoscopy is still a “point exposure” technique,
clinical diseases, including lumbar disc herniation, lumbar spi- with a high incidence of surgery-associated injury, including the
nal stenosis, lumbar instability, and lumbar spondylolisthesis.[1] dural sac, outlet nerve root, and dural injury on the walking
Lumbago and leg pain and/or nerve damage caused by these nerve root.[5] Park[6] observed 643 patients who underwent UBE
diseases are widespread and complicated in the clinic, seriously surgery and found that the incidence of dural injury was 4.5%.
affecting patients’ health and quality of life.[2] According to sta- Lee[7] reported that the incidence of dural injuries was as high as
tistics, the time-point prevalence of low back pain in the general 13.2%. Therefore, surgeons need to be familiar with the anat-
population is 18.3% and 30.8% during 1 month, which is the omy of the lumbar spine. In this study, the anatomical structure
first reason workers retire early.[3] of the lumbar spine involved in unilateral 2-channel endoscopy
Generally, lumbar degenerative diseases are treated conser- was reviewed comprehensively.
vatively, and surgical intervention is often required when the
effect of non-surgical treatment is poor or when symptoms of
severe nerve damage occur. In the past decades, mainstream spi- 2. Overview of lumbar anatomy
nal surgery has been open surgery. However, in recent years, the
rise of spinal endoscopy techniques has opened a new direction 2.1. The articular process and the pedicle
for minimally invasive spinal surgery. Its development direction Compared to the cervical and thoracic vertebrae, the facet of
is mainly small incision or pipeline technique. Contrary to the the lumbar vertebrae is closer to the sagittal plane, and the facet
development trend of endoscopic techniques in general and tho- angle to the sagittal plane increases gradually from the top down,
racic surgeries, the single-channel endoscopic technique was the averaging 33.[8] The facet of the lumbar spine has less mobility
first to become popular in spinal endoscopy with a light source, in the rotation direction but more mobility in the direction of
observation lens, and surgical instruments passing through the flexion and extension. Studies[9] have shown that the smaller the
same pipeline. Although the current single-channel endoscopic angle between the lumbar spine and sagittal plane, the more
spinal technique has been widely used in surgical removal of the likely it is that degenerative lumbar spondylolisthesis will occur.
protruding nucleus pulposus, surgical decompression of spinal It is worth noting that the superior articular process can be used
stenosis, and even intervertebral fusion,[4] it is still a targeted as one of the anatomical markers to determine the position of
technique with relatively limited surgical field and scope, and the disc. Studies[10] have shown that the distance between the
relatively high technical requirements for surgeons. highest point of the superior articular process and the central

This work was supported by the funding on the NEDP1 regulation of cyclin D1 Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
neddylation and colorectal cancer oncogenesis (81871956). This is an open access article distributed under the Creative Commons
The authors have no conflicts of interest to disclose. Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
The datasets generated during and/or analyzed during the current study are
available from the corresponding author on reasonable request. How to cite this article: Zhang Q, Wei Y, Wen L, Tan C, Li X, Li B. An overview of
lumbar anatomy with an emphasis on unilateral biportal endoscopic techniques: A
a
Department of Orthopedics, China Three Gorges University, Renhe Hospital, Yi review. Medicine 2022;101:48(e31809).
Chang, China.
Received: 8 September 2022 / Received in final form: 22 September 2022 /
* Correspondence: Xinzhi Li and Bo Li, Department of Orthopedics, China Three Accepted: 25 October 2022
Gorges University, Renhe Hospital, No. 410 Yiling Road, Yi Chang 443008, China
(e-mails: lixpj@163.com; Libo1019@126.com). http://dx.doi.org/10.1097/MD.0000000000031809

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Zhang et al. • Medicine (2022) 101:48Medicine

plane of the disc is 1 to 2 mm. Therefore, the position of the the disc level. 75% of S1 spinal nerves originate above the corre-
disc can be inferred from the position of the highest point of the sponding disc and 25% originate at the disc level, which explains
superior articular process. Pedicle shape was related to race, sex, why most disc herniations in L5/S1 are of the axillary type.[15]
weight, and other factors. Morita K[11] measured the morpho- The Kambin triangle, a safe area for posterolateral approach
logical parameters of the pedicle in 227 patients on computed discectomy and interbody fusion, consists of the lateral edge of
tomography (CT). From L1 to L5, the angle of the pedicle to the the dural sac, outlet nerve root, and upper edge of the lower
sagittal plane gradually increased by approximately 10 to 30°, vertebral body. The upper edge of the lower vertebra is the bot-
the width of the pedicle gradually increased by approximately tom edge of the Kambin triangle, which consists of the distance
7 to 16 mm, and the height of the pedicle decreased by approxi- between the outer edge of the dural sac and the inner edge of
mately 12 to 16 mm. The spinal nerve extends around the lower the outlet nerve root. The vertical edge of Kambin triangle is the
edge of the pedicle of the same ordinal vertebrae and exits the distance from the outlet nerve root of the dural sac to the upper
spinal canal. edge of the lower vertebral body. In the L1/2 to L3/4 planes, the
base of the Kambin triangle is approximately 11 to 13 mm, and
L4/5 to L5/S1 is approximately 14 to 17 mm.[16]
2.2. Spinal nerve
It is essential to master the anatomical structure of the nerve
2.4. The relationship between the lamina and the disc
tissue in the lumbar canal, because dural injury is the most com-
mon complication of UBE. The nerve tissue in the lumbar canal At the rear, the upper and lower boundaries of the intervertebral
consists of the dural sac and 6 pairs of spinal nerves (L1-L5, S1) space are at the lower edge of the upper lamina, the upper edge
that emanate from the dural sac. After the spinal nerve emanates of the lower lamina, and the upper edge of the lower lamina
from the dural sac, it travels diagonally, laterally, ventrally, and does not exceed the upper edge of the vertebral body. In L1 to
caudally and leaves the spinal canal around the lower edge of L5, the distance between the upper edge of the lower lamina
the pedicle at the same ordinal level (approx. 1 mm). The spinal and upper edge of the vertebral body was approximately 10 to
nerve was uplifted from the dural sac, and the width of L1 to L5 11 mm, and in S1, the distance between the upper edge of the
was approximately 15 mm, and that of S1 was approximately lower lamina and upper edge of the vertebral body was approxi-
10 mm. The angle between the spinal nerve and dural sac on the mately 14 mm. This is because the intervertebral space is usually
coronal plane gradually decreased from top to bottom. L1 was partially covered by the lower edge of the upper lamina, which
40° to 45°, L2 and L3 were generally between 30° and 40°, L4 exceeds the lower edge of the vertebral body by approximately
and L5 were generally between 25° and 30°, and S1 was gener- 2 to 4 mm. The width of the left-right intervertebral space grad-
ally 15° to 20°.[12] ually increased from top to bottom, and the width of the inter-
The spinal nerves are composed of anterior and posterior vertebral space was 16 to 19 mm from L1/2 to L3/4. The lamina
roots. The dorsal root has a distensible nodule composed of cen- space widths of L4/5 was approximately 23 mm, and that of L5/
tripetal sensory fibers, which are responsible for receiving nerve S1 was over 30 mm, respectively.[17]
impulses from bodily receptors and are closely associated with
spinal radicular pain. The location of the DRG varies signifi-
cantly among different spinal nerve segments. Most dorsal root 2.5. The arterial supply
ganglia from L1 to L3 are located in the intervertebral foramen. The lumbar artery emerges from the celiac artery and runs lat-
Most of the dorsal root ganglia of L4 (approx. 85%) are located erally around the vertebral body, giving off the major psoas
in the foramina, a few are located in the spinal canal (approx. branches about the middle of the vertebral body (anteroposte-
10%), and a few are located outside the foramina (approx. 5%). rior diameter). Before entering the foramina, the lumbar plexus
Most of the dorsal root ganglia of L5 (approx. 70%) are located branches emerged from the lumbar artery to the spinal nerve
in the foramina, some (approx. 20%) are located in the spinal junction, nourishing the lumbar plexus. Vertebral, lateral, and
canal, and a few (approx. 10%) are located outside the foram- dorsal branches are emitted at the outer orifice of the foramina.
ina. The dorsal root ganglion of the S1 spinal nerve is mostly A branch of the vertebral body enters the spinal canal below the
located in the spinal canal (approx. 75%), and partially in the pedicle and nourishes the posterior wall of the vertebral body.
foramina (approx. 25%). This partly explains why high cen- When the disc is exposed sideways, it can damage the arteries
tral and paracentral disc herniations often do not cause clinical and cause bleeding. The dorsal branches bypass the spinal nerves
symptoms, whereas extreme lateral disc herniations often cause and nourish the posterior paraspinal muscles. In addition, the
severe root symptoms. Foraminal stenosis in the L5/S1 segment dorsal branch sends out spinal nerve branches and nourishes the
was less likely to cause root symptoms.[13] spinal nerve. The lateral ramus passes caudally to the transverse
Spinal nerves L1 to L5 divide into anterior and posterior process and terminates at the abdominal wall.[18]
branches after leaving the foramina, whereas S1 usually does
not branch. According to the number of dorsal root ganglions
and anterior roots, spinal nerves can be divided into 3 types[14]: 2.6. The ligamentum flavum
type A, 1 dorsal root ganglion and 1 anterior root; type B, 1
dorsal root ganglion and 2 anterior roots; and type C, 2 dorsal A critical point of the UBE technique is how to quickly and
root ganglia and 2 anterior roots. Approximately 65% of L4 safely break through the ligamentum flavum into the spinal
nerve roots were type B and 30% were type C. More than 80% canal. The ligamentum flavum was divided into shallow and
of L5 roots were type B and approximately 15% were type C. deep layers. The superficial ligamentum flavum has a light-yel-
low fibrous structure with a 2.5 to 3.5 mm thickness. It is con-
nected to the base of the spinous process and ventral side of
2.3. The relationship between the intervertebral disc and the lower edge of the cephalic lamina at the proximal end,
to the dorsal side of the caudal lamina at the distal end, and
spinal nerves fused with the interspinous ligament at the midline. The deep
Spinal nerves L1 to L4 originate below the corresponding disc. ligamentum flavum is relatively thin (approx. 1 mm) and is
The distance from the L1 to L3 spinal nerve outlet to the corre- connected to the ventral lamina proximally and distally. The
sponding disc distance was generally 15 mm, and that from the attachment point of the deep ligamentum flavum varies from
L4 spinal nerve was generally 10 mm; 62.5% of L5 spinal nerves one segment to another. The lower the segment, the greater is
were generated below the corresponding disc, 12.5% were gen- the lamina covered by the ligamentum flavum. The ligamen-
erated above the corresponding disc, and 25% were generated at tum flavum covers approximately 50% of the cephalic lamina
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Zhang et al. • Medicine (2022) 101:48www.md-journal.com

at L1 to L2 and 70% at L4 to L5. At the caudal lamina, the References

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Author contributions Orthop Surg Res. 2018;13:22.
[26] Heo DH, Lee DC, Park CK. Comparative analysis of three types of
Conceptualization: Yongan Wei. minimally invasive decompressive surgery for lumbar central stenosis:
Formal analysis: Bo Li. biportal endoscopy, uniportal endoscopy, and microsurgery. Neurosurg
Methodology: Li Wen. Focus. 2019;46:E9.
Resources: Chang Tan. [27] Kang MS, You KH, Choi JY, et al. Minimally invasive transforaminal
Writing – original draft: Qiang Zhang. lumbar interbody fusion using the biportal endoscopic techniques ver-
Writing – review & editing: Xinzhi Li. sus microscopic tubular technique. Spine J. 2021;21:2066–77.