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

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

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

1
Zhang et al. • Medicine (2022) 101:48Medicine
plane of the disc is 1 to 2 mm. Therefore, the position of the
disc can be inferred from the position of the highest point of the
superior articular process. Pedicle shape was related to race, sex,
weight, and other factors. Morita K[11] measured the morpho-
logical parameters of the pedicle in 227 patients on computed
tomography (CT). From L1 to L5, the angle of the pedicle to the
sagittal plane gradually increased by approximately 10 to 30°,
the width of the pedicle gradually increased by approximately
7 to 16 mm, and the height of the pedicle decreased by approxi-
mately 12 to 16 mm. The spinal nerve extends around the lower
edge of the pedicle of the same ordinal vertebrae and exits the
spinal canal.
2.2. Spinal nerve
It is essential to master the anatomical structure of the nerve
tissue in the lumbar canal, because dural injury is the most com-
mon complication of UBE. The nerve tissue in the lumbar canal
consists of the dural sac and 6 pairs of spinal nerves (L1-L5, S1)
that emanate from the dural sac. After the spinal nerve emanates
from the dural sac, it travels diagonally, laterally, ventrally, and
caudally and leaves the spinal canal around the lower edge of
the pedicle at the same ordinal level (approx. 1 mm). The spinal
nerve was uplifted from the dural sac, and the width of L1 to L5
was approximately 15 mm, and that of S1 was approximately
10 mm. The angle between the spinal nerve and dural sac on the
coronal plane gradually decreased from top to bottom. L1 was
40° to 45°, L2 and L3 were generally between 30° and 40°, L4
and L5 were generally between 25° and 30°, and S1 was gener-
ally 15° to 20°.[12]
The spinal nerves are composed of anterior and posterior
roots. The dorsal root has a distensible nodule composed of cen-
tripetal sensory fibers, which are responsible for receiving nerve
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
ganglia from L1 to L3 are located in the intervertebral foramen.
Most of the dorsal root ganglia of L4 (approx. 85%) are located
in the foramina, a few are located in the spinal canal (approx.
10%), and a few are located outside the foramina (approx. 5%).
Most of the dorsal root ganglia of L5 (approx. 70%) are located
in the foramina, some (approx. 20%) are located in the spinal
canal, and a few (approx. 10%) are located outside the foram-
ina. The dorsal root ganglion of the S1 spinal nerve is mostly
located in the spinal canal (approx. 75%), and partially in the
foramina (approx. 25%). This partly explains why high cen-
tral and paracentral disc herniations often do not cause clinical
symptoms, whereas extreme lateral disc herniations often cause
severe root symptoms. Foraminal stenosis in the L5/S1 segment
was less likely to cause root symptoms.[13]
Spinal nerves L1 to L5 divide into anterior and posterior
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]:
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
root ganglia and 2 anterior roots. Approximately 65% of L4
nerve roots were type B and 30% were type C. More than 80%
of L5 roots were type B and approximately 15% were type C.
2.3. The relationship between the intervertebral disc and
spinal nerves
Spinal nerves L1 to L4 originate below the corresponding disc.
The distance from the L1 to L3 spinal nerve outlet to the corre-
sponding disc distance was generally 15 mm, and that from the
L4 spinal nerve was generally 10 mm; 62.5% of L5 spinal nerves
were generated below the corresponding disc, 12.5% were gen-
erated above the corresponding disc, and 25% were generated at
2
the disc level. 75% of S1 spinal nerves originate above the corre-
sponding disc and 25% originate at the disc level, which explains
why most disc herniations in L5/S1 are of the axillary type.[15]
The Kambin triangle, a safe area for posterolateral approach
discectomy and interbody fusion, consists of the lateral edge of
the dural sac, outlet nerve root, and upper edge of the lower
vertebral body. The upper edge of the lower vertebra is the bot-
tom edge of the Kambin triangle, which consists of the distance
between the outer edge of the dural sac and the inner edge of
the outlet nerve root. The vertical edge of Kambin triangle is the
distance from the outlet nerve root of the dural sac to the upper
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]
2.4. The relationship between the lamina and the disc
At the rear, the upper and lower boundaries of the intervertebral
space are at the lower edge of the upper lamina, the upper edge
of the lower lamina, and the upper edge of the lower lamina
does not exceed the upper edge of the vertebral body. In L1 to
L5, the distance between the upper edge of the lower lamina
and upper edge of the vertebral body was approximately 10 to
11 mm, and in S1, the distance between the upper edge of the
lower lamina and upper edge of the vertebral body was approxi-
mately 14 mm. This is because the intervertebral space is usually
partially covered by the lower edge of the upper lamina, which
exceeds the lower edge of the vertebral body by approximately
2 to 4 mm. The width of the left-right intervertebral space grad-
ually increased from top to bottom, and the width of the inter-
vertebral space was 16 to 19 mm from L1/2 to L3/4. The lamina
space widths of L4/5 was approximately 23 mm, and that of L5/
S1 was over 30 mm, respectively.[17]
2.5. The arterial supply
The lumbar artery emerges from the celiac artery and runs lat-
erally around the vertebral body, giving off the major psoas
branches about the middle of the vertebral body (anteroposte-
rior diameter). Before entering the foramina, the lumbar plexus
branches emerged from the lumbar artery to the spinal nerve
junction, nourishing the lumbar plexus. Vertebral, lateral, and
dorsal branches are emitted at the outer orifice of the foramina.
A branch of the vertebral body enters the spinal canal below the
pedicle and nourishes the posterior wall of the vertebral body.
When the disc is exposed sideways, it can damage the arteries
and cause bleeding. The dorsal branches bypass the spinal nerves
and nourish the posterior paraspinal muscles. In addition, the
dorsal branch sends out spinal nerve branches and nourishes the
spinal nerve. The lateral ramus passes caudally to the transverse
process and terminates at the abdominal wall.[18]
2.6. The ligamentum flavum
A critical point of the UBE technique is how to quickly and
safely break through the ligamentum flavum into the spinal
canal. The ligamentum flavum was divided into shallow and
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
the lower edge of the cephalic lamina at the proximal end,
to the dorsal side of the caudal lamina at the distal end, and
fused with the interspinous ligament at the midline. The deep
ligamentum flavum is relatively thin (approx. 1 mm) and is
connected to the ventral lamina proximally and distally. The
attachment point of the deep ligamentum flavum varies from
one segment to another. The lower the segment, the greater is
the lamina covered by the ligamentum flavum. The ligamen-
tum flavum covers approximately 50% of the cephalic lamina
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
ligamentum flavum covered 1 to 2 mm at L1 to L2, and 5 to
6 mm at L5 to S1.[19] Laterally, the deep ligamentum flavum
extended into the foramina, forming the posterior wall of the
foramina.[20]
2.7. The application of unilateral 2-channel endoscopic
techniques
With the increasing popularity of spinal endoscopy and
the expansion of surgical indications, single-channel spinal
endoscopy has shown significant limitations in lateral recess
decompression, contralateral decompression, and severe spi-
nal stenosis decompression, and its surgical efficiency is rela-
tively low owing to the limitations of the supporting surgical
tools.[21] Because to these limitations, the UBE technique has
been widely used in recent years. UBE is a surgical technique
in which 2 small percutaneous incisions in the posterior ipsi-
lateral spine are used to establish an observation and working
channel for internal and external spinal canal surgery. As early
as 1996, Kambin[22] used bilateral dual-channel endoscopy and
the UBE technique for the first time to remove the nucleus pul-
posus. De Antoni et al further improved the UBE technique in
the same year.[23] However, due to the lack of attention paid
to spinal endoscopy by the spine community at that time, and
the shunt effect of single-channel foraminoscopy,[24] which was
introduced in 1999, the UBE technique did not attract much
attention at that time.
In recent years, with the rise of the endoscopic technique,
scholars have realized that owing to the dual-channel design
of UBE, the observation and working channels are relatively
independent, with the advantages of convenient and flexible
operation, ample observation and operation space, the use of
conventional surgical instruments, and high efficiency.[21] In
addition, to remove the nucleus pulposus, the UBE technique
is also suitable for extensive decompression of spinal steno-
sis and interbody fusion. Kim et al analyzed 60 patients who
underwent discectomy using the UBE technique and found
that the clinical effect of patients in the UBE group was simi-
lar to that of traditional open surgery. However, the hospital
stay was relatively short, and early symptoms of low back pain
were relatively mild.[25] Heo[26] compared the application of the
UBE technique, traditional microendoscopy technique, and
single-channel spinal endoscopy technique for simple decom-
pression in patients with central spinal stenosis and found that
the clinical effect of the UBE technique is similar to that of
other technologies; however, compared with traditional tech-
niques, it has the advantages of a lighter degree of early post-
operative low back pain and relatively high comfort. Kang[27]
compared UBE lumbar fusion with microendoscopic-assisted
lumbar fusion and found that the 2 had similar clinical results,
with relatively small amounts of blood loss and postoperative
drainage.
3. Conclusion and outlook
ssion and tissue resection in a narrow working space, result-
ing in many surgery-associated injuries. Therefore, familiarity
with the anatomy of the lumbar spine is necessary to reduce
complications.
Author contributions
Conceptualization: Yongan Wei.
Formal analysis: Bo Li.
Methodology: Li Wen.
Resources: Chang Tan.
Writing – original draft: Qiang Zhang.
Writing – review & editing: Xinzhi Li.
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