Lofrese Giorgio, Mongardi Lorenzo, Cultrera Francesco, Trapella Giorgio, De Bonis Pasquale
Neurosurgery Division, M. Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy.
Department of Neurosurgery, S. Anna University Hospital, Viale Aldo Moro 8, 44121, Cona di Ferrara, Italy.
Acta Neurochir (Wien). 2017 Jul;159(7):1273-1281. doi: 10.1007/s00701-017-3198-9. Epub 2017 May 22.
Several disc disease nomenclatures and approaches for LDH exist. The traditional midline bone-destructive procedures together with approaches requiring extreme muscular retraction are being replaced by muscle sparing, targeted, stability-preserving surgical routes. The increasing speculation on LDHs and the innovative corridors described to treat them have lead to an extensive production of papers frequently treating the same topic but adopting different terminologies and reporting contradictory results.
The review of such literature somehow confounding gave us the chance to regroup by surgical corridors the vast amount of approaches for LDH differently renamed over time. Likewise, LDHs were simplified in intra-foraminal (ILDH), extra-foraminal (ELDH), and intra-/extra-foraminal (IELDH) in relation to precise anatomical boundaries and extent of bulging disc.
Through the analysis of the papers, it was possible to identify ideal surgical corridors for ILDHs, ELDHs, and IELDHs, distinguishing for each approach the exposure provided and the technical advantages/disadvantages in terms of muscle trauma, biomechanical stability, and nerve root preservation. A significant disproportion was noted between studies discussing traditional midline approaches or variants of the posterolateral route and those investigating pros and cons of simple or combined alternative corridors. Although rarely discussed, these latter represent valuable strategies particularly for the challenging IELDHs, thanks to the optimal compromise between herniation exposure and bone-muscle preservation.
The integration of adequate mastery of traditional approaches together with a greater confidence through unfamiliar surgical corridors can improve the development of combined mini-invasive procedures, which seem promising for future targeted LDH excisions.
存在多种腰椎间盘突出症（LDH）的椎间盘疾病命名法和治疗方法。传统的中线骨破坏手术以及需要极度肌肉牵拉的方法正被保留肌肉、靶向性、保留稳定性的手术路径所取代。对LDH的猜测不断增加，以及为治疗LDH而描述的创新通道，导致大量论文不断涌现，这些论文常常讨论相同的主题，但采用不同的术语并报告相互矛盾的结果。
对这类有些混乱的文献进行综述，使我们有机会按手术通道对大量随时间不同命名的LDH治疗方法进行重新分组。同样，根据精确的解剖边界和椎间盘突出的程度，将LDH简化为椎间孔内型（ILDH）、椎间孔外型（ELDH）和椎间孔内/外型（IELDH）。
通过对论文的分析，有可能确定ILDH、ELDH和IELDH的理想手术通道，区分每种方法所提供的暴露程度以及在肌肉创伤、生物力学稳定性和神经根保留方面的技术优缺点。在讨论传统中线方法或后外侧途径变体的研究与调查简单或联合替代通道利弊的研究之间，发现存在显著差异。尽管很少被讨论，但后者代表了有价值的策略，特别是对于具有挑战性的IELDH，因为在突出暴露和骨-肌肉保留之间实现了最佳平衡。
将对传统方法的充分掌握与通过不熟悉的手术通道获得更大的信心相结合，可以促进联合微创手术的发展，这对于未来有针对性的LDH切除术似乎很有前景。
