Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
J Neurol Surg A Cent Eur Neurosurg. 2024 May;85(3):307-315. doi: 10.1055/a-1994-8142. Epub 2022 Dec 8.
Intraforaminal lumbar disk herniations (IFDHs) represent a heterogeneous and relatively uncommon disease; their treatment is technically demanding due to the anatomical relationships with nerve roots and vertebral joints. Over time, several approaches have been developed without reaching a consensus about the best treatment strategy.
Authors comparatively analyze surgical operability and exposure in terms of quantitative variables between the different microsurgical approaches to IFDHs, defining the impact of each approach on surgical maneuverability and exposure on specific targets.A comparative microanatomical laboratory investigation was conducted. The operability score (OS) was applied for quantitative analysis of surgical operability.
Transarticular and combined translaminar-trans-pars-interarticularis approaches result in providing the best surgical exposure and maneuverability on all targets with surgical controls on both nerve roots, at the expense of a higher risk of iatrogenic instability. Trans-pars-interarticularis approach reaches comparable levels of operability, even limited to the pure foraminal area (lateral compartment); similar findings were recorded for partial facetectomy on the medial compartment. The contralateral interlaminar approach provides good visualization of the foramen without consensual favorable maneuverability, which should be considered the main drawback.
Approach selection has to consider disease location, the possible migration of disk fragments, the degree of nerve root involvement, and risk of iatrogenic instability. According to the findings, authors propose an operative algorithm to tailor the surgical strategy, based both on the precise definition of anatomic boundaries of exposure of each approach and on surgical maneuverability on specific targets.
椎间孔型腰椎间盘突出症（IFDH）是一种异质性且相对罕见的疾病；由于与神经根和椎间关节的解剖关系，其治疗具有一定的技术难度。随着时间的推移，已经开发出了几种方法，但仍未就最佳治疗策略达成共识。
作者比较分析了不同椎间孔型腰椎间盘突出症显微手术入路的手术可操作性和暴露程度，针对特定目标定义了每种入路对手术操作灵活性和暴露程度的影响。进行了一项比较性的显微解剖实验室研究。运用手术可操作性评分（OS）对手术可操作性进行定量分析。
经关节突和联合经椎板-跨关节突-关节间入路在所有目标上提供了最佳的手术暴露和操作灵活性，可对双侧神经根进行手术控制，但存在较高的医源性失稳风险。经关节突间入路可达到可操作性的相似水平，即使仅针对单纯的椎间孔区（外侧区）；对内侧区部分关节突切除也有类似的发现。对侧椎板间入路可提供良好的椎间孔可视化，但无共识性的有利操作灵活性，这应被视为主要缺点。
入路选择必须考虑疾病部位、椎间盘碎片可能的迁移、神经根受累程度以及医源性失稳的风险。根据研究结果，作者提出了一种手术策略的选择算法，该算法基于对每种入路暴露的解剖边界的精确定义以及对特定目标的手术操作灵活性。
