Abstract
Background 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.
Materials and methods 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.
Results 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.
Conclusions 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.
Keywords
intraforaminal - disk herniation - approaches - surgical operability - operative algorithm
