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J Neurol Surg A Cent Eur Neurosurg 2024; 85(03): 307-315
DOI: 10.1055/a-1994-8142
Surgical Technique Article

Comparative Analysis on Surgical Operability and Degree of Exposure of Microsurgical Approaches to Intraforaminal Lumbar Disk Herniations

Filippo Gagliardi 
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Edoardo Pompeo 
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Silvia Snider
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Francesca Roncelli
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Marzia Medone
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Pierfrancesco De Domenico
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Martina Piloni
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
,
Pietro Mortini
1   Department of Neurosurgery and Gamma Knife Radiosurgery, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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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

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Neither the article nor any part of its essential substance has been published or submitted for publication in other medical journals.


Ethical Standards

This article does not contain any studies with living human participants or animals performed by any of the authors.




Publication History

Received: 07 July 2022

Accepted: 05 December 2022

Accepted Manuscript online:
08 December 2022

Article published online:
11 May 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kornberg M. Extreme lateral lumbar disc herniations. Clinical syndrome and computed tomography recognition. Spine 1987; 12 (06) 586-589
    Google Scholar
  • 2 O'Brien MF, Peterson D, Crockard HA. A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation. J Neurosurg 1995; 83 (04) 636-640
    Google Scholar
  • 3 Lofrese G, Mongardi L, Cultrera F, Trapella G, De Bonis P. Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: many approaches for few surgical routes. Acta Neurochir (Wien) 2017; 159 (07) 1273-1281
    Google Scholar
  • 4 Gagliardi F, Boari N, Roberti F, Caputy AJ, Mortini P. Operability score: an innovative tool for quantitative assessment of operability in comparative studies on surgical anatomy. J Craniomaxillofac Surg 2014; 42 (06) 1000-1004
    Google Scholar
  • 5 Gagliardi F, Snider S, Roncelli F. et al. Combined, rib-sparing, bilateral approach to the ventral mid and low thoracic spine: study on comparative anatomy and surgical feasibility. World Neurosurg 2021; 150: e117-e126
    Google Scholar
  • 6 Fankhauser H, de Tribolet N. Extreme lateral lumbar disc herniation. Br J Neurosurg 1987; 1 (01) 111-129
    Google Scholar
  • 7 Foley KT, Smith MM, Rampersaud YR. Microendoscopic approach to far-lateral lumbar disc herniation. Neurosurg Focus 1999; 7 (05) e5
    Google Scholar
  • 8 Gioia G, Mandelli D, Capaccioni B, Randelli F, Tessari L. Surgical treatment of far lateral lumbar disc herniation. Identification of compressed root and discectomy by lateral approach. Spine 1999; 24 (18) 1952-1957
    Google Scholar
  • 9 Hodges SD, Humphreys SC, Eck JC, Covington LA. The surgical treatment of far lateral L3-L4 and L4-L5 disc herniations. A modified technique and outcomes analysis of 25 patients. Spine 1999; 24 (12) 1243-1246
    Google Scholar
  • 10 Hood RS. Far lateral lumbar disc herniations. Neurosurg Clin N Am 1993; 4 (01) 117-124
    Google Scholar
  • 11 Maroon JC, Kopitnik TA, Schulhof LA, Abla A, Wilberger JE. Diagnosis and microsurgical approach to far-lateral disc herniation in the lumbar spine. J Neurosurg 1990; 72 (03) 378-382
    Google Scholar
  • 12 O'Hara LJ, Marshall RW. Far lateral lumbar disc herniation. The key to the intertransverse approach. J Bone Joint Surg Br 1997; 79 (06) 943-947
    Google Scholar
  • 13 Porchet F, Chollet-Bornand A, de Tribolet N. Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations. J Neurosurg 1999; 90 (1, Suppl): 59-66
    Google Scholar
  • 14 Postacchini F, Cinotti G, Gumina S. Microsurgical excision of lateral lumbar disc herniation through an interlaminar approach. J Bone Joint Surg Br 1998; 80 (02) 201-207
    Google Scholar
  • 15 Postacchini F, Montanaro A. Extreme lateral herniations of lumbar disks. Clin Orthop Relat Res 1979; (138) 222-227
    Google Scholar
  • 16 Reulen HJ, Müller A, Ebeling U. Microsurgical anatomy of the lateral approach to extraforaminal lumbar disc herniations. Neurosurgery 1996; 39 (02) 345-350 , discussion 350–351
    Google Scholar
  • 17 Schlesinger SM, Fankhauser H, de Tribolet N. Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations. Acta Neurochir (Wien) 1992; 118 (3–4): 117-129
    Google Scholar
  • 18 Tessitore E, de Tribolet N. Far-lateral lumbar disc herniation: the microsurgical transmuscular approach. Neurosurgery 2004; 54 (04) 939-942 , discussion 942
    Google Scholar
  • 19 Eustacchio S, Flaschka G, Trummer M, Fuchs I, Unger F. Endoscopic percutaneous transforaminal treatment for herniated lumbar discs. Acta Neurochir (Wien) 2002; 144 (10) 997-1004 , discussion 1003–1004
    Google Scholar
  • 20 Liu T, Zhou Y, Wang J. et al. Clinical efficacy of three different minimally invasive procedures for far lateral lumbar disc herniation. Chin Med J (Engl) 2012; 125 (06) 1082-1088
    Google Scholar
  • 21 Epstein NE. Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations: indications and results. J Neurosurg 1995; 83 (04) 648-656
    Google Scholar
  • 22 Jane JA, Haworth CS, Broaddus WC, Lee JH, Malik J. A neurosurgical approach to far-lateral disc herniation. Technical note. J Neurosurg 1990; 72 (01) 143-144
    Google Scholar
  • 23 Melvill RL, Baxter BL. The intertransverse approach to extraforaminal disc protrusion in the lumbar spine. Spine 1994; 19 (23) 2707-2714
    Google Scholar
  • 24 Monteiro A, Lefèvre R, Pieters G, Wilmet E. Lateral decompression of a pathological disc in the treatment of lumbar pain and sciatica. Clin Orthop Relat Res 1989; (238) 56-63
    Google Scholar
  • 25 Müller A, Reulen HJ. A paramedian tangential approach to lumbosacral extraforaminal disc herniations. Neurosurgery 1998; 43 (04) 854-861 , discussion 861–862
    Google Scholar
  • 26 Ozveren MF, Bilge T, Barut S, Eras M. Combined approach for far-lateral lumbar disc herniation. Neurol Med Chir (Tokyo) 2004; 44 (03) 118-122 , discussion 123
    Google Scholar
  • 27 Reulen HJ, Pfaundler S, Ebeling U. The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation. I: a technical note. Acta Neurochir (Wien) 1987; 84 (1–2): 64-67
    Google Scholar
  • 28 Viswanathan R, Swamy NK, Tobler WD, Greiner AL, Keller JT, Dunsker SB. Extraforaminal lumbar disc herniations: microsurgical anatomy and surgical approach. J Neurosurg 2002; 96 (2, Suppl): 206-211
    Google Scholar
  • 29 Bernucci C, Giovanelli M. Translaminar microsurgical approach for lumbar herniated nucleus pulposus (HNP) in the “hidden zone”: clinical and radiologic results in a series of 24 patients. Spine 2007; 32 (02) 281-284
    Google Scholar
  • 30 Epstein NE. Different surgical approaches to far lateral lumbar disc herniations. J Spinal Disord 1995; 8 (05) 383-394
    Google Scholar
  • 31 Ikuta K, Tono O, Senba H. et al. Translaminar microendoscopic herniotomy for cranially migrated lumbar disc herniations encroaching on the exiting nerve root in the preforaminal and foraminal zones. Asian Spine J 2013; 7 (03) 190-195
    Google Scholar
  • 32 Papavero L, Langer N, Fritzsche E, Emami P, Westphal M, Kothe R. The translaminar approach to lumbar disc herniations impinging the exiting root. Neurosurgery 2008;62(3, Suppl 1):173–177, discussion 177–178
    Google Scholar
  • 33 Soldner F, Hoelper BM, Wallenfang T, Behr R. The translaminar approach to canalicular and cranio-dorsolateral lumbar disc herniations. Acta Neurochir (Wien) 2002; 144 (04) 315-320
    Google Scholar
  • 34 Vogelsang JP. The translaminar approach in combination with a tubular retractor system for the treatment of far cranio-laterally and foraminally extruded lumbar disc herniations. Zentralbl Neurochir 2007; 68 (01) 24-28
    Google Scholar
  • 35 Berra LV, Foti D, Ampollini A, Faraca G, Zullo N, Musso C. Contralateral approach for far lateral lumbar disc herniations: a modified technique and outcome analysis of nine patients. Spine 2010; 35 (06) 709-713
    Google Scholar
  • 36 Widmer J, Cornaz F, Scheibler G, Spirig JM, Snedeker JG, Farshad M. Biomechanical contribution of spinal structures to stability of the lumbar spine-novel biomechanical insights. Spine J 2020; 20 (10) 1705-1716
    Google Scholar
  • 37 Kambin P. Arthroscopic microdiscectomy. Arthroscopy 1992; 8 (03) 287-295
    Google Scholar