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Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes

  • Review Article - Spine
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Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

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Abbreviations

LDH:

Lateral disc herniation

ILDH:

Intraforaminal disc herniation

ELDH:

Extraforaminal disc herniation

IELDH:

Intra−/extraforaminal disc herniation

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Authors and Affiliations

  1. Neurosurgery Division, M. Bufalini Hospital, Viale Ghirotti 286, 47521, Cesena, Italy

    Giorgio Lofrese & Francesco Cultrera

  2. Department of Neurosurgery, S. Anna University Hospital, Viale Aldo Moro 8, 44121, Cona di Ferrara, Italy

    Lorenzo Mongardi, Giorgio Trapella & Pasquale De Bonis

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  1. Giorgio Lofrese
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  2. Lorenzo Mongardi
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  3. Francesco Cultrera
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Correspondence to Giorgio Lofrese.

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Lofrese, G., Mongardi, L., Cultrera, F. et al. Surgical treatment of intraforaminal/extraforaminal lumbar disc herniations: Many approaches for few surgical routes. Acta Neurochir 159, 1273–1281 (2017). https://doi.org/10.1007/s00701-017-3198-9

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