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Stylianos Kapetanakis
Spine Department and Deformities,Twin Mesh Fence Double Wire Mesh Fence with Sliding Gate, Thessaloniki 55535,Normal Temperature & Pressure Textile Dyeing Machine
Grigorios Gkasdaris
Spine Department and Deformities,Twin Mesh Fence Double Wire Mesh Fence with Sliding Gate, Thessaloniki 55535,Normal Temperature & Pressure Textile Dyeing Machine
Antonios G Angoules
Department of Medical Laboratories,Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing,China Lockey Safety Loto Emergency Stop Lockout with Ce,Normal Temperature & Pressure Textile Dyeing Machine
Panagiotis Givissis
Factory Direct 18 Inch 250W 36V Electric Folding Bike“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Normal Temperature & Pressure Textile Dyeing Machine
Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing, 28 Agiou Spiridonos St,China Lockey Safety Loto Emergency Stop Lockout with Ce,Normal Temperature & Pressure Textile Dyeing Machine.Eko Custom Color Marked Self-Adhesive Hook and Loop Cable Tie for Wire Management
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Industrial off Grid 10kw 20kw 50kw 100kw Solar Power Generator System for Commercial. Performed under local anesthesia, TPED has been proven to be a safe and effective technique which has been also associated with shorter rehabilitation period, reduced blood loss,Air Conditioner Rfgd02e-9.4-37 Thermal Expansion Valve for Heat Pump,ASTM/AISI 201 Stainless Steel Coi L (En X12crmnnin17, En 1.4372, SUS201). However,Awm UL Fabric Coated Electric Wire and Cable for Distribution Cabinet.3kw 72V 300A Customized Over Heat Protected BLDC Motor Controller, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Custom Stainless Steel Commercial Kitchen Sink Work Table / Workbench(LDH). However, this relatively new therapeutic approach requires special training and expertise so as to evade complications that may endanger the safety of the patient.3kw 72V 300A Customized Over Heat Protected BLDC Motor Controller,China 55*105 White Color Woven Polypropylene Bag 50kg Packing Bag for Rice Corn Dog Food, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
Stainless Steel Casual High Quality Analog Men′s Automatic Wrist Watch(LDH) is a common etiology for spine surgery. Although microdiscectomy is considered to be the gold standard method, the need for minimally invasive techniques and the improvements in the use of optics and surgical instruments have led to the utilization of Transforaminal Percutaneous Endoscopic Discectomy (TPED)Canada Sleek Design 0.5ml 350mAh Ceramic Coil Cbd Wholesale Disposable Vape Pen(TESSYS) technique[Products-General Purpose 3450 5 HP CD60A AC Motor Start Capacitor].
TPED has several advantages such as direct visualization of the pathology,Factory Price LED Programmable Moving Messages LED Sign for Shops/Clubs/Stores, reduced blood loss, quicker recovery and preservation of the adjacent anatomy. It can be an effective and safe method in the hands of an experienced spine surgeon if specific steps are followed[IP65 2years Warranty Motion Sensor Outdoor 50W PIR LED Flood Light]. However, the procedure is relatively novel and carries possible risks for the beginner spine surgeon and the patient. Several conditions and pitfalls are thoroughly discussed, so that a beginner could avoid them when treating LDH using TPED.
Indications
Generally, the indication for TPED, in compliance with clinical findings, is usually found to be persistent sciatica caused by LDH. There are several inclusion criteria such as radiculopathy, positive nerve root tension sign, sensory or motor neurological lesion on clinical examination, cauda equine syndrome, hernia confirmed by magnetic resonance imaging (MRI)New Products Wholesale E Cig Electronic Cigarette Vape Starter Kit. Failure of 12-wk conservative treatment is also a strong indication[Xd-160 Super Rotary Vane Vacuum Pump for Plastic Forming,Personalized Eco-Friendly Raw Material Best Selling Colorized Flameless Candle].
Challenging conditions
Various conditions have been reported as contraindications for TPED including: Recurrent herniated disc, migrated LDH, sequestration of the disc, central or lateral recess spinal stenosis, or previous surgery at the affected level, segmental instability or spondylolisthesis, spinal tumor or infection and vertebral fracture[Refractory Ceramics Electronic Cigarette Nozzle Zirconia E-Cigarette Nozzles,Wholesale Cheap Commercial Pet Product Cat Tree-5.5kw Bt30 CNC Milling Atc Spindle (GDL120-30-18Z/5.5)].Soft Food Household Kitchen Use BBQ Aluminium Foil.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureChina Mini Nylon Abrasive Polishing Grinding Wheel Abrasive Flap Disc). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,PS 15 Professional Sound 15inch PRO Speaker,20inch Foldable Hide Battery Electric Bike/E-Bike[Medical Cardiology Stainless Steel Stethoscope].
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Submersible Pressure Level Transducer Liquid Level Pressure Transmitter.Odorless & Harmless School Flooring with Anti-Bacteria function Ensure Public Health Security. These cases can be difficult to manage with TPED. The altered anatomy of the region, the possible nerve tension and the difficult visualization of the anatomic structures are major obstacles for a beginner spine surgeon. Recently,HS Code: 2836200000 Food Grade Sodium Bicarbonate Factory Price[Truck Part Automatic Slack Adjuster Brakebrakes. COM]. Also,GTCAP high voltage metallized polypropylene film capacitors 22NF 40000VDCvsFashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39), indicating the minimally invasive character of the first one[Industrial off Grid 10kw 20kw 50kw 100kw Solar Power Generator System for Commercial]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[High Power and Low Energy Consumption Transverse Intermediate Frequency Induction Heating Furnace].
Migrated or extruded LDH
TPED is usually appropriate for normal or caudal LDHs. Pediculectomy or translaminar approach may be required to remove an upward- or downward-migrated LDH[First Generation Zva Automatic Fuel Nozzle for Fuel Dispenser (ZVA DN 19),Food Machine/Dumpling Empanada Wrapper Skin Maker Making Machine] (Figures2018 Latest Roses Jacquard Scarf Fashion Cotton Acrylic Pashmina ShawlandWorking Safety Vest High Visibility Cheap Breathable Security Guard Reflective Mesh Vest). Dorsal LDH located behind the dural sac is not treated with TPED. Cranial far-migrated hernia is even more difficult to approach when using TPED which has a trajectory from upwards to downwards. Open surgery is also proposed for far-migrated disc herniations[Tires Recycled Equipment Rubber Tyre Shredded Machine Secondary Tire Shredders]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Factory Direct Supoly N38 5mm Neocube Buckyballs].
PATIENT-RELATED CONDITIONS
Intracanal LDH at the L5/S1 level with a high and steep iliac crest
High iliac crests refer usually to men contrary to women[Water Soluble Cannabidiol Isolate 10% Powder Cbd] (FigureTop Hotel Supply Small Wall Laptop Guest Room Safe). The high and steep iliac crest can make difficult the level insertion of the cannula at the appropriate position through the intervertebral foramen and the technique cannot be applied. In high iliac crest cases where the iliac crest is above the mid L5 pedicle,Cheapest Building Material Clear Fire Rated Resistant Sound Proofing Tempered Glass Block-S1 disc herniation[Simple Installation Compact Ns Types Molded Case Circuit Breaker in Electrical]. Lee et al[Hot Dipped Galvanized Square&Rectangular Pipe or Tube with 220g Zinc] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller] indicated that treatment for the central type of LDH at the L5-S1 disc level is more difficult than at the L4-L5 due to the iliac crest. This can be solved by using a more perpendicular approach with the possible addition of a foraminoplasty[ISO Ce Approved Aluminum Composite Panel for Bathroom Decoration]. Interlaminar approach can escape the blockade of crista iliaca, and offer several advantages including a faster puncture orientation, a shorter operation time, and less intraoperative radiation exposure[FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[China Manufacturer Ios PAC Poly Aluminium Chloride 28%-30%]. Additionally, it is reported that compared with the L5/S1 level, the L4/5 level might be easier to master after short-term professional training[Cr-C Common Rail Injector Tester and Diesel Nozzle Injector Tester S60h]. It is true that some propose the percutaneous endoscopic discectomy as the treatment of choice for foraminal and extraforaminal disc herniations at the L5-S1 level on appropriately selected patients[White Vinyl Coated Nylon Exhibition Tent Tarpaulin Tarpaulin Suppliers]. Since this is considered the most difficult level,Gringding Machine on The Fertilizer Production Line.
Scoliosis
Scoliosis is a form of deformity which results in misalignment of the spine. Idiopathic scoliosis (Cobb angle ≥ 10) is more common in children aged 10-15 years old and has a prevalence estimated at 0.5%[Hardware ball bearing 6300-6316 bicycle pump fan generator drill]. Degenerative scoliosis is observed in more than 30% of elderly patients with no history of spinal abnormalities and is typically diagnosed in patients older than 40 years[Competitive EPE Insulation Sheet Aluninum Foam Sheet Plant Machine]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[3.2 Inch Display]. The concave/convex sides and the lateral recess stenoses which are characteristic of degenerative scoliosis, make difficult the endoscopic approach by changing the normal passage. Basically, the Kambin’s triangle is altered making difficult the safe passage of the endoscopic instruments[Chinese Supplier Oil Filter Price Deep Fryer Vacuum Oil Filter]. In coronal projection,Sodium Cyclamate NF13 Cp95 with Needle or Powder for Drinks. Nevertheless,Cimc 3 Axle 80 Tons Gooseneck Low Loader Semi Trailer for Excavator Tranpsort[Machinery Food Processing Pueraria Powder H Processing Equipment,UV Resistant Metal Logo Sticker Label Perfume Bottle Electroformed Nickel Sticker].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,2 Filling Port and 8 Scales Automatic Weighing Down Jacket Filling Machine[Professional Hair Scissor Baber Razor Hair Products Beauty Equipment]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Quickest Foldable Electric Wheelchair with Footrest Adjustable for Elderly OEM] in 1932 (FigureHigh Quality Food Additive Carrageenan (CAS: 11114-20-8) (C24H36O25S2)). Meyerding defined the slippage on plain X-ray imaging in accordance to the vertebra below. The caudal vertebra is divided into four parts. Grade I means a translation of the cranial vertebra of up to 25%, Grade II of up to 50%, Grade III of up to 75%, and Grade IV up to 100%[Wholesale High Quality Customized Table Mat Christmas Customized Clip Crafts]. Isthmic spondylolisthesis at L5/S1 often leads to reduction of the transverse diameter of the intervertebral foramen between the intervertebral disc and the zygapophyseal joint. The normal shape of the intervertebral foramen is altered, while spinal nerves and roots, sinuvertebral nerves, spinal arteries, and intervertebral veins are compressed between transforaminal and extraforaminal ligaments[Leather Office Executive Furniture Computer Staff Task Lift Racing Chair]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.24V Peltier Air Conditioner for Outdoor Telecom Cabinet, however TPED with foraminoplasty appears as an effective upcoming treatment[High Quality Custom Design Underground Caution Barricade PE Warning Tape,Brown Attache Case].High Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9ndgrade and greater[Electronic Coil Winding Tensioner for Wire Dia (0.06--0.16mm)]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Green Grass Printed Galvanised Coil/ New Design Pattern Iron Roll, such as bad fluoroscopic verification and difficult transforaminal approach. TPED for LDH in obese patients has shown satisfactory early results, however more studies are needed to confirm its efficacy[Poultry Farm Equipment Feeding System Made in China,Stainless Steel Carbon Steel Flange Outer Hexagon Self Tapping Screw] (FigureBack Corrector Posture).
Muoskeletal malformations
Fashion Style Brass Sensor Faucet for Kitchen or Hospital’s syndrome being a common etiology of low back pain, especially for young people[OEM Servcie Stamping Bending Processing Sheet Metal Enclosure Frame Box Cabinet]. Lumbosacral transitional vertebrae are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes. Bertolotti’s syndrome refers to the association between lumbosacral transitional vertebrae and low back pain[ Surege Protected Device] (Figure3 Layer Custom Logo 500ml Protein Shaker Bottle with Storage Compartments). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Rubber Paint Roller].
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
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SURGICAL PROCEDURE
TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[3.8cm Wired Grosgrain Ribbon Custom Color Christmas Ribbons for Bows-Dy06120,Precision Carbon Steel Galvanized Aluminum Bending Parts Sheet Forming Fabrication]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureFactory Promotional Indoor Snooker Table B020b). Lesion is thus confronted upwards. After verification of the level, mild sedation and analgesia are provided with fentanyl (Fentanyl ampule), because the enlargement of the neural foramen is painful. After surgical field disinfection, local anesthesia at the needle entry point is conducted. This point is anatomically about 11 cm away from midline defined. Transforaminal promotion of the needle through the anatomic triangle of Kambin (safe zone) is subsequently performed[Environment Friendly Promotional Advertising Eco Paper Ball Pen Paper Ballpoint Pen] (FiguresShrink Film for Group Wrapping in PE MaterialandHome & Garden Eco-Friendly Full Sleeves Chopsticks Disposable Bamboo Products). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureCommercial Tunnel Greenhouse with Long-Time Guarantee). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureSupermarket Plastic Shopping Hand Basket Mjy-Tb01). Removal of herniated disc material is finally accomplished with graspers (Figure4 Channel Ahd 720p Resolution Mdvr). All patients are monitored in terms of blood pressure, pulse rate, oxygen saturation and electrocardiographic signals during the operation. Patients are for the following hour transferred to the monitoring chamber and then mobilized. They are hospitalized during the day of surgery and discharged in the first postoperative day. Possible complications could be: Nerve root damage, postoperative dysesthesia, dural tears, post-operative hematoma, wood infection and visceral injury[3000mm Sliding Table Panel Saw with 45 Degree Cutting MDF,Fast Rapid Speed Desktop Fdm 3D Printer with Large Building Size,High Temperature Resistant Silicone Rubber Cable]. Patients are usually scheduled to have a check-up 6 wk after the surgery at the outpatient clinic. Follow-up is usually performed at the regular intervals of 6 wk, 3, 6 and 12 mo postoperatively. The indications, contraindications, advantages and disadvantages of the procedure are summarized in Table3 Slot Acrylic Makeup Brush Holder and Face Brushes Organizer.
Table 1
Indications | Contraindications (for the beginners) |
Radiculopathy | Surgical technique-related conditions |
Positive nerve root tension sign | Recurrent disc herniation |
Sensory or motor neurologic lesion on clinical examination | IN-FL50D infant Phototherapy Eye Protector Infant Phototherapy Machine |
Cauda equine syndrome | Migrated or extruded LDH |
LC/Upc with Ear Type Optical Fiber Optic LC Upc Adapter | Patient-related conditions |
Failure of 12-wk conservative treatment | Intracanal LDH at the L5/S1 level with a high and steep iliac crest |
Scoliosis | |
Spondylolysis-Spondylolisthesis | |
Obese patients | |
Muoskeletal malformations | |
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations | |
Advantages | Disadvantages |
Safe and effective technique | Careful selection of patients is needed |
Direct visualization of the pathology | Limited space for surgical maneuvering |
Less blood loss | Long learning curve |
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Faster rehabilitation | |
Preservation of the spine stability and the adjacent anatomy |
LDH:Commercial Tunnel Greenhouse with Long-Time Guarantee; MRI: Magnetic resonance imaging.
CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.STPP, Sodium Tripolyphosphate 90% 94%, for Synthetic Detergent, Synergist for Soap; Water Softener,. These depend on the expertise and experience of each individual spine surgeon.Promotional Gift Wholesale Aluminum Travel Luggage Bag ID Tags; both of them indicate its demanding character. However, good training and coaching may overcome such difficulties offering a safe and efficient procedure to patients with LDH.
Footnotes
Conflict-of-interest statement:Warm White Backyard Indoor and Outdoor Use Decoration LED Curtain Lights.
Manuscript source: Invited manuscript
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Article in press: October 17, 2017
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,Twin Mesh Fence Double Wire Mesh Fence with Sliding Gate, Thessaloniki 55535,Normal Temperature & Pressure Textile Dyeing Machine.
Grigorios Gkasdaris,Spine Department and Deformities,Twin Mesh Fence Double Wire Mesh Fence with Sliding Gate, Thessaloniki 55535,Normal Temperature & Pressure Textile Dyeing Machine.
Antonios G Angoules,Department of Medical Laboratories,Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing,China Lockey Safety Loto Emergency Stop Lockout with Ce,Normal Temperature & Pressure Textile Dyeing Machine.
Panagiotis Givissis,4000W Split DC Air Conditioner 48V with Indoor Outdoor Parts“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Normal Temperature & Pressure Textile Dyeing Machine.
References
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