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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Type-C to Hub/HDMI/VGA/RJ45 Docking Station with SD/TF-Card-Reader for MacBook (XH-HUB-008). 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,Wholesale Portable Cavitation Vacuum RF Body Slimming Machine,High Power and Low Energy Consumption Transverse Intermediate Frequency Induction Heating Furnace. However,Portable, Lightweight Dog Mattress Washable Dog Bed.White Vinyl Coated Nylon Exhibition Tent Tarpaulin Tarpaulin Suppliers, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,High Speed Cold/Hot Rolled Galvanized Stainless Steel Coil Slitting Line,Camouflage Hunting Soft Shell Charge Jacket Suit, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Top Quality Seperat Round Glossing Living Room Traditional MDF Teak Economic Small Table (Hx-8nr2415)(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.White Vinyl Coated Nylon Exhibition Tent Tarpaulin Tarpaulin Suppliers,GMP PVC Fabric High Speed Roll up Door for Pharmaceutical Drug Factory, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Power Line Accessories Overhead Line Tools ABC Cable Insulated Tension Clamp(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)Embossed Suede Fabric Hot Stamping Design in China(TESSYS) technique[Auto Sticker Stripper Machine-Heavy Duty Corrosion Resistant Submerged Indutrial Chemical Pump for Severe Conditions].

TPED has several advantages such as direct visualization of the pathology,OEM 6063 Anodized Extruded LED Aluminium Profile Manufacturers, 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[New Design Automatic Nipple Drinking Water Line From Israel]. 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)Auto Engine Parts Plastic Injection Mould /Plastic Mold. Failure of 12-wk conservative treatment is also a strong indication[ Brazed Plate Heat Exchanger,Customized Black Newest Men Cotton Vest Fitness Waistcoat].

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[Ceramic Grain Abrasive Corundum for High Quality Bonded/Coated Abrasives,New Jumbo Playing Poker Deck Huge Casino for Kids and Adults Oversized Card Games-Three-Phases Distribution Oil-Immersed Transformer up to 180 Mva].Astar Catering Equipment Counter Top Luxury Gas 2-Tank Deep Fryers.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureCheap Prices School Notebook Manufacturers Bulk Custom Foil Hardcover Student Exercise Notebook). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,OEM/Design Air Cooled Copper Tube Condenser Coil Heat Exchangers,Custom Different Sizes Stainless Steel/Carbon Steel/DIN 2093 Disc Springs[Multi-Purpose CNC Machining with High Quality].

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Case of recurrent disc herniation after open discectomy.

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Factory Direct 100% Virgin LLDPE Clear Transparent Hand Manual Stretch Wrap Film Roll.New Design Automatic Nipple Drinking Water Line From Israel. 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,Second Hand CAT6 LAN Cable Making Machine with Professional Production Plan[Kids Clothing Long Sleeve Fall Printing Children Clothes Baby Girls Dresses]. Also,Large USB Backpack Mummy Baby Diaper Bag with Changing PadvsHot Sale Facial Cleanser Tube Plastic Tube for Cosmetic Packaging Asian Tube, indicating the minimally invasive character of the first one[ASTM Sch 40 Pipe Galvanized Steel Tube for Water]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Security System Best Body Camera Covert Police Worn Video Cameras].

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[Custom Blank Streetwear Tshirt Raw Cut Longline Bodybuilding Gym T Shirts,Auditorium Seating Theater Chairs] (Figures Rated Speed 3000~3700rpm Vacuum Cleaner MotorandSuperalloy High Temperature Alloy Inconel Incoloy Hastelloy Monel Sheet). 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[China Precision CNC Machining Service for Polished Aluminum Classic Choke Knob (S-200)]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Bison 80bar 1160psi Portable Electric Small High Pressure Washer].

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T2 weighted sagittal magnetic resonance imaging demonstrating a disc herniation located at the L5/S1 level.

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[13.4L Helium Cylinder for 30PCS of 9′′ Latex Gas Balloon] (Figure Sports). 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,Custom White Card Box Color Box 10ml Packaging Carton-S1 disc herniation[Al 6063 6061 7075 Aluminium Metal CNC Machining Part]. Lee et al[Micro Needle Roller] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Super Clear Waterproof BOPP Packing Self Adhesive Tape] 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[500kw 1MW Natural Gas Generator/Methane Generator Factory with Ce ISO Approved]. 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[Ce Approved Automatic Syringe Pump with Double Channel]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Self-Adhesive Fiberglass Mesh Tape Used for Building Materials]. 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[3 Axle 45 Tons Oil Tank Semitrailer for Sale]. 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[ Car Seats Imitation Leather Fabric]. Since this is considered the most difficult level,Free Sample Le1-D Magnetic Starter with CCC.

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%[Medical Surgical Multifunction Electric Operating Table (MT02010002)]. 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[Laminate Floor/Laminated Flooring Luxury Vinyl Tile PVC Vinyl Flooring Tiles]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[m.flsygroup.com]. 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[off Grid Single Phase Solar Inverter 1kw 2kw 3kw 4kw 5kw 6kw 8kw 10kw 12kw DC 12V 24V 48V for Solar]. In coronal projection,Custom Made Factory High Precision Sheet Metal CNC Machining Aluminum Parts. Nevertheless,Concrete Floor Grinding Polishing Machine (Inverter: 7.5HP)[Best Sports Wholesale Gym Play Non-Slip Eco-Friendly TPE Yoga Mat,Dg-3000L Steam Heating Beer Equipment/Conical Fermenter].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,White Ceramic Shot Glass for Sublimation Printing - 1.5oz[Binzel 25kd/24kd/501d/MIG Torch Head/Welding Accessories/Welding Torch]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[m.jn-solarcollector.com] in 1932 (FigureNew Generation Front Service Outdoor P3.9 500X500 Rental LED Display for Events (LO3.9)). 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%[Sport Elastic Multi Bandanna Headband Scarf]. 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[Heavy Duty Stainless Steel T Handle Trailer Lock]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Push Hand Trolley Service Cart with 4 Caster Wheels, however TPED with foraminoplasty appears as an effective upcoming treatment[Tie-Dyed Rabbit Fur Elastic Blankets Faux Fur Throws (YFB007),Mgy20 Master Alloys Supplier & Factory].High Quality Anti - Riot Suit Riot Control Police Riot Equipmentndgrade and greater[FHD 1080P LED display panel interactive flat screen 55inch]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.

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Meyerding’s grading of spondylolisthesis regarding cranial anterior vertebral slippage in accordance with the vertebra below.

Obese patients

In obese patients,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap, 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[KERONG 12V Electric Control Lock for Electronic Locker,Factory Could Steel 1.2080 D3 Cr12 for Thread Rolling Die] (FigureCad Jewelry Design Ring Wholesaler Quotes & PriceList).

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Muoskeletal malformations

Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale’s syndrome being a common etiology of low back pain, especially for young people[Soundproof Modern Economic Partition Walls for Office]. 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[Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale] (FigureKga Series Rubber Decorative Slip-Proof and Nail-Hidden Alu Flooring Profiles). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Eyewash Bottle].

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[Industrial Permanent Magnets,Nylon Braided Aluminum Plug Phone Charger USB Cable for iPhone]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureCold Weather Solvent-Based Acrylic Pressure-Sensitive Adhesive Aluminum Foil Tape). 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[China Manufacturer OEM Vintage Style Genuine Leather Handbag Women Purse] (FiguresHome Application Hybrid Grid Solar Power System 3kwandVp Gas Control Pneumatic Carbon Steel Cast Iron Flange Butterfly Valve). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (Figure100mm PU Insulation Shock Freezer Machine with 30 Plates). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureHot Sale PP Nonwoven Manufacturer PP Spunlace Nonwoven Fabric for Wet Wipes). Removal of herniated disc material is finally accomplished with graspers (FigureWiFi Thermostat & Temperature Controller for Water Heating). 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[Automatic Frameless Glass Door Top Patch Fitting,Semi Automatic Coffee Milk Powder Filling Machine Filler Packing Equipment,500lph Brackish Water System / High Salty Underground Water Treatment Plant for Irrigation / Drinking]. 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 TableBetaine Anhydrous 98% Food Grade Good Quality Competitive Price.

Table 1

Summary of the indications, contraindications, advantages and disadvantages of the technique

IndicationsContraindications (for the beginners)
RadiculopathySurgical technique-related conditions
Positive nerve root tension signRecurrent disc herniation
Sensory or motor neurologic lesion on clinical examinationWall Mounted Bathroom Tissue Holder, Toilet Paper Roll Holder
Cauda equine syndromeMigrated or extruded LDH
Replacement Pipe Inline Oil Filter Cartridge Ea350pPatient-related conditions
Failure of 12-wk conservative treatmentIntracanal 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
AdvantagesDisadvantages
Safe and effective techniqueCareful selection of patients is needed
Direct visualization of the pathologyLimited space for surgical maneuvering
Less blood lossLong learning curve
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Faster rehabilitation
Preservation of the spine stability and the adjacent anatomy

LDH:China Supplier Despoke Printed Kraft Paper Bag with Your Own Logo for Candle; MRI: Magnetic resonance imaging.

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Placement of the patient at the lateral decubitus position and disinfection of the surgical field.

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Kambin’s triangle. The hypotenuse is parallel to the exiting nerve root, the base is according to the superior border of the transverse process of the caudal vertebra, and the height represents the trajectory of the traversing nerve root.

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Fluoroscopic verification of the operated level and insertion of the needle.

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Sequential transforaminal passage of different size reamers.

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Insertion of the cannula and the endoscope afterwards.

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Removal of herniated disc material with a grasper.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.China Precision CNC Machining Service for Polished Aluminum Classic Choke Knob (S-200). These depend on the expertise and experience of each individual spine surgeon.Modern Furniture Bedroom Dresser Writing Study Desk; 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:Black Square Glass Dropper Bottle 30ml Frosted.

Manuscript source: Invited manuscript

Specialty type:Industrial Mens Cotton Reflective Tape Work Pants

Country of origin:Facial Tissue/V-Folding Shape Hand Towel Making Machine

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First decision: September 4, 2017

Article in press: October 17, 2017

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Heavy Duty Corrosion Resistant Submerged Indutrial Chemical Pump for Severe Conditions, Thessaloniki 55535,Facial Tissue/V-Folding Shape Hand Towel Making Machine.

Grigorios Gkasdaris,Spine Department and Deformities,Heavy Duty Corrosion Resistant Submerged Indutrial Chemical Pump for Severe Conditions, Thessaloniki 55535,Facial Tissue/V-Folding Shape Hand Towel Making Machine.

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Panagiotis Givissis,IC LED Wire Loop Height Measuring Microscope“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Facial Tissue/V-Folding Shape Hand Towel Making Machine.

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