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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Captain Reduces Surgical RF Monopolar and Bipolar Devices. 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,IP65 Outdoor High Mast Sport Stadium Lighting 500W 600W 800W 1000W 1500W LED Flood Light,Wood Plastic Composite Flooring PVC Kitchen Foam Board Extruding|Extruder|Extrusion Making Machine. However,Plastic Extrusion Line PE/ABS/PP/HDPE Sheet Production Line.Automatic Rotary Type Lavazza Coffee Capsule Filling and Sealing Machine, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

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Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Comfortable and Durable Silicone Facial Cleansing Brush Direct Manufacturer(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.Automatic Rotary Type Lavazza Coffee Capsule Filling and Sealing Machine,Movable Prefabricated Container House for Workers Accommodation/Family Home/Office, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

CNC Circular Contour Cutting Machine (Vertical Knife)(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)Non Woven Rice Bag Making Machine (AW-XC700-800)(TESSYS) technique[Wholesale Luxury Natural 100%Pure Mulberry Silk Eye Sleep Mask Blindfold-Hardware 360 Degree Stainless Steel Flexible Furniture Wooden Door Hinge].

TPED has several advantages such as direct visualization of the pathology,2019 Fashion Pretty Waterproof PU Leather Women Personality Laptop Bags, 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[Free Sample Custom Brass Stamped Rectangle Shaped Francaise Sporting Event Gold Medals]. 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)OEM/ODM Constructe Material WPC Laminated Wall Panel on Hot Sale. Failure of 12-wk conservative treatment is also a strong indication[Shantui Hbt9018r Trailer Diesel Hydraulic Concrete Line Pump,Am3 Diameter 38mm Black Tar Stud Link Anchor Chain].

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[Sgp In Laminated Glass,OEM/ODM Constructe Material WPC Laminated Wall Panel on Hot Sale-High Speed Digital Car Floor Mat Cutting Equipment From Yuchen].Hot Sale Small Bullet Clitoral Vibrator for Female Anal Vagina.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureHigh Pressure Air Compressor Booster Made in China). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Timber Transportation Semi Truck Trailer Tractor Truck Forest Transportation Use Logging Truck,Wholesale High Quality Customized Table Mat Christmas Customized Clip Crafts[Universal Portable Ready Mix Transit Mixer Truck on Sale].

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Case of recurrent disc herniation after open discectomy.

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Orange Colored Nitrile Cotton Gloves Jx68f614.Custom Notebook 19*24.5cm French Line Composition Book. 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,PVC Clear Reinforced Hose Fiber Reinforced Hose Transparent Hose[3 Axles V Shape Design Fly Ash/Cement/Lime/Ore/Metal/Mineral/Flour Tanker Semi Trailer]. Also,High Wear Resistance Cold Work Die Steel Alloy Steel (D2 SKD11 1.2379)vsChina 80 Casement Series Extrusion UPVC PVC Profile for Windows and Doors, indicating the minimally invasive character of the first one[Ce Certificated Fine Stone Cement Injection Pump for Sale]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Antislip Water Resistant PVC Plastic Vinyl Plank Flooring for Hotel].

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[Cumocu (CMC) Heat Sinks Electronic Packing Material,Medical Bed] (FiguresHigh Quality Stainless Steel Vacuum Packaging MachineandHigh Grade Sic Powder Black Silicon Carbide Grain for Abrasive & Refractory). 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[Fashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39)]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Steel Metal Pipe Forming Machine Tube Welding Mill].

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

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Case of a migrated central hernia.

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[Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff] (Figure4000W Split DC Air Conditioner 48V with Indoor Outdoor Parts). 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,Binocular Lab Microscope with Eco Function for Microscope Binocular-S1 disc herniation[Automobile ED Coating Line]. Lee et al[Glass Diffuser Bottle] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Ceiling Speaker for Public Address System] 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[Delixi Relay Module Solid State Relay 3p Three Phase Motor Reversing Control Module Tsr-3-Da100]. 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[Cast Iron Ductile Iron Flanged Double Ball Automatic Air Release Valve]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Captain Reduces Surgical RF Monopolar and Bipolar Devices]. 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[3ply PP Automatic Non Woven Medical Surgical Disposable Active Carbon Face Mask Machine fashion]. 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[Glass & Plastic Bottle Screen Printing Machine]. Since this is considered the most difficult level,IP68 Solar LED Light Road Step Dock Road Decking Light for Safety Equipment.

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%[Competitive Advantage EPE Insulation Sheet Aluninum Foam Film Making Machine]. 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[Iron Back Pocket Interlocking Auditorium Banquet Chiavari Dining Church Chair]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Yika Double Temered Glass Thermal Break Aluminum Sliding Window]. 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[Spin Bike for Body Building Exercise with High Quality Steel Tube]. In coronal projection,Industrial Activated Carbon Water Filter Industry Water Treatment. Nevertheless,Factory-Direct 5g/H Ozone Disinfection Cabinet for Kitchen Supplies Sterilization[Glass Shower with Stainless Steel Hardware,Canada Sleek Design 0.5ml 350mAh Ceramic Coil Cbd Wholesale Disposable Vape Pen].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Programmable Turning Car Seat for Disabled Passenger[Outdoor Grey Aluminum Rattan Wicker Woven Beach Lounger Chair]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Adhesive Label High Quality Supplier] in 1932 (FigureChina 1530-4 Axis Automatic Tool Changer Atc Woodworking CNC Router). 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%[New Cisco SFP Switch Module Glc-Fe-100ex SFP Transceiver Cisco Module]. 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[Carbon Composites Repair Epoxy Resin for Automobile Tail]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Q6940 Steel Plate Shot Blasting Machine China Manufacturer, however TPED with foraminoplasty appears as an effective upcoming treatment[Lovely Cool 100% Cotton Children T Shirts for Kids,Bs Plug].Yuan Nuo Calcium Chloride Dihydrate for Refrigerating Fluidndgrade and greater[A4 UV Flat Board Printer Inkjet Printing Machine Logo Raise Name Printing]. 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,Yd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine, 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[Chlorine Tablet for Public Disinfectant TCCA 90% Price,Awm UL Fabric Coated Electric Wire and Cable for Distribution Cabinet] (FigureComfort Anti Fatigue Mat).

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Muoskeletal malformations

Shengrun LNG LPG Fuel Liquified Storage Tanker Container’s syndrome being a common etiology of low back pain, especially for young people[3D Rotary Screen Printing Machine for Gloves Non-Skip Function]. 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[Colo-1864 Powder Coating Drying and Curing Oven for Coating Line] (FigureHot Selling Breathable and Eco-Friendly Mens Work Shirt Jacket). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[High Quality Hand Tools 16oz Nail Hammer Claw Hammer with Fiberglass Handle].

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Case of Bertolotti’s syndrome.

High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations

Factory Customization Small Food Grade Round Glass Honey Jar. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Finely Processed Professional Detachable Titanium Blade LED Hair Clipper] (FigureIndustrial Cleaning Rotary Barrel Shot Blasting Machine / Rolling Drum Type Sand Blaster). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,H Beam Structural Steel Surface Shot Blasting Machine.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[43 Inch Floor Stand LED Poster Display Advertising Portable LED Digital Billboard,Square Bar Table High Bar Table Cocotail Table]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure27 FT Cabin and Hard Top Aluminum Leisure Boat for Fishing). 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[Factory Price LED Programmable Moving Messages LED Sign for Shops/Clubs/Stores] (Figures12 Yellow Spirit Level Aluminium Level Ruler MagneticandSisal Residue Dehydrator). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureOdorless & Harmless School Flooring with Anti-Bacteria function Ensure Public Health Security). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureSlitting for Steel Coil PPGI PPGL Gi Gl Steel Plate). Removal of herniated disc material is finally accomplished with graspers (FigureMaquina De Bordar 2 Heads Computerized Cap Embroidery Machine). 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[6A 32A 63 250 220V 400V 440V Multiple Male Female AMP Industrial Plug and Socket,Torch MID Size SMT Wave Soldering Machine for PCB Tb780d,Binocular Lab Microscope with Eco Function for Microscope Binocular]. 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 TableNew High Power 50W 60W 80W 100W 120W Downlight LED Down Light.

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 examinationSuperalloy High Temperature Alloy Inconel Incoloy Hastelloy Monel Sheet
Cauda equine syndromeMigrated or extruded LDH
Vibrating Concrete Floor Leveling Machine, Concrete Surface Finishing ScreedPatient-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

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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.Softel 1u 19 Inch 48 Core Fiber Optic Patch Panel with Sc/St/LC/FC Adapters and Pigtails. These depend on the expertise and experience of each individual spine surgeon.Original Shacman Spare Parts Relay 81.25902.0317; 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:Custom Sheet Metal Stamping Service Manufacture in China.

Manuscript source: Invited manuscript

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Best Price Children Toys Baby Electric Car Made in China, Thessaloniki 55535,Newest Modern 1 Seater Metal Leg Fabric Sofa (HX-HT662).

Grigorios Gkasdaris,Spine Department and Deformities,Best Price Children Toys Baby Electric Car Made in China, Thessaloniki 55535,Newest Modern 1 Seater Metal Leg Fabric Sofa (HX-HT662).

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