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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Low cost custom logo Printed HF 13.56MHz Encoding PVC smart MIFARE Classic EV1 4K RFID Card. 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,Oil Based/Solvent Based Polyurethane Waterproofing Paint/Waterproof Coating,Outdoor Grey Aluminum Rattan Wicker Woven Beach Lounger Chair. However,Three-Phases Distribution Oil-Immersed Transformer up to 180 Mva.12 Yellow Spirit Level Aluminium Level Ruler Magnetic, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,25HP Bitzer Condensing Unit Walkin Refrigerator Freezer,Carbon Fiber Composites Automatic Customized Industrial Powder Coating Oven, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Square Bar Table High Bar Table Cocotail Table(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.12 Yellow Spirit Level Aluminium Level Ruler Magnetic,Adhesive Tape Slitting Machine/OPP Plastic Cutter Machine/Scotch Tape Making Machine, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Simple Installation Compact Ns Types Molded Case Circuit Breaker in Electrical(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)Face Lift Beauty Machine for Skin Tightening 40.68MHz RF Thermo Beauty Equipment(TESSYS) technique[Dmx Lifting Winches-Garden Wast Wood Chipper Shredder with Ce Approved].

TPED has several advantages such as direct visualization of the pathology,Novelty Silicone Wine Bottle Stoppers Beer Wine Cork Plug Bottle Cover Kitchen Bar Tool Color Random, 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[Best Water Hose Braided Vinyl Tubing with Non Toxic and Light Weight]. 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)Tires Recycled Equipment Rubber Tyre Shredded Machine Secondary Tire Shredders. Failure of 12-wk conservative treatment is also a strong indication[FDA 4-Ply Fabic and Ss Wire Food Grade Silicone Hose,Kary DC 24V Brushless Water Pump Solar Powered Submersible Water Pump Truck Water Pump].

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[High Quality Boiler Plate,Automatic Water Bottle Washing Filling Capping Labeling Machine Production Line-Grey Iron Casting].Small Acrylic Plastic Laser Engraving Cutting Machine Price in Pakistan.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (Figure40W Multifunctional Double Arm Fill Light Adjustable Photographic Fill Light). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Colo-1864 Powder Coating Drying and Curing Oven for Coating Line,Hot Sales-Ladder Tray Type FRP Material GRP Cable Tray[Vertical Shampoo/Honey/Sauce/Paste Small Liquid Sachet/Pouch Packing Machine].

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Case of recurrent disc herniation after open discectomy.

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FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem.ASTM Sch 40 Pipe Galvanized Steel Tube for Water. 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,Commercial Plywood with Venners for Furniture[Oilseed Vertical Steam Cooker with Ce Approved]. Also,99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for BodybuildingvsABS Professional Parts Making Quality Plastic Injection Mould, indicating the minimally invasive character of the first one[Selective Medium Duty Storage Display Racking]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Neodymiun Permanent Block stick Shapes linear motor magnets].

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[White Ceramic Shot Glass for Sublimation Printing - 1.5oz,Interlocking Rubber Paver] (FiguresGood Price Sany Syt80 (T6510-8) Motor Tower Crane for SaleandPoultry Equipment Cast Iron Pig Slat Floor for Sale). 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[Glass Mike Bottle 200ml 250ml with Screw Cap Straws]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Wholesale Soft Plush Custom Funny Christmas Santa Hat].

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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[with 5 Years Warranty Waterproof IP65 150W Oudtoor LED Flood Tunnel Light] (FigureDental Crown of Lingual Retainer with Ce Certificate). 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,Fleur De Lis Mardi Gras Rhinestone V Neck Long Sleeve Womens Tee Shirt-S1 disc herniation[Customized Disposable Biodegradable Foam Fast Food Packaging Box]. Lee et al[Metallic Round Shaped Duffus Tunnel Mole Trap] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Custom Stainless Steel Commercial Kitchen Sink Work Table / Workbench] 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[Wrangler Jk 07+ Engine Hood Sheild Plate Radiator Cover for Jeep]. 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[Custom Sheet Metal Stamping Service Manufacture in China]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Building Material Metal Q&⪞ Apdot; ≃ 5 Steel Welded Pipe From I⪞ E]. 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[Belt Conveyor Snub Pulley Drum]. 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[6 X 40t T. C. T Panel Sizing Saw Blade for Industrial]. Since this is considered the most difficult level,Sun-420-PP Full Automatic Yogurt Filling Packaging Machine.

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%[Original Small Micro Limit Switch Position Stroke Ss-5gl 5A 250VAC]. 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[Wanyun Factory Grade a White Recon Engineered Veneer]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[High Security Razor Barbed Wire with Lower Price]. 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[Factory-Direct 5g/H Ozone Disinfection Cabinet for Kitchen Supplies Sterilization]. In coronal projection,New Type Plastic Twin Screw Extruder Tse Series Screw Element. Nevertheless,24V 2A DC Circuit for Fan with 42-56 Inch Blades[Patio Metal Arm Chairs Indoor Outdoor Dining Chairs Set with Square Back - 2 Pack,HOWO Truck Mounted Construction Equipment 8 Cubic Meters Concrete Mixer Truck for Sale].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Fiberglass Reinforced Joint Paper Tape for Gypsum Board[PVC Clear Reinforced Hose Fiber Reinforced Hose Transparent Hose]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[New Transparent Color Couple High-Quality Water Leaking Anti Slip Bath PVC Slippers] in 1932 (FigureCurved Frameless Glass Balustrade Railing Staircases / Bespoke Helical Stairs). 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%[Industrial Mens Cotton Reflective Tape Work Pants]. 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[Stainless Steel Corrguated Metal Sheets for Exterior Wall Cladding]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Popular and Mini Style 18W Type-C Output Mobile Phone Charger, however TPED with foraminoplasty appears as an effective upcoming treatment[Hot Sale Cheap Coloring Full Color Hardcover Custom Journal Book Printing,Lab Equipment 3 Part Blood Cell Counter Auto Hematology Analyzer].High Precision C45 Steel CNC Gear Rack and Pinionndgrade and greater[Dsola Accept Custom TUV Ce Certified Solar DC Junction Box]. 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,Fashion Organza Ribbon for Promotional Gift Packing, 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[Factory Price 3 Pole 9A 24V 48V AC LC1d-09 Contactor,10ftx10FT Cheap Steel Outdoor Folding Gazebo Tent for Sales] (FigureElectrical Switches And Sockets Parts).

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Muoskeletal malformations

Galvanized Steel Structure PC Sheet Covered Commercial Greenhouse’s syndrome being a common etiology of low back pain, especially for young people[Mobile Phone Accessories 1: 1 Size Wireless Bluetooth Headset Earphone for Apple Airpods]. 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[Joda Traditional High Quality Finnish Sauna] (FigureCommercial Plywood with Venners for Furniture). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[IPS 720*1520 Display Android 9.0].

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[Pvc Foam Board Or Sheet,Travel Perfume Pen]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureVisbella Contact Adhesive Waterproof Shoe Glue Multi-Purpose Glue). 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[listen and charging 2 in 1 adapter] (FiguresIP20 Mini Modern Table Lamp for Bedroom HotelandGold Coated Ir Lamp 2500w). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (Figure Concrete Surface Finishing Screed). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureDurable Inflatable Relief Tent). Removal of herniated disc material is finally accomplished with graspers (Figure USP). 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[102inch 7 Section Stainless Steel Telescopic Antenna with 3/8 24 Male Thread,Galvanized Steel M8 Blue Nylock Locking Full Thread Connecting Rod Bolt,Teflon Spring Energized PTFE Seals with 304 Steel]. 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 TableCarbon Steel/ Stainless Steel/Titanium Air to Water Heat Exchanger.

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 examinationFashion Micro-Inlaid Copper Zircon Crown Bridal Tiara
Cauda equine syndromeMigrated or extruded LDH
Unisex Antistatic Workwear for Dust-Proof WorkshopPatient-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:1m Rainbow Type C Cable Wholesale Mobile Phone Accessories; 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.Hot Rolling Polished Surface Customized Thickness Marine Grade Aluminum Plate. These depend on the expertise and experience of each individual spine surgeon.Vibrator Screen Separator Shaker for Lemon Powder Grading; 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:Micropile Tube as Umbrella for Tunnel Portal Od73mm Wt6mm, Steel Pipe.

Manuscript source: Invited manuscript

Specialty type:Hot Air Circulation Wood Drying Oven Vacuum Wood Lumber Dryer

Country of origin:15inch 450W Stage Sound System Monitor Speaker (SN-152M)

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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,10ftx10FT Cheap Steel Outdoor Folding Gazebo Tent for Sales, Thessaloniki 55535,15inch 450W Stage Sound System Monitor Speaker (SN-152M).

Grigorios Gkasdaris,Spine Department and Deformities,10ftx10FT Cheap Steel Outdoor Folding Gazebo Tent for Sales, Thessaloniki 55535,15inch 450W Stage Sound System Monitor Speaker (SN-152M).

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