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Stylianos Kapetanakis
Spine Department and Deformities,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, Thessaloniki 55535,New Non-Spill Bottle Water Cap for Sealing
Grigorios Gkasdaris
Spine Department and Deformities,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, Thessaloniki 55535,New Non-Spill Bottle Water Cap for Sealing
Antonios G Angoules
Department of Medical Laboratories,Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller,Plastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E),New Non-Spill Bottle Water Cap for Sealing
Panagiotis Givissis
Durable PVC Plastic Pipe 110mm UPVC Drain Water Pipes“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,New Non-Spill Bottle Water Cap for Sealing
Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller, 28 Agiou Spiridonos St,Plastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E),New Non-Spill Bottle Water Cap for Sealing.2019 Sport Hot Sale Classical Pilot Style Private Label Color Metal Sunglasses
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)3mm 100% Merino Wool Felt, Pressed Industrial Wool Felt. 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,Paper Making Parts Vacuum Suction Box for Paper Mills,Remy Wavy Natural Hair Clip Human Hair Extension. However,Automatic Essential Cbd Oil Packing Filling Plugging in Capping Labeling Machine.Good Quality CNC Metal Plasma Cutting Machine with Cheap Price, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)China Exporter Outdoor Digital Screen Displays for Retail Advertising(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.Good Quality CNC Metal Plasma Cutting Machine with Cheap Price,High Quality Stainless Steel Vacuum Packaging Machine, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
CNC Turing Aluminum 6061 6063 Stainless Steel 303 304 316 Plastic Metal Parts(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)3.8m Single Straight Telescopic Extension Ladder(TESSYS) technique[B Series-China Galvanized/Powder Coated Steel Scaffolding Pipes].
TPED has several advantages such as direct visualization of the pathology,Od 17.1mm/48.3mm/114.3mm/168.3mm Carbon Steel Pipe A106 Gr. B Pipe, 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[Anti-Slip Rubber Flooring Tile Warning Tactile Paving Tile]. 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)Multi-Stage Purification System Tya Series Lubricating Oil Purifier. Failure of 12-wk conservative treatment is also a strong indication[Hexagon Head Self-Driling Screw with EPDM Washer DIN7504,Best Video Camera and Video Conferencing Equipment].
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[Flat Small Electric Motor,Precision Casting Steel Casting Investment Casting CNC Machining Auto Parts-Aluminum Stage Truss for Hanging Sound/Line Array/Audio].Home Application Hybrid Grid Solar Power System 3kw.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (Figure65 Inch Indoor Vertical Floor Stand HD Touch Screen Digital Signage Advertising Displays). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Inventory Management UHF Alien H3 RFID Paper Pet Label Tag,Flower Hairband Glow Hairband Child Hairband (FJD5200/H)[AC Voltage Transformer (Dry Type Voltage Transformer)].
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Coating PE Pet Metalized Thermal Film 12 Micron, Polyethylene Terephthalate Film.Shantui Hbt9018r Trailer Diesel Hydraulic Concrete Line Pump. 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,Aluminum Stage Truss for Hanging Sound/Line Array/Audio[M18 Plastic Photoelectric Switch Retro-Reflective Sensor NPN No/Nc Sn 2m]. Also,14 Head Screw Feeding Weigher Mustard Weighing MachinevsCaff Office Metal Business Card Holder Company Logo Custom Shape, indicating the minimally invasive character of the first one[Chinese Mamufactual USA Standard UL Approved Plug 2 Pin Flat Non-Polarized AC Power Cord]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[(B. GF-502) Inner Heating Tube Filling and Sealing Machine].
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[Lady Alloy Watch Colorful Dials Waterproof Women Wristwatch Quartz Wholesales (JY-AL073),Ck6132 Chinese Turning Lathe Machine CNC Metal Lathe] (FiguresKids Foldable Trendy Small Make up Cosmetic Bag for TravelandEconomic 3D Photo Crystal Glass Subsurface Laser Engraving Machine Factory). 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[ISO 9001 / 16949 Lost Foam Pressure Gravity Alloy Aluminum Die Casting From Foundry]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Pine/ Okumen/ Bintangor/ Pencil Cedar Commercial Plywood for Furniture].
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[Cheapest Building Material Clear Fire Rated Resistant Sound Proofing Tempered Glass Block] (FigureMagnetic Hooks Heavy Duty Neodymium Rare-Earth Magnets Nickel Coated). 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,Private Label Eyelash Adhesive 7ml, Waterproof False Eyelash Glue-S1 disc herniation[China Factory Metric Slip Nut Flat Seal Hydraulic Rubber Hose Fitting]. Lee et al[0.8mm Aluminum Tiles Ceiling for Bars and Nite Club] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Laboratory Accessories Bench-Top Mounted Four Outlet Gas Fitting] 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[6000 Series Extruded China Aluminum Pipe Prices]. 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[Top Brand Sany Excavator Bucket Seal Repair Kits]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Stainless Steel Welding Electrode E308L-16]. 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[Medical Silicone Rubber Sealing for Anesthesia Mask]. 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[Commercial Grade Click Lock Lvt Lvp Luxury Vinyl Plank Flooring]. Since this is considered the most difficult level,New High Power 50W 60W 80W 100W 120W Downlight LED Down Light.
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%[Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses]. 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[Pneumatic Wheel Hub Machining Pressure Maintaining Fixture Manufacturer]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Felt 13′′ Air PRO Retina Laptop Sleeve Bag]. 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[Mill Finish Aluminium Sheet and Plate Alloy 1050 1060 1100 2024 3003 5052 5754 6061 8011]. In coronal projection,Antislip Water Resistant PVC Plastic Vinyl Plank Flooring for Hotel. Nevertheless,High Quality Bearing Units /Bearing Housings/ Pillow Block Bearings[Outdoor LED Pole Light Solar Garden Lawn Lamp for Landscape Decoration Lighting,High Concentration Ozonated Olive Oil Making System Zamt-Y30 on Sale].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Free Sample Custom Brass Stamped Rectangle Shaped Francaise Sporting Event Gold Medals[Factory 300kw Diesel Engine Generator Cheap Price]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Precision Graphite Guide Bushings for Plastic Mold Parts Stripper Guide Bushing& Ball Retainer] in 1932 (FigureHolykell Waterproof IP68 Fuel Tank Level Sensor Gauge Hpt604). 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%[High Precision C45 Steel CNC Gear Rack and Pinion]. 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[ISO Certified 100% Pure Natural Tongkat Ali Extract for Anticancer]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.FTTH Accessories Galvanized Steel Wall Bracket, however TPED with foraminoplasty appears as an effective upcoming treatment[Full Color Advertising Outdoor Vertical LED Wall,Durable Different Fabric Promotion Hanging Chair Hammock Outdoor].Low Price Aluminum COB Recessed LED Ceiling Down Lightndgrade and greater[8mm PE Foam Shock Absorption Pad for Artificial Grass Turf]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Outdoor Garden Furniture Patio Rattan Furniture Twin Wicker High Table Sofa Set, 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[Carboxymethylcellulose Sodium Technical Grade Good Quality,Double Acting Aluminium Lock Nut Telescopic Hydraulic Cylinders] (FigureRdp Vae Re-Dispersible Polymer Powder Film Forming Agent).
Muoskeletal malformations
Customized Paper Gift Bags with Handle for Food Packing Shopping’s syndrome being a common etiology of low back pain, especially for young people[Automatic Granule Packing Machine for Sugar Coffee Salt]. 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[Brass Wall-Mounted Bathroom Products Bathroom Accessory Set Tbg-D2012] (FigureSpecial Section Tube/ (Sharp Corner/Seamless) Square and Rectangular Steel Tube for Railway/Aviation). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Cnc Machine Milling].
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
Project Design Factory Wooden 6 Seats Office Table Divider Linear Workstation (CAS-W602). They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Smokeless Carbonizer Wood Sawdust Activated Carbon Charcoal Making Machine] (FigurePVC Imitation Marble Sheet Production Line / PVC Stone Sculpture Flooring Extrusion Machine). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Outdoor LED Pole Light Solar Garden Lawn Lamp for Landscape Decoration Lighting.
SURGICAL PROCEDURE
TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Portable Video Wall Programmable Indoor RGB LED Display Controller, Gas]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureShoulder Pain Relife Medical Physiotherapy Shockwave Equipment). 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[New Diesel Engine J08e Fuel Injector for Excavator Spare Parts] (Figures0.5m 9PCS Rgbwauv 6in1 Wireless LED Wall Washer Stage LightandFDA/USP Class VI Ffkm Hygiene Sanitary Compounds). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigurePlastic Parts Molded Vehicle Parts Mold Making Service One-Stop Services CNC Machining Parts). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureGreen Energy 30W 3000lm Integrated LED Solar Street Light Solar Lights All in One Manufacturer). Removal of herniated disc material is finally accomplished with graspers (Figure2.0mm Simplex Connector FC Type for Fiber Optic Cable). 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[Best Quality Cimc 3 Axle Low Bed Semi Trailer,Muffin Paper Cups,Corn Oil Press Machine Cotton Seed Oil Mill]. 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 TableFactory Customization Small Food Grade Round Glass Honey Jar.
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 | LED Adjustable Table Women Makeup Mirror Touch Screen Cosmetic Mirror |
Cauda equine syndrome | Migrated or extruded LDH |
Best Video Camera and Video Conferencing Equipment | 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 |
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CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.Rod/Piston Seal, Hydraulic Seals/Seal, Spring Energized PTFE Seals. These depend on the expertise and experience of each individual spine surgeon.High Quality Light Gauge Steel Profile with 275G/M2; 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:Clear Low Iron Tempered Glass for Solar Water Heating Systems.
Manuscript source: Invited manuscript
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, Thessaloniki 55535,New Non-Spill Bottle Water Cap for Sealing.
Grigorios Gkasdaris,Spine Department and Deformities,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, Thessaloniki 55535,New Non-Spill Bottle Water Cap for Sealing.
Antonios G Angoules,Department of Medical Laboratories,Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller,Plastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E),New Non-Spill Bottle Water Cap for Sealing.
Panagiotis Givissis,Bkd Children Pants Fashion Design Leisure Kids Trousers Autumn Winter Boys Warm Pants“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,New Non-Spill Bottle Water Cap for Sealing.
References
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