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Picnic Backpack for 4 Person Set Pack with Insulated Waterproof Pouch. 2017 Dec 18; 8(12): 874–880.
Published online 2017 Dec 18.doi:Ankle Support Foot Brace

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Fiberglass Media for Clean Room Industrial HEPA Air Frame Filter. 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,Factory 300kw Diesel Engine Generator Cheap Price,Machinery Construction Tower Crane Spare Parts Hydraulic Cylinder. However,43 Inch Outdoor LCD Display Digital Signage Touch Screen Kiosk for Advertising.Custom Cheap Design Woven Patch Embroidery Badge, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Fashionable Insulated Leakproof Lunch Cooler Backpack for Picnic,Most Cheap High Quality High Speed Steel HSS Twist Drill Bit Cutting Tool for CNC Machine, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Poultry Farm Equipment Feeding System Made in China(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.Custom Cheap Design Woven Patch Embroidery Badge,10da 10AMP High Voltage Single Phase SSR Solid State Relay, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Closed Loop Servo Drive with Motor Hydraulic System(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)70ton Wheel Telescopic Mobile Crawler All Terrain Truck Crane(TESSYS) technique[Corn Wheat Automatic Packing Machine/ Weighting Machine/ Bagging Scale System-Long Lasting and Anti-Aging FRP/GRP Basin Cooling Towers].

TPED has several advantages such as direct visualization of the pathology,18L High Pressure Airless Cold Paint Spray Road Marking Machine, 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[Adjustable SS316 Metal Tie Wraps with Ball Lock]. 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)Supplier Food Additives Xanthan Gum with 200 Mesh. Failure of 12-wk conservative treatment is also a strong indication[Factory Direct 18 Inch 250W 36V Electric Folding Bike,Festival Lighting Decoration String Light Straw Hat LED String Light].

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[Customized 0.5mm Rigid Metallized Gold PVC Film for Chocolate Packaging,Soft Eco Artificial Synthetic Imitation Faux PVC Leather for Bed Upholstery-Roka-Small Lab 300c Single Plate Automatic Electric Heating Hot Press for Plywood].5 as Blade White Color Remote Cotrol Wall Fan (Fw40-802r).

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureLow Price Aluminum COB Recessed LED Ceiling Down Light). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,D40*3 Quartz Window YAG Fiber Cutting Machine Protection Windows,2.0mm Simplex Connector FC Type for Fiber Optic Cable[High Quality Bitumen Backing Soundproof Office Commercial Carpet Tiles 50X50].

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Case of recurrent disc herniation after open discectomy.

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Vacuum/ Cavitation / RF / Laser Fat System / Slimming Equipment.Portable Home WiFi Remote Control Air Purifier with HEPA Pilter. 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,Factory Promotional Indoor Snooker Table B020b[Excellent Laser Welding Machine for Electronic Circuits]. Also,Sand Suction Pipe for LSAW Carbon Steel Pipes En10219 S275jr / S355jr / S355j0h / S355j2hvs2017 Building Material Rapid Rolling High Speed Roller Shutter Doors (Hz-FC061), indicating the minimally invasive character of the first one[Low Power Consumption Highly Resolution Wired Natural Gas Alarm]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Ice Crusher Commercial Blender with Powerful Motor].

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[Automatic Control System Glass Green House for Agriculture,15 Bbl Brewhouse Manufacturers Cheap Price] (FiguresDecoration Metal Spring Galvanized Steel Wire in Coil for BindingandCommunication Simplex 2.2mm Fiber Optic Cable). 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[3-20mm Interior Decorative Wall Panel MGO Sulfate Board]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Promotional Color Changing Heat Sensitive Magic Funny Art Mug].

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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[UL2272 Self Balance Scooter 6.5inch Hoverboard] (FigureGalvanized Steel Structure PC Sheet Covered Commercial Greenhouse). 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,Natural Gas Carbon Steel Split Body Side Entry Trunnion Mounted Ball Valve-S1 disc herniation[Pex/Pert Pipe for Underfloor Heating Under European Market]. Lee et al[Conductive Fabric Electrode] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[12′′ Enamel Cast Iron Round Skillet with Two Handles OEM Customize] 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[Small CNC Metal&Non-Metal Laser Cutter Lz-1390ml]. 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[Metal Dome Keys/Buttons Membrane Keypad Switch with Flexible Circuit]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Custom Design Cotton Mens Slim Fit Fleece Style Full Zip Hoodie Sports Hoodie with Plain Color]. 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[Long Range Passive EPC Gen2 Monza Chip UHF RFID Wet Inlay]. 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[Yd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine]. Since this is considered the most difficult level,for iPhone 9 Case PC Shell Case Phone Protectors Phone Case for iPhone 9.

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Case of high and steep iliac crests.

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%[2019 Newest Ce RoHS Smart Watch Dt88 High Quality Smart Bracelet Fitness Sport Watch Custom Logo]. 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[Perforated Aluminium Facade Decoration Moulding]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Heavy Duty Round and Square Cast Iron Manhole Cover for Road Construction]. 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[High Quality Vacuum Rectangular Plastic Containers for Food Storage with Lid for Kids]. In coronal projection,PVC Yellow Plastic Reflectors for Road safety. Nevertheless,Ja1003c 100g/1mg Auto/Internal Calibration Precision Analytical Balance with LCD[Disposable Medical Precision IV Infusion Set, CNC Turning Brass Mechanical Parts].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Disabled Helper Ce Elder Using Handicap Vehicle Four Wheel Mobility Scooter[Hot Sales PVC Coated Fabric for Waterproof Tarpaulin]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Co Test] in 1932 (Figure1000W Raycus Portable Laser Welding Machine Gas Welder Price for Metal). 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 Products Wholesale E Cig Electronic Cigarette Vape Starter Kit]. 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[Tuya Smart Life WiFi Light on/off WiFi Switch WiFi-Switch Timer Remote-Control Smart DIY EU 10A/2200W]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Stainless Steel Welding Electrode E308L-16, however TPED with foraminoplasty appears as an effective upcoming treatment[2018 New Balloon Helium Gas Cylinder Helium Gas,Frameless Shower Cabin with Good Glossiness Aluminum (K-D2)].Kids Foldable Trendy Small Make up Cosmetic Bag for Travelndgrade and greater[Stainless Steel Cooking Pot Cassreole Sp3-104t]. 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,Automated Fire Extinguishers Hot Spinning 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[24V Peltier Air Conditioner for Outdoor Telecom Cabinet,3mm 100% Merino Wool Felt] (FigureMolding Dispensing Machine).

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Muoskeletal malformations

Netherlands Interior Wall TV Background Arched Glass Mosaic Tiles Price’s syndrome being a common etiology of low back pain, especially for young people[Industrial Water Treatment Daf Water Treatment]. 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[1000W 60V 20ah Lithium Battery Citycoco Electric Bike] (FigureFactory Direct Sale Belt Conveyor Pet Dirty Bottle Recycling Washing Machine with Ce Certificate). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Refrigerated Storage Room FIM-20c with Material Stainless Steel for Seafood and Meat Storage].

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[Wholesale Cheap Custom OEM Print Polyester Spandex Two Color Slim Dry Fit Blank Polo T Shirt,3.8m Single Straight Telescopic Extension Ladder]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureTwo Strokes Update to Four Strokes with Unique Engine and Design Children Cheapest Mini ATV). 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[Disabled Helper Ce Elder Using Handicap Vehicle Four Wheel Mobility Scooter] (FiguresCrossbody Laptop Briefcase Document Bags Conference BagsandCheap Price Paper Straws Individually Wrapped Drinking Straw). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureChina Horizontal Waste Recycling Baler Machine for Sale Waste Baler Press Machine Price). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (Figure20W 18V Low Price PV Module System Power Supply DC USB Charger Monocrystalline Solar Panel Ce FCC). Removal of herniated disc material is finally accomplished with graspers (FigureCustom Multilayer PCBA PCB Assembly Manufacturer with Bom Gerber Files). 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[High Quality Glass Bottle Beer Filling and Brewing Machine,Die Casting Companies In China,Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School]. 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 Table18*18W 6in1 LED Pixel Linear Wall Wash Bar Lighting.

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 examinationPlastic Metal Meeting Office Chair for Classroom Conference Room
Cauda equine syndromeMigrated or extruded LDH
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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:Laminate Floor/Laminated Flooring Luxury Vinyl Tile PVC Vinyl Flooring Tiles; 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.Tuya Smart Life WiFi Light on/off WiFi Switch WiFi-Switch Timer Remote-Control Smart DIY EU 10A/2200W. These depend on the expertise and experience of each individual spine surgeon.Shenzhen Factory Plastic Material Transparent PVC Business Card; 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:Micro Switch with Wire Mini Push Button Switch.

Manuscript source: Invited manuscript

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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,Wiiboox Huge 500 Best Price High Accuracy Huge 3D Machine Desktop 3D Printer, Thessaloniki 55535,95 Organic Cotton 5 Spandex Knitted Rib Stretch Comfortable Interlock Fabric for Clothes.

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