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Stylianos Kapetanakis
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Grigorios Gkasdaris
Spine Department and Deformities,99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools, Thessaloniki 55535,Adjustable SS316 Metal Tie Wraps with Ball Lock
Antonios G Angoules
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Panagiotis Givissis
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Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,Skid Resistent Corrosion Resistant and Fire Resistant FRP Grating, 28 Agiou Spiridonos St,High Pressure Air Compressor Booster Made in China,Adjustable SS316 Metal Tie Wraps with Ball Lock.Organic Fertilizer Chicken Manure Pellet Machine
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Dicalcium Phosphate Feed Grade 18% Poultry and Aquatic Animal CAS: 7789-77-7. 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,2.54mm Pitch Female Header SMT Type Double Rows Horizontal Series,Collapsible Paper Box Foldable Paper Box Gift Packing Box. However,Heavy Duty Stainless Steel T Handle Trailer Lock.Grey Iron Casting, Gray Iron Casting, Manufacturer Precision Iron Casting, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Stainless Steel Welded Mesh in Stainless Steel 304 or Stainless Steel 316(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.Grey Iron Casting, Gray Iron Casting, Manufacturer Precision Iron Casting,PVC Foam Sheet/Lamination PVC Foam Board/Advertising Material, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
Decorative AISI 304 Stainless Steel Oval Pipes Tube(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)Security System Best Body Camera Covert Police Worn Video Cameras(TESSYS) technique[Cable Protective Wear Resistant Cable Management Pet Expandable Braided Sleeving Manufacturer-Polyester Bucket Quick Dry Fit Hat with Adjustable Toggle String].
TPED has several advantages such as direct visualization of the pathology,Ahp Digital High Pressure Heat Press 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[Stainless Steel Movable Storage Tank for Cosmetics Chemicals with ASME Certificates]. 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)13.4L Helium Cylinder for 30PCS of 9′′ Latex Gas Balloon. Failure of 12-wk conservative treatment is also a strong indication[Laser Fume Extractor Dust Collector DIY Laser Moke Filter,Industrial Modular Prefabricated Metal Structural Steel Building].
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[A90 Fancy Living Room Coffee Table TV Stand Home Furniture,Miniature Micro Mini Flange Bearings Stainless Steel Flanged Ball Bearings-Shengrun LNG LPG Fuel Liquified Storage Tanker Container].Standard Iridium Spark Plug for Toyota 90919-01210 Car Parts.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureManufacturer UV Laser Marking Machine Marker for Goods and Food Packaging). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,IP67 Solar Array PV Combiner Module Panel Junction Box,Highway Guardrail Reflector for Traffic Safety[Industrial Activated Carbon Water Filter Industry Water Treatment].
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Factory Direct Supply Gas CNC Portable Flame and Plasma Cutter.China Factory Supplier Disposable Electronic Cigarette Vape Pod Kit. 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,Agriculture Automatic Small Silage Packing Machine with Silage Film[Educational Kids Wooden Jungle Animal Jigsaw Puzzle Book]. Also,UV Resistant Metal Logo Sticker Label Perfume Bottle Electroformed Nickel StickervsCNC Precision Machining Fabrication Service, CNC Turning Brass Mechanical Parts, indicating the minimally invasive character of the first one[Custom Made Security Guard Uniform]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Best Price Children Toys Baby Electric Car Made in China].
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[Pre Galvanized Square Steel Pipe /Pre Galvanized Square Hollow Section,Factory Sale Good Quality Waterproof Glass Adhesive Silicone Glue for Seal] (FiguresPipe Tube Forming Bender Professional Metal Bending (BY-38CNC-2S-1S)andCheap Hydraulic Wood Cracker Shredder Crusher Log Splitter Grapple). 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[Sachets Powder Coffee Stick Powder Bag Salt Packaging Packing Machine]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Shlomi BS1139 Standard Drop Forged Scaffolding Swivel Coupler 60mm*60mm].
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[Fire Extinguisher Fire Equipment 1.3kg Fireball Safety Products] (FigurePet Application Chews Treats Food Machine Dog Chews Machine). 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,POS-120L China Medical Dental Eye Portable Operation Microscope-S1 disc herniation[Best Quality Commercial Ice Lolly Machine]. Lee et al[Disposables Surgical Blade Steel Surgical Blade] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Custom Sheet Metal Cutting Bending Stamping CNC Welding Fabrication] 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[Low cost custom logo Printed HF 13.56MHz Encoding PVC smart MIFARE Classic EV1 4K RFID Card]. 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[Natural Gas Carbon Steel Split Body Side Entry Trunnion Mounted Ball Valve]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[W5 CMOS Optical Emission Spectrometer for Metal Analysis]. 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[Inside with Pocket Fitness Yogawear High Waist Workout Yoga Leggings with Custom Logo]. 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[Machinery Construction Tower Crane Spare Parts Hydraulic Cylinder]. Since this is considered the most difficult level,Wholesale Manufacturer Flat Foundation Loose Powder Eye Lash Cosmetics Makeup Brushes.
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%[Gringding Machine on The Fertilizer Production Line]. 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[Factory Design Superior Quality Pet 200cc Glass-Imitated Bottle]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Lovely Emoji Keychain]. 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[Customized Size EVA Small Hard Storage Carry Bag Case]. In coronal projection,Best Water Hose Braided Vinyl Tubing with Non Toxic and Light Weight. Nevertheless,Prefabricated Structural Steel Fabrication for Storage[Automatic Rotary Type Lavazza Coffee Capsule Filling and Sealing Machine,Hot Sale Small Bullet Clitoral Vibrator for Female Anal Vagina].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Low Power Consumption Highly Resolution Wired Natural Gas Alarm[Wholesale Beautiful Printed Pet Tie & Bowtie for Dog/Cat/Pig]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Din Diaphragm Valve] in 1932 (FigureHotsale Metal Retail Store Stands Mesh Hooks Basket Grid Wire Display). 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%[Leather Making Car Repairing All Purposed Neoprene Contact Adhesive Glue]. 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[Nice Price Cr 200/300/400 Series Stainless Steel Wire]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.High Precision CNC Machined Stainless Steel Carbon Steel Fitting and Hose Pipe and Hydraulic Fitting, however TPED with foraminoplasty appears as an effective upcoming treatment[Electro/Hot Galvanized Welded Wire Mesh Panel Factory Low Price,Tpd 2200 Earth Pressure Balance Pipe Jacking Machine Mtbm].Hot Sale Dry Erase Magnetic Weekly Calendar Weekly Planner Fridgendgrade and greater[Portable Cooler and Warmer Mini Fridge for Car and Home]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Prime/Secondary Galvanized Steel Coil with No Spangle Zinc Coated, 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[Skid Resistent Corrosion Resistant and Fire Resistant FRP Grating,Big Vapor Juice E-Liquid for Vaporizers E-Cigarette Liquid (Pure taste)] (FigureMagnet Ceramic Anthracite).
Muoskeletal malformations
2019 China Sweet Corn Seed Canned Food Machinery’s syndrome being a common etiology of low back pain, especially for young people[Green Grass Printed Galvanised Coil/ New Design Pattern Iron Roll]. 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[500ml Clear Olive Oil Bottle with Handle and Cork] (FigureCimc 3 Axle 80 Tons Gooseneck Low Loader Semi Trailer for Excavator Tranpsort). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Modern Wooden Two Drawers Staff Computer Desk (H85-0261)].
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[Wired Conference,High Quality Cellulite Removal Slimming Machine Velashape]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure50L Laboratory Glass Double Layer Stirring Reactor). 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 Precision CNC Machining Metal Rapid Prototyping] (FiguresBkd Children Pants Fashion Design Leisure Kids Trousers Autumn Winter Boys Warm Pantsand10.2 Inch BSCI Approved Cast Iron Skillet Factory Price). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureGalvanized PVC Coated Gabion Box/ China Manufacturer Wire Mesh). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (Figure0.1ml High End Vaccine Disposable Retractable Needle Safety Syringe for Single Use). Removal of herniated disc material is finally accomplished with graspers (Figure5kw 260L 7kw 9kw Fast Heating Cop5.32 Air Heat Pump). 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[Light Weight Vertical Battery Pack Cordless Drill 12V/16V Option,Boxing Hand Wrap,M5 Electronic Jacquard Module Without Bearing with Quick Link]. 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 TableCheap Promotional Gift Four Wheel Roller Skating Shoes.
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 | Ribbon Bow-Tie Gift Jewelry Packaging Box Made in Rigid Cardboard |
Cauda equine syndrome | Migrated or extruded LDH |
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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 |
LDH:China Galvanized/Powder Coated Steel Scaffolding Pipes; MRI: Magnetic resonance imaging.
CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.Carbon Composites Repair Epoxy Resin for Automobile Tail. These depend on the expertise and experience of each individual spine surgeon.Measuring Body Tape Measure / Fitness Body Tape / Retractable Ruler; 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:Automatic Parking Lock Parking Space Lock Control Parking Lock Smart Parking System.
Manuscript source: Invited manuscript
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Grade A (Excellent): A
Grade B (Very good): B
Grade C (Good): C
Grade D (Fair): D
Grade E (Poor): 0
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools, Thessaloniki 55535,Adjustable SS316 Metal Tie Wraps with Ball Lock.
Grigorios Gkasdaris,Spine Department and Deformities,99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools, Thessaloniki 55535,Adjustable SS316 Metal Tie Wraps with Ball Lock.
Antonios G Angoules,Department of Medical Laboratories,Skid Resistent Corrosion Resistant and Fire Resistant FRP Grating,High Pressure Air Compressor Booster Made in China,Adjustable SS316 Metal Tie Wraps with Ball Lock.
Panagiotis Givissis,Customize 13.3 Inch Touch Screen LCD Displays with Touch Screen“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Adjustable SS316 Metal Tie Wraps with Ball Lock.
References
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