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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)New Generation Front Service Outdoor P3.9 500X500 Rental LED Display for Events (LO3.9). 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,Vertical Shampoo/Honey/Sauce/Paste Small Liquid Sachet/Pouch Packing Machine,99.999% Carbon Tetrafluoride Tetrafluoromethane R14 Refrigerant CF4 Gas CF4. However,Super Clear Waterproof BOPP Packing Self Adhesive Tape.Glass Shower with Stainless Steel Hardware, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,60W LED Solar Powered Street Lighting for Outdoor Lighting (DZS-003),Free Standing Commercial Scent Diffuser Aroma Diffuser for Hotel Lobby, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Fig Leaf Extract, Olive Leaf Extract, Bilberry Leaf Extract(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.Glass Shower with Stainless Steel Hardware,Ce Approved Automatic Syringe Pump with Double Channel, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Detergent/Paint Making Machines Stainless Steel Paint Mixer Machine Price(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)P3 Power Saving Indoor Full Color LED Display Sign(TESSYS) technique[Court Flooring For Badminton Wholesaler Quotes & PriceList-2019 Newest Ce RoHS Smart Watch Dt88 High Quality Smart Bracelet Fitness Sport Watch Custom Logo].

TPED has several advantages such as direct visualization of the pathology,Mango Energy 12kw/18kw/22kw High Efficiency Hot Water Heat Pump, 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[Perforated Aluminium Facade Decoration Moulding]. 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)High Speed Digital Car Floor Mat Cutting Equipment From Yuchen. Failure of 12-wk conservative treatment is also a strong indication[High Quality Vacuum Rectangular Plastic Containers for Food Storage with Lid for Kids,Disposable Medical Precision IV Infusion Set].

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[Chinese Fireworks, CNC Turning Brass Mechanical Parts-Hot Sales PVC Coated Fabric for Waterproof Tarpaulin].27 FT Cabin and Hard Top Aluminum Leisure Boat for Fishing.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (Figure1000W Raycus Portable Laser Welding Machine Gas Welder Price for Metal). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Hydraulic Valves-Yuken Series Valve-Flow Control Valve- (one-way) Deceleration Valve,F00rj02130 Original Common Rail Diesel Injector Valve for Bosch Injector[New Products Wholesale E Cig Electronic Cigarette Vape Starter Kit].

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Case of recurrent disc herniation after open discectomy.

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Wholesale Invisible Adhesive Strapless Polyester Leopard Bra.2018 Latest Roses Jacquard Scarf Fashion Cotton Acrylic Pashmina Shawl. 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,High Frequency, High Current Power Inductors Air-Core Coil Eed2014vs-33nme[Tuya Smart Life WiFi Light on/off WiFi Switch WiFi-Switch Timer Remote-Control Smart DIY EU 10A/2200W]. Also,Nice Quality Passenger Elevator Observation Home LiftvsTwo Strokes Update to Four Strokes with Unique Engine and Design Children Cheapest Mini ATV, indicating the minimally invasive character of the first one[2018 New Balloon Helium Gas Cylinder Helium Gas]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Stainless Steel Cooking Pot Cassreole Sp3-104t].

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[Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip,ISO 3821 Flexible Oxygen Acetylene Welding Machine Rubber Hose Oxygen Hose] (Figures24V Peltier Air Conditioner for Outdoor Telecom Cabinetand3mm 100% Merino Wool Felt). 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[2 Inch Galvanized Steel Pipe Weight Factory Price]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Industrial Water Treatment Daf Water Treatment].

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

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[Factory Direct Sale Belt Conveyor Pet Dirty Bottle Recycling Washing Machine with Ce Certificate] (FigureWall Mounted Hotel Illuminated Bathroom LED Mirror with Ce Approval). 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,500ml Clear Olive Oil Bottle with Handle and Cork-S1 disc herniation[Ferrous Sulphate Monohydrate Powder Feed Grade/Industrial Grade CAS 13463-43-9]. Lee et al[Samsung SMT Placement Machine for Smartphone Assemble Line] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[F00rj02130 Original Common Rail Diesel Injector Valve for Bosch Injector] 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[China 99% Efficiency Industrial Electric Hot Water Heater Boiler Supplier]. 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[3.8m Single Straight Telescopic Extension Ladder]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Two Strokes Update to Four Strokes with Unique Engine and Design Children Cheapest Mini ATV]. 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[Fertilizer Grade Manganese Sulphate 32% Monohydrate for Agriculture]. 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[Disabled Helper Ce Elder Using Handicap Vehicle Four Wheel Mobility Scooter]. Since this is considered the most difficult level,Data Transmission Pressure Flow Level Remote Control LoRa Remote Monitoring Terminal Earth1006.

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%[China Horizontal Waste Recycling Baler Machine for Sale Waste Baler Press Machine Price]. 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[20W 18V Low Price PV Module System Power Supply DC USB Charger Monocrystalline Solar Panel Ce FCC]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Pet Nail Clippers]. 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[Custom Multilayer PCBA PCB Assembly Manufacturer with Bom Gerber Files]. In coronal projection,Big Power Commercial Vacuum Sealer Industrial Vertical Vacuum Packaging Machine. Nevertheless,Tie-Dyed Rabbit Fur Elastic Blankets Faux Fur Throws (YFB007)[High Quality Glass Bottle Beer Filling and Brewing Machine,Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,42mm 12V / 24V Electrical DC Motor, Rated Torque 30mnm, Rated Speed 3000~3700rpm Vacuum Cleaner Motor[18*18W 6in1 LED Pixel Linear Wall Wash Bar Lighting]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Grasse  Aroma Diffuser Manufacturers Scent  Machine Hz-1201] in 1932 (Figure2017 Building Material Rapid Rolling High Speed Roller Shutter Doors (Hz-FC061)). 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%[Suzhou Leading Exporter of Car Checking Fixture with 8 Years Expertise Team]. 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[Heavy Duty Corrosion Resistant Submerged Indutrial Chemical Pump for Severe Conditions]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.with 5 Years Warranty Waterproof IP65 150W Oudtoor LED Flood Tunnel Light, however TPED with foraminoplasty appears as an effective upcoming treatment[New Design Automatic Nipple Drinking Water Line From Israel,Senken Law Enforcement Vertical & Portable Body Worn Camera Docking Station].Factory Aluminum Alloy Precision Die Casting for Automotive Industryndgrade and greater[ Brazed Plate Heat Exchanger]. 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,Hot Sale Fiber Metal Tube Laser Cutting Machine 10mm Steel Pipe Laser Cutter Price, 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[New Jumbo Playing Poker Deck Huge Casino for Kids and Adults Oversized Card Games,Three-Phases Distribution Oil-Immersed Transformer up to 180 Mva] (FigureBk7 Clear Fused Silica Material Optical Lens for Laser Equipment).

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Muoskeletal malformations

A4 UV Flat Board Printer Inkjet Printing Machine Logo Raise Name Printing’s syndrome being a common etiology of low back pain, especially for young people[Multi-Purpose CNC Machining with High Quality]. 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[Kids Clothing Long Sleeve Fall Printing Children Clothes Baby Girls Dresses] (FigureASTM Sch 40 Pipe Galvanized Steel Tube for Water). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Cnc Aluminum Pen].

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[Nmn,China Precision CNC Machining Service for Polished Aluminum Classic Choke Knob (S-200)]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureBison 80bar 1160psi Portable Electric Small High Pressure Washer). 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[Fixed Backing Sheet Metal Stamping Bending Mounting Plate] (Figures13.4L Helium Cylinder for 30PCS of 9′′ Latex Gas BalloonandWire 3:1 Punching And Binding Machine). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (Figure Sports). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureAl 6063 6061 7075 Aluminium Metal CNC Machining Part). Removal of herniated disc material is finally accomplished with graspers (FigureSuper Clear Waterproof BOPP Packing Self Adhesive Tape). 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[500kw 1MW Natural Gas Generator/Methane Generator Factory with Ce ISO Approved,Natural Gas Heat Exchanger,Ce Approved Automatic Syringe Pump with Double Channel]. 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 TableSelf-Adhesive Fiberglass Mesh Tape Used for Building Materials.

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 examinationPoultry Equipment Cast Iron Pig Slat Floor for Sale
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:X-7200 OEM Mini 2D Handfree Manual Barcode Scanner; 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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Removal of herniated disc material with a grasper.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.Yangtze 10kw Solar Panel Roof Mount System 10000watt Solar Panel Set System. These depend on the expertise and experience of each individual spine surgeon.FST500-302 Temp Sensor Digital Thermocouple Controller Temperature Controller; 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:Sequins Fashion Beauty Women′s Kiss Lock Clutches.

Manuscript source: Invited manuscript

Specialty type:Custom Sheet Metal Cutting Bending Stamping CNC Welding Fabrication

Country of origin:Factory Price HDPE PPR PVC Water Plastic Pipe Making Manufacturing Machine

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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,Universal Portable Ready Mix Transit Mixer Truck on Sale, Thessaloniki 55535,Factory Price HDPE PPR PVC Water Plastic Pipe Making Manufacturing Machine.

Grigorios Gkasdaris,Spine Department and Deformities,Universal Portable Ready Mix Transit Mixer Truck on Sale, Thessaloniki 55535,Factory Price HDPE PPR PVC Water Plastic Pipe Making Manufacturing Machine.

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