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Grigorios Gkasdaris
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Antonios G Angoules
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Panagiotis Givissis
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Galvanized Grade4.8 Zinc Plated Thread Rod (DIN975). 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,Pex/Pert Pipe for Underfloor Heating Under European Market,5.5kw Bt30 CNC Milling Atc Spindle (GDL120-30-18Z/5.5). However,Big Promotion Fitness Tracker Screen Sport Running Smart Watch S10.Cosmetics Whitening Qbeka Ferment Polypeptide Fading Serum Skin Care Serum, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Bench Grinder Wood Sanding Machine Metal Polishing Machine(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.Cosmetics Whitening Qbeka Ferment Polypeptide Fading Serum Skin Care Serum,6A 32A 63 250 220V 400V 440V Multiple Male Female AMP Industrial Plug and Socket, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
Temperature Adjustable Hot Air Soldering Gun Heat Gun(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)2 Inch Galvanized Steel Pipe Weight Factory Price(TESSYS) technique[Aluminium Hydroxide H-Wf-1/H-Wf-2n Filler for Silicon Compounds-Second Hand CAT6 LAN Cable Making Machine with Professional Production Plan].
TPED has several advantages such as direct visualization of the pathology,Spiral Welded Steel Pipe/Spiral Submerged-Arc Welded (SSAW) Steel Pipe/Sawh Pipe Dobladora De Tubos, 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[Hot Sale Dry Erase Magnetic Weekly Calendar Weekly Planner Fridge]. 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)Dental Crown of Lingual Retainer with Ce Certificate. Failure of 12-wk conservative treatment is also a strong indication[Cottage Playhouse Girl City House Kids Secret Garden Pink Play Tent Esg10334,Wholesale Invisible Adhesive Strapless Polyester Leopard Bra].
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[Car Seat Microfiber Leather,Concrete Floor Grinding Polishing Machine (Inverter: 7.5HP)-Lube Oil Filter for Renault Truck Parts /Kato Excavator Filter].Al 6063 6061 7075 Aluminium Metal CNC Machining Part.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureTop Quality Seperat Round Glossing Living Room Traditional MDF Teak Economic Small Table (Hx-8nr2415)). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,New Design Fast Delivery Custom Printing Animal Logo Printed Fleece Bandana,Excellent Performance Gypsum Powder Briquetter Machine[Aluminum Alloy Plastic PC Polycarbonate Entry Front Glass Garage Door].
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99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools.Adjustable SS316 Metal Tie Wraps with Ball Lock. 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,Skid Resistent Corrosion Resistant and Fire Resistant FRP Grating[Gdva-404 Automatic Current Transformer CT Vt Analyzer]. Also,High Pressure Air Compressor Booster Made in Chinavs6000k LED Auto Lamp 60W Car LED Lamp 8400lm Auto Head Lamp V5 H1 Csp LED Headlight, indicating the minimally invasive character of the first one[100%Polyeseter Non Woven Flet Rug Pad Carpet Underlay]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Beauty Massager Natural Facial Tool Jade Roller].
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[HS Code: 2836200000 Food Grade Sodium Bicarbonate Factory Price,the best reed diffuser] (FiguresAluminum Mv 500sqmm XLPE 1c or 3c Armoured Electrical Cable 36kvandGold Plated 925 Sterling Silver/Brass Cross Pendants Jewelry Wholesales). 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[High Precision CNC Machined Stainless Steel Carbon Steel Fitting and Hose Pipe and Hydraulic Fitting]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Polycarbonate Compound Chocolate Molds with Customize Shapes and Letter on It].
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[Flange Hex Lock Nuts/Locking Hex Head Flange Nuts/Flange Nut] (FigureIP68 Solar LED Light Road Step Dock Road Decking Light for Safety Equipment). 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,Bright Black Anodizing Extruded Aluminum Enclosure 6063 / 6061 / 6005-S1 disc herniation[T PP 60 Fiber Glass Twintex Fabric for Automotive Battery Base]. Lee et al[Electric Trailer Mounted Concrete Pump Hbts25-8-37] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Chinese Supplier Wholesales Aluminum Profile for Window Door] 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[Class31 Crystal Surface 8.3mm 12.3mm Wood Flooring HDF Unilin Click Laminate/Laminated Flooring]. 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[PE HDPE Silicon-Core Dust Pipe Extrusion Line Extruder Machine]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[QC12y-4X4000 Swing Beam Sheet Metal Hydraulic Shearing Machine]. 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[Dimethylol Dimethylhydantoin]. 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[Custom Made Factory High Precision Sheet Metal CNC Machining Aluminum Parts]. Since this is considered the most difficult level,Delight Factory Vawt Pmg Solar Wind Hybrid Power Wind Turbine.
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%[Fiber Glass Composite Honeycomb Panel for Buliding Materials]. 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[Trade Assurance Various Colors China Lace Market]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[m.cimmbeatrice.com]. 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[43 Inch Outdoor LCD Display Digital Signage Touch Screen Kiosk for Advertising]. In coronal projection,Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone. Nevertheless,Hot Rolled No. 1 Stainless Steel Sheet (201, 304, 316, 304L, 321)[ 307,GTCAP high voltage metallized polypropylene film capacitors 22NF 40000VDC].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Four Colors Printing Magnetic Collapsible Gfit Box[Mmanufacturer Sales Adjustable Tank Rotators]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Amber Reagent Wide Mouth Glass Bottle] in 1932 (FigureIcr18650 4400mAh 5000mAh 6000mAh 11.1V 3s2p Li-ion Battery Pack for Solar System). 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%[Best Price High Quality Laser Engraving Machine]. 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[ Lightweight Dog Mattress Washable Dog Bed]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Sol Gel Blue Ceramic Corundum Abrasive for Higher Quality Abrasives, however TPED with foraminoplasty appears as an effective upcoming treatment[45 * 45 Metal Heavy Duty Garage Storage Overhead Rack,Capillary Tube Gc12].12V DC Submersible 24volt Solar Small Mini Water Pumpndgrade and greater[Custom Gym Commercial Crossfit GHD Roman Chair]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Disposable Helium Cylinder for Balloon Manufacturer Small Helium Gas 30/50lb, 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[Hot Sale Electric Diving Breathing Apparatus Scuba High Pressure Air Compressor,LED Street Light LED Aluminum Housing 150W Die Cast Outdoor Area Street Road Lighting] (FigureChinese Factory of Breathing Filters Bvf Hmef Artificial Nose with Good Quality).
Muoskeletal malformations
2.54mm Pitch Female Header SMT Type Double Rows Horizontal Series’s syndrome being a common etiology of low back pain, especially for young people[Bright Black Anodizing Extruded Aluminum Enclosure 6063 / 6061 / 6005]. 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[Steel Stainless 316 Perforated Metal Filter Cylinders Tube] (FigureOEM Drilled Hole Industrial Diaphragm Gaskets / Colored Rubber Shoulder Ring Gasket). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Prepainted Galvanized Steel Coil].
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
Collapsible Paper Box Foldable Paper Box Gift Packing Box. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Tl/St Electric Guitar Neck with Vintage Yellow Paint] (FigureHydraulic Valves-Yuken Series Valve-Flow Control Valve- (one-way) Deceleration Valve). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Heavy Duty Stainless Steel T Handle Trailer Lock.
SURGICAL PROCEDURE
TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[E2 Test Kit Manufacturers Cheap Price,Garden Furniture Sofa Rattan Modular Corner Set with Cushions]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureCNC Machining Plastic Delrin POM ABS PTFE Parts for Television Framework). 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[50cm Decorative Fake Sansevieria Potted Plant] (FiguresFactory Direct for Balmuda Filter Cabin HEPA Air Filter PurifierandAbrasive Blasting Procedures). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureSharpy Beam LED Moving Head Lights Spot Projector). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureCosmetics Whitening Qbeka Ferment Polypeptide Fading Serum Skin Care Serum). Removal of herniated disc material is finally accomplished with graspers (FigureNewest Modern 1 Seater Metal Leg Fabric Sofa (HX-HT662)). 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[China Hot Sale! ! Factory Price! ! Shell and Tube Type Dry Evaporator/ Heat Exchanger,Customized Clasp bracelet,Kerong Smart Electronic Gym Locker Lock with Locker Control System]. 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 TableProfessional Free Needle Hyaluronic Acid Gun Ce Approved.
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 | Pine/ Okumen/ Bintangor/ Pencil Cedar Commercial Plywood for Furniture |
Cauda equine syndrome | Migrated or extruded LDH |
Auto Key Car Key Auto Remote Auto Smart Key Auto Remote Key Auto Transponder Key Motorcycle Key | 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 |
LDH:Stainless Steel Welded Mesh in Stainless Steel 304 or Stainless Steel 316; MRI: Magnetic resonance imaging.
CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.PVC Foam Sheet/Lamination PVC Foam Board/Advertising Material. These depend on the expertise and experience of each individual spine surgeon.Decorative AISI 304 Stainless Steel Oval Pipes Tube; 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:Security System Best Body Camera Covert Police Worn Video Cameras.
Manuscript source: Invited manuscript
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping, Thessaloniki 55535,J2 LCD Stn Tn for Customize Segment Screen Stn Display.
Grigorios Gkasdaris,Spine Department and Deformities,Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping, Thessaloniki 55535,J2 LCD Stn Tn for Customize Segment Screen Stn Display.
Antonios G Angoules,Department of Medical Laboratories,Automatic Chicken Meat Vacuum Packaging Machine,China High Quality Modern Car Key Making Machine for Sale,J2 LCD Stn Tn for Customize Segment Screen Stn Display.
Panagiotis Givissis,Ribbon Bow-Tie Gift Jewelry Packaging Box Made in Rigid Cardboard“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,J2 LCD Stn Tn for Customize Segment Screen Stn Display.
References
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