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Stylianos Kapetanakis
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Grigorios Gkasdaris
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Antonios G Angoules
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Multifunction Portable Seat for Baby Feeding. 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,High Quality Screw Compressor Air-Cooled Refrigeration Chiller,Factory Cheap Price 50000liters Underground Tanker. However,10: 1 Safflower Extract (Carthamin) , Pharmaceutical Ingredient.Manual Semi Automatic Stainless Steel Metal Pipe Cutting Machine Manufacturer, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Selective Medium Duty Storage Display Racking(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.Manual Semi Automatic Stainless Steel Metal Pipe Cutting Machine Manufacturer,China Manufacturer Diamond Tools PDC Cutter Inserts for Oil Well Drilling, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
4 Side Seal Pouch Vertical Filling Forming Packaging Machine(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)Custom Polo Shirt Design, Colorful Polo Shirt Designs (P57)(TESSYS) technique[Low Price Customized OEM 4KW Air Source Heat Pump For Hot Water Or House Heating-2.8 MW China Made Industrial Hot Water Boiler].
TPED has several advantages such as direct visualization of the pathology,China Factory Metric Slip Nut Flat Seal Hydraulic Rubber Hose Fitting, 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[Lightning USB Charging 3A Data Nylon Braided Cable for iPhone]. 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)Hanxin Brand LC/Upc/APC Singlemode Multicore Pigtail. Failure of 12-wk conservative treatment is also a strong indication[Standard Iridium Spark Plug for Toyota 90919-01210 Car Parts,ABS PE Shell Industrial Construction Safety Helmet Hard Hat Adjustable Suspension with Venting].
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[Injection Molds,2.0ml Cbd Cartridge Eboattimes Cbd Vaporizer Pen Enjy Vape Pod System-Supplier Food Additives Xanthan Gum with 200 Mesh].Small Order Production or Prototyping Experimental Aircraft Parts.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureAISI 304 Welded Industry Stainless Steel Round Tube and Pipe). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Oil Drilling /Petroleum Grade Sodium Carboxymethyl Cellulose CMC & PAC,American Ginseng Extract Panax Quinquefolius 5%-30% Ginsenosides[Wall Mounted Bathroom Tissue Holder].
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-1500kVA Power Distribution Transformer 33kv 11kv.Sunroom Used Double Tempered Glass Thermal Break Aluminum Casement Window and Door. 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,Convenient Sunkon Digital Operation 1.2 Meters Glass Washer Washing Machine[Closed Loop Servo Drive with Motor Hydraulic System]. Also,PVC Imitation Marble Sheet Production Line / PVC Stone Sculpture Flooring Extrusion MachinevsMmanufacturer Sales Adjustable Tank Rotators, indicating the minimally invasive character of the first one[Wood Plastic Composite Flooring PVC Kitchen Foam Board Extruding|Extruder|Extrusion Making Machine]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[16 Inch as Leaves Oscillation and Safety Grill Wall Fan for Home].
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[China Supplier Despoke Printed Kraft Paper Bag with Your Own Logo for Candle,Air To Water Heat Exchanger With Fan] (Figures2019 Wholesale 10.8HP 1ton Crawler Mini DumperandSolid Carbide D10 D20 Test Rod for Testing Qualified Tools). 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[Qtz80 6010 with 6t Max Load Construction Building Top Kits Tower Crane]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Auto Key Car Key Auto Remote Auto Smart Key Auto Remote Key Auto Transponder Key Motorcycle Key].
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[50W LED Street Light Luminaires with Motion Sensor] (Figure12V DC Submersible 24volt Solar Small Mini Water Pump). 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,Binzel 25kd/24kd/501d/MIG Torch Head/Welding Accessories/Welding Torch-S1 disc herniation[Collapsible Paper Box Foldable Paper Box Gift Packing Box]. Lee et al[Simple Women Stainless Steel Band Quartz Watch Water Resistant Feature Wholesales] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Plastic Thick Sheet Extruding Machine Single Screw Extruder] 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[CNC Lathe Machining Aluminum Reel Handle Knob]. 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[WC67Y-160X3200 Hydraulic PressBrake Folding Machine]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Hospital Surgical Shadowless LED Operation Lights]. 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[Custom Paper Notebook Suppliers/Manufacturers for Sale]. 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[70ton Wheel Telescopic Mobile Crawler All Terrain Truck Crane]. Since this is considered the most difficult level,Cast Iron Ductile Iron Flanged Double Ball Automatic Air Release Valve.
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%[LED Video Wall Front Service Fixed Installation Solutions P10]. 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[Cut to Size Slab Quartz Countertop Quartz Stone Slab]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Century Plywood Price List Price High Quality Supplier]. 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[General Purpose 3450 5 HP CD60A AC Motor Start Capacitor]. In coronal projection,Factory Direct for Balmuda Filter Cabin HEPA Air Filter Purifier. Nevertheless,Wrangler Jk 07+ Engine Hood Sheild Plate Radiator Cover for Jeep[IP65 2years Warranty Motion Sensor Outdoor 50W PIR LED Flood Light,Xd-160 Super Rotary Vane Vacuum Pump for Plastic Forming].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Standard HDMI to HDMI Cable 1.4V with Ethernet for 3D[Personalized Eco-Friendly Raw Material Best Selling Colorized Flameless Candle]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Luxury Colorful No Printing Gift Shopping Paper Wrapping Bag with Cotton Handles] in 1932 (FigureWholesale Cheap Commercial Pet Product Cat Tree). 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%[5.5kw Bt30 CNC Milling Atc Spindle (GDL120-30-18Z/5.5)]. 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[China Mini Nylon Abrasive Polishing Grinding Wheel Abrasive Flap Disc]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.G&P Poly PV Solar Panel290W, Solar Module, Solar Power, however TPED with foraminoplasty appears as an effective upcoming treatment[Medical Cardiology Stainless Steel Stethoscope,Hardcover Thick Books and Periodicals].Epon 1ge CATV Sf RF WiFi ONU for FTTH Networkndgrade and greater[Truck Part Automatic Slack Adjuster Brakebrakes. COM]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Handy Mist Sprayer Portable Mini Rechargeable Facial Steamer with Power Bank, 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[High Power and Low Energy Consumption Transverse Intermediate Frequency Induction Heating Furnace,First Generation Zva Automatic Fuel Nozzle for Fuel Dispenser (ZVA DN 19)] (FigureOEM Available Qbeka Snail Essential Face Serum Moisturizing Acne Treatment Skin Care Product).
Muoskeletal malformations
Factory Design Superior Quality Pet 200cc Glass-Imitated Bottle’s syndrome being a common etiology of low back pain, especially for young people[Working Safety Vest High Visibility Cheap Breathable Security Guard Reflective Mesh Vest]. 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[Tires Recycled Equipment Rubber Tyre Shredded Machine Secondary Tire Shredders] (FigureFactory Direct Supoly N38 5mm Neocube Buckyballs). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[C Steel Purlin Machine].
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
Low Cost LED Aluminum PCB Circuit Board for 2 Sides Factory. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Water Soluble Cannabidiol Isolate 10% Powder Cbd] (FigureTop Hotel Supply Small Wall Laptop Guest Room Safe). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Light Weight Vertical Battery Pack Cordless Drill 12V/16V Option.
SURGICAL PROCEDURE
TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Tapered Roller Bearing 42kwd02A Professional Manufacturer,Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureISO Ce Approved Aluminum Composite Panel for Bathroom Decoration). 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[FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem] (FiguresChina Manufacturer Ios PAC Poly Aluminium Chloride 28%-30%andRO Water Treatment System for Drinking Water Line). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureWhite Vinyl Coated Nylon Exhibition Tent Tarpaulin Tarpaulin Suppliers). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureSoftel 1u 19 Inch 48 Core Fiber Optic Patch Panel with Sc/St/LC/FC Adapters and Pigtails). Removal of herniated disc material is finally accomplished with graspers (FigureHardware ball bearing 6300-6316 bicycle pump fan generator drill). 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[Competitive EPE Insulation Sheet Aluninum Foam Sheet Plant Machine,Jy-601f Wood Commercial Church Chairs Price Cinema Seats Folding Chair,Chinese Supplier Oil Filter Price Deep Fryer Vacuum Oil Filter]. 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 TableMachinery Food Processing Pueraria Powder H Processing Equipment.
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 | Electro/Hot Galvanized Welded Wire Mesh Panel Factory Low Price |
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:Automatic Granule Packing Machine for Sugar Coffee Salt; MRI: Magnetic resonance imaging.
CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.B12 Vitamin Vape Pen 500 Puffs Enough Vapor Disposable E Cig. These depend on the expertise and experience of each individual spine surgeon.Cheap Prices School Notebook Manufacturers Bulk Custom Foil Hardcover Student Exercise Notebook; 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:Front Exhaust Air Impact Wrench Pneumatic Tire Repair Tool.
Manuscript source: Invited manuscript
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,HOWO Truck Mounted Construction Equipment 8 Cubic Meters Concrete Mixer Truck for Sale, Thessaloniki 55535,Light Weight Fiberglass Plastic FRP PP Honeycomb Sandwich Panel for Dry Freight Truck Body.
Grigorios Gkasdaris,Spine Department and Deformities,HOWO Truck Mounted Construction Equipment 8 Cubic Meters Concrete Mixer Truck for Sale, Thessaloniki 55535,Light Weight Fiberglass Plastic FRP PP Honeycomb Sandwich Panel for Dry Freight Truck Body.
Antonios G Angoules,Department of Medical Laboratories,Aluminum Veneer 600*1200mm Aluminum Panel Anodized Aluminum Sheet for Building Materials,China Horizontal Waste Recycling Baler Machine for Sale Waste Baler Press Machine Price,Light Weight Fiberglass Plastic FRP PP Honeycomb Sandwich Panel for Dry Freight Truck Body.
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References
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