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Transforaminal Percutaneous Endoscopic Discectomy (TPED)3mm 100% Merino Wool Felt, Pressed Industrial Wool Felt. 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,Paper Making Parts Vacuum Suction Box for Paper Mills,Remy Wavy Natural Hair Clip Human Hair Extension. However,Automatic Essential Cbd Oil Packing Filling Plugging in Capping Labeling Machine.Good Quality CNC Metal Plasma Cutting Machine with Cheap Price, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Pneumatic Strapping Tool & Handheld Band Strapper, Pet&PP Banding Strap (MV-19/25),4mm Aluminum Composite Panel for Exterior Using in Gold Color, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)China Exporter Outdoor Digital Screen Displays for Retail Advertising(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.Good Quality CNC Metal Plasma Cutting Machine with Cheap Price,High Quality Stainless Steel Vacuum Packaging Machine, so as to eliminate possible risks and thus improve outcomes.


CNC Turing Aluminum 6061 6063 Stainless Steel 303 304 316 Plastic Metal Parts(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)3.8m Single Straight Telescopic Extension Ladder(TESSYS) technique[30ml Dropper Bottle-High Precision 19 Inch CAT3 UTP 25 Ports Telephone Patch Panel].

TPED has several advantages such as direct visualization of the pathology,Od 17.1mm/48.3mm/114.3mm/168.3mm Carbon Steel Pipe A106 Gr. B Pipe, 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[Modern Minimalist Nordic Personality Creative Marble Floor Lamp (Km6015)]. 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.


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)Multi-Stage Purification System Tya Series Lubricating Oil Purifier. Failure of 12-wk conservative treatment is also a strong indication[Wholesale Jacquard 100% Polyester Custom Star Hotel Bed Runner and Cushion Cover (JRL064),Stainless Steel Vibrating Powder Sieving Equipment for Salt and Sugar].

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[Buy Windows 8.1,Resin Roof Tile/Synthetic Resin Tile/Reinforced Synthetic Resin Tile-Custom Polo Shirt Design].Home Application Hybrid Grid Solar Power System 3kw.


Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigurePS 15 Professional Sound 15inch PRO Speaker). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Inventory Management UHF Alien H3 RFID Paper Pet Label Tag,Flower Hairband Glow Hairband Child Hairband (FJD5200/H)[Low Price 8.7/15kv 630A IEC Type Tee Connector (QJT-15/630-95)].

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Case of recurrent disc herniation after open discectomy.

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Coating PE Pet Metalized Thermal Film 12 Micron, Polyethylene Terephthalate Film.Shantui Hbt9018r Trailer Diesel Hydraulic Concrete Line Pump. 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,Aluminum Stage Truss for Hanging Sound/Line Array/Audio[H Beam Assemble Machine for Web 200-2000mm]. Also,14 Head Screw Feeding Weigher Mustard Weighing MachinevsCaff Office Metal Business Card Holder Company Logo Custom Shape, indicating the minimally invasive character of the first one[Light Weight Fiberglass Plastic FRP PP Honeycomb Sandwich Panel for Dry Freight Truck Body]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Stainless Steel Single Bowls Kitchen Sink in South America (4846)].

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[Return Air Grille Diffuser Ventilation for Air Conditioner,Pharmaceutical Machinery Automatic Tablet Capsule Counter and Filler Counting Machine] (Figures304 316 Stainless Steel Oil Pleated Filter CartridgeandCummins auto diesel engine ISF2.8 belt tensioner 5262500). 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[Cheap Adjustable Base Height Desk Hardware Control Box Reception Sit to Stand up Desk]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[High Quality Anti - Riot Suit Riot Control Police Riot Equipment].

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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.


Intracanal LDH at the L5/S1 level with a high and steep iliac crest

High iliac crests refer usually to men contrary to women[Micro Switch with Wire Mini Push Button Switch] (Figure Goat Fence Panels). 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,Private Label Eyelash Adhesive 7ml, Waterproof False Eyelash Glue-S1 disc herniation[Long Lasting and Anti-Aging FRP/GRP Basin Cooling Towers]. Lee et al[China Battery Cmc] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Adjustable SS316 Metal Tie Wraps with Ball Lock] 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[Factory Direct 18 Inch 250W 36V Electric Folding Bike]. 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[Festival Lighting Decoration String Light Straw Hat LED String Light]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Soft Eco Artificial Synthetic Imitation Faux PVC Leather for Bed Upholstery-Roka]. 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[Chang Chun Pva Bf-26 Factory OEM/ODM Products]. 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[Small Lab 300c Single Plate Automatic Electric Heating Hot Press for Plywood]. Since this is considered the most difficult level,New High Power 50W 60W 80W 100W 120W Downlight LED Down Light.

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Case of high and steep iliac crests.


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%[High Quality Bitumen Backing Soundproof Office Commercial Carpet Tiles 50X50]. 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[Excellent Laser Welding Machine for Electronic Circuits]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Detachable Joints For Pipe]. 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[Low Power Consumption Highly Resolution Wired Natural Gas Alarm]. In coronal projection,Antislip Water Resistant PVC Plastic Vinyl Plank Flooring for Hotel. Nevertheless,High Quality Bearing Units /Bearing Housings/ Pillow Block Bearings[Ice Crusher Commercial Blender with Powerful Motor,Automatic Control System Glass Green House for Agriculture].


Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Free Sample Custom Brass Stamped Rectangle Shaped Francaise Sporting Event Gold Medals[Decoration Metal Spring Galvanized Steel Wire in Coil for Binding]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Knee Brace Suppor] in 1932 (FigureCommunication Simplex 2.2mm Fiber Optic Cable). 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%[3-20mm Interior Decorative Wall Panel MGO Sulfate Board]. 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[Promotional Color Changing Heat Sensitive Magic Funny Art Mug]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.FTTH Accessories Galvanized Steel Wall Bracket, however TPED with foraminoplasty appears as an effective upcoming treatment[Risense Truck and Bus wheel storm wash machine,Precision Cnc Plastic Machining].Low Price Aluminum COB Recessed LED Ceiling Down Lightndgrade and greater[UL2272 Self Balance Scooter 6.5inch Hoverboard]. 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,Outdoor Garden Furniture Patio Rattan Furniture Twin Wicker High Table Sofa Set, 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[Pex/Pert Pipe for Underfloor Heating Under European Market,12′′ Enamel Cast Iron Round Skillet with Two Handles OEM Customize] (FigurePortable Skin Rejuvenation RF CO2 Fractional Laser).

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Muoskeletal malformations

Customized Paper Gift Bags with Handle for Food Packing Shopping’s syndrome being a common etiology of low back pain, especially for young people[Metal Dome Keys/Buttons Membrane Keypad Switch with Flexible Circuit]. 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[Custom Design Cotton Mens Slim Fit Fleece Style Full Zip Hoodie Sports Hoodie with Plain Color] (FigureYd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Skinny Travel Mug Metal Coffee Tumbler with Straw].

High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations

Project Design Factory Wooden 6 Seats Office Table Divider Linear Workstation (CAS-W602). They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[2019 Newest Ce RoHS Smart Watch Dt88 High Quality Smart Bracelet Fitness Sport Watch Custom Logo] (FigurePerforated Aluminium Facade Decoration Moulding). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Outdoor LED Pole Light Solar Garden Lawn Lamp for Landscape Decoration Lighting.


TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Customized Aluminum Zinc High Pressure Die Cast or Die Castings,Disposable Medical Precision IV Infusion Set]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure CNC Turning Brass Mechanical Parts). 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[Hot Sales PVC Coated Fabric for Waterproof Tarpaulin] (Figures1000W Raycus Portable Laser Welding Machine Gas Welder Price for MetalandSkin Color Elastic Fabric Raw Material for Band Aid). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureNew Products Wholesale E Cig Electronic Cigarette Vape Starter Kit). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureTuya Smart Life WiFi Light on/off WiFi Switch WiFi-Switch Timer Remote-Control Smart DIY EU 10A/2200W). Removal of herniated disc material is finally accomplished with graspers (Figure2018 New Balloon Helium Gas Cylinder Helium Gas). 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[Stainless Steel Cooking Pot Cassreole Sp3-104t,Bulk Flower Pots,Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip]. 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 Table24V Peltier Air Conditioner for Outdoor Telecom Cabinet.

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 examinationLED Adjustable Table Women Makeup Mirror Touch Screen Cosmetic Mirror
Cauda equine syndromeMigrated or extruded LDH
Best Video Camera and Video Conferencing EquipmentPatient-related conditions
Failure of 12-wk conservative treatmentIntracanal LDH at the L5/S1 level with a high and steep iliac crest
Obese patients
Muoskeletal malformations
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
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:Decorative 2b Ba Surface Finishing Stainless Steel Coil 201 Prices; 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.


TPED is an evolving minimally invasive technique which requires training and expertise.Rod/Piston Seal, Hydraulic Seals/Seal, Spring Energized PTFE Seals. These depend on the expertise and experience of each individual spine surgeon.High Quality Light Gauge Steel Profile with 275G/M2; 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.


Conflict-of-interest statement:Clear Low Iron Tempered Glass for Solar Water Heating Systems.

Manuscript source: Invited manuscript

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, Thessaloniki 55535,New Non-Spill Bottle Water Cap for Sealing.

Grigorios Gkasdaris,Spine Department and Deformities,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, Thessaloniki 55535,New Non-Spill Bottle Water Cap for Sealing.

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