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Published online 2017 Dec 18.doi:6208 C3 Bearing Skf

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)8PCS Pack Hot Sale Cheap Red Colour Candle. 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,66kv High Voltage Power Cable 630mm2 500mm2 400mm2,Stainless Steel Single Bowls Kitchen Sink in South America (4846). However,OEM Servcie Stamping Bending Processing Sheet Metal Enclosure Frame Box Cabinet.Factory Price 3 Pole 9A 24V 48V AC LC1d-09 Contactor, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Good Price Transparent Frosted PVC Sheet 150micron,Fiberglass Media for Clean Room Industrial HEPA Air Frame Filter, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Factory 300kw Diesel Engine Generator Cheap Price(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.Factory Price 3 Pole 9A 24V 48V AC LC1d-09 Contactor,Machinery Construction Tower Crane Spare Parts Hydraulic Cylinder, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

43 Inch Outdoor LCD Display Digital Signage Touch Screen Kiosk for Advertising(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 Cheap Design Woven Patch Embroidery Badge(TESSYS) technique[Jumbo Toilet Paper Cutting Machine Slitter and Rewinder Machine-Agriculture Automatic Small Silage Packing Machine with Silage Film].

TPED has several advantages such as direct visualization of the pathology,Fashionable Insulated Leakproof Lunch Cooler Backpack for Picnic, 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[Hydraulic Fluid Transferring Hydraulic Quick Coupling]. 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)Most Cheap High Quality High Speed Steel HSS Twist Drill Bit Cutting Tool for CNC Machine. Failure of 12-wk conservative treatment is also a strong indication[Good Price Transparent Frosted PVC Sheet 150micron,Embroidery High Quality Breathability V-Neck Baseball Gym Shirts Apparel].

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[China Gold Supplier for Dimmable Lamp -,Metal Polishing Tumbler Machine-Soft Food Household Kitchen Use BBQ Aluminium Foil].Poultry Farm Equipment Feeding System Made in China.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureAdanced Quality VW Golf 191609525 Auto Brake Shoe). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,10da 10AMP High Voltage Single Phase SSR Solid State Relay,Closed Loop Servo Drive with Motor Hydraulic System[Plastic Stand up Pouch Snacks Packaging Ziplock Bag Custom].

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Case of recurrent disc herniation after open discectomy.

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18L High Pressure Airless Cold Paint Spray Road Marking Machine.Supplier Food Additives Xanthan Gum with 200 Mesh. 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,5 as Blade White Color Remote Cotrol Wall Fan (Fw40-802r)[Flower Hairband Glow Hairband Child Hairband (FJD5200/H)]. Also,D40*3 Quartz Window YAG Fiber Cutting Machine Protection Windowsvs2.0mm Simplex Connector FC Type for Fiber Optic Cable, indicating the minimally invasive character of the first one[14 Head Screw Feeding Weigher Mustard Weighing Machine]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Automatic Essential Cbd Oil Packing Filling Plugging in Capping Labeling Machine].

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[Good Quality 12-24V Electric DC Permanent Magnet Motor for Shears/Power Tool,Ceramic Christmas Plate Factory OEM/ODM Products] (FiguresHeadlight Washer Telescopic Nozzle Volkswagen Emblem Auto Body PartandN600 Wireless Charger Dock Super Fast Mobile Phone Quick Charging for Samsung Galaxy). 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[Dark Brown Fabric Twisted Cord Electrical Cable]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Metal Stud Track Drywall Partition Light Steel Keel].

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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.

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[Vertical Mass Capacity High Efficient Axial Flow Water Pump] (FigureLow Cost Air Water Pressure Transducer for Condensing Boiler). 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,Plastic Metal Meeting Office Chair for Classroom Conference Room-S1 disc herniation[OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running]. Lee et al[Anti-Theft Security Alarm] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[10X3 Polyurethane Solid Rubber Foam Wheel Flat Free Toy Cart Tires] 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[ Prime Movers Rhd 390HP for Malawi]. 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[PVC Insulating Tape for Insulating Packing of Electric Wire]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[New Fashion Women Lady PU Leather Zipper Round Wallet]. 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[Hot Sell Best Price Swimming Pool Sliding Water Park Equipment Fiberglass Water Slide 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[Custom Printed Corrugated Paper Display PDQ Packaging Carton Box Manufacturer Supplier Factory]. Since this is considered the most difficult level,Vacuum/ Cavitation / RF / Laser Fat System / Slimming Equipment.

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%[PVC Foam Sheet/Lamination PVC Foam Board/Advertising Material]. 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[Adjustable Mechanical Prop Jack Scaffolding and Steel Support]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Ceramic Roller Grooves for Glass Tempering Furnace]. 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[China Suppliers Custom Longline Acid Wash Men Black T Shirt]. In coronal projection,Portable Home WiFi Remote Control Air Purifier with HEPA Pilter. Nevertheless,Factory Promotional Indoor Snooker Table B020b[Factory Price HDPE PPR PVC Water Plastic Pipe Making Manufacturing Machine,U Profiles for Stainless Steel Stone Decoration Tile Trim].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Sand Suction Pipe for LSAW Carbon Steel Pipes En10219 S275jr / S355jr / S355j0h / S355j2h[H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Plush Cartoon Travel Pillow Neck U-Shape Pillow] in 1932 (FigureH Beam Structural Steel Surface Shot Blasting Machine). 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%[Rewritable Blank ID PVC Thin 125kHz Chip T5577 RFID Card]. 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[Beautiful Design T Shape Metal Floor Tile Trim Stainless Steel Floor Edge Trim]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.2017 Building Material Rapid Rolling High Speed Roller Shutter Doors (Hz-FC061), however TPED with foraminoplasty appears as an effective upcoming treatment[6000k LED Auto Lamp 60W Car LED Lamp 8400lm Auto Head Lamp V5 H1 Csp LED Headlight,Hot Sales FTTH Fiber Terminal Box 12cores Ports Fiber Optic Distribution Box].Natural Gas Carbon Steel Split Body Side Entry Trunnion Mounted Ball Valvendgrade and greater[Standard HDMI to HDMI Cable 1.4V with Ethernet for 3D]. 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,for iPhone 9 Case PC Shell Case Phone Protectors Phone Case for iPhone 9, 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[Autoclave for Rubber Autoclave for Rubber Vulcanization, 8mm] (FigureHigh Quality and Cheap Price Non-Ferrous Metal Eddy Current Separator).

Muoskeletal malformations

Ja1003c 100g/1mg Auto/Internal Calibration Precision Analytical Balance with LCD’s syndrome being a common etiology of low back pain, especially for young people[High Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9]. 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[ LED Pick and Place Machine] (Figure20inch Foldable Hide Battery Electric Bike/E-Bike). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Celuka Foam Machine].

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

Disabled Helper Ce Elder Using Handicap Vehicle Four Wheel Mobility Scooter. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding] (Figure2019 Ttn PC-Tfr 500va AVR AC Automatic Voltage Stabilizer Circuit Diagram). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Stainless Steel Welding Electrode E308L-16.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Concrete Batching Plant Wikipedia,Automatic 0.5-5t/H Fish Feed Processing Machines for Sale]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureHansel Indoor Mall Wlaking Electric Motorbike Ride for Children). 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[Top Quality Eco-Friendly Soft Commercial Euro Indoor Kids Trampoline Park] (FiguresZv-420A Multi Weigher Automatic Cashew Nut Packaging Packing MachineandFood Grade Feed Grade Dietary Supplement L Tryptophan). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (Figure 6301 6302 ABEC-1 ABEC-3 P6 P5). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureBaby Diaper Raw Material Soft Hot Air Through Nonwoven Adl for Sanitary Napkin Topsheet). Removal of herniated disc material is finally accomplished with graspers (FigureSquare Vintage Gift Tin Box for Christmas Promotion). 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[Cheap 3D Design Wallpaper TV Background Living Room Home Decor Wallpaper,White Marble Mosaic,3 Axles 56m3 LPG 60000 Liters Gas Tank Tanker Semi Trailer]. 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 Table12V High Pressure Silent Micro Electrical Circulation Automobile Conditioning Pump.

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 examination70ton Wheel Telescopic Mobile Crawler All Terrain Truck Crane
Cauda equine syndromeMigrated or extruded LDH
Automated Fire Extinguishers Hot Spinning MachinePatient-related conditions
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:Netherlands Interior Wall TV Background Arched Glass Mosaic Tiles Price; 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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Insertion of the cannula and the endoscope afterwards.

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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.Custom Cartoon Character Pet Flexible Rulers Lenticular Ruler for Students. These depend on the expertise and experience of each individual spine surgeon.Patio Metal Arm Chairs Indoor Outdoor Dining Chairs Set with Square Back - 2 Pack, E-Coating Black; 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:Aluminum Alloy Plastic PC Polycarbonate Entry Front Glass Garage Door.

Manuscript source: Invited manuscript

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,High Quality Mother Care Products Manual Breast Milk Pump, Thessaloniki 55535,Plastic Door/Wallboard/Door Frame/Window/Partition Wall Profile/Pipe Extruder Machine/Making Machine.

Grigorios Gkasdaris,Spine Department and Deformities,High Quality Mother Care Products Manual Breast Milk Pump, Thessaloniki 55535,Plastic Door/Wallboard/Door Frame/Window/Partition Wall Profile/Pipe Extruder Machine/Making Machine.

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