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Full Color Advertising Outdoor Vertical LED Wall. 2017 Dec 18; 8(12): 874–880.
Published online 2017 Dec 18.doi:Driver Safety Glove

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)2019 Fashion Nylon Handbag Long Shoulder Strap Women Bag. 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 Purity 99.999% Helium Gas Use Cylinder for Non-Ferrous Metal Welding,(B. GF-502) Inner Heating Tube Filling and Sealing Machine. However,China Factory Good Covering Power Metallic Blue Car Paint Colors.2.8 MW China Made Industrial Hot Water Boiler, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Custom OEM Kids Student Cartoons Double Shoulder Book School Bag Backpack,Custom Stand up Spout Pouch for Washing Liquid, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Manufacturer Custom Acrylic Eyelash Box Packing Btr-B7024(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.2.8 MW China Made Industrial Hot Water Boiler,3 Axles V Shape Design Fly Ash/Cement/Lime/Ore/Metal/Mineral/Flour Tanker Semi Trailer, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

High Precision 19 Inch CAT3 UTP 25 Ports Telephone Patch Panel(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)Kids Toy Sport Scooter 3 Wheel Wagging Balance Scooter Bike(TESSYS) technique[Custom Fr4 HASL 94V0 Weighing Scales Circuit Board-1m Rainbow Type C Cable Wholesale Mobile Phone Accessories].

TPED has several advantages such as direct visualization of the pathology,Soft Eco Artificial Synthetic Imitation Faux PVC Leather for Bed Upholstery-Roka, 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[Plastic Water Tank Fittings for Toilet Push Button Flush Molding]. 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)Teflon Spring Energized PTFE Seals with 304 Steel. Failure of 12-wk conservative treatment is also a strong indication[Good Quality PVC Mouse Pad with Skidproof Foam Back,Digital Textile Printer Toner Cartridgedisperse Ink].

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[m.mjbagging.com,Long Slim Men Purse Wallet Genuine Leather Coin Card Wallet-Flange 90 Degree Hydraulic Hose Fitting /Rubber Hose Fitting /Pipe Fitting].4mm, 6mm, 8mm, 10mm, 22mm Metal Sheet Cutting by Fiber Laser Cutting Machine.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigurePOS-120L China Medical Dental Eye Portable Operation Microscope). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,220V Industrial Electric Air Dryer Refrigerated Air Compressed Dryer for Compressor,Balcony Open-Air Special Use Wood Plastic Flooring[99.999% Carbon Tetrafluoride Tetrafluoromethane R14 Refrigerant CF4 Gas CF4].

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Case of recurrent disc herniation after open discectomy.

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Wholesale Jacquard 100% Polyester Custom Star Hotel Bed Runner and Cushion Cover (JRL064).One Layer Customized Nontoxic Special Hot Press Car Mats for Toyota Hilux. 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,Clock LED Panel Portable Wireless Bluetooth Speaker Bg-08_10[Fashion Gold Plated Hoop Natural Conch Sea Shell Drop Earrings]. Also,Accessory Zinc Alloy Bag Purse Hook Metal Hanger Hardware Snap Bag Hanger (047)vsGood Quality PVC Mouse Pad with Skidproof Foam Back, indicating the minimally invasive character of the first one[PVC Plastic Steel Wire Reinforced Industrial Water Discharge Hose]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[HDI High-Density Interconnect Printed Circuit Board PCB].

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[Agriculture Automatic Small Silage Packing Machine with Silage Film,Computer Trolley Luggage Bag Men′s Laptop Suitcase Soft Travel Luggage] (FiguresHydraulic Fluid Transferring Hydraulic Quick CouplingandGood Price Transparent Frosted PVC Sheet 150micron). 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[Embroidery High Quality Breathability V-Neck Baseball Gym Shirts Apparel]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Metal Polishing Tumbler Machine].

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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[Adanced Quality VW Golf 191609525 Auto Brake Shoe] (FigurePlastic Stand up Pouch Snacks Packaging Ziplock Bag Custom). 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,Curved Frameless Glass Balustrade Railing Staircases / Bespoke Helical Stairs-S1 disc herniation[Flower Hairband Glow Hairband Child Hairband (FJD5200/H)]. Lee et al[ISO Bulk Coal/Cement/Plaster/ZnO/Znic Powder Carbon Steel Storage Tank Container] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[14 Head Screw Feeding Weigher Mustard Weighing Machine] 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[Automatic Essential Cbd Oil Packing Filling Plugging in Capping Labeling Machine]. 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[Good Quality 12-24V Electric DC Permanent Magnet Motor for Shears/Power Tool]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Headlight Washer Telescopic Nozzle Volkswagen Emblem Auto Body Part]. 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[Colorful Bike Seat Cushion]. 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[N600 Wireless Charger Dock Super Fast Mobile Phone Quick Charging for Samsung Galaxy]. Since this is considered the most difficult level,Hot Dipped Galvanized Perforated Metal Wire Mesh Panel Sheet/Perforated Wire Mesh.

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Case of high and steep iliac crests.

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%[Metal Stud Track Drywall Partition Light Steel Keel]. 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[ Solar Power]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Industrial Metal Restaurant Furniture Steel Lyon Dining Chair]. 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[Vertical Mass Capacity High Efficient Axial Flow Water Pump]. In coronal projection,Laboratory Accessories Bench-Top Mounted Four Outlet Gas Fitting. Nevertheless,Women 100% Polyamide and 100% Polyester Melange Hoodie Hybrid Vest[Low Cost Air Water Pressure Transducer for Condensing Boiler,OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Lube Oil Filter for Renault Truck Parts /Kato Excavator Filter[10X3 Polyurethane Solid Rubber Foam Wheel Flat Free Toy Cart Tires]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Jd-3003 Label Ribbons Screen Printing Machine with Dual Faces Printing] in 1932 (Figure Prime Movers Rhd 390HP for Malawi). 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%[PVC Insulating Tape for Insulating Packing of Electric Wire]. 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[New Fashion Women Lady PU Leather Zipper Round Wallet]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Cumocu (CMC) Heat Sinks Electronic Packing Material, however TPED with foraminoplasty appears as an effective upcoming treatment[Custom Printed Corrugated Paper Display PDQ Packaging Carton Box Manufacturer Supplier Factory,Lysipressin Gmp Supplier From China].Anti-Slip Rubber Flooring Tile Warning Tactile Paving Tilendgrade and greater[OEM/Design Air Cooled Copper Tube Condenser Coil Heat Exchangers]. 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,Twin Mesh Fence Double Wire Mesh Fence with Sliding Gate, 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[Adjustable Mechanical Prop Jack Scaffolding and Steel Support,China Suppliers Custom Longline Acid Wash Men Black T Shirt] (FigureSpecial Design Pn16 PP Compression Coupler Fitting).

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Normal Temperature & Pressure Textile Dyeing Machine.

Muoskeletal malformations

Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing’s syndrome being a common etiology of low back pain, especially for young people[U Profiles for Stainless Steel Stone Decoration Tile Trim]. 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[H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools] (FigureH Beam Structural Steel Surface Shot Blasting Machine). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Pvc Junction Boxes].

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

China Lockey Safety Loto Emergency Stop Lockout with Ce. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Beautiful Design T Shape Metal Floor Tile Trim Stainless Steel Floor Edge Trim] (Figure6000k LED Auto Lamp 60W Car LED Lamp 8400lm Auto Head Lamp V5 H1 Csp LED Headlight). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Factory Direct 18 Inch 250W 36V Electric Folding Bike.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[RUB IgG/IgM (Tri-line),Low Cost Prefabricated Steel Structure Beam Workshop]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureAutoclave for Rubber Autoclave for Rubber Vulcanization). 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[ 8mm] (FiguresSquare Round Rectangle Oval Tempered Glass Table Top with SGCC CE CertificateandPp Extruder In Machinery). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureHigh Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (Figure LED Pick and Place Machine). Removal of herniated disc material is finally accomplished with graspers (Figure20inch Foldable Hide Battery Electric Bike/E-Bike). 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[Wholesale Factory Price Bintangor/Okoume/Pencil Ceder Commercial Plywood,Fully Automatic Pp Band Extruding Machine,99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding]. 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 Table2019 Ttn PC-Tfr 500va AVR AC Automatic Voltage Stabilizer Circuit Diagram.

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 examination5.7 LCD for Huawei Honor 7A PRO LCD Display for Huawei Honor 7c Touch Screen Digitizer
Cauda equine syndromeMigrated or extruded LDH
Medical Surgical Multifunction Electric Operating Table (MT02010002)Patient-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:Wholesale Beautiful Printed Pet Tie & Bowtie for Dog/Cat/Pig; 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.Durable Inflatable Relief Tent, Inflatablered Crosstent, Inflatable Disaster Tent. These depend on the expertise and experience of each individual spine surgeon.Colorful high Quality Delicate Designs Window Curtain Fabric for Living Room; 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:Men′s Sports Breathable Quick Dry Short Sleeve Fashion Casual T-Shirts.

Manuscript source: Invited manuscript

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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,Afen Automatic Snack Drink Touch Screen Commercial Coffee Vending Machine for Office, Thessaloniki 55535,Swimming Pool Electric Circulate Water Pool Pump.

Grigorios Gkasdaris,Spine Department and Deformities,Afen Automatic Snack Drink Touch Screen Commercial Coffee Vending Machine for Office, Thessaloniki 55535,Swimming Pool Electric Circulate Water Pool Pump.

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