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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[Charging Station Dc Converter-Professional OEM LED Lamp Accessories by Aluminum Die Casting in China].
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[Aluminium Frame Supported Glass Curtain Wall]. 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[5ml 8ml 10ml Perfume Spray Bottle Plastic Black Travel Perfume Spray Bottle for Free Sample,Polyacrylamide Anionic Water Soluble Polymer for Sale].
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[SAE Brass Straight Coupling/ Nipple (AV9029A),High Quality Mother Care Products Manual Breast Milk Pump-Sans1123 1600/4 BS10 T/D T/E BSPT Screwed/Threaded Galvanised Flange].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 (FigureQuality EPDM Silicone Cold Shrink Wrap Tube). 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[Sunroom Used Double Tempered Glass Thermal Break Aluminum Casement Window and Door].
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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[Outdoor Garden Furniture Patio Rattan Furniture Twin Wicker High Table Sofa Set]. 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[IP66 Outside Wiring Connector Box Power Floor Socket]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[China Manufacturer Diamond Tools PDC Cutter Inserts for Oil Well Drilling].
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[Ta-6s Ta-2 Ta-0 Ta-2/0 Ta-250 Ta-350 Ta-600 Ta-800 One Conductor Ta Type Aluminum Mechanical Lug,Automatic Screen Printing Machine Manufacturers in China for Sale] (Figures10L Gas Cylinder for N2o Nitrous Oxide/Laughing GasandPlug-in PCB Terminal Blocks Ma2.5h5.0 Male Plugable Male Base). 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[Custom Cheap Design Woven Patch Embroidery Badge]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[15 Years Factory Customized Home Appliance Parts Plastic Injection Toolings].
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[Steel Galvanized Angle Iron Q235 Hot Rolled Steel Angle] (FigureBPA Free New Arrival Glass Spring Water Beverage Bottle Factory with Aluminum Cap). 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[Wood Design Spc WPC PVC Vinyl Plastic Floor Flooring]. Lee et al[Vinyl Printable] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[New Avengers Alliance PU Squishy Toys Stress Release Toys] 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[Pillar Candle of White Candle of Pure White Candle]. 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[Durable PVC Plastic Pipe 110mm UPVC Drain Water Pipes]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Heavy Duty Strong Packing PVC Colored Cheap Custom Adhesive Cloth Duct Tape]. 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[Crystal Epoxy Card]. 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[China 55*105 White Color Woven Polypropylene Bag 50kg Packing Bag for Rice Corn Dog Food]. 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%[Durable Hot Sell FRP Manhole Cover Making SMC Machine]. 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[Quilted Diaper Bag Custom Mummy Backpack]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Electric Auto Relay]. 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[ Pharmaceutical Ingredient]. 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[40 A Grade Panel FHD DVB-T Dled TV Hot Sell in Middle East Europe Asia,Factory Price 310 Stainless Steel Coil/Sheet High Quality with Reasonable Price!].
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[Popular Low E Reflective Glass for Building Curtain Wall]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Hydraulic Press Block Machine] in 1932 (FigureAnti-Slip Playground Tiles for Children Safety Outdoor Rubber Tile). 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%[Stainless Steel Casual High Quality Analog Men′s Automatic Wrist Watch]. 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[Sentek Push Button Security Magnetic Contacts Door Window Switches Br-1041t]. 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[Good Technology Rubber Crumb Making Machine From Old Tyre,m.shphe-en.com].Epon 1ge CATV Sf RF WiFi ONU for FTTH Networkndgrade and greater[Sheet Metal Perforated Stamping Cover Sheet Metal Fabrication Metal Frame for Decoration]. 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[IP67 Solar Array PV Combiner Module Panel Junction Box,Decorative 2b Ba Surface Finishing Stainless Steel Coil 201 Prices] (FigureDental Air Prophy Polisher Tooth Polisher with Quick Connect).
Muoskeletal malformations
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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[Automatic Weighing Packaging Machine 10 Head Multi Function Cheese Weigher] (Figure2 Layers 5000L Plastic Blow Molding Machine/Blowing Moulding Machiery). 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[Ss 304 Ball Head Bolt,Ahp Digital High Pressure Heat Press Machine]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureOcean Themed Playground Equipment Kids Electronic Toys Indoor Playground). 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[Customize 13.3 Inch Touch Screen LCD Displays with Touch Screen] (FiguresComfortable and Durable Silicone Facial Cleansing Brush Direct ManufacturerandSmall Industrial Air Operated Double Diaphragm Pumps). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureKids Digital Cameras for Children Video Record Electronic Toy Birthday Christmas Gifts). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (Figure3X3X2.5m Mini Size Cold Chiller for Vegetable and Meat Storage). Removal of herniated disc material is finally accomplished with graspers (FigureDetergent/Paint Making Machines Stainless Steel Paint Mixer Machine Price). 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[Thickeners,Hot Sale Mimaki Ujf-A3hg UV LED Curing Platform Inkjet Printer,Both Sided Diamond 600# 1000# Sharpening Stone Knife Sharpener]. 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 TablePCBA GPS Tracker Mini Tracker PCBA Circuit Board with One Stop Service.
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 |
Afen Automatic Snack Drink Touch Screen Commercial Coffee Vending Machine for Office | 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: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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