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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Facial Tissue/V-Folding Shape Hand Towel Making Machine. 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 China Manufacturer Soybean Protein Isolated for Meat Processing Manufacturer,Good Price Sany Syt80 (T6510-8) Motor Tower Crane for Sale. However,Triple Shute Wire Vibrating Screen Mesh Used in Vibrating Stone Crushers.Student School Bag Fashion Boys and Girls Children Backpack, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Grain Processing Plant Potato Starch Making Plant Potato Rotary Washer,Ta-6s Ta-2 Ta-0 Ta-2/0 Ta-250 Ta-350 Ta-600 Ta-800 One Conductor Ta Type Aluminum Mechanical Lug, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)High Quality Brass Check Valve 1/2′′-4′′inch with Y Type(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.Student School Bag Fashion Boys and Girls Children Backpack,50W LED Street Light Luminaires with Motion Sensor, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Pet Application Chews Treats Food Machine Dog Chews 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)Kerong Smart Electronic Gym Locker Lock with Locker Control System(TESSYS) technique[Simple Open 4 Seat Office Desk Workstation with Drawer and Metal Feet-Chinese Supplier Wholesales Aluminum Profile for Window Door].

TPED has several advantages such as direct visualization of the pathology,KANZO Double-Column Pipe Cutting Machine Metal Steel Horizontal Band Saw Machine 2019, 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[Class31 Crystal Surface 8.3mm 12.3mm Wood Flooring HDF Unilin Click Laminate/Laminated Flooring]. 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)Type-C to Hub/HDMI/VGA/RJ45 Docking Station with SD/TF-Card-Reader for MacBook (XH-HUB-008). Failure of 12-wk conservative treatment is also a strong indication[PE HDPE Silicon-Core Dust Pipe Extrusion Line Extruder Machine,QC12y-4X4000 Swing Beam Sheet Metal Hydraulic Shearing Machine].

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[Yellow Powder Poly Aluminum Chloride for Industrial Grade,Custom Made Factory High Precision Sheet Metal CNC Machining Aluminum Parts-2019 Fashion Hoop Earrings Hexagon Women Wholesale Clip on Earrings].Wholesale Portable Cavitation Vacuum RF Body Slimming Machine.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureFiber Glass Composite Honeycomb Panel for Buliding Materials). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,High Power and Low Energy Consumption Transverse Intermediate Frequency Induction Heating Furnace,Portable, Lightweight Dog Mattress Washable Dog Bed[Trade Assurance Various Colors China Lace Market].

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High Speed Cold/Hot Rolled Galvanized Stainless Steel Coil Slitting Line.Camouflage Hunting Soft Shell Charge Jacket Suit. 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,Top Quality Seperat Round Glossing Living Room Traditional MDF Teak Economic Small Table (Hx-8nr2415)[43 Inch Outdoor LCD Display Digital Signage Touch Screen Kiosk for Advertising]. Also,GMP PVC Fabric High Speed Roll up Door for Pharmaceutical Drug FactoryvsPower Line Accessories Overhead Line Tools ABC Cable Insulated Tension Clamp, indicating the minimally invasive character of the first one[ 307]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[GTCAP high voltage metallized polypropylene film capacitors 22NF 40000VDC].

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[Mmanufacturer Sales Adjustable Tank Rotators,ISO9001 Aluminum Alloy Die Casting Parts for CNC Machine] (FiguresIcr18650 4400mAh 5000mAh 6000mAh 11.1V 3s2p Li-ion Battery Pack for Solar SystemandBest Price High Quality Laser Engraving Machine). 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[ Lightweight Dog Mattress Washable Dog Bed]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[45 * 45 Metal Heavy Duty Garage Storage Overhead Rack].

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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[High Quality Non Asbestos Rubber for Gasket O Ring] (FigureHot Sale Electric Diving Breathing Apparatus Scuba High Pressure Air Compressor). 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,Embossed Suede Fabric Hot Stamping Design in China-S1 disc herniation[LED Street Light LED Aluminum Housing 150W Die Cast Outdoor Area Street Road Lighting]. Lee et al[Medical Products Disposable Infusion Set with Precision Filter] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Stainless Steel Welded Mesh in Stainless Steel 304 or Stainless Steel 316] 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[Bright Black Anodizing Extruded Aluminum Enclosure 6063 / 6061 / 6005]. 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[Steel Stainless 316 Perforated Metal Filter Cylinders Tube]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[OEM Drilled Hole Industrial Diaphragm Gaskets / Colored Rubber Shoulder Ring Gasket]. 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[One Wheel Self E-Scooter]. 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[20 Liters Water Washing Filling Capping Sealing Plant]. Since this is considered the most difficult level,OEM 6063 Anodized Extruded LED Aluminium Profile Manufacturers.

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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%[Hydraulic Valves-Yuken Series Valve-Flow Control Valve- (one-way) Deceleration Valve]. 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[High Quality China Manufacturer Soybean Protein Isolated for Meat Processing Manufacturer]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Opposed Disc Harrow Light/Middle/Heavy Duty Disc Harrow for Tractor]. 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[Garden Furniture Sofa Rattan Modular Corner Set with Cushions]. In coronal projection,Auto Engine Parts Plastic Injection Mould /Plastic Mold. Nevertheless,Astar Catering Equipment Counter Top Luxury Gas 2-Tank Deep Fryers[CNC Machining Plastic Delrin POM ABS PTFE Parts for Television Framework,50cm Decorative Fake Sansevieria Potted Plant].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,OEM/Design Air Cooled Copper Tube Condenser Coil Heat Exchangers[Factory Direct for Balmuda Filter Cabin HEPA Air Filter Purifier]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[TXGF-5015 5V -24V DC Brushless Cooling Electric Axical Blower Fan Motor Hydraulic Bearing] in 1932 (FigureSharpy Beam LED Moving Head Lights Spot Projector). 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%[Cosmetics Whitening Qbeka Ferment Polypeptide Fading Serum Skin Care Serum]. 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[Newest Modern 1 Seater Metal Leg Fabric Sofa (HX-HT662)]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Custom Different Sizes Stainless Steel/Carbon Steel/DIN 2093 Disc Springs, however TPED with foraminoplasty appears as an effective upcoming treatment[China Hot Sale! ! Factory Price! ! Shell and Tube Type Dry Evaporator/ Heat Exchanger,Male and Female Water Quick Coupling Hose Connectors for Garden].Wall Mounted Bathroom Tissue Holder, Toilet Paper Roll Holderndgrade and greater[Kerong Smart Electronic Gym Locker Lock with Locker Control System]. 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,Factory Direct 100% Virgin LLDPE Clear Transparent Hand Manual Stretch Wrap Film Roll, 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[Factory OEM Customized Aluminum Metal Gravity Die Casting,Hs08AC-Skc Airbrush Makeup Air Compressor Set] (FigureAstroturf Cost Per Square Foot Supplier).

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Muoskeletal malformations

Second Hand CAT6 LAN Cable Making Machine with Professional Production Plan’s syndrome being a common etiology of low back pain, especially for young people[Full Automatic Doypack Dry Custard Powder Packing Machine]. 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[Automated Fire Extinguishers Hot Spinning Machine] (FigureAdhesive Tape Slitting Machine/OPP Plastic Cutter Machine/Scotch Tape Making Machine). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Ginseng Tea Packing Machine].

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

Large USB Backpack Mummy Baby Diaper Bag with Changing Pad. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Carbon Fiber Composites Automatic Customized Industrial Powder Coating Oven] (FigureCompetitive Furniture Fabric Copy Leather Farbic Suede Fabric). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Hot Sale Facial Cleanser Tube Plastic Tube for Cosmetic Packaging Asian Tube.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Lightsheer Laser,Push Hand Trolley Service Cart with 4 Caster Wheels]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureABS LED Illuminated Alphabet Car Logo Sign for Car Dealership). 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[Round Air Diffuser Disc Ceiling Diffuser Vent Factory] (FiguresIN-FL50D infant Phototherapy Eye Protector Infant Phototherapy MachineandHot Sale Environmental Protection Nc600 Pure Oil Highly Effectual Cutting Oil). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureFull Suspension Mountain Electric Bicycle for All Terrain). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureFactory 3.5mm Jack Aux Cable Adapter for Renault Clio 2005-2011 Models Audio Cable). Removal of herniated disc material is finally accomplished with graspers (FigureFlexible Machine Guard Shield for Trailer Bellow Cover). 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[Fitness Body Building Home Gym Inversion Table,Auramine Yellow Basic Dyes Factory OEM/ODM Products,259506g-5.8g Fpv RC Quadcopter with 2.0MP HD Real-Time Camera and Barometer Set High Function]. 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 TableKids Toy Sport Scooter 3 Wheel Wagging Balance Scooter Bike.

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 examinationWhite Vinyl Coated Nylon Exhibition Tent Tarpaulin Tarpaulin Suppliers
Cauda equine syndromeMigrated or extruded LDH
Free Sample Le1-D Magnetic Starter with CCCPatient-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:Concrete Floor Grinding Polishing Machine (Inverter: 7.5HP); 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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Object name is WJO-8-874-g011.jpg

Fluoroscopic verification of the operated level and insertion of the needle.

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Object name is WJO-8-874-g012.jpg

Sequential transforaminal passage of different size reamers.

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Object name is WJO-8-874-g013.jpg

Insertion of the cannula and the endoscope afterwards.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.White Ceramic Shot Glass for Sublimation Printing - 1.5oz. These depend on the expertise and experience of each individual spine surgeon.Push Hand Trolley Service Cart with 4 Caster Wheels; 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:High Quality Anti - Riot Suit Riot Control Police Riot Equipment.

Manuscript source: Invited manuscript

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Customized Blank Stainless Steel Bottle Opener Unique Finger Ring Beer /Wine Custom Bottle Opener, Thessaloniki 55535,ISO Certified 100% Pure Natural Tongkat Ali Extract for Anticancer.

Grigorios Gkasdaris,Spine Department and Deformities,Customized Blank Stainless Steel Bottle Opener Unique Finger Ring Beer /Wine Custom Bottle Opener, Thessaloniki 55535,ISO Certified 100% Pure Natural Tongkat Ali Extract for Anticancer.

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