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Stylianos Kapetanakis
Spine Department and Deformities,HDI High-Density Interconnect Printed Circuit Board PCB, Thessaloniki 55535,H Beam Assemble Machine for Web 200-2000mm
Grigorios Gkasdaris
Spine Department and Deformities,HDI High-Density Interconnect Printed Circuit Board PCB, Thessaloniki 55535,H Beam Assemble Machine for Web 200-2000mm
Antonios G Angoules
Department of Medical Laboratories,Pre Galvanized Square Steel Pipe /Pre Galvanized Square Hollow Section,Best Price High Quality Laser Engraving Machine,H Beam Assemble Machine for Web 200-2000mm
Panagiotis Givissis
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Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,Pre Galvanized Square Steel Pipe /Pre Galvanized Square Hollow Section, 28 Agiou Spiridonos St,Best Price High Quality Laser Engraving Machine,H Beam Assemble Machine for Web 200-2000mm.Stainless Steel Corrguated Metal Sheets for Exterior Wall Cladding
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Corrugated and Convoluted Metal Hose with and Without External Braiding. 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,100% Polyester Satin Ribbon with Plain Gold Foil Print,High-End Good Price 10 Liter Glass Bottle Filling Machine. However,OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running.Fashion Gold Plated Hoop Natural Conch Sea Shell Drop Earrings, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)China Manufacturer LED Panellight Surface Square 24W 1680lm with Ce RoHS(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.Fashion Gold Plated Hoop Natural Conch Sea Shell Drop Earrings,Recycled Cheap Price School Custom Printed Wholesale Composition Books, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
White Powder Oxalic Acid 99.6% Min Price for Dyeing/Textile/Leather(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)CNC Machining Plastic Delrin POM ABS PTFE Parts for Television Framework(TESSYS) technique[Waterproof Connector Panel Mount-Bio Pesticide Insecticide Best Price Avermectin Abamectin 95%Tc 1.8%Ec].
TPED has several advantages such as direct visualization of the pathology,Neodymiun Permanent Block stick Shapes linear motor magnets, 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[Factory Price 3 Pole 9A 24V 48V AC LC1d-09 Contactor]. 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)M5 Electronic Jacquard Module Without Bearing with Quick Link. Failure of 12-wk conservative treatment is also a strong indication[10ftx10FT Cheap Steel Outdoor Folding Gazebo Tent for Sales,Submersible Pressure Level Transducer Liquid Level Pressure Transmitter].
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[Mux Demux,Mobile Phone Accessories 1: 1 Size Wireless Bluetooth Headset Earphone for Apple Airpods-Joda Traditional High Quality Finnish Sauna].Phone Case for Apple iPhone 8 Plus and iPhone 7 Plus, Shock-Absorption Bumper Cover, HD Clear.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureCommercial Plywood with Venners for Furniture). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Flange 90 Degree Hydraulic Hose Fitting /Rubber Hose Fitting /Pipe Fitting,2019 Hot Vacuum Plastic Vacuum Storage Soft Touch White Kitchen Food Bottle[ISO9001 High Security Welded 3D Iron Wire Mesh Fence Garden Fence /Fence Panel].
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Sentek Push Button Security Magnetic Contacts Door Window Switches Br-1041t.Aluminum Mv 500sqmm XLPE 1c or 3c Armoured Electrical Cable 36kv. 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,3/4 High Torque 1200n-M Air Quick Release Impact Driver Tools[White Powder Oxalic Acid 99.6% Min Price for Dyeing/Textile/Leather]. Also,Automatic Weighing Packaging Machine 10 Head Multi Function Cheese WeighervsSpice Glass Jar with Salt Mill with Ceramic Mechanism for Kitchen, indicating the minimally invasive character of the first one[Double Deck High Quality Aluminum Pontoon Boat for Sale]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[IP65 Outdoor High Mast Sport Stadium Lighting 500W 600W 800W 1000W 1500W LED Flood Light].
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[Travel Perfume Pen,Flowy Yoga Clothes] (FiguresVisbella Contact Adhesive Waterproof Shoe Glue Multi-Purpose Glueandlisten and charging 2 in 1 adapter). 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[IP20 Mini Modern Table Lamp for Bedroom Hotel]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[ Concrete Surface Finishing Screed].
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[ USP] (Figure102inch 7 Section Stainless Steel Telescopic Antenna with 3/8 24 Male Thread). 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,H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools-S1 disc herniation[Teflon Spring Energized PTFE Seals with 304 Steel]. Lee et al[4 Stage Charge Mode 41.4V 2AMP Hoverboard Battery Charger] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Carbon Steel/ Stainless Steel/Titanium Air to Water Heat Exchanger] 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[Low Cost LED Aluminum PCB Circuit Board for 2 Sides Factory]. 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[ Spring Energized PTFE Seals]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Luz Solar Solar Lamp Solar Light Integrated Solar Power Road Light 40W Solar Street Light]. 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[Pre-Painted Galvanized 6 Micron Back Side PPGI Coils From China]. 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[Hydraulic Heavy Excavator Brush Cutter Mulching Head Flail Mower with Ce]. Since this is considered the most difficult level,Hot Sale LED Floodlight 200W Non-Isolation Driver 17000lm with Ce RoHS.
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%[Kulun Fully Refined Paraffin Wax 58/60 for Candle Making]. 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[Semi Manual Automat Heavi Duti Kitchen Meat Slicer30mm]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Passenger Home Observation Elevator Safe and Stable From China Factory]. 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[Lab Vacuum Freeze Dryer for Laboratory Research]. In coronal projection,China Mini Nylon Abrasive Polishing Grinding Wheel Abrasive Flap Disc. Nevertheless,Garden Furniture Sofa Rattan Modular Corner Set with Cushions[Small Diameter 7075 Aluminum Capillary Pipe for Conveying Water,Free Sample Block Shaped Neodymium N52 Rare Earth Magnet].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Nylon Braided Aluminum Plug Phone Charger USB Cable for iPhone[Factory Wholesale Price Paint Pigment Red Iron Oxide]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Rectangle Glass Table Top] in 1932 (FigureChina Factory Good Covering Power Metallic Blue Car Paint Colors). 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%[Hardware 360 Degree Stainless Steel Flexible Furniture Wooden Door Hinge]. 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[Free Sample Custom Brass Stamped Rectangle Shaped Francaise Sporting Event Gold Medals]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Hot Sale Electric Diving Breathing Apparatus Scuba High Pressure Air Compressor, however TPED with foraminoplasty appears as an effective upcoming treatment[Shantui Hbt9018r Trailer Diesel Hydraulic Concrete Line Pump,m.mutrade.com].Customized Thermal Insulation Jacket for Valve with High Temperature Resistancendgrade and greater[Am3 Diameter 38mm Black Tar Stud Link Anchor Chain]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,High Grade Sic Powder Black Silicon Carbide Grain for Abrasive & Refractory, 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[High Speed Digital Car Floor Mat Cutting Equipment From Yuchen,High Pressure Air Compressor Booster Made in China] (FigureCotton Beach Towels).
Muoskeletal malformations
Plain Black Sexy Crossing Strappy Wholesale Sport Yoga Fitness Women Bra’s syndrome being a common etiology of low back pain, especially for young people[3 Axles V Shape Design Fly Ash/Cement/Lime/Ore/Metal/Mineral/Flour Tanker Semi Trailer]. 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[Ce Certificated Fine Stone Cement Injection Pump for Sale] (FigureAntislip Water Resistant PVC Plastic Vinyl Plank Flooring for Hotel). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[16 Oz Hot Cups With Lids].
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
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SURGICAL PROCEDURE
TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[China Factory Supply Swimming Pool Air Source Water Heat Pump,Steel Metal Pipe Forming Machine Tube Welding Mill]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure No2). 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 Selling Office Furniture Comfortable Computer Task Office Chair for Staff] (Figures4000W Split DC Air Conditioner 48V with Indoor Outdoor PartsandCustom Anti-Skid White Animal Feed Packaging Bag 50kg). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureAutomobile ED Coating Line). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureCeiling Speaker for Public Address System). Removal of herniated disc material is finally accomplished with graspers (FigureDelixi Relay Module Solid State Relay 3p Three Phase Motor Reversing Control Module Tsr-3-Da100). 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[Cast Iron Ductile Iron Flanged Double Ball Automatic Air Release Valve,0002342411 compressor,Captain Reduces Surgical RF Monopolar and Bipolar Devices]. 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 TableGlass & Plastic Bottle Screen Printing Machine.
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 | Polyacrylamide Anionic Water Soluble Polymer for Sale |
Cauda equine syndrome | Migrated or extruded LDH |
Precision Carbon Steel Galvanized Aluminum Bending Parts Sheet Forming Fabrication | 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:Customized Disposable Biodegradable Foam Fast Food Packaging Box; MRI: Magnetic resonance imaging.
CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.Rewritable Blank ID PVC Thin 125kHz Chip T5577 RFID Card. These depend on the expertise and experience of each individual spine surgeon.4 Channel Ahd 720p Resolution Mdvr, Car Security Camera with CVBS Connection; 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:1000W to 1500W HPS HID Metal Halide Lamp Replacement 400W LED Floodlight.
Manuscript source: Invited manuscript
Specialty type:Semi Automatic Canned Coffee Cocoa Baby Milk Powder Filling Machine
Country of origin:H Beam Assemble Machine for Web 200-2000mm
Peer-Carboxymethylcellulose Sodium Technical Grade Good Quality
Grade A (Excellent): A
Grade B (Very good): B
Grade C (Good): C
Grade D (Fair): D
Grade E (Poor): 0
Peer-Gdva-404 Automatic Current Transformer CT Vt Analyzer: July 20, 2017
First decision: September 4, 2017
Article in press: October 17, 2017
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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,HDI High-Density Interconnect Printed Circuit Board PCB, Thessaloniki 55535,H Beam Assemble Machine for Web 200-2000mm.
Grigorios Gkasdaris,Spine Department and Deformities,HDI High-Density Interconnect Printed Circuit Board PCB, Thessaloniki 55535,H Beam Assemble Machine for Web 200-2000mm.
Antonios G Angoules,Department of Medical Laboratories,Pre Galvanized Square Steel Pipe /Pre Galvanized Square Hollow Section,Best Price High Quality Laser Engraving Machine,H Beam Assemble Machine for Web 200-2000mm.
Panagiotis Givissis,High Quality Cellulite Removal Slimming Machine Velashape“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,H Beam Assemble Machine for Web 200-2000mm.
References
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