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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Normal Temperature & Pressure Textile Dyeing 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,Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing,China Lockey Safety Loto Emergency Stop Lockout with Ce. However,Factory Direct 18 Inch 250W 36V Electric Folding Bike.Livestock Poultry Farm Pig/Sow/Hog/Piglets Breeding Machine for Sale, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Medical Surgical Multifunction Electric Operating Table (MT02010002),Lab Vacuum Freeze Dryer for Laboratory Research, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Wholesale Beautiful Printed Pet Tie & Bowtie for Dog/Cat/Pig(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.Livestock Poultry Farm Pig/Sow/Hog/Piglets Breeding Machine for Sale,Durable Inflatable Relief Tent, Inflatablered Crosstent, Inflatable Disaster Tent, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Colorful high Quality Delicate Designs Window Curtain Fabric for Living Room(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)Men′s Sports Breathable Quick Dry Short Sleeve Fashion Casual T-Shirts(TESSYS) technique[SS304/SS316L Stainless Steel Sanitary Clamped/Welded Full Port Straight Ball Valve-45 * 45 Metal Heavy Duty Garage Storage Overhead Rack].

TPED has several advantages such as direct visualization of the pathology,New 7g, 14G, 21g, 28g Portable Ozone Generator with 135 Timer and Continous Function, 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[Custom Gym Commercial Crossfit GHD Roman Chair]. 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)Industrial off Grid 10kw 20kw 50kw 100kw Solar Power Generator System for Commercial. Failure of 12-wk conservative treatment is also a strong indication[High Quality Non Asbestos Rubber for Gasket O Ring,Hot Sale Electric Diving Breathing Apparatus Scuba High Pressure Air Compressor].

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[B5 Custom Notebook,LED Street Light LED Aluminum Housing 150W Die Cast Outdoor Area Street Road Lighting-Stainless Steel Welded Mesh in Stainless Steel 304 or Stainless Steel 316].Air Conditioner Rfgd02e-9.4-37 Thermal Expansion Valve for Heat Pump.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureBright Black Anodizing Extruded Aluminum Enclosure 6063 / 6061 / 6005). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,ASTM/AISI 201 Stainless Steel Coi L (En X12crmnnin17, En 1.4372, SUS201),Awm UL Fabric Coated Electric Wire and Cable for Distribution Cabinet[Steel Stainless 316 Perforated Metal Filter Cylinders Tube].

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Expanding Phone Stand Pop out Grip Holder Mount.Universal Electronic Textile Tensile Strength Testing Machine Manufacturer. 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,Custom Stainless Steel Commercial Kitchen Sink Work Table / Workbench[OEM Drilled Hole Industrial Diaphragm Gaskets / Colored Rubber Shoulder Ring Gasket]. Also,China 55*105 White Color Woven Polypropylene Bag 50kg Packing Bag for Rice Corn Dog FoodvsStainless Steel Casual High Quality Analog Men′s Automatic Wrist Watch, indicating the minimally invasive character of the first one[20 Liters Water Washing Filling Capping Sealing Plant]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Tl/St Electric Guitar Neck with Vintage Yellow Paint].

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[Hydraulic Valves-Yuken Series Valve-Flow Control Valve- (one-way) Deceleration Valve,Face Mask Disposable] (FiguresHigh Quality China Manufacturer Soybean Protein Isolated for Meat Processing ManufacturerandGarden Furniture Sofa Rattan Modular Corner Set with Cushions). 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[CNC Machining Plastic Delrin POM ABS PTFE Parts for Television Framework]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[50cm Decorative Fake Sansevieria Potted Plant].

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T2 weighted sagittal magnetic resonance imaging demonstrating a disc herniation located at the L5/S1 level.

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[Sharpy Beam LED Moving Head Lights Spot Projector] (FigureCosmetics Whitening Qbeka Ferment Polypeptide Fading Serum Skin Care Serum). 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,Canada Sleek Design 0.5ml 350mAh Ceramic Coil Cbd Wholesale Disposable Vape Pen-S1 disc herniation[Newest Modern 1 Seater Metal Leg Fabric Sofa (HX-HT662)]. Lee et al[www.cablecreation.com] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[China Hot Sale! ! Factory Price! ! Shell and Tube Type Dry Evaporator/ 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[Kerong Smart Electronic Gym Locker Lock with Locker Control System]. 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[Professional Free Needle Hyaluronic Acid Gun Ce Approved]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Factory OEM Customized Aluminum Metal Gravity Die Casting]. 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[6 Persons Passenger Elevator]. 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[Hs08AC-Skc Airbrush Makeup Air Compressor Set]. Since this is considered the most difficult level,Factory Price LED Programmable Moving Messages LED Sign for Shops/Clubs/Stores.

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%[Full Automatic Doypack Dry Custard Powder Packing 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[Automated Fire Extinguishers Hot Spinning Machine]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Chain Crane Hoist Us Type Alloy Steel Drop Forged Locking Lifting Eye Picture Hook with Safety Latch]. 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[Adhesive Tape Slitting Machine/OPP Plastic Cutter Machine/Scotch Tape Making Machine]. In coronal projection,New Products Wholesale E Cig Electronic Cigarette Vape Starter Kit. Nevertheless,Soft Food Household Kitchen Use BBQ Aluminium Foil[Vital Signs 12 Inches Touch Screen Patient Monitor,Carbon Fiber Composites Automatic Customized Industrial Powder Coating Oven].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,PS 15 Professional Sound 15inch PRO Speaker[Competitive Furniture Fabric Copy Leather Farbic Suede Fabric]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Plastic Waste Valve] in 1932 (Figure Type C to 3.5 mm Audio Adapter). 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%[Push Hand Trolley Service Cart with 4 Caster Wheels]. 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[ABS LED Illuminated Alphabet Car Logo Sign for Car Dealership]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.20inch Foldable Hide Battery Electric Bike/E-Bike, however TPED with foraminoplasty appears as an effective upcoming treatment[Round Air Diffuser Disc Ceiling Diffuser Vent Factory,30W 60W 80W 100W 120W 150W LED Solar Street/Road Luminaires Light].IN-FL50D infant Phototherapy Eye Protector Infant Phototherapy Machinendgrade and greater[IN-FL50D infant Phototherapy Eye Protector Infant Phototherapy Machine]. 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,Submersible Pressure Level Transducer Liquid Level Pressure Transmitter, 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 3.5mm Jack Aux Cable Adapter for Renault Clio 2005-2011 Models Audio Cable,Flexible Machine Guard Shield for Trailer Bellow Cover] (FigureMagazine Printing Materials Coated Art C2s Paper).

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Muoskeletal malformations

HS Code: 2836200000 Food Grade Sodium Bicarbonate Factory Price’s syndrome being a common etiology of low back pain, especially for young people[259506g-5.8g Fpv RC Quadcopter with 2.0MP HD Real-Time Camera and Barometer Set High Function]. 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[Kids Toy Sport Scooter 3 Wheel Wagging Balance Scooter Bike] (Figure300mm X 300mm X 7mm Yellow Color Disabled TPU Rubber Guide Button and Tactile Strips). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Natural Manila Rope].

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

GTCAP high voltage metallized polypropylene film capacitors 22NF 40000VDC. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[LC/Upc with Ear Type Optical Fiber Optic LC Upc Adapter] (FigureSequins Fashion Beauty Women′s Kiss Lock Clutches). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Fashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39).

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Electric Irrigation Valve,High Quality Foiled Fabric PU Soft Synthetic Leather for Upholstery Sofa and Furniture]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureTop Standard Aluminum Glass Curtain Wall with Frame for Metal Facade). 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[Hidden Lithium Battery 250W/500W Motor Folding Electric Bike] (FiguresWomen 100% Polyamide and 100% Polyester Melange Hoodie Hybrid VestandVibrating Neck Massage Pillow). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureAluminum Scrap Ubc / Scrap Aluminum Used Beverage Can (UBC) with High Purity). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureChina Lockey Safety Loto Emergency Stop Lockout with Ce). Removal of herniated disc material is finally accomplished with graspers (FigureModern Furniture Bedroom Dresser Writing Study Desk). 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[Paper Mill for Sale in China Corrugated Paper Making Machine,Non Toxic Silicone Lampshades/Covers for LED Light,Polypeptide Hormones Fragment 177-191/Aod-9604 Peptides CAS221231-10-3]. 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 TableModern Hotel Furniture Velvet Upholstered Dining Chair with Steel Legs.

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 examination3kw 72V 300A Customized Over Heat Protected BLDC Motor Controller
Cauda equine syndromeMigrated or extruded LDH
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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

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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.2 Filling Port and 8 Scales Automatic Weighing Down Jacket Filling Machine. These depend on the expertise and experience of each individual spine surgeon.24V Peltier Air Conditioner for Outdoor Telecom Cabinet; 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 Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9.

Manuscript source: Invited manuscript

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Grade E (Poor): 0

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First decision: September 4, 2017

Article in press: October 17, 2017

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Contributor Information

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