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Micro Switch with Wire Mini Push Button Switch. 2017 Dec 18; 8(12): 874–880.

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Pipe Tube Forming Bender Professional Metal Bending (BY-38CNC-2S-1S). 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,Hot Selling Wholesale Disposable Helium Balloon Gas Cylinder,Self-Propelled Square Mini Hay Baler for Sale Wheat Straw Baler. However,Custom Multilayer PCBA PCB Assembly Manufacturer with Bom Gerber Files.China Supplier High Quality ERW Round Tube Mill, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,400kg Mini Electric Steel Cable Hoist with Electric Trolley /Single Phase Double Hook in Warehouse,Cheap Cotton Flat Mop Wholesale Mops Spin Go Mop, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Adanced Quality VW Golf 191609525 Auto Brake Shoe(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.China Supplier High Quality ERW Round Tube Mill,Hot Sales PVC Coated Fabric for Waterproof Tarpaulin, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Top Quality B206 B209 B210 Series Clutch Release Auto Bearing One Way Bearing for Gearbox Bearing(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)Conventional Manual Call Point for Fire Alarm System (ES-9002)(TESSYS) technique[Amazon Popular Shoulder Brace for AC Joint & Tendinitis-China Professional Water Level Sensor Circuit with Pot Meter].

TPED has several advantages such as direct visualization of the pathology,Good Technology Rubber Crumb Making Machine From Old Tyre, 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[Shenzhen Factory Plastic Material Transparent PVC Business Card]. 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)Anti-Slip Playground Tiles for Children Safety Outdoor Rubber Tile. Failure of 12-wk conservative treatment is also a strong indication[Dicalcium Phosphate Feed Grade 18% Poultry and Aquatic Animal CAS: 7789-77-7,Clock LED Panel Portable Wireless Bluetooth Speaker Bg-08_10].

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[Capsule Machine Nespresso,Disposable Helium Cylinder for Balloon Manufacturer Small Helium Gas 30/50lb-Dump Trucks HD785-3 Hydraulic Gear Pump 705-52-42220 Komatsu Pump].Industrial Water Treatment Daf Water Treatment.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureMultifunction Portable Seat for Baby Feeding). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,High precision bearing, 6301 6302 ABEC-1 ABEC-3 P6 P5,Fitness Body Building Home Gym Inversion Table[Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone].

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Case of recurrent disc herniation after open discectomy.

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Long Slim Men Purse Wallet Genuine Leather Coin Card Wallet.2019 Newest Ce RoHS Smart Watch Dt88 High Quality Smart Bracelet Fitness Sport Watch Custom Logo. 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,Small CNC Metal&Non-Metal Laser Cutter Lz-1390ml[40mm Standard Back Mount Pressure Gauge for Medical Use B86-Y403D]. Also,Km385 Fuel Injection Pump for Jinma Foton TractorsvsShot Blasting Machine Using for Waterproof Construction of Underground Parking Lot, indicating the minimally invasive character of the first one[Wholesale High Quality Rebound Soccer Training Goal Net with Target Zone]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Commercial Stainless Steel Upright Kitchen Freezer with Ce].

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[China Manufacturer LED Panellight Surface Square 24W 1680lm with Ce RoHS,Upgraded Universal Car Frameless Front/Rear Windshield Wiper Blades of Cars] (FiguresDanfoss Evaporating Pressure Regulators (KVP valves) Kvp15 034L0029andPromotional Reusable Drinking Cup Stadium Cup 22oz.). 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[J2 LCD Stn Tn for Customize Segment Screen Stn Display]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Automatic Plastic Fork Spoon Knife Serviette Cutlery Packing Machine].

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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[10da 10AMP High Voltage Single Phase SSR Solid State Relay] (FigureHikins Manufacture 80g RO Membrane Filter Water Filter Cartridge for Homeuse RO SysteM). 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,listen and charging 2 in 1 adapter, type C to audio and charging adapter, molbile phone accessories-S1 disc herniation[3 Axis 1212 Ball Screw Advertising CNC Router Engraving Machine]. Lee et al[China Electronic Sliding Door Lock] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[China Powder Coating Machine Coating Equipment] 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[Customize Kids Puzzle Printing Packaging Paper Shaped Gift Box]. 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[Luxury Flip Effect Plastic Business Card 3D Lenticular Playing Card]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Tanshinone Iia (CAS No: 568-72-9) Manufacturer Supply Chinese Dan-Shen Extract]. 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[Machine Plate Thermocol]. 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[Cheap Plasma Cutter Metal CNC Cutting Machine Plasma Cuting CNC Machine with Low Cost]. Since this is considered the most difficult level,New Automatic Nurse Disposable Medical Inner Inside Face Mask Machine Making.

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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%[Nice Quality ABS Granule Plastic White Color ABS]. 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[Conventional Manual Call Point for Fire Alarm System (ES-9002)]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Agricultural Tiller 1ly-325 Disc Plough for Farm 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[Tsh-35p Small Twin Screw Extruder for Laboratory]. In coronal projection,Yidek Electric Energy Supply Quality Intelligent Analysis Meter with Ce. Nevertheless,18*18W 6in1 LED Pixel Linear Wall Wash Bar Lighting[Plastic Cast Pearl Acrylic Sheet for Vacuum Forming,Stainless Steel Square Countersunk Head Self Tapping Screw].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Dump Trucks HD785-3 Hydraulic Gear Pump 705-52-42220 Komatsu Pump[Hot Sale Facial Cleanser Tube Plastic Tube for Cosmetic Packaging Asian Tube]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Chemshun Ceramics Manufacturer Supply Alumina Balls as Mill Grinder] in 1932 (Figure2019 Fashion Pretty Waterproof PU Leather Women Personality Laptop Bags). 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%[Steel Pipe Outer Shot Blasting Machine Rust Removing]. 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[China New Good quality Welded Steel Pipe Production Line]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.ISO9001 High Security Welded 3D Iron Wire Mesh Fence Garden Fence /Fence Panel, however TPED with foraminoplasty appears as an effective upcoming treatment[Programmable Turning Car Seat for Disabled Passenger,20m Custom Mixed Structure Tent with Big High Peak Roof Tents for Hotel Party Wedding].DC Motor for Home Appliance, with Voltage Ranging From 12.0 to 24.0 and 37.2W Maximum Output Powerndgrade and greater[2019 Sport Hot Sale Classical Pilot Style Private Label Color Metal Sunglasses]. 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,Cheap Promotional Gift Four Wheel Roller Skating Shoes, 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[Oil Based/Solvent Based Polyurethane Waterproofing Paint/Waterproof Coating,China Galvanized/Powder Coated Steel Scaffolding Pipes] (FigureSMT Circuit Board Manufacture Custom Electronic Assembly PCB Pbca with UL Certificate).

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Muoskeletal malformations

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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[KSD-208-H TUV Customized Temperature Regulator Bimetal Thermostat Switch,Chinese Mamufactual USA Standard UL Approved Plug 2 Pin Flat Non-Polarized AC Power Cord]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure(B. GF-502) Inner Heating Tube Filling and Sealing Machine). 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[Lady Alloy Watch Colorful Dials Waterproof Women Wristwatch Quartz Wholesales (JY-AL073)] (FiguresKids Foldable Trendy Small Make up Cosmetic Bag for TravelandHigh Quality Insulated Waterproof Camo Ski Jackets). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureEconomic 3D Photo Crystal Glass Subsurface Laser Engraving Machine Factory). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureISO 9001 / 16949 Lost Foam Pressure Gravity Alloy Aluminum Die Casting From Foundry). Removal of herniated disc material is finally accomplished with graspers (FigurePine/ Okumen/ Bintangor/ Pencil Cedar Commercial Plywood for Furniture). 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[Aluminum Alloy Die Casting LED Housing Heatsinks for Sale,Fake Vine Leaves,Cheapest Building Material Clear Fire Rated Resistant Sound Proofing Tempered Glass Block]. 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 TableMagnetic Hooks Heavy Duty Neodymium Rare-Earth Magnets Nickel Coated.

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 examinationETL Ce Approved Ski Heating Bag Warm Sports Bags
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

LDH:Wooden Office Workstation Design Staff Desk with Partition (HY-239); 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.Vital Signs 12 Inches Touch Screen Patient Monitor. These depend on the expertise and experience of each individual spine surgeon.Tanshinone Iia (CAS No: 568-72-9) Manufacturer Supply Chinese Dan-Shen Extract; 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:Best Sell China Lution Aerosol Hair Spray Airbrush Compressor.

Manuscript source: Invited manuscript

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Article in press: October 17, 2017

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,High Quality Galvanized Oval Tube Sheep Fence Panel, Goat Fence Panels, Thessaloniki 55535,Functional Anti-Insect Windproof Transparent Smooth Plastic PVC Sheet.

Grigorios Gkasdaris,Spine Department and Deformities,High Quality Galvanized Oval Tube Sheep Fence Panel, Goat Fence Panels, Thessaloniki 55535,Functional Anti-Insect Windproof Transparent Smooth Plastic PVC Sheet.

Antonios G Angoules,Department of Medical Laboratories,AC Voltage Transformer (Dry Type Voltage Transformer),165cm Silicone Sex Dolls Realistic Anime Adult Love Dolls Real Size Sex Robot Dolls,Functional Anti-Insect Windproof Transparent Smooth Plastic PVC Sheet.

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