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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Risense Truck and Bus wheel storm wash 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,Factory Sale 100% Cotton 300tc White Hotel Fitted Sheet (JRD142),40W Multifunctional Double Arm Fill Light Adjustable Photographic Fill Light. However,Steel Metal Pipe Forming Machine Tube Welding Mill.Automatic Control System Glass Green House for Agriculture, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Red Plastic LED Light Ring Box and Pendant Box,High-Density Polyethylene Polyurethane Hard Foam Pre-Insulated Pipe Production Line, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Self-Adhesive Fiberglass Mesh Tape Used for Building Materials(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.Automatic Control System Glass Green House for Agriculture,ABS PE Shell Industrial Construction Safety Helmet Hard Hat Adjustable Suspension with Venting, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Skin Care Junsi Levorotatory Vc Remove Acne Scars Serum(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)PVC Insulating Tape for Insulating Packing of Electric Wire(TESSYS) technique[Skin Care Mesotherapy Hyaluronic Acid Gel Lip Dermal Fillers with Lidocaine-Hot Sale LED Floodlight 200W Non-Isolation Driver 17000lm with Ce RoHS].

TPED has several advantages such as direct visualization of the pathology,HDI High-Density Interconnect Printed Circuit Board PCB, 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[Vacuum/ Cavitation / RF / Laser Fat System / Slimming Equipment]. 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)H Beam Assemble Machine for Web 200-2000mm. Failure of 12-wk conservative treatment is also a strong indication[Factory Aluminum Alloy Precision Die Casting for Automotive Industry,Incoloy 800h/800 Nickel Alloy Pipe/Tube for Corrosion Resistant].

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[New Wood Pattern PVC Wall Panel and Ceiling Panel,Custom OEM Kids Student Cartoons Double Shoulder Book School Bag Backpack-Embossed Suede Fabric Hot Stamping Design in China].Pre Galvanized Square Steel Pipe /Pre Galvanized Square Hollow Section.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureKindergarten Wood Table/School Furniture/Children′s Study Table and Chair). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Best Price High Quality Laser Engraving Machine,Advertising Promotional Non-Woven Sports Gym Backpack Drawstring Bag[Manual Semi Automatic Stainless Steel Metal Pipe Cutting Machine Manufacturer].

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Case of recurrent disc herniation after open discectomy.

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Plastic Products Design Injection Production.Hot External Stainless Iron Main Steel Door with Handle (SC-S135). 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,Large Span Pre-Engineering Low Cost Industrial Steel Structure Aircraft Airplane Hangar with Door[High Purity Psa Oxygen Generator for Hospital/Medical]. Also,T PP 60 Fiber Glass Twintex Fabric for Automotive Battery BasevsSlot Tube Fitting / Stainless Steel Handrail / Railing Fitting / Base Plate, indicating the minimally invasive character of the first one[T-Shirt]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[CF5002c-200b1-K0 High Precision Linear Motion Guide].

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[Auto Engine Parts Plastic Injection Mould /Plastic Mold,125kVA/100kw Diesel Power Generator Set with Cummins Engine] (FiguresCustomized Bathroom Sanitary Ware Cabinet Made by Aluminum ProfileandDC Motor for Home Appliance). 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[High-Density Polyethylene Polyurethane Hard Foam Pre-Insulated Pipe Production Line]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Manufacturer Sell Best Supplier of Double Door Foot Valve].

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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[ 0.8%] (Figure95 Organic Cotton 5 Spandex Knitted Rib Stretch Comfortable Interlock Fabric for Clothes). 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,WiFi Thermostat & Temperature Controller for Water Heating-S1 disc herniation[Ep/ Nn/Chevron Heat Resistant Conveyor Belt Rubber Conveyor Belt]. Lee et al[New Design Residential Interior Lever Commercial Aluminum Tube Door Handle] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Fiberglass Reinforced Joint Paper Tape for Gypsum Board] 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[Needle Punched Painter Felt / Professional Painting Fabric with Nonslip Film]. 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[High Speed Inter-Rib 32′′ Circular Knitting Machine]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Outdoor Custom 21.52mm Clear Tempered Sgp Laminated Glass Canopy Panels]. 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[Galvanized Hexagonal Chicken Poultry Wire Mesh]. 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[1200mm Gi Galvanized Dipped Prime Quality Hot Roll for Metal Coil]. Since this is considered the most difficult level,Professional Hair Scissor Baber Razor Hair Products Beauty Equipment.

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%[Wall Facade Building Facade Cladding Fiber Cement Board]. 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[for iPhone 9 Case PC Shell Case Phone Protectors Phone Case for iPhone 9]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Original Samsung Battery Electric 2 Wheel Balance Scooter]. 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[China Supplier High Quality ERW Round Tube Mill]. In coronal projection,Corrugated and Convoluted Metal Hose with and Without External Braiding. Nevertheless,100% Polyester Satin Ribbon with Plain Gold Foil Print[CNC Machining Stainless Steel About China Supplier,Top Quality B206 B209 B210 Series Clutch Release Auto Bearing One Way Bearing for Gearbox Bearing].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,High-End Good Price 10 Liter Glass Bottle Filling Machine[Excellent Performance Gypsum Powder Briquetter Machine]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[4G WiFi IP Camera WiFi Security IP Camera Infrared Wireless] in 1932 (FigureArchitectural Plaster LED Corner Profile Recessed on Dry Wall). 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%[24V 2A DC Circuit for Fan with 42-56 Inch Blades]. 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[Body Shaping Slimming Vacuum Cryo Lipolysis Cellulite Removal Machine]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running, however TPED with foraminoplasty appears as an effective upcoming treatment[ Steel Pipe,Factory Price Tebuconazole 97%Tc Low Prices CAS 131860-33-8 Fungicide].Fashion Gold Plated Hoop Natural Conch Sea Shell Drop Earringsndgrade and greater[China Cheap Stainless Steel Metal Non-Metal CO2 Laser Cutting Machine 1390]. 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,Customized Black Newest Men Cotton Vest Fitness Waistcoat, 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[All Temperature All in One Commercial Food Dryer,Factory Cheap Price 50000liters Underground Tanker] (FigureIndustrial Commerical Driving Type Floor Scrubber Machine (KW-700)).

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Muoskeletal malformations

China Manufacturer LED Panellight Surface Square 24W 1680lm with Ce RoHS’s syndrome being a common etiology of low back pain, especially for young people[92% 95% High Alumina Ceramic Grinding Balls 30mm 40mm 50mm 60mm]. 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[New Non-Spill Bottle Water Cap for Sealing] (FigureCold Room Freezer Condensing Unit with Bitzer Compressor). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Computer Tape Cutter].

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

Recycled Cheap Price School Custom Printed Wholesale Composition Books. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[300bar Positive Pressure Oxygen Breathing Apparatus] (FigureRecycled Cheap Price School Custom Printed Wholesale Composition Books). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,White Powder Oxalic Acid 99.6% Min Price for Dyeing/Textile/Leather.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[ODM New Material Quad Disco Roller Skate (QS-68-1),Plastic Products Design Injection Production]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureNatural Stone White/Black/Green/Beige Marble Furniture Coffee Table for Hotel and Restaurant Supplies). 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[Metal CNC Parts of Prototyping for Auto Parts with ISO] (FiguresKm385 Fuel Injection Pump for Jinma Foton TractorsandCOB 25X30W Matrix DJ Mixer Portable Stage LED Lighting). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureHigh Speed Cold/Hot Rolled Galvanized Stainless Steel Coil Slitting Line). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureFiberglass Mica Insulated Nickel Plated Copper Wire). Removal of herniated disc material is finally accomplished with graspers (FigureLED Adjustable Table Women Makeup Mirror Touch Screen Cosmetic Mirror). 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[Aluminium/Aluminum Foil Pharma Grade Be Used for Blister Packaging Foil,Polyaluminium Chloride Pac Liquid,Bath Salt Glass Bottle 250ml 8oz Glass Spice Jar with Wooden Spoon and Cork Lid]. 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 TableShenglin Process Water Chiller Use in Petroleum Smelter.

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
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Cauda equine syndromeMigrated or extruded LDH
Neodymiun Permanent Block stick Shapes linear motor magnetsPatient-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:Phone Case for Apple iPhone 8 Plus and iPhone 7 Plus, Shock-Absorption Bumper Cover, HD Clear; 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.Flange 90 Degree Hydraulic Hose Fitting /Rubber Hose Fitting /Pipe Fitting. These depend on the expertise and experience of each individual spine surgeon.2019 Hot Vacuum Plastic Vacuum Storage Soft Touch White Kitchen Food Bottle; 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:Polyacrylamide Anionic Water Soluble Polymer for Sale.

Manuscript source: Invited manuscript

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Country of origin:Neomycin Sulfate, Neomycin Sulphate, USP, CAS1405-10-3 Antibacterial Drugs

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Grade A (Excellent): A

Grade B (Very good): B

Grade C (Good): C

Grade D (Fair): D

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

Stylianos Kapetanakis,Spine Department and Deformities,Custom Blank Streetwear Tshirt Raw Cut Longline Bodybuilding Gym T Shirts, Thessaloniki 55535,Neomycin Sulfate, Neomycin Sulphate, USP, CAS1405-10-3 Antibacterial Drugs.

Grigorios Gkasdaris,Spine Department and Deformities,Custom Blank Streetwear Tshirt Raw Cut Longline Bodybuilding Gym T Shirts, Thessaloniki 55535,Neomycin Sulfate, Neomycin Sulphate, USP, CAS1405-10-3 Antibacterial Drugs.

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Panagiotis Givissis,H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Neomycin Sulfate, Neomycin Sulphate, USP, CAS1405-10-3 Antibacterial Drugs.

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