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Transforaminal Percutaneous Endoscopic Discectomy (TPED)Incoloy 800h/800 Nickel Alloy Pipe/Tube for Corrosion Resistant. 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,China Professional Water Level Sensor Circuit with Pot Meter,54n16L TIG Welding Torch Long Alumina Ceramic Nozzle. However,Outdoor Custom 21.52mm Clear Tempered Sgp Laminated Glass Canopy Panels.Stone Balustrade Cutting Machine with Multi Blades (DYF600), pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Automatic Frameless Glass Door Top Patch Fitting,New Generation Front Service Outdoor P3.9 500X500 Rental LED Display for Events (LO3.9), Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Vertical Shampoo/Honey/Sauce/Paste Small Liquid Sachet/Pouch Packing Machine(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.Stone Balustrade Cutting Machine with Multi Blades (DYF600),99.999% Carbon Tetrafluoride Tetrafluoromethane R14 Refrigerant CF4 Gas CF4, so as to eliminate possible risks and thus improve outcomes.


Super Clear Waterproof BOPP Packing Self Adhesive Tape(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)Glass Shower with Stainless Steel Hardware(TESSYS) technique[High Gloss 220g Solvent Inkjet Printing Photo Paper-Quilted Diaper Bag Custom Mummy Backpack].

TPED has several advantages such as direct visualization of the pathology,60W LED Solar Powered Street Lighting for Outdoor Lighting (DZS-003), 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[ Pharmaceutical Ingredient]. 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.


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)Free Standing Commercial Scent Diffuser Aroma Diffuser for Hotel Lobby. Failure of 12-wk conservative treatment is also a strong indication[40 A Grade Panel FHD DVB-T Dled TV Hot Sell in Middle East Europe Asia,Factory Price 310 Stainless Steel Coil/Sheet High Quality with Reasonable Price!].

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[Circuit Board Assembly,Popular Low E Reflective Glass for Building Curtain Wall-Anti-Slip Playground Tiles for Children Safety Outdoor Rubber Tile].Fig Leaf Extract, Olive Leaf Extract, Bilberry Leaf Extract.


Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureStainless Steel Casual High Quality Analog Men′s Automatic Wrist Watch). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Ce Approved Automatic Syringe Pump with Double Channel,Detergent/Paint Making Machines Stainless Steel Paint Mixer Machine Price[Sentek Push Button Security Magnetic Contacts Door Window Switches Br-1041t].

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Case of recurrent disc herniation after open discectomy.

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Mango Energy 12kw/18kw/22kw High Efficiency Hot Water Heat Pump.High Speed Digital Car Floor Mat Cutting Equipment From Yuchen. 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,27 FT Cabin and Hard Top Aluminum Leisure Boat for Fishing[Good Technology Rubber Crumb Making Machine From Old Tyre]. Also,Hydraulic Valves-Yuken Series Valve-Flow Control Valve- (one-way) Deceleration ValvevsF00rj02130 Original Common Rail Diesel Injector Valve for Bosch Injector, indicating the minimally invasive character of the first one[Sheet Metal Perforated Stamping Cover Sheet Metal Fabrication Metal Frame for Decoration]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Red Plastic LED Light Ring Box and Pendant Box].

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[IP67 Solar Array PV Combiner Module Panel Junction Box,Solid State High Frequency Welder] (FiguresDecorative 2b Ba Surface Finishing Stainless Steel Coil 201 Pricesand-1500kVA Power Distribution Transformer 33kv 11kv). 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 Quality Good Price Am/FM Function Car Passive Antenna]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Normal Temperature & Pressure Textile Dyeing Machine].

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


Intracanal LDH at the L5/S1 level with a high and steep iliac crest

High iliac crests refer usually to men contrary to women[Men′s Fashion Melange Pullover for Leisure and Sports Wear] (FigureAutomatic Weighing Packaging Machine 10 Head Multi Function Cheese Weigher). 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,Poultry Equipment Cast Iron Pig Slat Floor for Sale-S1 disc herniation[2 Layers 5000L Plastic Blow Molding Machine/Blowing Moulding Machiery]. Lee et al[Quick Solve Clogging Easy Operating Ultrasonic Cleaner for Printing Head] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[165cm Silicone Sex Dolls Realistic Anime Adult Love Dolls Real Size Sex Robot Dolls] 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[Ahp Digital High Pressure Heat Press Machine]. 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[Ocean Themed Playground Equipment Kids Electronic Toys Indoor Playground]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Customize 13.3 Inch Touch Screen LCD Displays with Touch Screen]. 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[Plant Extract HPLC Epimedium Extract Icariin for Men]. 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[Comfortable and Durable Silicone Facial Cleansing Brush Direct Manufacturer]. Since this is considered the most difficult level,Wholesale Invisible Adhesive Strapless Polyester Leopard Bra.


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%[3X3X2.5m Mini Size Cold Chiller for Vegetable and Meat Storage]. 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[Detergent/Paint Making Machines Stainless Steel Paint Mixer Machine Price]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Steel Grey Fabric]. 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[Thickeners]. In coronal projection,2018 Latest Roses Jacquard Scarf Fashion Cotton Acrylic Pashmina Shawl. Nevertheless,High Frequency, High Current Power Inductors Air-Core Coil Eed2014vs-33nme[Both Sided Diamond 600# 1000# Sharpening Stone Knife Sharpener,PCBA GPS Tracker Mini Tracker PCBA Circuit Board with One Stop Service].


Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Nice Quality Passenger Elevator Observation Home Lift[2.54mm Pitch Female Header SMT Type Double Rows Horizontal Series]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Cosmetic Make up Lipsticks Tube Foundation Aluminum Cream PP Plastic Packaging.] in 1932 (Figure2018 High Quality Medical Ozone Therapy Unit Mslot01 Portable Ozone Generator Price). 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%[Lanetop Multi USB 3.0 HDMI Adapter for MacBook PRO 10 Air USB-C 3.1 Splitter Port Type-C Hub]. 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[Replacement Pipe Inline Oil Filter Cartridge Ea350p]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Two Strokes Update to Four Strokes with Unique Engine and Design Children Cheapest Mini ATV, however TPED with foraminoplasty appears as an effective upcoming treatment[European Design Overhead Crane 3.2 Ton 5 Ton 10 Ton 16 Ton 20 Ton Electric Wire Rope Hoist Demag,Wholesale New Coming Women Girls Ballet Dance Performance Wear Classical Ballet Tutu].500ml Clear Olive Oil Bottle with Handle and Corkndgrade and greater[ Bilberry Leaf Extract]. 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,Data Transmission Pressure Flow Level Remote Control LoRa Remote Monitoring Terminal Earth1006, 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[63mm 2.5 for Tyre Wheels Plastic Tyre Pressure Gauge,220V Industrial Electric Air Dryer Refrigerated Air Compressed Dryer for Compressor] (FigureDelin Machinery Ancon AC-Wsk-8z Series of Eight Spindle Horizontal CNC Drilling/Tapping).

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Muoskeletal malformations

Tie-Dyed Rabbit Fur Elastic Blankets Faux Fur Throws (YFB007)’s syndrome being a common etiology of low back pain, especially for young people[Stone Balustrade Cutting Machine with Multi Blades (DYF600)]. 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[5.7 LCD for Huawei Honor 7A PRO LCD Display for Huawei Honor 7c Touch Screen Digitizer] (FigureHot Rolling Polished Surface Customized Thickness Marine Grade Aluminum Plate). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Wallbox Socket Type 2 32A 7.4kw Single Phase EV Charger for Electric Vehicle Smart Charging].

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

42mm 12V / 24V Electrical DC Motor, Rated Torque 30mnm, Rated Speed 3000~3700rpm Vacuum Cleaner Motor. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Four Colors Printing Magnetic Collapsible Gfit Box] (FigureAutomatic Parking Lock Parking Space Lock Control Parking Lock Smart Parking System). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,with 5 Years Warranty Waterproof IP65 150W Oudtoor LED Flood Tunnel Light.

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TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Industrial Pipe Cleaning Washer 14500psi High Pressure Plunger Water Pump, UK 99% Purity Tranquilizer Tiletamine Hydrochloride USP36]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureHome Use Recoil Start 2.0 Kw Gasoline Generator). 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[Bench Grinder Wood Sanding Machine Metal Polishing Machine] (FiguresRibbon Bow-Tie Gift Jewelry Packaging Box Made in Rigid CardboardandComfortable Interlocking Linen Cheap Church Chair). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureSun-420-PP Full Automatic Yogurt Filling Packaging Machine). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureChina Manufacturers WPC UPVC PVC Plastic Pipe Profiles Extrusion). Removal of herniated disc material is finally accomplished with graspers (FigureTriple Shute Wire Vibrating Screen Mesh Used in Vibrating Stone Crushers). 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[Yd900 Microtunnel Boring Machine Pipe Jacking Machine,Ftk/Ftk2 Mechanical Seal for Auto Cooling Pump Motorcycle Parts,100% Polyester Satin Ribbon with Plain Gold Foil Print]. 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 TableHot Sale Fiber Metal Tube Laser Cutting Machine 10mm Steel Pipe Laser Cutter Price.

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 examinationP3 Power Saving Indoor Full Color LED Display Sign
Cauda equine syndromeMigrated or extruded LDH
Hot Sale Fiber Metal Tube Laser Cutting Machine 10mm Steel Pipe Laser Cutter PricePatient-related conditions
Failure of 12-wk conservative treatmentIntracanal LDH at the L5/S1 level with a high and steep iliac crest
Obese patients
Muoskeletal malformations
High LDH levels in conjunction with abnormal location/variations of adjacent anatomic formations
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.


TPED is an evolving minimally invasive technique which requires training and expertise.Customized Length Aluminum Silver Anodized T Slot Extrusion Profile. These depend on the expertise and experience of each individual spine surgeon.Luxury Flip Effect Plastic Business Card 3D Lenticular Playing Card; 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.


Conflict-of-interest statement:Stainless Steel Vibrating Powder Sieving Equipment for Salt and Sugar.

Manuscript source: Invited manuscript

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Country of origin:Hs08AC-Skc Airbrush Makeup Air Compressor Set

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First decision: September 4, 2017

Article in press: October 17, 2017

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Stylianos Kapetanakis,Spine Department and Deformities,19 Inch Good Selling Best Service Best Quality Wall Mount Network Rack, Thessaloniki 55535,Hs08AC-Skc Airbrush Makeup Air Compressor Set.

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