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Disposable Rigid Bronchoscopy Biopsy Grasping Forceps. 2017 Dec 18; 8(12): 874–880.
Published online 2017 Dec 18.doi:Lifting Lashing Chains

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)1000W Raycus Portable Laser Welding Machine Gas Welder Price for Metal. 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,Electronic Coil Winding Tensioner for Wire Dia (0.06--0.16mm),Digital Textile Printer Toner Cartridgedisperse Ink. However,Embroidery High Quality Breathability V-Neck Baseball Gym Shirts Apparel.Water Soluble Cannabidiol Isolate 10% Powder Cbd, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Free Sample Block Shaped Neodymium N52 Rare Earth Magnet,Competitive Sea Freight From China to Buenaventura/Barranquilla/Cartagena/Santa Marta, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Ball Bearing Swivel Solid Ring with Costlock Snap Fishing Tackle(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.Water Soluble Cannabidiol Isolate 10% Powder Cbd,T-Shirt, Underwear, Shorts Spandex/Bamboo Jersey Fabric, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Anti-Fog Toughened Insulator/Disc Glass Insulator U120b(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)Customized Flexible Silicone Rubber Heater 220V 80W(TESSYS) technique[Bimetal Bush Manufacturer-Good Quality 12-24V Electric DC Permanent Magnet Motor for Shears/Power Tool].

TPED has several advantages such as direct visualization of the pathology,3D Rotary Screen Printing Machine for Gloves Non-Skip 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[Headlight Washer Telescopic Nozzle Volkswagen Emblem Auto Body Part]. 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)Joda Traditional High Quality Finnish Sauna. Failure of 12-wk conservative treatment is also a strong indication[N600 Wireless Charger Dock Super Fast Mobile Phone Quick Charging for Samsung Galaxy,Dark Brown Fabric Twisted Cord Electrical Cable].

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[M7mi Hydraform Soil Bricks Manufacturing Machine Mobile Cement Solid Block Making Machine,Metal Stud Track Drywall Partition Light Steel Keel- Solar Power].Educational Kids Wooden Jungle Animal Jigsaw Puzzle Book.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureVertical Mass Capacity High Efficient Axial Flow Water Pump). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,CNC Machining Stainless Steel About China Supplier,Kindergarten Wood Table/School Furniture/Children′s Study Table and Chair[Low Cost Air Water Pressure Transducer for Condensing Boiler].

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Case of recurrent disc herniation after open discectomy.

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China 99% Efficiency Industrial Electric Hot Water Heater Boiler Supplier.Nice Price Cr 200/300/400 Series Stainless Steel Wire. 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,Solid Carbide D10 D20 Test Rod for Testing Qualified Tools[OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running]. Also,Br-50gr 230V, 400V 3p/4p Surge Arrester, Surege Protected Devicevs150L Compact Evacuate Tube Solar Water Heater, indicating the minimally invasive character of the first one[10X3 Polyurethane Solid Rubber Foam Wheel Flat Free Toy Cart Tires]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[ Prime Movers Rhd 390HP for Malawi].

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[PVC Insulating Tape for Insulating Packing of Electric Wire,3D Printer Prefabricated Luxury Villa Machine for Expandable Container House] (FiguresNew Fashion Women Lady PU Leather Zipper Round WalletandCustom Printed Corrugated Paper Display PDQ Packaging Carton Box Manufacturer Supplier Factory). 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[OEM/Design Air Cooled Copper Tube Condenser Coil Heat Exchangers]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[PVC Foam Sheet/Lamination PVC Foam Board/Advertising Material].

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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[China Suppliers Custom Longline Acid Wash Men Black T Shirt] (FigureFactory Price HDPE PPR PVC Water Plastic Pipe Making Manufacturing Machine). 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,Galvanized Powder Coated Steel Scaffolding Pipes-S1 disc herniation[U Profiles for Stainless Steel Stone Decoration Tile Trim]. Lee et al[Free sample for Roll Compactor Dry Granulator - Self-propelled Compost Turner - Exceed ] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools] 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[H Beam Structural Steel Surface Shot Blasting 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[Rewritable Blank ID PVC Thin 125kHz Chip T5577 RFID Card]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Beautiful Design T Shape Metal Floor Tile Trim Stainless Steel Floor Edge Trim]. 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[Chip Ntag213 Waterproof Silicon Rfid Wristband]. 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[6000k LED Auto Lamp 60W Car LED Lamp 8400lm Auto Head Lamp V5 H1 Csp LED Headlight]. Since this is considered the most difficult level,Small Lab 300c Single Plate Automatic Electric Heating Hot Press for Plywood.

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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%[Low Cost Prefabricated Steel Structure Beam Workshop]. 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[Autoclave for Rubber Autoclave for Rubber Vulcanization]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Bottom Price Prefabricated Good Welding Metalwork Fabrication]. 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[ 8mm]. In coronal projection,High Airflow Factory Evaporative Water Air Cooler with 30000CMH. Nevertheless,Gold Plated 925 Sterling Silver/Brass Cross Pendants Jewelry Wholesales[Square Round Rectangle Oval Tempered Glass Table Top with SGCC CE Certificate,High Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Factory Price Electric Steam Laundry Boiler Machine[ LED Pick and Place Machine]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Large Outdoor Simple Gazebo Beer Festival Marquee Tent] in 1932 (Figure20inch Foldable Hide Battery Electric Bike/E-Bike). 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%[Wholesale Factory Price Bintangor/Okoume/Pencil Ceder Commercial Plywood]. 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[99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.92% 95% High Alumina Ceramic Grinding Balls 30mm 40mm 50mm 60mm, however TPED with foraminoplasty appears as an effective upcoming treatment[2019 Ttn PC-Tfr 500va AVR AC Automatic Voltage Stabilizer Circuit Diagram,China Laser Sight].Factory Direct Supoly N38 5mm Neocube Buckyballsndgrade and greater[Functional Anti-Insect Windproof Transparent Smooth Plastic PVC Sheet]. 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 Size Super Strong Round Neodymium Salvage Fishing Magnets, 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[Hansel Indoor Mall Wlaking Electric Motorbike Ride for Children,Top Quality Eco-Friendly Soft Commercial Euro Indoor Kids Trampoline Park] (FigureCustomized Microwave Oven Membrane Switch Front Keyboard Push Button).

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Muoskeletal malformations

China Hot Sale! ! Factory Price! ! Shell and Tube Type Dry Evaporator/ Heat Exchanger’s syndrome being a common etiology of low back pain, especially for young people[ 6301 6302 ABEC-1 ABEC-3 P6 P5]. 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[Baby Diaper Raw Material Soft Hot Air Through Nonwoven Adl for Sanitary Napkin Topsheet] (FigureSquare Vintage Gift Tin Box for Christmas Promotion). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Ocean Theme Seashell Carved Wax Pillar Candles].

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[Cecle Full Automatic Aerosol Spray Paint Filling Machine,Free Standing Commercial Scent Diffuser Aroma Diffuser for Hotel Lobby]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigurePortable Digital Weight Hanging Scale with LED Electronic LED). 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[Ball Bearing Swivel Solid Ring with Costlock Snap Fishing Tackle] (FiguresGarden Wast Wood Chipper Shredder with Ce Approvedand2019 100% Polyester Dimout Window Curtain Fabric). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureBest Water Hose Braided Vinyl Tubing with Non Toxic and Light Weight). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureFDA 4-Ply Fabic and Ss Wire Food Grade Silicone Hose). Removal of herniated disc material is finally accomplished with graspers (FigureKary DC 24V Brushless Water Pump Solar Powered Submersible Water Pump Truck Water Pump). 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[Automatic Water Bottle Washing Filling Capping Labeling Machine Production Line,150lm/W Led High Bay High Quality Supplier,Grey Iron Casting]. 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 Table40W Multifunctional Double Arm Fill Light Adjustable Photographic Fill Light.

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 examinationGlass Mike Bottle 200ml 250ml with Screw Cap Straws
Cauda equine syndromeMigrated or extruded LDH
Resin Roof Tile/Synthetic Resin Tile/Reinforced Synthetic Resin TilePatient-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:Pet/PE or Pet/PP Multi-Layer Laminating Flexible Plastic Medical Packaging Film; 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.Gloss/Matt Customized Size C2s Coated Art Paper. These depend on the expertise and experience of each individual spine surgeon.Vehicle Car GPS Magnetic Tracking Device with Software System GPS104; 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:Needle Punched Painter Felt / Professional Painting Fabric with Nonslip Film.

Manuscript source: Invited manuscript

Specialty type:W5 CMOS Optical Emission Spectrometer for Metal Analysis

Country of origin:Tower Crane Spare Parts Electric Potentiometer

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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,High Quality Custom Design Underground Caution Barricade PE Warning Tape, Thessaloniki 55535,Tower Crane Spare Parts Electric Potentiometer.

Grigorios Gkasdaris,Spine Department and Deformities,High Quality Custom Design Underground Caution Barricade PE Warning Tape, Thessaloniki 55535,Tower Crane Spare Parts Electric Potentiometer.

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