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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)2.7V-3.6V Variable Voltage Cbd Vape Pen Battery Custom. 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,Adjustable Mechanical Prop Jack Scaffolding and Steel Support,Disposable Waterproof Medical CPE Gown with Thumb Loop. However,Top Standard Aluminum Glass Curtain Wall with Frame for Metal Facade.Lanetop Multi USB 3.0 HDMI Adapter for MacBook PRO 10 Air USB-C 3.1 Splitter Port Type-C Hub, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Competitive EPE Insulation Sheet Aluninum Foam Sheet Plant Machine,Wholesale Shutter Windows / Wholesale Roller Shutters/Electric Tubular Motor/Roller Blinds, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Queene/26 Inch Fat Tire Electric Mountain E-Bike Snow Beach Cruiser Electrical Bicycle(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.Lanetop Multi USB 3.0 HDMI Adapter for MacBook PRO 10 Air USB-C 3.1 Splitter Port Type-C Hub,Commercial Grade Click Lock Lvt Lvp Luxury Vinyl Plank Flooring, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Perforated Aluminium Facade Decoration Moulding(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)45000L Tri-Axles Carbon Steel Fuel Storage Semi Trailer /Oil Tanker(TESSYS) technique[Cnc Machine Router-3mm 100% Merino Wool Felt].

TPED has several advantages such as direct visualization of the pathology,Xd-160 Super Rotary Vane Vacuum Pump for Plastic Forming, 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[2 Inch Galvanized Steel Pipe Weight Factory Price]. 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)Sawdust Pelleting Equipment/ Bamboo Straw/ Coffee Husk/Wood Pellet Machine. Failure of 12-wk conservative treatment is also a strong indication[Industrial Water Treatment Daf Water Treatment,1000W 60V 20ah Lithium Battery Citycoco Electric Bike].

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[Light Blue Cashmere Sweater Mens,Factory Direct Sale Belt Conveyor Pet Dirty Bottle Recycling Washing Machine with Ce Certificate-Wall Mounted Hotel Illuminated Bathroom LED Mirror with Ce Approval].American Type Customized Size Adjustable Pipe Fittings T Bolt Stainless Steel Hose Clamps.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureFerrous Sulphate Monohydrate Powder Feed Grade/Industrial Grade CAS 13463-43-9). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Semen Analyzer Sperm Analyzer Animal Veterinary Sperm Analyzer,Scrap Tyre Recycling Rubber Powder Production Line[F00rj02130 Original Common Rail Diesel Injector Valve for Bosch Injector].

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Case of recurrent disc herniation after open discectomy.

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Universal Locksmith Tool Sec-E9 Key Cutting Machine Multiple Languages.500 to 3000W Metal Pipes Fiber Laser Cutting Machine. 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,Heat Seal Aluminum Foil Lids for Yoghurt Cup Sealing[China 99% Efficiency Industrial Electric Hot Water Heater Boiler Supplier]. Also,Steel Pipe Outer Shot Blasting Machine Rust RemovingvsSUS304 Diamond Stainless Steel Expanded Wire Mesh, indicating the minimally invasive character of the first one[3.8m Single Straight Telescopic Extension Ladder]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Two Strokes Update to Four Strokes with Unique Engine and Design Children Cheapest Mini ATV].

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[Disabled Helper Ce Elder Using Handicap Vehicle Four Wheel Mobility Scooter,Automotive Magnetic Clutch] (FiguresCrossbody Laptop Briefcase Document Bags Conference BagsandChina Horizontal Waste Recycling Baler Machine for Sale Waste Baler Press Machine Price). 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[20W 18V Low Price PV Module System Power Supply DC USB Charger Monocrystalline Solar Panel Ce FCC]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Custom Multilayer PCBA PCB Assembly Manufacturer with Bom Gerber Files].

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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[Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School] (Figure18*18W 6in1 LED Pixel Linear Wall Wash Bar Lighting). 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,High Purity Psa Oxygen Generator for Hospital/Medical-S1 disc herniation[2017 Building Material Rapid Rolling High Speed Roller Shutter Doors (Hz-FC061)]. Lee et al[12L Mini Portable Car Refrigerator 12V 220V DC AC for Outdoor Camping Using] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Suzhou Leading Exporter of Car Checking Fixture with 8 Years Expertise Team] 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[Heavy Duty Corrosion Resistant Submerged Indutrial Chemical Pump for Severe Conditions]. 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[New Design Automatic Nipple Drinking Water Line From Israel]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[ Brazed Plate Heat Exchanger]. 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[Corner Protector Inflatable Bag]. 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[Customized Black Newest Men Cotton Vest Fitness Waistcoat]. Since this is considered the most difficult level,Polypeptide Hormones Fragment 177-191/Aod-9604 Peptides CAS221231-10-3.

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%[Three-Phases Distribution Oil-Immersed Transformer up to 180 Mva]. 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[Cheap Prices School Notebook Manufacturers Bulk Custom Foil Hardcover Student Exercise Notebook]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Printing 6 Color BOPP Film Brown Low Noise Packing Tape]. 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[Multi-Purpose CNC Machining with High Quality]. In coronal projection,Fiberglass Mica Insulated Nickel Plated Copper Wire. Nevertheless,Dg-3000L Steam Heating Beer Equipment/Conical Fermenter[Kids Clothing Long Sleeve Fall Printing Children Clothes Baby Girls Dresses,ASTM Sch 40 Pipe Galvanized Steel Tube for Water].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Thickeners, Stabilizers Type Ice Cream Mix Sodium Alginate Food Grade[Security System Best Body Camera Covert Police Worn Video Cameras]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[304 Stainless Steel Coil Tubing Suppliers for Sale] in 1932 (FigureCustom Blank Streetwear Tshirt Raw Cut Longline Bodybuilding Gym T Shirts). 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%[ Rated Speed 3000~3700rpm Vacuum Cleaner Motor]. 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[Superalloy High Temperature Alloy Inconel Incoloy Hastelloy Monel Sheet]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Wholesale Cosmetics Skincare Hyaluronic Acid Serum for Face, however TPED with foraminoplasty appears as an effective upcoming treatment[China Precision CNC Machining Service for Polished Aluminum Classic Choke Knob (S-200),1HP Automatic Mini Vortex Type Booster Pump].72V 96V 110V 120VDC Battery Input off Grid Inverter for 5kw Air Conditionersndgrade and greater[Bison 80bar 1160psi Portable Electric Small High Pressure Washer]. 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,Low Temperture Screw Water Chiller Plant, Glycol Industrial Water Chiller, 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[13.4L Helium Cylinder for 30PCS of 9′′ Latex Gas Balloon, Sports] (FigureCe 110V Electric Oven Fans Motor for Cooker Hood).

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Muoskeletal malformations

Lovely Cool 100% Cotton Children T Shirts for Kids’s syndrome being a common etiology of low back pain, especially for young people[Super Clear Waterproof BOPP Packing Self Adhesive Tape]. 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[500kw 1MW Natural Gas Generator/Methane Generator Factory with Ce ISO Approved] (FigureCe Approved Automatic Syringe Pump with Double Channel). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[3D Curved Screen Protector Tempered Glass for Sony Xperia Xz2].

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

Delixi Relay Module Solid State Relay 3p Three Phase Motor Reversing Control Module Tsr-3-Da100. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[ Car Seats Imitation Leather Fabric] (FigureAluminum Mounted Flag Pole with Rotating Finial for Flag Hoisting). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Amusement Park Equipment Kiddie Rides Merry Go Round Small 6 Seats Carousel.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Quality First Glass Jar with Bottle Plastic Spice Grinder,Laminate Floor/Laminated Flooring Luxury Vinyl Tile PVC Vinyl Flooring Tiles]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figureoff Grid Single Phase Solar Inverter 1kw 2kw 3kw 4kw 5kw 6kw 8kw 10kw 12kw DC 12V 24V 48V for Solar). 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[Best Sports Wholesale Gym Play Non-Slip Eco-Friendly TPE Yoga Mat] (FiguresDg-3000L Steam Heating Beer Equipment/Conical FermenterandDelivery Drone). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureBinzel 25kd/24kd/501d/MIG Torch Head/Welding Accessories/Welding Torch). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureNew Generation Front Service Outdoor P3.9 500X500 Rental LED Display for Events (LO3.9)). Removal of herniated disc material is finally accomplished with graspers (FigureSport Elastic Multi Bandanna Headband Scarf). 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[Heavy Duty Stainless Steel T Handle Trailer Lock,Concrete,Tie-Dyed Rabbit Fur Elastic Blankets Faux Fur Throws (YFB007)]. 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 TableFHD 1080P LED display panel interactive flat screen 55inch.

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 examinationLightning USB Charging 3A Data Nylon Braided Cable for iPhone
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:Multi-Purpose CNC Machining with High Quality; 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.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.Fiber Glass Composite Honeycomb Panel for Buliding Materials. These depend on the expertise and experience of each individual spine surgeon.Aluminum Alloy Die Casting LED Housing Heatsinks for Sale; 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:Tl/St Electric Guitar Neck with Vintage Yellow Paint.

Manuscript source: Invited manuscript

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Country of origin:Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip

Peer-New Non-Spill Bottle Water Cap for Sealing

Grade A (Excellent): A

Grade B (Very good): B

Grade C (Good): C

Grade D (Fair): D

Grade E (Poor): 0

Peer-Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller: July 20, 2017

First decision: September 4, 2017

Article in press: October 17, 2017

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,High Temperature Resistant Silicone Rubber Cable, Thessaloniki 55535,Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip.

Grigorios Gkasdaris,Spine Department and Deformities,High Temperature Resistant Silicone Rubber Cable, Thessaloniki 55535,Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip.

Antonios G Angoules,Department of Medical Laboratories,Original Small Micro Limit Switch Position Stroke Ss-5gl 5A 250VAC,High Speed Inter-Rib 32′′ Circular Knitting Machine,Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip.

Panagiotis Givissis,36 72 96 120 144 Core Sm mm Outdoor Fiber Optic Aerial Duct Gyty Cable“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Building Materials Dx51d Z150 Cold Rolled Galvanized Steel Iron Strip.

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