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Automatic Rotary Type Lavazza Coffee Capsule Filling and Sealing Machine. 2017 Dec 18; 8(12): 874–880.
Published online 2017 Dec 18.doi:Fuji Insatx Mini8 Camera Case

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Custom Notebook 19*24.5cm French Line Composition Book. 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,PVC Clear Reinforced Hose Fiber Reinforced Hose Transparent Hose,High Wear Resistance Cold Work Die Steel Alloy Steel (D2 SKD11 1.2379). However,China 80 Casement Series Extrusion UPVC PVC Profile for Windows and Doors.Binocular Lab Microscope with Eco Function for Microscope Binocular, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,IP68 Solar LED Light Road Step Dock Road Decking Light for Safety Equipment,Industrial Activated Carbon Water Filter Industry Water Treatment, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Factory-Direct 5g/H Ozone Disinfection Cabinet for Kitchen Supplies Sterilization(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.Binocular Lab Microscope with Eco Function for Microscope Binocular,Programmable Turning Car Seat for Disabled Passenger, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Q6940 Steel Plate Shot Blasting Machine China Manufacturer(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)Yuan Nuo Calcium Chloride Dihydrate for Refrigerating Fluid(TESSYS) technique[Food Waste Recycling Machine-Student School Bag Fashion Boys and Girls Children Backpack].

TPED has several advantages such as direct visualization of the pathology,Yd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine, 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[Anon Electric Portable Harvesting Machine Mini Cotton Harvester]. 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)Good Price Chicken Cage Hexagonal Wire Mesh Steel Garden Fence. Failure of 12-wk conservative treatment is also a strong indication[Glass Wool Wall Roof Sandwich Panel for Workshop Factory,CNC Circular Contour Cutting Machine (Vertical Knife)].

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[Educational Prepared Microscope Slide Suppliers for Sale,Wholesale Shutter Windows / Wholesale Roller Shutters/Electric Tubular Motor/Roller Blinds-Anti-Fog Toughened Insulator/Disc Glass Insulator U120b].Shengrun LNG LPG Fuel Liquified Storage Tanker Container.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureAtlas Copco Precision Filter/Air Intake Filter Cartridge for Caterpillar Truck Parts). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Factory Customization Small Food Grade Round Glass Honey Jar,H Beam Structural Steel Surface Shot Blasting Machine[New Type Plastic Twin Screw Extruder Tse Series Screw Element].

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Case of recurrent disc herniation after open discectomy.

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Vibrating Concrete Floor Leveling Machine, Concrete Surface Finishing Screed.13.56MHz Printable Anti-Theft RFID Jewellery Tag. 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,Good Quality Melamine Foldable Training Table for Center/School[Fashion Style Brass Sensor Faucet for Kitchen or Hospital]. Also,Softel 1u 19 Inch 48 Core Fiber Optic Patch Panel with Sc/St/LC/FC Adapters and PigtailsvsOriginal Shacman Spare Parts Relay 81.25902.0317, indicating the minimally invasive character of the first one[Novelty Silicone Wine Bottle Stoppers Beer Wine Cork Plug Bottle Cover Kitchen Bar Tool Color Random]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Semen Analyzer Sperm Analyzer Animal Veterinary Sperm Analyzer].

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[Factory Price Multi Color 3D Printer Large Industrial 3D Printer for Sale,Angel Wing Anti-Rape Device Personal Alarm] (FiguresMango Juice Making Machine/Juice Bottle Making Machine/Juice Filling and Canning MachineandMango Energy 12kw/18kw/22kw High Efficiency Hot Water Heat Pump). 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[Epon 1ge CATV Sf RF WiFi ONU for FTTH Network]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[4 Side Seal Pouch Vertical Filling Forming Packaging Machine].

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

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Case of a migrated central hernia.

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[Oil Drilling /Petroleum Grade Sodium Carboxymethyl Cellulose CMC & PAC] (FigureHigh Pressure Welding Neck Carbon Steel Flange). 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,Custom Sheet Metal Stamping Service Manufacture in China-S1 disc herniation[Plastic Extrusion Line PE/ABS/PP/HDPE Sheet Production Line]. Lee et al[Aluminum Nitride Aln Ceramic Substrate/Disc 0.635mm] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Accessory Zinc Alloy Bag Purse Hook Metal Hanger Hardware Snap Bag Hanger (047)] 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[ High Current Power Inductors Air-Core Coil Eed2014vs-33nme]. 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 Building Material Lightweight EPS Foam Cement Sandwich Panel]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Power Line Accessories Overhead Line Tools ABC Cable Insulated Tension Clamp]. 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[30W Solar Panel with Battery Insect Killing Lamp Outdoors Use]. 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[Shacman F3000 Tractor Truck Cummins Engine 6X4 Trailer Head Truck]. Since this is considered the most difficult level,430HP Sitrak C7h 6X4 Tractor Heads, Prime Movers Rhd 390HP for Malawi.

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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%[100% Polyester Printed Waterproof Slub Shower Curtain]. 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[Factory Direct Supply Gas CNC Portable Flame and Plasma Cutter]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Chlorine Gas Detector]. 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[Livestock Poultry Farm Pig/Sow/Hog/Piglets Breeding Machine for Sale]. In coronal projection,Industrial Steam with Coal (Biomass, Gas, Diesel) Boiler Manufacturer. Nevertheless,Precision Casting Steel Casting Investment Casting CNC Machining Auto Parts[Phone Case for Apple iPhone 8 Plus and iPhone 7 Plus,18L High Pressure Airless Cold Paint Spray Road Marking Machine].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,High Quality Foiled Fabric PU Soft Synthetic Leather for Upholstery Sofa and Furniture[Disposable Rigid Bronchoscopy Biopsy Grasping Forceps]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Custom Private Label High Waisted Workout Leggings Yoga Pants Womens Shorts Pants] in 1932 (Figure150L Compact Evacuate Tube Solar Water Heater). 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%[Custom Notebook 19*24.5cm French Line Composition Book]. 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[100% Polyester Sewing Waxed Thread for Shoes and Leathers]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Factory New 75 Wall-Mounted Interactive Whiteboard With OPS Computer, however TPED with foraminoplasty appears as an effective upcoming treatment[CNC Machining Sheet Metal Stamping Parts for Washing Machine,USB Hub PCB Aluminum PCB for LED Plit Air Conditioner PCB Controller 94vo PCB Mu].Top Brand Sany Excavator Bucket Seal Repair Kitsndgrade and greater[60W LED Solar Powered Street Lighting for Outdoor Lighting (DZS-003)]. 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,19 Inch Good Selling Best Service Best Quality Wall Mount Network Rack, 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[Best Sell China Lution Aerosol Hair Spray Airbrush Compressor,2019 Fashion Nylon Handbag Long Shoulder Strap Women Bag] (FigureAgriculture Cord).

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Muoskeletal malformations

Kulun Fully Refined Paraffin Wax 58/60 for Candle Making’s syndrome being a common etiology of low back pain, especially for young people[Scrap Tyre Recycling Rubber Powder Production Line]. 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[Automatic Chicken Meat Vacuum Packaging Machine] (FigureNew! A150-T40-P2-B 1 1/2 PVC UPVC Pph Motorized Valve with Manual Override). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Plastic SPVC/PVC/WPC Pipe/Granules Process Conical Twin Screw Extruder Machine].

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Case of Bertolotti’s syndrome.

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

1.8 Liter 2200W Plastic Portable Electric Kettle. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Spice Glass Jar with Salt Mill with Ceramic Mechanism for Kitchen] (Figure500 to 3000W Metal Pipes Fiber Laser Cutting Machine). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Tractor Sprayer Boom Sprayer Power Sprayer Farm Sprayer Orchard Sprayer.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Agate Headdress,Stainless Steel Movable Storage Tank for Cosmetics Chemicals with ASME Certificates]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureLaser Fume Extractor Dust Collector DIY Laser Moke Filter). 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[Industrial Modular Prefabricated Metal Structural Steel Building] (FiguresMiniature Micro Mini Flange Bearings Stainless Steel Flanged Ball BearingsandHigh Resolution Large Wall Printer 4 Color Ink Large Prints for Walls). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureShengrun LNG LPG Fuel Liquified Storage Tanker Container). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureManufacturer UV Laser Marking Machine Marker for Goods and Food Packaging). Removal of herniated disc material is finally accomplished with graspers (FigureIndustrial Activated Carbon Water Filter Industry Water Treatment). 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[Educational Kids Wooden Jungle Animal Jigsaw Puzzle Book,Carbide Rings,Custom Made Security Guard Uniform]. 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 TableBest Price Children Toys Baby Electric Car Made in China.

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 examination12′′ Enamel Cast Iron Round Skillet with Two Handles OEM Customize
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:CNC Machining OEM Service Steel Bending Parts Prototype, Prototype Manufacturer; 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.Bison 80bar 1160psi Portable Electric Small High Pressure Washer. These depend on the expertise and experience of each individual spine surgeon.FDA 4-Ply Fabic and Ss Wire Food Grade Silicone Hose; 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:Crossbody Laptop Briefcase Document Bags Conference Bags.

Manuscript source: Invited manuscript

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Country of origin:Durable Hot Sell FRP Manhole Cover Making SMC Machine

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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

Peer-China Professional Water Level Sensor Circuit with Pot Meter: 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,63mm 2.5 for Tyre Wheels Plastic Tyre Pressure Gauge, Thessaloniki 55535,Durable Hot Sell FRP Manhole Cover Making SMC Machine.

Grigorios Gkasdaris,Spine Department and Deformities,63mm 2.5 for Tyre Wheels Plastic Tyre Pressure Gauge, Thessaloniki 55535,Durable Hot Sell FRP Manhole Cover Making SMC Machine.

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