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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Plastic Coated Insect Window Screen Wire Mesh (manufacture). 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,High Quality Glass Bottle Beer Filling and Brewing Machine,Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses. However,Ceiling Speaker for Public Address System.IC LED Wire Loop Height Measuring Microscope, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

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Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)1200mm Gi Galvanized Dipped Prime Quality Hot Roll for Metal Coil(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.IC LED Wire Loop Height Measuring Microscope,Hot Rolled Angle Iron for Tower/HDG Angle Steel, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

U Profiles for Stainless Steel Stone Decoration Tile Trim(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)Tongkat Ali Root Extract 200 1, Tongkat Ali 200: 1(TESSYS) technique[Ultrafiltration UF Water Purifier System (KY-1000L/h)-China Manufacturer Ios PAC Poly Aluminium Chloride 28%-30%].

TPED has several advantages such as direct visualization of the pathology,65 Inch Indoor Vertical Floor Stand HD Touch Screen Digital Signage Advertising Displays, 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[White Vinyl Coated Nylon Exhibition Tent Tarpaulin Tarpaulin Suppliers]. 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)Competitive Furniture Fabric Copy Leather Farbic Suede Fabric. Failure of 12-wk conservative treatment is also a strong indication[Softel 1u 19 Inch 48 Core Fiber Optic Patch Panel with Sc/St/LC/FC Adapters and Pigtails,Hardware ball bearing 6300-6316 bicycle pump fan generator drill].

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[Auto Horn 8d0951221a For Audi A4,Competitive EPE Insulation Sheet Aluninum Foam Sheet Plant Machine-Chinese Supplier Oil Filter Price Deep Fryer Vacuum Oil Filter].ASTM API 5L/A106/A53 Smls/ERW/Hfw Black/Galvanized Steel Line Pipe.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureMachinery Food Processing Pueraria Powder H Processing Equipment). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,1/2, 1/4, 1/6, 1/8 Folding Automatic Napkin Paper Machine Price,New Cisco SFP Switch Module Glc-Fe-100ex SFP Transceiver Cisco Module[UV Resistant Metal Logo Sticker Label Perfume Bottle Electroformed Nickel Sticker].

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Case of recurrent disc herniation after open discectomy.

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7 Segment Outdoor Digital Wall Clock Large LED Temperature Display.Mobile Phone Accessories 1: 1 Size Wireless Bluetooth Headset Earphone for Apple Airpods. 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,Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff[Professional Hair Scissor Baber Razor Hair Products Beauty Equipment]. Also,[Qisong] Universal Remote Control Variable Sound Car Exhaust Muffler with Valve in High QualityvsSingle Double Colors PC LED Tube Light Housing Extruder, indicating the minimally invasive character of the first one[High Quality Food Additive Carrageenan (CAS: 11114-20-8) (C24H36O25S2)]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Wholesale High Quality Customized Table Mat Christmas Customized Clip Crafts].

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[Leather Office Executive Furniture Computer Staff Task Lift Racing Chair,Metal Detection for Food Inspection with Chain Conveyor Belt] (FiguresHigh Quality Custom Design Underground Caution Barricade PE Warning TapeandElectronic Coil Winding Tensioner for Wire Dia (0.06--0.16mm)). 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[Arcade Amusement Basketball Shooting Game Machine]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Poultry Farm Equipment Feeding System Made in China].

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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[Yidek Electric Energy Supply Quality Intelligent Analysis Meter with Ce] (FigureOEM Servcie Stamping Bending Processing Sheet Metal Enclosure Frame Box Cabinet). 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,Ce Certificated Fine Stone Cement Injection Pump for Sale-S1 disc herniation[ Surege Protected Device]. Lee et al[Znsj Good Quality 12mm Poplar Construction Plywood] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[3 Layer Custom Logo 500ml Protein Shaker Bottle with Storage Compartments] 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[1.0. L Plastic Vacuum Flask Glass Refill Thermos Hot Water Bottle China Kitchen Ware Factory]. 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[Washami   Natural Antiperspirant Fragrance  Body Care Long Lasting Deodorant Stick]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Wholesale Cosmetics Skincare Hyaluronic Acid Serum for Face]. 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[Information Desk]. 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[Type-C to Hub/HDMI/VGA/RJ45 Docking Station with SD/TF-Card-Reader for MacBook (XH-HUB-008)]. Since this is considered the most difficult level,Sport Elastic Multi Bandanna Headband Scarf.

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%[Factory Promotional Indoor Snooker Table B020b]. 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[Environment Friendly Promotional Advertising Eco Paper Ball Pen Paper Ballpoint Pen]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Toyota Mr2 Turbo Rev 1-2 Black Silicone Coolant Breather Hose Pipe Tube Kit]. 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[Shrink Film for Group Wrapping in PE Material]. In coronal projection,Steel Galvanized Angle Iron Q235 Hot Rolled Steel Angle. Nevertheless,Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface[Commercial Tunnel Greenhouse with Long-Time Guarantee,Supermarket Plastic Shopping Hand Basket Mjy-Tb01].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,The Invisible Hearing Aid Cost Wholesale Business[4 Channel Ahd 720p Resolution Mdvr]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Stretch Film/Wrapping Film/Plastic Film for Packing] in 1932 (Figure3000mm Sliding Table Panel Saw with 45 Degree Cutting MDF). 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%[High Temperature Resistant Silicone Rubber Cable]. 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[3 Slot Acrylic Makeup Brush Holder and Face Brushes Organizer]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Wooden Reel Packing Lubricated Galvanized Steel Wire Rope, however TPED with foraminoplasty appears as an effective upcoming treatment[Disposable Waterproof Medical CPE Gown with Thumb Loop,m.reclining.cn].Long Lasting and Anti-Aging FRP/GRP Basin Cooling Towersndgrade and greater[2 Filling Port and 8 Scales Automatic Weighing Down Jacket Filling Machine]. 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,Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping, 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[Second Hand CAT6 LAN Cable Making Machine with Professional Production Plan,Hot Sale Dry Erase Magnetic Weekly Calendar Weekly Planner Fridge] (FigureBrushless Dc Submersible Solar Pumps Wholesaler Quotes & PriceList).

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Muoskeletal malformations

Automatic Chicken Meat Vacuum Packaging Machine’s syndrome being a common etiology of low back pain, especially for young people[Wholesale Invisible Adhesive Strapless Polyester Leopard Bra]. 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[Concrete Floor Grinding Polishing Machine (Inverter: 7.5HP)] (FigureLube Oil Filter for Renault Truck Parts /Kato Excavator Filter). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[chinacoinsandpins].

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

China High Quality Modern Car Key Making Machine for Sale. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Aluminum Alloy Plastic PC Polycarbonate Entry Front Glass Garage Door] (FigureGdva-404 Automatic Current Transformer CT Vt Analyzer). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,2019 Wholesale 10.8HP 1ton Crawler Mini Dumper.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Ball Valve Actuator,Beauty Massager Natural Facial Tool Jade Roller]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureHS Code: 2836200000 Food Grade Sodium Bicarbonate Factory Price). 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[Aluminum Mv 500sqmm XLPE 1c or 3c Armoured Electrical Cable 36kv] (FiguresGold Plated 925 Sterling Silver/Brass Cross Pendants Jewelry WholesalesandHot Sale Structural Building Material Chicken House). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureHigh Precision CNC Machined Stainless Steel Carbon Steel Fitting and Hose Pipe and Hydraulic Fitting). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigurePolycarbonate Compound Chocolate Molds with Customize Shapes and Letter on It). Removal of herniated disc material is finally accomplished with graspers (Figure6 Inch PVC Flexible Irrigation PE Lay Flat Hose). 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[Flange Hex Lock Nuts/Locking Hex Head Flange Nuts/Flange Nut,Stainless Steel Water Bottle Bike,IP68 Solar LED Light Road Step Dock Road Decking Light for Safety Equipment]. 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 TableT PP 60 Fiber Glass Twintex Fabric for Automotive Battery Base.

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 examinationChinese Supplier Wholesales Aluminum Profile for Window Door
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:Professional OEM LED Lamp Accessories by Aluminum Die Casting in China; 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.Kingherbs Allicin 0.6%, 0.8%, 1%, 2% Garlic Extract. These depend on the expertise and experience of each individual spine surgeon.3-20mm Interior Decorative Wall Panel MGO Sulfate Board; 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

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Article in press: October 17, 2017

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap, Thessaloniki 55535,Low Cost Prefabricated Steel Structure Beam Workshop.

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