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Stylianos Kapetanakis
Spine Department and Deformities,Industrial Mens Cotton Reflective Tape Work Pants, Thessaloniki 55535,Plastic Coated Insect Window Screen Wire Mesh (manufacture)
Grigorios Gkasdaris
Spine Department and Deformities,Industrial Mens Cotton Reflective Tape Work Pants, Thessaloniki 55535,Plastic Coated Insect Window Screen Wire Mesh (manufacture)
Antonios G Angoules
Department of Medical Laboratories,High Quality Glass Bottle Beer Filling and Brewing Machine,Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses,Plastic Coated Insect Window Screen Wire Mesh (manufacture)
Panagiotis Givissis
Ceiling Speaker for Public Address System“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Plastic Coated Insect Window Screen Wire Mesh (manufacture)
Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,High Quality Glass Bottle Beer Filling and Brewing Machine, 28 Agiou Spiridonos St,Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses,Plastic Coated Insect Window Screen Wire Mesh (manufacture).Magnetic Hooks Heavy Duty Neodymium Rare-Earth Magnets Nickel Coated
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Competitive Furniture Fabric Copy Leather Farbic Suede Fabric. 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,ASTM API 5L/A106/A53 Smls/ERW/Hfw Black/Galvanized Steel Line Pipe,1/2, 1/4, 1/6, 1/8 Folding Automatic Napkin Paper Machine Price. However,New Cisco SFP Switch Module Glc-Fe-100ex SFP Transceiver Cisco Module.Chinese Supplier Wholesales Aluminum Profile for Window Door, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff(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.Chinese Supplier Wholesales Aluminum Profile for Window Door,[Qisong] Universal Remote Control Variable Sound Car Exhaust Muffler with Valve in High Quality, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
Single Double Colors PC LED Tube Light Housing Extruder(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)Ce Certificated Fine Stone Cement Injection Pump for Sale(TESSYS) technique[LED Flexible Custom Neon Sign Light Strip-6000 Series Extruded China Aluminum Pipe Prices].
TPED has several advantages such as direct visualization of the pathology,Sport Elastic Multi Bandanna Headband Scarf, 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[Top Brand Sany Excavator Bucket Seal Repair Kits]. 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)Steel Galvanized Angle Iron Q235 Hot Rolled Steel Angle. Failure of 12-wk conservative treatment is also a strong indication[Stainless Steel Welding Electrode E308L-16,Commercial Grade Click Lock Lvt Lvp Luxury Vinyl Plank Flooring].
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[Air Hose,Amusement Park Equipment Kiddie Rides Merry Go Round Small 6 Seats Carousel-Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses].Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigurePneumatic Wheel Hub Machining Pressure Maintaining Fixture Manufacturer). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,The Invisible Hearing Aid Cost Wholesale Business,Wooden Reel Packing Lubricated Galvanized Steel Wire Rope[Mill Finish Aluminium Sheet and Plate Alloy 1050 1060 1100 2024 3003 5052 5754 6061 8011].
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Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping.J2 LCD Stn Tn for Customize Segment Screen Stn Display. 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,Automatic Chicken Meat Vacuum Packaging Machine[Outdoor LED Pole Light Solar Garden Lawn Lamp for Landscape Decoration Lighting]. Also,China High Quality Modern Car Key Making Machine for Salevs2019 Wholesale 10.8HP 1ton Crawler Mini Dumper, indicating the minimally invasive character of the first one[High Concentration Ozonated Olive Oil Making System Zamt-Y30 on Sale]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Factory 300kw Diesel Engine Generator Cheap Price].
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[Holykell Waterproof IP68 Fuel Tank Level Sensor Gauge Hpt604,Children Car Battery Remote Manufacturers Cheap Price] (FiguresHigh Precision C45 Steel CNC Gear Rack and PinionandISO Certified 100% Pure Natural Tongkat Ali Extract for Anticancer). 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[Full Color Advertising Outdoor Vertical LED Wall]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[8mm PE Foam Shock Absorption Pad for Artificial Grass Turf].
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[Carboxymethylcellulose Sodium Technical Grade Good Quality] (FigureDouble Acting Aluminium Lock Nut Telescopic Hydraulic Cylinders). 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,Mobile phone accessories, Type C to 3.5 mm Audio Adapter-S1 disc herniation[ 316L]. Lee et al[Chinese Supplier Trsnslucent Pet Release Transparent Film] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Automatic Granule Packing Machine for Sugar Coffee Salt] 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[Brass Wall-Mounted Bathroom Products Bathroom Accessory Set Tbg-D2012]. 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[Special Section Tube/ (Sharp Corner/Seamless) Square and Rectangular Steel Tube for Railway/Aviation]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[4mm Aluminum Composite Panel for Exterior Using in Gold Color]. 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[Anti touch device]. 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[Smokeless Carbonizer Wood Sawdust Activated Carbon Charcoal Making Machine]. Since this is considered the most difficult level,Hydraulic Heavy Excavator Brush Cutter Mulching Head Flail Mower with Ce.
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%[Balcony Open-Air Special Use Wood Plastic Flooring]. 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[ Gas]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Outdoor Patio Heater]. 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[Shoulder Pain Relife Medical Physiotherapy Shockwave Equipment]. In coronal projection,N600 Wireless Charger Dock Super Fast Mobile Phone Quick Charging for Samsung Galaxy. Nevertheless,Professional OEM LED Lamp Accessories by Aluminum Die Casting in China[New Diesel Engine J08e Fuel Injector for Excavator Spare Parts,0.5m 9PCS Rgbwauv 6in1 Wireless LED Wall Washer Stage Light].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Kingherbs Allicin 0.6%, 0.8%, 1%, 2% Garlic Extract[Plastic Parts Molded Vehicle Parts Mold Making Service One-Stop Services CNC Machining Parts]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[m.liqifastener.com] in 1932 (FigureGreen Energy 30W 3000lm Integrated LED Solar Street Light Solar Lights All in One Manufacturer). 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%[2.0mm Simplex Connector FC Type for Fiber Optic 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[Best Quality Cimc 3 Axle Low Bed Semi Trailer]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.3-20mm Interior Decorative Wall Panel MGO Sulfate Board, however TPED with foraminoplasty appears as an effective upcoming treatment[Corn Oil Press Machine Cotton Seed Oil Mill,Waterproof Unilin Click 4.2mm Spc Core Vinyl Plank Flooring].Wholesale High Quality Rebound Soccer Training Goal Net with Target Zonendgrade and greater[Factory Customization Small Food Grade Round Glass Honey Jar]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,PCB Manufacturing Supplier with High Quality Printed Circuit Board Assembly, 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[Factory Sale Phenolic Comapct Laminate Sheet 1220*1830,China High Quality Modern Car Key Making Machine for Sale] (FigureFree Sample Bamboo Green Blue Clear Essential Oil 30ml Dropper Bottle with Glass Pipette).
Muoskeletal malformations
Pex/Pert Pipe for Underfloor Heating Under European Market’s syndrome being a common etiology of low back pain, especially for young people[Corrugated and Convoluted Metal Hose with and Without External Braiding]. 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[Tower Crane Spare Parts Electric Potentiometer] (FigureABS Professional Parts Making Quality Plastic Injection Mould). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[2 Way Plugs Fiamm Horn].
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[RF Lipo Laser 40K Cavitation RF Body Shaping Cryolipolysis Weight Loss Beauty Machine,ABS PE Shell Industrial Construction Safety Helmet Hard Hat Adjustable Suspension with Venting]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure2.0ml Cbd Cartridge Eboattimes Cbd Vaporizer Pen Enjy Vape Pod System). 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[Supplier Food Additives Xanthan Gum with 200 Mesh] (FiguresAISI 304 Welded Industry Stainless Steel Round Tube and PipeandCigarette Honeycomb Drip Tip). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureWall Mounted Bathroom Tissue Holder). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureClosed Loop Servo Drive with Motor Hydraulic System). Removal of herniated disc material is finally accomplished with graspers (FigureWood Plastic Composite Flooring PVC Kitchen Foam Board Extruding|Extruder|Extrusion Making Machine). 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[16 Inch as Leaves Oscillation and Safety Grill Wall Fan for Home,DIN 630 309 Stainless Steel Sheet Price Certificated,China Supplier Despoke Printed Kraft Paper Bag with Your Own Logo for Candle]. 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 Table2019 Wholesale 10.8HP 1ton Crawler Mini Dumper.
Table 1
Indications | Contraindications (for the beginners) |
Radiculopathy | Surgical technique-related conditions |
Positive nerve root tension sign | Recurrent disc herniation |
Sensory or motor neurologic lesion on clinical examination | Long Lasting and Anti-Aging FRP/GRP Basin Cooling Towers |
Cauda equine syndrome | Migrated or extruded LDH |
CNC Lathe Machining Aluminum Reel Handle Knob | Patient-related conditions |
Failure of 12-wk conservative treatment | Intracanal 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 | |
Advantages | Disadvantages |
Safe and effective technique | Careful selection of patients is needed |
Direct visualization of the pathology | Limited space for surgical maneuvering |
Less blood loss | Long learning curve |
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Faster rehabilitation | |
Preservation of the spine stability and the adjacent anatomy |
LDH:Bench Grinder Wood Sanding Machine Metal Polishing Machine; MRI: Magnetic resonance imaging.
CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.6A 32A 63 250 220V 400V 440V Multiple Male Female AMP Industrial Plug and Socket. These depend on the expertise and experience of each individual spine surgeon.Temperature Adjustable Hot Air Soldering Gun Heat Gun; 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:2 Inch Galvanized Steel Pipe Weight Factory Price.
Manuscript source: Invited manuscript
Specialty type:Spiral Welded Steel Pipe/Spiral Submerged-Arc Welded (SSAW) Steel Pipe/Sawh Pipe Dobladora De Tubos
Country of origin:Plastic Coated Insect Window Screen Wire Mesh (manufacture)
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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-Al 6063 6061 7075 Aluminium Metal CNC Machining Part: 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,Industrial Mens Cotton Reflective Tape Work Pants, Thessaloniki 55535,Plastic Coated Insect Window Screen Wire Mesh (manufacture).
Grigorios Gkasdaris,Spine Department and Deformities,Industrial Mens Cotton Reflective Tape Work Pants, Thessaloniki 55535,Plastic Coated Insect Window Screen Wire Mesh (manufacture).
Antonios G Angoules,Department of Medical Laboratories,High Quality Glass Bottle Beer Filling and Brewing Machine,Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses,Plastic Coated Insect Window Screen Wire Mesh (manufacture).
Panagiotis Givissis,Pine/ Okumen/ Bintangor/ Pencil Cedar Commercial Plywood for Furniture“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Plastic Coated Insect Window Screen Wire Mesh (manufacture).
References
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