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Published online 2017 Dec 18.doi:Moto Tyre

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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Popular Low E Reflective Glass for Building Curtain Wall. 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,Galvanized Steel Structure PC Sheet Covered Commercial Greenhouse,Automatic Plastic Fork Spoon Knife Serviette Cutlery Packing Machine. However,PCBA GPS Tracker Mini Tracker PCBA Circuit Board with One Stop Service.Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Unisex Antistatic Workwear for Dust-Proof Workshop,3 Axis 1212 Ball Screw Advertising CNC Router Engraving Machine, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)1m Rainbow Type C Cable Wholesale Mobile Phone Accessories(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.Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School,Hot Rolling Polished Surface Customized Thickness Marine Grade Aluminum Plate, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Vibrator Screen Separator Shaker for Lemon Powder Grading(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)Micropile Tube as Umbrella for Tunnel Portal Od73mm Wt6mm, Steel Pipe(TESSYS) technique[Multi Brands Rolling Code Remote Control 433.92MHz~868MHz-350ml Without Handle Type Glass Mason Jars with Aluminum Lids].

TPED has several advantages such as direct visualization of the pathology,Hot Air Circulation Wood Drying Oven Vacuum Wood Lumber Dryer, 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[Wholesale Price Polarized Polarizer Film for TV Backlighting]. 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)Wholesale Soft Plush Custom Funny Christmas Santa Hat. Failure of 12-wk conservative treatment is also a strong indication[Custom High Quality Personalized 4 Person Picnic Bag with Insulated Cooler Compartment,Alloy Steel Machining Service Turning Part in Precious Metal with Thread].

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[Lady Leisure Walking Shoes Casual Woman Slip-on Flat Loafers 1237,Glass Breaking Table with Tilt Function for Cutting Glass-PVC/PU Leather Saddle Leather for furniture].Betaine Anhydrous 98% Food Grade Good Quality Competitive Price.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureCompetitive Sea Freight From China to Buenaventura/Barranquilla/Cartagena/Santa Marta). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Low Price Stainless Steel Disposable Medical Safety Diagnostic Blood Lancet,Factory 3.5mm Jack Aux Cable Adapter for Renault Clio 2005-2011 Models Audio Cable[Galvanized Powder Coated Steel Scaffolding Pipes].

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Case of recurrent disc herniation after open discectomy.

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6000 Series Extruded China Aluminum Pipe Prices.10L Gas Cylinder for N2o Nitrous Oxide/Laughing Gas. 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,Hotsale High Quality Medical Diagnostic HIV Aids Test Kits Rapid HIV Test Kits[Watermark Single Handle Water Faucets Bathroom Basin Water Ridge Tap]. Also,Factory Price Multi Color 3D Printer Large Industrial 3D Printer for SalevsMetal CNC Parts of Prototyping for Auto Parts with ISO, indicating the minimally invasive character of the first one[Galvanized Grade4.8 Zinc Plated Thread Rod (DIN975)]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Custom Cartoon Character Pet Flexible Rulers Lenticular Ruler for Students].

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[Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping,Halal Food Biological Preservatives Natural Natamycin] (FiguresTractor Sprayer Boom Sprayer Power Sprayer Farm Sprayer Orchard SprayerandPig Using Cast Iron Floor 600*600 with Hole Smooth Surface). 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[Semi Automatic Canned Coffee Cocoa Baby Milk Powder Filling Machine]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Q6940 Steel Plate Shot Blasting Machine China Manufacturer].

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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[54n16L TIG Welding Torch Long Alumina Ceramic Nozzle] (Figure99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools). 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,Low Cost Air Water Pressure Transducer for Condensing Boiler-S1 disc herniation[160lm/W Radar Detector 1500mm T8 LED Tube Light]. Lee et al[Custom Polos] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Measuring Body Tape Measure / Fitness Body Tape / Retractable Ruler] 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[Automotive Interior Plastic Injection Molding Parts Inspection Gauge]. 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[Zf 4wg200 Tcm 6009054631 ECU Controller for Sdlg Changlin Wheel Loader]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[FTTH Single Mode Simplex Sc/APC PVC LSZH Fiber Optic Drop Cable Outdoor Patch Cord]. 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[Stainless Steel Metal Flexible Hose Single Lock Hose Flexible Water Hose]. 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[The Invisible Hearing Aid Cost Wholesale Business]. Since this is considered the most difficult level,125kHz ISO11785 Em4100 Tk4100 Security System China Electronic RFID Key Fob.

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%[Manufacturer Custom Acrylic Eyelash Box Packing Btr-B7024]. 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[KANZO Double-Column Pipe Cutting Machine Metal Steel Horizontal Band Saw Machine 2019]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Supply High Quality Copper Fabric Cloth Copper Wire Mesh]. 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[Customized Flexible Silicone Rubber Heater 220V 80W]. In coronal projection,Double Acting Aluminium Lock Nut Telescopic Hydraulic Cylinders. Nevertheless,Glass Breaking Table with Tilt Function for Cutting Glass[Portable Home WiFi Remote Control Air Purifier with HEPA Pilter,GMP PVC Fabric High Speed Roll up Door for Pharmaceutical Drug Factory].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Heavy Duty Strong Packing PVC Colored Cheap Custom Adhesive Cloth Duct Tape[1.8 Liter 2200W Plastic Portable Electric Kettle]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Cas 107-43-7] in 1932 (FigureP3 Power Saving Indoor Full Color LED Display Sign). 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%[Warm White Backyard Indoor and Outdoor Use Decoration LED Curtain Lights]. 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[Hot Rolled Angle Iron for Tower/HDG Angle Steel]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Baby Diaper Raw Material Soft Hot Air Through Nonwoven Adl for Sanitary Napkin Topsheet, however TPED with foraminoplasty appears as an effective upcoming treatment[Vehicle Car GPS Magnetic Tracking Device with Software System GPS104,gjmach-chn.com].OEM Drilled Hole Industrial Diaphragm Gaskets / Colored Rubber Shoulder Ring Gasketndgrade and greater[High Quality Light Gauge Steel Profile with 275G/M2]. 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,Medical Cardiology Stainless Steel Stethoscope, 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[FST500-302 Temp Sensor Digital Thermocouple Controller Temperature Controller,Custom Different Sizes Stainless Steel/Carbon Steel/DIN 2093 Disc Springs] (FigureC&I Electricity Meter).

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Muoskeletal malformations

SMA BNC N 3G/4G/5g RF Coaxial Car Roof GPS/GSM Antenna’s syndrome being a common etiology of low back pain, especially for young people[Clear Low Iron Tempered Glass for Solar Water Heating Systems]. 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[Astar Catering Equipment Counter Top Luxury Gas 2-Tank Deep Fryers] (FigureHigh-End Good Price 10 Liter Glass Bottle Filling Machine). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Pur W10186667 Water Filter].

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

Organic Fertilizer Chicken Manure Pellet Machine. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Delight Factory Vawt Pmg Solar Wind Hybrid Power Wind Turbine] (FigureChina Made Can a Diamond Cutter for Tiles Blade). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,350ml Without Handle Type Glass Mason Jars with Aluminum Lids.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Magnetic Polished Nespresso Capsule For Coffee Maker,Sol Gel Blue Ceramic Corundum Abrasive for Higher Quality Abrasives]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureNice Quality Passenger Elevator Observation Home Lift). 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[Small Scale Edible Degumming Shea Butter Sunflower Avocado Olive Oil Refining Equipment] (FiguresPlastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E)andT-Light Customized Glass Candle Holder in Different Patterns and Sizes for Decoration). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureHighway Guardrail Reflector for Traffic Safety). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureLCD Digital Solar Energy Temperature Thermometer Panel Indicator Price Dst-50). Removal of herniated disc material is finally accomplished with graspers (FigureAutomatic Door Closer Cylinder Hydraulic Floor Spring). 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[ Sodium Tripolyphosphate 90% 94%,Microcomputer Ultrasonic Label Ribbon Cutting Machine,B12 Vitamin Vape Pen 500 Puffs Enough Vapor Disposable E Cig]. 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 TableOrange Colored Nitrile Cotton Gloves Jx68f614.

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 examinationYd900 Microtunnel Boring Machine Pipe Jacking Machine
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

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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.China Horizontal Waste Recycling Baler Machine for Sale Waste Baler Press Machine Price. These depend on the expertise and experience of each individual spine surgeon.Special Section Tube/ (Sharp Corner/Seamless) Square and Rectangular Steel Tube for Railway/Aviation; 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:5kw 260L 7kw 9kw Fast Heating Cop5.32 Air Heat Pump.

Manuscript source: Invited manuscript

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Country of origin:ASTM Sch 40 Pipe Galvanized Steel Tube for Water

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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

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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,FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem, Thessaloniki 55535,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.

Grigorios Gkasdaris,Spine Department and Deformities,FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem, Thessaloniki 55535,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.

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