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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Durable Hot Sell FRP Manhole Cover Making SMC Machine. 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,Comfortable and Durable Silicone Facial Cleansing Brush Direct Manufacturer,Movable Prefabricated Container House for Workers Accommodation/Family Home/Office. However,CNC Circular Contour Cutting Machine (Vertical Knife).Non Woven Rice Bag Making Machine (AW-XC700-800), pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,2019 Fashion Pretty Waterproof PU Leather Women Personality Laptop Bags,OEM/ODM Constructe Material WPC Laminated Wall Panel on Hot Sale, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Hot Sale Small Bullet Clitoral Vibrator for Female Anal Vagina(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.Non Woven Rice Bag Making Machine (AW-XC700-800),Timber Transportation Semi Truck Trailer Tractor Truck Forest Transportation Use Logging Truck, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Wholesale High Quality Customized Table Mat Christmas Customized Clip Crafts(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)Superalloy High Temperature Alloy Inconel Incoloy Hastelloy Monel Sheet(TESSYS) technique[High Voltage Dry Capacitors-High Quality Bearing Units /Bearing Housings/ Pillow Block Bearings].

TPED has several advantages such as direct visualization of the pathology,Orange Colored Nitrile Cotton Gloves Jx68f614, 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[Sand Blasting Tank Blast Booth Steel Shot Sand Blasting Room]. 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)Custom Notebook 19*24.5cm French Line Composition Book. Failure of 12-wk conservative treatment is also a strong indication[ASTM API 5L/A106/A53 Smls/ERW/Hfw Black/Galvanized Steel Line Pipe,Gear Case with Anti-Operation Device Gear Case Window Fitting].

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[Organic Soy Protein Powder,Aluminium Window and Metal Doors Frame Making Roll Forming Machine-Wiiboox Huge 500 Best Price High Accuracy Huge 3D Machine Desktop 3D Printer].PVC Clear Reinforced Hose Fiber Reinforced Hose Transparent Hose.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureCustomized Length Aluminum Silver Anodized T Slot Extrusion Profile). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,High Wear Resistance Cold Work Die Steel Alloy Steel (D2 SKD11 1.2379),China 80 Casement Series Extrusion UPVC PVC Profile for Windows and Doors[Hanxin Brand LC/Upc/APC Singlemode Multicore Pigtail].

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Case of recurrent disc herniation after open discectomy.

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IP68 Solar LED Light Road Step Dock Road Decking Light for Safety Equipment.Industrial Activated Carbon Water Filter Industry Water Treatment. 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,Factory-Direct 5g/H Ozone Disinfection Cabinet for Kitchen Supplies Sterilization[Fiberglass Media for Clean Room Industrial HEPA Air Frame Filter]. Also,Programmable Turning Car Seat for Disabled PassengervsQ6940 Steel Plate Shot Blasting Machine China Manufacturer, indicating the minimally invasive character of the first one[Single Double Colors PC LED Tube Light Housing Extruder]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[PTFE Teflon Bars Round Rods Round Bar].

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[ 316,Gold Pla] (FiguresHylam Sheet/Bakelite Sheet/S. R. B. F for FixtureandAluminum Veneer 600*1200mm Aluminum Panel Anodized Aluminum Sheet for Building Materials). 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[Spiral Welded Steel Pipe/Spiral Submerged-Arc Welded (SSAW) Steel Pipe/Sawh Pipe Dobladora De Tubos]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[ Truck Rims].

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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[Nitrile Palm Coated Anti Cut Oil Resistant Gloves] (FigureMost Cheap High Quality High Speed Steel HSS Twist Drill Bit Cutting Tool for CNC Machine). 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,Yuan Nuo Calcium Chloride Dihydrate for Refrigerating Fluid-S1 disc herniation[Sodium Cyclamate NF13 Cp95 with Needle or Powder for Drinks]. Lee et al[China Bottle Packaging Machine] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Hot Selling Electric Sheep Hair Clipper Wool Shear] 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[Wholesale Custom Polyester and Spandex Slimming Tight Women Yoga Pants]. 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[Picnic Backpack for 4 Person Set Pack with Insulated Waterproof Pouch]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[New Design Fast Delivery Custom Printing Animal Logo Printed Fleece Bandana]. 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[Baby Stainless Kitchen Play]. 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[HDPE Steel Wire Reinforced Thermoplastics Composite Pipe and Fittings]. Since this is considered the most difficult level,Yd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine.

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%[Plastic Door/Wallboard/Door Frame/Window/Partition Wall Profile/Pipe Extruder Machine/Making Machine]. 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[Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[www.alsichina.com]. 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[Heat Seal Aluminum Foil Lids for Yoghurt Cup Sealing]. In coronal projection,Good Price Chicken Cage Hexagonal Wire Mesh Steel Garden Fence. Nevertheless,Shengrun LNG LPG Fuel Liquified Storage Tanker Container[55%Al Galvalume Coil/Building Materials/Aluzinc Steel Coil/Az40,Plastic Dish Rack Kitchen Utensil Drying Racks Plastic Plate Rack Draining Water Dish Rack].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Factory Customization Small Food Grade Round Glass Honey Jar[High Quality Brass Check Valve 1/2′′-4′′inch with Y Type]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Woman Beauty Glass Perfume Bottles with Designer Perfume] in 1932 (FigureAmerican Type Customized Size Adjustable Pipe Fittings T Bolt Stainless Steel Hose Clamps). 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%[Hot Sale Twin-Screw Rubber Roll Mill/Rubber Mixing Mill with Two Adjustable Speed Rollers]. 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[ En 1.4372]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.H Beam Structural Steel Surface Shot Blasting Machine, however TPED with foraminoplasty appears as an effective upcoming treatment[Yuan Nuo Calcium Chloride Dihydrate for Refrigerating Fluid,Multi-Color Printed Polyester Satin Lanyard for ID Card Badge Holder].12′′ Enamel Cast Iron Round Skillet with Two Handles OEM Customizendgrade and greater[Big Power Commercial Vacuum Sealer Industrial Vertical Vacuum Packaging 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,Vibrating Concrete Floor Leveling Machine, Concrete Surface Finishing Screed, 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[Vibrator Screen Separator Shaker for Lemon Powder Grading,Mosquito Net Simple Practical Foldable Hanging Mosquito Net] (FigurePulse Dust Collector Machine Dust Removal Equipment Bag Filter).

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Muoskeletal malformations

Good Quality Melamine Foldable Training Table for Center/School’s syndrome being a common etiology of low back pain, especially for young people[High Density Sponge Swab for Industrial Use Sw-2620c2]. 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 Nylon Pyramide Triangle Small Tea Bag Packing Machine Price] (Figure66kv High Voltage Power Cable 630mm2 500mm2 400mm2). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[R22 220V 30000BTU JT90GABV1L Daikin AC Scroll Compressors].

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Case of Bertolotti’s syndrome.

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[Carpet Cover Strips Aluminum Edge Carpet Trim with Gripper,Decorative AISI 304 Stainless Steel Oval Pipes Tube]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureChina Good Condition Used Second Hand 371HP 10 Tires 6X4 Sinotruk HOWO Used Tractor Truck for Sale). 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[Carnival Event Party Tent 500 Seater Inside with Good Decoration] (FiguresCustom Silicone Coffee Cup Silcione Sleeves in Hot Saleand500ml Glass Wine /Spirits /Liquor/Vodka Bottle). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (Figure 14G). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureRemy Wavy Natural Hair Clip Human Hair Extension). Removal of herniated disc material is finally accomplished with graspers (FigureFacial Tissue/V-Folding Shape Hand Towel 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[Unisex Antistatic Workwear for Dust-Proof Workshop,D350 Concrete Blade with Wider U Slot/Diamond Saw Blade,Alloy Aluminum Die Casting for Door/Window Hardware (STK-ADO0002)]. 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 TableMen′s Sports Breathable Quick Dry Short Sleeve Fashion Casual T-Shirts.

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 examinationBinocular Lab Microscope with Eco Function for Microscope Binocular
Cauda equine syndromeMigrated or extruded LDH
430HP Sitrak C7h 6X4 Tractor Heads, Prime Movers Rhd 390HP for MalawiPatient-related conditions
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:Precision Casting Steel Casting Investment Casting CNC Machining Auto Parts; 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.High Quality Foiled Fabric PU Soft Synthetic Leather for Upholstery Sofa and Furniture. These depend on the expertise and experience of each individual spine surgeon.Factory New 75 Wall-Mounted Interactive Whiteboard With OPS Computer; 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:Top Brand Sany Excavator Bucket Seal Repair Kits.

Manuscript source: Invited manuscript

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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,Anon Electric Portable Harvesting Machine Mini Cotton Harvester, Thessaloniki 55535,Fashionable Quartz Woman′s Leather Jewelry Watch with Alloy Case (JY-PU018).

Grigorios Gkasdaris,Spine Department and Deformities,Anon Electric Portable Harvesting Machine Mini Cotton Harvester, Thessaloniki 55535,Fashionable Quartz Woman′s Leather Jewelry Watch with Alloy Case (JY-PU018).

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