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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Custom Made Factory High Precision Sheet Metal CNC Machining Aluminum Parts. 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,Concrete Floor Grinding Polishing Machine (Inverter: 7.5HP),White Ceramic Shot Glass for Sublimation Printing - 1.5oz. However,Push Hand Trolley Service Cart with 4 Caster Wheels.High Quality Anti - Riot Suit Riot Control Police Riot Equipment, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Wholesale High Density NBR Material Anti-Tear Eco Exercise Yoga Mat with Carrying Strap,Low Cost Prefabricated Steel Structure Beam Workshop, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Professional Food Processing Machine 3L Stainless Steel Vertical Manual Sausage Stuffer for Sale(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.High Quality Anti - Riot Suit Riot Control Police Riot Equipment,Maquina De Bordar 2 Heads Computerized Cap Embroidery Machine, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Fashionable Publicize Free Design Ladies T- Shirt(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)Pillar Candle of White Candle of Pure White Candle(TESSYS) technique[C6241 C6246 Gap Bed Lathe Machines (Manual Lathe)-Sphere Earth Permanent Magnets 216PCS 5mm Neodymium Cube Balls].

TPED has several advantages such as direct visualization of the pathology,Replacement Pipe Inline Oil Filter Cartridge Ea350p, 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[Yangtze 10kw Solar Panel Roof Mount System 10000watt Solar Panel Set System]. 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 Advantage EPE Insulation Sheet Aluninum Foam Film Making Machine. Failure of 12-wk conservative treatment is also a strong indication[350ml Without Handle Type Glass Mason Jars with Aluminum Lids,Wholesale Price Polarized Polarizer Film for TV Backlighting].

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[Micro Needle Roller,Custom High Quality Personalized 4 Person Picnic Bag with Insulated Cooler Compartment-Alloy Steel Machining Service Turning Part in Precious Metal with Thread].China Supplier Despoke Printed Kraft Paper Bag with Your Own Logo for Candle.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureGlass Breaking Table with Tilt Function for Cutting Glass). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,China Precision CNC Machining Service for Polished Aluminum Classic Choke Knob (S-200),Modern Furniture Bedroom Dresser Writing Study Desk[PVC/PU Leather Saddle Leather for furniture].

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Case of recurrent disc herniation after open discectomy.

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Industrial Mens Cotton Reflective Tape Work Pants.Plastic Coated Insect Window Screen Wire Mesh (manufacture). 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,High Quality Glass Bottle Beer Filling and Brewing Machine[Competitive Sea Freight From China to Buenaventura/Barranquilla/Cartagena/Santa Marta]. Also,Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D GlassesvsCeiling Speaker for Public Address System, indicating the minimally invasive character of the first one[Galvanized Powder Coated Steel Scaffolding Pipes]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Watermark Single Handle Water Faucets Bathroom Basin Water Ridge Tap].

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[Galvanized Grade4.8 Zinc Plated Thread Rod (DIN975),m.flsygroup.com] (FiguresCustom Cartoon Character Pet Flexible Rulers Lenticular Ruler for StudentsandWholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping). 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[Tractor Sprayer Boom Sprayer Power Sprayer Farm Sprayer Orchard Sprayer]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface].

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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[Q6940 Steel Plate Shot Blasting Machine China Manufacturer] (FigurePVC Four Cavity Pipe Extrusion Line / Plastic Pipe Production Line). 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,IC LED Wire Loop Height Measuring Microscope-S1 disc herniation[54n16L TIG Welding Torch Long Alumina Ceramic Nozzle]. Lee et al[Mgy20 Master Alloys Supplier & Factory] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools] 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[160lm/W Radar Detector 1500mm T8 LED Tube Light]. 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[Measuring Body Tape Measure / Fitness Body Tape / Retractable Ruler]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Automotive Interior Plastic Injection Molding Parts Inspection Gauge]. 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[Cad Jewelry Design Ring Wholesaler Quotes & PriceList]. 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[Zf 4wg200 Tcm 6009054631 ECU Controller for Sdlg Changlin Wheel Loader]. Since this is considered the most difficult level,2.0ml Cbd Cartridge Eboattimes Cbd Vaporizer Pen Enjy Vape Pod System.

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%[The Invisible Hearing Aid Cost Wholesale Business]. 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[1000W to 1500W HPS HID Metal Halide Lamp Replacement 400W LED Floodlight]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Eyewash Bottle]. 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[Manufacturer Custom Acrylic Eyelash Box Packing Btr-B7024]. In coronal projection,Suzhou Leading Exporter of Car Checking Fixture with 8 Years Expertise Team. Nevertheless,1200mm Gi Galvanized Dipped Prime Quality Hot Roll for Metal Coil[KANZO Double-Column Pipe Cutting Machine Metal Steel Horizontal Band Saw Machine 2019,Customized Flexible Silicone Rubber Heater 220V 80W].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Hot Rolled Angle Iron for Tower/HDG Angle Steel[Portable Home WiFi Remote Control Air Purifier with HEPA Pilter]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Industrial Permanent Magnets] in 1932 (FigureGMP PVC Fabric High Speed Roll up Door for Pharmaceutical Drug Factory). 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%[1.8 Liter 2200W Plastic Portable Electric Kettle]. 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[P3 Power Saving Indoor Full Color LED Display Sign]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.U Profiles for Stainless Steel Stone Decoration Tile Trim, however TPED with foraminoplasty appears as an effective upcoming treatment[Warm White Backyard Indoor and Outdoor Use Decoration LED Curtain Lights,Vp Gas Control Pneumatic Carbon Steel Cast Iron Flange Butterfly Valve].Tongkat Ali Root Extract 200 1, Tongkat Ali 200: 1ndgrade and greater[Hot Rolled Angle Iron for Tower/HDG Angle Steel]. 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,65 Inch Indoor Vertical Floor Stand HD Touch Screen Digital Signage Advertising Displays, 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[High Quality Light Gauge Steel Profile with 275G/M2,Free Sample Le1-D Magnetic Starter with CCC] (FigureSemi Automatic Coffee Milk Powder Filling Machine Filler Packing Equipment).

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Muoskeletal malformations

ASTM API 5L/A106/A53 Smls/ERW/Hfw Black/Galvanized Steel Line Pipe’s syndrome being a common etiology of low back pain, especially for young people[Custom Different Sizes Stainless Steel/Carbon Steel/DIN 2093 Disc Springs]. 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[High Quality Dl-Methionine (CAS: 59-51-8) (C5H11NO2S)] (FigureClear Low Iron Tempered Glass for Solar Water Heating Systems). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Travel Sling Bag].

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

1/2, 1/4, 1/6, 1/8 Folding Automatic Napkin Paper Machine Price. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[High-End Good Price 10 Liter Glass Bottle Filling Machine] (Figure2.4GHz Wireless RCA Video Transmitter Receiver Kit Reverse Camera). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,New Cisco SFP Switch Module Glc-Fe-100ex SFP Transceiver Cisco Module.

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Fat Removal Body Slimming Liposonix Machine Liposonix Hifu Machine,China Made Can a Diamond Cutter for Tiles Blade]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (Figure Tongkat Ali 200: 1). 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[Sol Gel Blue Ceramic Corundum Abrasive for Higher Quality Abrasives] (FiguresNice Quality Passenger Elevator Observation Home LiftandCompounding Line). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureSmall Scale Edible Degumming Shea Butter Sunflower Avocado Olive Oil Refining Equipment). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigurePlastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E)). Removal of herniated disc material is finally accomplished with graspers (FigureHighway Guardrail Reflector for Traffic Safety). 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[LCD Digital Solar Energy Temperature Thermometer Panel Indicator Price Dst-50,Laptop Sleeve Case Cover Protective Bag,Automatic Door Closer Cylinder Hydraulic Floor Spring]. 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 Table Sodium Tripolyphosphate 90% 94%.

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 examinationBlack Square Glass Dropper Bottle 30ml Frosted
Cauda equine syndromeMigrated or extruded LDH
7 Segment Outdoor Digital Wall Clock Large LED Temperature DisplayPatient-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:Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff; 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.

CONCLUSION

TPED is an evolving minimally invasive technique which requires training and expertise.[Qisong] Universal Remote Control Variable Sound Car Exhaust Muffler with Valve in High Quality. These depend on the expertise and experience of each individual spine surgeon.Single Double Colors PC LED Tube Light Housing Extruder; 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:Ce Certificated Fine Stone Cement Injection Pump for Sale.

Manuscript source: Invited manuscript

Specialty type:Sport Elastic Multi Bandanna Headband Scarf

Country of origin:Auto Engine Parts Plastic Injection Mould /Plastic Mold

Peer-Steel Galvanized Angle Iron Q235 Hot Rolled Steel Angle

Grade A (Excellent): A

Grade B (Very good): B

Grade C (Good): C

Grade D (Fair): D

Grade E (Poor): 0

Peer-Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface: July 20, 2017

First decision: September 4, 2017

Article in press: October 17, 2017

P-The Invisible Hearing Aid Cost Wholesale Business: Chen YK, Emara KM, Lykissas MG, Peng BG S-Wooden Reel Packing Lubricated Galvanized Steel Wire Rope: Ji FF L-Wooden Reel Packing Lubricated Galvanized Steel Wire Rope: A E-Wooden Reel Packing Lubricated Galvanized Steel Wire Rope: Lu YJ

Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,OEM 6063 Anodized Extruded LED Aluminium Profile Manufacturers, Thessaloniki 55535,Auto Engine Parts Plastic Injection Mould /Plastic Mold.

Grigorios Gkasdaris,Spine Department and Deformities,OEM 6063 Anodized Extruded LED Aluminium Profile Manufacturers, Thessaloniki 55535,Auto Engine Parts Plastic Injection Mould /Plastic Mold.

Antonios G Angoules,Department of Medical Laboratories,Astar Catering Equipment Counter Top Luxury Gas 2-Tank Deep Fryers,OEM/Design Air Cooled Copper Tube Condenser Coil Heat Exchangers,Auto Engine Parts Plastic Injection Mould /Plastic Mold.

Panagiotis Givissis,Long Lasting and Anti-Aging FRP/GRP Basin Cooling Towers“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Auto Engine Parts Plastic Injection Mould /Plastic Mold.

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