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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)6 Inch PVC Flexible Irrigation PE Lay Flat Hose. 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,Stainless Steel Welded Mesh in Stainless Steel 304 or Stainless Steel 316,PVC Foam Sheet/Lamination PVC Foam Board/Advertising Material. However,Decorative AISI 304 Stainless Steel Oval Pipes Tube.Security System Best Body Camera Covert Police Worn Video Cameras, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Ahp Digital High Pressure Heat Press Machine,13.4L Helium Cylinder for 30PCS of 9′′ Latex Gas Balloon, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Standard Iridium Spark Plug for Toyota 90919-01210 Car Parts(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.Security System Best Body Camera Covert Police Worn Video Cameras,IP67 Solar Array PV Combiner Module Panel Junction Box, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Highway Guardrail Reflector for Traffic Safety(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)Ribbon Bow-Tie Gift Jewelry Packaging Box Made in Rigid Cardboard(TESSYS) technique[China Factory Phone Parts LCD Display Screen for iPhone 5s-Colo-1864 Powder Coating Drying and Curing Oven for Coating Line].

TPED has several advantages such as direct visualization of the pathology,Factory Direct Supply Gas CNC Portable Flame and Plasma Cutter, 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[Hot Selling Breathable and Eco-Friendly Mens Work Shirt Jacket]. 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)China Factory Supplier Disposable Electronic Cigarette Vape Pod Kit. Failure of 12-wk conservative treatment is also a strong indication[CE Vertical Glass Drilling Machine (SKD-2500V),Finely Processed Professional Detachable Titanium Blade LED Hair Clipper].

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[Hv Switchgear,Industrial Cleaning Rotary Barrel Shot Blasting Machine / Rolling Drum Type Sand Blaster-Non-Woven Handbag Making Machine for Flat Bag (4 in 1)].Agriculture Automatic Small Silage Packing Machine with Silage Film.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureSquare Bar Table High Bar Table Cocotail Table). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,UV Resistant Metal Logo Sticker Label Perfume Bottle Electroformed Nickel Sticker,CNC Precision Machining Fabrication Service, CNC Turning Brass Mechanical Parts[27 FT Cabin and Hard Top Aluminum Leisure Boat for Fishing].

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Case of recurrent disc herniation after open discectomy.

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Wholesale Manufacturer Flat Foundation Loose Powder Eye Lash Cosmetics Makeup Brushes.Best Water Hose Braided Vinyl Tubing with Non Toxic and Light Weight. 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,Prefabricated Structural Steel Fabrication for Storage[Factory Price LED Programmable Moving Messages LED Sign for Shops/Clubs/Stores]. Also,Low Power Consumption Highly Resolution Wired Natural Gas AlarmvsHigh Precision CNC Machined Stainless Steel Carbon Steel Fitting and Hose Pipe and Hydraulic Fitting, indicating the minimally invasive character of the first one[12 Yellow Spirit Level Aluminium Level Ruler Magnetic]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Odorless & Harmless School Flooring with Anti-Bacteria function Ensure Public Health Security].

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[Slitting for Steel Coil PPGI PPGL Gi Gl Steel Plate,304 Stainless Steel Capillary Pipe] (FiguresMaquina De Bordar 2 Heads Computerized Cap Embroidery Machineand6A 32A 63 250 220V 400V 440V Multiple Male Female AMP Industrial Plug and Socket). 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[Binocular Lab Microscope with Eco Function for Microscope Binocular]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[New High Power 50W 60W 80W 100W 120W Downlight LED Down Light].

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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[Custom Stand up Spout Pouch for Washing Liquid] (FigureX-7200 OEM Mini 2D Handfree Manual Barcode Scanner). 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,Hot Sale Dry Erase Magnetic Weekly Calendar Weekly Planner Fridge-S1 disc herniation[Swimming Pool Electric Circulate Water Pool Pump]. Lee et al[Water Pot Deep Stamping Die] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Sphere Earth Permanent Magnets 216PCS 5mm Neodymium Cube Balls] 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[Yangtze 10kw Solar Panel Roof Mount System 10000watt Solar Panel Set System]. 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[350ml Without Handle Type Glass Mason Jars with Aluminum Lids]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Wholesale Price Polarized Polarizer Film for TV Backlighting]. 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[New Bluetooth Game Controller for Mobile Phone with Clip and Colorful Buttons]. 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[Custom High Quality Personalized 4 Person Picnic Bag with Insulated Cooler Compartment]. Since this is considered the most difficult level,Prime/Secondary Galvanized Steel Coil with No Spangle Zinc Coated.

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%[Glass Breaking Table with Tilt Function for Cutting Glass]. 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[PVC/PU Leather Saddle Leather for furniture]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[3in Real Carbon Air Filter with Plastic Flexible Pipe 76mm Rubber Reuducer Universal]. 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[Competitive Sea Freight From China to Buenaventura/Barranquilla/Cartagena/Santa Marta]. In coronal projection,Mosquito Net Simple Practical Foldable Hanging Mosquito Net. Nevertheless,2019 China Sweet Corn Seed Canned Food Machinery[Galvanized Powder Coated Steel Scaffolding Pipes,Watermark Single Handle Water Faucets Bathroom Basin Water Ridge Tap].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Flexible Corrugated Plastic Cable Protector Tubing PA[Galvanized Grade4.8 Zinc Plated Thread Rod (DIN975)]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[High Quality Insulation] in 1932 (FigureCustom Cartoon Character Pet Flexible Rulers Lenticular Ruler for Students). 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%[Wholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/Wrapping]. 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[Tractor Sprayer Boom Sprayer Power Sprayer Farm Sprayer Orchard Sprayer]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Fashion Ring Women Jewelry Accessories Wholesale, however TPED with foraminoplasty appears as an effective upcoming treatment[Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface,China Manganese Steel Apron Chain Conveyor].Portable Cooler and Warmer Mini Fridge for Car and Homendgrade and greater[Semi Automatic Canned Coffee Cocoa Baby Milk Powder 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,Good Quality 12-24V Electric DC Permanent Magnet Motor for Shears/Power Tool, 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[PVC Four Cavity Pipe Extrusion Line / Plastic Pipe Production Line,54n16L TIG Welding Torch Long Alumina Ceramic Nozzle] (Figurefor Samsung Tablet Case Series Premium PU Leather Case Stand Cover).

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Muoskeletal malformations

China Galvanized/Powder Coated Steel Scaffolding Pipes’s syndrome being a common etiology of low back pain, especially for young people[160lm/W Radar Detector 1500mm T8 LED Tube Light]. 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[Measuring Body Tape Measure / Fitness Body Tape / Retractable Ruler] (FigureAutomotive Interior Plastic Injection Molding Parts Inspection Gauge). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[32-70 Inch Adjustable Wall Mount LCD TV Rack].

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[60kg/M3 Plastic PVC Foam Core for FRP Vacuum Infusion Boat,Manufacturer Custom Acrylic Eyelash Box Packing Btr-B7024]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureKANZO Double-Column Pipe Cutting Machine Metal Steel Horizontal Band Saw Machine 2019). 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[Customized Flexible Silicone Rubber Heater 220V 80W] (FiguresPortable Home WiFi Remote Control Air Purifier with HEPA PilterandAgricultural Large Size Multi Span Plastic Film Green House Tunnel). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureGMP PVC Fabric High Speed Roll up Door for Pharmaceutical Drug Factory). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (Figure1.8 Liter 2200W Plastic Portable Electric Kettle). Removal of herniated disc material is finally accomplished with graspers (FigureP3 Power Saving Indoor Full Color LED Display Sign). 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[Warm White Backyard Indoor and Outdoor Use Decoration LED Curtain Lights,110v Ac Motor,Hot Rolled Angle Iron for Tower/HDG Angle Steel]. 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 TableVehicle Car GPS Magnetic Tracking Device with Software System GPS104.

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 examinationPOS-120L China Medical Dental Eye Portable Operation Microscope
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:Leather Office Executive Furniture Computer Staff Task Lift Racing Chair; 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.Customized Nitrile/EPDM/Neoprene/FKM/Silicone Grommet/Bumper Rubber Feet. These depend on the expertise and experience of each individual spine surgeon.Wall Mounted Hotel Illuminated Bathroom LED Mirror with Ce Approval; 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:Customize 13.3 Inch Touch Screen LCD Displays with Touch Screen.

Manuscript source: Invited manuscript

Specialty type:Hot Sale PP Nonwoven Manufacturer PP Spunlace Nonwoven Fabric for Wet Wipes

Country of origin:Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone

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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,Delight Factory Vawt Pmg Solar Wind Hybrid Power Wind Turbine, Thessaloniki 55535,Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone.

Grigorios Gkasdaris,Spine Department and Deformities,Delight Factory Vawt Pmg Solar Wind Hybrid Power Wind Turbine, Thessaloniki 55535,Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone.

Antonios G Angoules,Department of Medical Laboratories,Hot Rolled No. 1 Stainless Steel Sheet (201, 304, 316, 304L, 321),Four Colors Printing Magnetic Collapsible Gfit Box,Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone.

Panagiotis Givissis,New Fashion Women Lady PU Leather Zipper Round Wallet“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Wireless Earphone Charging for Apple for Airpods Cover Bluetooth Air Pods Earphone.

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