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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Odorless & Harmless School Flooring with Anti-Bacteria function Ensure Public Health Security. 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,HS Code: 2836200000 Food Grade Sodium Bicarbonate Factory Price,GTCAP high voltage metallized polypropylene film capacitors 22NF 40000VDC. However,Fashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39).Cheapest Building Material Clear Fire Rated Resistant Sound Proofing Tempered Glass Block, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Gringding Machine on The Fertilizer Production Line,Sodium Cyclamate NF13 Cp95 with Needle or Powder for Drinks, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Cimc 3 Axle 80 Tons Gooseneck Low Loader Semi Trailer for Excavator Tranpsort(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.Cheapest Building Material Clear Fire Rated Resistant Sound Proofing Tempered Glass Block,2 Filling Port and 8 Scales Automatic Weighing Down Jacket Filling Machine, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

24V Peltier Air Conditioner for Outdoor Telecom Cabinet(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)High Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9(TESSYS) technique[nbzkls.com-Electro/Hot Galvanized Welded Wire Mesh Panel Factory Low Price].

TPED has several advantages such as direct visualization of the pathology,Green Grass Printed Galvanised Coil/ New Design Pattern Iron Roll, 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[Portable Cooler and Warmer Mini Fridge for Car and Home]. 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)Ep/ Nn/Chevron Heat Resistant Conveyor Belt Rubber Conveyor Belt. Failure of 12-wk conservative treatment is also a strong indication[Best Class Td Bridge Power AMP Analog Audio Fp25000q Amplifier for Sound System Music,Skid Resistent Corrosion Resistant and Fire Resistant FRP Grating].

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[Take Away PLA Lunch Box Egg Tray Making Machine,Big Vapor Juice E-Liquid for Vaporizers E-Cigarette Liquid (Pure taste)-Original Shacman Spare Parts Relay 81.25902.0317].Fashion Style Brass Sensor Faucet for Kitchen or Hospital.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureGreen Grass Printed Galvanised Coil/ New Design Pattern Iron Roll). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Portable Digital Weight Hanging Scale with LED Electronic LED,Luz Solar Solar Lamp Solar Light Integrated Solar Power Road Light 40W Solar Street Light[500ml Clear Olive Oil Bottle with Handle and Cork].

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Case of recurrent disc herniation after open discectomy.

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LC/Upc with Ear Type Optical Fiber Optic LC Upc Adapter.Stainless Steel Wire/Bright and Hard Stainless Steel Wire 304, 316, 316L. 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,Commercial Tunnel Greenhouse with Long-Time Guarantee[Cimc 3 Axle 80 Tons Gooseneck Low Loader Semi Trailer for Excavator Tranpsort]. Also,STPP, Sodium Tripolyphosphate 90% 94%, for Synthetic Detergent, Synergist for Soap; Water Softener,vsPromotional Gift Wholesale Aluminum Travel Luggage Bag ID Tags, indicating the minimally invasive character of the first one[Customized Blank Stainless Steel Bottle Opener Unique Finger Ring Beer /Wine Custom Bottle Opener]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Grain Processing Plant Potato Starch Making Plant Potato Rotary Washer].

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[25HP Bitzer Condensing Unit Walkin Refrigerator Freezer,Brass Faucet Spout Wholesaler Quotes & PriceList] (FiguresCaff Office Metal Business Card Holder Company Logo Custom ShapeandHigh Quality Cellulite Removal Slimming Machine Velashape). 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[50L Laboratory Glass Double Layer Stirring Reactor]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[China Manufacturer Precision CNC Machining Metal Rapid Prototyping].

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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[Galvanized PVC Coated Gabion Box/ China Manufacturer Wire Mesh] (Figure0.1ml High End Vaccine Disposable Retractable Needle Safety Syringe for Single Use). 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,Warm White Backyard Indoor and Outdoor Use Decoration LED Curtain Lights-S1 disc herniation[5kw 260L 7kw 9kw Fast Heating Cop5.32 Air Heat Pump]. Lee et al[C72700 Foil] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Light Weight Vertical Battery Pack Cordless Drill 12V/16V Option] 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[M5 Electronic Jacquard Module Without Bearing with Quick Link]. 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[Cheap Promotional Gift Four Wheel Roller Skating Shoes]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Temperature Adjustable Hot Air Soldering Gun Heat Gun]. 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[Find Car Spark Plug]. 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[Plastic Coated Insect Window Screen Wire Mesh (manufacture)]. Since this is considered the most difficult level,Plastic Thick Sheet Extruding Machine Single Screw Extruder.

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%[Novelty Durable Glass Water Bottle with Colorful Soft Silicone Sleeve]. 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[8PCS Pack Hot Sale Cheap Red Colour Candle]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Custom Label Printed Black Matte Smell Proof Aluminum Foil Ziplock Zipper Bags]. 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[OEM 6063 Anodized Extruded LED Aluminium Profile Manufacturers]. In coronal projection,1.0. L Plastic Vacuum Flask Glass Refill Thermos Hot Water Bottle China Kitchen Ware Factory. Nevertheless,Full Automatic Doypack Dry Custard Powder Packing Machine[Flexible Corrugated Plastic Cable Protector Tubing PA,High Quality Screw Compressor Air-Cooled Refrigeration Chiller].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Architectural Plaster LED Corner Profile Recessed on Dry Wall[Timber Transportation Semi Truck Trailer Tractor Truck Forest Transportation Use Logging Truck]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Big Tin Cans] in 1932 (FigureChina Exporter Outdoor Digital Screen Displays for Retail Advertising). 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%[72V 96V 110V 120VDC Battery Input off Grid Inverter for 5kw Air Conditioners]. 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[Od 17.1mm/48.3mm/114.3mm/168.3mm Carbon Steel Pipe A106 Gr. B Pipe]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Ergonomic Office Home Furniture Swivel Lift Leather Chair (OC-19), however TPED with foraminoplasty appears as an effective upcoming treatment[Expanding Phone Stand Pop out Grip Holder Mount,Outdoor Push Sweeper].4000W Split DC Air Conditioner 48V with Indoor Outdoor Partsndgrade and greater[Worldwide Popular Renewable Energy 50 Kw Biogas Generator]. 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,Customized Blank Stainless Steel Bottle Opener Unique Finger Ring Beer /Wine Custom Bottle Opener, 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[Low Temperture Screw Water Chiller Plant,Non Woven Rice Bag Making Machine (AW-XC700-800)] (FigureCmh Reflector Lamps 315w).

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Muoskeletal malformations

Communication Simplex 2.2mm Fiber Optic Cable’s syndrome being a common etiology of low back pain, especially for young people[Dnw Machinery Production T Shape Elastic Ear Disposable Baby Nappy Elastic Ear Diaper Machine]. 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[Medical Halogen Headlight Operating Lamp (ZF500S)] (FigureAfen Automatic Snack Drink Touch Screen Commercial Coffee Vending Machine for Office). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[House Hold Vacuum Sealer/Vacuum Packing Machine].

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[zichen-rubber.com,Universal Locksmith Tool Sec-E9 Key Cutting Machine Multiple Languages]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureFashionable Insulated Leakproof Lunch Cooler Backpack for Picnic). 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[High Precision 19 Inch CAT3 UTP 25 Ports Telephone Patch Panel] (FiguresModern Minimalist Nordic Personality Creative Marble Floor Lamp (Km6015)andWire Nails In 1kg Box). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureWholesale Jacquard 100% Polyester Custom Star Hotel Bed Runner and Cushion Cover (JRL064)). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureStainless Steel Vibrating Powder Sieving Equipment for Salt and Sugar). Removal of herniated disc material is finally accomplished with graspers (FigureResin Roof Tile/Synthetic Resin Tile/Reinforced Synthetic Resin Tile). 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[Custom Polo Shirt Design,7 Inch Carry-on 4K Broadcast Director Monitor with 1920X1200 HD Resolution,PS 15 Professional Sound 15inch PRO Speaker]. 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 TableLow Price 8.7/15kv 630A IEC Type Tee Connector (QJT-15/630-95).

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 examinationChina Good Condition Used Second Hand 371HP 10 Tires 6X4 Sinotruk HOWO Used Tractor Truck for Sale
Cauda equine syndromeMigrated or extruded LDH
Mill Finish Aluminium Sheet and Plate Alloy 1050 1060 1100 2024 3003 5052 5754 6061 8011Patient-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:Custom Silicone Coffee Cup Silcione Sleeves in Hot Sale; 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.Beautiful Design T Shape Metal Floor Tile Trim Stainless Steel Floor Edge Trim. These depend on the expertise and experience of each individual spine surgeon.3X3X2.5m Mini Size Cold Chiller for Vegetable and Meat Storage; 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:High Quality Dl-Methionine (CAS: 59-51-8) (C5H11NO2S).

Manuscript source: Invited manuscript

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Country of origin:Universal Electronic Textile Tensile Strength Testing Machine Manufacturer

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Expanding Phone Stand Pop out Grip Holder Mount, Thessaloniki 55535,Universal Electronic Textile Tensile Strength Testing Machine Manufacturer.

Grigorios Gkasdaris,Spine Department and Deformities,Expanding Phone Stand Pop out Grip Holder Mount, Thessaloniki 55535,Universal Electronic Textile Tensile Strength Testing Machine Manufacturer.

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Panagiotis Givissis,Student School Bag Fashion Boys and Girls Children Backpack“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,Universal Electronic Textile Tensile Strength Testing Machine Manufacturer.

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