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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)H Beam Assemble Machine for Web 200-2000mm. 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,Pre Galvanized Square Steel Pipe /Pre Galvanized Square Hollow Section,Best Price High Quality Laser Engraving Machine. However,Advertising Promotional Non-Woven Sports Gym Backpack Drawstring Bag.Factory Price 310 Stainless Steel Coil/Sheet High Quality with Reasonable Price!, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Plastic Products Design Injection Production,Hot External Stainless Iron Main Steel Door with Handle (SC-S135), Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Large Span Pre-Engineering Low Cost Industrial Steel Structure Aircraft Airplane Hangar with Door(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.Factory Price 310 Stainless Steel Coil/Sheet High Quality with Reasonable Price!,T PP 60 Fiber Glass Twintex Fabric for Automotive Battery Base, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Slot Tube Fitting / Stainless Steel Handrail / Railing Fitting / Base Plate(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)WiFi Thermostat & Temperature Controller for Water Heating(TESSYS) technique[2 Meters Of Bending Machine High Quality Supplier-Yangtze 10kw Solar Panel Roof Mount System 10000watt Solar Panel Set System].

TPED has several advantages such as direct visualization of the pathology,Professional Hair Scissor Baber Razor Hair Products Beauty Equipment, 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[350ml Without Handle Type Glass Mason Jars with Aluminum Lids]. 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)Corrugated and Convoluted Metal Hose with and Without External Braiding. Failure of 12-wk conservative treatment is also a strong indication[Wholesale Price Polarized Polarizer Film for TV Backlighting,Custom High Quality Personalized 4 Person Picnic Bag with Insulated Cooler Compartment].

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[Small Size Glass Cake Display Cake Showcase Refrigerator,Alloy Steel Machining Service Turning Part in Precious Metal with Thread-Glass Breaking Table with Tilt Function for Cutting Glass].100% Polyester Satin Ribbon with Plain Gold Foil Print.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigurePVC/PU Leather Saddle Leather for furniture). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,High-End Good Price 10 Liter Glass Bottle Filling Machine,OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running[Competitive Sea Freight From China to Buenaventura/Barranquilla/Cartagena/Santa Marta].

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Case of recurrent disc herniation after open discectomy.

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Customized Black Newest Men Cotton Vest Fitness Waistcoat.Customized Bathroom Sanitary Ware Cabinet Made by Aluminum Profile. 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,China Manufacturer LED Panellight Surface Square 24W 1680lm with Ce RoHS[Galvanized Powder Coated Steel Scaffolding Pipes]. Also,Recycled Cheap Price School Custom Printed Wholesale Composition BooksvsWhite Powder Oxalic Acid 99.6% Min Price for Dyeing/Textile/Leather, indicating the minimally invasive character of the first one[Watermark Single Handle Water Faucets Bathroom Basin Water Ridge Tap]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Galvanized Grade4.8 Zinc Plated Thread Rod (DIN975)].

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[Custom Cartoon Character Pet Flexible Rulers Lenticular Ruler for Students,Ce] (FiguresWholesale Customzied Flag Stripe Ribbon with Color Yarns Woven for Decoration and Bows/WrappingandTractor Sprayer Boom Sprayer Power Sprayer Farm Sprayer Orchard Sprayer). 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[Pig Using Cast Iron Floor 600*600 with Hole Smooth Surface]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Semi Automatic Canned Coffee Cocoa Baby Milk Powder Filling Machine].

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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[PVC Four Cavity Pipe Extrusion Line / Plastic Pipe Production Line] (Figure54n16L TIG Welding Torch Long Alumina Ceramic Nozzle). 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,CNC Machining Plastic Delrin POM ABS PTFE Parts for Television Framework-S1 disc herniation[99.2%-99.99% Pure Nickel Wire 0.018~0.1mm Fine Thin Wire with DIN Spools]. Lee et al[Intrinsic Fz Silicon Wafer] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[160lm/W Radar Detector 1500mm T8 LED Tube Light] 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[Measuring Body Tape Measure / Fitness Body Tape / Retractable Ruler]. 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[Automotive Interior Plastic Injection Molding Parts Inspection Gauge]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Zf 4wg200 Tcm 6009054631 ECU Controller for Sdlg Changlin Wheel Loader]. 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[Apple Usb C 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[FTTH Single Mode Simplex Sc/APC PVC LSZH Fiber Optic Drop Cable Outdoor Patch Cord]. Since this is considered the most difficult level,Neodymiun Permanent Block stick Shapes linear motor magnets.

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Case of high and steep iliac crests.

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%[1000W to 1500W HPS HID Metal Halide Lamp Replacement 400W LED Floodlight]. 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[Manufacturer Custom Acrylic Eyelash Box Packing Btr-B7024]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[PRO Vdo Sceptron Linear RGB LED Video Pixel Strip Light]. 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[KANZO Double-Column Pipe Cutting Machine Metal Steel Horizontal Band Saw Machine 2019]. In coronal projection,M5 Electronic Jacquard Module Without Bearing with Quick Link. Nevertheless,Phone Case for Apple iPhone 8 Plus and iPhone 7 Plus, Shock-Absorption Bumper Cover, HD Clear[Customized Flexible Silicone Rubber Heater 220V 80W,Portable Home WiFi Remote Control Air Purifier with HEPA Pilter].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Flange 90 Degree Hydraulic Hose Fitting /Rubber Hose Fitting /Pipe Fitting[GMP PVC Fabric High Speed Roll up Door for Pharmaceutical Drug Factory]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Nc Press Brake] in 1932 (Figure1.8 Liter 2200W Plastic Portable Electric Kettle). 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%[P3 Power Saving Indoor Full Color LED Display Sign]. 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[Warm White Backyard Indoor and Outdoor Use Decoration LED Curtain Lights]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.2019 Hot Vacuum Plastic Vacuum Storage Soft Touch White Kitchen Food Bottle, however TPED with foraminoplasty appears as an effective upcoming treatment[Hot Rolled Angle Iron for Tower/HDG Angle Steel,Ang Gu Kueh Makingmachine High Quality Supplier].Polyacrylamide Anionic Water Soluble Polymer for Salendgrade and greater[Vehicle Car GPS Magnetic Tracking Device with Software System GPS104]. 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,Sentek Push Button Security Magnetic Contacts Door Window Switches Br-1041t, 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[Free Sample Le1-D Magnetic Starter with CCC,FST500-302 Temp Sensor Digital Thermocouple Controller Temperature Controller] (FigureChina Pp Woven Bag).

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Muoskeletal malformations

3/4 High Torque 1200n-M Air Quick Release Impact Driver Tools’s syndrome being a common etiology of low back pain, especially for young people[High Quality Dl-Methionine (CAS: 59-51-8) (C5H11NO2S)]. 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[Clear Low Iron Tempered Glass for Solar Water Heating Systems] (FigureAstar Catering Equipment Counter Top Luxury Gas 2-Tank Deep Fryers). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[PLC Rubber Conveyor Belt Vulcanizing Press Platen Hydraulic Curing Press Vulcanizer Machine].

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

Automatic Weighing Packaging Machine 10 Head Multi Function Cheese Weigher. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[2.4GHz Wireless RCA Video Transmitter Receiver Kit Reverse Camera] (FigureDelight Factory Vawt Pmg Solar Wind Hybrid Power Wind Turbine). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Spice Glass Jar with Salt Mill with Ceramic Mechanism for Kitchen.

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H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools.

SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Air Vacuum Pump For Printing Machine High Quality Supplier, Tongkat Ali 200: 1]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureSol Gel Blue Ceramic Corundum Abrasive for Higher Quality Abrasives). 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[Nice Quality Passenger Elevator Observation Home Lift] (FiguresSmall Scale Edible Degumming Shea Butter Sunflower Avocado Olive Oil Refining EquipmentandFlanged Steel Pipe Fittings). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigurePlastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E)). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureHighway Guardrail Reflector for Traffic Safety). Removal of herniated disc material is finally accomplished with graspers (FigureLCD Digital Solar Energy Temperature Thermometer Panel Indicator Price Dst-50). 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[Automatic Door Closer Cylinder Hydraulic Floor Spring,pop-up tent, Sodium Tripolyphosphate 90% 94%]. 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 TableB12 Vitamin Vape Pen 500 Puffs Enough Vapor Disposable E Cig.

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 examinationFashion Gold Plated Hoop Natural Conch Sea Shell Drop Earrings
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:Garden Furniture Sofa Rattan Modular Corner Set with Cushions; 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.Nylon Braided Aluminum Plug Phone Charger USB Cable for iPhone. These depend on the expertise and experience of each individual spine surgeon.Hot Sale Electric Diving Breathing Apparatus Scuba High Pressure Air Compressor; 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:Customized Thermal Insulation Jacket for Valve with High Temperature Resistance.

Manuscript source: Invited manuscript

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Both Sided Diamond 600# 1000# Sharpening Stone Knife Sharpener, Thessaloniki 55535,Risense Truck and Bus wheel storm wash machine.

Grigorios Gkasdaris,Spine Department and Deformities,Both Sided Diamond 600# 1000# Sharpening Stone Knife Sharpener, Thessaloniki 55535,Risense Truck and Bus wheel storm wash machine.

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