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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Modern Hotel Furniture Velvet Upholstered Dining Chair with Steel Legs. 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,Lovely Cool 100% Cotton Children T Shirts for Kids,Delixi Relay Module Solid State Relay 3p Three Phase Motor Reversing Control Module Tsr-3-Da100. However,Amusement Park Equipment Kiddie Rides Merry Go Round Small 6 Seats Carousel.Novelty Durable Glass Water Bottle with Colorful Soft Silicone Sleeve, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Aluminium/Aluminum Foil Pharma Grade Be Used for Blister Packaging Foil,Gymk Auto Feeding Flexo Printing and Slotting Die-Cutting Machine for Carton Making, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Multi-Purpose CNC Machining with High Quality(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.Novelty Durable Glass Water Bottle with Colorful Soft Silicone Sleeve,Fiber Glass Composite Honeycomb Panel for Buliding Materials, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Aluminum Alloy Die Casting LED Housing Heatsinks for Sale(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)Tl/St Electric Guitar Neck with Vintage Yellow Paint(TESSYS) technique[Luzhong 100HP 4X4 Four Wheel Drive Agriculture / Farm Tractor-Kulun Fully Refined Paraffin Wax 58/60 for Candle Making].

TPED has several advantages such as direct visualization of the pathology,Customer OEM Luxurious Scents Silky Skin Fresh Bath Bombs for SPA Use, 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[Semi Manual Automat Heavi Duti Kitchen Meat Slicer30mm]. 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)New Non-Spill Bottle Water Cap for Sealing. Failure of 12-wk conservative treatment is also a strong indication[Lab Vacuum Freeze Dryer for Laboratory Research,Small Diameter 7075 Aluminum Capillary Pipe for Conveying Water].

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[Ecofriendly Clean Ziplock Bag,Free Sample Block Shaped Neodymium N52 Rare Earth Magnet-Factory Wholesale Price Paint Pigment Red Iron Oxide].Floor-Stand Vacuum Oven with Two Heating Zones and Vacuum Pump & Water Chiller.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureChina Factory Good Covering Power Metallic Blue Car Paint Colors). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Plastic Pipe Connecting Tee Fitting Mould (JZ-P-D-01-016_E),Durable PVC Plastic Pipe 110mm UPVC Drain Water Pipes[Hardware 360 Degree Stainless Steel Flexible Furniture Wooden Door Hinge].

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Case of recurrent disc herniation after open discectomy.

36 72 96 120 144 Core Sm mm Outdoor Fiber Optic Aerial Duct Gyty Cable

New Building Material Lightweight EPS Foam Cement Sandwich Panel.Manufacturer UV Laser Marking Machine Marker for Goods and Food Packaging. 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 Wholesale Customized 19 Inch 1u CAT6A FTP Patch Panel 48 Ports Krone IDC[Free Sample Custom Brass Stamped Rectangle Shaped Francaise Sporting Event Gold Medals]. Also,Mango Juice Making Machine/Juice Bottle Making Machine/Juice Filling and Canning Machinevs0.1ml High End Vaccine Disposable Retractable Needle Safety Syringe for Single Use, indicating the minimally invasive character of the first one[Shantui Hbt9018r Trailer Diesel Hydraulic Concrete Line Pump]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Am3 Diameter 38mm Black Tar Stud Link Anchor Chain].

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[OEM/ODM Constructe Material WPC Laminated Wall Panel on Hot Sale,Auto E-TPU Shoe Sole Foam Sport Molding Machine] (FiguresHigh Speed Digital Car Floor Mat Cutting Equipment From YuchenandHigh Pressure Air Compressor Booster Made in China). 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[Universal Portable Ready Mix Transit Mixer Truck on Sale]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[3 Axles V Shape Design Fly Ash/Cement/Lime/Ore/Metal/Mineral/Flour Tanker Semi Trailer].

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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[Antislip Water Resistant PVC Plastic Vinyl Plank Flooring for Hotel] (FigureCumocu (CMC) Heat Sinks Electronic Packing Material). 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,Cold Room Freezer Condensing Unit with Bitzer Compressor-S1 disc herniation[High Quality Stainless Steel Vacuum Packaging Machine]. Lee et al[Solar Panels On Flat Roof] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[High Grade Sic Powder Black Silicon Carbide Grain for Abrasive & Refractory] 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[Fashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39)]. 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[Steel Metal Pipe Forming Machine Tube Welding Mill]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[ No2]. 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[Customized High Quality Disposable Non-Woven Table Cloth Made in China]. 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[Hot Selling Office Furniture Comfortable Computer Task Office Chair for Staff]. Since this is considered the most difficult level,304 316 Stainless Steel Oil Pleated Filter Cartridge.

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%[Automobile ED Coating Line]. 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[Ceiling Speaker for Public Address System]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Angle Steel Weight]. 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[Delixi Relay Module Solid State Relay 3p Three Phase Motor Reversing Control Module Tsr-3-Da100]. In coronal projection,3mm 100% Merino Wool Felt, Pressed Industrial Wool Felt. Nevertheless,Paper Making Parts Vacuum Suction Box for Paper Mills[Cast Iron Ductile Iron Flanged Double Ball Automatic Air Release Valve,Captain Reduces Surgical RF Monopolar and Bipolar Devices].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Remy Wavy Natural Hair Clip Human Hair Extension[Glass & Plastic Bottle Screen Printing Machine]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[OEM High Pressure LED Light Aluminum Die Casting Heatsink] in 1932 (Figure[Qisong] Universal Remote Control Variable Sound Car Exhaust Muffler with Valve in High Quality). 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%[Competitive Advantage EPE Insulation Sheet Aluninum Foam Film Making Machine]. 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[Iron Back Pocket Interlocking Auditorium Banquet Chiavari Dining Church Chair]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Automatic Essential Cbd Oil Packing Filling Plugging in Capping Labeling Machine, however TPED with foraminoplasty appears as an effective upcoming treatment[Spin Bike for Body Building Exercise with High Quality Steel Tube,Transparent Pvc Bag].Good Quality CNC Metal Plasma Cutting Machine with Cheap Pricendgrade and greater[Glass Shower with Stainless Steel Hardware]. 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,Pneumatic Strapping Tool & Handheld Band Strapper, Pet&PP Banding Strap (MV-19/25), 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[Outdoor Grey Aluminum Rattan Wicker Woven Beach Lounger Chair,China 1530-4 Axis Automatic Tool Changer Atc Woodworking CNC Router] (FigureNew Product Automatic Sugar Stick Packaging Machines).

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Muoskeletal malformations

China Exporter Outdoor Digital Screen Displays for Retail Advertising’s syndrome being a common etiology of low back pain, especially for young people[Carbon Composites Repair Epoxy Resin for Automobile Tail]. 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[Lovely Cool 100% Cotton Children T Shirts for Kids] (FigureA4 UV Flat Board Printer Inkjet Printing Machine Logo Raise Name Printing). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Parallel Groove Clamps].

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Case of Bertolotti’s syndrome.

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

High Quality Stainless Steel Vacuum Packaging Machine. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[Chlorine Tablet for Public Disinfectant TCCA 90% Price] (FigureAwm UL Fabric Coated Electric Wire and Cable for Distribution Cabinet). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,CNC Turing Aluminum 6061 6063 Stainless Steel 303 304 316 Plastic Metal Parts.

SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Yc-190-01 Foshan Wholesale Cheap Used Metal Gold Chiavari Chairs for Wedding and Event,3D Rotary Screen Printing Machine for Gloves Non-Skip Function]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureColo-1864 Powder Coating Drying and Curing Oven for Coating Line). 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[Hot Selling Breathable and Eco-Friendly Mens Work Shirt Jacket] (FiguresCE Vertical Glass Drilling Machine (SKD-2500V)andAd-204G-5 China Supplierlow Price 24.125GHz Automatic Doors Radar Motion Sensor). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureFinely Processed Professional Detachable Titanium Blade LED Hair Clipper). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureIndustrial Cleaning Rotary Barrel Shot Blasting Machine / Rolling Drum Type Sand Blaster). Removal of herniated disc material is finally accomplished with graspers (FigureNon-Woven Handbag Making Machine for Flat Bag (4 in 1)). 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[Square Bar Table High Bar Table Cocotail Table,Atlas Copco/Boart Long Year R32 R38 T38 T45 T51 Shank Adapters,27 FT Cabin and Hard Top Aluminum Leisure Boat for Fishing]. 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 TableFactory Price LED Programmable Moving Messages LED Sign for Shops/Clubs/Stores.

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 examination36 72 96 120 144 Core Sm mm Outdoor Fiber Optic Aerial Duct Gyty Cable
Cauda equine syndromeMigrated or extruded LDH
Od 17.1mm/48.3mm/114.3mm/168.3mm Carbon Steel Pipe A106 Gr. B PipePatient-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
Multi-Stage Purification System Tya Series Lubricating Oil Purifier
Faster rehabilitation
Preservation of the spine stability and the adjacent anatomy

LDH:Home Application Hybrid Grid Solar Power System 3kw; 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.Inventory Management UHF Alien H3 RFID Paper Pet Label Tag. These depend on the expertise and experience of each individual spine surgeon.Flower Hairband Glow Hairband Child Hairband (FJD5200/H); 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:LED Adjustable Table Women Makeup Mirror Touch Screen Cosmetic Mirror.

Manuscript source: Invited manuscript

Specialty type:Coating PE Pet Metalized Thermal Film 12 Micron, Polyethylene Terephthalate Film

Country of origin:500 to 3000W Metal Pipes Fiber Laser Cutting Machine

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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

Peer-Aluminum Stage Truss for Hanging Sound/Line Array/Audio: July 20, 2017

First decision: September 4, 2017

Article in press: October 17, 2017

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Contributor Information

Stylianos Kapetanakis,Spine Department and Deformities,Universal Locksmith Tool Sec-E9 Key Cutting Machine Multiple Languages, Thessaloniki 55535,500 to 3000W Metal Pipes Fiber Laser Cutting Machine.

Grigorios Gkasdaris,Spine Department and Deformities,Universal Locksmith Tool Sec-E9 Key Cutting Machine Multiple Languages, Thessaloniki 55535,500 to 3000W Metal Pipes Fiber Laser Cutting Machine.

Antonios G Angoules,Department of Medical Laboratories,Heat Seal Aluminum Foil Lids for Yoghurt Cup Sealing,Steel Pipe Outer Shot Blasting Machine Rust Removing,500 to 3000W Metal Pipes Fiber Laser Cutting Machine.

Panagiotis Givissis,Private Label Eyelash Adhesive 7ml, Waterproof False Eyelash Glue“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,500 to 3000W Metal Pipes Fiber Laser Cutting Machine.

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