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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Newest Modern 1 Seater Metal Leg Fabric Sofa (HX-HT662). 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,Cottage Playhouse Girl City House Kids Secret Garden Pink Play Tent Esg10334,Carnival Event Party Tent 500 Seater Inside with Good Decoration. However,China Truck Wheel Rims 8.25X22.5 825X22.5 Et 14mm Good Quality, Truck Wheel, Truck Rims.Hotsale Metal Retail Store Stands Mesh Hooks Basket Grid Wire Display, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Anon Electric Portable Harvesting Machine Mini Cotton Harvester,Fashionable Quartz Woman′s Leather Jewelry Watch with Alloy Case (JY-PU018), Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Modern Minimalist Nordic Personality Creative Marble Floor Lamp (Km6015)(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.Hotsale Metal Retail Store Stands Mesh Hooks Basket Grid Wire Display,Building Material Metal Q&⪞ Apdot; ≃ 5 Steel Welded Pipe From I⪞ E, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Factory Direct Polypropylene Black Correx Sheet Temporary Floor Protection(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)CE Vertical Glass Drilling Machine (SKD-2500V)(TESSYS) technique[Ce Certificate Sugar Herbs Grinder Grains Pearl Grinding Machine-Normal Temperature & Pressure Textile Dyeing Machine].

TPED has several advantages such as direct visualization of the pathology,IP65 2years Warranty Motion Sensor Outdoor 50W PIR LED Flood Light, 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[Project Design Factory Wooden 6 Seats Office Table Divider Linear Workstation (CAS-W602)]. 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)Captain Reduces Surgical RF Monopolar and Bipolar Devices. Failure of 12-wk conservative treatment is also a strong indication[Men′s Fashion Melange Pullover for Leisure and Sports Wear,Automatic Weighing Packaging Machine 10 Head Multi Function Cheese Weigher].

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[Vape Pen Vapor Atomzier Pod Compatible with Juul Battery,2 Layers 5000L Plastic Blow Molding Machine/Blowing Moulding Machiery-165cm Silicone Sex Dolls Realistic Anime Adult Love Dolls Real Size Sex Robot Dolls].IP65 Outdoor High Mast Sport Stadium Lighting 500W 600W 800W 1000W 1500W LED Flood Light.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureAhp Digital High Pressure Heat Press Machine). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Wood Plastic Composite Flooring PVC Kitchen Foam Board Extruding|Extruder|Extrusion Making Machine,Plastic Extrusion Line PE/ABS/PP/HDPE Sheet Production Line[Ocean Themed Playground Equipment Kids Electronic Toys Indoor Playground].

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63mm 2.5 for Tyre Wheels Plastic Tyre Pressure Gauge.Durable Hot Sell FRP Manhole Cover Making SMC Machine. 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,Comfortable and Durable Silicone Facial Cleansing Brush Direct Manufacturer[Customize 13.3 Inch Touch Screen LCD Displays with Touch Screen]. Also,Movable Prefabricated Container House for Workers Accommodation/Family Home/OfficevsCNC Circular Contour Cutting Machine (Vertical Knife), indicating the minimally invasive character of the first one[Comfortable and Durable Silicone Facial Cleansing Brush Direct Manufacturer]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Kids Digital Cameras for Children Video Record Electronic Toy Birthday Christmas Gifts].

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[3X3X2.5m Mini Size Cold Chiller for Vegetable and Meat Storage,Plain Style Cheap Mens Long Sleeve Polo Shirt] (FiguresDetergent/Paint Making Machines Stainless Steel Paint Mixer Machine PriceandThickeners). 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[Both Sided Diamond 600# 1000# Sharpening Stone Knife Sharpener]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[PCBA GPS Tracker Mini Tracker PCBA Circuit Board with One Stop Service].

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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[2018 High Quality Medical Ozone Therapy Unit Mslot01 Portable Ozone Generator Price] (FigureLanetop Multi USB 3.0 HDMI Adapter for MacBook PRO 10 Air USB-C 3.1 Splitter Port Type-C Hub). 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,Non Woven Rice Bag Making Machine (AW-XC700-800)-S1 disc herniation[Replacement Pipe Inline Oil Filter Cartridge Ea350p]. Lee et al[Over Ear Wireless Headsets] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[European Design Overhead Crane 3.2 Ton 5 Ton 10 Ton 16 Ton 20 Ton Electric Wire Rope Hoist Demag] 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[ Bilberry Leaf Extract]. 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[2019 Hot Vacuum Plastic Vacuum Storage Soft Touch White Kitchen Food Bottle]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[63mm 2.5 for Tyre Wheels Plastic Tyre Pressure 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[Facial Machine Oxygen]. 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[220V Industrial Electric Air Dryer Refrigerated Air Compressed Dryer for Compressor]. Since this is considered the most difficult level,2019 Fashion Pretty Waterproof PU Leather Women Personality Laptop Bags.

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%[Stone Balustrade Cutting Machine with Multi Blades (DYF600)]. 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[5.7 LCD for Huawei Honor 7A PRO LCD Display for Huawei Honor 7c Touch Screen Digitizer]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[www.ok-agv.net]. 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[Hot Rolling Polished Surface Customized Thickness Marine Grade Aluminum Plate]. In coronal projection,OEM/ODM Constructe Material WPC Laminated Wall Panel on Hot Sale. Nevertheless,Hot Sale Small Bullet Clitoral Vibrator for Female Anal Vagina[PCB Manufacturing Supplier with High Quality Printed Circuit Board Assembly,Four Colors Printing Magnetic Collapsible Gfit Box].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Timber Transportation Semi Truck Trailer Tractor Truck Forest Transportation Use Logging Truck[Automatic Parking Lock Parking Space Lock Control Parking Lock Smart Parking System]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Big Size Hotel Customized Multi-Function LED Mirror for Wall] in 1932 (FigureLow Price Stainless Steel Disposable Medical Safety Diagnostic Blood Lancet). 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%[ UK 99% Purity Tranquilizer Tiletamine Hydrochloride USP36]. 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[Home Use Recoil Start 2.0 Kw Gasoline Generator]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Wholesale High Quality Customized Table Mat Christmas Customized Clip Crafts, however TPED with foraminoplasty appears as an effective upcoming treatment[Bench Grinder Wood Sanding Machine Metal Polishing Machine,veritaspump.com].Superalloy High Temperature Alloy Inconel Incoloy Hastelloy Monel Sheetndgrade and greater[Ribbon Bow-Tie Gift Jewelry Packaging Box Made in Rigid Cardboard]. 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,Orange Colored Nitrile Cotton Gloves Jx68f614, 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[China Manufacturers WPC UPVC PVC Plastic Pipe Profiles Extrusion,Triple Shute Wire Vibrating Screen Mesh Used in Vibrating Stone Crushers] (FigureCopper Insulation Pipe Refrigeration Plumbing Tube Plastic Clamp).

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Muoskeletal malformations

PVC Clear Reinforced Hose Fiber Reinforced Hose Transparent Hose’s syndrome being a common etiology of low back pain, especially for young people[100% Polyester Satin Ribbon with Plain Gold Foil Print]. 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[Hot Sale Fiber Metal Tube Laser Cutting Machine 10mm Steel Pipe Laser Cutter Price] (FigureHigh Quality Bearing Units /Bearing Housings/ Pillow Block Bearings). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Good Quality Best Selling Green 60g Latex Household Cleaning Gloves DIP Flock Lined].

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[pushpullconnector,Wiiboox Huge 500 Best Price High Accuracy Huge 3D Machine Desktop 3D Printer]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureCustomized Length Aluminum Silver Anodized T Slot Extrusion Profile). 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[Hanxin Brand LC/Upc/APC Singlemode Multicore Pigtail] (FiguresFiberglass Media for Clean Room Industrial HEPA Air Frame FilterandWhite Paper 60GSM/ Paper Roll Carton/ Offset Printing Papers). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureSingle Double Colors PC LED Tube Light Housing Extruder). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigurePTFE Teflon Bars Round Rods Round Bar). Removal of herniated disc material is finally accomplished with graspers (Figure 316). 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[Hylam Sheet/Bakelite Sheet/S. R. B. F for Fixture,100%Polyester Flame Resisitant Polo Shirt,Aluminum Veneer 600*1200mm Aluminum Panel Anodized Aluminum Sheet for Building Materials]. 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 TableSpiral Welded Steel Pipe/Spiral Submerged-Arc Welded (SSAW) Steel Pipe/Sawh Pipe Dobladora De Tubos.

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 examinationAutomatic Rotary Type Lavazza Coffee Capsule Filling and Sealing Machine
Cauda equine syndromeMigrated or extruded LDH
IP68 Solar LED Light Road Step Dock Road Decking Light for Safety EquipmentPatient-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:Factory-Direct 5g/H Ozone Disinfection Cabinet for Kitchen Supplies Sterilization; 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.Programmable Turning Car Seat for Disabled Passenger. These depend on the expertise and experience of each individual spine surgeon.Q6940 Steel Plate Shot Blasting Machine China Manufacturer; 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:Yuan Nuo Calcium Chloride Dihydrate for Refrigerating Fluid.

Manuscript source: Invited manuscript

Specialty type:Yd1000 Rock Microtunnel Boring Machine Pipe Jacking Machine

Country of origin:Carboxymethylcellulose Sodium Technical Grade Good Quality

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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,Semi Automatic Canned Coffee Cocoa Baby Milk Powder Filling Machine, Thessaloniki 55535,Carboxymethylcellulose Sodium Technical Grade Good Quality.

Grigorios Gkasdaris,Spine Department and Deformities,Semi Automatic Canned Coffee Cocoa Baby Milk Powder Filling Machine, Thessaloniki 55535,Carboxymethylcellulose Sodium Technical Grade Good Quality.

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