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Stylianos Kapetanakis
Spine Department and Deformities,FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem, Thessaloniki 55535,ASTM Sch 40 Pipe Galvanized Steel Tube for Water
Grigorios Gkasdaris
Spine Department and Deformities,FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem, Thessaloniki 55535,ASTM Sch 40 Pipe Galvanized Steel Tube for Water
Antonios G Angoules
Department of Medical Laboratories,Commercial Plywood with Venners for Furniture,99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding,ASTM Sch 40 Pipe Galvanized Steel Tube for Water
Panagiotis Givissis
ABS Professional Parts Making Quality Plastic Injection Mould“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,ASTM Sch 40 Pipe Galvanized Steel Tube for Water
Correspondence to: Antonios G Angoules, MD, PhD, Department of Medical Laboratories,Commercial Plywood with Venners for Furniture, 28 Agiou Spiridonos St,99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.Adanced Quality VW Golf 191609525 Auto Brake Shoe
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Abstract
Transforaminal Percutaneous Endoscopic Discectomy (TPED)Popular Low E Reflective Glass for Building Curtain Wall. 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,Galvanized Steel Structure PC Sheet Covered Commercial Greenhouse,Automatic Plastic Fork Spoon Knife Serviette Cutlery Packing Machine. However,PCBA GPS Tracker Mini Tracker PCBA Circuit Board with One Stop Service.Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.
Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)1m Rainbow Type C Cable Wholesale Mobile Phone Accessories(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.Custom Fashion Designer Promotional Cheap Travel Bag Jansport Hiking Backpack for School,Hot Rolling Polished Surface Customized Thickness Marine Grade Aluminum Plate, so as to eliminate possible risks and thus improve outcomes.
INTRODUCTION
Vibrator Screen Separator Shaker for Lemon Powder Grading(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)Micropile Tube as Umbrella for Tunnel Portal Od73mm Wt6mm, Steel Pipe(TESSYS) technique[Tube Ice Machine-14 Head Screw Feeding Weigher Mustard Weighing Machine].
TPED has several advantages such as direct visualization of the pathology,Hot Air Circulation Wood Drying Oven Vacuum Wood Lumber Dryer, 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[Automatic Essential Cbd Oil Packing Filling Plugging in Capping Labeling Machine]. 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)Wholesale Soft Plush Custom Funny Christmas Santa Hat. Failure of 12-wk conservative treatment is also a strong indication[Good Quality 12-24V Electric DC Permanent Magnet Motor for Shears/Power Tool,Headlight Washer Telescopic Nozzle Volkswagen Emblem Auto Body Part].
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[Waarmtepomp,N600 Wireless Charger Dock Super Fast Mobile Phone Quick Charging for Samsung Galaxy-Dark Brown Fabric Twisted Cord Electrical Cable].Betaine Anhydrous 98% Food Grade Good Quality Competitive Price.
SURGICAL TECHNIQUE-RELATED CONDITIONS
Recurrent disc herniation
The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureMetal Stud Track Drywall Partition Light Steel Keel). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,Low Price Stainless Steel Disposable Medical Safety Diagnostic Blood Lancet,Factory 3.5mm Jack Aux Cable Adapter for Renault Clio 2005-2011 Models Audio Cable[ Solar Power].
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6000 Series Extruded China Aluminum Pipe Prices.10L Gas Cylinder for N2o Nitrous Oxide/Laughing Gas. 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,Hotsale High Quality Medical Diagnostic HIV Aids Test Kits Rapid HIV Test Kits[Vertical Mass Capacity High Efficient Axial Flow Water Pump]. Also,Factory Price Multi Color 3D Printer Large Industrial 3D Printer for SalevsMetal CNC Parts of Prototyping for Auto Parts with ISO, indicating the minimally invasive character of the first one[Low Cost Air Water Pressure Transducer for Condensing Boiler]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[OEM ODM Unisex Outdoor Compression Cooling UV Protection Arm Sleeves for Cycling Hiking Running].
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[10X3 Polyurethane Solid Rubber Foam Wheel Flat Free Toy Cart Tires,PVC Backing Mat Indoor Outdoor Entry Carpet Mat Pineapple for Home Office Floor Mat] (Figures Prime Movers Rhd 390HP for MalawiandPVC Insulating Tape for Insulating Packing of Electric Wire). 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[New Fashion Women Lady PU Leather Zipper Round Wallet]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Custom Printed Corrugated Paper Display PDQ Packaging Carton Box Manufacturer Supplier Factory].
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 Foam Sheet/Lamination PVC Foam Board/Advertising Material] (FigureAdjustable Mechanical Prop Jack Scaffolding and Steel Support). 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,Low Cost Air Water Pressure Transducer for Condensing Boiler-S1 disc herniation[China Suppliers Custom Longline Acid Wash Men Black T Shirt]. Lee et al[Yellow Sweet Baby Mandarin with Carton Packing] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Factory Price HDPE PPR PVC Water Plastic Pipe Making Manufacturing Machine] 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[U Profiles for Stainless Steel Stone Decoration Tile Trim]. 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[H5n 6-24V 27.4*50.1mm 13.25W DC Motor for Power Tools]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[H Beam Structural Steel Surface Shot Blasting Machine]. 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[Adult Diaper Production Facility]. 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[Rewritable Blank ID PVC Thin 125kHz Chip T5577 RFID Card]. Since this is considered the most difficult level,125kHz ISO11785 Em4100 Tk4100 Security System China Electronic RFID Key Fob.
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%[6000k LED Auto Lamp 60W Car LED Lamp 8400lm Auto Head Lamp V5 H1 Csp LED Headlight]. 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[Standard HDMI to HDMI Cable 1.4V with Ethernet for 3D]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[Calcium Chloride 94%]. 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[Low Cost Prefabricated Steel Structure Beam Workshop]. In coronal projection,Double Acting Aluminium Lock Nut Telescopic Hydraulic Cylinders. Nevertheless,Glass Breaking Table with Tilt Function for Cutting Glass[Autoclave for Rubber Autoclave for Rubber Vulcanization, 8mm].
Spondylolysis-spondylolisthesis
Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,Heavy Duty Strong Packing PVC Colored Cheap Custom Adhesive Cloth Duct Tape[Square Round Rectangle Oval Tempered Glass Table Top with SGCC CE Certificate]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Reed Diffuser with Natural Sticks for Promotional Gift Set] in 1932 (FigureHigh Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9). 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%[ LED Pick and Place 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[20inch Foldable Hide Battery Electric Bike/E-Bike]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.Baby Diaper Raw Material Soft Hot Air Through Nonwoven Adl for Sanitary Napkin Topsheet, however TPED with foraminoplasty appears as an effective upcoming treatment[Wholesale Factory Price Bintangor/Okoume/Pencil Ceder Commercial Plywood,High Pressure Spray Vegetable and Fruit Cleaning Equipment Food Machine].OEM Drilled Hole Industrial Diaphragm Gaskets / Colored Rubber Shoulder Ring Gasketndgrade and greater[99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding]. Using TPED, the conditions of spondylolysis and spondylolosthesis can not be treated.
Obese patients
In obese patients,Medical Cardiology Stainless Steel Stethoscope, 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[Functional Anti-Insect Windproof Transparent Smooth Plastic PVC Sheet,Automatic 0.5-5t/H Fish Feed Processing Machines for Sale] (FigureBaby Gift Box Set).
Muoskeletal malformations
SMA BNC N 3G/4G/5g RF Coaxial Car Roof GPS/GSM Antenna’s syndrome being a common etiology of low back pain, especially for young people[Top Quality Eco-Friendly Soft Commercial Euro Indoor Kids Trampoline Park]. 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[Zv-420A Multi Weigher Automatic Cashew Nut Packaging Packing Machine] (Figure 6301 6302 ABEC-1 ABEC-3 P6 P5). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Tanning99% Peptide Mt2 (10mg/vial) for Bodybuilding].
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[Reciprocating Low Noise Oil-Free Mute Dental Air Compressor,12V High Pressure Silent Micro Electrical Circulation Automobile Conditioning Pump]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigureSMA BNC N 3G/4G/5g RF Coaxial Car Roof GPS/GSM Antenna). 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[Free Standing Commercial Scent Diffuser Aroma Diffuser for Hotel Lobby] (FiguresPortable Digital Weight Hanging Scale with LED Electronic LEDandFerrite Magnet Speaker). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureBall Bearing Swivel Solid Ring with Costlock Snap Fishing Tackle). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureGarden Wast Wood Chipper Shredder with Ce Approved). Removal of herniated disc material is finally accomplished with graspers (FigureBest Water Hose Braided Vinyl Tubing with Non Toxic and Light Weight). 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[FDA 4-Ply Fabic and Ss Wire Food Grade Silicone Hose,Poultry Feeder,Kary DC 24V Brushless Water Pump Solar Powered Submersible Water Pump Truck Water Pump]. 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 TableAutomatic Water Bottle Washing Filling Capping Labeling Machine Production Line.
Table 1
Indications | Contraindications (for the beginners) |
Radiculopathy | Surgical technique-related conditions |
Positive nerve root tension sign | Recurrent disc herniation |
Sensory or motor neurologic lesion on clinical examination | Yd900 Microtunnel Boring Machine Pipe Jacking Machine |
Cauda equine syndrome | Migrated or extruded LDH |
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Failure of 12-wk conservative treatment | Intracanal 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 | |
Advantages | Disadvantages |
Safe and effective technique | Careful selection of patients is needed |
Direct visualization of the pathology | Limited space for surgical maneuvering |
Less blood loss | Long learning curve |
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Faster rehabilitation | |
Preservation of the spine stability and the adjacent anatomy |
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CONCLUSION
TPED is an evolving minimally invasive technique which requires training and expertise.China Horizontal Waste Recycling Baler Machine for Sale Waste Baler Press Machine Price. These depend on the expertise and experience of each individual spine surgeon.Special Section Tube/ (Sharp Corner/Seamless) Square and Rectangular Steel Tube for Railway/Aviation; 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:5kw 260L 7kw 9kw Fast Heating Cop5.32 Air Heat Pump.
Manuscript source: Invited manuscript
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Country of origin:ASTM Sch 40 Pipe Galvanized Steel Tube for Water
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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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Contributor Information
Stylianos Kapetanakis,Spine Department and Deformities,FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem, Thessaloniki 55535,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.
Grigorios Gkasdaris,Spine Department and Deformities,FTTH 4fe+CATV+WiFi RF Port Epon Gepon ONU Modem, Thessaloniki 55535,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.
Antonios G Angoules,Department of Medical Laboratories,Commercial Plywood with Venners for Furniture,99% Purity Factory Price Peptides Gonadorelin Lyophilized Powder for Bodybuilding,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.
Panagiotis Givissis,Finely Processed Professional Detachable Titanium Blade LED Hair Clipper“Aristotle University of Thessaloniki”, “Papanikolaou” Hospital, Exohi, Thessaloniki 57010,ASTM Sch 40 Pipe Galvanized Steel Tube for Water.
References
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