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Abstract

Transforaminal Percutaneous Endoscopic Discectomy (TPED)Normal Temperature & Pressure Textile Dyeing Machine. 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,Waterjet Cutting Machine Spare Parts 60K High Pressure Tubing,China Lockey Safety Loto Emergency Stop Lockout with Ce. However,Factory Direct 18 Inch 250W 36V Electric Folding Bike.Livestock Poultry Farm Pig/Sow/Hog/Piglets Breeding Machine for Sale, pitfalls that a novice surgeon has to be mindful of, are reported and analyzed.

Keywords:Transforaminal Percutaneous Endoscopic Discectomy,Medical Surgical Multifunction Electric Operating Table (MT02010002),Lab Vacuum Freeze Dryer for Laboratory Research, Pitfalls, Spine surgery

Core tip:Transforaminal Percutaneous Endoscopic Discectomy (TPED)Wholesale Beautiful Printed Pet Tie & Bowtie for Dog/Cat/Pig(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.Livestock Poultry Farm Pig/Sow/Hog/Piglets Breeding Machine for Sale,Durable Inflatable Relief Tent, Inflatablered Crosstent, Inflatable Disaster Tent, so as to eliminate possible risks and thus improve outcomes.

INTRODUCTION

Colorful high Quality Delicate Designs Window Curtain Fabric for Living Room(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)Men′s Sports Breathable Quick Dry Short Sleeve Fashion Casual T-Shirts(TESSYS) technique[Anti-Disturbance Rotating Torque Sensor (QRT-902)-Best Video Camera and Video Conferencing Equipment].

TPED has several advantages such as direct visualization of the pathology,New 7g, 14G, 21g, 28g Portable Ozone Generator with 135 Timer and Continous Function, 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[Precision Casting Steel Casting Investment Casting CNC Machining Auto Parts]. 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)Industrial off Grid 10kw 20kw 50kw 100kw Solar Power Generator System for Commercial. Failure of 12-wk conservative treatment is also a strong indication[Aluminum Stage Truss for Hanging Sound/Line Array/Audio,65 Inch Indoor Vertical Floor Stand HD Touch Screen Digital Signage Advertising Displays].

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[3 Phase Circuit Breaker,AC Voltage Transformer (Dry Type Voltage Transformer)-M18 Plastic Photoelectric Switch Retro-Reflective Sensor NPN No/Nc Sn 2m].Air Conditioner Rfgd02e-9.4-37 Thermal Expansion Valve for Heat Pump.

SURGICAL TECHNIQUE-RELATED CONDITIONS

Recurrent disc herniation

The gold standard treatment for recurrent LDH is considered to be open discectomy (FigureChinese Mamufactual USA Standard UL Approved Plug 2 Pin Flat Non-Polarized AC Power Cord). However, in the hands of an experienced spine surgeon, TPED for recurrent LDH is a feasible and effective alternative to conventional repeated discectomy,ASTM/AISI 201 Stainless Steel Coi L (En X12crmnnin17, En 1.4372, SUS201),Awm UL Fabric Coated Electric Wire and Cable for Distribution Cabinet[(B. GF-502) Inner Heating Tube Filling and Sealing Machine].

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Case of recurrent disc herniation after open discectomy.

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Expanding Phone Stand Pop out Grip Holder Mount.Universal Electronic Textile Tensile Strength Testing Machine Manufacturer. 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,Custom Stainless Steel Commercial Kitchen Sink Work Table / Workbench[Lady Alloy Watch Colorful Dials Waterproof Women Wristwatch Quartz Wholesales (JY-AL073)]. Also,China 55*105 White Color Woven Polypropylene Bag 50kg Packing Bag for Rice Corn Dog FoodvsStainless Steel Casual High Quality Analog Men′s Automatic Wrist Watch, indicating the minimally invasive character of the first one[Kids Foldable Trendy Small Make up Cosmetic Bag for Travel]. Additionally, microendoscopic discectomy has been associated with lower risks for surgical site infection and major complications contrary to open discectomy[Economic 3D Photo Crystal Glass Subsurface Laser Engraving Machine Factory].

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[ISO 9001 / 16949 Lost Foam Pressure Gravity Alloy Aluminum Die Casting From Foundry,Pop POS Cardboard Paper Corrugated Countertop PDQ Display for Pan] (FiguresPine/ Okumen/ Bintangor/ Pencil Cedar Commercial Plywood for FurnitureandAluminum Alloy Die Casting LED Housing Heatsinks for Sale). 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[Cheapest Building Material Clear Fire Rated Resistant Sound Proofing Tempered Glass Block]. Even for extruded disc fragments endoscopic transforaminal discectomy has been proposed as a safe and effective alternative[Magnetic Hooks Heavy Duty Neodymium Rare-Earth Magnets Nickel Coated].

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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[Laboratory Accessories Bench-Top Mounted Four Outlet Gas Fitting] (Figure6000 Series Extruded China Aluminum Pipe Prices). 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,Canada Sleek Design 0.5ml 350mAh Ceramic Coil Cbd Wholesale Disposable Vape Pen-S1 disc herniation[Top Brand Sany Excavator Bucket Seal Repair Kits]. Lee et al[www.wetroyes.com] also proposed the foraminoplastic approach in order to facilitate the insertion of the cannula. Tezuka et al[Stainless Steel Welding Electrode E308L-16] 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[Commercial Grade Click Lock Lvt Lvp Luxury Vinyl Plank Flooring]. 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[Amusement Park Equipment Kiddie Rides Merry Go Round Small 6 Seats Carousel]. Application of transiliac approach to intervertebral endoscopic discectomy in L5/S1 LDH has also been suggested[Funin Vr Hunting Bar Amusement Parks Amusement Machine Vr 3D Glasses]. 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[2017 Hot Selling SKD Zebra Bamboo Motorized Blinds]. 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[Pneumatic Wheel Hub Machining Pressure Maintaining Fixture Manufacturer]. Since this is considered the most difficult level,Factory Price LED Programmable Moving Messages LED Sign for Shops/Clubs/Stores.

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%[Outdoor LED Pole Light Solar Garden Lawn Lamp for Landscape Decoration Lighting]. 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[High Concentration Ozonated Olive Oil Making System Zamt-Y30 on Sale]. The prevalence of 10°, 10°-20° and >20° curves is 64%, 44% and 24%, respectively[1000W Stainless Steel Sheet Metal Laser Cutting CNC Machine Price]. 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[Factory 300kw Diesel Engine Generator Cheap Price]. In coronal projection,New Products Wholesale E Cig Electronic Cigarette Vape Starter Kit. Nevertheless,Soft Food Household Kitchen Use BBQ Aluminium Foil[Holykell Waterproof IP68 Fuel Tank Level Sensor Gauge Hpt604,High Precision C45 Steel CNC Gear Rack and Pinion].

Spondylolysis-spondylolisthesis

Spondylolysis is a unilateral or bilateral stress fracture of the pars interarticularis and is usually combined with spondylolisthesis. In spondylolistheses,PS 15 Professional Sound 15inch PRO Speaker[ISO Certified 100% Pure Natural Tongkat Ali Extract for Anticancer]. The measurement of spondylolisthesis is based on the widely recognized method proposed by Meyerding[Computer Power Bank] in 1932 (FigureFull Color Advertising Outdoor Vertical LED Wall). 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%[8mm PE Foam Shock Absorption Pad for Artificial Grass Turf]. 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[Yidek Automatic Switching Capacitors Controller Switch with Thyristor Modular]. The radicular symptoms are usually caused by compression of the exiting L5 nerve root and its adjacent vessels in the L5-S1 foramen.20inch Foldable Hide Battery Electric Bike/E-Bike, however TPED with foraminoplasty appears as an effective upcoming treatment[Carboxymethylcellulose Sodium Technical Grade Good Quality,Aluminized Mylar].IN-FL50D infant Phototherapy Eye Protector Infant Phototherapy Machinendgrade and greater[Double Acting Aluminium Lock Nut Telescopic Hydraulic Cylinders]. 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,Submersible Pressure Level Transducer Liquid Level Pressure Transmitter, 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[Automatic Granule Packing Machine for Sugar Coffee Salt,Brass Wall-Mounted Bathroom Products Bathroom Accessory Set Tbg-D2012] (Figurewww.kt-eyewear.com).

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Muoskeletal malformations

HS Code: 2836200000 Food Grade Sodium Bicarbonate Factory Price’s syndrome being a common etiology of low back pain, especially for young people[4mm Aluminum Composite Panel for Exterior Using in Gold Color]. 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[Smokeless Carbonizer Wood Sawdust Activated Carbon Charcoal Making Machine] (FigurePVC Imitation Marble Sheet Production Line / PVC Stone Sculpture Flooring Extrusion Machine). On the co-existence with LDH, Bertolotti’s syndrome makes difficult the transforaminal passage through the Kambin’s triangle during TPED[Smart EU Plug 2 Ports USB Charger 5V 2A Fast Wall Adapter Mobile Phone Charger].

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

GTCAP high voltage metallized polypropylene film capacitors 22NF 40000VDC. They are normally located between the transverse processes of T12-L3 vertebrae, with the left kidney typically more superior in position than the right[ Gas] (FigureShoulder Pain Relife Medical Physiotherapy Shockwave Equipment). Treating high level LDHs, especially T12-L1, L1-L2 and L2-L3,Fashion Design Cordless Vacuum Cleaner with Low Price (WSD1801-39).

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SURGICAL PROCEDURE

TPED using the efficacy of TESSYS technique is performed under local anesthesia and mild sedation[Automatic Standard Parts Processing.,0.5m 9PCS Rgbwauv 6in1 Wireless LED Wall Washer Stage Light]. Patients are initially placed at the lateral decubitus position, lying down on the opposite side (FigurePlastic Parts Molded Vehicle Parts Mold Making Service One-Stop Services CNC Machining Parts). 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[Green Energy 30W 3000lm Integrated LED Solar Street Light Solar Lights All in One Manufacturer] (Figures2.0mm Simplex Connector FC Type for Fiber Optic CableandStainless Steel Pipe Price Per Meter). Sequential transforaminal passage of three different size reamers (5.5, 6.5, 7.5 mm, joimax GmbH) constitute the next step (FigureBest Quality Cimc 3 Axle Low Bed Semi Trailer). The cannula and endoscope are afterwards carefully inserted, in order to ensure nerve root preservation (FigureCorn Oil Press Machine Cotton Seed Oil Mill). Removal of herniated disc material is finally accomplished with graspers (FigureFactory Customization Small Food Grade Round Glass Honey Jar). 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[Big Promotion Fitness Tracker Screen Sport Running Smart Watch S10,Contactless Nfc Business Card Manufacturers Cheap Price,Factory Sale Phenolic Comapct Laminate Sheet 1220*1830]. 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 TableChina High Quality Modern Car Key Making Machine for Sale.

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 examination3kw 72V 300A Customized Over Heat Protected BLDC Motor Controller
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

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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.2 Filling Port and 8 Scales Automatic Weighing Down Jacket Filling Machine. These depend on the expertise and experience of each individual spine surgeon.24V Peltier Air Conditioner for Outdoor Telecom Cabinet; 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 Purity 99% D-Extromethorphan Hydrobromide Dxm Hbr CAS 125-69-9.

Manuscript source: Invited manuscript

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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,Wholesale Jacquard 100% Polyester Custom Star Hotel Bed Runner and Cushion Cover (JRL064), Thessaloniki 55535,One Layer Customized Nontoxic Special Hot Press Car Mats for Toyota Hilux.

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