Guidance for counseling patients amid the flurry of marketing
By Ryan Brennan, MD, and Thomas E. Mroz, MD
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In recent years, patients have been inundated by advertising and social media campaigns that make laser spine surgery sound like a real-life, science fiction-inspired cure-all. As a result, increasing numbers of patients are expressing interest in this alternative to standard surgical treatments of spinal conditions. The heavy marketing push that positions this surgical technique as a panacea has some spine surgeons tamping down the claims.
What patients — and even some physicians and surgeons — might not know is that this technique has been utilized for nearly 30 years and is an effective approach in selected patients.
Peter Ascher and Daniel Choy became the pioneers of laser spine therapy in 1986, performing the first percutaneous laser disk decompression (PLDD) procedure at the Neurosurgical Department, University of Graz, in Austria.1
The first and still most common application of laser spine therapy is for the treatment of lumbar herniated nucleus pulposus (HNP).
Today, advances in technology, the development of new lasers and equipment, and improved imaging have allowed for the expansion of laser spine interventions to include the cervical, thoracic and lumbar spine.
Applications include percutaneous laser disk decompression of the cervical, thoracic and lumbar spine; laser-assisted posterior cervical foraminotomies and diskectomy for lateral and foraminal cervical disk herniation; laser-assisted anterior cervical corpectomy for cervical myelopathy patients with multilevel ossification of the posterior longitudinal ligament; and laser ablation of spinal growths such as tumors and vascular lesions.
Patient selection criteria for laser spine surgery is similar to that for conventional open surgery: ages 18 to 70, sciatica or cervical radiculopathy due to lumbar or cervical disk herniation for which conservative measures have failed and disk herniation of less than one-third the diameter of the central canal, without concomitant lateral recess stenosis or sequestration.
The use of laser therapy has spread worldwide.
Choy has theorized that the use of PLDD centers on the principle that the disk, surrounded by a fibrous annular ring, represents an enclosed hydrologic space and that laser ablation of even a small amount of intradiskal material can lead to a reduction in the intradiskal pressure that is significantly disproportionate to the reduced volume.2,3 As a result, a newly created vacuum within the disk pulls the bulging or herniated disk fragment back into this space, thereby relieving the pressure on the neural elements.2 This theory, however, is not proven — and many doubt that this actually occurs.
Others have suggested that the drop in intradiskal pressure is a placebo byproduct of placing the needle into the disk and not due to the laser ablation itself. However, intradiskal pressure measurements have confirmed that the disk pressure remains stable when the needle is placed and is reduced only after the laser ablation is completed.4
To obtain optimal outcomes using the percutaneous approach to laser therapy, proper placement of the needle tip just interior to the annulus is key, with the needle parallel to the disk space and centered between the endplates of the levels above and below the affected disk. An optical fiber is then introduced into the intervertebral disk, allowing administration of laser thermal energy.3
Advantages of PLDD include outpatient care, shorter hospitalizations and earlier return to work.
To date, most clinical studies of this technology are level 2B data (i.e., individual cohort studies, including low-level randomized controlled trials with less than 80 percent follow-up), as defined by the National Institutes of Health’s levels of evidence scale.
In the laser spine therapy literature, successful outcomes are measured primarily through the assessment of post-procedure pain and disability levels using standard measures such as the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI) and the MacNab criteria, which ranks the patient’s pain and any impact on activity from excellent to poor. In the longest follow-up periods to date (17 years), successful outcomes reported in the literature range from 44 to 92 percent (typically 70 to 89 percent) of cases.1 When laser spine surgery is successful, time from surgery to return to work can be one week or less.1
Although rare severe complications have been reported with laser spine surgery, the overall complication rates (0.3 to 1 percent per year) remain lower than those for conventional spine surgery (about 2 percent per year), and these severe complications appear to be aberrations rather than a reflection of the norm.1 The most common complication appears to be diskitis associated with the percutaneous needle placement, though in reported cases this was mild to moderate in severity and treated successfully with IV antibiotic therapy
In a 17-year follow-up report, Choy described how this procedure, due to low production of scar tissue, may also confer advantages in revision surgery over open techniques. He also reported that PLDD was not associated with a single nerve or cord injury. Choy suggested that the sustained results demonstrated in this long term follow-up study clearly rule out the placebo effect that many conventional spine surgeons have asserted occurs in these cases.
With conventional open spine surgery, patients typically return to work after six weeks. With laser therapies such as PLDD, some studies report return to work in as few as five days. The faster return-to-work time and lower reported overall complication rate of this minimally invasive surgical technique in theory carries a significant socioeconomic impact, though this is not yet validated
A literature search did not reveal any prospective, randomized, directly comparative studies to evaluate the socioeconomic impact of conventional open versus laser spine surgery. Further evaluation is needed to determine the true comparative cost-benefit ratio of open versus laser spine surgery.
A review of the literature suggests that when patients are appropriately selected for laser spine procedures, there is a low infection rate, few complications and outcomes comparable to those achieved with conventional surgical options.
Further prospectively conducted randomized controlled trials are needed to validate outcome parameters and rule out potential investigator bias in the early literature. If outcomes are validated, the potential socioeconomic and clinical impact of wider adoption of this technique could be significant.
Dr. Brennan is Chief Spine Fellow, Neurosurgery, in the Center for Spine Health. He can be reached at brennar@ccf.org.
Dr. Mroz is Co-Director of the Center for Spine Health and Director of the Spine Surgery Fellowship Program. He can be reached at mrozt@ccf.org or 216.445.9232.
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