Chronic low back pain is one of the major chronic debilitating conditions involving tremendous loss of money, work, and quality time. Lasers are used in different fields of medicine and confer unique advantages. In the treatment of lumbar disc disease, they are useful and advantageous. Laser discectomy is an outpatient procedure with one-step insertion of a needle into the disc space. Disc material is not removed; instead, nucleus pulposus is burned by the laser. Laser discectomy is minimally invasive, cost-effective, and free of postoperative pain syndromes, and it is starting to be more widely used at various centers.
The rapid acceptance of minimally invasive surgery in the United States has occurred largely without statistical proof of its superiority over traditional methods. All members of the healthcare field now see the need for valid outcome studies supporting the efficacy of new treatment techniques. Percutaneous laser disc decompression (PLDD) will gain wide acceptance only if it is demonstrated statistically to be a safe and effective alternative treatment for lumbar disc herniation.
Epiduroscopic laser neural decompression is considered an effective treatment alternative for chronic refractory low back and/or lower extremity pain, including lumbar disc herniation, lumbar spinal stenosis, and failed back surgery syndrome that cannot be alleviated with existing noninvasive conservative treatment.
PLDD performed with computed tomographic (CT) and fluoroscopic guidance appears to be a safe and cost-effective treatment for herniated intervertebral discs and is being used with increasing frequency. It is minimally invasive, can be performed in an outpatient setting, requires no general anesthesia, results in no scarring or spinal instability, shortens to rehabilitation time, is repeatable, and does not preclude open surgery should that become necessary.
Various laser wavelengths have been used, but no consensus exists regarding which is most efficacious. Good candidates for this procedure have a classic clinical syndrome and neuroimaging evidence.
In cases of ruptured posterior longitudinal ligament (ie, epidural leak of contrast medium in discography), PLDD is not indicated. Indications for the operation first of all depend on the clinical symptoms, but the success of the operation depends on the discographic findings.
Laser-assisted posterior cervical foraminotomy and discectomy is an efficacious surgical option for treating lateral cervical disc herniation. The pinpoint accuracy of the laser scalpel facilitates sophisticated decompression within a limited surgical field and may reduce the risk of intraoperative bleeding and neural damage.
This minimally invasive technique can be performed in patients who need surgical intervention for disc herniation (see the image below) with leg pain from radiculopathy. Patient selection, and especially disk morphology, are the two most important factors determining the choice of the technique.
Disc herniation classification. A: Normal disc anatomy demonstrating nucleus pulposus (NP) and annular margin (AM). B: Disc protrusion, with NP penetrating asymmetrically through annular fibers but confined within the AM. C: Disc extrusion with NP extending beyond the AM. D: Disc sequestration, with nuclear fragment separated from extruded disc.
Exclusion criteria include stenosis or facet hypertrophy and disc fragment, though a review from Knight et al described its use in foraminoplasty. Relative contraindications are progressive neurologic deficit, involvement in workers' compensation cases, and previous surgery at the same disc level.
In general, the herniation must have continuity with the parent disc; rupture of the annulus is not a contraindication. All patients must be considered on an individual basis.
Criteria for inclusion are undergoing continuing change. Although the optimal candidate, as previously described, is one who has an untreated single-level herniation with limited migration or sequestration of free fragments, a study from Ahn et al showed the procedure to be effective for recurrent disc herniations in some selected cases. What is unacceptable now may, with modifications, become acceptable in the future. During this early stage of PLDD, not adopting a fixed position is important.