Laser Spine Surgery: Help or Hype?

Herniated disc surgery is less invasive than ever. Microdiscectomy is the standard, but what about percutaneous laser disc decompression? Get our experts’ assessments on this treatment method.

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Has there ever been a time when lasers weren’t fascinating and futuristic? Pick a science fiction movie from any decade and it’s a safe bet that lasers played a pretty big part, no matter what level the special effects.

Spine surgeons performing laser spine surgeryShould you get laser spine surgery? Two experts weigh in.

Lasers now even play a part in trying to address back pain, including common ailments like sciatica, the burning pain that runs down the back of your leg.

Most cases of sciatica are caused by a herniated disc, and sciatica affects about 1.5 million in the United States, according to the American Journal of Neuroradiology.

What the Science Suggests

About 20% to 40% of those affected typically end up getting relief through surgery. Conventional lumbar disc surgery involves going under the knife but there are minimally invasive alternatives. Among them is percutaneous laser disc decompression (PLDD) -- laser spine surgery.

“It’s a nice concept in your mind: take a laser and zap it,” said neurosurgeon Mark McLaughlin, MD. “It sounds more precise, with a connotation of being precise. It does have that ring to it but doesn’t deliver what the patient is imagining.” Dr. McLaughlin is founder of Princeton Brain, Spine and Sports Medicine, where his practice focuses on trigeminal neuralgia and cervical spine surgery.

A 2006 paper in the American Journal of Neuroradiology (AJNR) suggested that a scientific comparison of percutaneous laser disc decompression (PLDD) with both conventional survey and conservative management of lumbar disc herniation is needed. Although the sample size was only 30 patients, a more recent study from 2019 concluded that the use of PLDD reduces pain and disability in patients as a noninvasive procedure.

A study in AJNR from 2017 followed two groups of people who had surgery to relieve sciatica. One group of 57 patients had conventional microdiscectomy and another group of 55 had PLDD. After two years, the study found a re-operation rate of 21% of patients who had conventional surgery compared with 52% of those who had PLDD.

“Although the rate of reoperation in the PLDD group was higher than expected, surgery could be avoided in 48% of those patients that were originally candidates for surgery,” according to the study. “Percutaneous laser disc decompression, as a non-surgical method, could have a place in the treatment arsenal of sciatica caused by contained herniated discs.”

An earlier study from 2015 found the number of reoperations was less for both surgeries but significantly less among the conventional surgery group, 16% versus 38%. “Overall, a strategy of PLDD, with delayed surgery if needed, resulted in noninferior outcomes at 1 year.”

Drawbacks of Percutaneous Laser Disc Decompression

Dr. McLaughlin is less sanguine about laser surgery. Lasers generate heat and don’t turn around corners like instruments do, according to Dr. McLaughlin, or a precise depth of understanding or penetration. “I don’t think it’s well suited for routine spine surgery” that requires decompression, removal of bone spurs or reconstructive surgery.

For a standard, single-level disc herniation causing sciatica, a minimally invasive microdiscectomy is the standard procedure, according to Dr. McLaughlin. Another option is a standard discectomy, which involves a slightly bigger incision than a microdiscectomy.

“Once you get to where you want to get to, a laser is not going to do the job,” Dr. McLaughlin said. “Bone biters, a drill, maybe a shaver, something that will debulk the disc that’s pinching the nerve. A laser is not the tool for that.”

Whatever benefits a laser may have don’t outweigh potential drawbacks, according to McLaughlin. “My belief that incidents of recurrence are probably higher with laser decompression because generally they’re not going to be able to do the job that physical instruments will,” he said, suggesting a higher recurrence rate and higher incidence of nerve injury related to heat.

In the spine, nerves coming and going, bending around corners, and you can’t bend or twist the laser, Dr. McLaughlin said.

When to Use Percutaneous Laser Disc Decompression

The way orthopedic spine surgeon Colin Haines, MD sees it, laser surgery lends itself to procedures where you have to be careful around soft tissue and muscle, like ultra-minimally invasive surgeries.

Any soft tissue when pressing that should not be may be ideal for laser surgery, according to Haines, and that could include spinal stenosis and nerve pressure, soft tissue nerve pressure, facet swelling, and sciatica, caused by a herniated disc.

Dr. Haines, a spine surgeon at the Virginia Spine Institute (VSI) in Reston, Va., said made the analogy to a grape. Traditional types of disc removal procedures involve an incision to remove bone and remove the grape. In laser spine surgery, the laser is used to stiffen the grape and shrink it, like a raisin.

“It all goes to what the laser is. It’s focused light, essentially heat,” Dr. Haines said. The laser “allows us to shrink tissues through heating. There are circumstances where we can do that extremely appropriately,” he said. The laser may not be the best option in some cases, where heat is not appropriate, perhaps a tight corridor or nerves that are blocking visualization to get to the problem site.

Laser surgery allows you to shrink soft tissue like herniations, Haines said. In other circumstances, endoscopic surgery may be a better option. That involves inserting a tiny camera through an incision and carefully navigating around nerves to relieve pressure, “The spine has many nooks and crannies in it,” he said. “Sometimes you gently have to pull nerves aside and remove a little tissue to get to problem areas."

Recovery from Laser Disc Decompression

One issue with spine surgery is just getting access to the spine, which has a lot of muscle surrounding it. That involves big incisions with lots of muscle cutting and that equals longer recovery time, Dr. Haines said.

Recovery timelines depend on the size of the surgery. Dr. Haines suggested three to six months for traditional spine surgery compared with three to six days for endoscopy and laser surgery.

Dr. McLaughlin suggested recuperation from incisional pain is about one to two weeks and “taking it easy” another two to four weeks, depending on one’s condition coming into surgery and how long they’ve been ill.

Laser surgery advocates suggest a quicker recovery, more like one week. “That’s because it’s not doing the job that needs to be done to compress the nerve,” Dr. McLaughlin said. “You’re maybe putting the laser on a disc and shrinking it a little; it’s temporary relief,” he said.

When PLDD is successful, return to normal work averages one week, according to a paper presented at the American Institute of Physics conference in 2010. The study, which took into account almost 20,000 procedures, found a success rate ranging from 70% to 89%. Long term follow‐up to 23 years found a recurrence rate of 4% to 5%.

The good news, according to Dr. Haines, is that 90 percent of the time -- whether it’s disc herniation, nerves or spine pain -- issues can get better without surgery.

As laser continues to improve and surgeons become more adept, laser surgery will become more of a mainstay, predicts Dr. Haines. “I would not call it mainstream yet. There are a lot of challenges in adapting new technology in health care,” he said.

On the other hand, Dr. McLaughlin suggests to patients seeking some type of decompression procedures to at least get an opinion of a fellowship-trained spinal surgeon so they can make an informed decision.

Updated on: 03/31/21
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