POPULAR APPEAL OF LASER SPINE SURGERY
One of the most common questions I am asked by patients is if laser can be used to perform their spine surgery, and there seems to be a general perception that lasers are a modern, futuristic tool that can perform bloodless surgery. Lasers are certainly used to great effect in some, limited medical procedures, most commonly in refractive eye surgery and dermatological procedures. In reality, laser is an old technology, more than 50 years old, (it was invented in 1960), and is not useful in spine surgery.
PROBLEMS WITH LASER SPINE SURGERY
When it comes to spinal surgery, electrocautery (using a needle or other implement heated by electricity) is much more effective when it comes to cutting or dissecting soft tissue. While lasers can cut disc tissue, they take too long and can be potentially more difficult to control. Since the nerve root lies adjacent to the disc, the risk of damaging the nerve root with the laser is higher compared to electrocautery or microinstruments. Additionally, lasers cannot cut bone, so they cannot be used to decompress patients with spinal stenosis from bone spurs, limiting their usefulness.
RESEARCH AND CLINICAL HISTORY OF LASER SPINE SURGERY
Despite these limitations with laser-based treatments, trials with laser in disc decompression started in the 1980s. The concept was based on the idea that heating the bulging disc vaporized enough tissue to relieve pressure on nerves or reduced disc pressure to alleviate pain. These laser techniques involved introduction of an optical fiber into the bulging or degenerated disc and administering laser energy. Unfortunately, the results from these trials were inconclusive at best, and none of these techniques were deemed promising enough to warrant a full scale prospective medical study. The best study to date was published in the May 2015 Spine Journal titled “Percutaneous laser disc decompression versus conventional microdiscectomy in sciatica: a randomized controlled trial.” This study showed that percutaneous laser disc decompression (PLDD) was not inferior to standard microdiscectomy surgery. However, microdiscectomy patients recovered faster and PLDD patients had a higher rate of needing reoperations.
More recent techniques utilizing laser in spine surgery involve combining endoscopes with laser. Known as epiduroscopic laser neural decompression (ELND), these procedures are widely performed in Asia and parts of Europe. Published reports on this technique are sparse and involve small numbers of patients with short follow up. Even with these low standards, the outcomes reported have not been encouraging. Some of the short term relief reported in a subset of these patients are thought to be due to placebo effect. As a result, national spine surgery organizations in the United States have not accepted the role of laser in spine surgery.