DESCRIPTION:

Percutaneous laser disc decompression (PLDD) is a minimally invasive procedure for treating therapy-resistant, radiologically and neurologically manifest slipped discs, predominantly in the lumbar and lumbosacral area.

SYMPTOMS:

A slipped disk presses on a nerve, causing pain, numbness, or weakness in the area of the body to which the nerve goes. Depending on the position of the herniated disc, pain could arise in the front of the thigh, shoulders, arms, or chest. Sciatica may develop. Low back pain may accompany the leg pain.

INCIDENCE AND CAUSES:

Forty percent of the residents of industrialized countries experience back pain at least once in a life time. The annual incidence rate for herniated disks is 150 out of 100,000 residents. 61 of them are usually treated by surgery.

Genetic disposition is often related to the occurrence of disk herniation. Other causes include single-sided permanent exposure during professional or leisure activities, muscular incompetence or a traumatic event like an accident are more direct causes for a disk to slip. Due to wear, a crack can develop in the outer layer of the disk. The jellylike material inside the disk (nucleus) is forced out through the crack in the capsule causing the disk to bulge. This often happens as a result of sudden heavy strain or a sudden twisting movement. The bulge then presses on a nerve causing pain. The herniated disk can also break open (rupture), or break into fragments. The average age of incidence for this disease is around 40. Most frequently, the lumbar region is affected.

ANATOMY:

Coming Soon

PATIENT SELECTION:

Contraindications for PLDD are:

• Patients, who have not had adequate conservative treatment for at least 6 – 8 weeks.
• Patients with severe spondylolisthesis (vertebra slips forward onto the one below it).
• Patients with severe scoliosis (spine is bent sideways).
• Patients with metastatic cancer.
• Patients with vertebral compression fracture.
• Bone spurs pressing on nerve roots.
• Patients with free fragments.
• Moderate to severe vacuum phenomenon (gas bubbles in the disc).
• Male patients over 80. (There is not enough water content in the nucleus anymore.)
• Patients with hemorrhagic diathesis that cannot be reversed.
• Patients with hemangioma adjacent to the disc.
• Patients with multiple sclerosis
• Patients with other demyelinating disease of the central nervous system.
• Patients with systemic infections.

PROCEDURE:

During initial consultation with the patient, use case history, movement tests and diagnostic imaging tests to determine if a laser treatment is beneficial. MRI scans can image a crushed nerve root caused by a slipped disk or CT scans with myelograms show difficult-to-detect cases of nerve root crushing.

If a herniated disk is diagnosed a conservative therapy treatment should be used initially. If symptoms do not improve after 6 – 8 weeks, the laser treatment can be discussed with the patient providing contraindications do not exist. 

During the minimally invasive PLDD surgery using the Dornier fibertom 5100 the patient receives local anesthesia.  If pain becomes too great for the patient during treatment an anesthesiologist should administer further analgesic.  A puncture needle is inserted into the nucleus pulposus of the disc using x-ray monitoring. A contrast agent is injected through the needle to verify the correct position. The laser fiber is then introduced into the nucleus through the needle. The laser light is radiated in short pulses by stepping on the foot pedal, until a specific amount of energy is applied to the disc. The fiber remains in the same position for the entire laser treatment; only the angle of the needle and therefore angle of the fiber is slightly changed. The absorption of the laser light causes the tissue water to vaporize and surrounding cells to heat. This shrinks the cells and therefore the nucleus, resulting in genuine mechanical pressure relief and elimination of pain.  Applying the laser in short pulses prevents any thermal damage of the surrounding tissue. The patient is asked to move his feet several times during the treatment to confirm function control.

This treatment can also be performed with the Dornier Medilas D fibertom, a diode laser with a wavelength of 940 nm.

POST PROCEDURE PROTOCOL:

PLDD surgery may be performed as an inpatient or an outpatient procedure.

An active treatment with physical therapy or specialized workout for the back is recommended.

International clinical studies have shown the success rate of percutaneous laser disc decompression to be around 80 % with an extremely low complication rate. The use of PLDD can therefore avoid open surgery for many intervertebral disc patients.

ALTERNATIVE TREATMENT OPTIONS:

• Laminectomy (open decompression) - The laminectomy surgery is the process of  removing a small portion of the bone either over the nerve root (disc material) or from under the nerve root or both to give more space to the nerve root. The incision is long and muscle stripping must be performed. The healing process is relatively long. The surgery often causes instability of the spine and is therefore refused today.

• Microdiscectomy – The microdiscectomy differs from laminectomy only in a smaller incision and less muscle stripping. Therefore healing process and side effects are less. The results of both techniques are similar.

• Chemonucleolysis – During this minimally invasive treatment, the gas ozone is injected with a percutanous needle through a puncture in the herniated disk. The ozone improves blood circulation within the disc and healing of inflammations. In the nucleus pulposus, the results are a reduction of the water content, a reduction of the volume of the disk and a decrease in pain. This method could cause various side effects and is thus not recommended.

• Percutaneous Nucleotomy – After local anesthesia is administered, a thin probe is inserted in the herniated disk, similar to the PLDD method. With an automated discector, which is a suction shaver that can perform controlled removal of disc material, the volume of the herniated disk is reduced. Due to insufficient results this method is not used.