Does laser spine surgery work? No. But you can continue reading the remainder of this blog if you wish to know why.
“Laser” is a pretty cool word. Sci-fi movies depicting battles with lasers gives a futuristic impression. Watching a burglar navigate through a laser lattice of alarms seems sophisticated. It, therefore, seems logical that anything in life incorporating lasers must be cutting edge technology. When it comes to spine surgery, however, lasers have been around since the 1980s. CO2 lasers were originally used to treat lumbar disc herniations but quickly fell out of favor. Applying heat with a laser, small amounts of collagen fibers in the disc herniation contract and parts of the disc herniation recoil back into the disc space. Unfortunately, it was found that less than about 0.1 mL of the disc could be treated using this technique when an average symptomatic disc herniation is larger. Additionally, applying focal and steady heat near nerves risks nerve injury. Therefore, this technique was nearly abandoned for good reason.
More recently, numerous clinics have monopolized on the marketability of using lasers to treat both cervical and lumbar disc herniations, in addition to just about any spine condition. They imply that this technique is somehow bloodless, more minimally invasive, painless and can provide an excellent outcome for any spine conditions compared to standard procedure. These results have never been validated in any randomized controlled study.
How is Laser Spine Surgery Performed?
Laser spine surgery initially begins the same way as a standard minimally invasive discectomy. A small incision, usually ~2cm, is made in the skin. Interestingly, nearly all the patients we have seen at RMBSI who have undergone prior laser spine surgery have horizontal incisions, compared to standard vertical incisions well-trained surgeons usually use. Basic surgical principles use Langer’s lines to guide incisions, and these horizontal incisions violate this technique and lead to poorer skin healing.
Often, a tubular retractor is advanced through the muscles down to the bone, just like a standard minimally invasive surgery. As lasers do not penetrate bone, “laser spine surgeons” drill away some of the bone covering the nerves (laminectomy) in the same way as the standard procedure. The nerves are then gently retracted to the side to expose the disc, just like the standard procedure. The next part is the only difference. In a standard microdiscectomy, a spine surgeon uses a microinstrument to quickly but safely physically grab the disc fragment. A “laser spine surgeon” focuses the laser on the disc and slowly burns it, hopefully without burning the nerve. The incision is then closed the same way in each procedure.
What Does the Research Show?
Few comparative studies have been performed regarding laser spine surgery. Again, this has less to do with lasers being new or innovative with new data churning on the presses but more to do with the fact that laser spine surgery has already been proven ineffective. In a recent comparative study of cervical laser discectomy, improvement following the procedure was no better than nonsurgical management.
In a 2-year randomized controlled trial of laser lumbar decompression versus conventional microdiscectomy, the reoperation rate for laser spine procedures was double that of the standard procedure. And in the few studies showing some temporary beneficial improvement, this improvement appears to be linked to a placebo effect. At major spine meetings and in major spine journals, there is little to no evidence documenting beneficial effect of using lasers in spine surgery. On the contrary, standard minimally invasive spine decompressions, fusions, and artificial discs have very defined success rates proven through randomized controlled trials.
Who are the Laser Spine Surgeons?
As laser spine surgery has not been proven to be an effective treatment strategy, most insurances will not pay for this procedure. Cash is most often the payment method, and it’s expensive. In a cash-based system, there essentially is no regulation on who can perform this procedure. However, the surgeons tend to be orthopedic surgeons or pain physicians (not surgeons) who have completed a residency. Some neurosurgeons perform the procedure. Interestingly, while many of these surgeons claim to be fellowship trained, careful examination of their credentials show they tend not to be fellowship trained in spine surgery. The caveat is some completed the “Laser Spine Institute fellowship,” which of course is not an accredited program.
Can Lasers Treat Any Spine Condition?
The CO2 laser only has use in addressing “soft” tissues like a disc herniation. The laser cannot cut through bone, nor can it stabilize a spine that is moving incorrectly. Therefore, the only potential application of a laser is in disc herniation or spine tumor. It will not effectively treat spinal stenosis, facet disease, or spondylolisthesis. It cannot replace fusion spine procedures.
Will We Ever Use Lasers in Spine Surgery Again?
It’s possible an indication will again arise for lasers. They are increasingly being investigated in neurosurgery for brain tumors. They could be used for spine tumors. However, in the degenerative spine world, as medicine advances and old techniques turn to the wayside, they tend not to resurface. Advancements in minimally invasive surgery will more likely focus on robotics, preservation of motion, and reduction of adjacent level changes.
Questions about laser spine surgery? Give us a call today at Rocky Mountain Brain & Spine Institute to learn more about this technique, and to discuss which surgery option is best for you.