Percutaneous laser disc decompression

Percutaneous laser disc decompression ( PLDD ) is a minimally invasive therapy method for the treatment of herniated discs that can be performed under local anesthesia. In contrast to open back surgery, the patient is usually spared a general anesthetic , and this results in shorter hospital and rehabilitation stays.

Indications

PLDD can be indicated for disc-related back pain, such as a herniated disc (prolapse), bulging ( protrusion ) or wear and tear (degeneration), if conservative measures (such as pain relievers or physiotherapy) have been unsuccessful for at least six weeks.

Limitations

PLDD is not suitable for every patient with a herniated disc or for every stage of disc degeneration. Patients with mild intervertebral disc symptoms often respond to medication, physiotherapy and other adjuvant (supportive) measures.

Conversely, there are also advanced stages of intervertebral disc degeneration, in which it is difficult to achieve an improvement in symptoms for the patient by decompressing the intervertebral disc. As well as degenerative diseases of the bony skeleton of the spine , which at least make PLDD considerably more difficult.

There are also herniated discs in which so-called sequesters form. This means that part of the herniated intervertebral disc has become detached and is now separated from the intervertebral disc in the spinal canal or at the nerve root leading to neurological failures or pain. The decompression of the intervertebral disc using a laser only has an effect on the sequester in exceptional cases.

execution

A laser fiber is inserted into the affected intervertebral disc through a puncture cannula inserted through the skin. This cannula, which functions as a guide, is positioned in the affected intervertebral disc without surgical opening of the back and is carried out under radiographic control. So that the surrounding structures on the spine (spinal nerves, vessels and spinal cord ) are not injured, it is of particular importance to know the exact position of the laser fiber and its guide cannula. In order to guarantee the correct orientation of the puncture plane and to avoid complications, the puncture process is carried out using X-ray, CT or, more recently, MRT navigation (image control). If the guide cannula is correctly positioned in the intervertebral disc, the laser fiber is advanced a small, defined distance out of the guide needle and then lies as a so-called “bare fiber” in the target tissue (nucleus pulposus = gelatinous core) of the intervertebral disk. Depending on the type of laser - usually Nd: YAG laser or Ho: YAG laser, as these are particularly suitable for PLDD due to their properties - a specific protocol is now followed. The laser energy is transmitted to the intervertebral disc in the form of amplified light (laser) via a glass fiber. The nucleus pulposus of the intervertebral disc is heated and the proteins located there are denatured, coagulated and evaporated . The resulting loss of volume within the intervertebral disc and circular “shrinking” reduces the pressure on surrounding structures (nerve roots, spinal cord), which is the cause of the pain and neurological symptoms.

PLDD under X-ray and CT control is already successfully carried out today in the case of persistence of pain after conservative therapy (physiotherapy, anti-inflammatory drugs) of the herniated disc and the resulting pain. Due to the tunnel configuration, conventional MRI is not suitable for PLDD without restrictions, as the doctor cannot get close enough to the therapy area (usually the lower lumbar spine). As an alternative, openly configured magnetic resonance tomographs (MRT) are generally available. So far, however, their field strength has been too low (low-field MRT) to achieve sufficient image quality and to guarantee the precision required for the procedure in the needle guidance.

research

Since January 2007, various laser-assisted interventions in open high-field MRI have been researched at the Charité as part of a project funded by the TSB and the EU ( EFRE ), including the PLDD.

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