Clinical application of percutaneous laser disk decompression

HUANG Xianglong NIAN Dingfang LU Junming (Department of Radiology, Huashan Hospital, Shanghai

Medical University, Shanghai 200040, China)

【Abstract 】Objective To evaluate the therapeutic effects of lumbar disk herniation treated by

semiconductor laser. Methods One-hundred cases of lumbar disk herniation diagnosed by clinic and CT

or MRI within three months underwent percutaneous laser disk decompression, including 65 cases of

L4-5 and 35 cases of L5-S1 disk. Results In this group of patients, the successful rate of penetration was

100% and the rate of efficiency was 72%. There was no complication in the following 6-18 months.

Conclusion Percutaneous laser disk decompression with semiconductor laser was a convenient, safe,

efficient and minimally invasive technique.

【Key words】Diskectomy, percutaneous; Laser surgery; Radiology, interventional

In recent years, the author of semi-conductor laser therapeutic apparatus using percutaneous laser disc

decompression (percutaneous laser disk decompression, PLDD) treatment of lumbar disc herniation, has

achieved some results. Automatic aspiration of the technology and compared to excision, a simple, safe,

injury, etc., are presented below.

Materials and Methods

1.Clinical data: 100 cases collected by the hospital to be diagnosed as clinical lumbar disc herniation by

CT or MRI in patients with a clear diagnosis for PLDD treatment, follow-up of 6 to 18 months. 100 cases

of patients, male 56 cases, 44 cases of women aged 17 ~ 72 years old, the average age of 48.5 years old.

Course of disease and clinical performance: the initial incidence of 2 months to 20 years, clinical low

back pain with radiation leg pain, inability to walk, limp, the affected muscle atrophy, limb cold. Physical

examination: unilateral or bilateral limb elevation test positive, the level of the corresponding disc next to

the spinous process tenderness. After pre-treatment CT or MRI examination. L4 ~ 5 of them were 65

cases of disc herniation, L5 ~ S1 disc herniation, 35 cases have been more than six weeks of

conservative treatment is invalid or the result is not significant.

Semiconductor Laser Therapeutic Apparatus used: wavelength 980 nm, the end of the maximum output

power 15 W. Optical fibers: 400 nm; 18G needle 2, a long 15 cm; Y-type switch 1.

Selected for the following conditions have PLDD indications: (1) clinically diagnosed as lumbar disc

herniation, with recent (within 3 months) CT or MR for the diagnosis of lumbar disc herniation were clear;

(2) 6 weeks of conservative treatment fails; (3) the extent of leg pain than back pain; (4) positive straight

leg raising test; (5) of sensory, motor response, tendon reflexes were diminished. And for the following

contraindications: (1) there is a serious clinical bleeding tendency and who can not be corrected; (2)

spondylolisthesis; (3) disc was broken from the Free State; (4) spinal stenosis (bony, ligament thickening,

calcification). (5) Marking the level of the history of trauma or surgery has been the history of lumbar

intervertebral disc or Chemonucleolysis history; (6) significant stenosis in the vertebral space; (7) clear

mental disorder; (8) pregnant women.

2. Operation Methods: Patients from lateral position (side up) in the DSA machine tools, positioning

under fluoroscopy puncture, topical 2% lidocaine anesthesia 5 ml (from the skin to the superficial muscle

layer), with 18G, length 15 cm of the needle away from the open side of vertebral spinous process

centerline 8 ~ 14 cm Department (L4 ~ 5 to 8 ~ 12 cm, L5 ~ S1 for 10 ~ 14 cm), under the supervision of

the perspective from the rear side into the needle, needle sagittal direction of the trunk surface and 45 ° ~

60 ° angle. Needle is located in the best position of the corresponding intervertebral space after the 1 / 3

the level of the Agency (Figure 1), after the success of lateral puncture, rotating C-arm, is situated to the

perspective, the spinous process at the level of the needle puncture nucleus, the L5 ~ S1 disc iliac wing

due to stop before the needle into the needle bent into approximately 160 ° around (Figure 2), after the

correct position, pull out the needle puncture needle core, will be 0.4 mm thick needle through the

fiber-optic delivery into, and beyond the top needle 0.5 cm, the use of Y-shaped lock switch and then to

the end of the output power 15 W, pulse time of 1 s, interval time of 5 s on the nucleus points to 1 point or

more laser decompression. Operation, when patients have a bulging waist flu, with space needle by

Y-switch liposuction, each disc to the energy by about 1 200 ~ 1 300 J (L3 ~ 4, L5 ~ S1), 1 300 ~ 1 500 J

(L4 ~ 5), the whole process about 20 ~ 30 min.

Results

100 cases of 100 patients with intervertebral disc, the success rate of puncture was 100%, follow-up

period was 6 to 18 months. Reference MacNab [1] to evaluate the standard cure, 72% efficient. Of which

22 patients were cured and 50 cases of effective, 28 cases were followed up for 6 months without

improvement in symptoms was considered null and void, without any complication. According to the

affordability of different patients, respectively after 3,6 months or 1,3,6,12-month CT or MRI follow-up visit,

some cases (24/100) 1 month for only the performance of the Department of nucleus density circular

lower three months after the performance of some patients to varying degrees for the disc back to Steiner

(49/100), part of cases (23/100) had no significant disc back satisfied, but to improve symptoms in

varying degrees.

Discussion

Principle PLDD through laser vaporization of the nucleus pulposus for cutting, as well as the solidification

of the part of disc nucleus pulposus to reduce intradiscal pressure and volume, so as to achieve the

purpose of treatment of lumbar disc herniation [2]. In recent years the use of laser disc decompression

has been in clinical and medical skills to gradually extend the awareness of staff and patient acceptance,

especially in recent years introduced by the British Diomed diode laser treatment of lumbar disc

herniation, more in line with the interventional radiology Development trends and operation of

micro-trauma of the requirements, should be promoted as a new method for the treatment of disc

herniation [3].

1. Percutaneous laser decompression of lumbar intervertebral disc with automatic suction cutting head

(APLD) comparison: in 1985, the United States and other Onik [4] introduced APLD achieved good

results, but relatively cumbersome to operate, and compare the work of casing large, especially for the

L5 ~ S1 disc cutting treatment, certain difficulties, complications rate was about 1%, mainly discitis, nerve

root injury waist muscle hematoma [5]. Percutaneous laser lumbar disc decompression, compared with a

decrease of APLD procedures for the replacement of equipment, only to be a 18G, diameter 1.0 ~ 1.2

mm, length 15 cm of the needle penetration in the TV monitor under the lumbar intervertebral disc with

prominent, and then through the optical fiber directly into the puncture needle prominent lumbar

intervertebral disc, therefore, a more simple procedure, surgical process more secure, virtually no

complications.

2. Puncture needle into the location of the relationship with the surrounding structure: puncture is

generally chosen from the open side of vertebral spinous process centerline 8 ~ 14 cm (L4 ~ 5:8 ~ 12 cm,

L5 ~ S1: 10 ~ 14 cm) Office. Anatomy shows that disc is located in the upper and lower vertebral body

between the central part of nucleus, nucleus enveloping the outside layer of annulus fibrosus, vertebral

body from top to bottom edge for the cartilage plates, cartilage under pressure of the buffer plays a role in

lateral After the nerve root from the ramp to walk forward, the nerve root and the upper edge of the next

vertebral body and posterior facet joint security triangle. Therefore, the necessary accuracy of needle

from the intervertebral space after the 1 / 3 into the nucleus of the central parts. In addition, the needle

should be avoided near the cartilage plate, in order to avoid its injury. If the needle near the cartilage,

then easy to damage [6], leading to ineffective treatment or the occurrence of complications, I have the

same experience.

3. Laser energy: issues on the laser energy, Gangi, etc. [3] that the disc can be used per 1 500 J, to 15 J

is appropriate for each. This set of data showed that average people better than 1 300 J, which may be

smaller than the size of foreign citizens who are small on the nucleus. In addition, any method of

treatment, the greater the damage to the organization, caused by swelling of the opportunity to organize

more, nucleus pulposus as well, around the nucleus because of the lack of blood circulation, edema

slower absorption. Therefore, the energy is too large to give easy edema caused by nucleus pulposus

and annulus fibrosus, nerve root compression, resulting in the short term treatment of patients with bad

results, but over time, will gradually absorb edema. After the follow-up 3 to 6 months, the majority of

patients compared with the preoperative symptoms in varying degrees to improve.

4. The reasons for poor treatment and Countermeasures: Gangi, etc. [3] that 1 year does not improve

symptoms of treatment was designated as invalid. Follow-up observation of this group showed that some

patients with symptoms can be alleviated, and some patients after 1 to 2 days or a few days’ symptoms

are repeated, the phenomenon may be related to puncture site of tissue injury and repair. Kutschera, etc.

[7] have on the disc after PLDD Biomechanical changes in the studies, which show that the degree of

intervertebral disc nucleus pulposus to reduce or completely satisfied and will take about 1 to 6 months,

or even longer, this Some patients with symptoms that take longer time to improve. According to this

characteristic, I realize the necessary 6 months of clinical observation, such as improvement of clinical

symptoms without any treatment can be confirmed invalid. According to my experience may be invalid

and the following factors: (1) laser points or relative shortage of energy, not the purpose of

decompression. (2) Puncture during the next facet more periosteal injury, or other organizations, arising

from chronic inflammatory changes. (3) Indications of improper hands. In this regard, my experience is:

(1) single-point laser burn, the carbonization and necrosis of the scope of smaller, multi-point laser

burning can increase the scope of carbonization and necrosis. (2) Efforts to improve the success rate of a

puncture: puncture process, to minimize damage from top to bottom needle synovial facet. (3) Strictly

PLDD indication is to improve the efficacy of the fundamental guarantee for PLDD.

The degree of postoperative intervertebral disc and 5.PLDD signal change and the relationship between

symptom improvement: Steiner, etc. [8] described the technique PLDD, the dynamic changes of

postoperative intervertebral disc, the disc shows the performance for only a short period of time after the

signal changes the form of annulus fibrosus and no significant change, and that the disc level and the

signal change and symptom improvement in patients with non-related, the group was followed up by CT

or MRI also proved this point of view.

6. After processing: PLDD its easy to operate, on a small tissue injury, so patients can be hospitalized for

observation need to go home to rest, three days of oral broad-spectrum antibiotic to prevent infection. No

bed rest period, but the need to avoid heavy work and cross waist movement across the flexor.

Symptoms such as repeated, to give help or partly inunction, after 6 months follow-up of patients with no

improvement in symptoms, and CT or MRI confirmed disc review satisfied no significant return, and could

be considered the 2nd line PLDD.

donna@gigaalaser.com