Literature References Supporting the Technique LASER DISCECTOMY J Clin Laser Med Surg. 2003 Apr;21(2):61-6. Nonendoscopic Nd-YAG 1064 nm PLDN in the treatment of thoracic discogenic pain syndromes. Hellinger J, Stern S, Hellinger S. Novamed Hospital, Munich, Germany. Hellinger@gmx.de OBJECTIVE: The purpose of the present study was to discover new minimal invasive treatments of discogenic thoracic pain caused by protrusions or extrusions using the promising method of nonendoscopic Nd-YAG 1064 nm PLDN in the lumbar and cervical regions. Because early symptoms of chronic thoracic discogenic pain syndromes have not been characterized, interventional therapy is usually started late and involves a high complication rate. MATERIALS AND METHODS: A prospective controlled clinical study was undertaken by neurologists using Nd-YAG 1064 nm PLDN to treat 42 patients with thoracic disc protrusions and extrusions. Patients with discogenic pain syndromes and MRI-confirmed disc pathology with spinal canal impairment were enrolled; 68 discs were treated. Maximal Nd-YAG laser 1064 nm dose was 1,000 watts per segment. Disc puncture was performed by dorsolateral approach. Monitored parameters were VAS, McNab score, subjective condition, neurological findings and peripheral EMG. A different, independent neurologist examined each case before and after surgery. RESULTS: At 6 weeks after treatment, 41 patients had a successful outcome; only one with a clinical suspicion of spondylodiscitis was dissatisfied. In all others, clinical parameters improved. EMG leaks had disappeared. Combined spastic paresis improved in 2/4 cases. Complications were one pneumothorax, one pleuritis and one suspected spondylodiscitis. CONCLUSION: Pain relief and decompression of spinal structures is effective and immediate by disc vaporization, shrinkage, nociceptor destruction and discogenic kinius denaturation. Nonendoscopic percutaneous Nd-YAG 1064 nm PLDN is a highly effective method for the treatment of thoracic disc disorders with minimally invasive access and is recommended prior to any open surgery. Mt Sinai J Med. 2000 Sep;67(4):278-82. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty. Chiu JC, Clifford TJ, Greenspan M, Richley RC, Lohman G, Sison RB. California Center for Minimally Invasive Spine Surgery, Thousand Oaks, USA. OBJECTIVE: To study the surgical outcome of outpatient percutaneous microdecompressive endoscopic cervical discectomy with lower energy laser for shrinkage of disc material (thermodiskoplasty). METHOD: Since 1994, 200 patients with herniated cervical discs have presented at the authors' clinic, with unilateral radicular pain. The diagnosis was confirmed by MRI or CT, and EMG. RESULTS: At an average follow-up of 25 months, 94.5% of the cases had good-to-excellent results. Eleven patients (5.5%) remained symptomatic, with persistent neck and upper extremity pain associated with paresthesias. There were no significant postoperative complications. Average time before returning to work was 10 days. CONCLUSIONS: Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty has proven to be a safe and efficacious minimally invasive procedure J Clin Laser Med Surg. 1998 Dec;16(6):325-31. Percutaneous laser disc decompression (PLDD): twelve years' experience with 752 procedures in 518 patients. Choy DS. Columbia University College of Physicians & Surgeons, New York, New York, USA. DSC7.@columbia.educ BACKGROUND AND OBJECTIVE: Percutaneous laser disc decompression (PLDD) is a procedure in which herniated intervertebral discs are treated by reduction of intradiscal pressure through laser energy. This is introduced by a needle inserted into the nucleus pulposus under local anesthesia and fluoroscopic monitoring. The small volume of nucleus vaporized results in a sharp fall of intradiscal pressure, with consequent migration of the herniation away from the nerve root. First proposed by the author in 1984, this concept was validated by 2 years of in vitro experiments. Our aim was to apply this concept to a large series of patients with herniated disc disease. STUDY DESIGN/MATERIALS AND METHODS: A nonrandomized, nonblinded study was conducted in male and female patients with symptomatic, image-documented intervertebral herniated discs in a 12-year period using PLDD as the only treatment modality. RESULTS: The author's own series consists of 752 intervertebral discs in 518 patients over a period of 12 years. The overall success rate ranged from 75% to 89% with a complication rate of less than 1%. CONCLUSION: PLDD has proven to be safe and effective. It is minimally invasive, is performed in an outpatient setting, requires no general anesthesia, results in no scarring or spinal instability, reduces rehabilitation time, is repeatable, and does not preclude open surgery should that become necessary. Surg Neurol. 1998 Jun;49(6):588-97; discussion 597-8. Endoscopic transforaminal lumbar discectomy and reconfiguration: a postero-lateral approach into the spinal canal. Ditsworth DA. Division of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA. BACKGROUND: In the past, minimally invasive procedures (chemonucleolysis, laser, automated percutaneous discectomy, percutaneous manual nucleotomy, arthroscopy) have been largely confined to intradiscal work. This study represents cases of working channel, transforaminal spinal endoscopy performed using an endoscope which, because of its small size and flexibility, can bend up to 90 degrees (depending on the guiding cannula), and pass completely through the foramen into the spinal canal (truly transforaminal, as opposed to just going through part of the foramen and into the disc), to directly remove free fragments and reconfigure disc, relieving root and dural displacement at all lumbar levels. METHODS: The records of 533 patients who had outpatient, minimally invasive operations performed over a 6-year period (ending in 1995) by this author were analyzed. Of these, 110 had small scope transforaminal procedures, forming the basis of this study. RESULTS: An independent observer followed the 110 patients who had endoscopic transforaminal procedures for 2 or more years. Using MacNab's criteria, the success rate (excellent or good) was 95% in the 75 patients with disc presenting lateral to the dura-"lateral presenting,"-and 83% in the 35 patients not presenting disc for direct removal-"non-lateral presenting" (i.e., dura in the pathway)-making an overall success rate of 91%. One patient who developed discitis was the only complication. CONCLUSION: Guideable endoscopes small enough to pass completely through the foramen allow percutaneous surgery to include non-contained disc herniations and even some migrated free fragments, depending on the location. The percutaneous transforaminal endoscopic technique can be an effective, safe approach for disc removal through the foramen, especially in cases where the disc presents itself for direct removal. Radiographics. 1996 Jan;16(1):89-96. Percutaneous laser disk decompression under CT and fluoroscopic guidance: indications, technique, and clinical experience. Gangi A, Dietemann JL, Ide C, Brunner P, Klinkert A, Warter JM. Department of Radiology B, University Hospital of Strasbourg, France. The aim of percutaneous laser disk decompression (PLDD) is to vaporize a small portion of the nucleus pulposus of an intervertebral disk, thereby reducing the volume and pressure of a diseased disk. This minimally invasive technique can be performed in patients who need surgical intervention for disk herniation with leg pain. PLDD is usually performed under fluoroscopic guidance with or without diskoscopy. However, it can also be performed under dual computed tomographic (CT) and fluoroscopic guidance as an outpatient procedure. CT and fluoroscopic guidance increases the safety and accuracy of PLDD, with high precision of instrument guidance, direct visualization of nucleus pulposus vaporization, and reduced risk of complications. Of 119 patients with lumbar disk herniation treated with PLDD under CT and fluoroscopic guidance, 91 (76.5%) had a good or fair response. PLDD performed with CT and fluoroscopic guidance appears to be a safe and effective treatment for herniated intervertebral disks. J Neurosurg. 1994 Jun;80(6):1039-45. Comment in: J Neurosurg. 1994 Oct;81(4):639-40. J Neurosurg. 1994 Oct;81(4):640-1. Same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy. Savitz MH. Department of Surgery, Good Samaritan Hospital, Rockland County, New York. The 2-year experience of one neurosurgeon with Kambin's orthopedic instruments and frame for arthroscopic microdiscectomy is reported. Arthroscopy using a unilateral approach and monoportal technique is a valuable adjunct to fluoroscopic monitoring. One hundred patients underwent same-day microsurgical arthroscopic lateral-approach laser-assisted (SMALL) fluoroscopic discectomy. In addition, suspected spinal tumors in three patients were treated by biopsy and infection of the disc space was drained in one. A prototype operating discoscope was employed for delivery of the neodymium:yttrium-aluminum-garnet laser beam to assist with hemostasis. Seventy-five "ideal" cases were identified that exhibited the following features: 1) up to a 6-month history of unilateral sciatica symptoms, which responded to bed rest; 2) mechanical signs of nerve root irritation when the patient was erect; 3) computerized tomography or magnetic resonance imaging studies interpreted as showing one protruding or prolapsed disc without extrusion; 4) no segmental spondylosis at the level of a herniated nucleus pulposus; 5) no motor weakness; 6) no prior disc surgery; 7) no obesity; and 8) no diabetes mellitus. Twenty-five "nonideal" cases failed to meet one or more of the above criteria. Good outcome rates were not substantially different in the two groups, success being judged in part by patient satisfaction. Complete success was evidenced in two-thirds of cases by early return to work, but improvement was also determined by increased mobility and a reduction in pain medication from narcotic to analgesic agents. Three patients underwent repeat surgery (laminotomy), but only one improved. Two years has provided sufficient clinical experience to determine that a percutaneous endoscopic procedure under neuroleptanalgesia may become a significant surgical alternative.