Myths and Truths About Laser Spine Surgery
Myth #1- The laser is experimental for use in spine surgery
This is simply not the case. The holmium laser was FDA approved for use in orthopedics and the spine in the 1980’s and the laser is Medicare approved to treat painful lumbar discs as an outpatient. And getting Medicare approval for a surgical procedure is no small feat!
Use of the laser in spine surgery has generated lots of controversy for several reasons. First, the laser unit is costly, maintenance is expensive and the laser fibers are disposable (which means you have to use a new one for each case), so cost is a factor.
Secondly, most spine surgeons were never trained to operate through a tube of ½” or less. The typical incisions are larger and the patients are under general anesthesia, so the benefits of the laser may not seem that clear to someone not operating through a small tube. These points are inarguable.
Dr. Tony Mork sums it up this way:
“If a procedure can be performed through a smaller incision (more comfort to the patient and less soft tissue disruption) and get the same outcome as a more invasive procedure measured a year out, I will take the smaller incision any day.”
The laser is a helpful tool that can be very effective, but it must be used properly and for the correct indications, if the best results are to be obtained. To date, Dr. Mork is unaware of any prospective papers that compare procedures, with and without the use of the laser, for the treatment of stenosis, facet syndrome or sacroiliac joint syndrome. He uses the laser in the treatment of all the conditions mentioned above.
Myth #2- The laser is the primary tool for bony spinal stenosis
The truth is that the laser is a tool that can be very useful when performing certain types of spine surgery, although it may not be the primary tool to solve a problem. A necessary requirement to perform spine surgery safely is great visualization, and this means that all bleeding must be under control.
The smaller the tube used (more minimally invasive), the more critical the vision is. The main benefit of using the laser in a small tube is that it doesn’t take up much room and it can deliver a very powerful beam of energy (heat). Soft tissues and soft tissue bleeders respond very well to the heat from laser, because of their water content. They just shrink back or go up in smoke (vaporize) when hit with the beam of light. The beam is very small and can be accurately aimed at a specific target, particularly small capillary bleeders, without injuring nearby tissues. This type of accuracy is critical in a tight space or when a small tube is used to perform the surgery.
The main tools that relieve bony stenosis are mechanical bone cutting instruments. This is because bone doesn’t respond that well to the heat from the laser and boney stenosis is usually quite thick. It is Dr. Mork’s opinion that the best way to control the soft tissues and bleeding is to be able to visualize the areas that need to be decompressed, especially when using a small tube. In many ways the laser replaces electro-cautery, allowing the use of the smallest tube possible to perform the surgery safely.
The smaller the approach (tube) when performing surgery, the less pain the patient will experience, less scar tissue will form, fewer pain pills are needed, and shorter recovery is indicated. Using this approach it is more likely it can be performed as an outpatient procedure.
Myth#3- The main benefit of the laser are its healing qualities.
The statement is wrong. The main benefit of the laser is its heating qualities! The laser is able to heat, vaporize and coagulate soft tissues, including scar tissue, while operating in a very small space. The laser can almost eliminate the need for electro-cautery when doing spinal surgery, which is good because some people are quite sensitive to electric current when surgery is performed under conscious sedation.
Another benefit rarely mentioned is how helpful the heat from the laser is in revision spine surgery where there is a lot of scar tissue wrapped around the spinal nerves. The scar tissue wrapped around the nerves makes it difficult to see them. If the laser is aimed at the scar tissue from a short distance, it will warm the scar tissue and give the patient a sense of warmth in the leg or arm if a nerve is nearby. This is another reason that Dr. Mork advocates conscious sedation with the use of the laser, especially when performing revision spine surgery, as the patient can assist him in avoiding injury and solving their problem.
Myth #4- The laser works just as well on all disc herniations
This is not true. Once a disc fragment forms inside the disc, the question becomes “where will the disc fragment go?” If the fragment stays inside the disc confines, then the laser might be helpful. The laser beam travels in a straight line only and can be aimed directly at the disc fragment or can be used to create a space adjacent to the fragment for the fragment to fall back into.
A disc fragment can also migrate out of the confines of the disc into the spinal canal or lose complete contact with the disc and become a sequestered fragment. When this happens, the majority of the fragment may not be seen directly. If it cannot be seen directly, it is not safe to use the laser, since the laser beam does not travel around corners.
A fragment that has moved outside the confines of the disc may be in contact with a spinal nerve, causing leg pain. These fragments are often sizable, and difficult to see in their entirety. They need to be teased away from the spinal nerves and grabbed with some type of grasper; the laser alone is not sufficient. Complete removal of a good-sized extruded or sequestered disc fragment with the laser alone would be very difficult, if not impossible, from a technical and safety point of view.
Myth #5- The most critical component to spine surgery is the use of the laser.
Probably not, remember that the laser is a tool, and how this tool is used is an important part of the process. So experience with this tool is very important. Dr. Mork has used the laser in thousands of surgeries, almost all performed under conscious sedation. He has studied many review articles about the laser, but none talk about its benefits in revision spine surgery, because very few people have used it with conscious sedation.
Although the laser is a necessary part of many of the surgeries that he performs, the most critical component to a successful spine surgery is a correct diagnosis, which is another topic for discussion. Use of the laser alone will not be enough; it requires experience – and a lot of dedication on the part of the surgeon you choose.