“Do you use a laser in your spinal surgeries?”
That question makes the hair stand up on the back of my neck. I reply calmly and with authority, “No.” I continue, “I am trained in laser surgery. It has almost zero usefulness in your spine surgery and in fact, may be harmful.”
Let me explain. Lasers have always connotated cutting-edge precision. It is only natural that introducing this into surgery could be considered by the public as something that might benefit and enhance procedures. In fact, lasers in certain areas of surgery have been very helpful. For instance, in lipomeningocele surgery, used to remove fatty tissue that is unnaturally and dangerously pressing or pulling on the spinal cord, lasers is an invaluable tool. For a compelling majority of all spine surgeries, however, the laser has no purpose or role.
At the age of 43, standing at the doorstep to the middle of my career, I want to be sure that I am not the surgeon I vowed I would never be. That is—an older surgeon who, because of stubbornness or academic laziness, is unwilling to adopt new technology. I never want to be closed-minded.
Therefore I ask: Why do I reject the laser as a tool for spine surgery?
There are many claims made by proponents of laser spinal surgery. At the heart of these arguments is that the laser scalpel is better than other surgical options because it is more technically advanced and minimally invasive. In other words, laser surgery will theoretically cause decreased blood loss and scarring. Doctors who support laser spinal surgery maintain it is more efficient, effective and gentle than traditional methods.
The truth is, minimally invasive spine surgery (MISS) can be performed as effectively, and probably more effectively, without a laser. In fact, more than 95% of minimally invasive spine procedures in the U.S. are done without laser. MISS is based upon the surgical approach to the spine, not what kind of scalpel a surgeon uses.
It is important to understand that generally, MISS is a technique used to surgically correct a pathological problem. It does this by minimizing tissue trauma through smaller incisions and creating passageways through more natural cleavage plains to the spine. In essence, MISS is a pathway, not the definitive procedure. It is a less traumatic pathway to allow a surgeon to “get the job done” with less anatomical disruption of tissue.
At first glance, it appears as though a laser is a safer and more effective option since it can be used in MISS. However, since it has been shown that MISS can be performed using a traditional scalpel or a laser, it is important to compare the instruments themselves. If MISS is an option for both traditional and laser spinal surgery, why is the traditional surgical technique better? The difference between laser and scalpel can be understood when considering three central aspects of their mechanism: angles, heat and gas, and depth of penetration.
To begin with, minimally invasive spine surgeons go through a very small opening, often with a microscope or endoscope, and have to look around corners to find what’s causing the problem. A laser is a straight beam of light ill-suited for removing lesions hiding around corners. The ability to navigate angles safely is an important feature for the traditional scalpel.
Secondly, lasers obliterate tissue and cut but they do so with heat and sometimes gas production (due to the boiling of water molecules). This heat can be transmitted to adjacent anatomical structures and can damage nerves. In contrast, a scalpel is basically a razor sharp knife that also separates tissue by cutting but does not generate heat. In a seasoned surgeon’s hand, the precision of a scalpel equals any laser incision.
The third aspect to consider is the depth of penetration of the tool used. Think of a laser as a surgical scalpel that has a variable length. Generally, surgeons apply a certain amount of tactile pressure to achieve the appropriate depth of penetration when creating tissue planes. Imagine if a surgeon, while putting that pressure down on the scalpel, also could step on a button that made the scalpel sharper or duller. This would make for a dangerous situation because the surgeon would not know how deep he was cutting. When lasers cut through tissue, the depth of penetration can be variable depending on how long the beam sits at one part of the cut. Therefore, structures below the desired depth may be inadvertently injured. The traditional scalpel, in contrast, has a consistent edge. An experienced surgeon, therefore, can determine the depth of penetration based on the give and take of feedback he gets from tissue pressures.
These three factors are the major reason why spine surgeons have not generally adopted the laser into their armamentarium. Some might argue that the laser is an appropriate (or ideal) tool for spine surgery, but this is not generally accepted within the neurosurgical spine community or among leading spine surgeons. The laser has been around spine surgery for more than 20 years. With the exception of lipomeningocele surgery, it has not gained mainstream acceptance. While any technology can be improved or in some way modified to work, at the present time I do not see that happening with laser spinal surgery.
If you are considering laser spinal surgery, ask yourself a few important questions.
- Does the practice or institute you are considering teach courses on the use of the laser at national spine meetings?
- Are they disseminating this information to the medical community to better society?
- Is this procedure they are proposing something that other respected surgeons around the country and world have adopted?
If the answer to these questions is ‘no,’ that should raise a red flag.
If one person or group does laser surgery and markets it, it is a gimmick. When a number of surgeons adopt the technique and long-term studies demonstrate safety and significant benefit, then laser spine surgery may be a legitimate option.
Consider this. One study published in 2016 examined percutaneous endoscopic laser diskectomy (PELD), percutaneous lumbar disc decompression (PLDD), and target percutaneous laser disc decompression (T-PLDD) in patients with minimal/mild disc herniations. The study found that not only were lasers significantly less effective than minimally invasive microdiscectomy but that they also resulted in a near doubling of the need for a subsequent surgery. Certainly, these are not the kind of results that would lead me to change my thoughts on the use of lasers in spine surgery.
Although gaining popularity in the lay public, at this time many spine experts have not endorsed this technique. Laser spine surgery may not be appropriate for most patients. Before you choose to have laser surgery of the spine make sure you have more than one opinion from a fellowship-trained orthopedic or neurosurgical spine surgeon.
This article was originally published in early 2009. My opinion has not altered since then, but in 2011 I did become aware of this intriguing article about laser spine surgery on Bloomberg News. It does make you think.