Percutaneous Laser Disc Decompression A Practical Guide

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Daniel S.J. Choy, MD
Assistant Clinical Professor of Medicine, Columbia University College
of Physicians & Surgeons, New York, New York; and Director of
Laser Spine Center, New York, New York

Editor

Percutaneous Laser
Disc Decompression
A Practical Guide

With 149 Illustrations, 6 in Full Color

Daniel S.J. Choy, MD
Assistant Clinical Professor of Medicine
Columbia University College of
Physicians & Surgeons
New York, NY 10032
and
Director of Laser Spine Center
New York, NY 10021
USA
[email protected]

Cover illustration: Figure 2.1. Array of 24 UV lasers aimed at a suspended deuterium

pellet for a fusion experiment. (Courtesy of Institute of Optics, University of Roch-
ester, Rochester, NY.)

Library of Congress Cataloging-in-Publication Data

Percutaneous laser disc decompression : a practical guide / editor, Daniel S.J. Choy.
p. cm.
Includes bibliographical references and index.
ISBN 0-387-00260-X (alk. paper)
1. Intervertebral disk—Diseases. 2. Intervertebral disk—Surgery. 3. Intervertebral
disk—Hernia. 4. Intervertebral disk displacement. 5. Lasers in surgery. 6. Lasers in
medicine. I. Choy, Daniel S.J.

RD771.I6P469 2003
617.5⬘6—dc21 2003042428

ISBN 0-387-00260-X Printed on acid-free paper.

© 2003 Springer-Verlag New York, Inc.

All rights reserved. This work may not be translated or copied in whole or in part
without the written permission of the publisher (Springer-Verlag New York, Inc., 175
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age and retrieval, electronic adaptation, computer software, or by similar or dissim-
ilar methodology now known or hereafter developed is forbidden.
The use in this publication of trade names, trademarks, service marks, and similar
terms, even if they are not identified as such, is not to be taken as an expression of
opinion as to whether or not they are subject to proprietary rights.
While the advice and information in this book are believed to be true and accurate
at the date of going to press, neither the authors nor the editors nor the publisher
can accept any legal responsibility for any errors or omissions that may be made. The
publisher makes no warranty, express or implied, with respect to the material con-
tained herein.

Printed in the United States.

987654321 SPIN 10904770

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Springer-Verlag New York Berlin Heidelberg

A member of BertelsmannSpringer Science⫹Business Media GmbH
 This book is dedicated to

Dr. Peter Wolf Ascher, former professor of

neurosurgery at the University of Graz, Graz,
Austria, and presently Professor and Chairman of
the Department of Neurosurgery at the University of
Rostock, Rostock, Germany

Professor Robert B. Case, professor of medicine at the

Columbia University College of Physicians &
Surgeons, New York, New York

my patients, without whose help this book would not

have been possible.
 Preface

Percutaneous laser disc decompression (PLDD) is an entirely new

approach to the treatment of herniated intervertebral disc dis-
ease. The traditional laminectomy and discectomy procedure was
first performed at the Massachusetts General Hospital in 1934.
In the intervening 69 years, science has moved forward with mag-
netic resonance imaging, sequencing of the human genome, ion
propulsion, landing men on the moon and robots on Mars, the
laptop computer, global positioning system navigation, black
hole theory, string theory, and the successful cloning of animals.
And yet, the same soft tissue–destroying, scar-inducing, poste-
rior wall–weakening, and spinal instability–inducing cutting op-
eration is still being taught and performed. Advances in ortho-
pedics and neurosurgery occur slowly.
Percutaneous laser disc decompression is minimally invasive;
it can be performed as an outpatient procedure, requires no gen-
eral anesthesia, and has a high success rate, a low recurrence rate,
and a low complication rate. By the middle of 2002, some 35,000
PLDD procedures had been performed worldwide.
This book covers the history of the development of PLDD, laser
physics, anatomy and pathophysiology of the herniated disc, the
physics and mechanical principles that form the basis of PLDD,
patient selection, radiographic considerations, the neurologic ex-
amination, a step-by-step description of the PLDD procedure, the
complications of PLDD and their treatments, special cases
amenable to PLDD, postoperative care, and rehabilitation proce-
dures. In short, this is a compendium of PLDD from A to Z.

vii
viii Preface

The author hopes the publication of this volume will persuade

a new generation of orthopedic and neurologic surgeons to open
their minds and hearts to a twenty-first-century innovation in the
treatment of herniated intervertebral disc disease.

Daniel S.J. Choy, MD

 Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

1 Introduction: Percutaneous Laser Disc Decompression . . . . 1

Daniel S.J. Choy

2 Principles of Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Daniel S.J. Choy

3 Anatomy and Pathophysiology of Intervertebral Discs . . . 29

Sohail K. Mirza

4 Familial Incidence of Disc Herniation. Epidemiologic and

Genetic Evidence: A Hypothesis Suggesting That
Laminectomy and Discectomy Are Counterproductive . . . 59
Daniel S.J. Choy

5 Patient Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Daniel S.J. Choy

6 The Neurologic Examination . . . . . . . . . . . . . . . . . . . . . . . 71

Daniel S.J. Choy

7 The Role of Radiology in Percutaneous Laser

Disc Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
John A. Botsford

8 Magnetic Resonance Imaging of the Lumbothoracic

Spine Under Compression . . . . . . . . . . . . . . . . . . . . . . . . 125
Daniel S.J. Choy

ix
x Contents

9 Initial Consultation and First Interview . . . . . . . . . . . . . . 131

Daniel S.J. Choy

10 The Percutaneous Laser Disc

Decompression Procedure . . . . . . . . . . . . . . . . . . . . . . . . 137
Daniel S.J. Choy

11 Complications of Percutaneous Laser Disc

Decompression and Their Treatments . . . . . . . . . . . . . . . 163
Daniel S.J. Choy

12 Postprocedure Physical Therapy . . . . . . . . . . . . . . . . . . . 173

Arpad S. Fejos

13 Complicated Disc Herniations Responding to

Percutaneous Laser Disc Decompression . . . . . . . . . . . . . 183
Daniel S.J. Choy

14 Unexpected Results in Patients Treated with

Percutaneous Laser Disc Decompression . . . . . . . . . . . . . 191
Daniel S.J. Choy

15 Endoscopic Laser Foraminoplasty: A Treatment

Concept and Two-Year Outcome Analysis . . . . . . . . . . . . 197
M.T.N. Knight and A.K.D. Goswami

16 Role of Percutaneous Laser Disc Decompression

in the Treatment of Discogenic Back Pain . . . . . . . . . . . . 211
William Black, Arpad S. Fejos, and Daniel S.J. Choy

17 Clinical Experience in 2088 Percutaneous Laser

Disc Decompression Procedures . . . . . . . . . . . . . . . . . . . 217
Daniel S.J. Choy

18 Percutaneous Laser Disc Decompression: A 10-Year

Follow-Up of Clinical Data . . . . . . . . . . . . . . . . . . . . . . . 223
Daniel S.J. Choy and Arpad S. Fejos

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
 Contributors

William Black, MD
Director of Neurosurgery (Retired), Community Medical Center,
Scranton, PA 18510, USA.

John A. Botsford, MD
Director of Radiology, The Deaconness Hospital, Cincinnati, OH
45243, USA.

Daniel S.J. Choy, MD

Assistant Clinical Professor of Medicine, Columbia University
College of Physicians & Surgeons, New York, NY 10032, USA;
Director of Laser Spine Center, New York, NY 10021, USA;
Attending Physician, Lenox Hill Hospital, New York, NY 10021,
USA; Former Director, Laser Laboratory, St Luke’s–Roosevelt
Hospital Center, New York, NY 10027, USA; Executive Editor,
Journal of Clinical Laser Medicine & Surgery.

Arpad S. Fejos, MD
Staff, Columbia University College of Physicians & Surgeons, New
York, NY 10032, USA; Lenox Hill Hospital, New York, NY 10021,
USA; Laser Spine Center, New York, NY 10021, USA.

A.K.D. Goswami, MS Mch (Orth), FRCS (Orth), DNB, DHA,

Honorary Lecturer, University of Central Lancashire, Rochdale,
Lancaster OL11 4LZ, UK.

M.T.N. Knight, FRCS

Consultant Spinal Surgeon, Honorary Senior Lecturer, University
of Central Lancashire, Rochdale OL11 4LZ, UK; Honorary
Research Fellow, University of Manchester, Manchester M13 9PL,
UK; The Spinal Centre, Rochdale, Lancaster OL11 4LZ, UK.

xi
xii Contributors

Sohail K. Mirza, MD
Associate Professor of Orthopedics, Department of Orthopedics &
Sports Medicine and Department of Neurological Surgery,
University of Washington, Seattle, WA 98195, USA; Harborview
Medical Center, Seattle, WA 98104, USA.
 1
Introduction: Percutaneous Laser
Disc Decompression
Daniel S.J. Choy

Background

This book is devoted to a new approach in the treatment of her-

niated disc disease. Traditional open surgery, with its many dis-
advantages, has been in existence since 1934 when it was intro-
duced at the Massachusetts General Hospital. In the intervening
69 years, science has achieved spectacular advances elsewhere:
black holes, supersonic flight, the sequencing of the human ge-
nome, landing men on the moon, quarks, global position navi-
gation, cloning. Yet spine surgeons are still making incisions,
spreading and damaging muscle fibers, cutting out pieces of lam-
ina, making holes in the annulus and removing nucleus pulpo-
sus, and leaving behind the detritus of scar tissue. These severe
disturbances of normal anatomy sometimes make fusion neces-
sary. Fusion then leads to the adjacent disc syndrome caused by the
additional stress placed on the disc superior or inferior and ad-
jacent to the level of fusion. This in turn has led to the develop-
ment in the past few years of the various forms of artificial
metal/plastic disc prostheses at great expense and effort in the
new field of vertebroplasty. In May 2002, the author attended the
“Spine Arthroplasty 2” symposium held in Montpellier, France,
where numerous manufacturers displayed at least seven models
of these devices. None of these would be necessary if a treatment
of herniated disc disturbed the anatomy and geometry of the of-
fending disc only minimally. Most of the panelists were of the

1
2 D.S.J. Choy

opinion that discogenic pain arises from chemical mediators—

cytokines, pH modifiers, and tumor necrosis factors—and that
these arise from disc material. Hence the anatomic structure pro-
ducing these offending agents must be removed as completely
as possible. Sometimes an experiment in nature is more inform-
ative than a well-designed, double-blind, prospective study with
crossover. The author reported on a stunt pilot with a herniated
lumbar disc and sciatica whose pain was sharply aggravated by
a 6 G pull out from a dive; independently, the pilot discovered
that his pain could be almost immediately relieved by climbing
to 10,000 feet and performing an outside loop, producing minus
3 Gs. In a 6 G pull-out, centrifugal force increases body weight
by six times gravity; in a minus 3 G outside loop, when the air-
craft flies in a curve with the apex pointed up, the body weight
is decreased threefold. The time parameters of these two ma-
neuvers are more consistent with a pressure/mechanical mech-
anism of discogenic pain than a chemical one.1
In the healing arts there are other examples of complications
of one therapy that produce the need for another therapy. Wit-
ness the early total gastrectomies causing the dumping syn-
drome, the early intestinal bypass operations for obesity leading
to severe malabsorption syndromes and hepatic damage, the nec-
essary immunosuppression of organ transplant recipients, which
increases susceptibility to infection and lymphoma, and the im-
plantation of metallic left ventricular assist devices, resulting in
almost universal mediastinitis.
The history of interventional therapeutic modalities for back
pain and sciatica due to intervertebral disc protrusion is seen in
Table 1.1. When offered open surgery, many patients demur,
some out of fear of having their backs “cut open,” some because
of a justifiable fear of general anesthesia, and some because they
have heard horror stories of complications and bad results. De-
spite this, some 500,000 back operations are performed annually
in the United States, a resident of the northwest having three
times the likelihood of being operated upon than a resident of
the northeast. These invasive procedures include laminectomy,

Table 1.1 Interventional Treatments for Herniated Disc Disease

History of open surgical methods
1934 Laminectomy and discectomy, Massachusetts General
Hospital, Boston, followed by microdiscectomy in the 1980s
History of percutaneous methods
1975 Hijikata, percutaneous discectomy
1983 Kambin, trephine, rongeur, suction
1984 Onik, nucleotome
1986 Choy/Ascher, percutaneous laser disc decompression
2000 Saal, IDET (intradiscal electrothermal annuloplasty)
 1 Introduction: Percutaneous Laser Disc Decompression 3

discectomy, microdiscectomy, fusion, and automated percuta-

neous nucleotomy. Chemonucleolysis with chymopapain is los-
ing favor because of reports of neurologic complications from
chymopapain leakage, with myelitis, allergic and anaphylactic
reactions, and even some deaths. The latest is intradiscal elec-
trothermal (IDET) annuloplasty, a radiofrequency method that
heats up and destroys the pain fibers in the outer layers of the
annulus without retracting the disc herniation.
In 1984, to address these problems, the author conceived the
idea of introducing laser energy into a herniated/protruded disc
to vaporize a small volume of nucleus pulposus and thus lower
intradiscal pressure. The pressure reduction would create a pres-
sure gradient, leading to migration of the herniated portion away
from an involved nerve root. This approach is based on the phys-
ical principle that in an intact, enclosed hydraulic space, since
water is noncompressible, a small change in volume will result
in a disproportionately large change in pressure. It is well known
that the water content of nucleus pulposus ranges from 50 to 89%
and is age dependent, decreasing with advancing years. That was
the entire concept. If it worked, it would lead to a major advance
in the treatment of herniated disc disease.
Two physicians, to whom this book is dedicated, made it pos-
sible for me to test this hypothesis in the laboratory and to test
it in the clinical setting. These were first, Professor Robert B. Case,
Director of the Investigative Cardiology Laboratory at St. Luke’s–
Roosevelt Hospital, Columbia University College of Physicians
& Surgeons in New York City, and second, Professor Peter
Ascher at the Neurosurgical Institute of the University of Graz,
Graz, Austria.
My connection with Dr. Case came about through my inven-
tion of the laser catheter for the intraoperative recanalization of
obstructed coronary arteries with a laser beam. This was devel-
oped first in a basement laboratory at the Lenox Hill Hospital in
New York, and when bureaucratic obstacles arose, Dr. Robert
Roven persuaded his colleague to invite me to join the Inves-
tigative Cardiology Laboratory at St. Luke’s. This was a com-
pletely equipped laboratory with a tinkerer’s (me) dream of in-
strumentation, reminding me of the Aero Medical Laboratory at
Wright Patterson Air Force Base, where I had spent time in the
early 1950s performing the early rocketry experiments. From 1981
to 1983 the laboratory experiments validating the concept of laser
angioplasty were completed,2 and on September 17, 1983, our
group performed the first five intraoperative laser coronary an-
gioplasties successfully at the University of Toulouse in France,
followed by three others in January 1984.3
On my return to New York, the New York Times report and pre-
sentations at the Texas Heart Institute and the American College
4 D.S.J. Choy

of Cardiology led to inquiries from several major industrial firms

producing the Gruntzig angioplasty catheters. In short order, my
laser catheter patent was circumvented, leaving our laboratory
with four lasers occupying space, unused.
Unwilling to allow laser equipment worth a half-million dol-
lars to sit idle, I then drew on my 12-year experience as a part-
time surgeon for the New York City Police Department. As such
I regularly rode around town in police cars with flashing lights
and siren, and carried a Walther PPK 9 mm automatic in a shoul-
der holster. With the rank of deputy inspector, I had 1500 men
under me. In that capacity I saw hundreds of cases of back pain,
many caused by herniated discs. An officer could retire at three-
quarters pay, tax free, for life, if he could prove to the retirement
board that he had had a back injury “on the job” causing total
disability. It was important for me to learn all I could about bad
backs and herniated disc disease. I suddenly had an insight. The
intervertebral disc, I knew, was a contained hydraulic space. The
nucleus pulposus is mostly water. Water is not compressible. If
the volume of a noncompressible medium is reduced by a small
amount, there should be a sharp decrease in pressure. The idea
for using a laser to treat herniated disc disease was born.
First, the hypothesis that a small volume change in the disc
would be associated with a disproportionate pressure change had
to be proved.4 Research funding and a Messerschmitt Bolkow
and Blohm (MBB) Medilase Nd:YAG laser were generously pro-
vided by Walter Solomon of Endolase. Technical assistance came
from Lucy Eron, chief technician of Endolase, and Peter Altman,
a brilliant young bioengineer from Columbia. Always present
was the eminence gris of Professor Robert B. Case, ready with
advice and hands-on participation. Fresh (less than 24 hours old)
cadaver lumbar spine segments were obtained. A simple pres-
sure recording device was made from a 20-gauge needle with the
tip soldered shut. A half-moon window was filed in the shaft
near the tip and covered with condom rubber sheet glued on with
rubber cement (Fig. 1.1). Total cost: about 24 cents. A year later,

Condom sheath

Figure 1.1. A 20-gauge needle modified with a window cut into the dis-
tal end and covered with a condom sheath glued onto the needle with
rubber cement. The needle tip has been soldered shut. The modified
needle is the sensor for intradiscal pressure.
 1 Introduction: Percutaneous Laser Disc Decompression 5

Figure 1.2. Two needles inserted into an intervertebral disc: one for
pressure measurement, and one for infusion of saline with a Harvard
pump.

in a telephone conversation, I mentioned this cost to Dr. Alf

Nachemson, the pioneer of intradiscal pressure measurements.
There was a moment of silence, then the great man remarked that
the Japanese firm that made his recording needles had charged
him something like U.S. $1500 each. He did not sound happy.
By filling our modified needle with saline and connecting it to
a water manometer, we could obtain accurate pressure readings.
The lumbar spine was immobilized with clamps to a ring stand.
The pressure needle and a second 20-gauge needle were inserted
into the disc at 90 degrees apart. Connected to the second nee-
dle was a Harvard pump (Fig. 1.2). Saline was pumped into the
disc while pressures were recorded. The results are seen in Fig-
ure 1.3. One mL of volume change produced a pressure change
of 312 kPa (⫽ 2340 mmHg).
Next, laser dosage had to be established in terms of pressure
fall induced, laser tract size, and histologic changes determined
with an appropriate energy delivered. For reasons to be discussed
later, it was decided to use a Neodymium:YAG (Nd:YAG) laser
emitting at 1064 nm. An aluminum frame was designed and con-
structed by Dr. Khan of the Columbia School of Engineering to
hold the lumbar spine segment upright and to exert static load
pressure duplicating in some measure the weight of the upper
two-thirds of the body on the lumbar spine (Fig. 1.4). Load on
the spine specimen was by the addition of 20-pound lead bricks
on the platform. The pressure needle was inserted, as was an 18-
6 D.S.J. Choy

Figure 1.3. Graph plotting intradiscal pressure versus volume of saline

infused. This is 312 kPa per milliliter of saline infused. (Reprinted with
permission from Case RB, Choy DSJ, Altman P. Change of intradiscal
pressure versus volume change. J Clin Laser Med Surg 1995;13:125–126.)

Figure 1.4. Metal frame designed to stabilize a portion of the lumbar

spine in a vertical orientation. The loading platform accommodates a
lead brick load. Four wing nuts provide a constant loading pressure on
the discs when the lead weight is removed.