Back Laser

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Back Laser

Laser / July 12, 2022

As a practicing spine surgeon, I am often asked by patients if their disc decompression surgery can be done with a laser. There is a perception by the general population that lasers are a modern, almost futuristic, up and coming technology. The reality is that lasers have been around for a long time and are almost completely useless when it comes to spine surgery.

A laser is a focused beam of light that can be used for cutting soft tissue. In eye surgery, they are definitely useful and have changed corrective eye procedures drastically. In the spine, electrocautery is much more practical for cutting soft tissue. Lasers can cut disc tissue, but it is far easier and more reliable to mechanically grab the disc fragment and remove it from compressing the nerve. Also, since discs lie right next to the nerve root, one risks the chance of damaging the nerve root with the laser. Lasers cannot cut bone so they cannot be used to decompress patients with spinal stenosis.

It seems to me that the most practical use for lasers in spine surgery is for marketing. Like most businesses, spine surgery is very competitive, and having an edge in marketing can make a practice standout. I knew a spine surgeon who would tell his patients he could use a laser to do their surgery. He would cut the skin with a scalpel, then bring in a laser to cut the subcutaneous fat, then go back to electrocautery. However, since the laser was so slow, he would only use it for about thirty seconds before he went back to electrocautery. The laser performed no useful function during the surgery, but helped him for marketing purposes.

Spine-health.com has thousands of pages of information, all of which have been peer reviewed by a medical advisory board of prominent spine physicians. However, there is not one article on laser surgery as it is not an accepted spine procedure. At the major spine meetings and in the major spine journals there is a paucity of (if any) peer reviewed articles documenting any use of lasers in spine surgery.

So, if mainstream spine surgery is not interested in lasers, and lasers are primarily only useful as a good marketing tool, why do patients remain so interested in lasers? Perception plays a central role, and many patients perceive lasers to be a useful technology. Lasers are often perceived as an effective surgical approach for spine surgery because of two reasons: placebo response, and the tendency to always think the second opinion sounds more knowledgeable.

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Placebo response: Patients with pain want to get better, and if they undergo an invasive procedure, they will try to get better if at all possible. The placebo response in patients with chronic pain can be as high as 70%, even if the procedure was a complete sham and did not address their spine pathology. However, in patients with true pathology the response doesn’t last very long.

I recently operated on an elderly woman who had a degenerative spondylolisthesis and severe lumbar spinal stenosis. She had initially seen a local surgeon who had recommended a posterior decompression, instrumentation and fusion (which is what she needed for correction of her condition). She went to a center that claimed a laser surgery would suffice. After the laser surgery, she felt better for a couple of weeks, but then realized her pain was about the same. This is the placebo response. When I saw her and offered her the surgery she should have had in the first place, the reason the laser surgery had failed became apparent. I could see that none of the bone around the nerve roots had been removed, as would be expected since a laser surgery would have limited exposure and limited ability to deal with the anatomic problem causing the pain.

We did perform the surgery that was needed and she has subsequently done very well, as would be expected since this is a reliable surgery. The previous laser surgery had been touted as a minimally invasive surgery, which is its main benefit, but the drawback is that it does not address the pathology of lumbar spinal stenosis – the laser surgery does not remove the bone that is pressing against the nerve root and causing the pain. Unfortunately, since her laser surgery was not covered by insurance, the patient was out the cash.

Second opinion. The other factor that allows lasers to be marketed for spine surgery is that almost any second opinion for surgery has a tendency to sound smarter than the first opinion. The above patient had seen another surgeon prior to going to having laser surgery, and the first surgeon had recommended the appropriate surgery for her condition (decompression, instrumentation and fusion). The surgeon who wanted to use the laser, however, probably sounded smarter since he gave the second opinion. I have frequently heard that nobody should have a spine surgery unless they get a second opinion. The danger is that the next opinion a patient obtains may or may not be any smarter that the first opinion, and it may be based more on marketing than on any sound medical science. This is not to say that patients shouldn’t get second opinions – I am very much in favor of the patient having as much information as possible prior to deciding on surgery. Just be aware of the natural tendency for the second opinion to sound better.