Percutaneous Procedures in Disc Herniation Treatment: Laser Discectomy Rationale' Literature overvie

1
Percutaneous Procedures in Disc Herniation
Treatment Laser Discectomy Rationale.Literature
overview and ISLASS Protocol.
ISLASS Guest Session 1Oth EFORT Congress,
Wien, 3 June , 2009

• G. Canero M.D.,
• San Feliciano Hospital, Rome (Italy)
• P.P.M. Menchetti M.D., F.R.C.S. (US)
• Sapienza University , Rome (Italy)

www.islass.org
2
Laser light

• Light amplification (by) stimulated emission (of)
  radiation
• Laser radiation properties
• Monocromaticity
• Coherence (spatial and temporal)
• Polarisation
• VERY HIGH POWER DENSITY

3
Laser experimental data

• Laser irradiation decompresses the herniated disc
  because of vaporization in the water-rich nucleus
  polposus
• (Ascher Laser Surg.Med. 1985 9I.C.N.S.1989)
• A small reduction of volume in the disc
• (closed hydraulic space) results in a large
• fall of pressure
• (Case J. Clin. Laser Med. Surg. 1985)

4
Laser experimental data

• 1000J 1064nm NdYAG laser application to nucleus
  polposus in human lumbar discs decreased the
  intradiscal pressure of averaged 55.6
• (Choy, Altman Spine 1993)
• MRI and histologic studies show a fibrocartilage
  replacement after NdYAG and Diode laser in the
  disc from the inner layer of the annulus by 3
  weeks, returning to normal disc composition after
  3 months
• (Turgut Acta Neuroch. 1996 Kosaka Orthop.
  Science 1996)

5
Laser experimental data

• No adverse effects and secondary changes on the
  intervertebral discs and adjacent vertebral
  bodies after Diode 810nm Laser irradiation on MRI
  and histologic examination were found
  (Nakai - 21
  I.S.M.I.S.S. Course 2003)

6
Background

• Surgical Diode Lasers were developed in the mid
  90s as a replacement for continuous wave (C.W.)
  NdYAG lasers
• Similar clinical effects, similar applications
• Similar fiber optics (400 - 1000µm core)
• Very compact, efficient, highly reliable systems

7
Diode 980nm advantage for PLDD

• 980nm waters absorption 10 times more than
  810nm
• 980nm waters absorption 5 times more than
  NdYAG 1.064nm
• 980nm is at a small water peak therefore
  absorption in soft tissue is higher than for
  810nm and 1064nm. The best absorption by water
  HNP content increases heat focusing coupled with
  less scattering in the disc (no discitis)

1064nm
980nm peak
1064nm
810nm
8
Percutaneous Laser Discectomy

• LITERATURE OVERVIEW
• NdYAG (1064nm, 1320nm), KTP 532nm, Carbon
  Dioxide 10.6 µm (Ascher Neurosurg. Rev. 1984
  Lasers Surg.Med. 1985 Nurochir. 1986 9
  I.C.N.S. 1989 Operative Neurosurg. Tech. 1995)
• NdYAG 1064nm (Yonezawa Spine 1990)
• CO2 (Kolarik Zentralb Neuroch 1990)
• NdYAG 1064nm (Choy Spine 1992 J.Clin.Laser
  Med.Surg. 1998)
• KTP 532nm (Davis J.Fla.Med.Assoc. 1992)
• NdYAG 1064nm (Maroon Neurosurg.Clin.N.Am 1993)

9
Percutaneous Laser Discectomy

• HoYAG 2100nm (Sherk Clin.Sports Med. 1993)
• HoYAG, NdYAG (Ohnmeiss Spine 1994)
• NdYAG, HoYAG (Chambers J.Clin.Laser Med.Surg
  1995)
• HoYAG 2100nm (Caspar Lasers Surg. Med. 1995)
• NdYAG (Gangi Radiographics 1996)
• KTP 532nm (Bosacco Am.J.Orthop. 1996)
• NdYAG (Simpson J.Orthop.Assoc. 1996)
• HoYAG (Tonami Clin. Radiol. 1997)

10
Percutaneous Laser Discectomy

• NdYAG (Dangaria J.Clin.Laser Med.Surg. 1998)
• NdYAG (Steiner Eur.Radiol. 1998)
• HoYAG, KTP 532nm (Knight J.Clin.Laser
  Med.Surg. 2001)
• HoYAG (Goswami J.Clin.Med.Surg. 2001)
• HoYAG (Chiu Lasers Med. Sci. 2003)
• Diode 940nm (Hellinger Spine 2000)
• Diode 810nm (Nakai Biomed. Optics Prog. 2003)
• Diode 980nm (Gevargez Eur. Radiology 2000
  Groenemeyer J.Clin.Laser Med. Surg. 2003
  Menchetti Laser Med.Sci. 2003 Laser Med. Sci.
  2004 J.Min.Inv.Spin.Tech. 2005 Von Jako - Laser
  Surg. Med. 2008)

11
Purpose

• Because a small volume reduction in herniated
  disc (closed hydraulic space) results in a large
  fall of pressure (Case J.Clin.Laser Med.Surg
  1985) with consequent retraction from the nerve
  root
• Evaluation of Diode 980nm Laser Disc
  decompression and nucleotomy on HNP (herniated
  nucleus polposus)

12
Purpose

• Diode 980nm Laser Effect on intervertebral disc
• RETRACTION
• ABSORPTION

13
Material

• 10 intervertebral human lumbar disc after
  microdiscectomy
• vs
• 10 intervertebral specimen lumbar disc
• Disc tickness 3mm
• Mean age both discs 42 2 yrs

14
Method

• Diode 980nm Laser (Biolitec AG)
• 360µm Silica Fiber Optic
• Intradiscal temperature average 95C
• Pulsed Wave
• Exposure Time 0.60 sec
• Pause 2 sec
• Power 12 W
• Total Energy 1200 J

15
Results

• POLPOSUS NUCLEUS ABSORPTION TEST
• Diode 980nm Laser power after going 3mm thick
  human sample after discectomy
• 
  (Menchetti et al. - J.Min.Inv.Spinal Tech. 2005)
• ABSORPTION 90.27 on 3.8
  mm²
• DEPTH PENETRATION 4.2 mm² /-
  0.5 mm²

16
Results

• POLPOSUS NUCLEUS ABSORPTION TEST
• Diode 980nm Laser power after going 3mm thick
  specimen sample
• 
  (Menchetti et al. - J.Min.Inv.Spinal Tech.
  2005)
• ABSORPTION 87.2 on 3.2
  mm²
• DEPTH PENETRATION 5.2 mm² /-
  0.5 mm²

17
Results

• POLPOSUS NUCLEUS RETRACTION TEST
• Diode 980nm Laser acting on human sample
• (Menchetti et al. -
  J.Min.Inv.Spinal Tech. 2005)
• RETRACTION 40 (2.3) on 3.8 mm²

18
Results

• POLPOSUS NUCLEUS RETRACTION TEST
• Diode 980nm Laser on specimen sample
• (Menchetti et al. -
  J.Min.Inv.Spinal Tech. 2005)
• RETRACTION 50 ( 1.7) on 2.7
  mm²

19
Ongoing future

• 2004 ISLASS Constitution
• www. ISLASS.org

20
ISLASS Protocol

• Standardized ISLASS Protocol and
• Data Acquisition
• C-arm Operating theatre/
• CT-Scan Radiologic Operating theatre
• E.V. sedation and L.A.
• Antibiotic prophylaxis
• Diode 980nm Laser (Biolitec AG)
• 21G (0.80mm) Atraumatic Tip Chiba Needle
• Disposable 360µm Silica Fiber Optic
• Pulsed Wave
• Exposure Time 0.60 sec
• Pause 2 sec
• Power 12 W
• Total Energy 800-1200J

21
Conclusion

• Why use Diode 980nm Laser system ?
• Specially designed and optimised system for
  discectomy treatment
• LASER UNIT
• Optimal wavelength 980nm
• Absorption and Retraction experimental studies
  show no heat diffusion on surrounding tissue
  avoiding undesirable side effects (chemical
  discitis)
• SPECIFIC ACCESSORIES
• Dedicated atraumatic tip 21G needle, fully
  protected fiber introduction
• Ergomomic handpiece with fiber blockage and
  built - in smoke evacuation to eliminate laser
  produced vaporization
• Dedicated optical fiber
• Exclusive vacuum pump

22
Conclusion

• Preliminary reports confirm the experimantal
  trials with a high successfull rate (Menchetti
  et al. Laser Med.Sci. 2003 Laser Med. Sci.
  2004 J.Min.Inv.Spin.Tech 2005)

23
ROME SPINE 2009

• IV International Meeting
• Tradition and Innovation in
• Spine Surgery
• December, 4-5, 2009
• www.spineinstitute.it
• info_at_formazionesostenibile.it

24
Thank You