Presentation
By
DR. DEEPAK VANGANI
Consultant Neuro Surgeon
Bhandari Hospital Laser Surgery Centre
JAIPUR (INDIA)
Ph. : 0141-2554394, 9829013398 (Mobile)
E-mail - dvangani2001@[Link]
Clinic : L-24, Income Tax Colony, Tonk Road, Jaipur
A
Percutaneous Laser
Lumbar Disc
Decompression
(PLDD)
PLDD
• Prolapse disc – Common cause of
low Backache and Scitica – affects
millions of people each year.
• It is the number one cause of lost
time from work during worker's
productive year.
PLDD
Clinical Studies have validated that
● 60 % Patients improve satisfactorily with
conservative treatment
● 10 –15 % require surgery
● Remaining 20 – 30 % - continue with non-
surgical treatment for indefinite period
●
1/3rd visits average 12 doctors /year
●
1/3rd hospitalised for pain
PLDD
● Standard surgical intervention
with its high cost and
associated patient risks, is
not considered treatment
alternative for these patients.
PLDD
● It has been estimated that this
group of patients costs society
billions of dollar annually in
medical and psychosocial
costs.
PLDD
● Keeping this in mind the spinal
surgeon must address the
problem with as little
destruction of normal structure
as possible, in order to keep
future management precise
and safer.
PLDD
SEARCH FOR LESS TRAUMATIC
SPINAL DISCECTOMY BEGAN
i) 1964 - Lyman Smith reported intradiscal
chymopapain injection.
ii) 1985- Omik et al developed APD device for
continuos aspiration / imigation of disc tissue.
iii)1985 - Hijikata et al described Percutaneous
Nucleotomy
iv)1986- Ascher & Choy first reported Laser
Discectomy to decrease intradiscal pressure.
PLDD
● PLDD comes as the most
innovative, logical and
minimal invasive procedure
for prolapsed disc.
PLDD
We use Holmium : YAG Laser as it is
the best choice for discectomy
● It is pulsed, minimal thermal damage to
the disc and surrounding tissue
● Its wave length (2.1 µ) is readily
absorbed by water, greatly increasing
precision of ablation (.5 mm)
COMPARISONS OF LASERS
PLDD
Principles of Laser Discectomy
● Nucleus pulposus is evaporated
● Disc Height is maintained
● Buffer /washer action preserved
● Delays onset of facet joint arthritis
● Delays creeping degeneration (due to
acids and enzymes in disc)
PLDD
ADVANTAGES
• OPD Procedure
• Doesn’t preclude alternative surgical
options / procedures
• Reduce risk of complication
• Minimum soft tissue injury
• Immediate relief of pain
• No epidural fibrosis
PLDD
CANDIDATE FOR LASER DISCECTOMY
• Unilateral leg pain with or without back pain.
• Positive SLR.
• Neurological finding on physical
examination
(Motor Weakness, Sensory alteration, reflex
asymmetry)
Supervised trial of conservative treatment
of at least 6 weeks duration suggested.
PLDD
RADIOLOGICAL INVESTIGATIONS
• Plain X-rays under weight bearing condition
and in flexion & extension
• MRI Spine – Degree of disc protusion
– Position & Shape of
disc
• EMG :When signs of compression are
confusing or when assessment of likely
recovery of function is required
PLDD
HO: YAG LASER DISCECTOMY SHOULD
BE PERFORMED IN PATIENTS WITH
● Disc protusion occupying < 30% of AP diameter
of spinal canal
● Weight bearing IVD Ht of 4mm or more
● Dynamic retrolisthesis of 3mm or less
● Contained disc
● Previously treated disc with preserved Ht
PLDD
APPROACH
● Postereolateral in prone position
● Transspinal extradural in lateral position
PROCEDURE
● Cannula in disc space under C – Arm
● Discography - to Confirm
- to elicit memory pain
● laser fiber discectomy
PLDD
POST –OPERATIVE CARE
● Restricted routine activities for few
days (2-3)
● Gradually to resume normal function.
PLDD
OUR EXPERIENCE
PLDD
Since Dec.2000, 100 consecutive spinal discs in
90 patients were treated using PLDD method
Patient Selection Rate - 20 %
Average Age - 42 Years
Male : Female - 65 : 25
Duration of Symptoms - 18 Months
Mean Follow Up - 12 Months
Success Rate - 84.9 %
NUMBER OF PATIENTS
AGE MALE FEMALE TOTAL
(YEARS)
15-25 03 - 03
26-35 17 03 20
36-45 19 12 31
46-55 14 05 19
56-65 07 03 10
> 65 05 02 07
TOTAL 65 25 90
PLDD
INVOLVED DISC LEVELS
LEVEL MALE FEMALE TOTAL
L1-2 01 02 03
L2-3 04 01 05
L3-4 07 01 08
L4-5 48 17 65
L 5 - S1 14 05 19
TOTAL 74 26 100
PLDD
INVOLVED DISC LEVELS
8 (L3-4)
65 (L4-5)
84
5 (L2-3)
3 (L1-2)
19 (L5-S1)
PLDD
Observations
● 65% of above Patients had only L4-L5
disc
● 19% of above Patients had only L5-S1
disc
● 16% of above had multiple disc
● Lesser the SLR better the result
PRE & POST OPERATIVE
RESULTS ACHIEVED IN 50
PATIENTS
SYMPTOM PRE OP. POST OP. POST OP. POST OP.
(3 months) (6 months) (12
months)
Severe Muscle Pain 10 - - -
Mild Spine Pain 20 05 - -
Required Analgesics 50 10 02 -
Muscle Weakness 08 02 01 -
Persistent Numbness 50 05 03 01
PLDD
COMPLICATIONS SEEN :
No. Of Patients
●
Aseptic Discitis - 5 (Post Operative)
●
Psoas Hematoma - 1 (Post Operative)
●
Vasovagal reaction - 1 (Intra Operative)
●
Residual Radicular Pain - 6 (Post Operative)
●
Cauda equina - 1 (Post Operative)
Syndrome
PLDD
CONCLUSION
● Proper Selection of Patients
● Excellent patient compliance
● Not a substitute of Open Surgery
● Located some where between failed
conservative & conventional surgery
PLDD
Post Operative
PLDD
Post Operative
PLDD
Hope you enjoyed the
Presentation
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