One of the most common questions that I get asked in my clinic (more so than any question about stem cells) is “are you going to use lasers in my surgery?” This usually comes up after I describe a minimally-invasive technique used to perform a particular operation. To the average patient the term “minimally-invasive” sounds advanced and I think it’s a natural leap to consider laser spine surgery (LSS) in the same breath. Also, while I was once aggravated by these questions, I realize now that one can’t blame patients for being interested in LSS. The centers that perform these procedures spend millions of dollars each year bombarding prospective patients with print, TV and especially Google targeted advertising. These advertisements portray LSS as a high-tech alternative to conventional spinal surgery (because hey, if lasers are involved then it must be high-tech and therefore better for one’s health than non-laser spine surgery, right??)
I’m not going to use this post as a forum to share my personal feelings about LSS (I don’t want to get a cease and desist letter from lawyers representing LSS centers.) I’m also not going to get into the growing number of high-profile lawsuits against LSS centers for malpractice and unethical practices. Rather, I’ll just outline a few facts about LSS and will let you, learned Spinal (con)Fusion readers, be the judge. Many of these facts are outlined in more detail in an excellent Bloomberg News exposé about LSS that I encourage you to read (I am considering handing out print copies of this exposé in my waiting room.)
Fact #1: The limited use of lasers in the treatment of herniated discs in the lumbar spine was first described nearly 30 years ago. These ablation procedures employ a laser deployed via a fine cannula into the disc near a contained disc herniation (sometimes called a “bulge”) that is compressing a nerve root. Once there the laser heats (or ablates) the nucleus pulposus (NP) near the disc herniation thereby causing the water molecules within the NP tissue to evaporate. This creates a void within the disc which theoretically creates negative pressure that “sucks” the herniated fragment back into the disc space and off of the nerve root. In other reported techniques a laser is used to directly degrade a herniated disc fragment as an adjunct to a traditional lumbar microdiscectomy procedure. While variations of these techniques have been performed for decades now, their efficacy as treatments for herniated discs has never been validated with sound randomized controlled data. Yes, a search of the pubmed database for “laser spine surgery” does reveal several studies. Most of these studies, though, are heavily biased observational studies with small numbers of patients, published in obscure journals such as Photomedicine and Laser Surgery and not in any of the core clinical journals of spinal surgery. It’s also important to note that even in these lesser quality studies most of these ablation techniques are only advocated for a very small subset of patients with “contained” disc herniations, not those with free disc fragments or in patients with annular tears (thereby ruling out the majority of patients with lumbar degenerative disc disease) Thus, if the use of lasers in spinal surgery has only been described for a very small subset of patients (with only limited success at that), how can it be advocated by LSS centers for the treatment of the many other degenerative spinal conditions that they purport to cure? Personally, I’ve only used lasers during spine surgery to remove complex spinal tumors. I don’t believe LSS is an effective treatment for herniated discs (or any other degenerative condition of the spine) and therefore would never offer LSS to a patient over standard minimally-invasive surgical treatments.
Fact #2: Your insurance company probably isn’t going to pay for LSS. I’ve seen many patients in my office who have travelled to an LSS center for a consultation. They tell me about cash fees of $15,000-$30,000 that must be paid prior to treatment. Why? Because (I can’t believe I’m putting this in writing) the people who work at insurance companies aren’t stupid and know that there isn’t good data supporting LSS. If there isn’t good data they’re not going to pay for the procedure and the patient gets stuck with the bill for that high-tech laser. Ordinarily the governing societies of spinal surgery argue quite vehemently in favor of surgeons versus insurance companies when it comes to surgical procedures being denied coverage. The fear is that once one procedure is denied coverage the insurance companies will feel emboldened to look for reasons to not cover others. Recently, however, in an unprecedented move the North American Spine Society, arguably the world’s most prominent society of spinal surgeons, recommended that insurance providers not cover LSS procedures. Citing a “lack of quality clinical trials concerning laser spine surgery in the cervical and lumbar spine” the authors of the coverage recommendations state that “laser spine surgery…is NOT indicated at this time.” Thus, if you’re considering LSS be prepared to pay out of pocket for it. The irony is that lasers aside, in the end you’re going to pay thousands of dollars in cash for the same minimally-invasive procedure that I and any other reputable minimally-invasive surgeon would provide under your insurance coverage. Oh, and most incisions from standard minimally-invasive procedures can also be covered by a Band-Aid.
Fact #3: Your doctor isn’t going to refer you for LSS. Traditionally, a primary care physician (PCP) refers his patients to specialists who have provided good, safe care to his patients in the past. He does this because he, more than any other physician, has his patients’ best interests at heart. This vetting process is an important safeguard against specialists practicing subpar medicine. Chances are, specialists who perform unnecessary surgeries or consistently have poor outcomes won’t be referred patients and therefore will be run out of town. LSS centers rely on a different model in which medical services are offered directly to the consumer. These services are offered via relentless advertising on TV, online and in “seminars” all over the country. This then allows patients to find their way to an LSS center without the guidance of their PCP. Why is this bad? Because unlike on that ad on TV for the latest cholesterol drug, the claims about outcomes and risks made by LSS centers isn’t screened as closely by the Food and Drug Administration. Thus, patients suffering from degenerative conditions of the spine, patients that are often in severe pain and desperate for relief, are vulnerable to exploitation.
I’ve found that if a patient has his mind set on pursuing LSS they will do so regardless of what I just discussed. Ultimately, though, I will always encourage him to a) look at the data about LSS, b) be skeptical of any medical service or procedure that requires a substantial cash payment up front, and c) trust that their PCP will have their best interests at heart and will refer him to the best specialist for his care.
Thanks for reading.
J. Alex Thomas, M.D.
1. Singh V, Manchikanti L, Calodney AK, Staats PS, Falco FJE, Caraway DL, et al.: Percutaneous Lumbar Laser Disc Decompression: An Update of Current Evidence. 229–260, 2013
2. Back-Surgery Center Dangled Illegal Incentives, Lawsuit Alleges: http://www.businessweek.com/articles/2014-10-15/laser-spine-institute-dangled-illegal-incentives-to-attract-back-surgery-patients-lawsuit-alleges
4. NASS coverage recommendations: https://www.spine.org/Documents/PolicyPractice/CoverageRecommendations/LaserSpineSurgery.pdf