The National Institute for Health and Clinical Excellence (NICE) issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on percutaneous endoscopic laser thoracic discectomy in June 2004. In accordance with the Interventional Procedures Programme Process Guide, guidance on procedures with special arrangements are reviewed 3 years after publication and the procedure is reassessed if important new evidence is available.
The guidance was considered for reassessment in October 2009 and it was concluded that NICE will not be updating this guidance at this stage. However, if you believe there is new evidence which should warrant a review of our guidance, please contact us via the email address below.
This procedure is used to treat symptomatic thoracic disc herniation (TDH).
In comparison to asymptomatic thoracic disc herniation which has a prevalence of approximately 7-15%, symptomatic thoracic disc herniation is rare accounting for between 0.25-0.57% of all disc herniations reported in the literature. Typically, symptoms appear up to two years before the patient presents for treatment. Symptoms include back pain, radicular pain, nondermatomal leg pain, bladder dysfunction, and lower extremity weakness. If left untreated serious neurological sequelae may occur.
A number of endoscopic techniques have been described. However, these techniques all use multiple portal incisions and are performed under general anaesthetic. By contrast percutaneous endoscopic laser thoracic discectomy aims to decompress the disc using a percutaneous needle and laser ablation. As a consequence it is only indicated where the disc herniation is contained inside the nucleus pulposus and is contraindicated where free disc fragmentation is evident.
Unlike open procedures, which are indicated for persistent severe myelopathy, endoscopic laser thoracic discectomy is contraindicated in patients with myelopathy, or other vascular pathologies, as well as in patients with cancer, degenerative or congenital bony defects of the spine and severe spinal cord compression.
After the patient's eligibility for surgery has been confirmed, the disc is decompressed under endoscopic magnification using curettes, microforceps and discectome inserted through a small cannula. A Holmium:YAG laser is used to ablate disc material and then shrink and contract the disc further (laser thermodiskoplasty). Any charred debris is removed via the discectome and the probe and cannula are removed after inspection shows that the site is clear. Neurological status is monitored intraoperatively, and a postoperative chest x-ray is used to rule out pneumothorax.
The alternative to this procedure is either an open technique for thoracic discectomy or endoscopic discectomy (without the use of decompression and laser ablation).
SNOMED CT preferred term (concept ID)
Percutaneous endoscopic laser thoracic discectomy (822481000000105)
V31.4 Primary percutaneous endoscopic excision of thoracic intervertebral disc
V55.- Levels of spine
Y08.3 Laser destruction of organ NOC
Y53.- Approach to organ under image control
Note: Codes within category V55.- are assigned in second place each time a spinal operation is coded: if the levels of spine are not specified, V55.9 Unspecified levels of spine is used.
Codes within category Y53.- are used as secondary codes to classify interventions that are percutaneous and require some form of image control: if the method of image control is unspecified, Y53.9 Unspecified approach to organ under image control is assigned.
The NHS Classifications Service of NHS Connecting for Health is the central definitive source for clinical coding guidance and determines the coding standards associated with the classifications (OPCS-4 and ICD-10) to be used across the NHS. The NHS Classifications Service and NICE work collaboratively to ensure the most appropriate classification codes are provided. www.connectingforhealth.co.uk/clinicalcoding
Diagnosis or health condition
SNOMED CT preferred term (concept ID)
Prolapsed thoracic intervertebral disc (240216005)
SNOMED CT provides clinical terms for entry into the patient record to store clinical information relevant to that encounter. The mandated classifications (OPCS-4 or ICD-10) provide a method to collect and aggregate data to allow accurate and consistent data analysis.
The Clinical Classifications Service of the Health and Social Care Information Centre is the central definitive source for clinical coding guidance and determines the coding standards associated with the classifications (OPCS-4 and ICD-10) to be used across the NHS. The Clinical Classifications Service and NICE work collaboratively to ensure the most appropriate classification codes are provided. Clinical Classifications Service — Health and Social Care Information Centre