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).
This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.