2 The procedure

2.1 Indications

2.1.1 Percutaneous endoscopic laser thoracic discectomy is used to treat symptomatic thoracic disc herniation. This occurs when a portion of the intervertebral disc protrudes into the spinal canal and impinges on a nerve root. Symptoms include back pain, radicular pain, nondermatomal leg pain, bladder dysfunction and lower extremity weakness. If left untreated, serious neurological sequelae may occur.

2.1.2 Standard discectomy for thoracic disc herniation may be either by open posterolateral or anterior approaches. A percutaneous endoscopic approach may lessen the morbidity associated with the procedure by allowing access and visualisation of the anterior and lateral aspects of the disc. The choice of approach will depend upon the characteristics of the disc herniation and the surgeon's experience with the above techniques.

2.2 Outline of the procedure

2.2.1 Percutaneous endoscopic laser thoracic discectomy is usually done under local anaesthesia through a small incision in the back, using X-ray monitoring. A needle is introduced into the centre of the affected intervertebral disc. A guidewire is passed through the needle, followed by small instruments, which are used to remove some disc material. A Holmium–YAG laser is then introduced and laser energy is used to destroy more of the disc. Debris is removed by surgical instruments. The patient's neurological status is monitored throughout.

2.3 Efficacy

2.3.1 No controlled studies were identified. The studies identified provided little detail of study design and outcomes. In one study 96% (96/100) of patients reported 'good-to-excellent results/symptomatic relief', but the meaning of this was not defined. The average time to return to work in this study was 10 days. For more details, refer to the 'Sources of evidence' section.

2.3.2 One Specialist Advisor commented that there was no evidence to support the efficacy of the procedure, and that the procedure was difficult to master.

2.4 Safety

2.4.1 No operative or postoperative complications were reported in the studies identified. However, these studies provided little detail of study design and outcomes.

2.4.2 One Specialist Advisor considered that this procedure had the potential for serious neurological complications, and was concerned about risks to patients while surgeons learnt the procedure. This Advisor also thought that the procedure could result in nerve injury.

2.5 Other comments

2.5.1 This decision relates to the procedure when used in isolation (for example, to treat degenerative disc disease). No judgement is made regarding the use of this procedure as part of a larger operation, such as the treatment of scoliosis.

2.5.2 Appropriate patient selection for this procedure is important and may be difficult.

Andrew Dillon
Chief Executive
May 2004