Lasers, Stem Cells and Minimally Invasive Spine Surgery
Discussing news and issues in orthopedics and spine health care. This is Spine Talk. Hi, this is Dr. John Shim, and today I want to talk about a topic that's of high interest to the Tampa Bay area, and that's about the use of lasers and spinal surgery. Well, it's now mid-May 2019. Approximately two - two and a half months ago one of the biggest spinal centers in the country called Laser Spine Institute announced their closure. That left a lot of people without doctors and prescribed surgeries could not be performed. So, there was a lot of panic and angst in our community. I decided not to do this blog until things have calmed down, but today I want to talk about that topic. What is a laser and how does it get used during spinal surgery? Jason I know you've been doing some research on this topic. It's been of interest to some doctors and some surgeons for quite a long time. What have you found when you looked through the literature, and looked through the publications by various entities? So actually, you know when you when you look through the literature on this, and in searching the last 5 and 10 years, there's really not a lot of great information out there. We know that lasers have been used in medicine for 40 or 50 years now. People are familiar with it in plastic surgery, tattoo removal, even eye surgery. When it comes to spine surgery - maybe for the last thirty years it's been used off and on, but if you comb through the literature, there's actually very very little good data out there supporting the use of the laser. And in fact, there's really nothing showing that it's really efficacious or any better than the traditional techniques with it that we use. The the few studies that do exist - they're kind of very small numbers and really don't tell us a whole lot. Well, so when I was a resident and when I was a fellow, this was years going back to early 1990s, there was a lot of discussion about the efficacy of something called a percutaneous diskectomy. Basically small straw is placed in through the disc and basically removed disc material through that straw. At one time they were actually using lasers through that straw to remove that disc tissue, and there were some studies done the different type of laser beams. There's CO2 - carbon dioxide lasers, there was the YAG lasers, there's holmium lasers. Each of these lasers had a different profile on how it removed tissue, how it caused what's called a zona necrosis an area burning, and so initially there was a fair amount of studies going on this back in the 1990s, and then it just kind of stopped. We didn't see a lot of information about it. Of course, lots of patients started asking for the use of the laser surgery. Now, you know, it's very interesting because you fielded a lot of calls about the use of lasers and spinal surgery. What is your concept of what patients thought these things were being used for? So for actually many years we've gotten a lot of these calls patients asking, "Hey, do you do laser surgery?", "Does Dr. Shim do this kind of surgery?" I think there's a lot that have come out of it. A lot of misnomers many patients feel that it's minimally invasive, and number two is that the laser that I think many feel that it's used it for the entire procedure. And I say minimally invasive as you described Laser is a kind of a tool that we use. It can be used for a micro diskectomy through a small incision. The laser can also be used during an open procedure or even a endoscopic procedure. And then again, patients feel that I'm going for laser surgery - they're gonna use the laser on my back for the entire operation. In fact, we know that that's really not the reality - is we know that they have to make a small incision. You still have to expose or remove tissue to get down to the problem area, and then the laser is actually used for maybe, I don't know, a small amount of time - a few seconds at best, and then the - the other aspect to with this is that patients feel that the risk profile the surgery is much less than at that of a regular surgery. I don't know, in my mind you're adding some more risk because you're putting concentrated energy into one area. And as you mentioned, there's kind of a zone. Within that zone there's there soft tissue, there's there's neuro and Vascular structures that also can get affected by the laser. Well, I think what's going on is people are watching too much science fiction. So, you know, you know, I watch Star Trek, you know. So, back in the in the future they would put these little dials and it would actually cure you, and so there's, I think in the minds of the population, lasers work in that manner, there's no real cut, it actually goes through the skin, and they'll take care of whatever needs to be done. The reality is you still have to make an incision, you still have to get to where you have to go, and in the end as you stated before lasers are just a tool. Laser can help evaporate certain tissues, but frankly from my review of what's going on at these places like - the former Laser Spine Institute, the laser, oftentimes is not even used. They still do the traditional exposure. It might be a smaller incision, or a more minimally invasive approach, but whatever is causing the problem that causes the pinched nerve sensation - that has to be removed. It can be removed by a small drill, it can be removed by small little punches, or graspers that remove the tissue or in certain instances I guess they would use a laser. My interpretation having read multiple operative notes from these type of procedures is the laser itself was rarely used for the operation, but the laser was definitely used in the presentation. So you would like to have surgery with that facility. It's a - I hate to say it, but I thought the laser was a great marketing tool. I don't think it really was a surgical tool. Right. So, do you see any role at all for the laser in, let's just say lumbar surgery to begin with? Well, I don't think we know what it really does. Like I said, I think in the early 90s, there was some effort to identify what kind of zonin necrosis it was causing, and perhaps it made sense they used a laser to evaporate disc material as long as you knew where that disc material is being removed. But right now, there are other tools that do the same things probably in a safer manner. There's different ways to deliver energy to remove and evaporate tissue. So, there are other options besides a laser. In an open procedure, where you have everything open up - when you have direct visualization, why use a laser? You can use small tools and have direct control of how much tissue you can remove. So, in our practice, and you've been with me for a long time Jason, we have not used a laser because we still don't understand what the advantage of it - besides saying that we do it because it's a great marketing tool. Yeah. So, you know, we see a lot of patients that come in and see us from all over for for opinions, and many of them are second opinions. They've - they had been to - as you mentioned Laser Spine Institute, and told that they needed to have surgery. Well, a lot of these people come in and they're sold on the laser. Exactly that - it was a marketing tool, they are - they are definitely wanting to have surgery. They they feel that that laser is gonna take care of their issue, but they're coming in for a second opinion just I think for in their mind to know that that was the right thing. What do you tell those patients after you see them? Well, it's a very difficult discussion. People have already flown all the way from wherever to Tampa specifically to get an operation - already set in their mind to get the operation. The last thing they want to hear is "well, you know, you should consider something else." They've already bought into it. So, as you know, we kind of stopped actually accepting some of those second opinions because it became harder and harder for us to actually do our job, which is to give true opinions. If somebody's really biased in what they want, they just want confirmation that their decision was correct, but don't want to hear if it's not - it puts me in a very bad position. I will tell people very straightforward, look - if you came to Tampa just to have the laser procedure, but you were seen by other good surgeons in your local area, and they recommend against surgery, or didn't have a surgical option for you - maybe those other doctors are being straightforward. Sometimes there isn't a surgical solution, or sometimes your complaint is not a complaint that can actually get better with an operation. So, it is hard because you have to be the so-called proverbial adult in the room sometimes, and it sounds horrible because these are people who are truly in pain. They truly want help. They truly want something done, but at the same time I have to be able to look people straight in the eye and tell them "I don't think an operation is gonna do what you want." Not everybody wants to hear that, and you know as they say sometimes you can't handle the truth, and you know that this does not make me a popular guy - does not make me a popular spinal surgeon in my community to say those things, but it's the truth. Yeah, I - definitely been a kind of a challenging issue to say the for a number of years, and now that the Laser Spine Institute is gone now I've - you know, it's really not not so much an issue. I don't hear that that much from patients anymore on that. Well, there's a flip-side of this. I mean, we have to be also straightforward. A lot of the times, these institutions that have the lasers or markings or what not - the doctors who work there - actually don't own the facility. So, to them, they're in a way a very expensive cog in a wheel, and so they're there to take care of their, you know, their role in that machine. To me, the business of medicine is often a very difficult thing to navigate. So, I'm not saying that physicians and entities that take care of people shouldn't also be compensated for it, but you have to be wary when the main objective of the use of the tool laser was for marketing, and not for actually taking care of patients. That's kind of my editorial comment on this. I know this is not going to make me very popular, but I think that's just the truth. Jason, any final word? No, that's it I - I think this is a very relevant discussion now, especially in, again, in light of kind of what's going on here in the last couple months. So this is Dr. John Shim and Jason Mazza talking about lasers in spinal surgery. A very difficult topic. I did dance around this a little bit because it makes me slightly uneasy with my relationship with other spinal specialists in the area, but the truth is laser is more of a marketing tool than actually an operative tool. This is Dr. John Shim. I hope you found this information useful.
As a spine surgeon, I get it! In the ideal situation, spine surgery will have a tiny incision, with no surgical pain, the latest technology, and the ability to recreate the normal state after the procedure.
Many times, you can acheive success if you wait long enough. That is because many spine problems can improve without surgical management. When you get better without surgery, it is non invasive, and you are using your own body’s reparative processes. In terms of technology, our modern diagnostic capabilities can provide patients information that will identify limb or life threatening problems that require immediate surgical intervention, vs painful situations that can be given more time to improve before having surgery.
As a surgeon, I can tell you that many patients have had surgical recommendations, but have improved and recovered without surgery. As a patient, the goal is to identify Surgeons that will thoughtfully present the non-surgical option for the appropriate situation.
If you are definitely looking for a surgical solution because of a recurrent, or persistent spine problem, there should be no shortage in finding a surgeon to perform your surgery.
If you are looking for a surgeon that will present the surgical and non surgical options, the patient must be willing to ask questions about the diagnosis, and ask about these non-surgical options. Surgeons are professionals, and should present the best solutions, even if it means the surgeon will not be performing the financially advantageous surgical procedure.
If you are looking only for non-surgical solutions, perhaps you should seek opinions by the non-surgical spine specialists like Neurologists, Physiatrists, or Pain Management Specialists.
As a spine surgeon, I would also advise patients to learn about the surgeon who will perform the surgery. While technology such as Laser Surgery, Robotic Surgery, and Stem Cell treatments appear advanced and effective, understand that it is the thoughtful judgement, and technical skill of the surgeon that will determine the outcome, not just the tools of the trade.
To give an analogy, great tasting food is created by a great chef using the best ingredients. Poor chefs can still ruin the best ingredients.
Likewise, all the latest Technology cannot achieve a good surgical outcome without the judgement and skill of the Surgeon.
It’s not the tool, it’s the use of the tool. Surgical skill, clinical judgement, and technology restraint are all factors that should be considered when determining the best solution ( surgical AND non-surgical) for a particular spine problem!
- Helm S 2nd, Racz GB, Gerdesmeyer L, Justiz R, Hayek SM, Kaplan ED, El Terany MA, Knezevic NN. Percutaneous and Endoscopic Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis. Pain Physician. 2016 Feb;19(2):E245-82. PubMed PMID: 26815254