Laser Surgery is a technique of spinal surgery that uses a laser as its tool, instead of other surgical instruments. Since the mid-1980s lasers have been used in spinal surgery. During laser spine surgery, a focused beam of light (laser) is used to cut away tissue. If the goal of the surgery is to remove a small amount of soft tissue, laser may be used to essentially vaporize the material or shrink it away so it is no longer important.
Most surgeons have access to lasers and have been trained to use them, but the use of lasers in spinal surgery remains relatively limited, since there are no clear benefits to laser surgery over more established surgical techniques. Similarly, the laser has never been studied and directly compared to other techniques to prove its effectiveness. A laser is just a tool, like any other surgical instrument, and it is really the thought process behind the surgical procedure that will be most important.
So, if mainstream spine surgery is not interested in lasers, and lasers are primarily only useful as a good marketing tool, why do patients remain so interested in lasers? Perception plays a central role, and many patients perceive lasers to be a useful technology. Lasers are often perceived as an effective surgical approach for spine surgery because of two reasons: placebo response, and the tendency to always think the second opinion sounds more knowledgeable.
Placebo response: Patients with pain want to get better, and if they undergo an invasive procedure, they will try to get better if at all possible. The placebo response in patients with chronic pain can be as high as 70%, even if the procedure was a complete sham and did not address their spine pathology. However, in patients with true pathology the response doesn’t last very long. I recently operated on an elderly woman who had a degenerative spondylolisthesis and severe lumbar spinal stenosis. She had initially seen a local surgeon who had recommended a posterior decompression, instrumentation and fusion (which is what she needed for correction of her condition). She went to a center that claimed a laser surgery would suffice. After the laser surgery, she felt better for a couple of weeks, but then realized her pain was about the same. This is the placebo response. When I saw her and offered her the surgery she should have had in the first place, the reason the laser surgery had failed became apparent. I could see that none of the bone around the nerve roots had been removed, as would be expected since a laser surgery would have limited exposure and limited ability to deal with the anatomic problem causing the pain.
We did perform the surgery that was needed and she has subsequently done very well, as would be expected since this is a reliable surgery. The previous laser surgery had been touted as a minimally invasive surgery, which is its main benefit, but the drawback is that it does not address the pathology of lumbar spinal stenosis – the laser surgery does not remove the bone that is pressing against the nerve root and causing the pain. Unfortunately, since her laser surgery was not covered by insurance, the patient was out the cash.
Second opinion. The other factor that allows lasers to be marketed for spine surgery is that almost any second opinion for surgery has a tendency to sound smarter than the first opinion. The above patient had seen another surgeon prior to going to having laser surgery, and the first surgeon had recommended the appropriate surgery for her condition (decompression, instrumentation and fusion). The surgeon who wanted to use the laser, however, probably sounded smarter since he gave the second opinion. I have frequently heard that nobody should have a spine surgery unless they get a second opinion. The danger is that the next opinion a patient obtains may or may not be any smarter that the first opinion, and it may be based more on marketing than on any sound medical science. This is not to say that patients shouldn’t get second opinions – I am very much in favor of the patient having as much information as possible prior to deciding on surgery. Just be aware of the natural tendency for the second opinion to sound better.