Abstract
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The first laser applications in medicine were by Leon Goldman in dermatology, and Francis L'Esperance and Stephen Trokel in opthamology, as the skin and the eyes were accessible to the laser. I was invited to perform the first applications in cardiology at the University of Toulouse in 1979 and 1983.
In 1980, President Carter organized a transfer of technology mission to China consisting of 33 top laser physicists from Europe, the Massachusetts Institute of Technology, Lawrence Livermore, Alamogordo, Sandia National Laboratories, The United States Army and Naval Weapons Research Laboratories, and Bell Labs. Included were eight physicians from around the world, who were involved with lasers.
One of the latter was Dr. Peter Ascher of Austria, the first to use a laser in the brain. On the trip he was always surrounded by Chinese people who had never seen a rotund figure in an alpine lederhosen outfit and an alpine hat with a feather and ski medals, sporting a curved alpine pipe. I myself was invited because of my audacity in proposing and introducing an argon laser into the coronary arteries, although a case had not yet been completed.
Deng Xiaopeng gave a dinner party and afterwards held a receiving line. Surrounded as he was by bodyguards dressed as waiters, it was difficult for the top physicians' wives to photograph them with him. Therefore, thinking that to Chinese eyes all Westerners look alike, these top physicians and chairmen of their departments went back in line three or four times until their wives got that all important picture!
Given my Chinese face, my wife had no such problem. On being congratulated on having created a better society than the one I had left 40 years earlier, Deng, with typical Chinese self-denigration replied, “Oh no, we are still a very backward society.”
On my returning to New York, Robert Case, head of the Investigative Cardiology Laboratory at St. Luke's Hospital, Columbia University, provided me with world-class laboratory facilities. We were able to perform basic experiments of laser interaction with coronary arteries. We found that an argon laser would follow a curved path through a vessel filled with saline, with negligible power loss. We were the first to demonstrate this phenomenon. This was vital for arterial work. No turning, no laser effect! We were discovering new laser properties. We could “bend” an argon laser as much as 60 degrees! More than this, the laser beam would “escape” from the curved vessel! All these parameters had to be discovered before the beam could be directed.
In September 1983, Dr. Simon Stertzer and I performed the first eight coronary laser angioplasties at the University of Toulouse, with only one perforation by Stertzer alone. 1
There is much humor in clinical research. After the first patient whose artery was successfully “lasered open,” we went to report to his waiting wife. She said, “Never mind that he's doing well! Did you use the laser? Did you use the laser?”
This “first” was hailed in the French press and television as a triumph of “Franco-American medical science.” Cardiovascular surgery had a new tool suitable for the twenty-first century!
Deciding that arterial perforation was too great a risk, I searched for a safer target in another common disease: the herniated lumbar disc.
Dr. Frank Frank, 2 chief, Laser Division, of Messershmitt, Bolkow U. Bloem (MBB, Munich) invited me to perform a series of laser experiments on various animal tissues. We quickly determined that the MBB Nd-YAG laser was totally unsuited for arterial work, but ideal for herniated lumber discs.
I will never forget our first case 3 in Graz in February 1986. A Turkish immigrant worker had a herniated lumbar disc. Using an MBB Nd-YAG laser, we had planned to deliver 1000 J via an optical fiber in a 1.0 mm needle inserted into the disc nucleus, with radiographic guidance, with the patient under local anesthesia. At 600 J, the patient, who was awake, cried out “Die Schmerzen Sind Vorbei! The pain is gone!” Ascher and I celebrated at a local tavern with a “Deci” of Weiswein.
This early relief of pain is a common occurrence. As the laser shrinks the herniated disc, the herniated portion is pulled away from the nerve root and the pain disappears. My wife can also attest to this firsthand. She was brave enough to let me laser her L3-4 and L4-5 discs several years ago.
The “gold standard” treatment for herniated intervertebral disc worldwide—laminectomy and discectomy—was invented at the Massachusetts General Hospital in 1934. From then to the present (80 years), new inventions have arrived: color television, e-mail, rovers on Mars, gene therapy, and organ transplantation. However, this twentieth century prescription is still being used in the twenty-first century.
In 1995, Annunen of Finland found a genetic weakness in the annulus of Finnish men with herniated nucleus pulposus (HNP). 4 The familial incidence (43%) of this disease in the first order relatives is well known; the weakened annulus allows elevated intradisc pressure to push out disc material beyond the annulus to impinge on the nerve root. Does it make any sense to further increase the annular weakness by laminectomy? The recurrence rate in surgical treatment of disc herniation is as high as 35%.
The beauty of our technique of percutaneous laser disc decompression (PLDD) is that the increased intradisc pressure is decreased almost instantly by laser vaporization of intradisc water. (The water content of disc nuclear material is 70%.) The insertion of a 1 mm needle through the annulus causes almost no damage to the annular ring. This minimal damage is responsible for the high success and low recurrence rates of our original PLDD. More>100,000 PLDDs are performed worldwide annually, but not in America. Financial concerns are certainly involved.
A seminal article 5 published in Munich by Drs. Tassi (4000 cases), Hellinger (9000 cases), and Choy (8000 cases) lists success rates of 84–92%, complication rates of 0.1–1%, and a recurrence rate of 5%. One cannot do much better than that.
Unfortunately, a splinter group has arisen seeking higher fees. They have added different lasers providing excessive power requiring cooling saline irrigation, and optical endoscopy, which is unnecessary. One has a side firing fiber. These superficial extras mandate thicker trochars up to 2.5 mm, compared with the 1 mm diameter needle of the simple, pure PLDD. The results have been lower success rates, higher complication rates (including thermal damage to nerve roots), and higher costs.
New “minimally invasive spine surgical societies” have sprung up both in Europe and the United States. Thankfully, the pioneers of PLDD are trying to keep the original, simple, and pure system of PLDD simple and pure.
We believe that the laser offers many unique qualities that have yet to be explored by future investigators. All that is required is imagination, imagination, and more imagination.