Percutaneous endoscopic laser cervical discectomy (interventional procedures consultation)
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
Interventional procedure consultation document
Interventional procedure overview of percutaneous endoscopic laser cervical discectomy
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Symptomatic cervical disc prolapse occurs when one or more of the spinal discs in the neck bursts and pushes against the spinal cord or nerve roots that run through the backbone. It can cause pain in the neck or back, or pain, weakness and numbness in the arms. The aim of a percutaneous endoscopic laser cervical discectomy is to remove the part of the disc that is pushing against the spinal cord or nerve root. A small cut is made in the skin and a small flexible camera inserted to enable use of special equipment including a laser to heat and destroy some of the disc and remove its protruding part |
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The National Institute for Health and Clinical Excellence (NICE) is examining interventional procedure overview of percutaneous endoscopic laser cervical discectomy and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. NICE's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about percutaneous endoscopic laser cervical discectomy. This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:
Note that this document is not NICE's formal guidance on this procedure. The recommendations are provisional and may change after consultation. The process that NICE will follow after the consultation period ends is as follows.
For further details, see the Interventional Procedures Programme manual, which is available from the NICE website (www.nice.org.uk/ipprogrammemanual). NICE is committed to promoting through its guidance race and disability equality and equality between men and women, and to eliminating all forms of discrimination. One of the ways we do this is by trying to involve as wide a range of people and interest groups as possible in the development of our guidance on interventional procedures. In particular, we aim to encourage people and organisations from groups in the population who might not normally comment on our guidance to do so. We also ask consultees to highlight any ways in which draft guidance fails to promote equality or tackle discrimination and give suggestions for how it might be improved. NICE reserves the right to summarise and edit comments received during consultations, or not to publish them at all, where in the reasonable opiPercutaneous endoscopic laser cervical discectomy nion of NICE, the comments are voluminous, publication would be unlawful or publication would otherwise be inappropriate. Closing date for comments: 24 March 2009 Target date for publication of guidance: June 2009 |
| 1 | Provisional recommendations |
| 1.1 | Current evidence on the safety and efficacy of percutaneous endoscopic laser cervical discectomy is inadequate in quantity and quality. Therefore this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. |
| 1.2 |
Clinicians wishing to undertake percutaneous endoscopic laser cervical discectomy should take the following actions.
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| 1.3 | Clinicians undertaking this procedure should have specific training in the use of lasers and in endoscopy of the spinal canal. |
| 1.4 | NICE may review the procedure on publication of further evidence. |
| 2 | The procedure |
| 2.1 | Indications and current treatments |
| 2.1.1 | Symptomatic cervical disc prolapse occurs when part of the intervertebral disc protrudes into the spinal canal and impinges on a nerve root or the spinal cord. The protruding disc may compress one or more nerve roots, which may cause neck, shoulder and back pain, radicular arm pain, weakness and numbness. Many mild episodes settle spontaneously but, in severe cases, serious neurological sequelae may occur. |
| 2.1.2 | Conservative treatments include analgesics and non-steroidal anti-inflammatory medication and physical therapy. Epidural steroid injections can also be used. Surgery to remove disc material is considered if there is evidence of nerve or spinal cord compression causing neurological loss or persistent symptoms that are unresponsive to conservative treatment. Surgical treatment options include open surgical decompression by discectomy with or without grafting or disc replacement. |
| 2.2 | Outline of the procedure |
| 2.2.1 | The procedure is carried out with the patient under general anaesthesia and with endoscopic guidance. A small retractor port is inserted into the anterior neck to expose the disc. All or part of the disc material is removed using a combination laser to ablate disc material and to shrink and contract the disc further (laser thermodiskoplasty), and curettes, microforceps and a discotome to decompress the nerve root or spinal cord. |
| Sections 2.3 and 2.4 describe efficacy and safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview, available at www.nice.org.uk/IP734overview. |
| 2.3 | Efficacy |
| 2.3.1 | A case series of 111 patients treated by percutaneous endoscopic laser cervical discectomy reported that 47% (52/111) of patients were classified as having an ‘excellent' outcome, 33% (37/111) had a ‘good' outcome, 8% (9/111) had a ‘fair' outcome, and 12% (13/111) had a ‘poor' outcome (measured by the McNab criteria four-point scale, which ranges from poor [no or insufficient improvement to enable an increase in activities] to excellent [no pain or restriction of activity]) (mean follow-up 49 months). |
| 2.3.2 | The Specialist Advisers stated that the comparator procedure is open microscopic decompression and the key efficacy outcomes (Visual Analogue Scores for arm and neck pain, Neck Disability Index and SF36 Oswestry Disability Index) are the same for both these procedures. |
| 2.4 | Safety |
| 2.4.1 | The case series of 111 patients treated by percutaneous endoscopic laser cervical discectomy reported that 3% (3/111) of patients needed additional surgery because of incomplete decompression and ‘symptom aggravation' (mean follow-up 49 months). |
| 2.4.2 | The Specialist Advisers considered the most important theoretical risk to be heat damage to nerve roots or to the spinal cord, potentially leading to quadriplegia. One Specialist Adviser stated that neurological damage had occurred in a patient as a result of using laser in the lumbar region of the spine. |
| 2.5 | Other comments |
| 2.5.1 | The Committee noted that the extent to which laser ablation was used instead of, or in addition to, mechanical methods of removing prolapsed disc material was unclear in much of the published evidence. |
| 3 | Further information |
| 3.1 | This guidance requires that clinicians undertaking the procedure make special arrangements for audit. NICE has identified relevant audit criteria and is developing audit support (which is for use at local discretion), which will be available when the guidance is published. |
| 3.2 | NICE has published interventional procedures guidance on prosthetic intervertebral disc replacement in the cervical spine (www.nice.org.uk/IPG143). |
Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
December, 2008
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It is the responsibility of consultees to accurately cite academic work in order that they can be validated.
This page was last updated: 30 March 2010