The National Institute for Clinical Excellence is examining percutaneous endoscopic laser thoracic discectomy and will publish guidance on its safety and efficacy to the NHS in England and Wales. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about percutaneous endoscopic laser thoracic discectomy.

This document has been prepared for public consultation. It summarises the procedure and sets out the provisional recommendations made by the Advisory Committee.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare the Final Interventional Procedure Document (FIPD) and submit it to the Institute.
• The FIPD may be used as the basis for the Institute's guidance on the use of the procedure in the NHS in England and Wales.

For further details, see the Interim Guide to the Interventional Procedures Programme, which is available from the Institute's website (www.nice.org.uk/ip).

Closing date for comments: 27 January 2004

Target date for publication of guidance: April 2004

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of percutaneous endoscopic laser thoracic discectomy does not appear adequate for this procedure to be used without special arrangements for consent and for audit or research.

Clinicians wishing to undertake percutaneous endoscopic laser thoracic discectomy should:

• inform the clinical governance leads in their Trusts.
• ensure that patients understand the uncertainty about the procedure's safety and efficacy and should provide them with clear written information. Use of the Institute's Information for the Public is recommended.
• audit and review clinical outcomes of all patients having percutaneous endoscopic laser thoracic discectomy. Publication of safety and efficacy outcomes will be useful in reducing the current uncertainty. The Institute may review the procedure upon publication of further evidence.

Percutaneous endoscopic laser thoracic discectomy is used to treat symptomatic thoracic disc herniation (TDH). 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.

Standard discectomy for TDH may be either by open postero-lateral or anterior approaches. Percutaneous endoscopic approaches lessen the morbidity of 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.

In this procedure, an endoscope is inserted into the pleural cavity to visualise the affected disc. The disc is entered using a discotome, which can be inserted through a small cannula. In percutaneous endoscopic laser thoracic discectomy, a Holmium: YAG laser is used to ablate the central disc material (nucleus pulposis) and then any further debris can be removed by discotome and curettes. The patient's neurological status is monitored throughout the procedure and a post-operative chest x-ray is indicated to rule out pneumothorax.

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 (see Appendix).

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

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

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

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.

Appropriate selection of patients for this procedure is important and may be difficult.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• Interventional Procedure Overview of percutaneous endoscopic laser thoracic discectomy, October 2002

Available from: www.nice.org.uk/ip176overview