Lasers Med Sci (2006) 21: 245–249
DOI 10.1007/s10103-006-0393-y
REVIEW ARTICLE
Barry Schenk . Patrick A. Brouwer .
Mark A. van Buchem
Experimental basis of percutaneous laser disc decompression
(PLDD): a review of literature
Received: 21 May 2006 / Revised: 26 June 2006 / Accepted: 30 June 2006 / Published online: 26 August 2006
# Springer-Verlag London Limited 2006
Keywords Percutaneous . Lumbar disc herniation .
Laser surgery . Minimally invasive
Introduction
Percutaneous laser disc decompression (PLDD) is one of
the so-called “minimally invasive” treatment modalities for
lumbar disc herniation. The treatment is performed
percutaneously; therefore, morbidity and convalescence
period are postulated to be less than for conventional
surgery. Because of the minimally invasive nature and the
fact that return to work is usually possible within a few
days after treatment, PLDD appears to be an interesting
alternative to conventional surgery. However, PLDD still
encounters a considerable amount of skepticism. Oppo-
nents usually dismiss PLDD as being an experimental
treatment with unproven efficacy, while those advocating
the use of PLDD tend to present it as some kind of miracle
treatment. While well-designed clinical trials focusing
primarily on the efficacy of PLDD are scarce [1], the
amount of preclinical studies investigating the technical
and biophysical aspects of PLDD has been growing
steadily since its introduction in the late 1980s. By
grouping the results of these preclinical trials, this review
attempts to provide a comprehensive basis for further
clinical research.
Selection of literature
To find papers relevant to this review, a search was
conducted within Pubmed, Embase, and the Web of
Science. The search strategy is reflected in Table 1. Two
B. Schenk (*) . P. A. Brouwer . M. A. van Buchem
Department of Radiology, C2-S,
Leiden University Medical Center,
P.O. Box 9600, 2300 RC Leiden, The Netherlands
e-mail: b.schenk@lumc.nl
Tel.: +31-71-5262042
Fax: +31-71-5248256
independent reviewers (B.S. and P.A.B.) conducted study
selection, data abstraction, and methodological quality
assessment. We deliberately used a broad range of search
terms to miss as little information as possible. The search
produced initially 600 papers (Pubmed, 207 papers;
Embase, 244 papers; Web of Science, 149 papers). A
first selection took place on the basis of subject and
information provided in the abstracts. Only papers
concerning research directly related to PLDD (n=93) and
written in English, Dutch, German, Portuguese, Spanish, or
French (n=83) were included. The remaining 83 papers
were subjected to another round of selection. Clinical trials
primarily focusing on assessing the efficacy of PLDD
(n=61) were excluded from the review, leaving a total of 21
papers.
After selection according to the criteria previously
described, 21 preclinical studies remained, which can be
divided into three groups:
1. Studies focusing primarily on the biophysical fundaments
of PLDD (n=5) [2–7]
2. Studies that primarily address tissue changes and
biochemical effects of PLDD (n=5) [8–12]
3. Studies focusing primarily on technical development
of PLDD (n=11) [6, 13–22]
Most experiments were conducted in vitro, with the
exception of five in vivo animal experiments (rabbits [9],
guinea pigs [10–12], and dogs [14]). In vitro experiments
can be divided into experiments using human preparations
[2–6, 13, 17–20, 22] and experiments on animal material
(cows [7, 15] or pigs [8, 16, 18, 21]).
Technique of PLDD
PLDD is a percutaneous treatment for lumbar disc hernia-
tion. The procedure is conducted under local anesthesia of
the skin and underlying muscles. After assessment of the
correct disc level using fluoroscopy, a hollow needle is
inserted 10 cm from the midline, pointing toward the center
of the disc. When the needle is in place, its correct position is
246
Table 1 Search strategy
Pubmed search terms:

“Intervertebral Disk Displacement”[MeSH] OR “Intervertebral Disk Chemolysis”[MeSH]) OR ((hernia OR herniated OR hernias OR

slipped OR prolapse OR prolapsed OR prolapses OR displacement OR displacements OR bulged OR bulging) AND (disc OR discs OR
disk OR disks)) AND (“Lasers”[MeSH] OR “Laser Surgery”[MeSH] OR laser OR lasers OR laser*) OR percutaneous laser disk
decompression OR percutaneous laser disc decompression OR pldd
Embase search terms:
(exp Intervertebral Disk Hernia/ AND (exp laser/ OR laser$.mp. OR exp laser surgery/)) OR ((hernia$.mp or slipped.mp or prolaps$.mp or
displace$.mp or bulg$.mp) and (disc$.mp or disk$.mp) AND (exp laser/ OR laser$.mp. OR exp laser surgery/)) OR percutaneous laser disk
decompression.mp. OR percutaneous laser disc decompression.mp OR pldd.mp
Web of Science search terms:
((hernia* OR slipped dis* OR dis* prolaps* OR dis* displace* OR bulg* dis*) AND Laser*) OR percutaneous laser disk decompression
OR percutaneous laser disc decompression OR pldd

verified using biplane fluoroscopy, sometimes in combina-
tion with CT imaging. A laser fiber is inserted through the
needle into the center of the nucleus pulposus. Laser energy
is then delivered into the nucleus pulposus to vaporize its
content and to reduce intradiscal pressure (Fig. 1).
The biomechanical fundaments of PLDD
The original treatment principle of PLDD as described by
Choy et al. [23] was based on the concept of the
intervertebral disc being a closed hydraulic system. This
system consists of the nucleus pulposus, containing a large
amount of water, surrounded by the inelastic annulus
fibrosus. Choy hypothesized that an increase of water
content of the nucleus pulposus would lead to a dispropor-
tional increase of intradiscal pressure. In vitro experiments
showed that an increase of intradiscal volume of only 1.0 ml
caused the intradiscal pressure to rise by as much as 312 kPa.
A subsequent experiment by Choy showed that laser
evaporation of nucleus pulposus tissue leads to a decrease
of intradiscal volume, therefore reducing pressure. Using a
Nd:YAG laser (20 W, pulse duration 1.0 s, pulse interval
3–4 s, 1,064 and 1,320 nm), a total of 1,000 J of laser
energy was delivered into the nucleus pulposus of bovine
intervertebral discs. The total decrease of mean intradiscal

Fig. 1 a Herniated disc before

PLDD. I Thecal sac, II disc
herniation, III nerve root, IV
annulus fibrosus, V nucleus
pulposus. b Application of laser
energy into the nucleus pulpo-
sus. I Thecal sac, II disc herni-
ation, III nerve root, IV laser
beam, V needle, VI gas in disc
herniation, VII annulus fibrosus,
VIII nucleus pulposus, IX cavum
created by laser. c Herniated
disc after PLDD. I Thecal sac, II
nerve root, III annulus fibrosus,
IV nucleus pulposus, V cavum
created by laser

pressure was 179±80 kPa (55.6%) [3]. In nine control discs
treated in the same manner but without laser application,
this decrease of intradiscal pressure did not occur.
The decrease of intradiscal volume that results from
evaporation of water in the nucleus pulposus only provides
an explanation for the short-term effects of PLDD. Because
of the natural tendency of the nucleus pulposus to attract
water, intradiscal volume (and therefore pressure) would
gradually increase toward its original value if no other
mechanisms were at work. Research by Choi et al. [7]
showed that laser irradiation of disc material not only causes
a decrease in water content, but also causes protein
denaturation and renaturation within the disc material itself.
These structural changes irreversibly limit the disc’s future
ability to attract water and are thought to be responsible for
the long-term effects of laser disc decompression.
The changes that occur within the intervertebral disc as a
result of laser irradiation also affect its biomechanical
properties. Experiments performed by Kutschera et al. have
shown (within the bandwidths of power and irradiation
time used) a negative correlation between the applied
amount of laser energy and disc stiffness [4]. After laser
application using a 14-W 2,100-nm Ho:YAG laser (pulse
duration 0.25 s, pulse interval not mentioned), the poste-
rolateral parts of the disc showed a relative increase of
external deviation, while more anterior parts of the disc
remained unchanged. The localized reduction of disc
bulging at the site of disc herniation resulting from the
decrease of intradiscal pressure is countered by an increase
of disc circumference due to reduced stiffness. Experi-
ments by Castro [6] showed (within the bandwidths of
power and irradiation time used) a linear reduction of
intervertebral disc height and intradiscal pressure with
increasing amounts of applied laser energy of 0.15 mm per
500 J and 100 kPa per 500 J, respectively. Both radial
bulging and the size of the transversal plane increased with
the amount of energy applied.
These results indicate that the effect of laser disc
decompression might be based on a more even distribution
of pressure over all of the annulus fibrosus rather than
localized reduction of disc bulging at the site of disc
herniation [5].
Tissue changes induced by PLDD
To assess the efficacy of PLDD for clinical practice,
various researchers have designed experimental models
that allowed investigation of direct and long-term effects of
laser energy on intervertebral disc tissue and the surround-
ing vertebrae. While direct effects can readily be assessed
in vitro, long-term effects can only be assessed using in
vivo experimental models.
Thal et al. [8] investigated the early histologic changes in
intervertebral discs after laser irradiation. Using cadaver
porcine spines obtained immediately after death, the nuclei
pulposi of eight lumbar intervertebral discs were irradiated
using a Nd:YAG laser (1,064 nm) [14]. Histological
examination of irradiated disc material revealed partial
247
evaporation of nucleus pulposus tissue, with an almost
complete necrosis. The annulus remained untouched
except for a small necrotic zone at the point of needle
entry. A regeneration zone of fibrous tissue was found
surrounding the site of laser ablation, indicating that the
laser effect was confined to the nucleus pulposus [8].
Experiments by Hirohashi et al. indicate that the tissue
changes induced by laser irradiation, within the bandwidths
of power and irradiation time used, depend on the applied
amount of laser energy. To assess changes in radiographic
and MRI findings, laser irradiation was performed in 12
rabbits at three different energy levels. Radiographic and
T2-weighted sagittal MR images of the lumbar spines were
obtained immediately after irradiation and at 1, 4, and 12
weeks after laser irradiation. On radiographic and MRI
evaluation, irradiated intervertebral discs show an initial
decrease in disc height and signal intensity in the first
4 weeks after laser irradiation [9–11]. During the following
8 weeks, disc height and signal intensity tend to increase
toward their initial value. On radiographic and MRI
evaluation 12 weeks after laser irradiation, only higher
amounts of laser energy will have resulted in a permanent
reduction of disc height and signal intensity [9].
A possible explanation for these phenomena could be
that while both lower and higher amounts of laser energy
can cause evaporation of water and subsequent reduction of
intradiscal pressure, higher amounts of laser energy
(or, more accurately, longer irradiation times at an
effective power level) are needed to cause enough structural
changes in the nucleus pulposus to effectively limit its
future ability to attract water.
The effective laser evaporation of nucleus pulposus
tissue requires localized intradiscal temperatures of at least
a 100°Celsius. For PLDD to be useful for clinical practice,
it is very important that these high temperatures remain
confined to the nucleus pulposus to prevent thermal
damage to adjacent structures. Turgut et al. assessed the
thermal effects of laser irradiation on the vertebral end
plates of guinea pigs. Thirty-two guinea pigs underwent
surgery to create artificial herniation and degeneration of
cervical discs. In 16 animals, the original wounds were
reopened and closed again without further action, in the
other 16 animals laser irradiation of degenerated discs was
performed (Nd:YAG laser, 1,064 nm). Histological exam-
ination of irradiated cervical discs showed necrotic
destruction of the end plates, with marked damage of the
surrounding bone and fibrous marrow changes. From these
results, Turgut et al. [12] conclude that laser irradiation of
degenerated discs is associated with extensive end-plate
damage, which is a known cause of sterile spondylodiscitis.
However, considering the large difference in size between
guinea pig and human intervertebral space, it is difficult to
extrapolate these results to humans.
Technical development of PLDD
Since the early days of percutaneous laser disc decom-
pression, researchers have tried to determine which laser
248
technique was most suitable for PLDD. Vorwerk et al. [17]
took a theoretical approach in determining the laser of
choice by assessing the optical properties of degenerated
disc tissue in the wavelength range of the different laser
types used in clinical practice (200 to 2,200 nm). The
highest absorption rate (83%) was found at 2,060 nm,
which is the wavelength of the Ho:YAG laser. However,
because the existing laser fibers could only transmit lasers
with wavelengths between 300 and 2,000 nm at the time of
the experiment (1989), the Ho:YAG laser was not found
appropriate for PLDD, in spite of its high absorption rate.
For practical rather than theoretical reasons, Vorwerk et al.
conclude that the 1,320 nm Nd:YAG laser appears more
appropriate for laser disc surgery. This laser is commonly
used in other disciplines of medicine such as gastroenter-
ology, making it readily available without the need for large
investments. Its absorption rate of 60%, although being
lower than that of the Ho:YAG laser, is still considered
sufficient for effective ablation of the nucleus pulposus
tissue [17].
Other researchers have tried to asses the laser of choice
by measuring the amount of vaporization or the size of the
defect created by the various lasers [2, 12, 15, 16, 21]. The
CO2 laser appears to be the most efficient laser for ablation
of disc tissue in vitro [2, 12, 16]. However, its clinical use is
limited by the fact that none of the existing laser fibers are
capable of conducting CO2 laser beams [2]. Opinions differ
with respect to the Ho:YAG laser and 1,320-nm Nd:YAG
laser. While Sherk et al. [2] state that the Ho:YAG laser
appears to be the best laser for clinical use, others state that
both are equally effective [15, 21]. Theoretically, the 1,320-
nm Nd:YAG would provide better vaporization of disc
tissue than its 1,064-nm counterpart due to its higher
absorption in water. Choy et al. [13] found both lasers to be
equally effective. However, according to Choy, the more
penetrating 1,064-nm Nd:YAG laser causes carbonization
of nucleus pulposus tissue, thereby increasing its efficacy
through a change in optical properties [13].
The main determinant of the extent of evaporation of the
disc material was found to be the total amount of applied
laser energy [9, 14, 15, 21]. Within bandwidths of power
and irradiation time used in the various trials, this affected
the extent of disc evaporation more than the variation of
single parameters such as power, frequency, or energy per
pulse [15]. Searching for means to provide better
monitoring of the process of tissue evaporation for clinical
use, Min et al. [19] conducted an experiment to determine a
quantitative relationship between the applied amount of
laser energy and the amount of ablated disc tissue. Choy et
al. found a linear correlation between the amount of laser
energy applied and the amount of tissue ablation [13]. The
ablation of nucleus pulposus for the Ho:YAG laser was
found to be 32 mg/kJ in dry weight and 105 mg/kJ in
physiologic weight. The ablation capacity in annulus
fibrosus tissue was 50% of that in nucleus pulposus tissue,
possibly due to its lower water content (and resulting lower
absorption rate) [19]. Sato et al. tried to increase this
difference in absorption rates even more by injecting
indocyanine green dye (ICG) into the nucleus pulposus.
Since all lasers used in PLDD have wavelengths in the
infrared spectrum, the use of a green colorant would
theoretically increase the absorption of laser energy
significantly [22]. Their experiment showed that to achieve
an effective amount of nucleus pulposus evaporation, up to
66% less laser energy was needed in the presence of ICG
than without ICG. At this lower level of laser energy,
histologic examination of sagittal sections of the lumbar
spine showed that ICG-stained nucleus pulposus tissue had
been almost completely removed, leaving the annulus
fibrosus and vertebral end plates undamaged.
Discussion
The results of the preclinical trials discussed in this review
provide a better understanding with respect to the
principles of percutaneous laser disc decompression and
its possible side effects. However, they cannot replace
clinical research of sufficient scientific strength to prove
the efficacy of PLDD. The main reason for this is that
almost all preclinical trials use normal disc material in their
experiments, while the condition targeted by PLDD
involves degenerated, herniated discs. The principle of
PLDD depends largely on the concept of an intervertebral
disc as a closed hydraulic system [23]. This concept has
been experimentally verified for normal discs with an intact
annulus fibrosus, but it still remains uncertain if it is also
applicable to degenerated discs with an annular defect. Not
only do the water content and the ability to attract water
differ largely between normal and degenerated discs, one
could also imagine that the pressure characteristics of a
weakened (or ruptured) annulus fibrosus are quite different
from those of a normal annulus fibrosus.
In the various trials, energy was established to be the
main determinant of the extent of evaporation of disc
material [9, 14, 15, 21]. All other parameters where
considered less important to determine treatment outcome.
Although many authors relate the effect of PLDD solely to
the total amount of energy delivered, it is likely that the
exact relation between power, pulse duration, frequency,
and total time is much more complicated. It is hard to
imagine that the application of 0.001 W for 1,000 s would
yield the same effect as 100 W for 0.01 s. At lower power
levels and longer irradiation times, dissipation of heat
becomes a factor of increasing importance, eventually
reaching a point where effective heating of the target area
will no longer occur. Based on the results of these trials, it
is too bold to conclude that the total amount of laser energy
delivered is, by itself, the main determinant of the extent of
evaporation of disc material. It would have been safer to
conclude that, within the bandwidths of power and
irradiation time used in the various trials, the amount of
energy delivered appeared to be the main determinant of
the extent of disc evaporation. The authors propose that
future literature on this subject should always include
information on power, total time, pulse frequency, pulse
duration, and pulse interval. Instead of using the rather
vague term “laser energy,” the authors propose to speak of

the product of power and irradiation time, which is
essentially the same but provides better insight in the
method used during laser application.
Because of the difference in water content, it is difficult
to predict the effect of different laser types in degenerated
disc tissue from experiments on normal discs. The laser that
provides the best results in normal, highly water-containing
disc tissue might not perform so well in degenerated discs.
In this respect, the experiment conducted by Sato et al. [22]
is promising because it shows that injection of a colorant
into nucleus pulposus tissue allows not only selective
ablation, but also with much lower laser energies. By
injecting dye with an absorption peak at the wavelength of
the laser used, the effect of differences in water content or
color of disc tissue could possibly be diminished, allowing
a more accurate prediction of the rate of tissue ablation and
limiting the risk of damaging surrounding tissues. This
subject is certainly worthy of further investigation.
Choy et al., treated their first patient in 1986 [24], at a
time when no preclinical research had been published on
this matter. Since then, the results of experimental research
have consistently supported the original concept of PLDD
and have provided enough information on possible risks
and side effects to consider it as “safe.” However, the value
of PLDD for clinical practice cannot be determined from
experimental research alone. The lack of randomized,
controlled clinical trials is probably the most important
cause of its ongoing controversy. Well-designed research of
sufficient scientific strength, comparing conventional sur-
gery to PLDD, is needed to determine whether or not
PLDD deserves a prominent place in the treatment arsenal
for lumbar disc herniation.
References
1. Schenk B, Brouwer PA, Peul WC, van Buchem MA (2006)
Percutaneous laser disk decompression: a review of the
literature. AJNR Am J Neuroradiol 27(1):232–235 (Jan)
2. Sherk HH, Black J, Rhodes A, Lane G, Prodoehl J (1993) Laser
discectomy. Clin Sports Med 12(3):569–577 (July)
3. Choy DS, Altman P (1995) Fall of intradiscal pressure with
laser ablation. J Clin Laser Med Surg 13(3):149–151 (Jun)
4. Kutschera HP, Buchelt M, Lack W, Beer R (1995) Circumfer-
ential measurement of anulus deviation after laser nucleotomy.
Lasers Surg Med 20(1):77–83
5. Kutschera HP, Lack W, Buchelt M, Beer R (1998) Comparative
study of surface displacement in discs following chemonucleo-
lysis and lasernucleotomy. Lasers Surg Med 22(5):275–280
6. Castro WH, Halm H, Jerosch J, Schilgen M, Winkelmann W
(1993) Changes in the lumbar intervertebral disk following use
of the Holmium–Yag laser—a biomechanical study (in Ger-
man). Z Orthop Ihre Grenzgeb 131(6):610–614 (Nov–Dec)
249
7. Choi JY, Tanenbaum BS, Milner TE, Dao XV, Nelson JS, Sobol
EN, Wong BJ (2001) Thermal, mechanical, optical, and
morphologic changes in bovine nucleus pulposus induced by
Nd:YAG (lambda=1.32 microm) laser irradiation. Lasers Surg
Med 28(3):248–254
8. Thal DR et al (1996) Effects of Nd:YAG laser radiation in
cultured porcine vertebral disc tissue. Proc SPIE Int Soc Opt
Eng 2623:312–320
9. Hirohashi T (2000) Effects of holmium(HO)–YAG laser
irradiation on rabbit lumbar discs. Kurume Med J 47(1):73–78
10. Turgut M, Ozcan OE, Sungur A, Sargin H (1996) Effect of Nd:
YAG laser on experimental disc degeneration. Part I.
Biochemical and radiographical analysis. Acta Neurochir
(Wien) 138(11):1348–1354
11. Turgut M, Ozcan OE, Sungur A, Sargin H (1996) Effect of Nd:
YAG laser on experimental disc degeneration. Part II. Histo-
logical and MR imaging findings. Acta Neurochir (Wien) 138
(11):1355–1361
12. Turgut M, Onol B, Kilinic K, Tahta K (1996) Extensive damage
to the end-plates as a complication of laser discectomy. An
experimental study using an animal model. Acta Neurochir
(Wien) 139(5):404–409 (discussion 409–410)
13. Choy DS, Altman PA, Case RB, Trokel SL (1991) Laser
radiation at various wavelengths for decompression of inter-
vertebral disk. Experimental observations on human autopsy
specimens. Clin Orthop 267:245–250 (Jun)
14. Nerubay J, Caspi I, Levinkopf M, Tadmor A, Bubis JJ (1997)
Percutaneous laser nucleolysis of the intervertebral lumbar disc.
An experimental study. Clin Orthop 337:42–44 (April)
15. Schlangmann BA, Schmolke S, Siebert WE (1996) Temperature
and ablation measurements in laser therapy of intervertebral disk
tissue. Orthopade 25(1):3–9 (Feb)
16. Sutter B et al (1996) Experimental and clinical results of laser-
assisted percutaneous nucleus pulposus vaporisation. Laser
Medizin 9(2):78–84
17. Vorwerk D, Husemann T, Blazek V, Zolotas G, Gunther RW
(1989) Laser ablation of the nucleus pulposus: optical properties
of degenerated intervertebral disk tissue in the wavelength range
200 to 2200 nm (in German). Rofo 151(6):725–728 (Dec)
18. Fischer R, Konig K, Ruck A, Puhl W, Steiner R (1994)
Fluorescence spectroscopy in selective percutaneous nucleotomy
using the excimer—laser experimental studies. Z Orthop Ihre
Grenzgeb 132(1):9–15 (Jan–Feb)
19. Min K, Leu H, Zweifel K (1996) Quantitative determination of
ablation in weight of lumbar intervertebral discs with holmium:
YAG laser. Lasers Surg Med 18(2):187–190
20. Phillips JJ, Kopchok GE, Peng SK, Mueller MP, White RA
(1993) MR imaging of Ho:YAG laser diskectomy with
histologic correlation. J Magn Reson Imaging 3(3):515–520
(May–Jun)
21. Quigley MR, Maroon JC, Shih T, Elrifai A, Lesiecki ML
(1994) Laser discectomy. Comparison of systems. Spine 19
(3):319–322 (Feb)
22. Sato M, Ishihara M, Arai T, Asazuma T, Kikuchi T, Hayashi T,
Yamada T, Kikuchi M, Fujikawa K (2001) Use of a new ICG-
dye-enhanced diode laser for percutaneous laser disc decom-
pression. Lasers Surg Med 29(3):282–287
23. Choy DS, Michelsen J, Getrajdman G, Diwan S (1992)
Percutaneous laser disc decompression: an update—spring
1992. J Clin Laser Med Surg June 1992, pp. 177–184
24. Choy DS, Ascher PW, Ranu HS, Saddekni S, Alkaitis D, Liebler
W, Hughes J, Diwan S, Altman P (1992) Percutaneous laser disc
decompression. A new therapeutic modality. Spine 17:949–956