Download original article

Percutaneous Laser Disc Decompression (PLDD) is often presented as a minimally invasive alternative to surgery for lumbar disc herniation. A Dutch multicenter randomized controlled trial evaluated whether a PLDD-first strategy (with surgery only if needed) could deliver outcomes comparable to conventional microdiscectomy in patients with sciatica who were already surgical candidates.

Study at a Glance

• Design: Randomized, prospective, non-inferiority trial (intention-to-treat).
• Setting: Multiple hospitals in the Netherlands.
• Population: Adults with persistent sciatica due to lumbar disc herniation, eligible for surgery.
• Key comparison: PLDD strategy vs conventional surgery strategy.

Who Was Included

Patients were eligible if they were 18–70 years old, had sciatica refractory to conservative care for more than 6–8 weeks, had MRI-confirmed disc herniation at the corresponding level, and the herniated fragment was smaller than one-third of the spinal canal.

What Was Compared

• PLDD strategy: CT-guided percutaneous laser disc decompression under local anesthesia, followed by surgery only if symptoms persisted or the effect was insufficient.
• Conventional surgery strategy: Discectomy (open or microscope-assisted) under general or spinal anesthesia.

Outcomes Assessed

The main effectiveness outcome was functional disability measured by the Roland-Morris Disability Questionnaire (RDQ) for sciatica. Additional outcomes included leg and back pain (VAS), perceived recovery (Likert scale), complications, and the need for additional surgical intervention during follow-up.

Key Findings

1) Disability at 8 weeks and 1 year: PLDD strategy was not inferior

The primary endpoint (RDQ) demonstrated non-inferiority of the PLDD strategy compared with conventional surgery at both 8 weeks and 52 weeks. In practical terms, when PLDD was used as the first step and surgery was reserved for those who still needed it, overall disability outcomes at 1 year were comparable.

2) Speed of recovery favored conventional surgery

Although final outcomes at 1 year were similar, the trial found a faster recovery in the conventional surgery group. This suggests surgery tended to provide earlier symptom resolution.

3) Additional surgery was more common after PLDD

The main trade-off for a PLDD-first approach was a higher likelihood of needing subsequent surgery during the first year. In the trial, 24 patients (44%) in the PLDD arm underwent additional surgical intervention, compared with 9 patients (16%) who required reoperation in the surgery arm. 

Illustration of the disc herniation and route of the needle. The size of the disc herniation should be less than one-third of the spinal canal to be eligible for the trial.
The needle is placed centrally in the nucleus pulposus via a posterolateral approach for the percutaneous laser disc decompression treatment.

Safety and Technical Considerations

Both strategies had relatively low rates of serious adverse outcomes. The trial reported no permanent deficits. In the surgery group, the complication rate was 11% and included events such as dural tear/CSF leak and transient nerve root injury. In the PLDD group, the complication rate was 5%, mainly transient nerve root injury; however, technical failure of the PLDD procedure occurred in 9% of cases (most often due to inability to reach the disc space).

A. Curve of the mean scores (6standard error [SE]) for the Roland-Morris Disability Questionnaire (RDQ). The graphs represent the course of the scores within the first 52 weeks after randomization. In Graphs 1 and 2, the minimum score is 0 mm and the maximum score is 100 mm. Graph 3 shows the RDQ with scores ranging from 0 to 23. The maximum scores represent poorer clinical conditions. B. Curve of the mean scores (6SE) for the visual analog scale for leg pain. The graphs represent the course of the scores within the first 52 weeks after randomization. In Graphs 1 and 2, the minimum score is 0 mm and the maximum score is 100 mm. Graph 3 shows the RDQ with scores ranging from 0 to 23. The maximum scores represent poorer clinical conditions. C. Curve of the mean scores (6SE) for the visual analog scale for back pain. The graphs represent the course of the scores within the first 52 weeks after randomization. In Graphs 1 and 2, the minimum score is 0 mm and the maximum score is 100 mm. Graph 3 shows the RDQ with scores ranging from 0 to 23. The maximum scores represent poorer clinical conditions. D. Inverse Kaplan-Meier curves of the cumulative incidence of recovery based on a dichotomized 7-point Likert scale. The hazard ratio assessed with the Cox model was 0.64 (95% CI, 0.42–0.97). PLDD, percutaneous laser disc decompression; CI, confidence interval; OR, odds ratio.

What This Means for Patients

• If your priority is a minimally invasive first step (local anesthesia, outpatient setting), a PLDD-first strategy can be reasonable for carefully selected herniations.
• If your priority is faster recovery and a lower chance of needing a second procedure, conventional surgery may be the more straightforward path.
• The PLDD-first approach can still lead to good 1-year outcomes, but you should be comfortable with a higher probability of later surgery if symptoms do not improve sufficiently.

Reference

Brouwer PA et al. The Spine Journal 15 (2015) 857–865. “Percutaneous laser disc decompression versus conventional microdiscectomy in sciatica: a randomized controlled trial.”