OrthoNeuroSpine & Pain Institute

Most surgeons have access to lasers and have been trained to use them, but the use of lasers in spinal surgery remains relatively limited, since there are no clear benefits to laser surgery over more established surgical techniques. Similarly, the laser has never been studied and directly compared to other techniques to prove its effectiveness. A laser is just a tool, like any other surgical instrument, and it is really the thought process behind the surgical procedure that will be most important.

So, if mainstream spine surgery is not interested in lasers, and lasers are primarily only useful as a good marketing tool, why do patients remain so interested in lasers? Perception plays a central role, and many patients perceive lasers to be a useful technology. Lasers are often perceived as an effective surgical approach for spine surgery because of two reasons: placebo response, and the tendency to always think the second opinion sounds more knowledgeable.

Placebo response: Patients with pain want to get better, and if they undergo an invasive procedure, they will try to get better if at all possible. The placebo response in patients with chronic pain can be as high as 70%, even if the procedure was a complete sham and did not address their spine pathology. However, in patients with true pathology the response doesn’t last very long. I recently operated on an elderly woman who had a degenerative spondylolisthesis and severe lumbar spinal stenosis. She had initially seen a local surgeon who had recommended a posterior decompression, instrumentation and fusion (which is what she needed for correction of her condition). She went to a center that claimed a laser surgery would suffice. After the laser surgery, she felt better for a couple of weeks, but then realized her pain was about the same. This is the placebo response. When I saw her and offered her the surgery she should have had in the first place, the reason the laser surgery had failed became apparent. I could see that none of the bone around the nerve roots had been removed, as would be expected since a laser surgery would have limited exposure and limited ability to deal with the anatomic problem causing the pain.

We did perform the surgery that was needed and she has subsequently done very well, as would be expected since this is a reliable surgery. The previous laser surgery had been touted as a minimally invasive surgery, which is its main benefit, but the drawback is that it does not address the pathology of lumbar spinal stenosis – the laser surgery does not remove the bone that is pressing against the nerve root and causing the pain. Unfortunately, since her laser surgery was not covered by insurance, the patient was out the cash.

Second opinion. The other factor that allows lasers to be marketed for spine surgery is that almost any second opinion for surgery has a tendency to sound smarter than the first opinion. The above patient had seen another surgeon prior to going to having laser surgery, and the first surgeon had recommended the appropriate surgery for her condition (decompression, instrumentation and fusion). The surgeon who wanted to use the laser, however, probably sounded smarter since he gave the second opinion. I have frequently heard that nobody should have a spine surgery unless they get a second opinion. The danger is that the next opinion a patient obtains may or may not be any smarter that the first opinion, and it may be based more on marketing than on any sound medical science. This is not to say that patients shouldn’t get second opinions – I am very much in favor of the patient having as much information as possible prior to deciding on surgery. Just be aware of the natural tendency for the second opinion to sound better.Hospital Recovery

After the operation, you will be brought to the recovery room or intensive care unit (ICU) for observation. When you wake up from the anesthesia, you may be slightly disoriented, and not know where you are. The nurses and doctors around you will tell you where you are, and remind you that you have undergone surgery. As the effects of the anesthesia wear off, you will feel very tired, and, at this point, will be encouraged to rest.

Members of your surgical team may ask you to respond to some simple commands, such as “Wiggle your fingers and toes” and “Take deep breaths.” When you awaken, you will be lying on your back, which may seem surprising, if you have had surgery through an incision in the back; however, lying on your back is not harmful to the surgical area.

Prior to the surgery, an intravenous (IV) tube will be inserted into your arm to provide your body with fluids during your hospital stay. The administration of these fluids will make you feel swollen for the first few days after the operation.

When you awake from the anesthesia, you may feel the urge to urinate. So, in addition to the IV, a catheter tube (also commonly called a Foley Catheter) may be placed into your bladder to drain urine from your system. The catheter serves two purposes: (1) it permits the doctors and nurses to monitor how much urine your body is producing, and (2) it eliminates the need for you to get up and go to the bathroom. Once you are able to get up and move around, the catheter will be removed, and you can then use the bathroom normally.

During your hospital stay, you will get additional instructions from your nurses and other members of your surgical teams regarding your diet and activity.

Proper nutrition is an important factor in your recovery. Your surgeon may restrict what you drink and eat, or place you on a special diet, depending on the surgical approach that was used during the operation. Calories and food intake are an important part of recovery. Some patients find that their physician orders are less restrictive than the diet they follow at home. After the surgery, you will continue to receive intravenous fluids until you are able to tolerate regular liquids, which typically involves gradually transitioning you from sips of clear fluids to full liquids (including JELL-O® gelatin). From there, you will be given small amounts of solid food until you are ready to return to a regular diet.

With respect to physical activity, in most cases, your surgeon will want for you to get out of bed on the first or second day after your surgery. Nurses and physical therapists will assist you with this activity until you feel comfortable enough to get up and move around on your own.

Home Recovery

Before you are discharged from the hospital, your doctor and other members of the hospital staff will give you additional self-care instructions for you to follow at home – a list of “dos and don’ts,” which you will be asked to follow for the first 6 to 8 weeks of your home recovery. So, if you are unsure of any of these instructions, ask for clarification. Following these instructions is crucial to your recovery.

Nowadays, surgery involves one or more incisions depending on the surgical approach used to perform the operation. Therefore, when you are discharged home you may still have a surgical dressing on your incision(s). Either a nurse will visit your home to change the dressing or a caregiver, such as one of your family members, will be taught to do it for you. It is important that the dressing be changed daily and kept dry.

If any signs of infection are observed while changing the dressing, call your doctor. These signs include:

• Fever – a body temperature greater than 101°F (38°C)
• Drainage from the incision(s)
• Opening of the incision(s), and
• Redness or warmth around the incision(s).
• In addition, call your doctor if you experience chills, nausea/vomiting, or suffer any type of trauma (e.g., a fall, automobile accident).
• During this recovery period, you will also be instructed to keep your incision(s) clean, making sure only to use soap and water to cleanse the area. In general, you should not shower until your doctor has permitted you to do so.
• In addition to caring for your incision(s), you will also be encouraged to:
• Drink plenty of fluids
• Maintain a healthy diet (high in protein)
• Walk or do deep-breathing exercises, and
• Gradually increase your physical activity.
• Activities to avoid include any heavy lifting, climbing (including stairs), bending, or twisting. You should also avoid the use of skin lotion in the area of the incision(s); you need to keep this area dry until it has had the opportunity to heal well.

Follow up with your doctor on a regular basis during this post-operative period, and make sure to call your doctor if you have any concerns or questions.