Percutaneous Laser Disc Decompression (PLDD)

What is it?

Percutaneous laser disc decompression (PLDD) is an interventional procedure in which the disc is reached through the skin with a needle. A thin laser fibre passed through the needle delivers controlled laser energy to the soft, gel-like centre of the disc (the nucleus pulposus). The aim is to lower the pressure inside the disc and ease the pressure that the bulging part places on a nerve root.

PLDD is used for lumbar disc herniation and in selected cases of cervical disc herniation. To see where it fits in a stepwise plan, see non-surgical lumbar disc treatment and non-surgical cervical disc treatment.

PLDD should not be confused with low-power laser treatments applied over the skin in physiotherapy. In PLDD, the laser fibre is placed inside the disc, and the procedure is carried out under imaging guidance in sterile conditions.

When is it considered?

PLDD only makes sense when the herniation is still contained within the outer ring of the disc. For the lower back, the UK's National Institute for Health and Care Excellence (NICE) limits its use to people with severe pain that has not responded to conservative treatment, whose imaging shows a bulge in an intact disc, and who do not have nerve damage that requires surgical decompression.

The evidence shows that pain can be meaningfully reduced in carefully selected patients. However, in a randomised trial comparing PLDD with conventional microdiscectomy, some patients in the PLDD group went on to need surgery during follow-up. At one year, a strategy of PLDD first, followed by surgery if needed, gave results that were not inferior to surgery alone. PLDD is therefore viewed as one part of a stepwise plan in which surgery remains an option.

The evidence for the neck is more limited, and the procedure needs extra care there because of the nearby spinal cord, major blood vessels and oesophagus.

How does it work?

The disc is a closed structure, so a small reduction in the water and tissue inside it can produce a relatively large drop in pressure. The laser energy vaporises a small part of the water and tissue in the core and shrinks some of the rest. As the pressure falls, the bulging part is expected to press less on the nerve.

The laser energy is delivered in short bursts, and the total dose is adjusted to the area being treated. This helps limit the effect of heat on surrounding tissue and the vertebral surfaces. The procedure does not remove the herniation entirely, and it may still be visible on a later MRI. What matters most is the change in your symptoms.

Before the procedure

Before the procedure, your examination and recent MRI are reviewed together, and further imaging is requested if needed. You and your doctor will plan how to manage blood thinners and your other regular medicines. A preventive antibiotic may be given beforehand to lower the risk of disc infection.

The aim of the procedure, its expected benefits, possible risks and the alternatives are explained in detail before you give written consent. If sedation is planned, you will be asked to fast for a few hours beforehand.

What happens during the procedure?

For a lumbar procedure you lie face down, and the needle is advanced into the disc from the side at an angle, along a path that avoids the nerve roots. For a cervical procedure you lie on your back and the disc is approached from the front; the doctor gently separates the windpipe and oesophagus from the carotid artery with the fingers to create a safe path. Fluoroscopy images from different angles confirm that the needle tip sits in the centre of the disc.

The laser energy is delivered in short bursts, with pauses that allow the tissue to cool. You may feel warmth, pressure or something similar to your usual pain in the back or neck. If you feel a new, sharp pain in your leg or arm, tell the team straight away so the treatment can be adjusted or stopped.

After the procedure

You will be observed for a while after the procedure, and most people go home the same day. Pain and muscle spasm around the needle site may occur in the first days and usually ease within days.

Short walks are encouraged. For the first few weeks, avoid heavy lifting, sudden twisting and sitting for long periods. Many people can return to desk work within a few days, while heavy physical work and sport may need longer. Exercise is introduced when your doctor advises, and your pain and nerve examination are reassessed at follow-up.

When might you notice results?

Some people notice relief in the first few days, but the effect often develops gradually over several weeks. Temporary pain from the procedure itself can make the early days hard to judge.

Results vary from person to person. If pain does not ease enough, other interventional options such as an epidural steroid injection, or surgery, may be considered; where surgery is needed, the decision is made together with a spinal surgeon. To find out whether your herniation is suitable for this procedure, you can request a consultation.