# Laser Reconstruction of Spinal Discs Experiments and Clinic
## 4 Clinical Aspects of LRD of IVD in DDD of the Spine
### LRD Puncture
To do this, an 18G needle is inserted into the disc through the natural hernial orifice in the defect of the AF. Before needle insertion, medial traction of the root and dural sac is performed to expose the disc. If the defect in the AF is closed by an intact posterior longitudinal ligament, then the needle is inserted by piercing it. After inserting the needle and removing the mandrel, a laser fiber is inserted into it. Then, the disc is irradiated according to the standard protocol in three zones of the NP: in the center, at its proximal and distal border with the AF along the disc puncture line. Patient, 44 years old, suffered from acute S1 radiculopathy against the background of hernial protrusion of the L5-S1 disc of the vertebrae. On MRI of the patient before the operation, there is a pronounced degenerative lesion of the L5S1 disc of grade 4 according to Pfirrmann [74]. During the operation, after removal of the hernia, intraoperative laser reconstruction of the L5S1 IVD in three areas was performed according to the standard protocol. In the postoperative period, the patient showed excellent results. During the follow-up, the MRI showed not only a full decompression of nerve structures, but also a visible regenerative IVD response, during which the MRI showed positive dynamics with a decrease in the gradation of degenerative lesion of the L5S1 disc up to the third after 6.5 months and up to 2 nd after 3 years, when a well-formed homogeneous central nucleus was formed in the IVD adjacent to the irradiated disc. This zone of contact between bone and cartilage tissue is important for metabolic processes in the disc and reflects it. In Figure 10, T1 VI shows an increase in the signal from the subcortical layer of the vertebral body near the disc. This means an increase in fluid metabolism and may indirectly indicate an increase in disc metabolism. Currently, endoscopic discectomy is becoming the new standard in the treatment of IVD hernias. The technique of percutaneous endoscopic discectomy using a single-portal approach and an endoscope no more than 7 mm in diameter takes full advantage of the benefits of endoscopic surgery. In this case, the iatrogenic postoperative cicatricial process is minimal both in the epidural space and in the paravertebral muscles and tissues. This allows for achieving excellent clinical results, reducing the time spent in the hospital to one day, and restores the patient's ability to work as early as possible. Modern techniques of percutaneous lumbar discectomy are implemented through transforminal and intercutaneous access. The development of these techniques is associated with the names of Hijikat, Kambin, and Ruetten [80; 81; 82]. After the endoscopic removal of the sequestration is completed, the final stage of the LRD operation on the disc is performed. In the case of an interstitial approach, the introduction of a laser guidewire is performed without a needle under visual endoscopic control into the area of the AF defect. In transforminal surgery, laser irradiation can be performed similarly through an endoscope, or through a separate puncture with a transforminal needle after removal of the endoscopic port. In both cases, the irradiation protocol is identical to that described above. _Example 3._ Combination of LRD with percutaneous lumbar transforminal endoscopic discectomy. A 51-year-old patient with hernial protrusion at the level of L4L5 vertebrae with clinical manifestations of discradical conflict and DDD of grade 4 according to Pfirrmann [74]. Percutaneous lumbar transforminal endoscopic discectomy with LRD was performed at the level of L4L5 vertebrae from the right-sided approach. Immediately after the LRD, a persistent regression of pain syndrome was observed, and after 9 months, in addition to the clinical effect, the control MRI showed a pronounced positive dynamic of the degree of DDD according to Pfirrmann--from 4 to 2 degrees. At the same time, the T2 VI MRI mode showed a pronounced development of cartilage tissue in the disc cavity (Figure 11).