# Laser Reconstruction of Spinal Discs Experiments and Clinic
## 4 Clinical Aspects of LRD of IVD in DDD of the Spine  
### LRD Puncture  
LRD is a new approach to the treatment of DDD, based on the control of mechanical stress in tissues that have been exposed to local, short-term non-destructive laser irradiation. After detailed studies on animals and clinical studies on a selected group of patients, the LRD medical technology received the approval of the Ministry of Health of the Russian Federation and has been regularly used in the clinic since 2006. Currently, LRD is one of the most common effective methods for the prevention of degenerative diseases of the spine. LRD was applied to more than 5000 patients with 92.5% positive effect over 5 years of follow-up. _Indications for puncture LRD_ are: 1. Chronic disogenic pain syndrome, which cannot be stopped by conservative therapy; 2. Degenerative changes in IVD grade 2-4 according to the Pfirrmann MRI classification [74]. A more accurate diagnostic procedure is provocative discography or its version of CT discography. Thus, the detection of concordant pain syndrome using discography in combination with DDD according to MRI data is an indication for LRD. _Contraindications for puncture LRD_ are: 1. Compression of nerve structures with radicular pain syndrome or spondylogenic myelopathy; 2. Significant decrease in the height or fibrosis of the IVD. 4 th degree according to the Pfirrmann classification [74]; 3. Absence of signs of DDD on MRI and discography (first degree according to the Pfirrmann classification); 4. Local or generalized inflammatory process; 5. Disorders of the blood coagulation system and untreated coagulopathy; 6. Significant psycho-emotional component in pain syndrome, including discography intolerance. _Technique of LRD_[32, 33, 34]. The scheme of LRD is presented in Figure 5. The puncture LRD using optimal laser dosimetry is performed under local anesthesia using continuous X-ray control in full contact with the patient. This makes it possible to completely avoid cases of trauma to the nerve structures and to evaluate the effect of exposure to the disc during the irradiation itself. To prevent the development of complications, antibiotic prophylaxis is performed (1 g of Ceftriaxone 30 min before the operation). Before the intervention, a provocative discography is performed to identify the degree of concordance of pain, as well as the severity of degenerative lesions of the IVD. The water-soluble contrast Omnipak-300 is used, which provides good visualization of the IVD during discography. Laser irradiation of the disc is carried out using a 1560 nm fiber laser with feedback control system (Arcuo Medical Inc., Los Altos, CA, USA) [75]. Optical fiber with a diameter of 600 \(\upmu\)m is inserted into the IVD through a puncture needle G18, and irradiation of three or four zones of the NP is performed in the following mode: pulse duration 2 s, interval between pulses 1 s, and the number of pulses in series is 10; interval between series 20 s, the number of series is three. Laser power is 1.2 W and 1.0 W for the back and neck discs, respectively. _Cervical spine._ Puncture of the IVD of the cervical spine is carried out according to the method of Cloward [76]. The patient is placed in a supine position with a bolster under the shoulders and the head thrown back (Figure 6). The needle insertion point is in the groove between the trachea and the sternocleidomastoid muscle The side of the puncture depends on the presence of previous surgical interventions, deforming scars and the preference of the surgeon. In the cervical spine, one central zone of the disc is exposed to radiation, and two at the sites of the transition from the NP to the AF. _Lumbar spine._ Puncture of the lumbar intervertebral discs is performed with the patient lying on his stomach. The needle is inserted into the lumbar discs from the postero-lateral approach. The needle is inserted up to the AF, the course of its installation is controlled by an image intensifier in the fluoroscopy mode (Figure 7).