As the spine ages, the normal buoyant capability of the disc is slowly degraded as the water content within the disc is lost and the disc becomes more fibrous in nature. Settling then begins within the disc and degenerative bone spurs can form around the disc and in the facet joints in the back part of the spine. For some patients, this degenerative process in the disc can become painful. Pain is most often noticed in the low back with sitting for an extended length of time, and when the body is maintained in one position for an extended period of time, whether sitting or standing. Relief is usually achieved with lying down. When discs become worn out and settle, we refer to the condition as Degenerative Disc Disease (DDD).

Nonoperative Treatment

   Initial treatment to degenerative disc disease is always conservative care. Acetaminophen (Tylenol) or non-steroidal anti-inflammatory medications such as aspirin, Advil or Aleve can be helpful at alleviating some of the backache associated with degenerative disc disease. Sometimes it is necessary to take a prescribed anti-inflammatory medication. It is critical to long-term and ongoing successful management of DDD that aggressive trunk strengthening programs in physical therapy be instituted. It is just as important to realize that one must continue a home exercise program performed on a daily basis at the conclusion of physical therapy. As the trunk muscles become stronger, some of the load across the spine is alleviated and patients feel less back pain. In some cases, strengthening and stretching can reduce the need for pain medications. Using a cane or walker can reduce stress to the spine as well.

Surgical Options

   For patients who have diligently tried anti-inflammatory medications, physical therapy, and an aggressive home exercise program for at least six to twelve months, the possibility of surgery can be entertained. Just because a patient has back pain, which has failed six to twelve months of conservative care, doesn't mean that surgery will help. Further investigation is required. For patients who have multiple spinal levels which are degenerative and causing pain, surgery is much less effective. The best candidates for surgery are those who have a single disc involved and who have failed their best effort at conservative care.

There are currently four surgical options for patients with isolated degenerative disc disease.

Intradiscal Electrotermal Therapy (IDET)

   IntraDiscal ElectroThermal Therapy (IDET) involves insertion of a catheter into the disc through a small incision in the back. This catheter is then heated which causes new scar tissue to grow into the disc, providing some additional stability and eliminating pain generating nerve endings within the disc. The scar tissue that forms from the disc heating provides additional support to the containing structures for the disc. This technique has shown some promise with a limited number of patients being improved after surgery. How long this procedure will provide the improvement from back pain remains unknown. Whether the procedure will lead to more disc pain in the future is also unknown. This treatment is best reserved for people who do not have advanced arthritis and don’t have multilevel disease.

Anterior Interbody Fusion with a Cage

   Cage technology has emerged as an excellent technique in spine surgery. An incision is made in the front part of the abdomen and the spine is approached from the front. The disc is completely removed. Bone morphogenetic protein (BMP) is placed inside a special plastic or titanium cage to “turn on” the bone forming capability of the surrounding bone. These cages are then inserted into the disc with the hope that the vertebrae will fuse on either side of the cage. The success rate with this technique appears to be approximately 85 - 95%. This is the procedure of choice for many patients with isolated single level degenerative disc disease that has failed conservative care.

Posterior Spinal Fusion with Instrumentation

   This is the procedure with the longest track record in treating degenerative disc disease. The incision is made from the back part of the spine and painful vertebrae are fused together with bone graft, screws and rods. The success rate with this approach is approximately 70 to 80%. The long-term follow up appears to suggest that these good results are maintained over a number of years. This approach is presently recommended for patients who do not want surgery done through the abdomen, for patients who are overweight, and for patients who want a procedure with a longer track record of research and known long-term results.

The Artificial Disc

   A new technology currently being researched involves removing a disc from the front of the spine (through the abdomen) and positioning an artificial disc in its place. There has been an extended experience with this technique in Europe and a large multi-center research trial in the United States. We were part of this multi-center study investigating the artificial disc and are cautiously optimistic about the results in carefully selected patients. This procedure is definitely not for everyone with back pain or arthritis of the spine.

The Future

   Since aging is a fact of life, almost everyone will develop degeneration in his or her lumbar discs. Just because a lumbar disc is degenerative doesn't mean that it will cause pain. Just because the patient has pain in their low back and also has degenerative discs, doesn't mean that the degenerative discs are the cause of that back pain. Care must be taken by a skilled and experienced physician to evaluate the appropriate treatment approach for degenerative disc disease. Until we are better able to exactly choose which patients will benefit from fusion, surgery will continue to be the last resort for these patients.

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