Deciding on surgery for degenerative disc disease
Surgery considerations for a degenerated disc

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Everyone’s discs degenerate as we get older. Disc degeneration can also be seen as early as the late teens as a result of trauma, surgery, or just bad genetics. Most people with degenerative disc disease can manage their ongoing pain, as well as more painful flare episodes, with conservative (non-surgical) care. Yet, for a small percentage of patients surgery may become the right option because conservative treatments have not worked well, and their severe pain and muscle spasms make it difficult to function normally. While it is sometimes true that the pain from a degenerated disc can subside after the disc has fully degenerated, this process can take years and is highly variable.

For people with ongoing severe, disabling pain and associated symptoms (e.g., numbness, tingling, difficulty sitting) it is sometimes not possible to wait for non-surgical therapy to work and/or for nature to run its course. Consequently, surgery - either the more standard fusion surgery or the newer artificial disc replacement surgery - may be warranted if patients meet the following criteria:

They have conscientiously engaged in at least six months of non-surgical pain treatment and active exercise-based physical rehabilitation for core strengthening;

Their pain is still significant, both in terms of magnitude and its inability to be controlled with acceptable doses of medication or treatment, and, most importantly;

Their ability to function in every day activities is seriously diminished. Patients may be advised to apply “the every day test”. This means that if they are making concessions to their normal lifestyle every day of their lives because of their back pain, despite adequate non-operative treatments, then a surgical consultation is appropriate.

Practical point
If back pain causes one to make concessions to his or her normal lifestyle on a daily basis, despite adequate non-operative treatments, then a surgical consultation is warranted. Degenerated disc surgery
Determining whether to undergo surgery is a complex decision, and each person has their own personal threshold for when it is time to make that choice. However, using these criteria can help patients and physicians judge if the time is right.

Lack of pain relief with non-surgical treatment and rehabilitation
Even for patients experiencing a significant amount of pain from a degenerated disc in the low back (lumbar region), the standard recommendation is to work hard at six months of conservative treatment. Non-surgical treatment is actually a multi-faceted strategy involving:

Pain management. As a first step, patients need to gain control of the pain. Ice to relieve pain and heat to treat stiffness or warm up muscles are low cost, accessible options. Both over-the-counter and prescription medications can provide pain relief by controlling inflammation and treating pain. Epidural steroid injections and a number of alternative treatments, such as chiropractic care or acupuncture, can also be useful to manage pain. Most patients need to pursue a trial and error approach to identify the combination of pain management treatments that works best for them. There is no “cook book” that works for everyone.

Active physical therapy/exercise. Once the pain is under control, patients should engage in active exercise rehabilitation or physical therapy. Exercise is really the only way to help the body heal because it increases strength and encourages the flow of nutrients to the back and degenerated disc. Stretching, strengthening and aerobic conditioning should all be part of an exercise program. Improving the resting tone in the deep muscles that run alongside the spine will help off-load stresses on the disc, and frequently dramatically reduces pain and improves function. Specific core strengthening exercises are necessary to achieve this, and need to be demonstrated and monitored by an appropriate therapist.

Behavioral and lifestyle changes. Finally, patients can change behaviors that impact disc health. Productive changes include refraining from activities that physically stress or twist the low back. It could also mean using a more ergonomic chair or mattress. Patients who smoke should definitely consider quitting, since smoking deprives the disc of nutrients needed to maintain height and hydration. Some patients may also benefit from weight loss.

Uncontrollable, severe pain
Back pain that does not respond to non-operative pain treatment can be a good indication that surgery should be considered. Because there are a wide range of pain treatments available, patients may have to try different medications or combinations before finding the right one. Even if two people have almost identical symptoms of degenerated disc disease, they can experience pain differently and respond very differently to pain treatment. It can take a number of months for an individual patient to find the pain management strategy that works. Each patient must determine the balance between enough medication to take the edge off their pain without overmedicating and interfering with their function.

However, patients who have tried a number of different pain management treatments and strategies and still suffer from pain that they would characterize as persistent and functionally disabling should consult with their physician about whether surgery should be considered. Any patient that is experiencing motor impairment, such as foot drop or muscle weakness, should consider a surgical consultation more promptly.

Disability or severely limited everyday functionality
Some people may find that their quality of life is significantly diminished because of their pain and other symptoms, making it impossible to function. The inability to do such every day tasks as picking up and holding a child, folding laundry, driving a car or sitting down for dinner or a meeting at work may indicate that surgery is needed to try to restore an acceptable level of functionality and improve the patient’s quality of life.

For some patients, surgery may be considered before a full six months of non-surgical care centered on pain management and physical therapy has elapsed. It is rare, however, for there to be any lasting irreversible damage or other negative consequences due to delaying surgery for a degenerated lumbar disc, so the six-month guideline holds true for most people. This is not only because most patients do respond to non-operative care over time, but also because back surgery for lumbar degenerative disc disease are major procedures, with their attendant surgical risks and requirements for lengthy post-surgical rehabilitation.

Surgery for a degenerated disc
Patients who have not found pain relief through conservative care and have suffered diminution in their quality of life and ability to function because of a symptomatic degenerated disc should educate themselves and discuss the benefits and risks of each type of surgery with their physician. When possible, obtaining a second opinion from a similarly-credentialed surgeon may be useful to get as comprehensive a perspective as possible on what surgery entails, and to confirm that non-surgical approaches have been exhausted, leaving surgery as the next appropriate step.

Practical point
It is important to obtain an accurate diagnosis of the cause of the pain prior to considering surgery.Benefits of surgery
In addition to possibly improving one’s quality of life, there are some benefits to surgery:

Once the disc has been identified as the source of pain, surgery directly treats that source by removing the degenerated disc. Non-surgical interventions focus on managing the pain and improving back functionality, but do not reverse the pathologic process of disc degeneration.

Surgical techniques and devices continue to evolve so that the outcomes of procedures improve. Less invasive fusion techniques, artificial discs, newer bone harvesting techniques and bone graft substitutes constitute real breakthroughs that expand surgical options for patients.

There are two main types of surgery used to treat pain and symptoms from lumbar degenerated disc: lumbar fusion surgery and artificial disc replacement.

Lumbar fusion surgery
Lumbar fusion is designed to stabilize, or stop the motion of, the vertebral segment where the degenerated disc is located. The operation involves accessing the segment through a back and/or stomach incision (both of which require moving muscles and ligaments), and typically inserting hardware (such as pedicle screws) along with an interbody cage, spacers, or structural bone graft) to temporarily immobilize the affected segment while the fusion is healing.
Biologically, a fusion uses the body’s fracture-healing mechanism to allow bone to grow across the degenerated disc segment. Most often, a bone graft is placed where the affected disc was removed by the surgeon to stimulate fusion between the vertebrae. The bone can come from the patient’s iliac crest (pelvis), or from a cadaver through a bone bank, and sometimes a synthetic bone stimulating substance may be an additional option.

Artificial disc replacement surgery
Artificial disc replacement (ADR), sometimes called total disc replacement (TDR), is a newer and somewhat more complex procedure than fusion.

Artificial disc replacement surgery involves the following steps:

Accessing the affected vertebral segment by making an incision in the lower abdominal wall;

Dissecting behind the “six-pack” muscles;

Working behind the bag of abdominal contents without disturbing them;

Removing the degenerated disc;

Restoring the height of the collapsed disc;

Remobilizing the segment by releasing the contracted ligaments around the disc;

And inserting an artificial disc in the correct position.

This type of surgery has been available in some countries for a number of years, and in the US one technology was made generally available in 2004 (the Charite disc) and another in 2006 (the ProDisc).

For both types of surgery, it is important that the source of the pain be identified before a surgical plan is made. Back pain can come from many sources, and even with today’s high-powered diagnostic tests, the source of an individual’s disabling pain cannot always be pinpointed. Back pain can come from pathology in the bones, ligaments, facet joints, nerves, and discs. Diagnostic tests must be used as only part of the workup, in addition to the history and physical exam. A surgeon’s clinical experience, judgment, and interpersonal skills are also important parts of the process.

Potential risks of surgery for a degenerated disc
Patients who have not found pain relief through conservative care and have suffered diminution in their quality of life and ability to function because of a symptomatic degenerated disc should educate themselves and discuss the benefits and risks of each type of surgery with their physician. When possible, obtaining a second opinion from a similarly-credentialed surgeon may be useful to get as comprehensive a perspective as possible on what surgery entails, and to confirm that non-surgical approaches have been exhausted, leaving surgery as the next appropriate step.

Practical point
In addition to the discomfort of major surgery, both fusion and artificial disc surgery require a long period of post-surgical rehabilitation.Both lumbar fusion and artificial disc replacement surgery for a symptomatic degenerated disc have a number of potential risks and disadvantages, and it is important for each patient to fully consider these general disadvantages – as well as potential risks and drawbacks that are specific to the patient – prior to deciding about surgery.

Drawbacks to surgery for degenerative disc disease
Because both spine fusion surgery and disc replacement surgery are major operations, it is important to consider the risks in going forward with surgery. An obvious consideration is how disruptive the surgery, hospitalization and rehabilitation are likely to be compared to the pain of living with degenerative disc disease. The hospital stay can range anywhere from an outpatient procedure, in which case the patient may go home the same day of surgery, to a 3 to 4 day hospital stay. Either way, the patient generally has some activity restrictions for at least 3 to 4 weeks following surgery, followed by up to 3 to 6 months of post-surgical rehabilitation.

Potential reasons to avoid fusion surgery
There are serious potential risks that accompany any surgical procedure. There are risks specific to fusion surgery related to both medical outcomes and personal health preferences. This is by no means a complete list, but among the most important factors to consider are:

There can be a significant amount of pain from at the area of the incision(s). Depending on the technique used by the surgeon, it is possible for fusion surgery to require both anterior (front) and posterior (back) incisions. Also, if a bone graft is taken, there could be pain in the hip where the bone grafts are usually accessed.

It can take a long time for fusion to set up. The fusion between the bone morsels (in the space where the disc was) and the vertebral bodies into one long bone takes place gradually, and may not be solid for over six months to two years. During this time patients may need to modify their activities to allow the fusion to take place. Not every fusion heals, and not every healed fusion leads to pain relief.

Fusion surgery changes the mechanics of the back forever. Because the fused segment is immobilized, the back’s flexibility diminishes and added stress is distributed to non-fused segments. This weakens those segments over time, and a significant percentage of patients (30% or more) will develop degenerative disease at the neighboring segments. Fusion does not result in a normal back, although it generally reduces the preoperative pain level and improves preoperative function.

Fusion is irreversible; it cannot be converted to an artificial disc or un-fused at a later date. A patient should be satisfied that he or she has exhausted their non-surgical care and rehabilitation options before consenting to fusion.

Potential reasons to avoid disc replacement surgery
Disc replacement surgery also carries some inherent risks of the surgical procedure, as well as some unique risks because it is a relatively new operation. This is by no means an exhaustive list, but prior to having artificial disc replacement surgery patients should consider the following:

The long-term efficacy and potential complications of artificial discs for lumbar degenerative disc disease are not known. The artificial discs have only been approved for use in the U.S. since 2004 (other countries granted approval to artificial discs before the U.S.). The FDA studies for both Charite and ProDisc followed the patients enrolled in the study closely for 2 years after their surgery, and post-market surveillance will follow these patients for 5 years after their surgery. European artificial disc experience goes back 20 years, but follow-up data is not as rigorously documented. Artificial disc technology continues to evolve.

It is not known how long the artificial discs will last. Patients who have artificial disc replacement surgery may find they need another operation sometime in the future to replace the artificial disc, which leaves them at risk for increased surgical complications. Unlike hip replacement surgery, which typically occurs later in life, disc replacement surgery typically occurs when patients are in their 30s or 40s, so for most people the disc will need to last 30 or 40 years. Laboratory testing suggests that type of longevity, but discs haven’t been around long enough to have human experience with their lifespan.

Patients should definitely question their surgeon about his or her experience and success in performing the specific artificial disc replacement procedure. As with most new procedures, surgeons need time to become familiar with and adept at artificial disc replacement. The technical skill requirements for accessing the disc space and correctly placing the artificial disc are considerable. Preparing the disc space to accept an artificial disc requires skills that are different than those used by surgeons in performing a fusion. Ask your surgeon how many he has done, and how long ago did he start doing this specific procedure.

Making the right decision
Most patients with occasional or even frequent but tolerable low back pain do not need surgery. It is critical to engage in extensive non-surgical pain treatment and physical rehabilitation before even considering surgery. It will undoubtedly take time to find the right combination of pain management strategies, exercises and lifestyle changes, but the vast majority of patients with degenerative disc disease find enough relief with non-surgical approaches to let them avoid an operation.

However, there are those patients for whom surgery is a better option than continuing pain and functional disability, particularly if their quality of life has been dramatically altered. There is strong scientific evidence in the form of prospective randomized multi-center studies that shows less pain and improved function in appropriately selected patients after either lumbar fusion surgery or artificial disc replacement surgery. An appropriately trained spine surgeon should be able to ensure that non-operative care has been maximized, that the pain generator has been correctly defined, and that surgical options have been clearly presented so that an educated decision can be made by the patient.

By: Jack Zigler, MD
November 9, 2006
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