Degenerative disc disease: Spine surgeon viewpoint
Treatment of patients with lumbar degenerative
disc disease is largely dependent on the length
of time the patient has had symptoms and the
amount of pain and disability. For the first
three to six months, conservative treatment is
usually recommended. For patients with severe
pain, epidural injections can be used to try
to decrease the inflammation in the area around
the damaged disc. The pain largely comes from
both micromotion instability and the inflammation
caused by the disc material. Most cases of degenerative
disc disease will improve with time and proper
conservative treatment. If the patient can function
well and enjoy most of their normal activities,
even if conservative treatment does not provide
complete relief, spine surgery still may not
be advisable.
If conservative treatment fails and the patient
continues to have a lot of pain and dysfunction,
then a spine surgeon may recommend surgery. The
primary surgical treatment for degenerative disc
disease has been spine fusion surgery, with the
rationale that if you stop the motion at a painful
motion segment the pain should improve. There
are many ways to do a spine fusion surgery and
the spine can be approached from the front, the
back, or both. In this particular case doing
an anterior (front) interbody fusion would not
be a good option since the disc space height
is well preserved. If the disc space is collapsed
the outside of the disc can be tensioned with
distraction of the disc and this helps stabilize
an anterior interbody graft. Fusion from the
back alone leaves the degenerated disc in place
so the pain "generator" is still present.
Two other options that could be taken by the
spine surgeon would be fusing the disc space
from the back (posterior interbody fusion) or
a front anterior interbody fusion followed by
a posterior instrumentation and spine fusion.
The latter two procedures require a substantial
amount of surgery and - although they would stabilize
the segment - it would be a lot to heal from.
Recently, a new surgical procedure has been
developed that is not a spine fusion procedure
and is less invasive. It is known as intradiscal
electrothermal coagulation (IDET) and consists
of heating up the disc space to stiffen the disc
and increase the stability at this level. It
also "burns" the nerve endings that
pick up the pain from the disc space. It is a
new procedure and at the time of this article
there have not been any long term or controlled
studies on its efficacy. At this point, the results
have been quoted to be that 60% of well-selected
patients will have 50% or better pain relief.
If it doesn’t work a spine fusion surgery
could still be done in the future if needed.
In summary, if this patient has had less than
6 months of conservative treatment it would be
good to continue with aggressive conservative
treatment. Surgery would only be advisable if
she continued to have severe pain and dysfunction.
Since she still has a "tall" disc,
she might be best suited for an IDET procedure,
as the only other options she would have would
be a large fusion procedure. Fusion surgery is
usually felt to be mainly a last resort type
of option.
By:
Peter F. Ullrich, Jr., MD
July 20, 2000 |
