Determining whether to undergo a fusion or other type of surgery for degenerative disc disease is a complex decision, and each person has their own personal threshold for when it is time to make that choice. The standard spinal fusion, as well as the newer artificial disc and other motion preservation surgery options, are all extensive surgeries and require fairly extensive recovery and rehabilitation.
The following criteria are intended to help patients with this important decision, and provide several guidelines for how to judge if the time is right to undergo spinal fusion or another type of surgery for degenerative disc disease.
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 (nonoperative) 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 single "cookbook" 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 an ergonomic office 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.
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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.