Degenerative Disc Disease: Doctor Answers Patient Questions

Question:

I have had debilitating lower back pain for two years. My MRI indicates I have bulging discs. My doctor recommended exercise, but that has not helped. What are some alternatives to keep my discs from bulging?

Doctor’s response:

Bulging discs in and of themselves are not necessarily painful. 30-60% of patients with no pain can have the finding of an asymptomatic bulging disc on their MRI scan. The MRI scan is not necessarily diagnostic as to what is the cause of your pain. The more accurate the diagnosis you receive the better your treatment plan will be.

Depending on what is causing your pain, there are various treatment options. Consult a spine specialist, such as an orthopedic spine surgeon or a physiatrist. Treatment options for conditions such as degenerative disc disease may include medications, physical therapy, manipulation (e.g. by a chiropractor), injections, and occasionally, surgery or other invasive procedures.

Your doctor is right in that exercise is an important component of your rehabilitation in almost all cases of back pain. However, doing the right exercises the right way is essential. I usually recommend working with an appropriately trained physical therapist to develop a home exercise program.

Question:

I have 2 ruptured and degenerated discs (L4-L5 and L5-S1) with recurrent low back pain (debilitating) at least once a year, and more recently every six months. I have researched some alternatives to surgery, and have found the VAX-D therapy to be the most comprehensive. I am 35 years old and fairly active (when able). The VAX-D therapy consists of 30 sessions at 200 dollars each, and insurance will not cover it. Am I better off opting for implant surgery (which would be my preference to fusion), or should I try the VAX-D therapy? What is your opinion of VAX-D, and is the PRODISC (or any comparable artificial disc) implant an available alternative yet?

Doctor’s response:

My understanding is that there basically is no scientific evidence that VAX-D changes the natural history of low back pain. It is expensive and not covered by insurance because it is unproven. That is not to say that it does not work on some people, but it can be a lot of money for little benefit.

The PRODISC artificial disc is not commercially available as of yet, and the Charité artificial disc, which is FDA-approved for use in the U.S., is not approved for two-level artificial disc replacement surgeries. [Editorial note: The PRODISC-L was approved by the U.S. FDA on August 14, 2006 for use at a single vertebral level.]

A two-level fusion procedure in a young healthy adult is a big undertaking and should only be considered as a salvage procedure if you cannot function well. The best alternative is to try to manage the pain with an active exercise program focused on stretching, strengthening, and conditioning. If your pain is only intermittent, any type of surgical intervention (either artificial disc or fusion surgery) is probably a bit aggressive. It is probably better to manage your bouts of pain rather than shoot for a "cure."

Question:

Over five years ago, I had a discectomy of L4-L5 where the surgeon just cut the bulging disk. About a year ago, I had another discectomy of L4-L5. My surgeon told me that he had completely removed my disc in L4-L5 without a fusion. Currently, if I try to bend forward at all or straighten up, there is intense sharp pain. I didn't feel this way at all after my first surgery. Is it normal to remove the entire disk without fusing? Also, is it safe to do a fusion now on L4-L5?

Doctor’s response:

I would highly doubt that the spine surgeon completely removed the disc. The only way to completely remove the whole disc is to go through an anterior approach through the abdomen, and I would doubt any surgeon would do that without fusing the spine.

It is much more likely that your disc space itself is still painful. If this is the second disc herniation, it may be continuing to degenerate (meaning that you have degenerative disc disease). If you do not improve with conservative treatment, you may in the future benefit from a fusion. Basically, a fusion is designed to stop the motion at a painful motion segment, and in cases of advanced disc space degeneration it can be quite effective. Generally, it is not advisable to consider a fusion unless the pain is significantly limiting your activities. Otherwise, exercises, including stretching and conditioning, should suffice to control the pain.

Question:

I am a 32 year old female and have chronic low back and leg pain that goes down to my foot on the left. An MRI showed degenerative disc disease L3 thru S1, a diffuse bulge at L4/5 (worse to the left) and facet osteoarthropathy mildly impinging the L5 nerve roots. It also showed an annular tear at L5/S1 and posterior protrusions at L3/4 and L4/5. I am due to have an epidural block for the leg pain and facet injections. I am also in physical therapy. Do you think it is possible to rehabilitate my back to the level of being able to lift in excess of 50 lbs? If I pick up my 25 lb child too much, my back pain gets worse.

Doctor’s response:

In all likelihood, a lot of the findings that are on your MRI scan were there before you were having much back pain. The findings on your MRI are not specific or diagnostic of any specific pathology. Probably the more important question is whether or not your nerve root is pinched by the disc bulge. If it is, the epidural may help calm down the inflammation. At that point, exercises would be helpful. If the injection does not help, you may want to see a spine surgeon to see if you would be a candidate for a microdecompression.

Rehabilitation is probably your best place to start. Assuming that it helps relieve your back pain, I do not know why you wouldn't be able to lift 50lbs, as there are not any significant structural defects in your back based on the MRI scan findings.

Question:

I am 30 years old and I started suffering lower back pains about a year ago. Around six months ago, my doctor sent me for x-rays and told me I had degenerative spinal disorder. He put me on pain killers (when needed) and 800mg of ibuprofen three times daily. He asked me to take the ibuprofen religiously for six months, and to give his office a call and let them know how I have been. Well, it will be six months next week and I have had a few good days and a lot of bad days. What should I expect from this point? Is surgery or a cortisone shot my only options now? And do most people get back to a “normal” lifestyle after one of these treatments?

Doctor’s response:

I think your physician was most likely referring to degenerative disc disease, which is fairly common among 30 year olds. The best treatments are anti-inflammatory medications (i.e. NSAIDs or ibuprofen) and physical therapy. For patients with degenerative disc disease, exercises are very important to reestablish the normal motion and strength in the spine. A daily hamstring stretching program is key to help relieve pain from degenerative disc disease. Also important are stabilization exercises and aerobic conditioning. Cortisone shots and surgery for degenerative disc disease are only warranted if extensive conservative treatment fails to restore function.

What next?

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Peter Ullrich, MD

The explanations, insights and advice listed above about degenerative disc disease - including conservative treatments and surgical options - are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.com.

Patients frequently e-mail us questions about degenerative disc disease, and while we don’t provide individual responses, periodically, Dr. Ullrich will take time to respond to the more frequently asked questions and we publish the responses in this section of the site.

Please understand that the preceding responses to questions about degenerative disc disease represent the opinion of one physician, and are intended for informational purposes only and not as a substitute for professional medical help or advice.

Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health.com’s Medical Advisory Board.