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.
