Patients who have not found pain relief through conservative (nonsurgical) 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.
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.