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 asymptomatic 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.
Benefits of Surgery
In addition to possibly improving one's quality of life, there are some benefits to surgery:
- Once the disc has been identified as the source of pain, surgery directly treats that source by removing the degenerated disc. Non-surgical interventions focus on managing the pain and improving back functionality, but do not reverse the pathologic process of disc degeneration.
- Surgical techniques and devices continue to evolve so that the outcomes of procedures improve. Less invasive fusion techniques, artificial discs, newer bone harvesting techniques and bone graft substitutes constitute real breakthroughs that expand surgical options for patients.
There are two main types of surgery used to treat pain and symptoms from lumbar degenerated disc: lumbar fusion surgery and artificial disc replacement.
Practical pointIt is important to obtain an accurate diagnosis of the cause of the pain prior to considering surgery.
Lumbar Fusion Surgery
Lumbar fusion is designed to stabilize, or stop the motion of, the vertebral segment where the degenerated disc is located. The operation involves accessing the segment through a back and/or stomach incision (both of which require moving muscles and ligaments), and typically inserting hardware (such as pedicle screws) along with an interbody cage, spacers, or structural bone graft) to temporarily immobilize the affected segment while the fusion is healing.
Biologically, a lumbar fusion uses the body's fracture-healing mechanism to allow bone to grow across the degenerated disc segment. Most often, a bone graft is placed where the affected disc was removed by the surgeon to stimulate fusion between the vertebrae. The bone can come from the patient's iliac crest (pelvis), or from a cadaver through a bone bank, and sometimes a synthetic bone stimulating substance may be an additional option.
Artificial Disc Replacement Surgery
Artificial disc replacement surgery involves the following steps:
- Accessing the affected vertebral segment by making an incision in the lower abdominal wall;
- Dissecting behind the "six-pack" muscles;
- Working behind the bag of abdominal contents without disturbing them;
- Removing the degenerated disc;
- Restoring the height of the collapsed disc;
- Remobilizing the segment by releasing the contracted ligaments around the disc;
- And inserting an artificial disc in the correct position.
This type of surgery has been available in some countries for a number of years, and in the US one technology was made generally available in 2004 (the Charite disc) and another in 2006 (the ProDisc).
For both types of surgery, it is important that the source of the pain be identified before a surgical plan is made. Back pain can come from many sources, and even with today's high-powered diagnostic tests, the source of an individual's disabling pain cannot always be pinpointed. Back pain can come from pathology in the bones, ligaments, facet joints, nerves, and discs. Diagnostic tests must be used as only part of the workup, in addition to the history and physical exam. A surgeon's clinical experience, judgment, and interpersonal skills are also important parts of the process.