As a patient suffering from unremitting low back pain, if at least six months of aggressive nonsurgical treatment has failed to help, and especially if the pain and other symptoms are making it difficult to complete everyday activities, then back surgery may be an option to bring about pain relief and restore one’s ability to function. For patients in this situation, this article provides an overview of the two types of back surgery now available: spinal fusion and artificial disc replacement (ADR, sometimes referred to as total disc replacement or TDR).
Lumbar Spinal Fusion
The traditional approach to treating pain and/or disability from lumbar degenerative disc disease is spinal fusion. This surgery involves forming a direct bony connection between the vertebrae surrounding the painful disc(s); pain relief occurs by stopping the motion of the painful disc(s).
There are a wide variety of options available with spinal fusion, each with their own advantages and disadvantages. Surgical techniques include fusion approached from the front, the back, or both. Spinal instrumentation in the form of implants and/or pedicle screws provide internal structural support while the bone fuses, and bone graft can either be harvested from the patient or one of a number of synthetic bone graft substitutes or extenders can be used.
Lumbar Artificial Disc Replacement
Another surgical option for the treatment of painful lumbar discs in the US is artificial disc replacement.
With artificial disc replacement, the procedure is designed to bring about pain relief by removing the painful disc, and motion at that spinal segment is maintained with the use of a prosthetic implant. This is more similar in theory to the artificial hip and knee joint surgeries that orthopedic surgeons have been using for more that 40 years to maintain motion and relieve the pain of arthritic joints. However, there is a significant difference in that only one of the three joints that are present at each vertebral level is being replaced, whereas a hip or knee joint the total joint is typically replaced.
Fusion surgery is still by far the most prevalent surgery, and many patients will not be eligible for a disc replacement as it can only treat limited types of disc pathology.
Some of the considerations are the same for certain types of fusion and for artificial disc replacement. For example, an anterior approach (from the front) is used for both an anterior lumbar interbody fusion and artificial disc replacement, which means that the risks and potential complications are similar for this aspect of both surgeries. However, for the most part, there are unique considerations for each type of surgery, and patients are well advised to become as educated as possible when considering the two surgeries and discuss their options thoroughly with their treating physician(s).
Before considering any type of surgery, however, patients with chronic low back pain must first remember that not all pain is treatable by surgery. Failure of non-operative treatment does not mean that surgery is necessarily the next step. Evaluation with MRI and x-rays may be enough for the surgeon to render an opinion, but other tests, including CT scan and provocative discography may be needed to determine if surgery is an appropriate and if both spinal fusion and artificial disc replacement are options.
To help patients better understand their options, this article lays out some of the more important considerations for each of the two main types of back surgery for lumbar degenerative disc disease.