As a patient suffering from unremitting low back pain, if at least six months of aggressive conservative (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 intervertebral cages 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.

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Lumbar Artificial Disc Replacement

A newer surgical option for the treatment of painful lumbar discs in the US is artificial disc replacement. The first disc implant was approved for use in the general patient population in October 2004, and a second technology was approved in August 2006. With two technologies now available, artificial disc replacement is arguably becoming more popular and discussed more frequently as a treatment option.

With artificial disc replacement, pain relief is brought about by removal of the painful disc and motion is maintained with the use of a prosthetic implant made of metal (with or without a plastic bearing surface). This is more similar in theory to the artificial hip, knee, and shoulder joints that orthopedic surgeons have been using for more that 35 years to maintain motion and relieve the pain of arthritic extremity 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 replaced.

Fusion surgery is still by far the most prevalent surgery, and patients should be aware that most patients will not be eligible for a disc replacement as it can only treat limited types of disc pathology.

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Some of the considerations are the same for certain types of fusion and for artificial disc replacement. For example, an anterior approach 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.