What are the management options for degenerative disc disease?

Management of Degenerative Disc Disease

Lumbar fusion should be performed for patients whose low-back pain is refractory to conservative treatment and is due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis. 1

Initial Conservative Management

Conservative management should be the first-line approach for degenerative disc disease (DDD), with surgical interventions reserved for refractory cases:

1. Non-pharmacological interventions:

   • Physical therapy with eccentric strengthening exercises 2
   • Activity modification to avoid positions that exacerbate pain 2
   • Comprehensive rehabilitation program incorporating cognitive therapy (equivalent efficacy to fusion in some patients) 1

2. Pharmacological options:

   • NSAIDs as first-line medication 2
   • Analgesics for pain control 3

3. Interventional procedures:

   • Epidural steroid injections - particularly effective in patients with inflammatory end-plate changes (Modic Type 1) on MRI 4
   • Intradiscal steroid injections - may provide significant improvement in select patients with inflammatory end-plate changes 4
   • Radiofrequency ablation - conventional or thermal radiofrequency ablation of the medial branch nerves should be performed for medial branch pain when previous diagnostic or therapeutic injections have provided temporary relief 1

Surgical Management

When conservative measures fail after an appropriate trial (typically 3 months), surgical options should be considered:

1. Lumbar fusion:

   • Recommended for patients with low-back pain refractory to conservative treatment due to 1- or 2-level DDD without stenosis or spondylolisthesis 1
   • Consider as an option in patients with:
     • Significant chronic axial back pain
     • Manual labor occupation
     • Severe degenerative changes
     • Evidence of instability 1

2. Discectomy:

   • Primary treatment for disc herniation causing radiculopathy 1
   • Lumbar fusion is NOT recommended as a routine addition to primary disc excision 1
   • Reoperative discectomy with fusion is a treatment option for recurrent disc herniations associated with instability or chronic axial low back pain 1

3. Intradiscal Electrothermal Therapy (IDET):

   • May be considered for young active patients with early single-level DDD with well-maintained disc height 1

Treatment Algorithm

1. First 4-8 weeks:

   • Conservative management with physical therapy, NSAIDs, activity modification
   • Avoid routine imaging for acute pain without red flags 2

2. Persistent symptoms (2-3 months):

   • Consider MRI imaging to assess disc pathology and presence of inflammatory changes
   • Trial of interventional procedures (epidural injections, radiofrequency ablation)

3. Refractory symptoms (>3 months):

   • Reassess with imaging
   • Consider surgical options based on specific findings:
     • For 1-2 level DDD without stenosis/spondylolisthesis: lumbar fusion
     • For disc herniation with radiculopathy: discectomy alone
     • For recurrent herniation with instability: discectomy with fusion

Important Considerations and Pitfalls

• Avoid unnecessary imaging: Routine imaging for acute low back pain (<4 weeks) without red flags provides no clinical benefit and may lead to unnecessary interventions 2

• Fusion is not always necessary: Lumbar discectomy alone shows equivalent or better outcomes compared to discectomy with fusion for primary disc herniations 2

• Patient selection is critical: The STarT Back tool can help identify patients at low, medium, or high risk for developing persistent disabling pain, guiding appropriate management approaches 2

• Emerging therapies: Regenerative medicine approaches including mesenchymal stem cells, gene therapy, and biologic treatments show promise but lack standardized clinical data for routine use 5, 6

• Prognosis: The prognosis for DDD is generally favorable with appropriate management, but patients with neurological symptoms may experience deterioration if not appropriately treated 3