What are the treatment options for Degenerative Disc Disease (DDD)?

Treatment Options for Degenerative Disc Disease (DDD)

For patients with degenerative disc disease (DDD), initial conservative treatment should be attempted before considering surgical options, with lumbar fusion reserved for those with intractable low-back pain refractory to conservative measures and due to 1-2 level disease without stenosis or spondylolisthesis. 1

Conservative Management (First-Line)

• Physical therapy with stabilizing exercises is more effective than mobilizing exercises, with studies showing a 17% reduction in clinical overall scores compared to a 10% increase with mobilizing treatment 2
• Comprehensive rehabilitation programs incorporating cognitive therapy are recommended as effective alternatives to surgery for chronic low-back pain due to DDD 1
• Conservative management should include:
  • Analgesics and NSAIDs for pain control 3
  • Epidural steroid injections for radicular symptoms 3
  • Physical methods such as bracing and flexion strengthening exercises 3

Surgical Management (Second-Line)

• Lumbar fusion is recommended for patients whose low-back pain:

  • Is refractory to conservative treatment (physical therapy or other nonoperative measures)
  • Is due to 1- or 2-level degenerative disc disease
  • Has no stenosis or spondylolisthesis 1

• Surgical considerations for specific populations:

  • Manual laborers may benefit from fusion at the time of discectomy, with 89% of fusion patients maintaining work activities at 1 year (compared to 53% with discectomy alone) 4
  • Patients with recurrent disc herniations show good outcomes with fusion (92% improvement rate and 90% satisfaction with posterior decompression and fusion) 4

Comparative Effectiveness

• Recent evidence shows no significant differences between surgical and non-surgical treatments for DDD in terms of long-term outcomes 1
• Meta-analyses comparing lumbar spine fusion with non-operative management reported no differences in Oswestry Disability Index scores, though fusion was associated with surgical complications 1
• When comparing minimally invasive versus open transforaminal lumbar interbody fusion, the minimally invasive approach is associated with less blood loss but longer fluoroscopy time 1

Clinical Decision Algorithm

1. Initial approach: Begin with 6-12 weeks of conservative management including physical therapy (emphasizing stabilizing exercises), NSAIDs, and pain management 1, 2

2. If symptoms persist:

   • Evaluate for specific surgical indications
   • Consider comprehensive rehabilitation program with cognitive therapy as an alternative to surgery 1

3. Consider surgical referral when:

   • Conservative treatment fails after adequate trial (typically 3-6 months)
   • Patient has significant functional limitations despite conservative care
   • Imaging confirms 1-2 level degenerative disc disease without stenosis/spondylolisthesis 1, 4

4. Special considerations for surgical approach:

   • Manual laborers with significant axial back pain may benefit from fusion 4
   • Patients with recurrent disc herniations are good candidates for fusion 4
   • Patients with demonstrated preoperative instability should be referred to spine surgeons 4

Cautions and Limitations

• Surgical complications must be considered when recommending fusion, as meta-analyses show similar effectiveness between operative and non-operative interventions but with added surgical risks 1
• Emerging techniques (intradiscal electrothermal therapy, disc prostheses) lack sufficient long-term outcome studies and should not be considered first-line treatments 5, 6
• The accurate diagnosis of discogenic low back pain is difficult, and treatment approaches remain inconsistent across practice settings 5