What are the treatment options for degenerative disc disease?

Treatment Options for Degenerative Disc Disease

Conservative management should be the first-line treatment for degenerative disc disease, with surgical intervention reserved only for specific circumstances such as intractable pain refractory to at least 6 months of comprehensive conservative therapy. 1

Conservative Treatment Options

• Physical therapy focusing on core strengthening and flexibility exercises is the cornerstone of initial treatment for degenerative disc disease 1
• Analgesics and NSAIDs can help control pain associated with degenerative disc disease 2
• Epidural steroid injections (ESIs) may provide short-term improvement in pain and function, particularly in patients with inflammatory end-plate changes visible on MRI 3
• Intradiscal steroid injections have shown significant improvement in patients with inflammatory end-plate changes but only minimal temporary improvement in patients without these changes 3
• Bracing and flexion strengthening exercises may be beneficial as part of conservative management 2

When to Consider Surgical Intervention

• Surgery should only be considered when:
  • Nonoperative treatments fail to provide adequate relief
  • Progressive neurological deficits are present
  • Cauda equina syndrome develops
  • Severe, disabling pain persists despite at least 6 months of comprehensive conservative management 1, 4

Surgical Options

• Decompression without fusion is typically sufficient for patients with primarily radicular symptoms without significant axial back pain 1
• Lumbar spinal fusion is NOT recommended as routine treatment following primary disc excision in patients with isolated herniated lumbar discs causing radiculopathy 5, 6, 4
• Lumbar spinal fusion may be considered as a potential option only in specific circumstances:
  • Patients with significant chronic axial back pain
  • Manual laborers (89% of fusion patients vs. 53% of discectomy-only patients maintain work activities at 1 year)
  • Patients with severe degenerative changes
  • Patients with instability associated with radiculopathy 5, 4
• Reoperative discectomy and fusion is a treatment option for patients with recurrent disc herniations associated with instability or chronic axial low back pain (92% improvement rate and 90% satisfaction with posterior decompression and fusion) 5, 4

Important Considerations and Pitfalls

• The pathological changes of intervertebral disc degeneration include senescence and apoptosis of nucleus pulposus cells, progressive degeneration of extracellular matrix, fibrosis of annulus fibrosus, and inflammatory response 7
• Healing occurs primarily in the disc periphery (outer annulus and endplate) where cell density and metabolite transport are greatest, which can relieve discogenic pain by re-establishing a barrier between nucleus pulposus and nerves 8
• Manual laborers who undergo discectomy alone return to work faster (12 weeks) compared to those who undergo fusion (25 weeks), but have lower rates of maintaining work activities at 1 year 4
• Meta-analyses comparing surgical procedures versus non-surgical treatment have shown similar outcomes between operative and non-operative interventions, highlighting the importance of appropriate patient selection 1
• Emerging biotherapies including mesenchymal stem cells show promise in experimental settings but have not yet been translated to clinical practice 7
• Patients with inflammatory end-plate changes (Modic Type 1) on MRI may represent a unique subgroup that responds better to steroid injections 3