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

Treatment Options for Degenerative Disc Disease (DDD)

Conservative management should be the first-line treatment for degenerative disc disease, with surgical options reserved only for patients who fail comprehensive non-operative treatment for at least 6 months. 1, 2

Initial Conservative Management

• Physical therapy focusing on core strengthening and flexibility exercises should be the cornerstone of initial treatment for DDD 1, 2
• Patients should remain active rather than resting in bed, as this approach is more effective for managing acute or subacute low back pain 2
• If severe symptoms require brief periods of bed rest, patients should be encouraged to return to normal activities as soon as possible 2
• Self-care education materials based on evidence-based guidelines can effectively supplement clinician advice 2
• Most disc herniations with radiculopathy will improve within the first 4 weeks with noninvasive management 2

Pharmacological Management

• Non-steroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation associated with DDD 2
• Muscle relaxants may be prescribed for short-term relief of muscle spasms 2
• For persistent radicular symptoms despite conservative therapy, epidural steroid injections can be considered 2

Advanced Imaging

• MRI or CT is recommended only for evaluating patients with persistent back and leg pain who might be candidates for invasive interventions 2
• Imaging should be reserved for patients who are potential candidates for surgery or epidural steroid injection, as routine imaging does not improve outcomes 2
• Findings on imaging studies should be carefully correlated with clinical symptoms, as asymptomatic disc abnormalities are common 2

Surgical Options

• Surgery should only be considered after at least 6 months of failed comprehensive conservative management 1
• Decompression without fusion is typically sufficient for patients with primarily radicular symptoms without significant axial back pain 1
• Routine fusion following primary disc excision for isolated herniated discs causing radiculopathy is not recommended 1, 2, 3
• Fusion may be considered in specific circumstances: significant chronic axial back pain, manual laborers, severe degenerative changes, or instability associated with radiculopathy 2, 3
• Total disc replacement (TDR) has been studied as an alternative to fusion, but evidence suggests no clinically relevant differences between TDR and fusion techniques, with small overall success rates in both treatment groups 4

Emerging Biologic Treatments

• Biologic treatment options are being investigated as alternatives to conventional management 5, 6
• These include protein-based therapies (administration of biologic factors to enhance matrix synthesis, delay degeneration, or impede inflammation) and cell-based therapies (to replace necrotic cells or minimize cell death) 5
• Cell-based therapies may be more appropriate in moderate stages of DDD when cell population is diminished 5
• While promising in early studies, these treatments are still experimental and not yet part of routine clinical practice 5, 6

Important Considerations and Caveats

• Meta-analyses comparing surgical procedures versus non-surgical treatment have shown similar long-term outcomes, highlighting the importance of appropriate patient selection 1, 2, 4
• The natural history of DDD is generally favorable, and patients should be informed of this when discussing treatment options 2
• Treatment decisions should be based on clinical correlation between symptoms and radiographic findings, severity of symptoms, patient preferences, and risks 2
• Complications related to surgical approaches can range from 2.1% to 18.7%, with reoperation rates at the index level reported in 1.0% to 28.6% of patients 4
• Long-term outcomes must be considered when making treatment decisions, as devices remain implanted indefinitely, and back pain could recur if degeneration progresses or the device fails 7