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 patients with intractable pain refractory to at least 6 months of comprehensive conservative therapy. 1, 2, 3

Initial Conservative Management

• Physical therapy focusing on core strengthening and flexibility exercises is the cornerstone of initial treatment for degenerative disc disease 1, 2, 3
• Patients should be advised to remain active rather than resting in bed, as this is more effective for acute or subacute low back pain 3
• Self-care education materials based on evidence-based guidelines can effectively supplement clinician advice 3
• Pharmacological therapy including analgesics and NSAIDs can help control pain symptoms 4
• Most patients with degenerative disc disease will show improvement within the first 4 weeks with noninvasive treatment 3

Intermediate Treatment Options

• For persistent radicular symptoms despite conservative therapy, epidural steroid injections may be considered 3
• MRI or CT imaging should be reserved for patients who are potential candidates for surgery or epidural steroid injection, as routine imaging does not improve outcomes 3
• Findings on imaging studies must be correlated with clinical symptoms, as radiographic findings alone are insufficient for treatment decisions 3

Surgical Intervention Algorithm

When to Consider Surgery

• Surgery should only be considered when:
  • Nonoperative treatments have failed after at least 6 months 1, 2
  • Progressive neurological deficits are present 2
  • Cauda equina syndrome develops 2
  • Severe, disabling pain persists despite comprehensive conservative management 1, 2

Surgical Options Based on Symptom Pattern

1. For Primarily Radicular Symptoms:

   • Decompression without fusion is typically sufficient for patients with primarily radicular symptoms without significant axial back pain 1, 2
   • Lumbar fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy 2, 3

2. For Chronic Axial Back Pain with Degenerative Changes:

   • Lumbar fusion may be considered for patients whose low-back pain is refractory to conservative treatment and due to 1- or 2-level degenerative disc disease without stenosis or spondylolisthesis 2
   • Fusion should be considered in specific circumstances:
     • Significant chronic axial back pain 2
     • Manual labor occupations (89% vs. 53% maintain work activities at 1 year compared to discectomy-only) 2
     • Severe degenerative changes 2
     • Instability associated with radiculopathy 2
     • Recurrent disc herniations (92% improvement rate with fusion) 2

Important Considerations and Pitfalls

• Meta-analyses comparing surgical procedures versus non-surgical treatment have shown similar long-term outcomes, highlighting the importance of appropriate patient selection 1, 3
• Fusion increases surgical complexity, prolongs surgical time, and potentially increases complication rates without proven medical necessity in many cases 2
• Return to work is faster with discectomy alone (12 weeks) compared to fusion (25 weeks) 2
• Fusion may accelerate the degenerative process at adjacent levels over the long term 5
• Disc arthroplasty is an alternative to fusion with at least equivalent long-term outcomes and may not accelerate adjacent degeneration, though concerns remain about long-term safety 5
• Emerging biotherapies including mesenchymal stem cells show promise in experimental settings but have not yet been translated to clinical practice 6