What are the treatment options for patients with degenerative disc disease?

Treatment of Degenerative Disc Disease

Conservative management with physical therapy focusing on core strengthening and flexibility exercises should be the initial treatment for all patients with degenerative disc disease, as most patients improve within 4 weeks without invasive intervention. 1, 2

Initial Conservative Management (First-Line Treatment)

• Physical therapy with core strengthening and flexibility exercises is the cornerstone of treatment and should be initiated immediately 1, 2, 3
• Patients must remain active rather than resting in bed, as activity is more effective for acute or subacute low back pain 2
• If severe symptoms require brief bed rest periods, return to normal activities should occur as soon as possible 2
• Self-care education materials based on evidence-based guidelines should supplement clinician advice as an inexpensive and efficient method 2
• Most lumbar disc herniations with radiculopathy improve within the first 4 weeks with noninvasive management 2
• Conservative therapy must be attempted for at least 6 months before considering surgical intervention 1, 3

When Imaging is Indicated

• MRI or CT should be reserved for patients who are potential candidates for surgery or epidural steroid injection, as routine imaging does not improve outcomes 2
• Imaging is recommended for evaluating patients with persistent back and leg pain who might be candidates for invasive interventions 2
• Imaging findings must be correlated with clinical symptoms, as treatment decisions depend on concordance between symptoms and radiographic findings 2

Interventional Treatment Options (After Failed Conservative Management)

Epidural Steroid Injections

• For persistent radicular symptoms despite conservative therapy, epidural steroids are a potential treatment option 2

Radiofrequency Ablation

• Conventional (80°C) or thermal (67°C) radiofrequency ablation of the medial branch nerves to the facet joint should be performed for low back (medial branch) pain when previous diagnostic or therapeutic injections have provided temporary relief 4
• Water-cooled radiofrequency ablation may be used for chronic sacroiliac joint pain 4
• Conventional or thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for lumbar radicular pain 4

Intradiscal Electrothermal Therapy (IDET)

• IDET may be considered for young active patients with early single-level degenerative disc disease with well-maintained disc height 4

Cryoablation

• Cryoablation may be used in selected patients with postthoracotomy pain syndrome, low back pain (medial branch), and peripheral nerve pain 4

Surgical Intervention Algorithm

Indications for Surgery

• Intractable pain refractory to at least 6 months of comprehensive conservative management 1, 3
• Progressive neurological deficits 3
• Cauda equina syndrome 3
• Severe, disabling pain persisting despite comprehensive conservative therapy 3

Surgical Decision-Making Based on Symptom Pattern

For Primarily Radicular Symptoms (Leg Pain Predominant):

• Decompression without fusion is typically sufficient for patients with primarily radicular symptoms without significant axial back pain 1, 2, 3
• Discectomy alone is appropriate for isolated herniated discs causing radiculopathy 2
• Lumbar fusion is NOT recommended as routine treatment following primary disc excision for isolated herniated discs causing radiculopathy 2, 3
• Return to work is faster with discectomy alone (12 weeks) compared to fusion (25 weeks) 3

For Chronic Axial Back Pain (Back Pain Predominant):

• Lumbar fusion is recommended 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 3

Special Circumstances Where Fusion Should Be Considered:

• Significant chronic axial back pain with degenerative changes 2, 3
• Manual labor occupations (89% maintain work activities at 1 year after fusion vs. 53% after discectomy-only) 3
• Severe degenerative changes 2, 3
• Instability associated with radiculopathy 2, 3
• Recurrent disc herniations (92% improvement rate with fusion) 3

Critical Pitfalls and Caveats

• Meta-analyses show similar long-term outcomes between surgical and non-surgical treatment, emphasizing the critical importance of appropriate patient selection 1, 2, 3
• Fusion increases surgical complexity, prolongs surgical time, and potentially increases complication rates without proven medical necessity in many cases 3
• Treatment must target the level with both imaging abnormalities AND concordant clinical symptoms 2
• The presence of multilevel degenerative changes should not deter from addressing the symptomatic level 2
• Other treatment modalities should be attempted before consideration of ablative techniques 4
• Chemical denervation (alcohol, phenol, or high-concentration local anesthetics) should not be used in routine care of patients with chronic noncancer pain 4