What orthopedic (ortho) interventions are available for Degenerative Joint Disease (DJD) of the spine?

Orthopedic Interventions for Degenerative Joint Disease of the Spine

Conservative management should be the first-line approach for DJD of the spine, as surgical interventions show no significant superiority over non-operative treatment for most patients, though surgery may be considered for specific indications like spinal stenosis with spondylolisthesis or refractory radiculopathy. 1

Non-Surgical Orthopedic Management

Conservative orthopedic interventions are equally effective as surgery for most presentations of spinal DJD and should be exhausted first:

• Physical therapy, exercise programs, and rehabilitation form the cornerstone of treatment, showing equivalent outcomes to surgical decompression in meta-analyses 1
• Orthotic devices (bracing) can provide symptomatic relief 1
• NSAIDs and analgesics for pain control 1
• Epidural steroid injections may provide temporary relief 1
• Transcutaneous electrical nerve stimulation (TENS) and heat/cold therapies as adjunctive measures 1

The evidence quality supporting these interventions is low-grade, but critically, surgical decompression procedures showed similar effects to non-operative interventions in three separate meta-analyses 1

Surgical Orthopedic Interventions

Spinal Decompression for Stenosis

Decompression surgery (laminectomy, laminotomy, discectomy) shows no clinically meaningful difference compared to conservative treatment in patients with spinal canal stenosis 1. The single highest-quality RCT comparing segmental decompression with NSAIDs and physiotherapy found both groups improved equally with no difference in walking ability 1

Critical caveat: Among different decompression techniques, outcomes are equivalent except that interspinous process device implantation has higher reoperation rates than standard spinal decompression 1

Lumbar Fusion for Degenerative Disc Disease

Lumbar fusion shows no advantage over non-operative management (physical therapy, education, exercise) in Oswestry Disability Index scores, but is associated with surgical complications 1. Two meta-analyses confirmed no differences in success rates or return to work between fusion and cognitive intervention with exercises 1

However, if fusion is pursued, total disc replacement is superior to traditional lumbar fusion, showing:

• Significantly improved pain and patient satisfaction 1
• Reduced reoperation rates 1
• Shorter operation time and hospital stays 1
• Decreased post-surgical complications 1

Minimally invasive transforaminal lumbar interbody fusion offers modest advantages over open fusion: less blood loss, shorter hospital stay, and slightly less disability 1

Specific Indication: Stenosis with Spondylolisthesis

Decompression with fusion is recommended as an effective treatment for symptomatic stenosis associated with degenerative spondylolisthesis in patients desiring surgical intervention 1. The SPORT trial (Level II evidence) demonstrated that patients choosing surgery experienced superior outcomes in every clinical measure at all time points for at least 4 years 1

Evidence Quality and Clinical Reality

A major limitation across all studies: no RCTs have compared surgical interventions to placebo or no treatment 1. The GRADE quality of evidence ranges from very low to low 1

Discography should NOT be used as a stand-alone test for treatment decisions in patients with low-back pain, as it may accelerate degenerative processes 1

Practical Algorithm

1. Start with 6-12 months of aggressive conservative management (physical therapy, NSAIDs, exercise, epidural injections if needed) 1, 2

2. Consider surgery only for:

   • Stenosis with spondylolisthesis causing neurogenic claudication 1
   • Disc herniation with refractory radiculopathy 2
   • Failed conservative treatment with clear anatomic correlation 2

3. If surgery is chosen:

   • For fusion candidates: prefer total disc replacement over traditional fusion 1
   • For decompression: avoid interspinous devices due to higher reoperation rates 1
   • Consider minimally invasive approaches when technically feasible 1

The evidence strongly suggests that most patients with spinal DJD will improve with time and conservative measures, making surgical intervention unnecessary in the majority of cases 1, 2