Back Pain due to Degenerative Disc Disease

Alfie in London, UK, asks:

"I have back pain which my doctor has said is due to degenerative disc disease. He also said that I may require surgery later. Could you explain more about this please?"

Colin Natali, Consultant Spinal, Trauma and General Orthopaedic Surgeon at the back2normal back and neck clinic, London, replies:

"Degenerative disc disease (DDD) is an ongoing process that can be present in individuals who do not have symptoms of low back pain. In those who do complain of symptoms, the causes range from mechanical back pain to nerve root compression, (caused by stenosis (narrowing of the spinal canal) or a prolapsed intervertebral disc) as well as several other causes within that spectrum of conditions.

"With such wide ranging clinical entities and causes, there is no simple answer to the question of 'What surgical treatment should be used in DDD?'

"In an attempt to answer the question there are several pre-requisites that should be fulfilled:

Patients should have exhausted all conservative therapies and be on maximal medication.
If, in spite of this, the symptoms are still sufficiently severe to limit activity to the point where quality of life is compromised, then surgery can be considered.
The surgery should be directed at the pain generator and not simply an MRI abnormality!

"These three axioms may seem straight forward enough, but they are often ignored.

"The table below can often be used as a diagnostic chart:

Pain Source	Diagnosis	Supplementary Investigations	Surgical Treatment Options	Alternative Treatments
Nerve root compression	Prolapsed intervertebral disc - slipped disc.	MRI scan	Decompression (to relieve pressure on the nerve root) and discectomy (to remove the disc)	Laser foraminotomies (minimally invasive opening of the passage through which the spinal nerve roots and blood vessels pass)
Nerve root claudication (compromise of blood supply to the nerve root)	Spinal Stenosis (narrowing of the spinal column)	MRI scan	Spinal Decompression (to relieve pressure on the nerve root)
Mixed root and axial back pain	Stenosis plus mechanical instability	MRI scan and provocative discography	Spinal decompression and stabilisation using screw fixation	Wallis stabilisation ligament
Mechanical low back pain	DDD without compression	MRI scan and provocative discography	Spinal fusion of two vertebral levels	Disc replacement

"Essentially, for those who exhibit neural compression, MRI scan be used to confirm the diagnosis and direct the treatment. However, it should be remembered that in the case of a prolapsed intervertebral disc, there has been a major failure of a large avascular structure in the spine. Back pain and ongoing symptoms are extremely common. In some studies it has been estimated that up to 66% complain of ongoing leg and back pain, even 10 years after surgery that has been reported as being technically successful from the surgeons view point.

"For those who complain of central back pain, the problem of spinal instability has to be addressed. The surgical method of addressing this falls between fusion of two vertebral levels or maintaining movement between these vertebral levels. The results of spinal fusion for back pain are dogged by poor quality research papers and misleading articles. The results of a Swedish study suggest that in the majority of patients who undergo fusion, there will be reduced pain although the operation is obviously a major undertaking.

"Total disc replacements have been around now for over 15 years and the results in selected studies appear encouraging, although the long term behaviour of the disc is as yet unknown.

"As back pain affects over 65% of the adult population at some time in their lives, and is the major cause of sickness and disability in the working population, the search for 'cures'will continue. Unfortunately, some devices meet with more media interest than scientific proof and as such should be carefully examined both by patients and those healthcare professionals involved in the treatment of such conditions.

"Back pain can be viewed as a lifelong condition which has to be managed wisely, using all of the evidence available to us, both on an individual patient basis and from a critical review of the scientific evidence that is published in the journals and the press.

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Article published: 6th November 2003