For people with ongoing severe, disabling pain and associated symptoms (e.g., numbness, tingling, difficulty sitting) it is sometimes not possible to wait for non-surgical therapy to work and/or for nature to run its course. Consequently, surgery - either the more standard fusion surgery or the newer artificial disc replacement surgery - may be warranted if patients meet the following criteria:
They have conscientiously engaged in at least six months of non-surgical pain treatment and active exercise-based physical rehabilitation for core strengthening;
Their pain is still significant, both in terms of magnitude and its inability to be controlled with acceptable doses of medication or treatment, and, most importantly;
Their ability to function in every day activities is seriously diminished. Patients may be advised to apply “the every day test”. This means that if they are making concessions to their normal lifestyle every day of their lives because of their back pain, despite adequate non-operative treatments, then a surgical consultation is appropriate.
Pain management. As a first step, patients need to gain control of the pain. Ice to relieve pain and heat to treat stiffness or warm up muscles are low cost, accessible options. Both over-the-counter and prescription medications can provide pain relief by controlling inflammation and treating pain. Epidural steroid injections and a number of alternative treatments, such as chiropractic care or acupuncture, can also be useful to manage pain. Most patients need to pursue a trial and error approach to identify the combination of pain management treatments that works best for them. There is no “cook book” that works for everyone.
Active physical therapy/exercise. Once the pain is under control, patients should engage in active exercise rehabilitation or physical therapy. Exercise is really the only way to help the body heal because it increases strength and encourages the flow of nutrients to the back and degenerated disc. Stretching, strengthening and aerobic conditioning should all be part of an exercise program. Improving the resting tone in the deep muscles that run alongside the spine will help off-load stresses on the disc, and frequently dramatically reduces pain and improves function. Specific core strengthening exercises are necessary to achieve this, and need to be demonstrated and monitored by an appropriate therapist.
Behavioral and lifestyle changes. Finally, patients can change behaviors that impact disc health. Productive changes include refraining from activities that physically stress or twist the low back. It could also mean using a more ergonomic chair or mattress. Patients who smoke should definitely consider quitting, since smoking deprives the disc of nutrients needed to maintain height and hydration. Some patients may also benefit from weight loss.
However, patients who have tried a number of different pain management treatments and strategies and still suffer from pain that they would characterize as persistent and functionally disabling should consult with their physician about whether surgery should be considered. Any patient that is experiencing motor impairment, such as foot drop or muscle weakness, should consider a surgical consultation more promptly.
For some patients, surgery may be considered before a full six months of non-surgical care centered on pain management and physical therapy has elapsed. It is rare, however, for there to be any lasting irreversible damage or other negative consequences due to delaying surgery for a degenerated lumbar disc, so the six-month guideline holds true for most people. This is not only because most patients do respond to non-operative care over time, but also because back surgery for lumbar degenerative disc disease are major procedures, with their attendant surgical risks and requirements for lengthy post-surgical rehabilitation.
By: Jack Zigler, MD
November 9, 2006
