Lumbar Degenerative Disk Disease Treatment & Management

Updated: Aug 03, 2020
  • Author: Rajeev K Patel, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Treatment

Rehabilitation Program

Physical Therapy

Physical rehabilitation with active patient participation is a key approach to treatment of patients with diskogenic pain. Physical therapy programs prescribed specifically to address the primary site of injury and secondary sites of dysfunction can provide a means of treatment, with or without adjunct medications, therapeutic procedures, or surgical intervention.

Relative rest, which restricts all occupational and avocational activities, for up to the first 2 days after an acute episode, may be indicated to help calm initial pain. Rest for longer periods has not been shown to be beneficial and can cause deconditioning, loss of bone density, decreased intradiskal nutrition, loss of muscle strength and flexibility, and increased segmental stiffness. Passive modalities are valuable during the initial 48 hours of relative rest to aid in pain relief, but protracted courses of passive treatments become counterproductive, as they place patient in a dependent role instead of an active one.

Education is one of the most important components of any back-care program and should include an explanation of the natural history of acute, subacute, and chronic disk injury. The physical rehabilitation program should also include training in proper body mechanics and lumber ergonomics during various functional, occupational, and avocational activities. Manual techniques may be applied to increase soft tissue pliability when secondary myofascial tightness is present. If the aforementioned measures are appropriate and completed, an active, dynamic rehabilitation program to stabilize the lumbar spine may be started on an outpatient basis. In addition, rehabilitation of other associated components of the functional kinetic chain may be appropriate, as these structures may also be affected.

Dynamic lumbar-spine stabilization programs are aimed at maintaining a neutral spine position throughout various daily activities. An extension bias commonly is used to help reduce intradiskal pressure. This position allows for balanced segmental force distribution between the disk and zygapophyseal joints, it provides functional stability with axial loading to help minimize the chance for acute dynamic overload upon the disks, it minimizes tension on ligaments and fascia planes, and it decreases symptoms. Repetition is key to increasing flexibility, building endurance, and developing the required muscle motor engrams that subconsciously activate a series of key multimuscular contractions to maintain the lumbar spine in a neutral position throughout static and dynamic activities.

For athletes, the aforementioned program can be progressively combined with sport-specific plyometrics to help the lumbar spine maintain neutral position during high-intensity, unpredictable, reaction-intensive sports. Rehabilitation of athletes should also train them to maintain a neutral spine position in sport-specific motions. These component motions should then be grouped into a new, safe spine-stable movement. Cardiovascular training is an important adjunct to comprehensive rehabilitation programs because it provides endurance necessary to prevent fatigue of the muscles that stabilize the spine.

Occupational Therapy

Occupational therapy can be an important adjunct in the rehabilitation process when generalized muscular deconditioning has created adverse effects on strength, endurance, and flexibility of the upper extremities and/or impairment in activities of daily living (ADLs).

An occupational therapist often provides this portion of the rehabilitation program. Essential elements consist of ensuring proper ergonomics at the work site, which may involve simply reconfiguring a desktop and/or workstation, or it may require complex solutions. Another aspect involves rehabilitation before the patient resumes full-time duties. After the offending source of pain is resolved, the patient typically has deconditioning and may require activity-specific reconditioning to prevent new or recurring injury.

Recreational Therapy

Recreation therapy may have a role in assisting the patient to resume avocational activities, possibly with adaptations in technique or with the use of adaptive equipment.

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Medical Issues/Complications

Medical causes of LBP include the spondyloarthropathies (eg, enteric arthropathy, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis), Marfan syndrome, fibromyalgia, myofascial pain syndrome, diskitis, and neoplastic disease.

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Surgical Intervention

Available surgical approaches include anterior, posterior, and combined procedures; interbody fusion with allograft autologous bone or threaded titanium cage; and intertransverse process in situ fusion with or without instrumentation. The introduction of disk arthroplasty has been proposed as a possible surgical option in those patients who would like to maintain as much segmental motion as possible.

The rate of surgical treatment for LDDD in the United States more than doubled during the first decade of the 21st century, according to a study by Yoshihara and Yoneoka. Using Nationwide Inpatient Sample data from patients aged 18 years or older with lumbar/lumbosacral DDD, the investigators found that between 2000 and 2009, the population-adjusted incidence of LDDD surgery increased 2.4-fold. More specifically, the incidence of combined anterior and posterior lumbar fusion (APLF) rose three-fold, while that for posterior lumbar interbody fusion/posterolateral lumbar fusion (PLIF/PLF) increased 2.8-fold. In contrast, the incidence of total disk replacement (TDR) did not significantly rise. [35]

Of the more than 380,000 patients who underwent LDDD surgery between 2000 and 2009, according to the study, the majority (67.9%) were treated with PLIF/PLF, while 16.8% underwent anterior lumbar interbody fusion (ALIF), 13.6% were treated with APLF, and 1.8% underwent TDR. While TDR was more commonly performed in younger patients than in older ones, the opposite was true for PLIF/PLF. Regionally, it was found that LDDD surgery was more frequently performed in the Midwestern and Southern United States than it was in the Northeast. [35]

Effectiveness of surgery

To date, no prospective, randomized, blind study has demonstrated the superiority of any surgical approach or technique. One retrospective study was performed to compare posterolateral fusion with iliac-crest allografting and translaminar facet-screw augmentation, anterior interbody fusion with fibula allografting, posterolateral fusion with pedicle screw-rod fixation, and anterior interbody threaded cage fusion combined with facet-joint fusion and posterolateral fusion. The results suggested that the last procedure may provide superior outcomes.

Other investigators report outcome rates ranging from 39% to 82-93% for various procedures. With respect to disk arthroplasty, the literature is not clear on its definitive role, if any, in the treatment of symptomatic LDDD.

In a study of 59 patients suffering from low back pain and 1- or 2-level LDDD, Freudenberger et al compared the effectiveness of ALIF with anterior tension band plating (ALIF-ATB) with that of PLIF with pedicle screw instrumentation. [36] The investigators found that both techniques had similar fusion rates, but that patients who underwent PLIF had greater estimated blood loss and required more surgical time than did patients who were treated with ALIF-ATB.

Similarly, a study by Bozzio et al reported some advantages to ALIF in comparison with anteroposterior fusion and transforaminal lumbar interbody fusion (TLIF) performed in association with posterior fusion. The investigators cited a shorter surgical time in patients who underwent ALIF, as well as less blood loss and a decreased hospital stay. They also found that ALIF and anteroposterior fusion had better results than TLIF with regard to disk angle, disk height, and pelvic tilt. However, fusion rates did not differ between the three techniques. [37]

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Consultations

Consultation of the primary care physician with a nonsurgical spine specialist is appropriate for patients with symptoms lasting longer than 6 weeks secondary to LDDD. Consultation with a spinal surgeon may be appropriate for patients with intractable severe function-limiting symptoms secondary to IDD, at 1 or 2 contiguous levels, for those with symptoms lasting longer than 6 months who have had no relief from nonsurgical approaches, and for persons with abnormal neurologic findings.

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Other Treatment

Steroid injections

Initial reports of epidural injections almost a century ago described the instillation of cocaine into the epidural space to treat lumbago and sciatica. In the early 1900s, epidural injection of local anesthetic was used to treat intractable sciatica. In 1952, Robecchi and Capra reported success with the first epidural steroid instillation in treating lumbar and associated sciatic pain. [38] Instillation of steroid into the epidural space has become a common modality in treating lumbar and lower-extremity pain due to a suspected inflammatory etiology.

Patient characteristics that may suggest an unfavorable or suboptimal response to possible epidural steroid injection (ESI) are a long duration of symptoms, a nonradicular diagnosis, unemployment because of pain, smoking, increasing use of pain medication, increasing number of treatments for pain, pain not relieved by medication, and pain not increased by activity.

Optimal timing for the administration of epidural steroids has not been elucidated. Patients generally undergo conservative palliative measures (eg, NSAID therapy, lumbar-spine stabilization therapy) before they are considered for ESIs. However, do not delay epidural injections when conservative treatments do not seem to be helping. Delaying aggressive treatment may allow the ongoing inflammatory process to result in fibrosis and possibly permanent damage.

How often ESIs can be administered is unknown. Practitioners often wait as long as 2 weeks before reassessing the patient for a response to the injection and for possible reinjection. This practice became popular after Swerdlow and Sayle-Creer suggested that steroid injected into the epidural space may remain in situ for up to 2 weeks. [39]

In 1972, Winnie and colleagues emphasized the importance of placing medication as close to the site of pathology as possible to maximize the outcome. [40] They reported improvement in 80% of patients in whom steroids were injected at the site of pathology. The best route for injection of steroids into the epidural space in patients with a diskogenic source is transforaminal. This route allows the clinician to drive the injected steroid ventrally with approximately 5 mL of local anesthetic to bathe the suspected diskogenic inflammatory source. The efficacy of this approach has been demonstrated in various prospective studies in lumbar axial pain syndromes and in those associated with corroborative radicular pain.

Only 2 nonrandomized, retrospective studies have address the outcome of transforaminal ESIs on spinally mediated lumbar axial pain due to diskogenic pathology without imaging evidence of nerve-root involvement.

Rosenberg and colleagues reported greater than 50% pain reduction after 1 year in 59% of patients. [41]

Manchikanti and colleagues examined patients with spinally mediated lumbar axial pain treated with blind interlaminar ESI, fluoroscopically guided caudal injection, or fluoroscopically guided transforaminal injection. The authors reported superior short- and long-term pain relief with the transforaminal route. [42] This conclusion makes anatomic sense because transforaminal ESIs likely distribute the injectate more focally to the ventral epidural space than do the interlaminar and caudal routes. Therefore, is may be most target specific when one attempts to deliver medication to the focus of a posterior diskogenic inflammatory response.

The optimal route for injection of corticosteroids into the epidural space at the site of pathology in patients with diskogenic mediated lumbar axial pain syndromes with corroborative radicular involvement is the transforaminal route. This approach allows the clinician to deliver the injectate, composed of a betamethasone 6-12 mg and 1% lidocaine 0.5-1 mL. The goal is to precisely eradicate the known inflammatory response emanating from the potentially inflammagenic herniated nucleus pulposus (HNP) focally on the corroborative inflamed nerve root sleeve.

The efficacy of the aforementioned approach has been demonstrated in 4 randomized prospective, double-blind controlled clinical trials.

Riew and colleagues reported the results of fluoroscopically guided lumbar transforaminal injections in 55 patients with imaging evidence of nerve-root compression and corroborative radicular symptoms. [43] Twenty-eight patients received bupivacaine and betamethasone, and 27 received bupivacaine. At 13- to 26-month follow-up, 33.3% of patients in the bupivacaine group decided not to have surgery, compared with 71.4% of the bupivacaine-and-betamethasone group. The difference in surgical rates was statistically significant (P< .004). This study demonstrated the beneficial effect of precisely delivered corticosteroids in obviating operative treatment in patients with HNP and/or spinal stenosis.

Kraemer and colleagues reported long-term pain relief with transforaminal ESI. [44] In their study, 49 patients with lumbar radicular pain were randomly assigned to into a corticosteroid group and control group.

Karppinen and colleagues reported 160 consecutive patients with symptomatic herniated disks with no history of lumbar-spine surgery. [45] Patients were randomly selected for a corticosteroid group or a normal-saline group. Outcome measures obtained at 2 weeks, 3 months and 6 months included pain relief, sick leave, medical costs, findings on the Nottingham Health Profile, and future requirements for surgical intervention. Transforaminal ESI provided significant short- and long-term improvement in all of the outcome measures.

Thomas and colleagues reported the relative effectiveness of fluoroscopically guided lumbar transforaminal ESIs versus blind interlaminar ESIs in patients with radicular pain. [46] Transforaminal ESIs were superior a variety of outcome measures, including finger-to-floor lumbar flexion, daily activity (including work and vocational function), and Dallas pain scores. Findings from this direct comparison underscore the importance of fluoroscopic guidance and of delivering medication accurately and precisely to the site of a potential ongoing inflammatory response.

In a prospective nonblinded randomized study by Buttermann, transforaminal ESIs provided efficacy measured by reduced symptoms and disability and obviation of surgery at a follow-up of up to 3 years. Patients had large (>25% of the cross-sectional area of the spinal canal) symptomatic lumbar herniated disks. Buttermann also reported that patients who had short-term improvement or ineffectiveness of transforaminal ESIs and who require surgical diskectomy had no adverse effect in the outcome of that surgery, due to the temporal delay caused by the trial of transforaminal ESIs. [47]

Findings from several prospective nonrandomized clinical trials of the efficacy of transforaminal ESI strongly suggest the beneficial effects of transforaminal ESIs for HNP that causes lumbar axial pain with corroborative radicular pain.

Weiner and colleagues reported that 21 of 28 patients with a CT-documented HNP and corroborative lower-extremity pain had moderate or complete pain relief after receiving a single transforaminal infusion of betamethasone and 1% Xylocaine; patients did not require surgery at an average of 3.4 years during follow-up. [48]

Lutz and colleagues reported 69 patients, with an average of 22 weeks of symptoms, who had MRI evidence of a HNP and radicular pain. [49] Patients underwent an average of 1.8 transforaminal injections of betamethasone and 1% Xylocaine followed by a 6- 12-week course of lumbar-spine stabilization therapy. At an average of 80 weeks of follow-up, 75% of patients had a success outcome (defined as pain reduction by 50% or more and return to previous or near-previous level of function).

In a retrospective evaluation, Wang and colleagues demonstrated significant short- and long-term symptomatic improvement and the avoidance of diskectomy in 77% of patients with lumbar disk herniations who were treated with 1-6 transforaminal ESIs. [50]

The literature discussed above strongly suggests that transforaminal ESI should be the standard of care for index interventional spinal procedure in patients with spinally mediated lumbar axial pain syndromes associated with radicular involvement due to diskogenic disease and/or HNP when more conservative measures fail. Furthermore, in most cases of HNP, the known phagocytic immunologic response and consequent benign anatomic natural history contributes to the relatively high long-term success rates of transforaminal ESIs.

Contraindications to steroid instillations in the epidural space are pregnancy (because of the adverse effects of fluoroscopy on the fetus), hypersensitivity to any component of the injected steroid, bacteremia, full anticoagulation, and bleeding diathesis. Other concerns are elevation of serum glucose levels in patients with diabetes, elevation of blood pressure in hypertensive patients, and fluid retention in patients with congestive heart failure. Use of aspirin and other NSAIDs has not been demonstrated to predispose patients to clinically significant bleeding when they are receiving epidural injections.

Other therapies

New intradiskal techniques are being investigated to ascertain whether they can obviate fusion procedures. With intradiskal electrothermal therapy, a navigable intradiskal catheter is used to heat the posterior annular wall at the nuclear interface corresponding to the 4- to 8-o'clock zone. [51, 52] Temperatures produced in the outer annulus (46-48°C) are sufficient for thermal coagulation of nervous tissue. Temperatures in the nucleus and the annulus (65-75°C) are sufficient for collagen contraction or shrinkage.

Saal and colleagues observed 20% focal nuclear shrinkage (by volume) and 7% total nuclear shrinkage after treatment. [53] Therefore, some authorities postulate that this intervention may cause thermocoagulation of annular nerve fibers. In addition, by means of collagen shrinkage, it may also result in tightening of the fibrous structure of annular tissue that then may enhance structural integrity of a degenerated or damaged disk and possibly stabilize annular fissures. Intradiskal electrothermal therapy showed great promise in initial studies and was touted as being effective at controlling diskogenic axial lumbar back pain. However, a later investigation, a double-blinded, controlled study conducted by Freeman and colleagues, established safety with limited efficacy. [54]

  • Saal and Saal reported their results in 36 patients who were followed up for 6-13 months. [53] Improvement in function, lowering of pain scores, and improvement in sitting tolerance times were observed in 75%.

  • In a clinical trial of 20 patients, Derby reported a mean 2-point decrease on a 10-point visual analog scale (P< .05) at 6 months. [55] In addition, 73% reported satisfaction with outcome and indicated that they would repeat the procedure for the same outcome. Although early results are promising with this exciting novel technique, no definitive judgments can be made because only preliminary outcomes with short-term follow-up have been reported to date.

  • The idea of intradiskal injections and procedures is becoming exciting with new trials of OB1 and other biological therapies being developed in the hopes of being able to regenerate diskal materials and reverse the degenerative cascade underway.

  • Since their discovery by Marshall Urist, MD at UCLA, bone morphogenetic proteins have been categorized as either growth or differentiation factors and consist of a family of proteins with important regulatory and developmental effects on bone growth and the development of musculoskeletal tissue. These proteins are clinically used by spine surgeons to facilitate bony fusion and obviate the need for autografting.

    • Studies have shown that these proteins are capable of controlling the mRNA transcription of cells within human and animal disk models. At the 2002 North American Spine Society (NASS) annual meeting, studies were presented that showed great promise with regard to the development of treatments for degenerative disk disease using bone morphogenic proteins 2 and 7, with augmentation of diseased disks employed at an early stage to offset the degenerative cascade. [56, 57]

    • Miyamoto and colleagues showed restoration of disk viscoelastic properties in a rabbit model of degenerative disk disease after injection of osteogenic protein 1 (OP-1). It is hoped that disk regenerative therapy using intradiskal injections of biological pharmaceuticals will become an effective treatment for degenerative disk disease. [58]

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