Primary management for DDD is non-operative and includes nonsteroidal anti-inflammatory medications (NSAIDs) and exercise programs to strengthen abdominal and spinal musculature, improve aerobic fitness, and reduce lumbar lordosis (swayback).
Surgical intervention is an option when nonoperative medical management fails to adequately relieve the intolerable pain during activities of daily living which is individual-specific. It should also be considered in patients with initial signs and symptoms of progressive neurologic deterioration, specifically numbness or muscle weakness.
Classical surgical treatment for DDD which has failed nonoperative management is a spine fusion. However, advances in disc replacement technologies have made this technique a viable option for many individuals. Early investigations have demonstrated lumbar disc replacements have had outcomes equivalent to spine fusion. Not all individuals with DDD are good candidates for disc replacement surgery. concomitant spinal deformity (scoliosis, kyphosis), history of spinal infection, posterior spinal arthritis, and multilevel disc disease are relative or absolute contraindications.
For those individuals who are not candidates for lumbar disc replacement, lumbar spine fusions have had good short-term and long-term outcomes. Fusion involve creating a solid bony connection between two or more vertebrae anteriorly, posteriorly, or both.
In a spine fusion procedure, the surgeon joins two or more adjacent vertebrae. Bone taken from other parts of the body, usually the pelvis just above the hip joint, is placed across the vertebrae. Plugs of bone shaped like hockey pucks or cages made of metal or plastic are used between the vertebrae anteriorly. Posteriorly the bone is ground up into small pieces and laid down over the spine. The vertebrae and bone graft grow together as healing progresses, eventually forming a single unit without motion across them.
If the spine is in overall good position, spinal implants may not be necessary. So while not all spinal fusions require implants, many patients whose spines are weakened by injury or disease or whose deformities must be corrected are treated with internal fixation or spinal implants. If the spine needs to be placed and maintained in a new position, spinal implants will typically be necessary. The implants can include rods, screws, and hooks to fixate and stabilize the spine. Various types of implants are used depending on the problem that required the fusion, the patient's age, and the surgeon’s judgment. These implants are usually left implanted indefinitely to minimize the possible loss of spinal alignment. The development of a spine fusion may take up to one year during which time physical activity may be limited and a spine brace may be recommended.
Fusion surgery is inherently more complicated, more painful, and riskier than procedures such as discectomy and laminectomy. There is no consensus in the medical community as to the appropriate indications for fusion surgery.