Low Back Degenerative Disc Disease (DDD)

Degenerative disc disease, or DDD, indicates that the intervertebral disc has undergone degenerative, wear-and-tear (arthritic) changes, which may or may not lead to significant spinal problems. These degenerative changes may occur alone or in combination with other lumbar disorders such as a herniated disc. Chronic lower back (lumbar) pain is not only a result of DDD. Some patients develop severe back pain due solely to degenerative disc disease, but most who experience severe symptoms also have some other spinal disorder. 

How is it diagnosed?

Factors involved in diagnosis include moderate or severe disc height loss. This is diagnosed by X-ray or MRI. The doctor then evaluates the location and quality of the back pain to determine if the degenerated disc is actually generating the patient’s pain. Based on the findings, the doctor will recommend a treatment option.

What are the treatment options?

1. Medications

Neck and back problems are the second most common reason patients seek medical attention. Fortunately, the vast majority of patients recover with or without medical treatment. However, patients who develop acute, sudden neck or back pain may suffer significantly until it resolves, which may be days or even weeks. Chronic spinal conditions may take months or years to settle down on their own. Therefore, most physicians recommend the use of medications to help relieve spinal pain and speed up the recovery process.

Specific oral (taken by mouth) medications listed below generally allow patients with spinal pain to improve, and improve more rapidly, as well as reduce inflammation and the likelihood of a recurrence of symptoms.

Medications often prescribed include:

• Anti-inflammatories (NSAIDS)
• Acetaminophen
• Muscle relaxants
• Narcotics
• Corticosteroids
• Anticonvulsants

Anti-inflammatories (NSAIDS)

Because spinal disorders often generate pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed pain-relief medications for mechanical neck and back pain worldwide and are very effective. NSAIDs include ibuprofen and naproxen and are available over-the-counter without a physician prescription. Stronger NSAIDs such as ketorolac or indomethacin are also available by prescription. NSAID medications work by reducing the inflammation and swelling, which typically reduces the pain as well. NSAIDS should not be used by patients with severe kidney disease.

Acetaminophen

Acetaminophen (Tylenol) is a common, over-the-counter medicine that favorably decreases pain in many patients with spinal pain. Acetaminophen should not be used by patients with severe liver dysfunction.

Muscle relaxants

Muscle relaxants are another category of medicine, which are routinely prescribed for spinal disorders. These medications work by decreasing the muscle spasms, which can be promoting the pain and inflammation.

Narcotic (opioids) 

These are controlled, prescription medications that are used specifically for pain. Narcotic medications, such as Tylenol with codeine or Tylenol with oxycodone, are mainstays for the short-term treatment of severe neck or back pain but should be used sparingly for patients with chronic spinal pain.

Corticosteroids

Corticosteroids such as methylprednisolone or prednisone are appropriate for patients with significant radicular nerve pain, such as sciatica from a disc herniation. However, patients with diabetes should be carefully followed because steroid medicines can disturb sugar metabolism.

Anticonvulsants 

This type of medication, which can stabilize nerve membranes and decrease nerve inflammation, are frequently effective for patients with significant nerve pain unrelieved with other medicines or treatments

2. Physical Therapy

Physical therapy can aid in achieving and maintaining optimal health of a patient’s spine and alleviating pain. Overall, the goal of physical therapy is to identify and teach patients efficient management strategies to improve spine-related problems with an emphasis on decreasing current pain symptoms, improving strength and function, and minimizing recurrence of symptoms. Physical therapy, with or without other conservative treatments, can often cure spinal pain, as evidenced by the fact that fewer than one percent of patients with neck or back problems ultimately go on to have a spinal surgery.

The USC physical therapy group provides top-level conservative treatment with a primary focus on spinal stabilization to improve the strength, endurance, balance and control of abdominal, trunk and back muscle groups. Patients are issued a program booklet and personally instructed by the therapist on strengthening exercises. As patients strengthen their core and back muscles and improve their flexibility, more of the joint-loading forces of the spine are stabilized by the muscles. There is less strain on the injured disc and ligaments, which generally leads to less inflammation and pain.

3. Surgical Procedures

Anterior Lumbar Corpectomy and Fusion Surgery 

What is it?

Anterior Lumbar Corpectomy and Fusion is a special type of spinal decompression and fusion surgical procedure that removes bone and tissue around the vertebrae causing compression of the spinal cord and nerves. However, it generally involves removing nearly the entire vertebral body and disc, which must be replaced with a piece of bone graft and fused together to maintain stability. A small metal plate with screws may also be used to add additional stability.

Who should have it?

This type of surgery is most often performed for patients with a spinal fracture, tumor or infection that is causing compression of the spinal nerves.

Why should I consider it?

This minimally invasive treatment carries less risk of nerve injury and better chance of improvement than does posterior corpectomy. The procedure is performed through an incision in the side of the body (anterolateral) through the abdomen rather than through an incision in the back (posterior). This allows the bone, disc and lesion to be easily accessed and removed without retraction of the spinal cord and nerve structures.

The treatment can also be performed in the chest region (thoracic) or lower chest/mid-back region (thoracolumbar).

Patients with a severe spinal problem or instability may also require a posterior spinal fusion with metal instrumentation in addition to the anterior corpectomy and fusion. If necessary, the second surgery is typically performed in a staged fashion one to four days after the first anterior surgery. 

Post-Operative Care

• In-patient physical and occupational therapy during the first four to seven days after surgery. If posterior spinal surgery is also performed, patients will typically stay approximately six to 10 days in the hospital
• No bending at the waist, lifting (more than five pounds) and twisting in the first two to four weeks after surgery to avoid a strain injury
• Gradual bending, twisting and lifting after four to six weeks as the pain subsides and back muscles get stronger
• If necessary, use of a small, soft or rigid lumbar corset to provide additional neck or back support after surgery

Anterior Lumbar Interbody Fusion (ALIF) Surgery

What is it?

Anterior Lumbar Interbody Fusion (ALIF) is a type of spinal fusion surgery that enters through the front (anterior) abdominal region to fuse the lumbar spine bones together. Interbody fusion means the intervertebral disc is removed and replaced with a bone (or metal) spacer. This technique is often favored when multiple spinal levels are being fused and multiple discs need to be removed, but is also ideal when only one spinal level is fused and posterior decompression surgery and/or instrumentation (use of metal screws/rods) is not also required. ALIF offers a decreased risk of nerve damage.

Who should have it?

ALIF is commonly performed for a variety of painful spinal conditions involving pinched nerves, such as a dislocated vertebrae (spondylolisthesis) and degenerative disc disease, among others.

Post-Operative Care

• In-patient physical and occupational therapy during the first three to four days after surgery. If posterior spinal surgery is also performed, patients will typically stay approximately four to seven days in the hospital.
• No bending at the waist, lifting (more than five pounds) and twisting in the first two to four weeks after surgery to avoid a strain injury
• Gradual bending, twisting and lifting after four to six weeks as the pain subsides and back muscles get stronger
• If necessary, use of a small, soft or rigid lumbar corset to provide additional lower back support in the first two weeks after surgery

Posterior Lumbar Fusion (PLF)

What is it?

Posterior Lumbar Fusion (PLF) describes the technique of surgically mending two (or more) lumbar spine bones together along the sides of the bone. A bone graft is placed alongside the spine bones — not in between the disc spaces, which is called an inter body fusion — and ultimately fuses them together. PLF may be performed in conjunction with or without a posterior decompression and/or the use of metal screws/rods. Typically, metal screws and rods are placed so as to give immediate stability while the bone mends and to increase the possibility of successful bone fusion.

Who should have it?

PLF is commonly performed for a variety of spinal conditions, such as spondylolisthesis, spinal fractures, tumors, infections, and curvature of the spine (scoliosis or kyphosis), among others. 

Post-Operative Care

• In-patient physical and occupational therapy during the first two to five days after surgery
• No bending at the waist, lifting (more than five pounds) and twisting in the first two to four weeks after surgery to avoid a strain injury
• Gradual bending, twisting and lifting after four to six weeks as the pain subsides and back muscles get stronger
• If necessary, use of a small, soft or rigid lumbar corset to provide additional lower back support in the first two weeks after surgery
• Use of a custom molded thoracolumbar (upper and lower back) brace for patients undergoing multilevel fusion surgery for curvature of the spine, spinal infections or tumors