True Disc Problems Respond Best to Surgery
When it comes to treating chronic low back pain, there still remains quite a bit of debate and controversy. That's because it can be very difficult to tell what is the problem and where the pain is coming from.

Even when studying the same problem (e.g., low back pain from disc disease), researchers often come up with conflicting results. For example, some will show conservative care is effective when dealing with degenerative disc disease. Others conclude surgery gives better results.

In order to narrow the playing field, this group of researchers from Chiba University in Japan studied a very select group of patients with painful disc disease. Each one had confirmed disc disease at one lumbar level (either L45 or L5S1). No one had leg pain -- just low back pain.

No one involved in a worker's compensation claim was included. Likewise, anyone who had previous back or spine surgery was not allowed to participate either. The presence of any other spine problems also excluded some people.

The goal was to get patients with disc degeneration and only disc degeneration and at only one lumbar level. It's easier to tell if treatment is effective if everyone has the same exact problem.

The diagnosis was made using MRIs, pain provocation on discography, and pain relief by discoblock. You are probably familiar with MRIs (magnetic resonance imaging) as a diagnostic tool. MRIs use radio and magnetic waves to show details of internal structures like discs and ligaments. Discography and discoblock may be more unfamiliar terms.

Discography is the use of a radioactive dye injected directly into the disc. The patient's response to the injection is telling. An increase in or reproduction of their pain suggests the pain is coming from the disc. CT scans of the area also show areas where the dye has gone where it shouldn't indicating tears, fissures, holes, or other damage to the disc and/or its outer covering.

Discography isn't always reliable and even if it's positive, that's not a sure sign that the patient will develop back pain or experience chronic problems because of the damaged disc. That's why discoblock was developed.

With discoblock, an injection of a numbing agent like bupivacaine (similar to novacaine) is used. Immediate pain relief signals the disc is the problem. The test is accurate and reliable.

The surgeon uses a special real-time X-ray called fluoroscopy to make sure the injection gets to the exact right place (inside the disc). Studies show that patients who have a discoblock and then go on to have disc surgery have improved results from the operation when compared to patients who had a discography instead.

All that was just to diagnose the problem as accurately as possible. Now for the treatment. There were three groups. Two groups had surgery (two different approaches to spinal fusion) and the third group received minimal treatment (conservative care, a nonoperative approach).

The conservative approach was daily walking and stretching prescribed and supervised by a physical therapist. The program was carried out everyday for two years. Patients had to report monthly to their physicians. If they did not do the exercise program, they were not included in the study.

In order to measure the results, the authors assessed pain levels, function, and disability before and after therapy. Patients were followed for two years before the final "after" results were measured.

They found that the patients in the surgical groups had better overall results compared with the exercise group. The results were actually reported as significantly better for surgery.

When comparing the two types of fusion procedures used, the patients who had an anterior (from the front of the spine) approach had significantly better results than those who had a posteriolateral (from the back and side) fusion.

The anterior interbody fusion (ABF) procedure involved removing the disc and placing bone taken from the patient's pelvic bone and using that to fuse the bones together. No hardware was used in this procedure.

The posterolateral approach was used when MRIs showed important blood vessels were too close together and couldn't be avoided using an anterior approach. Screws and bone graft were used in the posterolateral fusion procedure.

Patients expressed their overall satisfaction with the treatment they received using a four-point scale: 1) treatment met expectations, 2) not as much improvement as expected, 3) treatment helped but not enough to do it over, and 4) same or worse than before treatment. More patients in the exercise group rated their results as poor (worse than before treatment). Patients in both surgical groups gave their results a fair-to-good rating.

The results of this study show that when patients truly have a degenerative disc as the main reason for their pain (carefully verified with testing), surgery yields better results than nonoperative care. The preferred fusion technique is an anterior approach. But when there is sufficient reason to use a different method, then a posterolateral approach offers good results as well.
Seiji Ohtori, MD, PhD, et al. Surgical Versus Nonsurgical Treatment of Selected Patients with Discogenic Low Back Pain. In Spine. March 1, 2011. Vol. 36. No. 5. Pp. 347-354.