Physiotherapy as effective as surgery for degenerative disc disease

Research shows that patients with low back pain due to degenerative disc disease do as well with physiotherapy as with spinal fusion surgery.

Chronic low back pain is a very common and debilitating condition that results in enormous health-related expenditures.  In some cases chronic low back pain is believed to stem from degenerative disc disease, a chronic and painful condition arising from the gradual breakdown of intervertebral discs in the spine.  Disc degeneration typically accompanies the process of aging, and most people with signs of disc degeneration have no associated symptoms or disabilities. However, symptomatic individuals may experience chronic pain and a significant decrease in quality of life.

Physiotherapy treatment for degenerative disc disease

Standard “conservative” treatment for suspected degenerative disc disease relies on physiotherapy, but may also include anti-inflammatory medications, and in more severe cases, epidural injections.  Physiotherapy can help relieve pain and increase movement and flexibility through exercise therapy, manual therapy to improve joint flexibility and muscle stiffness, posture and movement education, and pain relieving treatments such as traction and electrical stimulation.  Exercise therapy is a key component of physical rehabilitation (ref1).  Exercise therapy should incorporate stretching exercises to promote optimal spinal and hip joint mobility, as well as address tight musculature in the back, buttock and hip regions.  Strengthening exercises should also be incorporated to help support disc joints and decrease load thereby relieving pain.   Further to physiotherapist-directed exercise therapy, healthy eating and aerobic exercise can also help by decreasing body weight and therefore spinal load.  Non-surgical treatment for degenerative disc disease can be very effective, and is likely the best course of treatment for the majority of patients (ref2).

Surgical treatment for degenerative disc disease

If conservative treatment options fail to provide adequate relief, in some cases patients may opt for surgical treatment.  For degenerative disc disease resulting in low back pain, lumbar fusion surgery can be performed.  This surgery involves removing the affected disc(s) and replacing it with a bone graft that will subsequently grow and effectively fuse together the corresponding vertebrae.  Disc replacement surgery is another option gaining popularity, and its effectiveness in the short term may be at least equivalent to spinal fusion procedures (ref3).  Surgery is not without risks and side effects, and its effectiveness for treating the symptoms of degenerative disc disease is variable (ref2).
Spinal surgery should only be considered as a last resort option.

Surgery vs. physiotherapy – which works better?

There is a large and growing body of clinical research centered on the role, methods and effectiveness of spinal surgeries to treat degenerative disc disease.  It is not currently clear whether non-operative treatments alone should be used, or if surgery is any more effective (ref4).  A recent retrospective study examined the effectiveness of lumbar fusion surgery versus physiotherapy for treating low back degenerative disc disease in patients with a confirmed diagnosis by discography.

The study examined a group of patients with degenerative disc disease who elected for fusion surgery, to a group of their peers who elected instead to receive non-operative treatment (physiotherapy) (ref4).  The authors hypothesized that the group that received surgery would show significant improvements over the group that received non-operative treatment.  They were wrong.  While the mean pain score was found to be significantly improved in both the fusion surgery and physiotherapy groups, the authors found no significant difference between these two treatments with regard to pain scores, disability, health status, or patient satisfaction.  These results concur with 3 of the 4 prior studies that compare spinal fusion to physiotherapy for chronic low back pain, although these prior studies suffered from methodological flaws (ref5).  Unfortunately, given the design of the current study, the authors were unable to determine if there were any differences in how fast patients in the two groups got better.  Larger sample sizes and stronger study designs are needed to confirm and expand upon these findings.

Summary

Normally only a minority of patients with chronic low back pain arising from degenerative disc disease undergo surgery.  Although clinical data suggests that patients who opt for surgery obtain good outcomes, they may in fact fair no better than their peers who opt instead for conservative treatment involving physiotherapy.  Surgery should therefore be reserved as a viable alternative for the minority of patients who do not see adequate improvements after a concerted effort using conservative therapy involving physiotherapy, and after addressing any contributing psychosocial factors.  Current clinical evidence supports a concerted “physiotherapy-first” strategy for treating degenerative disc disease and low back pain.

References

1. Hayden J.A., van Tulder M.W., et al.  Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005 Jul 20;(3).
2. Karppinen J., Shen F.H., et al. Management of degenerative disk disease and chronic low back pain. Orthop Clin North Am. 2011 Oct;42(4):513-28.
3. Jacobs W.C., van der Gaag N.A., et al. Total disc replacement for chronic discogenic low back pain: a Cochrane review. Spine (Phila Pa 1976). 2013 Jan 1;38(1)24-36.
4. Smith J.S., Sidhu G., et al. Operative and nonoperative treatment approaches for lumbar degenerative disc disease have similar long-term clinical outcomes among patients with positive discography. World Neurosurg. 2013 Sept 15 (Epub ahead of print).
5. Techy F. and Benzel E.C. Editorial Statement “Perspectives” on the article: “Operative and nonoperative treatment approaches for lumbar degenerative disc disease have similar long-term clinical outcomes among patients with positive discography”. World Neurosurg. 2013 Oct 27 (Epub ahead of print).