Treatment of Degenerative Disc Disease and Degenerative Spondylolisthesis of the Lumbar Spine - Non Operative Treatment

A wide variety of non–operative treatments have been advocated for the treatment of low back pain 5, 7, 8, 11, 29, unfortunately the multiplicity of treatment methods implies the absence of a single superior treatment program. While nearly 80% of adults will experience back pain at some point in their lives, only 1–2% will undergo lumbar spine surgery. Thus the last majority will respond to non–operative treatment programs. Patient selection continues to be the major factor in determining a good outcome. Getting to know the patient well through a long period of non–operative treatment is critical to this selection process.

Exercise Program

There is controversy about the best exercise programs for persons with low back pain 7, 11 Flexion exercises, extension exercises, stretching programs, and aerobic 17 . conditioning all have been advocated by experts in the field. Many treatment programs prescribe a combination and although there is little agreement or specific programs, there is a consensus that exercise plays a major role in the treatment of mechanical low back pain. As evidence against the efficacy of passive treatment mounts, there has been a definite shift toward more active therapy, with involvement if the patient is in various exercise programs.

Aerobic exercise is usually prescribed for patients with mechanical low back pain with the goal of improving muscular endurance, neuromotor control, coordination, mechanical efficiency as well as strength of lower extremities and abdominal musculature. In addition aerobic exercise may result in weight loss and improve anxiety and depression. The type of exercise is relatively unimportant and walking, bicycling and swimming are commonly prescribed. High impact activities such as running should probably be avoided.

Stretching exercise programs are also commonly prescribed with the intention of improving flexibility of trunk muscles. Muscle mobility frequently becomes limited in low back pain patients in response to pain.

Flexion exercise programs such as the one popularized by Williams are also commonly prescribed in low back patients 7, 29. The rational is to widen the intervertebral foramina and facet joints thereby reducing nerve root compression. They also were designed to stretch hip flexors, back extensors, to strengthen abdominal and gluteal muscles. Some have suggested that strengthening abdominal muscles creates an internal corset reducing loads on the lumbar spine. A theoretical concern about certain flexion exercises is that they can increase intradermal pressure, which could aggravate a herniated intervertebral disc. Extension exercise programs popularized by McKenzie have become very popular in recent years 11. The program is individualized to the patient's symptoms and emphasizes centralizing radiating pain.

Acupuncture

Recent research suggests that acupuncture may act by principles of the ''gate'' theory, which hypothesized that a type of sensory input (back pain) could be inhibited in the CNS by another kind of input (acupuncture needling).

Acupuncture may also stimulate endorphin production, as well as acetylcholine and serotonin thereby enhancing analgesia. Certainly acupuncture alone is not warranted but in conjunction with an exercise program as a method of pain control it may be beneficial.

Druq Therapy

A variety of drugs are widely utilized in the treatment of degenerative disc disease. These include analgesics such as narcotics, acetaminophen, anti–inflammatory agents, muscle relaxants and anti–depressants. Narcotic analgesics are efficacious in the management of acute low back pain. They all should be time limited because of their potential for abuse with chronic use.

The clinical trials on non–steroidal anti–inflammatory drugs (NSAIDS) suggest that they are efficacious in the treatment of low back pain 8. The efficacy in the treatment of chronic low back pain remains unclear.

The use of muscle relaxants is predicated on the notion that acute low back pain is caused by muscle spasm. Their major effect is usually sedation with minimal effect on muscle relaxation.

Tricyclic anti–depressant medications are also widely used for chronic back pain syndromes for several reasons. First, depression may be a major factor in chronic low back pain. Second, these drugs may have significant analgesic properties. Lastly, these drugs are sedating and may improve sleep in low back pain patients.

Manipulation

The selection of patients who may respond to spinal manipulation therapy is difficult due to the poor understanding of the pathogenesis of low back pain. Manipulation has been shown to be effective during the first month of back pain without radiculopathy, 5, 8. Its efficacy is unproven after the first month of symptoms. Again, manipulative treatment alone is probably ineffective but in conjunction with an exercise program it may be useful.

The most reasonable explanation of the effectiveness of spinal manipulation in patients with lumbar disc disease relates to its effect on spinal mobility. Restricted intersegmental motion of the lumbar spine is more common in patients with low back pain than in asymptomatic individuals 8.

Conditions most likely to respond to manipulative treatment include acute low back pain and possibly, chronic low back pain, and degenerative disc disease as long as nerve root compression is not present.

Non–Effective Treatments

Prolonged bedpost, traction, TENS unit, corsets and braces, and biofeedback all have no scientific evidence for efficacy and probably have no place in the treatment of lumbar spinal disorders 5, 8, 10.