Treatment of Degenerative Disc Disease and Degenerative Spondylolisthesis of the Lumbar Spine - Low Back Pain

At the onset of treatment it is important to explain to the patient the excellent prognosis for returning to work and normal activities. They need reassurance that most back problems are not disabling. They should be told that mild pain with activity is not a problem and does not necessitate activity restrictions. There is also strong evidence that a fitness program, which includes cessation of smoking, and weight reduction, reduces the frequency and severity of episodes of low back pain. Patient compliance may be an important problem also. Lifestyle modification is very difficult for many patients. Written instructions and regular follow–up visits may enhance patient compliance.

Treatment Program For Acute Low Back Pain < 6 Weeks:

A 1 –2 day period of bedpost for patients with severe acute low back pain usually provides some symptomatic relief . If pain is less severe then less activity restriction is recommended. If a disc herniation is present then a slightly longer period of bedpost should be considered. The use of non–steroidal anti–inflammatory medication is appropriate. A muscle relaxant also could be considered for up to a week in patients with muscle spasm but should be time limited.

Early ambulation should be considered even if a disc herniation is present. This helps to limit musculoskeletal reconditioning and loads on the disc with walking are only slightly greater than when lying down.

After the acute symptoms have subsided (2–3 weeks) back and aerobic exercises can usually be started. A combination of stretching, flexion and extension exercise program along with aerobic exercises should be utilized. The choice of aerobic exercises used is probably not important as long as excessive torsion and flexion forces are not utilized in the program. Back exercises should be done daily and the aerobic program 30 minutes to 1 hour, three times a week maximum to result in cardiovascular conditioning. In patients whose pain persists more than three weeks and do not have a disc herniation, spinal manipulation could be considered.

Sub–Acute Back Pain (6 Wks – 3 Mos):

This group of patients is probably the most critical treatment group. They have already demonstrated a problematic clinical course but have not yet become chronic pain patients. Aggressive non–operative treatment in this group may prevent chronic pain syndromes whose management is often palliative.

The use of non–steroidal anti–inflammatory agents (NSAIDS) should be considered. There is no place for the use of muscle relaxants or narcotics in this group. A back exercise program consisting of stretching, flexion and extension should be instituted if it hasn't already been done. Certainly an aerobic program should also be started if it hasn't already been in place. At this phase referral to a physical therapist or a structured work conditioning program should be considered to provide better supervision and better treatment adherence. If a highly individualized exercise program (McKenzie) is to be used this is the group of patients for whom it is appropriate.

Chronic Back Pain ( > 3 Months):

If these patients haven't yet been through a structured, supervised work conditioning program this is the time to institute such a program. In patients with degenerative disc disease with persistent mechanical low back pain this is the time to consider further diagnostic work–up in consideration for surgical treatment if they have not responded to an aggressive non–operative program. These studies should include imaging studies (CT–Myelogram, MRI), and possibly discography and diagnostic injections when deemed appropriate

For patients who do not meet the appropriate surgical criteria for one reason or another it is reasonable to institute a trial of tricycles anti–depressants therapy especially in patients with clinical evidence of depression. A more strenuous supervised exercise program should be instituted. The major goal of structured pain treatment programs is the resumption if functioning with pain relief as a secondary goal, which often parallels functional restorations.