Progressive Back Pain in a 26-Year-old Male
The patient is a 26-year-old male with progressive back pain. Five-years ago, he underwent discectomy for radicular leg pain but now has persistent non-radiating low back pain.
On physical exam, he has normal strength and sensation. He has limited range of motion of the lumbar spine due to pain. He has minimal paraspinous tenderness.
The sagittal MRI shows disc space narrowing of L5-S1 with dark signal in the disc. (Figure 1) There is no spondylolisthesis noted and minimal facet disease. The MRI shows minimal neurological compression.
Discography demonstrates a degenerative pattern at the L5-S1 with concordant pain and concordant pain and normal controls at the L3-L4 and L4-L5 levels. (Figures 2, 3)
Degenerative disc disease with mechanical back pain at L5-S1.
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This patient failed conservative nonsurgical treatment consisting of physical therapy, anti-inflammatory medications, and an exercise program. The patient underwent facet injections with no effect. The patient maintained this program for 8-months without improvement. The patient was offered surgical intervention and the different options were presented including primary fusion or disc arthroplasty. The patient decided to undergo surgical intervention with a lumbar disc arthroplasty.
The postoperative radiographs demonstrate the placement of a disc arthroplasty in the L5-S1 disc space. (Figures 4, 5)
The patient had excellent relief from his back pain. He is now 1-year from surgery and has resumed normal activities.
This case illustrates the prevalent condition of discogenic low back pain, particularly in a patient who had undergone discectomy for radiculopathy in the past. The majority of patients with disc degeneration and mild to moderate low back pain improve with time and can be successfully treated without surgery. Some patients have severe low back pain despite conservative treatment and invasive procedures, and surgery may be considered.
The first option of no surgery should be seriously considered. There is conflicting evidence in the literature about the benefit of spinal fusion in patients with discogenic low back pain. A study by Fritzell and associates showed that lumbar fusion, in a well-informed and selected group of patients with severe low back pain, can diminish pain and decrease disability rather than commonly used nonsurgical treatment for back pain. (1) This study showed the improvement rate was only 63% (122 of 195 patients) in the surgical group compared with 29% (18 of 62 patients) in the nonsurgical group. The disability, according to Oswestry, was reduced by only 25% (47 to 36) compared with 6% (48 to 46) among nonsurgical patients.
On the other hand, Brox and associates showed the main outcome was equal between nonoperative treatment with cognitive intervention and exercises and lumbar fusion. (2) In this study, the Oswestry Disability Index was significantly reduced in both surgical (41 to 26) and nonsurgical (42 to 30) groups. The success rate was 70% after surgery and 76% after cognitive intervention and exercises.
Fairbank and associates also found no clear evidence that spinal fusion surgery was any more beneficial than intensive rehabilitation. (3) The mean Oswestry Disability Index changed favorably from 46.5 to 34.0 in the surgery group and 44.8 to 36.1 in the rehabilitation group after 2-years.
Based on these level-one studies published in the literature, spinal fusion for chronic low back pain should be cautiously considered and only as a last resort. Thorough discussion with the patient and informed consent on realistic outcome expectation(s) is advised.
Once a patient is deemed a good candidate for surgery, a myriad of surgical options exist today. For fusion alone, the author of this paper gives 4 choices. Even though there is much debate about the best way to fuse the motion segment, there is no clear evidence cited in the literature that benefits of one over another fusion technique. In fact, Fritzell and associates analyzed 3 different fusion techniques from the cohorts of the multi-center randomized controlled trial. There was no obvious disadvantage in using the least demanding surgical technique of posterolateral fusion without internal fixation compared to posterolateral fusion combined with pedicle screws or posterolateral fusion combined with interbody fusion and pedicle screws. (4) All the fusion techniques used in the study equally reduced pain and improved function in this selected group of patients with severe chronic low back pain.
There are even more fusion techniques today, including minimally invasive techniques with or without BMP (bone morphogenetic protein), bone graft substitutes, or extenders. It is clear that whatever technique the surgeon chooses, he should be well-trained and familiar with the technique, have a high fusion rate, and be mindful of the procedure's cost-benefit ratio. Today, I personally would recommend stand-alone ALIF with cage-screw stabilization and BMP in this patient.
Lumbar arthroplasty was obviously a good choice in this patient with a good outcome so far. Careful and appropriate patient selection is mandatory for any procedure, particularly for lumbar arthroplasty. Disc space narrowing should be present, but not completely collapsed, and the facet joints should be "healthy." If there is too much disc space collapse, motion is restricted and facet joints are secondarily affected, and fusion is a better choice. The L5-S1 joint is anatomically stable with less motion and therefore, lumbar arthroplasty is better at L4-L5 in terms of preserving motion. However, the L4-L5 disc is more difficult to approach anteriorly and implanting in the perfect midline position is relatively more difficult at L4-L5.
This patient is doing well at short-term follow-up, but long-term follow-up studies will reveal the outcome compared to fusion and reveal the durability of the implant and facet joints. Another consideration is the activity level of the patient following fusion versus artificial disc. There is usually no problem for the patient to engage in heavy duty or sport activities following one-level fusion, but activity modification might be needed following arthroplasty.
The last treatment option choice is "other." One option is IDET (Intradiscal Electrothermal Therapy). This procedure is FDA-approved and has been available for use to treat discogenic low back pain for several years. Pauza and associates have shown that IDET appears to provide pain relief in carefully selected discogenic low back pain patients. (5) Freeman and associates found no significant benefit of IDET compared to placebo. (6) In my view, IDET could be tried as a minimally invasive treatment option prior to performing surgery; many patients will improve to avoid spinal fusion or disc arthroplasty. (7) The intervertebral disc should be degenerated without herniation or stenosis and disc space narrowing should be no greater than 50%. It might be potentially more beneficial in patients with multi-level involvement, as spinal fusion or disc arthroplasty is less appealing in these patients. There are many other emerging technologies, such as dynamic stabilization devices, biological therapy, etc. that might give a more predictable outcome with minimal morbidity to the patient in the future.
1. Fritzell P, Hagg O, Wessberg P, Nordwall A. 2001 Volvo Award Winner in Clinical Studies: Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 26: 2521-32; 2001.
2. Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, Ingebrigtsen T, Eriksen HR, Holm I, Koller AK, Riise R, Reikeras O. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 28: 1913-21, 2003.
3. Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 330: 1233, 2005.
4. Fritzell P, Hagg O, Wessberg P, Nordwall A. Chronic low back pain and fusion: a comparison of three surgical techniques: a prospective multicenter randomized study from the Swedish lumbar spine study group. Spine 27: 1131-41, 2002.
5. Pauza K J, Howell S, Dreyfuss P, Peloza JH, Dawson K, Bogduk N. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain. Spine J 4:27-35, 2004.
6. Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine 30: 2369-77, 2005.
7. Biyani A, Andersson GB, Chaudhary H, An HS. Intradiscal electrothermal therapy: a treatment option in patients with internal disc disruption. Spine 28:S8-14, 2007.