The two major forms of surgery for chronic discogenic lower back pain are lumbar spinal fusion and disc replacement. Surgery may be the only option when nonoperative and minimally invasive treatments have failed to produce adequate relief.

Lumbar spinal fusion involves full discectomy (removal of the affected disc) and fusion of the 2 neighboring vertebrae into a single non-moving unit. This can be done by making an incision in the abdomen (anterior lumbar interbody fusion) or in the back (posterior fusion). S pinal fusion is thought to eliminate the source of pain by removing the bad disc. Things to consider before choosing lumbar fusion include:

• The procedure involves lengthy incisions, which may be painful in and of themselves and take considerable time to heal.
• Recently, less invasive techniques for lumbar fusion have been introduced, such as laparoscopic anterior lumbar interbody fusion. However, operating times for these procedures are much longer, and the rate of sexual dysfunction in men may be much higher with this technique.
• Conventional open surgery lets surgeons see discs and vertebrae more clearly than newer, less invasive fusion techniques.

Another surgical option for a severely damaged disc is to replace it with a synthetic (or man-made) one. In this way, a compressed, “shortened” disc can be replaced with one of full thickness. This may restore flexibility to a patient’s motion segment (2 vertebrae and the disc between them). Disc replacement is reportedly successful in about 60% to 70% percent of cases, but appears to have the following disadvantages:

• The long-term stability, endurance, and strength of most synthetic discs is not known.
• The impact of disc replacement on facet joints is unknown.

• The facet joints limit the bending range of the spine, and consist of bony projections from the top of the vertebrae, hollow receptacles into which those projections fit, and associated cartilage and lubricating fluid.

• Significant facet joint osteoarthritis, a common finding in older patients, is a condition that makes disc replacement inadvisable (a contraindication). Osteoarthritis causes the cartilage in the facet joints to break down.
• Facet joint enlargement and accelerated spinal stenosis may be long-term complications of disc replacement surgery.

• Spinal stenosis is a narrowing of the openings in the vertebrae through which spinal nerves pass. If this narrowing produces enough pressure on nerve endings, pain may result. Facet joint enlargement reduces range of motion in the spine.

If you have chronic discogenic lower back pain that continues despite nonoperative and minimally invasive treatments, it may help to discuss surgical options with a qualified specialist.