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The two major surgical interventions for chronic discogenic lower back pain are lumbar spinal fusion and disc replacement. Surgery for back pain lacks compelling evidence of efficacy and is accompanied by the typical risks of surgery. Indications for surgery are unrelenting pain and disability after at least 6-12 months of conservative therapy. Another indication for surgery may be the failure of minimally invasive methods, such as the IDET◊ procedure.

Lumbar spinal fusion involves the surgical removal of the affected disc and fusing the adjacent vertebrae. This can be done through the abdomen (anterior lumbar interbody fusion) or through the back (posterior fusion). In theory, fusion surgery eliminates the source of pain by removing the bad disc.

• Lengthy incisions and extensive muscle dissection are disadvantages of conventional fusion techniques.
• Recently, percutaneous techniques for posterior fusion and pedicle screw fixation have been described. Endoscopic techniques such as laparoscopic anterior lumbar interbody fusion have also been adapted, but operative times are much longer, and the rate of sexual dysfunction in men is much higher.
• Conventional open surgical technique appears to provide better visualization than newer, less invasive fusion techniques.

Another surgical alternative for a severely damaged and otherwise untreatable disc is to remove it and replace it with a synthetic disc. This procedure restores disc height and flexibility to the motion segment. The procedure is reportedly successful in about 60% to 70% percent of cases, but it appears to have the following disadvantages:

• Long-term stability, endurance and strength is unknown for most synthetic discs.
• Significant facet joint osteoarthritis is a contraindication.
• Impact of disc replacement on facet joints is unknown.
• Facet joint hypertrophy with accelerated spinal stenosis may be a long-term complication.