File:General ladder of management of intervertebral disc disease in an ideal scenario.png

English: General ladder of management of intervertebral disc disease in an ideal scenario. (A) Relief of pain by conservative management comprises of physiotherapy, oral analgesia, and nutrition supplements supplemented with or without pain injections. Alternative medicine, such as acupuncture and chiropractor practice, has been described but it is beyond the scope of this review. (B) Restorative therapy involves molecular therapy, such as gene, growth factor, and cell therapy, which aim to restore the anabolic function and decrease the catabolic function of the disc in an attempt to repair the disc damage. (C) Reconstructive therapy involves reshaping the disc through decompression, such as mechanical, thermal, and chemical decompression, and biomaterial injection, such as polyvinyl alcohol cryogel, which has biomechanical properties similar to an intervertebral disc. (D) Relief surgery, such as decompression surgery, relieves compression of the neural elements from the associated pathological thickening of the ligamentum flavum or bulging disc from degenerative disc disease. Replacement surgery, such as total disc replacement, removes the affected diseased disc segment and replacing it with an artificial disc, hence preserving the motion of the lumbar spinal segment. (E) Rigid fusion surgery is the most invasive and definitive management, where the motion of the spinal segment is sacrificed, with the intervertebral disc removed and replaced with bone grafts to facilitate fusion of the lumbar segment. It is of note that many of the restorative and reconstructive therapies are under experimental and clinical trial stages; widespread practice on the general population is not recommended unless more evidence is gathered. Hence, only in the “ideal” situation when all the treatment options are available, can we fully utilize this ladder of management.