Prolotherapy: An option for lumbar spinal stenosis

Ross Hauser, MD  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

In this article, we will examine the challenges and findings of researchers looking for the optimal treatment of lumbar spinal stenosis.

You have had recurring and chronic back pain. Sometimes this back pain flares up and becomes almost intolerable. But you have to work or continue on with daily routine activities so this pain needs to be managed. Eventually you make the appointment at the doctor and your trip to the doctor or health care provider revels a diagnosis of lumbar spinal stenosis. Something is wrong with your lower back that appears to be more than you can now manage on your own with painkillers and anti-inflammatory medication and stretching.

The health care provider may explain to you that you have:

  • Degenerative lumbar foraminal stenosis or lateral stenosis or Neural foraminal stenosis.
    • The diagnosis names listed above all refer to the most common type of lumbar spinal stenosis.
    • The nerves that leave your spinal cord and travel around the body have to pass through a gap or opening in the spine’s facet joints, the foramen. When that space is compromised or made smaller by bone spurs, herniated or bulging disc, facet joint osteoarthritis, and inflammation,  the nerve gets “pinched.”
  • Central spinal stenosis 
    • This is the diagnosis when the central canal, where the spinal cord rests within the spine is closing in on the spinal cord.

Non-surgical treatment options for lumbar spinal stenosis

The Lumbar spinal stenosis treatment journey – from diagnosis to surgery

Your lumbar stenosis journey typically began one day when your back pain became significant enough that you could no longer self-manage it on a daily basis. You may have been self-medicating with over-the-counter medications and anti-inflammatories, you may have even gone on line for yoga or back stretching exercises to help you. But now the pain is worse and it is now moving down your hip and into your legs.

First stop the x-ray or MRI


The dangers of stenosis diagnosis based on x-ray

You may have decided first to go to a chiropractor or physical therapist to deal with your back pain. Perhaps your insurance plan insisted that you see a doctor first. It is likely that whoever you saw, you were getting an X-ray and then you were moved onto MRI to confirm the diagnosis of stenosis.

  • We will now explore research that suggests that getting an x-ray or MRI may send you down the wrong path of treatment and eventually to a surgery that you did not need.

The dangers of getting an x-ray at the chiropractor’s office:

We often have good things to say about chiropractic, however, in our office we generally do not rely on an MRI or X-ray to determine the best course of treatment for a patient’s pain challenges. If a patient were to ask us if they should get a routine x-ray at the chiropractor office, we may recommend no. The patient will ask why? We will tell them it can be sometimes counter productive to their treatment if they get an x-ray. In fact the x-ray can give a false image and led the patient down that wrong path of treatment. As this can be considered a powerful recommendation against x-ray at the chiropractor’s let’s bring in a chiropractor’s opinion:

This was published in the journal Chiropractic and manual therapies, November 2018 (1). It comes from authors at the Department of Chiropractic, Faculty of Science and Engineering, Macquarie University, Sydney, Australia and the  School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada.

  • “The use of spinal X-rays in chiropractic has been controversial, with benefits for the use of routine spinal X-rays being proposed by some elements of the profession. However, evidence of these postulated benefits is limited or non-existent.
  • There is strong evidence to demonstrate potential harms associated with spinal X-rays including increased ionizing radiation exposure, overdiagnosis, subsequent low-value investigation and treatment procedures, and increased unnecessary costs.
  • Therefore, in the vast majority of cases who present to chiropractors, the potential benefit from spinal X-rays does not outweigh the potential harms. Spinal X-rays should not be performed as a routine part of chiropractic practice, and the decision to perform diagnostic imaging should be informed by evidence based clinical practice guidelines and clinician judgement.”

The keywords here are:

  • x-ray can possibly lead to overdiagnosis,
  • x-ray can possibly lead to low-value investigation and
  • x-ray can possibly lead to treatment procedures, and increased unnecessary costs

The dangers of stenosis diagnosis based on MRI

The MRI came back: Your doctor read the report to you

  • Degenerative disc disease causing pressure on the spinal nerves
  • You have spinal arthritis
  • You have bone spurs on the vertebrae closing the spinal canals through which nerves pass through
  • You have a problems with the ligamentum flavum. The big ligament that holds your spine together.

Is this report correct? Maybe not the MRI reading can be wrong.

We have written extensively on the over reliance of MRIs in determining back pain treatment and the great concern that the MRI is sending a patient for a surgery they do not need, will not help them, and may make the patient’s situation worse. Please see our article: MRIs causing spinal surgery patients don’t need. In this article you will see

  • Radiologists publishing research saying that doctors are ordering too many inappropriate MRIs.
  • MRI interpretations vary widely, you may get multiple interpretations from different radiologists.
  • Surgeons saying these problems may lead to unnecessary and unsuccessful spinal surgery.

Conservative Care before surgery

If you are diagnosed with lumbar stenosis, there is a good chance surgery will be recommended. But before the surgery, there is usually a long period of conservative care options. Usually a  patient will be happy to try these treatments as surgery is something they would like to consider last.

What is conservative care? Conservative means non-surgical.

A brief discussion on epidural steroid injections for lumbar spinal stenosis – the news is not good

Research:

  • Patients receiving epidural steroid injections for lumbar spinal stenosis had less improvement and greater need for surgery
    • Research: What should a patient expect from epidural steroid injections for lumbar spinal stenosis? Little improvement, more complicated surgeries, and longer hospital stays, especially if you are over 60.
    • Research: Epidural steroid injections are low value health care

When discussing the use of epidural steroid injections, it is always best to bring in orthopedic opinion.

First study is from the Department of Orthopaedics, Wexner Medical Center, The Ohio State University and Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois. This research was published in the International Journal of Spinal Surgery August 2018.(2)

Highlights: Attention Medicare People

  • Epidural steroid injections are widely used but have come under increased scrutiny
  • If you are over 65 and on Medicare you were more likely to get an Epidural than if you had private insurance
  • If you were on Medicare you had a higher risk of going to surgery

This new study agrees with research published in the medical journal Spine, suggesting that the Epidural steroid injections were associated with significantly less improvement at four years among all patients with spinal stenosis…Furthermore, epidural steroid injections were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with Epidural steroid injections. . . ”(3)

Our opinions are based on over 25 years of empirical and clinical observation of how treatments help or not help lumbar stenosis patients. In our articles we also like to bring in the opinion of specialists. Here is what pain management specialists offer as an opinion to conservative care options for lumbar spinal stenosis:

“the benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive”

In the medical journal Current opinion in anaesthesiology, (4pain management doctors discuss the latest trends in lumbar spinal stenosis treatments, this includes a run down of the conservative non-surgical treatments. Here is what the researchers said:

“Our review of current literature within the past 12–24 months for the treatment of lumbar spinal stenosis serves to update providers on recent advances and comparisons regarding therapy spanning lifestyle modification, pharmacologic therapy, minimally invasive interventions, and surgical interventions.

  • Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin (anti-seizure medications used for nerve pain) within an initial treatment regimen has been positive.
  • A recent randomized, double-blinded clinical trial of adding calcitonin (a protein hormone) to epidural steroid injections have shown improvement in pain and function up to 1 year.
  • The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function.
  • Spinal cord stimulation (SCS) may have a role for select patients with lumbar spinal stenosis.

Finally,

  • the benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of lumbar spinal stenosis, and a lack of standardized treatment guidelines.
  • long-term research with validated, objective measurements for the aforementioned treatments are needed to draw any definitive conclusions for clinical practice.

In the British Medical Journal, (5) doctors looked at the options in conservative care. This is what they found:

“The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment.”

  • In this study the spinal injections were cortisone and epidurals.

In the medical journal Best practice and research. Clinical rheumatology, doctors wrote:

“Analgesics (pain killers), NSAIDs, muscle relaxants and opioid are commonly used in patients with lumbar spinal stenosis although their use is extrapolated (taken) from studies of patients with non-specific low back pain. Each of these medication classes poses risks to patients, especially among older individuals.”(6)

More studies: No clear benefits were observed with surgery versus non-surgical treatment in patients with lumbar stenosis. The one benefit conservative care offers – no immediate side-effects.

Doctors at the Italian Scientific Spine Institute published their research in the Cochrane database of systematic reviews which gave this warning to patients considering surgery for spinal stenosis. To be fair, we should point out that the Italian Scientific Spine Institute specializes in the non-surgical treatment of spinal diseases.

  • We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. No clear benefits were observed with surgery versus non-surgical treatment.
  • However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment.
  • These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects.(7)

The bone is closing in all around the nerves. Understanding what causes spinal stenosis and the “narrowing of the spine” may help you avoid surgery.  Spinal Stenosis

Bone spurs form as a result of microinstability of the spine. Bone spurs are an “inner cast” which the body forms to help hold the spine in its correct position. Unfortunately bone overgrowth also causes problems of reduced mobility and eventual nerve compression.

  • Our body has a difficult decision to make:
    • Bone spurs and narrowing of the spine which limit the destructive spinal motion that causing pressure on the nerve (bone spurs limit spinal instability).
    • Allow the spine to move without restriction and cause possible damage to the spinal cord.
    • The body has to make the choice between the lesser of the two evils. Usually the body generates the bone spurs or the narrowing of the spinal canal.

Questioning surgery: No association has been found between the severity of pain and the degree of stenosis

  • The hallmark symptom of spinal stenosis is neurogenic claudication, which is neurologically-based pain that occurs upon walking; other common symptoms include:
    • sensory disturbances in the legs,
    • low back pain,
    • weakness, and
    • pain relief upon bending forward.
  • No association has been found between the severity of pain and the degree of stenosis, although patients who are symptomatic tend to have narrower spine openings than asymptomatic patients.
  • Making a diagnosis of spinal stenosis based on the absolute size of the spinal canal also has its drawbacks since it does not indicate whether or not there is impingement or distortion of either the spinal cord or nerve roots. Impingement or encroachment of the spinal cord by bone is called myelomalacia; impingement of the spinal nerve roots is called radiculopathy.

In their study, surgeons from the Rothman Institute at Thomas Jefferson University wrote of the problem of correctly classifying patients with lumbar stenosis for the purpose of increasing effectiveness of treatments.

While surgery may be effective for some, the surgical techniques vary widely from a decompression procedure to a spinal fusion procedure. This variation in technique and what the researchers call the “lack of an accepted classification system,” can lead to problems for patients with complications.(8)

We describe many spinal surgery techniques and their independent medical reviews in supportive research on this website including our articles:

Research: “Spine surgeons should be increasingly asked why they are offering these operations to their patients?”

Nancy Epstein of Winthrop University Hospital wrote in the medical journal Surgical neurology international.

The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusions (ALIF), extreme lumbar interbody fusions (XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques.

“Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?”(9)

Research: Findings warn doctors to stop doing certain spinal surgeries

Diagnosing stenosis as the cause of a patient’s pain is very problematic. We are going to the following problems that may lead to failed back surgery due to surgery not addressing the true cause of the patient’s pain.

  • No association has been found between the severity of pain and the degree of stenosis, although patients who are symptomatic tend to have narrower spines than asymptomatic patients.
  • Studies have found that diagnosing spinal stenosis with 10 mm as the sagittal diameter (the amount of space) alone produces false positive rates approaching 50%.
  • Making a diagnosis of spinal stenosis based on the absolute size of the spinal canal also has its drawbacks since it does not indicate whether or not there is impingement or distortion of either the spinal cord or nerve roots. Impingement or encroachment of the spinal cord by bone is called myelomalacia; impingement of the spinal nerve roots is called radiculopathy.

One more time: Back to questioning the MRI


Research: “Spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis.”

Above we discussed problems with the MRI and the over reliance of surgeons on recommending surgery to their patients.

Published in the medical journal Osteoarthritis and Cartilage researchers at one of Japan’s leading medical research centers, Wakayama Medical University Hospital, discovered something unsettling for the diagnosed stenosis patient. It seems that many asymptomatic individuals (patients with no complaints or symptoms) have radiographic lumbar spinal stenosis.

  • There seems then to be confusion if the patient is not complaining of back pain, but the MRI says it is stenosis, does the patient has a problem that needs to be operated on?

So in 938 patients with an average age of about 66, they found when they did an MRI, Lumbar Spinal Stenosis was very prevalent. But when they asked the patient if they had back pain or other spinal problems, spinal stenosis complaint was uncommon.(10) 

In recent research, surgeons in Mexico publishing in the Spanish language medical journal Cirugía y Cirujanos (Surgeons and surgery) say that spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis.(11)

YET, patients are convinced to have the surgery anyway

More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms”(12This according to research in the Journal of Neurosurgery fromWayne State University School of Medicine

Our option to Surgery and Conservative Care – Prolotherapy injections

In the research above we highlighted the research that suggests:

  • Conservative care options for lumbar spinal stenosis has limited success
  • Surgical, both open and minimally invasive surgery, are not as successful as one would think
  • MRIs can reveal a stenosis that causes no pain
  • MRI can reveal a stenosis in a situation where back pain exists BUT it may not be the stenosis causing the pain.

So if in your instance, it is not the stenosis causing pain as we outlined above, something else has to be responsible for the back pain or leg pain in diagnosed cases of spinal stenosis. What is it? How do you find out?


The examination of the patient with a stenosis diagnosis not responding to conservative care

When we examine a patient who has a big medical chart with x-rays, MRIs, treatment recommendations, surgeon recommendations, we usually start with: “When does your back hurt?”

  • Most people will refer to some motion, often one of combined flexion (bending) and rotation that they performed before developing certain positional symptoms.
  • For instance, symptoms that are worse with one position or motion (for example, walking or standing) then improve with spinal flexion (for example, sitting).

Based on our experience and the observations of thousands of patients, this presents us with a clue that the spinal ligaments are loose and causing symptoms based on the patient’s position.

Our patients are people who want to avoid a surgery for their lumbar spinal stenosis. They are also people that have exhausted all or most options on the conservative care side. They come to our clinics looking for the realistic possibility that simple dextrose injections (Prolotherapy) will help them achieve their goal of reducing or being pain-free without surgery and continuous treatments. Typically, in all their treatments, very few will have had any discussion with their health care provider about the role of spinal ligaments in spinal instability as the cause of their problems.

lumbar spinal stenosis degeneration

 

In approximately 90% of patients, low back pain is mechanical in nature, typically originating from overuse, straining, lifting, or bending that results in ligament sprains, muscle pulls, or disc herniation. The popular understanding of back pain is disc herniation as a frequent cause, but to a much greater extent, ligament injury forms the underlying basis. Ligaments hold the disk in place, and with ligament weakness, the disk is more likely to herniate.

The first step in determining in whether Prolotherapy will be an effective treatment for the patient is to determine the extent of ligament laxity or instability in the lower back by physical examination. The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain. Pain here is an indicator that Prolotherapy can be very effective for the patient.

Treating the spinal ligaments may be the answer

This is why giving Comprehensive Prolotherapy to stabilize the ligaments is often the ideal treatment, even in patients who have been diagnosed with spinal stenosis. Many times a patient will find it hard to believe that dextrose injections, sometimes dextrose injections plus concentrated blood platelet healing factors (Platelet Rich Plasma therapy) will help them even after his/her doctor told them only a surgery can help. These patients also find it hard to believe that after their Prolotherapy treatments that they do not have to go to surgery.

Research: Prolotherapy for back pain

There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.

  • Research from the University of Manitoba, The journal of alternative and complementary medicine.(13)  
    • One hundred and ninety (190) patients were treated between, June 1999-May 2006.
    • Both pain and Quality of Life scores were significantly improved at least 1 year after the last treatment.
    • This study suggests that prolotherapy using a variety of proliferants can be an effective treatment for low back pain from presumed ligamentous dysfunction for some patients when performed by a skilled practitioner
  • Harold Wilkinson MD, in the journal The Pain Physician (14)
    • Prolotherapy can provide significant relief of axial pain (soft tissue damage) and tenderness combined with functional improvement, even in “failed back syndrome” patients.

Citing our own Caring Medical and Rehabilitation Services published research in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy, but the mental aspect of treatment as well.

  • In our study, 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option.
  • In these 145 low backs,
    • pain levels decreased from 5.6 to 2.7 after Prolotherapy;
    • 89% experienced more than 50% pain relief with Prolotherapy;
    • more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability
    • 75% percent were able to completely stop taking pain medications. (15)

If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.

Prolotherapy for patients who had longstanding and often severe pain and disability

In other Prolotherapy research published in the journal International Musculoskeletal Medicine (16), researchers in the United Kingdom explored the use of Prolotherapy in patients who had failed to respond to conservative approaches including spinal manipulation and physiotherapy. These patients had longstanding and often severe pain and disability. Utilizing only treatments that included 3 injections over a 3 to 5 week period, they confirmed that 91% of respondents were better or not worse off after 12 months.

Prolotherapy injections for chronic low-back pain

Pinched nerve or lumbar radiculopathy in cases of stenosis

If you have ever experienced a pinched nerve or lumbar radiculopathy, you know the pain is excruciating. Burning pain zooming down an extremity can cause such blinding pain, it will stop anyone in their tracks. But even in cases of acute pain, we have to ask why this problem started in the first place. The answer is ligament laxity, which causes the vertebrae to slip out of place and pinch the nerve.

In our office, people with Pinched nerve or lumbar radiculopathy are cases are often seen as needing a two-part solution.

  • First, we have to work to get the patient out of acute pain. Nerve blocks utilizing a 70.0% Sarapin and 0.6% lidocaine solution are often given, in addition to Prolotherapy. The nerve block provides initial pain relief, so the person is able to rest and repair while the Prolotherapy begins to work. Upon nerve relaxation, the vertebrae will realign and the nerve compression will cease. Even in cases of such extreme pain as a pinched nerve, the pain is typically positional. This means that it gets more intense when a person gets into certain positions. For example, if someone has unbearable pain upon sitting or kneeling, but is relieved somewhat while standing or lying flat, this means certain positions are causing the vertebrae to slip and pinch on the nerve. This also should be the point where someone is picking up the phone for a Prolotherapy treatment.
  • In our in-house analysis of consecutive patients treated for radiculopathy with Prolotherapy, the average starting pain level in patients treated for lumbar radiculopathy was 6.3 and ending pain level was 2.5 (VAS 0-10). In this same radiculopathy data, we looked at cervical radiculopathy patient outcomes as well. They were equally impressive with an average starting pain level of 5.6 and an ending pain level of 1.
  • Prolotherapy proved to be an excellent nonsurgical option for the unrelenting pain characteristic of radiculopathy. Whether the spine or other joints, positional pain is indicative of joint instability and an ideal application for Prolotherapy!

Spinal Stenosis Prolotherapy

 

Spinal Stenosis at Rest, Spinal Stenosis with Activity – when should you consider surgery, when should you consider Prolotherapy?

We can think of spinal stenosis as two different disorders, one needs surgery and the other Prolotherapy. There is SSAR and SSWA which stand for Spinal Stenosis At Rest and then Spinal Stenosis With Activity. (See Figure)

Spinal Stenosis at Rest and with Movement

Surgery is needed for Spinal Stenosis At Rest but Prolotherapy resolves Spinal Stenosis With Activity.

They are differentiated on symptoms and a test called electromyography/nerve conduction studies (EMG/ NCV). The patient who has severe pain, especially nerve irritation down the leg at rest has a narrowing of the space for the nerves that is not affected by activity. It means that there just is never enough room for the nerve, even at rest. In these instances, a lot of nerve damage or irritation is present on an EMG/NCV test. This patient would be referred for a surgical decompressive surgery, where the surgeon makes more room for the nerve. Any residual pain after the surgery can then be treated with Prolotherapy.

However, almost all the cases of spinal stenosis fall into the second category, Spinal Stenosis With Activity.

These are patients who have no symptoms when they are sitting and laying recumbent and resting. But upon standing or walking for too long, they develop back pain, buttock pain and pain down the leg. In other words, the symptoms are only precipitated by movement or change in position. This means that the nerves have enough room at rest, but the room for the nerve is decreased with standing or walking. The symptoms are dependent on position. Positional pain is a hallmark feature of conditions that respond to Prolotherapy, in the spine and any joint of the body!

When presented with all this information, on a patient’s first visit, he/she is sometimes disbelieving that Prolotherapy or Prolotherapy in conjunction with Platelet Rich Plasma Therapy  can provide benefit and help relieve the pain of spinal stenosis, yet, the answer to their commonly asked questions can be found in the above research.

If this article has helped you understand problems of lumbar stenosis and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

Prolotherapy Specialists lumbar spinal stenosis degeneration

Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD

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