Non-surgical treatment options and surgery outcomes in lumbar spinal stenosis

Ross Hauser, MD., Danielle Matias, PA-C

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

If you are like many people that we see at our clinic, you have had recurring and chronic back pain for some time. Sometimes this back pain flares up and becomes almost intolerable for you. But, you have to go to work or continue on with your daily routine activities so this pain needs to be managed. Eventually, you will make appointments with a few or many different health care professionals and during one of these trips to the doctor or health care provider, it will be revealed to you that you have a diagnosis of lumbar spinal stenosis. Now your medical journey will probably be filled with diagnoses and terms that require you to educate yourself on what is happening in your back.

Often we will hear a patient say: “I had back and leg pain for months. I went to the doctor, I had an MRI and the doctor told me I had spinal stenosis. I had no idea what the doctor was talking about. My doctor told me that he/she would prescribe some pain relievers for me to see if that helped. My question to my doctor was “will this ever go away?” The doctor looked at me and said, “I hope so, but it is not likely without surgery.”

Surgery?

The health care provider may then try to 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.

If you are reading this article it is very likely that you and your doctors have already made a valiant try to keep you away from surgery with a steady dose of medications, cortisone or epidural injections, physical therapy, and chiropractic. The recommendation to get surgery is coming closer and closer if it has not already been suggested to you. Some of you reading this article may already have a surgical date.

Discussion points of this article.

  • Delays to treatment or surgery cause patient suffering.
    • Patients struggle to be believed and taken seriously.
  • Are patients waiting for surgery because they are told or think surgery is the only answer?
  • Did the MRI tell them that surgery was the only way to treat lumbar spinal stenosis?
    • Did the MRI interpretation scare the patient into a surgery they did not need?
    • The dangers of stenosis diagnosis based on MRI.
  • The difference between Dynamic Spinal Stenosis and Static Spinal Stenosis and who should get surgery and who can benefit without surgery.
  • The Lumbar spinal stenosis treatment journey – from diagnosis to surgery.
  • Conservative Care before surgery.
    • Research: Is conservative care for lumbar stenosis a waste of time and resources?
    • Three years later, many patients who chose not to have spinal surgery for stenosis are doing good.
    • Is conservative care a waste of time and money for women?
    • Chiropractic care
    • Chiropractic care in patients over 80.
    • Physical therapy for lumbar spinal stenosis.
  • Epidural injections for lumbar spinal stenosis.
    • A brief discussion on epidural steroid injections for lumbar spinal stenosis – the news is not good.
    • Little improvement after steroid injections, more complicated surgeries, and longer hospital stay, especially if you are over 60.
  • Research: Findings warn doctors to stop doing certain spinal surgeries.
  • “The benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive.”
    • ” 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery”
  • The different types of surgeries for lumbar spinal stenosis.
    • Using interspinous spacers.
    • Minimally Invasive Lumbar Decompression.
    • Endoscopic Decompression (for Foraminal Stenosis).
    • Invasive Open Decompression Surgery.
    • Limited vs Multilevel Decompression Surgery.
  • 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.
  • Questioning surgery: No association has been found between the severity of pain and the degree of stenosis.
  • Is it canal narrowing or wearing away of the vertebrae endplates that are causing pain attributed to lumbar spinal stenosis?
    • What are endplate defects?
  • 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 the effectiveness of treatments.
  • Research: “Spine surgeons should be increasingly asked why they are offering these operations to their patients?”
  • Research: Findings warn doctors to stop doing certain spinal surgeries.
  • Research: “Spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis.”
  • Our option to Surgery and Conservative Care – Prolotherapy injections
  • The examination of the patient with a stenosis diagnosis does not respond to conservative care.
  • 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.
  • Treating the spinal ligaments may be the answer.
    • Research: Prolotherapy for back pain.
    • Prolotherapy for patients who had longstanding and often severe pain and disability.
  • Pinched nerve or lumbar radiculopathy in cases of stenosis.
  • Spinal Stenosis at Rest, Spinal Stenosis with Activity – when should you consider surgery, when should you consider Prolotherapy?

Waiting for surgery because surgery is the only answer? The rate of side effects ranged from 10% to 24% in surgical cases

In this article, we will present research and clinical observations that for some people, there can be other options beyond being pain managed with medications until they can get a lumbar spinal stenosis surgery. We will take the path from pain to MRI to the surgical recommendation and show how in some people, not all, lumbar spinal stenosis surgery can be avoided and the suffering of waiting for surgery can be eliminated.

There is a great debate in medicine as to which path of treatment to pursue in patients suffering from lumbar spinal stenosis. In December 2016, researchers led by the Italian Scientific Spine Institute looked at nearly 13,000 previous published research studies and narrowed down this list to 24 extensive papers that could be used to debate which treatment options would be most beneficial to which patients. (1) This is what they concluded:

“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. 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. No clear benefits were observed with surgery versus non-surgical 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.”

This 2016 paper’s guidelines on conservative care treatment has been cited by 76 other publications including a July 2022 paper in the journal BioMed Central musculoskeletal disorders (2) which found “supervised physical therapy yielded similar effects to lumbar surgery.” Further, “These results suggest that supervised physical therapy is preferred over surgery as first-choice treatment, to prevent complications and to minimize health care costs, especially in mild to moderate cases of lumbar spinal stenosis.”

Throughout the course of this article we will see various comparison studies citing surgery is superior to conservative care treatments or that surgery is no better than conservative care treatment and surgery has its own complications. Many people do have very successful surgeries. Others do not. In this next section we will explore why your MRI may have lead you to a surgery failure.

Did the MRI interpretation scare the patient into a surgery they did not need?

In my article Is your MRI sending you to a back surgery you do not need because of fear and panic? I discuss many research studies, one was July 2021 when two surgeons and a radiologist published a randomized control trial study in the European Spine Journal. (3) The basis of this study was, did the MRI interpretation scare the patient into a surgery they did not need? Further, did the patient have poor surgical outcomes because their MRI report sent them into “catastrophic thought?”

Another study from July 2021 (4) cited an epidemic of unnecessary MRIs sending people to unnecessary surgery and worsening the patient’s condition by creating “failed back surgery syndrome” in many of them. In this paper, researchers expressed concerns over how many MRIs were being ordered by general practitioners for musculoskeletal problems in the United Kingdom. The researchers note phenomena found here in the United States as well that there is limited supporting evidence that these MRIs will be helpful to the patient and worse there is the potential for patient harms from early imaging overuse.

Summary of this and other related research:

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

The MRI

In some people, the state of their stenosis has made them a walking MRI interpretation. Maybe this is like you. You have been contacting doctor’s offices and simply emailing your MRI results to see if that doctor can help. We have been helping people coming up on three decades. While an MRI can be helpful in understanding someone’s problem, it may not truly represent the patient’s pain. This is why there is a problem with failed back surgery syndrome. The pain remains after surgery. The surgery was addressed the MRI and may have missed the true cause of the patient’s problem. One thing the MRI could miss is spinal ligament laxity. Which we will explain below.

Many people suffering from spinal stenosis do very well with surgery. The majority of patients have a great deal of pain relief. These are not the patients that we see at our center. We see the patients who have had surgery and now in some cases have been recommended to spinal fusion surgery. These people we see would like to see if avoiding that surgery is possible.

The dangers of stenosis diagnosis based on MRI

In brief summary, the MRI came back: Your doctor read the report to you or maybe you were just given the MRI report with no explanation. What you read then seems to suggest:

  • Degenerative disc disease causes pressure on the spinal nerves (stenosis)
  • You have spinal arthritis – (foraminal stenosis)
  • You have bone spurs on the vertebrae closing the spinal canals through which nerves pass through. (Foraminal stenosis and central stenosis).
  • You have problems with the ligamentum flavum. The big ligament that holds your spine together.

Many times a patient will come in with the diagnosis of lumbar stenosis and scans and images to support the diagnosis. But their doctors are not sure what to do about.

Many times a patient will come in with the diagnosis of lumbar stenosis and scans and images to support the diagnosis. But their doctors are not sure that what to do about. A December 2021 study in the journal Orthopedic Reviews (5) examined and described the different aspects of patient suffering related to lumbar spinal stenosis and how suffering is managed before lumbar spinal stenosis surgery. In this paper, researchers talked to 18 patients on the waiting list for lumbar spinal stenosis surgery. They basically asked: “How do you feel?” The researchers then took all the answers and come up with an analysis. See if this sounds like you.

Patients struggling to be believed and taken seriously

“The suffering from lumbar spinal stenosis before surgery included the main theme of experiencing an impaired physical and social life and struggling to be believed and taken seriously. This had coping strategies to manage symptoms before surgery: a good physician-patient relationship alleviates the burden of long waiting times; ways to manage pain and disability; ambiguous expectations and hope for recovery, and; ways to handle concerns before surgery).

Conclusion: Being a person with lumbar spinal stenosis includes suffering and a possibility to discover coping abilities or having support structures for doing so. (This) study emphasizes the importance of a supportive dialogue, where physicians and patients make the suffering from lumbar spinal stenosis and care before lumbar spinal stenosis surgery more comprehensible and manageable.”

What the researchers here are suggesting is that not enough is being done to ease patient suffering before they can get to surgery. But what is it that patients are not getting enough of? What aren’t you getting enough of?

In this video, Ross Hauser, MD, discusses the difference between Dynamic Spinal Stenosis and Static Spinal Stenosis and who should get surgery and who can benefit without surgery

These are some learning points from the video:

  • Spinal Stenosis is the result of degenerative arthritis. The earlier you treat the osteoarthritis of the spine, the less stenosis risk factor.
  • When I was a medical student thirty years ago, the traditional treatment for spinal stenosis was laminectomy surgery. The idea was that by cutting away the bone the spinal cord would have more room or not be compressed. Unfortunately, years later, many of these surgical patients would develop worsening spinal arthritis and would have worse symptoms than those that sent them to the original surgery. This is why surgeons are more careful in who they offer this surgery. The surgery of choice now is decompression fusion.
  • In decompression fusion, the spinal cord is given its room and the vertebrae are fused to prevent future stenosis at that segment level. Because there is a fusion to stabilize the vertebrae, this gives us the understanding that the cause of stenosis is spinal instability.

How do we determine in the office who needs surgery and who doesn’t?

  • We examine the symptoms the patient is experiencing.
    • When a person walks a short distance or stands for some time, and they develop terrible back pain and they have to sit down because of the pain and because their legs feel heavy, and, if the person does not have back pain or little back pain and no leg pain when they sit down and the symptoms go away. This person would likely not need surgery.
    • The pain this person is suffering from is related to certain positions, standing as opposed to sitting for example. We know that this is being caused by an instability problem, we can treat this with Prolotherapy injections. (This is explained below). We call this a problem of dynamic spinal instability or dynamic spinal stenosis.
    • Sometimes we have to do nerve regeneration therapy with Prolotherapy. This is typical in a person who has pain relief when they sit but the pain does not go away completely. This can mean that there’s a part of the nerve that’s actually injured or the sheath that surrounds the nerve is damaged inject platelet-rich plasma or bone marrow cells onto the nerve to stimulate repair.
    • If someone has leg pain all the time, there is no alleviation from sitting or standing, this is what we call Static Spinal Stenosis, and those are the cases we typically recommend decompression fusion surgery.
This picture describes how classical spinal canal stenosis can compress the spinal cord, whereas intervertebral neural foraminal stenosis impinges on the nerve root.
This picture describes how classical spinal canal stenosis can compress the spinal cord, whereas intervertebral neural foraminal stenosis impinges on the nerve root.

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 online 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.

The problems of spinal stenosis are a long journey. Your story may sound very similar to this one:

For the last few years, my back pain has been slowly getting worse. I have had a few diagnoses, hip bursitis was one, sacroiliitis was another. I was finally diagnosed with lumbar foraminal spinal stenosis (L5/S1). I have a bulging disc and arthritis in my spine. The degenerative disc disease I have is worse on the right side which correlates with the symptoms I have, primarily sciatica which radiates into my right leg down into my foot. It’s “better,” on the left side. The sciatica pain only goes to my knee.

Sometimes when I walk I have to be careful on inclines, slopes, or stairs as this will cause a very sharp pain in my back. 

I am told I will need surgery. Not now but sometime in the future. I basically have to wait for my condition to get worse. I do not want surgery but I do not know what else to do. 

Conservative Care before surgery: Researchers ask: Is conservative care for lumbar stenosis a waste of time and resources? When is surgery not indicated?

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 are non-surgical.

Is conservative care for lumbar stenosis a waste of time and resources?

Three years later, many patients who chose not to have spinal surgery for stenosis are doing good.

Not everyone will need a stenosis surgery. A May 2022 paper published in JAMA, the Journal of the American Medical Association (6) writes about a “series of patients with lumbar spinal stenosis followed up for up to three years without operative intervention.” In this group of patients:

  • approximately one-third of patients reported improvement,
  • approximately 50% reported no change in symptoms,
  • and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse.

Further,

  • “Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated.”
  • “Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management.”

However, surgery needs to be carefully recommended. The researchers note:

  • In a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis, decompressive laminectomy improved symptoms more than nonoperative therapy.
  • Among persons with lumbar spinal stenosis and diagnosed with spondylolisthesis, lumbar fusion provided symptom resolution in one study, but two other trials showed either no important differences between nonoperative therapy and spinal fusion or lumbar decompression alone compared with lumbar decompression plus spinal fusion.
  • In a noninferiority trial (a study demonstrating that a new treatment is better than an old treatment , 71.4% treated with lumbar decompression alone vs 72.9% of those receiving decompression plus fusion achieved a 30% or more reduction in Oswestry Disability Index score (0 – 100 scoring). “Fusion is associated with greater risk of complications such as blood loss, infection, longer hospital stays, and higher costs. Thus, the precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear.”

For some people the answer appears to be yes: But what kind of people should just move forward with the surgery? Smokers; type 2 diabetics; and obese people.

Ten years later, spinal stenosis did not progress to a level requiring surgery

In October 2022, doctors writing in the Journal of Clinical Medicine (7) looked at the ten year follow ups of 1862 patients initially diagnosed with lumbar spinal stenosis. The doctors were looking for the outcomes of patients who did not have surgery. How did they fare? The age of the patients ranged from 19 to 93 years old at the time of diagnosis. What the doctors found was that  62% of the patients of this study, who initially were diagnosed with lumbar spinal stenosis did not have or showed significantly less symptoms ten year later.  Overall, about 60% of people recovered from lumbar spinal stenosis symptoms after 10 years, and younger people were particularly likely to recover from lumbar spinal stenosis symptoms.

The study doctors also noted that it would be expected that the condition would worsen over time. Many people we see who had a diagnosis of lumbar spinal stenosis had it suggested to them that their situation would probably get worse.  However, the researchers noted, the frequency of lumbar spinal stenosis symptoms switching from bad to good (or bad to better) at the 10-year follow-up support the description of North American Spine Society Evidence-Based Clinical Guidelines which states “the natural history of patients with clinically mild to moderately symptomatic degenerative lumbar stenosis can be favorable in about one-third to one-half of patients”  even with a 10-year follow-up period.

What could make lumbar spinal stenosis worse was other conditions the patient suffered from such as hypertension, diabetes mellitus, osteoarthritis and depressive symptoms.

This is a March 2019 study from the Departments of Neurosurgery at Rush University Medical Center, the University of Texas South Western Medical Center, and the University of Cincinnati Medical Center. It was published in the medical journal Spine. (8)

Here are the learning points:

  • The study examined 4133 patients who underwent 1, 2, or 3-level posterior lumbar instrumented fusion.
    • 20.8% of patients were smokers
    • 44.5% had type II diabetes,
    • 38.2% were obese
  • The patients had long-term nonoperative therapy that included:
    • 66.7% used nonsteroidal anti-inflammatory drugs (NSAIDs),
    • 84.4% used opioids,
    • 58.6% used muscle relaxants,
    • 65.5% received lumbar epidural steroid injections,
    • 24.9% received chiropractor treatments

The point of the study was that these patients who went to surgery anyway spent a lot of money and healthcare resources on treatments that would not help them. We are going to review the treatments that did not help them.

A December 2023 report (36) in the medical journal Spine examined to what extent diabetes mellitus is as a risk factor for lumbar spinal stenosis development and evaluated the impact of diabetes duration, glycemic control, and associated complications on this risk.

Using a nationwide database of patient charts, a total of 49,576 patients diagnosed with lumbar spinal stenosis had their cases reviewed. The researchers found a higher likelihood of lumbar spinal stenosis diagnosis in diabetic patients. Those with A1C levels over 7 and more than one diabetes-related complication also had an elevated likelihood. Prolonged diabetes exposure increased the risk.

Is conservative care for stenosis a waste of time and money for women?

The same research team published these findings in the December 2018 journal World Neurosurgery. (9)

  • A total of 4133 patients (58.5% women) underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion.
  • A significantly greater percentage of female patients used nonsteroidal anti-inflammatory drugs, lumbar epidural steroid injections, physical and/or occupational therapy, and muscle relaxants and yet still went to surgery.

Taking this research further, a March 2021 paper (10) found that even though men and women reported the same symptom severity for their lumbar spinal stenosis, female patients had more disability and depression.

Chiropractic care in lumbar stenosis patients over 80

A small study on twelve patients published in October 2022 in the Journal of bodywork and movement therapies (11) evaluated chiropractic care including flexion distraction spinal manipulation for improving function, symptoms and performance-based mobility in patients with lumbar spinal stenosis.

Results: Twelve patients  completed the average midpoint visit at 9 visits and the final visit at 13.7 visits.

Conclusion: Significant improvement in objective and subjective outcomes were found after a pragmatic course of care including spinal manipulation in lumbar spinal stenosis patients.

Physical therapy for lumbar spinal stenosis

  • We are going to discuss a bit more about physical therapy here: A January 2019 study from the Department of Neurosurgery, University of Texas Southwestern Medical Center at Dallas made these remarks about physical therapy. This study was published in the biomedical journal F1000 Research. (12)
    • “Physical therapy for lumbar spinal stenosis usually involves some combination of core strengthening, flexibility training, and stability exercises. The optimal combination of these exercises and their frequency, duration, and the appropriate setting is not clear at this time.”
    • “The evidence of benefit from physical therapy alone is not clear. However, a limited course of physical therapy should still be considered as part of the initial treatment discussion and conservative measures.”
  • What makes physical therapy and its frequent companion treatment chiropractic manipulation dangerous is that they were given to patients who could not benefit.
    • But it wasn’t the physical therapy that was dangerous, it was the failure to achieve pain relief from it that created the danger for patients.
    • When these patients went back to the orthopedist and reported a lack of success in physical therapy, chiropractic, massage, yoga, etc., the failure of these treatments was used as justification to send that patient to possible unnecessary spinal surgery. That is the danger of the failure of these treatments.”
    • In our article, mentioned above, how physical therapy will not help certain people, we wrote: “Physical therapy is a major component of the orthopedist’s “conservative” approach to low back pain relief. The Caring Medical experience is that the results of PT are often disappointing. Disappointing may not be the right word, perhaps dangerous would be better.

Epidural injections for lumbar spinal stenosis

  • Epidural injections

Our opinions are based on over 25 years of empirical and clinical observation of how treatments help or do 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:

Treatment with Epidural injections is a frequent question we receive at our clinics: In our article Alternatives to Epidural Steroid Injections | why do patients still get epidurals? We answer common patient questions about epidurals and provide the research as to why we do not offer this treatment as a standard of care.

Neurogenic claudication

Bone spurs form as a result of microinstability of the spine, as the body attempts to stabilize the unstable spine, which can eventually narrow the spinal canal and cause resultant spinal stenosis. Spinal stenosis is defined as a specific type and amount of narrowing of the spinal canal, nerve root canals, or intervertebral foramina and can be either congenital or developmental or be acquired from degenerative changes.

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. Segmental instability is thought to be a source of the low back 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.

A January 2022 study (13) led by the University of Toronto examined the growing older adult health problem of neurogenic claudication. They found: “There is moderate-quality evidence from (previously published studies) that: Manual therapy and exercise provides a superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education, and exercise delivered using a cognitive-behavioral approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term.”

Conclusions: There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of lumbar spinal stenosis with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness.

  • 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.

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


Little improvement, more complicated surgeries, and longer hospital stay, especially if you are over 60.

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 stay, 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 an orthopedic opinion.

The first study is from the Department of Orthopaedics, Wexner Medical Center, 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. (14)

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 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 a longer duration of surgery and longer hospital stay. There was no improvement in outcome with Epidural steroid injections. . . ”(15)

A February 2021 paper published in the Brazilian Journal of Orthopaedics (16) offered a review assessment of conservative care treatments for lumbar stenosis up to the point. In reviewing previously published literature the researchers pointed out the following:

  • Conservative treatment consists of physical therapy with thermal analgesia (heat therapy) plus exercises and calcitonin (medication to help with pain from osteoporosis and bone fracture.)  The patients showed statistically significant improvement, except for deep reflex changes (motor neuron activity).
  • If neurogenic claudication is not severe and there are no symptoms of motor deficit, the initial treatment must attempt to relieve pain with rest and changes in daily activities.
  • Initially, analgesics and nonsteroidal anti-inflammatory drugs are recommended, possibly associated with muscle relaxants. In this phase, physical therapy with thermal analgesia, transcutaneous nerve stimulation (TENS), and light mobilization exercises with stretching and progressive muscle strength for postural correction can be performed for pain relief. Acupuncture, chiropractic procedures, and McKenzie exercises can also be used for pain relief. None of these methods has proven superiority over another, and none provides significant neurogenic claudication improvement.
  • Steroids may be indicated in case of radicular irritation worsening, always for a brief period of time to reduce the risk of side effects; narcotic analgesics can also be used.
  • Epidural block with a steroid injection into the epidural space relieves spinal stenosis symptoms; this treatment is more efficient in radiculopathies than in neurogenic claudication, although there are no studies demonstrating its long-term effectiveness.

Research: Findings warn doctors to stop doing certain spinal surgeries

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

In the medical journal Current Opinion in Anaesthesiology, (17pain management doctors discuss the latest trends in lumbar spinal stenosis treatments, this includes a rundown 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 has shown improvement in pain and function for 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 in select patients with lumbar spinal stenosis.

Finally,

  • the benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis are 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 is needed to draw any definitive conclusions for clinical practice.

In the British Medical Journal, (18) 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, (19) doctors wrote:

“Analgesics (painkillers), NSAIDs, muscle relaxants, and opioids 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.”

33% of the patients reported failure, and 22% reported worsening of pain and disability

A February 2023 study in The spine journal (20) comes to us from the Norwegian University of Science and Technology, Akershus University Hospital and Oslo University Hospital. In this study, the Norwegian doctors explored why some patients do not improve after lumbar spinal stenosis surgery and why the surgery may increase risk for complications and spine deterioration in some patients.

In this study, 8919 lumbar stenosis surgical patients, average age about 67 and 52% being female, were assessed 12 months after surgery.

Here are the findings:

  • Before the surgery, the patients were evaluated using the Oswestry Disability Index (ODI) scoring system. This scoring system is based on a 0 – 100 score. The average score of these patients was 39.8 signifying that they suffered from moderate disability bordering on severe disability.
  • All patients had lumbar decompression surgery, and 1494 (12.6%) had an additional fusion procedure.

Twelve months after surgery, the average  Oswestry Disability Index (ODI)  score was 23.9 (low end moderate disability), however 2950 patients (33.2%) were classified as surgical failures and 1921 (21.6%) were classified as worse off.

The conclusion of this research was: “After surgery for lumbar spinal stenosis, 33% of the patients reported failure, and 22% reported worsening as assessed by Oswestry Disability Index. Preoperative duration of back pain for longer than 12 months, former spinal surgery, and age above 70 years were the strongest predictors for increased odds of failure and worsening after surgery.”

” 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery”

A November 2019 study (21) that combined patient outcomes at 13 medical universities, hospitals, and spine centers in Canada, Australia, and Denmark that included the University of Toronto, the University of Ottawa, the University of Calgary, Murdoch University, University of Southern Denmark, and McGill University Health Centre among others, examined patient groups following surgery for degenerative lumbar spinal stenosis. The research simply sought to see who the surgery would help and who it would not.

Study learning points:

  • Patients with degenerative lumbar spinal stenosis were deemed to be surgical candidates.
  • The study examined:
    • Leg pain and back pain before and after surgery. After surgery at 3, 12, and 24 months.
    • Data from 548 patients ( average age 66.7 years old 46% female) were included.
  • Outcomes after surgery:
    • leg pain (excellent outcome = 14.4%, good outcome = 49.5%, poor outcome = 36.1%),
    • back pain (excellent outcome = 13.1%, good outcome = 45.0%, poor outcome = 41.9%),
    • and disability (excellent outcome = 30.8%, fair outcome = 40.1%, poor outcome = 29.1%).

Conclusion: “Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.”

A January 2023 study (34) looked at spinal stenosis and its implications in being “the most common indication for surgical treatment in patients over 65 years old” having spinal issues. The key to this study was to assesses the incidence and indications for revision surgery after previous spinal decompression and fusion for patients being treated with lumbar spinal stenosis.

The researchers looked at the outcomes of 1233 patients with lumbar spine stenosis who underwent spinal decompression and fusion surgery between 2014 and 2018. The number and causes of readmission were evaluated.

Of the 1233 patients, 164 were readmissions.

  • Revision surgery at the same level was performed in 63 patients (38.4%), at the higher level – 72 (43.9%), at the lower level – in 29 (17.7%) patients.
  • The most common indication for readmission was spondyloarthrosis with facet joint syndrome (94 (57.3%) patients) or adjacent segment degeneration.
  • The second common complication was pseudoarthrosis or the failure of the spinal fusion to achieve the fusion (26 (15.9%) patients).
  • The most common indication for readmission was adjacent segment degeneration.

The different types of surgeries for lumbar spinal stenosis

A December 2023 paper in the Journal of orthopaedic surgery and research (35) examined the rate of disc herniation following decompression of lumbar spinal stenosis. According to the paper, “Previous studies suggested that open lumbar decompression techniques, associated with relative segmental instability especially in the presence of degenerated disc in older patients, are more likely to result in disc herniation compared to minimally invasive techniques.” In this study the researchers compared the incidence of acute disc herniation following mini-open and minimally invasive decompression of lumbar spinal stenosis. What they found was “The incidence of postoperative disc herniation following spinal decompression for symptomatic lumbar stenosis was 5.8% following mini-open bilateral partial laminectomy compared to only 0.8% after minimally invasive laminotomy.” They conclude that their findings “highlight the more extensive nature of mini-open surgery associated with relative segmental instability that poses a greater risk for postoperative disc herniation.”

What are we seeing in this image? Spinal instability at the L3-L4 segment above a previous L5-S1 fusion. Adjacent Segment problems.

  • In the first of the three panels starting at the left, we see the patient in the NEUTRAL, standing straight position. In this position, we see the L3 has slipped well forward above the L4 vertebrae. We also see space between the Neuroforamina.
  • In the center of the three panels, we see the FLEXION position. The patient is bending forward. We also see space between the Neuroforamina.
  • The third panel is an image of the spine in EXTENSION. This would be a position not only of bending backward but a position many athletes, tennis, golf, running, or sports or work with overhead arm motion required. In this position, there is a narrowing of the space between the Neuroforamina. This can cause Lumbar Radiculopathy or lumbar stenosis situation.

Surgeons writing in the medical journal Pain Medicine (22) gave an excellent rundown of surgical procedures that someone with lumbar spinal stenosis can explore. Here is a brief summary of their learning points and some explanatory notes.

Surgical options range from minimally invasive decompression surgery for indirect lateral and central stenosis using interspinous spacers to more conventional invasive decompression surgery, either with or without fusion. Here are brief descriptions.

  • Using interspinous spacers
    •  If you have been researching or contemplating this type of surgery, you know that a spacer is inserted into the rear portion of the vertebrae to hold them apart. For instance, a spacer is placed between L3 and L4 if that is where your stenosis is. The spacer will help alleviate pressure.
      • The study authors note that: “Stand-alone interspinous spacers are designed for the treatment of symptoms of intermittent neurogenic claudication, (pain, pins, and needle sensation, numbness, back to legs spasming) that are brought on by moderate lumbar spinal stenosis.” The benefit of this type of surgery is that it avoids getting near the spinal canal. You are not getting fused and some degree of flexibility can be maintained. The downside is higher complication rates have been reported. The authors again note: “Not all patients are suitable for treatment with an interspinous spacer. Patients with osteoporosis (risk of spinous process fracture) and spondylolisthesis with dynamic instability (risk of posterior migration of implant) are not appropriate candidates for interspinous spacers.”

Minimally Invasive Lumbar Decompression

  • If you have been researching or contemplating this type of surgery, you know that this is a multipart surgery. It is considered minimally invasive because of the size of the surgical entrance.  The idea of using minimal invasive lumbar decompression surgery rests with the notion that it will do less damage to the surrounding tissue in the spine. In open surgery, muscles have to be moved out of the way often damaging the muscles and the connective tissue such as tendons and spinal ligaments. Using smaller holes and cameras, surgeons can effectively repair minimally damage the surrounding tissue. Typically in this surgery, the central stenosis is addressed. A laminotomy is performed, that is the cutting away of the bone towards the rear of the vertebrae, the lamina and the ligamentum flavum, the long ligament that runs the length of the spine from C2-S1 and is offered hypertrophied in cases of spinal instability- that is thickened because of stress to help hold the spine together, is shaved down to prevent it from compressing nerves roots.

Endoscopic Decompression (for Foraminal Stenosis)

  • If you have been researching or contemplating this type of surgery, you know that this surgery is perhaps the least invasive. A small incision is made at the point of the problem’s disc area. The surgeon goes through this incision and removes the piece of disc or cuts away the piece of the vertebrae that is pressing on the nerves. The surgeon can also cut away or use radiofrequency to make the compressed passages such as in the foramen bigger. While many people can get benefit from this surgery, researchers have questioned the long-term results.

Invasive Open Decompression Surgery

  • If you have been researching or contemplating this type of surgery, you know that this surgery is the big incision surgery, that is why it is called open and invasive. As in the minimally invasive surgery, a laminotomy is performed, the ligamentum flavum is shaved down to prevent it from compressing nerve roots. The reason open invasive is chosen is that a Laminectomy and fusion need to be performed.
    • The authors of this research study cited above say: “Laminectomy has been the standard surgical treatment for lumbar spinal stenosis, demonstrating significant improvement in symptoms and functioning. Laminectomy can be either with or without fusion, depending on the disease characteristics and surgeon preference. Different studies have found conflicting results, with some reporting a more favorable outcome of decompression surgery alone and others reporting the opposite. In general, treatment with decompression alone without fusion was shown to be effective in 80% of patients with severe symptoms of lumbar spinal stenosis. The primary goal of spinal fusion would be to improve regional back pain and improve stability.”

Limited vs Multilevel Decompression Surgery

  • If you have multi-level problems in your spine your surgeon may recommend a multi-level procedure, getting to all the problem discs at once. This would require open spinal surgery with a big incision.
    • The authors of this research study cited above say: “Limited open decompression may be performed when one to three affected segments are involved. However, there remains controversy concerning how many levels need to be operated on in the case of multilevel lumbar spinal stenosis for the best clinical outcome.”
    • They also note “patient satisfaction at two years was higher in patients that had single-level decompression and fusion.”

Risks 

  • The authors of this research study cited above say: “In general, although open decompression surgery allows for direct visualization of the decompression site and has been shown to be safe and effective in the majority of patients, the procedure is also associated with higher morbidity (adverse effects), secondary spinal instability, longer recovery time, and more risks and might be less tolerated in patients with advanced age.
  • The decision of whether to perform decompression surgery alone or to combine it with fusion is largely based on the clinical judgment of the surgeon. Generally, multilevel spinal stenosis involving foraminal and lateral stenosis with significant central canal stenosis, compounded with multilevel spondylosis with significant segmental dynamic instability, will require extensive multilevel decompression including medial facetectomy and multilevel spinal fusion.”

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.

Bone spurs form as a result of the microinstability of the spine. Bone spurs are an “inner cast” that 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 limit the destructive spinal motion that causes 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 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

  • 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.

Is it canal narrowing or wearing away of the vertebrae endplates that are causing pain attributed to lumbar spinal stenosis

A September 2021 study in The Spine Journal (23) addressed the controversy as to whether lumbar spinal stenosis itself contributes to low back pain. What these researchers are suggesting is that even when an MRI shows stenosis, that may not be what is causing the patient’s problems. The researchers write: “Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to low back pain. However, whether these factors cause low back pain in patients with lumbar spinal stenosis is unclear.” To then answer this question, the researchers looked at 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication (neurologic symptoms going from numbness to possibly bladder dysfunction) caused by lumbar spinal stenosis. What did they find? The presence of erosive endplate defects. . . These results suggest that low back pain in patients with lumbar spinal stenosis should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.”

What are endplate defects?

The endplates are the rim of the vertebrae, endplate defects represent the wearing away or dissolving of the rim of the vertebrae. This can occur from spinal instability which allows the bones to become hypermobile and bang and wear against each other  The damage to the endplate can not only result in the flattening of the disc and disc herniation, but modic changes as well (damage to the bone marrow within the vertebrae causing bone marrow edema or inflammation).

What are we seeing in this image? The caption reads: MRI of the lower back demonstrating Modic changes in several lumbar vertabrae. The person in this image suffers from degenerative Modic Type 1 endplate bone marrow signal changes at L3-L4 (signifying lesions and other damage). In this case, the patient was treated with Prolotherapy injections which helped stabilize the spine.

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 the 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. (24)

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?”(25)

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. (26) 

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. (27)

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”(28), according to research in the Journal of Neurosurgery from Wayne 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 outcomes, both open and minimally invasive surgery, are not as successful as one would think
  • MRIs can reveal stenosis that causes no pain
  • MRI can reveal 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?

Treating the spinal ligaments may be the answer to stenosis


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 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.

This picture describes degenerative progression of the lower spine.

 

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 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 surgery can help. These patients also find it hard to believe that after their Prolotherapy treatments 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. (29)  
    • 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 (30)
    • 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 published research in which we followed 145 patients who had suffered from back pain on average for 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 were told by their medical doctor(s) that there were no other treatment options for their pain, and a subset of 26 patients was 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. (31)

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 (32), 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


The Spinal ligament repair injection treatment option Prolotherapy

Summary and Learning Points of Prolotherapy to the low back

  • Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
  • Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
  • We treat the whole low back area to include the sacroiliac or SI joint. In the photo above, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.

  • Why the black crayon lines? This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
  • After treatment we want the patient to take it easy for about 4 days.
  • Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.

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 a 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 should be contacting us 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 the 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 non-surgical 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!
This picture illustrates how a Prolotherapy injection can tighten the spinal ligaments and provide relief through providing vertebral alignment therapy. This will help alleviate the pressure caused by pinched nerves and herniated discs.
This picture illustrates how a Prolotherapy injection can tighten the spinal ligaments and provide relief through providing vertebral alignment therapy. This will help alleviate the pressure caused by pinched nerves and herniated discs.

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 are SSAR and SSWA which stand for Spinal Stenosis At Rest and then Spinal Stenosis With Activity. (See Figure)

This picture illustrates the severity of symptoms that can occur in situations referred to as Spinal Stenosis At Rest and Spinal Stenosis With Activity. It also explains when surgery will likely be recommended for Stenosis At Rest and when surgery can be avoided in cases of Stenosis With Activity.
This picture illustrates the severity of symptoms that can occur in situations referred to as Spinal Stenosis At Rest and Spinal Stenosis With Activity. It also explains when surgery will likely be recommended for Stenosis At Rest and when surgery can be avoided in cases of Stenosis With Activity.

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 are 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 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!

The issue of pain catastrophizing and walking after stenosis surgery

A December 2022 study in the journal BioMed Central musculoskeletal disorders (33) examined whether walking speed is associated with postoperative pain catastrophizing in patients with lumbar spinal stenosis. In other words, do people who walk more slowly have worse surgical outcomes because of pain catastrophizing? In this study, the researcheres assessed the medical records and outcomes of consecutive patients with clinically and radiologically defined lumbar spinal stenosis who underwent surgical treatment (decompression, or posterolateral or transforaminal lumbar interbody fusion). Various pain and function scoring systems, including a pain catastrophizing scale, were used preoperatively and at three, six, and 12 months postoperatively.

  • Initially ninety-four patients were included at baseline, at 12 months 82 patients remained in the study. The pain catastrophizing scale was significantly correlated with walking speed, leg pain, and back pain. The pain catastrophizing scale was associated with walking speed at all evaluation time points. The researchers concluded: “walking speed is a necessary assessment for the management of pain catastrophizing and associated pain and disability in patients after lumbar spine surgery.”

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.

For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your back problems and spinal instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

Subscribe to our newsletter 

Research citations:

1 Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Jan 29;(1): [Google Scholar]
2 Minetama M, Kawakami M, Teraguchi M, Enyo Y, Nakagawa M, Yamamoto Y, Matsuo S, Nakatani T, Sakon N, Nakagawa Y. Supervised physical therapy versus surgery for patients with lumbar spinal stenosis: a propensity score-matched analysis. BMC Musculoskeletal Disorders. 2022 Jul 11;23(1):658. [Google Scholar].
3 Rajasekaran S, Pushpa BT, Ananda KB, Prasad A, Rishi MK. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of’clinical reporting’: results from an RCT and blinded trials. European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2021 Mar 21. [Google Scholar]
4 Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ open quality. 2021 Jul 1;10(3):e001287. [Google Scholar]
Knutsson B, Jong M, Sayed-Noor A, Sjödén G, Augutis M. Waiting for lumbar spinal stenosis surgery: suffering and a possibility to discover coping abilities. Orthopedic Reviews. 2021 Dec 10:30716. [Google Scholar]
6 Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022 May 3;327(17):1688-99. [Google Scholar]
7 Igari T, Otani K, Sekiguchi M, Konno SI. Epidemiological Study of Lumbar Spinal Stenosis Symptoms: 10-Year Follow-Up in the Community. Journal of Clinical Medicine. 2022 Oct 7;11(19):5911. [Google Scholar]
8 Adogwa O, Davison MA, Vuong VD, Khalid S, Lilly DT, Desai SA, Moreno J, Cheng J, Bagley C. Long Term Costs of Maximum Non-Operative Treatments in Patients with Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery: A Five-Year Cost Analysis. Spine. 2018 Aug. [Google Scholar]
9 Davison MA, Vuong VD, Lilly DT, Desai SA, Moreno J, Cheng J, Bagley C, Adogwa O. Gender Differences in Use of Prolonged Nonoperative Therapies Before Index Lumbar Surgery. World Neurosurgery. 2018 Dec 1;120:e580-92. [Google Scholar]
10 Peteler R, Schmitz P, Loher M, Jansen P, Grifka J, Benditz A. Sex-Dependent Differences in Symptom-Related Disability Due to Lumbar Spinal Stenosis. Journal of Pain research. 2021 Mar 16:747-55. [Google Scholar]
11 Smith DL, Olding K, Malaya CA, McCarty M, Haworth J, Pohlman KA. The influence of flexion distraction spinal manipulation on patients with lumbar spinal stenosis: A prospective, open-label, single-arm, pilot study. Journal of Bodywork and Movement Therapies. 2022 May 18. [Google Scholar]
12 Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun S, El Ahmadieh T. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Research. 2019 Jan 31;8. [Google Scholar]
13. Ammendolia C, Hofkirchner C, Plener J, Bussières A, Schneider MJ, Young JJ, Furlan AD, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. BMJ open. 2022 Jan 1;12(1):e057724. [Google Scholar]
14 Virk SS, Phillips FM, Khan SN. Factors Affecting Utilization of Steroid Injections in the Treatment of Lumbosacral Degenerative Conditions in the United States. International Journal of Spine Surgery. 2018 May 1:5021. [Google Scholar]
15 Radcliff K, Kepler C, Hilibrand A, Rihn J, Zhao W, Lurie J, Tosteson T, Albert T, Weinstein J. Epidural Steroid Injections Are Associated with Less Improvement in the Treatment of Lumbar Spinal Stenosis: A subgroup analysis of the SPORT. Spine (Phila Pa 1976). 2012 Dec 12.  [Google Scholar]
16 Hennemann S, Abreu MR. Degenerative Lumbar Spinal Stenosis. Revista Brasileira de Ortopedia. 2021 Apr 5;56:9-17.
17 Patel J, Osburn I, Wanaselja A, Nobles R. Optimal treatment for lumbar spinal stenosis: an update. Current Opinion in Anesthesiology. 2017 Oct 1;30(5):598-603. [Google Scholar]
18 Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 4;352:h6234. [Google Scholar]
19 Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010;24(2):253-65. [Google Scholar]
20 Alhaug OK, Dolatowski FC, Solberg TK, Lønne G. Predictors for failure after surgery for lumbar spinal stenosis, a prospective observational study. The Spine Journal. 2022 Nov 5. [Google Scholar]
21 Hebert JJ, Abraham E, Wedderkopp N, Bigney E, Richardson E, Darling M, Hall H, Fisher CG, Rampersaud YR, Thomas KC, Jacobs B. Patients undergoing surgery for lumbar spinal stenosis experience unique courses of pain and disability: A group-based trajectory analysis. PloS one. 2019;14(11):e0224200-.
22 Diwan S, Sayed D, Deer TR, Salomons A, Liang K. An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach. Pain Medicine. 2019 Dec 1;20(Supplement_2):S23-31. [Google Scholar]
23 Minetama M, Kawakami M, Teraguchi M, Matsuo S, Sumiya T, Nakagawa M, Yamamoto Y, Nakatani T, Nagata W, Nakagawa Y. Endplate defects, not the severity of spinal stenosis, contribute to low back pain in patients with lumbar spinal stenosis. The Spine Journal. 2021 Sep 30. [Google Scholar]
24 Schroeder GD, Kurd MF, Vaccaro AR. Lumbar Spinal Stenosis: How Is It Classified? J Am Acad Orthop Surg. 2016 Dec;24(12):843-852.  [Google Scholar]
25 Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let’s tell someone. Surg Neurol Int. 2016 Jan 25;7(Suppl 3):S96-S101.  [Google Scholar]
26 Ishimoto† Y, Noriko Y, Shigeyuki M, Hiroshi Y, et al. Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: The Wakayama Spine Study. Osteoarthritis Cartilage. 2013 Mar 5. pii: S1063-4584(13)00706-1. doi: 10.1016/j.joca.2013.02.656.  [Google Scholar]
27 Romero-Vargas S, Obil-Chavarria C, Zárate-Kalfopolus B, Rosales-Olivares LM, Alpizar-Aguirre A, Reyes-Sánchez AA. [Profile of the patient with lumbar failed surgery syndrome at National Institute of Rehabilitation. Comparative analysis]. Cir Cir. 2015 May 15.  [Google Scholar]
28 Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. [Google Scholar]
29 Watson JD, Shay BL. Treatment of chronic low-back pain: a 1-year or greater follow-up. J Altern Complement Med. 2010 Sep;16(9):951-8. doi: 10.1089/acm.2009.0719. [Google Scholar]
30 Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”: a single blinded, randomized and cross-over study. Pain Physician. 2005 Apr;8(2):167-73. [Google Scholar]
31 Hauser R, Hauser M. Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study. Journal of Prolotherapy. 2009;1(3):145-155.
32 Jacks A, Barling T. Lumbosacral prolotherapy: a before-and-after study in an NHS setting. International Musculoskeletal Medicine. 2012 Apr 1;34(1):7-12.  [Google Scholar]
33 Wada T, Tanishima S, Kitsuda Y, Osaki M, Nagashima H, Noma H, Hagino H. Walking speed is associated with postoperative pain catastrophizing in patients with lumbar spinal stenosis: a prospective observational study. BMC Musculoskeletal Disorders. 2022 Dec;23(1):1-6. [Google Scholar]
34 Lebedev VB, Epifanov DS, Osipov II, Esin AI, Kinzyagulov BR, Zuev AA. [Revision surgery after previous spinal decompression and fusion for lumbar spinal stenosis]. Zh Vopr Neirokhir Im N N Burdenko. 2023;87(1):70-76. Russian. doi: 10.17116/neiro20238701170. PMID: 36763556.
35 Uri O, Alfandari L, Folman Y, Keren A, Smith W, Paz I, Behrbalk E. Acute disc herniation following surgical decompression of lumbar spinal stenosis: a retrospective comparison of mini-open and minimally invasive techniques. J Orthop Surg Res. 2023 Dec 18;18(1):974. doi: 10.1186/s13018-023-04457-2. PMID: 38111077
36 Shemesh S, Laks A, Cohen I, Turjeman A, Blecher R, Kadar A. Diabetes Mellitus and Poor Glycemic Control are Associated with a Higher Risk of Lumbar Spinal Stenosis: An Analysis of a Large Nationwide Database. Spine.:10-97. [Google Scholar]

Get Help Now!

You deserve the best possible results from your treatment. Let’s make this happen! Talk to our team about your case to find out if you are a good candidate.