Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.

The concept behind this treatment and Lumbar Spondylolisthesis is that in Grade 1 and Grade 2 Spondylolisthesis, Prolotherapy injections may be able to help pull the vertebrae back into alignment. Grade 3 and Grade 4 Spondylolisthesis may benefit from Prolotherapy but results are challenging and surgery may be needed.

Spondylolisthesis grading is based on the amount of “slippage.” Slippage can also tell us how weak the spinal ligaments are.

Ligaments are the connective tissue that holds the vertebrae in place. When you have slippage, it is because the strong bands of ligaments are no longer strong enough to hold the vertebrae in place. Generally speaking, the more slippage the weaker the connective tissue.

• grade I: 0-25% slippage – can be repaired with Prolotherapy
• grade II: 26-50% – can be repaired with Prolotherapy
• grade III: 51-75% – Prolotherapy may offer pain benefits, surgery may be more realistic
• grade IV: 76-100% – Prolotherapy may offer pain benefits, surgery may be more realistic
• grade V (spondyloptosis): >100%

The many complexities of the spine and the spinal ligaments can be seen at the intervertebral joints – where vertebrae connect to each other.

• Here the interspinous ligament weaves between the spinous processes connecting the back of the vertebrae bony processes.
• The supraspinous ligament connects the spinous processes. Running towards the cervical spine it forms the nuchal ligament.
• The intertransverse ligaments connect the adjacent transverse processes, and the ligamentum flavum connects the laminae of adjoining vertebrae.

It should be clear that the spinal ligaments are key factors in spinal stability and instability which can lead to degenerative disc and possible nerve compression at the facet joints in flexion or extension, and at the lower back ligaments of the sacroiliac joints.

In other words, back pain can be due to an unstable disc problem, facet joint locking, or sacroiliac dysfunction caused by problems of the spinal ligaments.

“It is of high importance to understand how changes in mechanical properties affect the response of the lumbar spine, specifically in an effort to differentiate those associated with disc degeneration from ligamentous changes (problems of the spinal ligaments).”

The opening statement of a recent research article from doctors at the Mayo Clinic brings all these concerns together when the researchers state: “Understanding spinal kinematics (the movement of the spine)  is essential for distinguishing between pathological conditions of spine disorders, which ultimately lead to low back pain.

It is of high importance to understand how changes in mechanical properties affect the response of the lumbar spine, specifically in an effort to differentiate those associated with disc degeneration from ligamentous changes (problems of the spinal ligaments), allowing for more precise treatment strategies.”(1)

In April 2016 doctors from the Hospital for Special Surgery in New York, the University of Southern California, and the University of Virginia published their findings that acknowledged Degenerative Disc Disease is just that, a problem of degeneration and aging and that the vertebrae and facet joints of the spine represent a three-joint complex that relies heavily on their supporting ligaments to hold the joint together. (2) 

What are we seeing in this image?

When spinal ligaments become loose because of wear and tear of acute injury, they can no longer do the job they were intended to do, hold your spine in proper alignment. When the spine becomes unstable, the vertebrae move. When the vertebrae move, they can slip out of place and cause Lumbar Spondylolisthesis.

The ligaments of the spine as the key to spinal instability

In one study doctors from Brigham Young University (3) even suggest that the ligaments may be the key to degenerative disc disease and spinal degenerative changes. The researchers suggest that it is hard for doctors and MRIs to figure out the pain sources in low back pain and that even when people have it, there are no symptoms for it. Yet, eventually, it will develop into worsening low back pain and disc problems.

But, these researchers also say that there are “patterns” of disc degeneration that may provide insight into where the pain is coming from and that by addressing these patterns – further disc degeneration can be managed, What do doctors need to address? Spinal ligaments.

Specifically, individuals with contiguous multi-level disc degeneration have been shown to exhibit higher presence and severity of low back pain as compared to patients with skipped-level disc degeneration (i.e. healthy discs located in between degenerated discs).

Here is the reason: Stresses on the surrounding ligaments, facets, and pedicles (the area of the vertebrae where many spinal procedures begin) at vertebral levels where there was no degeneration of the spine were generally lower than where degeneration occurred.

It should be obvious that stable ligaments equal stable spines – unstable ligaments – unstable spines.

A Prolotherapy treatment into the lumbar spine.

Learning Points

• 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 these images, 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.
• The black crayon marks all down the midline of this patient’s back give guidance to where the injections should be placed. The horizontal line is drawn where the patient’s pain stops. 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.

Comprehensive Prolotherapy which includes the use of stem cell therapy can be an ideal treatment for patients with developing spondylolisthesis because it strengthens the ligaments and tendon enthesis surrounding and attached to the slipped vertebrae. As the ligaments and tendons are strengthened spinal stability is restored.

Treatments are given to the ligaments on the back of the spine.  By tightening the ligaments in the back of the spine Prolotherapy helps stabilize the area thereby giving pain relief and allowing for other structures to heal. Typically a patient will require 3-6 visits, although some patients require more visits depending on their overall health status and the extent of their injury.

“Prolotherapy injections produce an inflammatory response, which can augment collagen fiber and ligament structure regeneration.”

In the Journal of Prolotherapy, (4) James Inklebarger, MD and  Simon Petrides, MD wrote: “Prolotherapy injections produce an inflammatory response, which can augment collagen fiber and ligament structure regeneration, resulting in tightening and strengthening of spinal ligaments, thereby reducing the incidence of discogenic low back pain by improving intersegmental stability.”

They concluded their research by suggesting: “There are currently few treatment choices other than surgical fusion for intractable lumbar discogenic pain and instability. Prolotherapy may offer a minimally invasive, cost-effective, and safe management option for these patients.

The findings in this study are in keeping with conclusions of other studies in that Prolotherapy, in conjunction with rehabilitation, would appear to be an effective intervention for the treatment of discogenic lower back pain associated with degenerative disc disease of the lumbar spine.^“

Caring Medical Research

Citing our own 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. (5)

By correcting the instability of the lumbar spine at an early stage, Prolotherapy will cause less stress to be imposed on the disc and less degeneration to occur at the disc.

We concluded this research by suggesting that in this study on the use of  Prolotherapy, patients with over four years of unresolved low back pain were shown to improve their pain, stiffness, range of motion, and quality of life measures even 12 months subsequent to their last Prolotherapy session. This pilot study shows that Prolotherapy is a treatment that should be considered and further studied for people suffering from unresolved low back pain.

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

Diagnosing lumbar instability & treatment with Prolotherapy, PRP, cortisone, nerve blocks

Ross Hauser, MD and Danielle Matias, PA-C discuss the types of cases we see at Caring Medical Florida for low back pain and spinal instability.

Summary: Is this treatment right for you?

To recap: Lumbar spinal fusion operations fuse together several segments of the vertebrae. Such an operation is commonly performed for spondylolisthesis to pull the vertabrae back into a natural alignment. While many people have successful surgeries many people can also suffer from post-operative back pain and adjacent segment disease or other complications caused by the surgery. After surgery, mobility can be decreased causing increased stress on the areas above and below the fused segment. While fusion is sometimes a necessary surgery, the long-term consequences should be known and all conservative efforts tried.

It may be difficult for some people to think that Prolotherapy may offer them an option when so many treatments before have failed. It may be hard for some patients to ignore strong recommenders to consider a spinal surgery that may or may not help and may or may not make their situation worse than it is today. Is this treatment right for you? Would you be a good candidate? Ask us.

References

1 Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2016;19(9):1009-18. doi: 10.1080/10255842.2015.1088524. Epub 2015 Sep 24. PMID: 26404463; PMCID: PMC4808500. [Google Scholar]
2 Iorio JA, Jakoi AM, Singla A. Biomechanics of degenerative spinal disorders. Asian spine journal. 2016 Apr;10(2):377. [Google Scholar]
3 Von Forell GA, Stephens TK, Samartzis D, Bowden AE. Low back pain: a biomechanical rationale based on “patterns” of disc degeneration. Spine. 2015 Aug 1;40(15):1165-72. [Google Scholar]
4 Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [Google Scholar]
5 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155. [JOP/CMRS]