Undiagnosed spinal ligament damage as the main culprit behind back pain

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Most patients who come to Caring Medical with low back or lumbar disc disease, and thoracic or neck (cervical) pain have MRIs that show disc degeneration. On examination, we find that the MRI’s interpretation or demonstration of disc degeneration is seldom what is causing their pain. Some of the clues we have seen in our thirty-plus years of helping patients that may lead a doctor to believe that pain is not coming from the disc problem include:

  • Pain on either side of the spine not on the midline.
  • Sensation is intact, with regular sensations of pain, temperature, and lack of numbness or tingling.
  • Muscle strength is strong. Lack of muscle atrophy.
  • Pain upon lying down.
  • Pain is not worse with sitting.
  • Pain is not worse with bending over.
  • Cracking.

All of the above symptoms suggest ligament laxity of the spine or sacroiliac ligament problems. Disc problems are more indicative if the person has low back pain for instance that is:

  • Central.
  • Sitting makes it worse.
  • Standing (compared to lying) makes it worse.
  • Bending over while standing increases the central pain.

Spinal ligaments as the main culprit behind back pain

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

  • Here the interspinous ligament weaves between the spinous processes connecting the back of the vertebrae and 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.

The spine relies heavily on the supporting ligaments to hold itself together

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)

The above paper is from 2016. Despite the fact that spinal ligament laxity has been thought to be a culprit in back pain for decades, a 2023 paper (2) from doctors at Johns Hopkins University and the University of Minnesota writes: “Degeneration of the lumbar spine, and especially how that degeneration may lead to pain, remains poorly understood. In particular, the mechanics of the facet capsular ligament may contribute to low back pain, but the mechanical changes that occur in this ligament with spinal degeneration are unknown.” In this paper, the research team isolated the facet capsular ligament. What they found was that the composition of the facet capsular ligament changed and correlated with degeneration of the lumbar spine. Further, they suggested that degeneration of the lumbar spine including the facet capsular ligament appears to be occurring as a whole joint phenomenon.

What does this mean? As we have explained throughout this website, osteoarthritis is a whole joint disease. In the case of the spine, an initial wear and tear or trauma injury to the spinal ligaments started a degenerative cascade where spinal ligament weakness caused degenerative disc disease and degenerative disc disease caused spinal ligament weakness and spinal instability and pain.

This idea is not new. 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. (3) The researchers wrote: “Ligaments have variable strengths and act via different lever arm lengths to contribute to spinal stability. As a consequence of the longer moment arm (the longer length of these ligaments) from the spinous process to the instantaneous axis of rotation, inherently weaker ligaments (interspinous and supraspinous) are able to provide resistance to excessive flexion (hypermobility). ”

Listen to the opening of this 2015 research review, this is from Batson Children’s Hospital, University of Mississippi Medical Center: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.”(4)

A November 2022 (5) study published in the journal BioMed Research International, citing the call for more research in the 2015 study and presenting an examination of ligament variations and changes over time mentioned in the previous studies, noted in their examination of cadavers, variation in the morphological appearance of the vertebra-pelvic ligament complex distinguished in the iliolumbar ligament, the sacrospinous ligament, and the sacrotuberous ligament. Morphological variation may cause instability in the sacroiliac joint and could be related to unexplained lower back pain. The researchers concluded: “Additional clinical and radiological investigations are crucial in real patients with unspecified cause of lower back pain to explore the relation between idiopathic lower back pain and the variant type of the iliolumbar ligament. More studies are needed to investigate the etiology of lower back disc prolapse and if it has an association with the variant type of the iliolumbar ligament.”

The ligaments of the spine as the key to degenerative disc disease

In one study doctors from Brigham Young University (6) 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 of 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.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, and reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on research and clinical results, Prolotherapy may be 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.

Prolotherapy repairs collagen fibers in the ligaments, strengthening the ligaments and restoring spinal strength and stability.

In the Journal of Prolotherapy(7) 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.

Other studies include:

From the Department of Veterans Affairs, Northern California Health Care System published in the journal Complementary Therapies in Medicine: (8)

  • “A satisfactory proportion of patients with symptomatic SI joint instability as an etiology of low back pain can have clinically meaningful functional gains with prolotherapy treatment.”

University of Manitoba, Winnipeg, Manitoba, Canada. The Journal of Alternative and Complementary Medicine (9)

  • 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.7

Harold Wilkinson MD, in the journal The Pain Physician (10)

  • Prolotherapy can provide significant relief of axial pain (soft tissue damage) and tenderness combined with functional improvement, even in “failed back syndrome” patients.

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 were told by their doctor(s) that surgery was their only option.
  • In these 145 low backs,
    • pain levels decreased from 5.6 to 2.7 after Prolotherapy;
    • 89% experienced more than 50% pain relief with Prolotherapy;
    • More than 80% showed improvements in walking and exercise ability, anxiety, depression, and overall disability;
    • 75% percent were able to completely stop taking pain medications. (11)

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.

Prolotherapy, by tightening the capsular ligaments of the spine, can improve spinal alignment through the vertebrae. Possibly relaxing spinal cord decompression and a "pinched" nerve.

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 the repair of the ligament attachment to the bone.
  • We treat the whole lower back area including 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.

Is this treatment right for you?

It may be difficult for some people to think that Prolotherapy may offer them an option when so many treatments 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.

Summary and contact us. Can we help you?

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

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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. Computer methods in biomechanics and biomedical engineering. 2016 Jul 3;19(9):1009-18. [Google Scholar]
2 Middendorf JM, Budrow CJ, Ellingson AM, Barocas VH. The Lumbar Facet Capsular Ligament Becomes More Anisotropic and the Fibers Become Stiffer with Intervertebral Disc and Facet Joint Degeneration. Journal of biomechanical engineering. 2023 May 1;145(5):051004. [Google Scholar]
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5 Albatati AS, Khalifa AF, El-Sherbiny M, Alfayez MA, Abualmakarim S, Ebrahim HA, Aljahdali AR, Darwish H. Deferent Anatomical Presentations of Iliolumbar Ligament: A Cadaveric Study. BioMed Research International. 2022 Nov 2;2022. [Google Scholar]
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7 Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [Google Scholar]
8 Hoffman MD, Agnish V. Functional outcome from sacroiliac joint prolotherapy in patients with sacroiliac joint instability. Complementary therapies in medicine. 2018 Apr 1;37:64-8. [Google Scholar]
9 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]
10 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]
11 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]

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