Lumbar instability and osteoarthritis of the spine
Ross Hauser, MD
This is a companion article to our more comprehensive article Prolotherapy treatments for lumbar instability and low back pain.
Many people that read articles on lumbar or spinal instability are clearly searching for some answers. They are typically someone who has had many years of treatment, general and more specific recommendations to consider various forms of spinal surgery and most simply and most impactful, a reduced quality of life because of back pain and loss of function. These people do understand that their lumbar instability describes two or more vertebrae in the lumbar spine that are wandering around, banging into each other, compressing nerves and herniating discs. They are progressing to a point where their spine will no longer be able to support the weight of their core, torso and upper body. They may be at a point where their bodies are desperately trying to support the spine with bone spurs and a natural form of spinal fusion. They are at the point of lumbar osteoarthritis.
Aren’t degenerated discs the problem?
Most people experience some form of back pain by the time they reach middle age. However, athletes who participate in twisting sports such as golf, tennis, and bowling, due to the forces exerted during their sports, are more at risk for developing osteoarthritis of the spine. Other athletes experience repeated strain on the back due to posture, such as back packing and hiking. We cannot forget, however, the constant poor posture of most Americans as they sit at their desks, slouch on their couches, all the while face down into their computers or mobile devices.
A good portion of the population suffers from daily back pain and ends up choosing back surgery in hopes of alleviating the pain. Unfortunately, many patients are left with even more pain because the surgery that was supposed to strengthen the weak area actually ended up weakening the area to the point that the non-surgerized back was actually stronger. Degeneration occurs in the back due to a weakening of the support structures. Left untreated, this leads to osteoarthritis with accompanying pain and stiffness.
Aren’t degenerated discs the problem? The intervertebral disc is a major component contributing to segmental stability as well as a major load-bearing structure. Disc abnormalities that occur in osteoarthritis, however, are not associated with pain. Many patients and athletes are distressed at being told that they are suffering from one or more degenerated discs. Disc degeneration occurs as age advances, but often causes no pain. Thus the other structures in the back are causing the problem.
The spinal ligaments are the focus of this article – not the muscles – not the discs
The most common cause of unresolved chronic back pain is spinal instability. People who have low back (lumbar) pain know that rest, pain medications, trigger point shots, manipulation, and massage may be helpful, but they did not long-term alleviate their pain. Common sense tells us that if chronic lumbar pain were simply and only a muscle problem, anyone could sit in a hot tub for two hours or get a long massage and they would be cured of their pain. But we know this does not occur. Those therapies only help temporarily. The underlying cause of the chronic pain is not the muscles themselves but rather muscle spasms brought on by ligament laxity. Since over 90% of the injuries to any one of the over 900 ligaments in the body cannot be seen on conventional x-ray or MRI, patients are not told that the reason for their chronic low back pain is facet joint instability from ligament laxity. Spinal instability, in large part, is due to facet joint capsular ligament injury and is the cause of almost every chronic spinal pain.
More specifically, in the instance of low back pain, injury to the sacroiliac ligaments typically occurs from bending over and twisting with the knees in a locked, extended position. This maneuver stretches the sacroiliac ligaments, placing them in a vulnerable position. The ligaments are white (poor blood supply), they are very unlikely to heal on their own, especially in chronic back pain, yet are incredibly important for spinal stability and movement.
The supraspinatus and interspinatus ligaments go from vertebra to vertebra. The iliolumbar ligaments attach along the ilium to sacrum (sacroiliac ligaments). Cumulative injury (without repair) over years of sports or improper movement can result in small tears in these ligaments. Often healing never occurs and people report “chronic nagging back pain.” Since the ligaments do not heal, the intervertebral discs do not have the support that they need. Instability and ligament laxity with resultant instability cause chronic low back pain.
Thus, spending a lot of time and money on therapies that work the surrounding muscles is only going to produce a temporary benefit. Patients with back pain frequently complain about muscle tightness, spasms, or feeling like the SI might “give out.” They focus so much on the muscles (workout harder, stretch more, get more massage, etc…), that they ignore or do not know why the muscles got that way is due to overcompensation for the lack of stability in the ligaments that hold the lumbar spine and sacroiliac joints in place.
Symptoms of worsening lumbar spinal instability
- Back pain and spine “giving out” is progressively worsening.
- You develop a fear of certain movements such as bending over.
- You have to pace yourself or slowly rise from a bent position into standing straight. Sometimes telling yourself “don’t hurt yourself” when changing into the upright position.
- Sleeping in certain positions is giving you spasms and pain in your lower back when you wake up.
- You have difficulty with unsupported sitting (such as on a stool or chair without good back support) and better with supported backrest.
- Chronic, daily, frequent bouts or episodes of symptoms (recurrence, not first episode).
- Chronic, daily, frequent episodes of muscle spasms.
- Need to frequently crack or pop the back to reduce symptoms.
- Pain increased with sudden, trivial, or mild movements. You throw you back out for no reason. You were just standing there and you spasmed.
- Temporary relief with back brace or corset.
I have been diagnosed with lumbar stenosis. I have terrible pain in my lower back, buttocks and upper thighs. Especially when I stand. I have a stability problem in my back and with my ability to balance myself from tipping over. If I fall, I cannot get up. I have diminished leg strength and now need a cane or a walker to get myself around. I have dad this going on 20 years. Most recently the problem has accelerated. I have had physical therapy and epidural injection.
Mechanical and functional spinal instability
What are we seeing in this image? The caption reads: Almost all chronic pain in the lower back occurs in a six-by-four inch area. Pain in the lower back occurs in the area where the lumbar vertebrae join the sacrum and the iliac crest.
Ninety-five percent of low back pain is located in a six-by-four inch area, the weakest link in the vertebral-pelvis complex.
At the end of the spine, four structures connect in a very small space, which happens to be the six-by-four inch area. The fifth lumbar vertebra connects with the base of the sacrum. This is held together by the lumbosacral ligaments. The sacrum is connected on its sides to the ilium and iliac crest. This is held together by the sacroiliac ligaments. The lumbar vertebrae is held to the iliac crest and ilium by the iliolumbar ligaments.
Lumbar instability begins when the stabilizing structures of the spine, especially the ligaments can no longer hold adjacent bones together. When present, this is termed mechanical instability. The term functional instability is used when the mechanical instability causes symptoms with a certain function or activity (like those described above). Many people are walking around with mechanical instability but are asymptomatic because the force required to perform current normal activities is not beyond the ligaments and muscles ability and strength to perform these functions.
Problems develop when the mechanical instability worsens when patients overdo an activity or start a new exercise program. Thus the patient may have symptoms only when performing a certain activity, such as back pain with running. From the patient’s perspective, pain symptoms do not exist during any other activities. This is called functional spinal instability with running and mechanical instability of the entire low back.
Functional instability, or symptomatic instability with movement, occurs with mechanical failure of the spinal ligaments and the subsequent excessive motion of adjacent bones. This can be caused by trauma, disease, surgery, or any combination there of to one or more regions of the spine.
How to treat lumbar spinal instability?
Except in a life-threatening situation or impending neurologic injury, surgery should always be a last resort and performed only after all conservative treatments have been exhausted. Pain is not a life-threatening situation, although it can be very anxiety-provoking, life-demeaning, and aggravating. Pain should not be an automatic indication that surgery is necessary. As you are reading this article it is very likely that you have had years of various treatments with various degrees of short-term success. Obviously if your treatments or surgery were successful, you would not be reading this article.
The problem of treatments for lumbar spinal instability is the subject of numerous medical research papers. An August 2021 study published in The Spine Journal (1) lead by researchers at the Department of Orthopaedics and Physical Medicine, Medical University of South Carolina; Brigham and Women’s Hospital, Harvard Medical School; Tufts University School of Medicine selected 131 different patient scenarios and presented them to doctors for possible recommendation of treatments. The Main diagnosis these scenarios centered on was lumbar spondylolisthesis.
Here are some of the learning points of this research:
- These scenarios addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities that may impact the success of treatment.
- For most of these scenarios, appropriateness of treatment was established for:
- physical therapy,
- and various forms of surgical intervention.
- Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits.
- Epidural steroid injections were most appropriate in patients with radiculopathy.
- Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis.
- Patients with mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making.
- Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers.
Physical therapy can help highly obese patients
A January 2021 study (2) in the journal Medicine comes from the Department of Physical Therapy, Daejeon University in Korea. In this research the therapists wrote that intensive neuromuscular stabilization exercise on highly obese patients with low back pain results in positive effects of body fat decline (weight loss) and prevention of complications. Further a more progressive neuromuscular stabilization exercise (exercises that concentrate on muscle strength) on unstable surface (areas of instability) on pain, motor function, psychosocial factors, balance, and abdominal contraction with highly obese patients with lumbar instability.
Please see our article Weight loss can reduce back pain for a more detailed discussion on benefits and motivation for weight loss in the treatment of lumbar instability and back pain.
Prolotherapy strengthens the lumbar vertebral ligaments and prevent the progressive degeneration that occurs with age to the intervertebral discs. A patient with chronic low back pain is typically treated with Prolotherapy injections into the insertions of the lumbosacral, iliolumbar, and sacroiliac ligaments. The initial assessment may reveal that the chronic low back pain and referred leg pain may be caused by a referred pain from other areas such as the pubic symphysis, hip joint, ischial tuberosity, sacrospinous, and sacrotuberous ligaments. Therefore, these areas are also examined.
In a paper published in the Journal of Prolotherapy, (3) doctors offered a case study series as to how Prolotherapy injections might be advantageous in the management of discogenic low back pain through improving vertebral segmental stability. This is achieved by addressing damage to the spinal ligaments. The authors noted: “In comparison to other soft tissues, ligaments have less vascularity. Once injured or degenerated, this lack of blood supply may delay healing. Prolotherapy may offer the stimulus for ligament regeneration. However, without a program of lumbar stabilization exercises, it is likely to be less effective in directing the healing tissues to become more organized, flexible and less prone to re-injury. Therefore, rehabilitative exercise is an essential component to achieve a maximum stabilization effect.”
A December 2021 paper in the Journal of back and musculoskeletal rehabilitation (4) performed Prolotherapy on six hundred fifty-four patients with chronic low back pain and lumbar disc herniation at four to six week intervals. The results were:
The Visual Analogue Scale (0-10 0 = no pain 10 = severe, unbearable pain) scores decreased from a very severe pain of 7.2 to a mild to almost no pain score of 0.9 after 52 weeks of the treatment. Thirty-four patients’ treatments resulted in poor clinical results (5.2%), and 620 of the patients’ pain improved (94.8%).
Conclusion: “Prolotherapy can be regarded as a safe way of providing a meaningful improvement in pain and musculoskeletal function compared to the initial status. Diagnostic injection is an easy way to eliminate patients and may become a favorite treatment modality. 5% dextrose is a more simple and painless solution for Prolotherapy and also has a high success.”
Questions about our treatments?
If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
1 Reitman CA, Cho CH, Bono CM, Ghogawala Z, Glaser J, Kauffman C, Mazanec D, O’Brien Jr D, O’Toole J, Prather H, Resnick D. Management of degenerative spondylolisthesis: development of appropriate use criteria. The Spine Journal. 2021 Mar 6. [Google Scholar]
2 Park SH, Lee MM. Effects of progressive neuromuscular stabilization exercise on the support surface on patients with high obesity with lumbar instability: A double-blinded randomized controlled trial. Medicine. 2021 Jan 29;100(4). [Google Scholar]
3 Inklebarger J, Petrides S. Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977.
4 Solmaz I, Orscelik A, Koroglu O. Modified prolotherapy by 5% dextrose: Two years experiences of a traditional and complementary medicine practice center in Turkey. Journal of Back and Musculoskeletal Rehabilitation. 2021(Preprint):1-8. [Google Scholar]