Ross Hauser, MD
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.
The ligaments are the focus of this article – not the muscles.
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. 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.
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.
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.
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:
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.”
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.