Lumbar scoliosis and hip pain. Exploring non-surgical treatment options
Ross Hauser, MD., Danielle R. Steilen-Matias, PA-C., Brian Hutcheson, DC.
Lumbar scoliosis and hip pain. Exploring non-surgical treatment options.
If you are reading this article you are likely someone who has been diagnosed with scoliosis “since I was a kid.” In many cases, maybe like yours, you were treated with a “watch and see” treatment program to see how your scoliosis continued to develop. Possibly you were also given recommendations and fittings for back braces, physical therapy, and various exercise programs. On occasion, you were given guidelines for some over-the-counter medications on the “rough” days. But, as the rough days got closer and closer together and more frequent, you may have been told at some point in the future you will need to call in a neurosurgeon or an orthopedic surgeon for their opinion moving forward.
Maybe you have reached this point already. Maybe your case sounds like this:
Sharp, stabbing pain:
I have scoliosis in my lumbar region, it never really progressed beyond that point but I know it has affected my entire spine all my life. I have been managing my low back pain very well until recently. Suddenly I developed a burning, sharp, constant stabbing pain in my back. When I stand up I literally have to catch my breath because as I start standing the pain in my lower back causes spasms and more pain in my buttocks, hips and radiates down into my legs. As soon as I stand up straight I have to stop for a moment, “regroup,” and start moving. It has now reached the point that I can only walk a little bit before I have to sit down and start the whole process over again.
I have been told that I have developed lumbar stenosis, it is pinching at my nerves and that is why I have this pain. I have been given strong pain medications which I do not want to take and physical therapy has now been ruled out as not helpful. My next two steps are steroid or cortisone injections and if they don’t help, laminectomy, laminotomy, or fusion surgery. Which I also want to avoid.
We are going to address all these concerns below and present treatment options. For some people, even though they have a great desire to avoid surgery, they may need to have one. Many people do very well with these surgeries. These are not the people we see at our center. We typically see more complicated cases where surgery is not given a realistically good chance of being successful. We will present our treatment options below and discuss other options.
Research: Surgeons tell surgeons decompressive laminectomy, by itself, not helpful, will make a patient worse.
This is a December 2020 study published in the medical journal Clinics in Orthopedic Surgery. (1)
Here are the learning points of this research:
- Decompressive laminectomy (as a stand-alone treatment) for degenerative lumbar scoliosis is not recommended because it can lead to further instability.
Did the surgery CAUSE the instability or did the surgery fail to address the instability or both?
That is the question asked by the surgeons. Here is what they found:
- It is uncertain whether instability at the decompressed segments is directly affected by laminectomy or the natural progression of degenerative lumbar scoliosis. The purpose then of this study was to answer that question. Did the surgery cause the instability, did the surgery fail to address the instability? Both?
The surgeons then examined the case files of sixty (60) patients with degenerative lumbar scoliosis.
- The 60 patients were divided into two groups.
- Patients with post-laminectomy instability at the point of the surgery. (For example, if scoliosis is in L3, L4, L5 and you have continued instability there.)
- Patients with post-laminectomy instability in the adjacent segments. (For example, if scoliosis is in L3, L4, L5 and you have instability now in L1, L2)
One in 5 needed another surgery, one in 4 had a new instability
- This is what happened in the 60 patient group:
- Twelve patients (20.0%) underwent revision surgery.
- Eleven patients (18.3%) showed continued post-laminectomy instability at the index segments (that is in the vertebrae where the scoliosis was centered and operated on.)
- and 15 patients (25%) showed post-laminectomy instability at the adjacent segments, not related to the laminectomy site.
Conclusions: The development of post-laminectomy instability was not always related to laminectomy at the index level. However, post-laminectomy instability developed more rapidly at the index level, compared to the natural progression of the scoliotic curve at the adjacent segments.
In other words, the surgery caused it.
Here are further resources and research you can explore on our site:
- Post Lumbar and Cervical Laminectomy Syndrome treatment options: A laminectomy is a surgical procedure to relieve “pinched nerves.” The procedure removes bone from the spinal vertebrae to take the pressure off the affected nerves. This article will examine what happens when the laminectomy procedure is not as successful as the doctor and patient hoped for and examines the resulting Post-laminectomy syndrome and what treatments can be offered for it.
Lumbar Scoliosis Surgery, then hip replacement?
They have been trying to talk me into surgery for years
As you have seen, and as many of you know personally, hip pain is often accompanied by scoliosis, or scoliosis is often accompanied by hip pain. That is not a play on words, it depends on what your primary diagnosis is. For many people who have been managing their lumbar scoliosis and have developed hip pain along the way, they are told that they should consider prioritizing their pain so that the proper sequence of surgeries can be scheduled. For some people, surgery is the only way because they may have a level of degeneration in their hip where the ball of the hip has collapsed and bone spurs have now frozen the joint, or there is continued, burning nerve pain and numbness in the feet.
For some people, the thought of a sequence of surgeries is very unappealing.
For some people, the thought of a sequence of surgeries is very unappealing. This could be especially true in active, physical people who see surgery as a prolonged period of inactivity. Some are also concerned that once you do one surgery, then you open yourself up for more and repeated surgeries. Here is a sample of a concern expressed to us:
I have been suffering from a lot of hip pain. I have wear and tearing of my labrum and general hip instability. Over the last few years, my hip pain has really accelerated and I have had to cut back on a lot of my fitness routines and I can feel myself getting “out of shape.” I don’t do physical therapy because of how active I am, I don’t want to do medications because I think they will eventually do more harm than good.
I have been told now on a few occasions that I should consider a hip replacement. I am in my early 50’s and I also have an issue with lumbar scoliosis which has never really slowed me down but now with my hip pain, I feel the scoliosis is getting worse as well. It is especially painful if I sit too long and then try to stand up. My concern is, if I get the hip replacement, I will be immobile and then the scoliosis will get worse. I can see where I will be in recovery and rehab for years, and that is if everything goes right. I am concerned that I may have surgical complications and then I will never get my fitness back.
Let’s stop here for a second and remind everyone that many people do very well with hip replacements and then subsequent surgery for lumbar scoliosis. Some people do not.
Surgeons talking to surgeons about these very concerns of numerous surgeries and proper sequencing
A December 2020 study in The Journal of International Medical Research (2) has surgeons talking to surgeons about these very concerns and how to plan the sequence of surgeries to give the patient the best chance at achieving the surgical goals of less pain.
Here are the learning points:
- Twenty-six patients treated for both degenerative scoliosis and hip disease
- Eleven patients underwent hip replacement followed by lumbar surgery (Group A).
- and 15 patients underwent lumbar surgery followed by hip replacement (Group B).
So which group did better? Hip replacement then spinal surgery (Group A) or spinal surgery then hip replacement (Group B)?
- There were significant surgical outcome differences between Group A (hip replacement first) and Group B (spinal surgery first).
- In the hip replacement first group – the surgeons noted a post-surgical problem with acetabular anteversion (the hip is not lined up right or twisted – the surgeons also noted that five patients in the hip replacement first group had unequal shoulder heights and inclination of the trunk to one side. In other words, these people were tilted.)
- In some of the hip replacement first group, a decrease in function as measured by standard scoring systems, and the lower surgical success scores also measured by standard patient-reported outcomes were noted.
- In the lumbar spinal surgery group, after the back surgery but before the hip replacement, eight patients could not walk, and the limitation was more severe than that preoperatively. (The patients were worse off).
So what was the concluding advice the surgeons recommended to their colleagues?
“Spinal surgery may be performed first to resolve lumbar nerve symptoms and restore sagittal balance of the spine; hip replacement may then be performed to simplify hip replacement difficulties and resolve the imbalance after spinal surgery. Severely limited range of motion exists after lumbar surgery and before total hip arthroplasty.”
In other words, do the spinal surgery first, prepare the patients that they will have severe and significant limitations, including the inability to walk until a hip replacement can be performed.
Here are further resources and research you can explore on our site:
- Hip-spine syndrome can lead to failed hip replacement and lumbar spinal fusion complications. It is challenging enough to think about getting a major surgery such as a spinal fusion or a hip replacement. It is even more challenging to think that after you had this one surgery, you now need the other.
Danielle R. Steilen-Matias, MMS, PA-C explains hip-spine syndrome
Learning points summary:
- Hip-Spine Syndrome is not exclusive to patients suffering from scoliosis, but scoliosis patients can suffer from this problem.
- Hip-spine syndrome is a pain syndrome characterized by degenerative injuries in both the hip and the low back (which could have its basis in scoliosis in some patients) that impact each other.
- Many times we will see a patient in the office. They will have a very specific diagnosis that their problems all come from the hip, or they will have a very specific diagnosis that their problems are all coming from the lower back. After we do a physical examination and talk to the patient about their medical history, it is clear that this patient has issues in both the hip and spine.
- Often we find that patients have completed a conservative care treatment course for their lower back or they have completed a conservative care treatment course for their hip, yet they still have pain. In this situation, conservative care may have been directed at the wrong pain triggers.
- In patients like this, we treat the hip, spine, sacroiliac joint, sacrum areas with Prolotherapy (explained below) to bring stability into the area by restoring normal function to damaged or weakened spinal and hip ligaments. (The treatment is explained below in greater detail).
As I got older, my lumbar scoliosis became worse. Why?
In this section we are going to start introducing the idea of lumbar ligament laxity for the progression of lumbar scoliosis and how to treat it. Lumbar ligament laxity is a weakening or “stretched-out,” ligament problem that is allowing for lumbar hypermobility and a worsening curvature. This will be explained further below.
Unfortunately, for the many people who had scoliosis “since they were a kid,” and did their best to manage it, their symptoms became worse. If this is happening to you, you are not unique to the idea of degenerative disc disease caused by worsening scoliosis but you probably feel alone and isolated when your back pain really flairs up. Researchers have been trying to figure out a way to help you by at least understanding what you are going through.
“Lumbar curvature that developed during adolescence accelerates intervertebral disc degeneration in adulthood.”
Let’s look at a November 2020 study in the aptly named medical journal Spine deformity (3) Here doctors want to understand how the “Residual lumbar curvature that developed during adolescence accelerates intervertebral disc degeneration in adulthood.” That is actually the title of the paper.
Here are the learning points:
- A total of 102 patients (8 men, 94 women, average age about 31 and a half) who had developed idiopathic (no obvious or known cause) scoliosis at the age of 10-18 years and underwent preoperative lumbar spine MRI after the age of 20 were included in the study.
- These patients were in a group that was recommended for corrective surgery. In fact, they were being classified by surgical plan modifiers. Many of you are probably very familiar with the surgical modifier categories.
- The adult scoliosis patients into two groups: Group A consisted of patients with lumbar modifier A. (Lumbar modifier A in simplest terms for those reading this article who have not had this explained as a surgical classification guide, is a less pronounced “C” shape to the lower spine.)
- The second group, called Group BC consisted of those with Lumbar modifiers B and C. (Lumbar modifier B in simplest terms is a more pronounced “C” shape which is developing into Lumbar modifier C a dual curvature resembling an “S” spinal shape.)
- The patients had an MRI to help assess the level of degenerative disc disease from L1/2 to L5/S1.
- Group A patients with lumbar modifier A, a less pronounced “C” shape to their spine had significant degenerative disc disease at L2/3 and L3/4
- As expected,
- the Group BC patients, with greater abnormal curvature, had significant degenerative disc disease at all levels except for L5/S1.
- The proportion of degenerative disc disease patients was significantly higher in Group BC than those in Group A at L3/L4 and L4/L5.
- Furthermore, the severity of significant degenerative disc disease was significantly greater in group BC than in group A at all levels, except for L5/S1, especially in patients aged under 30 years.
Conclusion: This study showed that the residual lumbar curvature from adolescent idiopathic scoliosis may have accelerated disc degeneration in adulthood, especially in patients aged under 30 years old.
Prolotherapy injections: Treating the ligaments in the lumbar spine
When people search for help with their scoliosis related pain and they start to focus on why their spine is curving, like the researchers above, they may come across an article, like this one, where the possible cause of the worsening curve of their spine is thought to come from weakened ligaments. There are not many of these types of articles unless you are searching for why surgery to correct this condition may have failed and you found out that your scoliosis was worse after surgery because of surgical damage to the ligaments.
In one patient category, however, ligament laxity or weakness is described at length. That is in people with hEDS or Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders. This is a topic of another article, we invite you to begin this exploration here: Prolotherapy for Hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders.
At our center, we see many adult patients with spinal instability and a history of scoliosis. They are at our center because the many problems and challenges that these people have in their spine are getting worse.
We do see many patients who have had surgery for their spinal deformities whose outcomes had less than the desired results. We also see many patients considering adult spinal deformity surgery. As we discussed above surgery is a treatment that should be given great and careful consideration. Many people do very well with surgery. Some do not. Those who do well should be monitored because they can develop degenerative disc disease of the lumbar spine.
Weak, damaged, overstretched lumbar spine ligaments that are not holding the vertebrae in their natural position.
There are many causes for the development of scoliosis, perhaps one of the simplest, overlooked, and easier to treat problems is a problem of weak, damaged, overstretched lumbar spine ligaments that are not holding the vertebrae in their natural position.
In common language, scoliosis means that the spine is crooked. The spine is held together by the same thing that holds all the bones together, ligaments. As you know first hand, people often experience pain at the site where the spine curves. At the apex of this curve, the ligaments are being stretched with the scoliosis, and localized ligament weakness is one of the etiological bases for it.
In other words, weak ligaments are causing the vertebrae to move out into “C” or “S” shapes and the “C” or “S” shape is pulling on these ligaments in a tug of war that is making them weaker. It is a cycle.
Traditional treatments for scoliosis, especially during adolescence, include observation, bracing, and surgery. Very few people are assessed for ligament weakness.
Damage or weakness to these ligaments will cause the vertebrae to move out of place and could result in problems of the curvature of the spine including scoliosis.
What are we seeing in this image?
In this illustration, we are using the springs as a visual image to help understand the natural movement of a spinal ligament. In flexion, bending your head forward with your chin moving towards your chest we see that the spring is stretched to accommodate that movement. In extension, this would be with your chin pointed upwards in the air, we see that the spring is compressed. In lateral flexion, you are moving your head with your ear moving towards your shoulder. You get both ligament motions. Damage or weakness to these ligaments will cause the vertebrae to move out of place and could result in problems of the curvature of the spine including scoliosis.
- Prolotherapy is multiple injections of simple dextrose into the damaged lumbar 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. This helps the spine stabilize and line up in a more natural curve.
- 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.
The black crayon line is the scoliosis guide
- 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.
Prolotherapy for Back Pain
Prolotherapy treats low back pain by addressing the root cause of pain: ligament laxity. Very few cases of low back pain actually stem from a herniated disc. Rather, the herniated disc is proof that ligament laxity exists. Prolotherapy is an injection technique that induces a mild inflammation to stimulate the body’s immune system to heal the injured area. When compared to Prolotherapy, percutaneous disc decompression raises some red flags in the case of low back pain:
In Caring Medical published research in the Journal of Prolotherapy, (4) we cited our own research and that of others in demonstrating the effectiveness of Prolotherapy for back pain.
In our research, we reported on 145 patients who experienced low back pain for an average of 58 months, who were treated on average with four sessions of dextrose (12.5%) Prolotherapy, quarterly, at a charity clinic.
The patients were contacted on average 12 months after their last Prolotherapy session. In these patients:
- pain levels decreased from 5.6 to 2.7 (numerical rating scale NRS, 1-10 scale);
- 89% experienced more than 50% pain relief
Results were similar in the patients who were told by at least one medical doctor that there was no other treatment option (55 patients) or that surgery was the only option (26 patients).
Prolotherapy repairs collagen fibers in the ligaments, strengthening the ligaments and restoring spinal strength and stability
In the Journal of Prolotherapy, (5) James Inklebarger, MD and Simon Petrides, MD wrote: “Prolotherapy injections produce an inflammatory response, which can augment collagen fibre 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.“
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 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.
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