Prolotherapy Non-surgical treatment of a herniated or bulging disc
In our many years of treating patients with cervical neck and back pain, we came across patients who had continued back pain after spinal surgery. The reason? A coincidental finding on MRI of a herniated disc. Coincidental means, “oh by the way, you have a herniated disc, we are not sure that is the problem, but to make sure, let’s go to disc surgery.” The outcomes of this medical strategy did not go as well as hoped for in many patients we have seen.
Our extensive articles bear this out. After you are done reading this article see Failed back surgery syndrome treatment options for pain and instability, Lumbar decompression surgery complications, Lumbar spinal stenosis surgery alternatives.
A person with a degenerated, bulging, prolapsed, or herniated disc must realize that this may be a coincidental finding and unrelated to the actual pain he or she is experiencing. In other words you can walk around with a herniated disc that is not causing you pain.
Before you continue with this article, if you have questions about herniated discs and back pain, you can get help and information from our Caring Medical staff.
Searching for the source of pain, the pinched nerve
The single most dangerous motion that can injure a disc is axial rotation, and the most dangerous combination of motions is axial rotation and lateral bending.
Together, axial rotation and flexion put the most amount of pressure on the disc and are the motions most likely to cause it to herniate.
- Because the spinal nerve root lies directly above the outer disc, a herniation that occurs near the weak spot puts direct pressure on the nerve, resulting in a pinched nerve.
- Any nerve impingement in the lumbar spine will then cause pain to radiate along the path of the nerve, traveling through the buttock and down the leg. This type of pain is called lumbar radiculopathy, more commonly known as sciatica.
- Mechanical compression or deformity of nerve roots as a cause of pain or nerve dysfunction is the classic concept related to nerve problems caused by disc herniation.
- Although compression behavior of the motion segments has been studied thoroughly, it has yet to be related to the clinically observed failures of disc herniation. In other words, evidence of disc herniation on MRI scan correlates poorly with clinical evidence of nerve irritation. Many people have MRI disc herniations with no back pain and no evidence of a nerve being irritated.
Bending and other rotatory loads, on the other hand, may easily produce spinal joint instability. This causes excessive movement of the motion segment, which causes the facet joint bones to touch and irritate a nerve. This can be documented on motion MRIs or motion fluoroscopy to confirm the missing diagnosis: spinal microinstability.
Herniated disc symptoms
Indications of a herniated disc include one or more of these symptoms:
- leg pain (sciatica) that is often severe;
- weakness and/or tingling in the leg;
- low back pain and/or pain in the buttock;
- and loss of bladder or bowel control, the latter of which is rare and warrants medical attention because it may indicate a more serious condition called caudal equina syndrome.
Most disc herniations occur in the lower portion of the spine at the L4-L5 or L5-S1 level, either of which can lead to additional symptoms.
- L5 nerve impingement at L4-L5 can cause weakness in extending the big toe and potentially weakness in the ankle (foot drop), as well as numbness and pain on top of the foot, with the pain radiating into the buttock.
- S1 nerve impingement at L5-S1 can cause loss of the ankle reflex and/or weakness in ankle push off (inability to do toe rises), as well as numbness and pain that can radiate down to the outside of the foot or underneath to the sole.
A herniated disc causing spinal radiculopathy is relatively easy to diagnose. Based on history and neurologic examination alone, a physician may expect to be correct 60% of the time. With the addition of certain test procedures, accuracy is cumulative: with a straight leg raising test positive, accuracy increases to 70%; with a positive electromyogram, to 80%; and with a positive water soluble contrast myelogram, to 90%. MRI is able to show internal disc morphology.
Conservative care for a herniated disc
This is why many doctors will recommend many and varied courses of conservative care before recommended a spinal surgery.
Conservative care for herniated disc includes:
- epidural steroid injection,
- Narcotic pain-killers which can increase chronic pain,
- non-steroidal anti-inflammatory drug (NSAIDs) usage which can also make pain worse,
- Chiropractic care, physical therapy, and various spinal and muscle stimulators.
When do you decide that conservative care is not helping and you need to go to surgery?
In a recent study, doctors at the University of Salzburg presented these findings on the surgical and conservative care of herniated disc.(1)
According to these doctors, when should a patient have disc surgery?
- When conservative treatment did not improve clinical symptoms.
- When progressive or persisting neurological deficits, as well as for persisting pain which alters the quality of the patient`s life.
The researchers however also warn, “Results of surgery are strongly dependent on the preoperative duration of symptoms. Paramount is the “timing” of surgery: poorer surgical results associated with increasing preoperative duration of symptoms.”
The longer the patient waits for surgery, the more difficult it gets. The same can be said for comprehensive Prolotherapy treatments, the longer the patients waits for treatment, the harder it gets to treat.
Please see our articles on our non-surgical treatments:
Finally the above cited researchers suggested that surgery should be the LAST CHOICE, and that all conservative treatment methods must be FIRST exhausted.
- It is important to note again that the above paper from spinal surgeons recommended strongly, that surgery be the last choice, BUT, treatments of any kind should not be delayed.
First choice of herniated disc treatment
Let’s look at the first choice of herniated disc treatment through the eyes of a Canadian research team who reviewed the current concepts and clinical guidelines for the management of low back pain to assess their quality of care.
In this February 2017 study published in the European Pain Journal, doctors and researchers found according to high-quality guidelines:
- All patients with acute or chronic low back pain should receive:
- and instruction on self-management options;
- Patients with acute low back pain should be encouraged to return to activity and may benefit from:
- nonsteroidal anti-inflammatory drugs (NSAIDs),
- or spinal manipulation;
- Patient with chronic low back pain may include:
- paracetamol or NSAIDs,
- manual therapy,
- and multimodal rehabilitation (combined physical and psychological treatment); and
- Patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation.
This new study found some of these guidelines to still be in practice but outdated, specifically the use of paracetamol for acute low back pain and other herniated disc symptoms.
The other problem they found was the recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments., were guidelines targeted to nonspecific low back pain.(2)
If you are reading this article, there is very good chance you were not helped by these herniated disc treatment guidelines, you have been recommended to herniated disc surgery, and you are exploring alternatives.
- As mentioned above, the use of NSAIDs have been shown to be a culprit in causing greater pain, see our article When NSAIDs make pain worse, and how NSAIDs inhibits healing.
- Please read our article on long-term problems of spinal and over-manipulation
Discectomy or Microdiscectomy
Complications from this surgery are explained better by the surgeons who perform this procedure – this is from the American Academy of Orthopaedic Surgeons website:
“One of the major drawbacks of open surgery is that the pulling or ‘retraction’ of the muscle can damage the soft tissue. Although the goal of muscle retraction is to help the surgeon see the problem area, it typically affects more anatomy than the surgeon requires. As a result, there is greater potential for muscle injury, and patients may have pain after surgery that is different from the back pain felt before surgery.”
A discectomy is the surgical removal of the disc material (nucleus pulposus) bulging out onto the nerve root or the spinal cord. This is an “open back surgery.” The procedure often involves a laminotomy, removing a small piece of bone (the lamina) to allow the surgeon access to the herniated disc.
Lumbar microdiscectomy is a less invasive technique and procedure and even then is delayed in patients who present radicular pain, paresthesias, and in extreme cases weakness or foot drop. As noted in one paper typically patients are treated conservatively for 6-8 weeks with a combination of nonsteroidal anti-inflammatory drugs, physical therapy, epidural steroid injections, and rest.
In the absence of symptom improvement, microdisectomy is recommended to patients who are not improving after 6 weeks of non-operative treatment.
In discussing revision lumbar discectomy, surgeons say the procedure can be a more technically complicated operation.
Percutaneous Disc Decompression for Herniated Discs
Decompression is a term used to describe the treatment of a “compressed” disc that is causing bulging or herniation. Percutaneous disc decompression involves dissolving or removing parts of a herniated disc to alleviate back pain. This therapy is used for patients who present with low back pain and numbness with pain radiating down one or both legs. Most patients who undergo this procedure have an MRI that shows a modest herniated disc. In other words, this treatment is not for people with “severely” herniated discs.
The treatment involves placing a needle into the herniated disc using X-ray guidance. Depending on the type of decompression therapy, excess disc tissue is either dissolved through radio waves or removed by a revolving needle. The result is decreased pressure on the disc and adjacent nerves. Although some studies show effective pain relief, we believe the long-term effects of removing tissue are not worth the short-term pain relief.
What is a successful surgery for herniated, ruptured or bulging disc?
For many patients who move onto surgery their definition of success may be based on the following questions and the answers they get from their surgeon:
- “What is the rate of success in herniated disc surgery?,”
- “How long will my recovery time be?,”
- “Will I be able to return to work quickly?”
Conflicting evidence suggests that these may be difficult questions to answer prior to surgery. Or that the patient and the doctor may have two different definitions of success and what should be the goals of treatment. This one concluding statement from a research study from the University of Leipzig in Germany spells out likely outcomes of herniated disc surgery.
- “In the majority of disc surgery patients, a long-term reduction in pain was observed. Cervical surgery patients seemed to profit less from surgery than the lumbar surgery patients. In the long-term a considerable number of patients still reported high levels of pain.(3)
In recap: The surgery was successful for some, did not work better for herniated discs in neck than lumbar disc herniation, and for a “considerable” number of patients long-term high levels of pain remained after surgery.
For working people, one study tried to give a better predictive value for returning to work. In this research in the medical journal Health technology and informatics, in 153 patients doctors found the most decisive risk factors in prolongation of work absence were:
- psychosocial factors,
- mobility of the spine and structural changes of the facet joint and the patient’s ability to perform the physical demands that their work required.(4)
For herniated disc treatment to be successful – the disc must be the problem
A recent study from doctors in Australia published in the medical journal Pain Medicine questioned the prevalence of back pain caused by the discs. In their research the doctors noted the widespread belief that up to 42% of chronic low back pain is attributed to a problem lumbar disc(s). BUT, these estimates on the number of pain causing discs largely originated from research conducted 20 years ago and that the estimates may be too high, something else may be causing the pain.
- The doctors tested 223 patients and 644 discs.
- Positive discograms (a controversial injection procedure to determine if pain is coming from the discs) were recorded in 74% of patients, with 22.9% negative and 3.1% assessed as indeterminate.
- Among patients receiving both discography and diagnostic blocks, 63% had proven discogenic pain, 18% had pain of mixed pain causes and 14% remained undiagnosed.
Taking into account all low back pain cases during this study, discogenic pain prevalence was 21.8%. The researchers concluded that while lower than believed the research supported the clinical use of discography.(5)
Is Discography Useful?
The Discography or discogram procedure usefulness a test and evaluation tool is controversial. Like an MRI it may show things that are not the root cause of the problem. In the procedure a dye is injected into the discs to look for cracks or other abnormalities. Sometimes several discs are injected. Like an MRI, the discogram may show damage that are not causing symptoms, so the discogram may be leading doctors to treat something that is not the problem.
A patient may also receive a diagnosis of disc desiccation. This is a common degenerative change of intervertebral discs over time caused by “aging.”
Why did the disc degenerate in the first place?
Degeneration of a disc begins as soon as the lumbar ligaments become loose and cause spinal instability, allowing the vertebral segments to move excessively and cause pain. The body attempts to correct this by tensing the back muscles. The hypermobile vertebral segments add strain to the vertebral discs. Eventually these discs cannot sustain the added pressure and begin to flatten and/or herniate.
The incidence climbs with age, and to a large degree a gradual desiccation is a ‘normal’ part of disc aging. It results from replacement of the jelly like nucleus polposus with fibrocartilage. It should be pointed out that the body is acting in this way to stabilize the spine.
Prolotherapy strengthens the annulus fibrosis and other ligaments that support the disc, helping the condition resolve without surgical intervention. If the disc material is pressing on the nerve, then other treatments in addition to Prolotherapy may be indicated, including nerve blocks or epidural injections to decrease the inflammation on the nerve.
Prolotherapy vs. Disc Decompression for Herniated Discs
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 and Rehabilitation Services published research in the Journal of Prolotherapy 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 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).6
When steroids and Prolotherapy are needed
When disc material prolapses or herniates through the annulus, a severe inflammatory reaction occurs, which affects the lumbar nerves and causes excruciating pain. This is one time when steroids are needed to resolve the pain. With appropriate treatment using steroids injections onto the nerve(s) and Prolotherapy treatment to the lower back, it is possible to strengthen the ligaments through which the disc herniated. Anyone this debilitated by pain would likely need to come into the office in a wheelchair or be in obvious discomfort but after treatment often would be able to leave walking out much happier.
If you have been diagnosed for bulging disc, slipped disc, herniated disc, Prolotherapy is safe, effective, and cost-friendly. It is a low-risk procedure that treats a herniated disc symptoms.
Questions about your back pain? You can get help and information from our Caring Medical staff.
1 Heider FC, Mayer HM. Surgical treatment of lumbar disc herniation. Oper Orthop Traumatol. 2017 Feb;29(1):59-85. doi: 10.1007/s00064-016-0467-3.
2 Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. European Journal of Pain. 2016 Oct 1.
3 Dorow M, Löbner M, Stein J, Pabst A, Konnopka A, Meisel HJ, Günther L, Meixensberger J, Stengler K, König HH, Riedel-Heller SG. The course of pain intensity in patients undergoing herniated disc surgery: a 5-year longitudinal observational study. PloS one. 2016 May 31;11(5):e0156647. PLoS ONE. 2016;11(5):e0156647.
4 Papić M, Brdar S, Papić V, Lončar-Turukalo T. Return to Work After Lumbar Microdiscectomy – Personalizing Approach Through Predictive Modeling. Stud Health Technol Inform. 2016;224:181-3.
5 Verrills P, Nowesenitz G, Barnard A. Prevalence and Characteristics of Discogenic Pain in Tertiary Practice: 223 Consecutive Cases Utilizing Lumbar Discography. Pain Med. 2015 Aug;16(8):1490-9. doi: 10.1111/pme.12809. Epub 2015 Jul 27.
6. Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.