Non-surgical treatment options for lumbar spinal stenosis

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

In this article, we will examine the challenges and findings of researchers looking for the optimal treatment of lumbar spinal stenosis.

You have had recurring and chronic back pain. Sometimes this back pain flares up and becomes almost intolerable. But you have to go to work or continue on with your daily routine activities so this pain needs to be managed. Eventually, you make the appointment at the doctor and your trip to the doctor or health care provider reveals a diagnosis of lumbar spinal stenosis.

Now your medical journey gets filled with a diagnosis and terms that require you to educate yourself on what is happening in your back.

Often we will hear a patient say: “I had back and leg pain for months. I went to the doctor, I had an MRI and the doctor told me I had spinal stenosis. I had no idea what the doctor was talking about. My doctor told me that he/she would prescribe some pain relievers for me to see if that helped. My question to my doctor was “will this ever go away?” The doctor looked at me and said, “I hope so, but it is not likely without surgery.”

Surgery?

The health care provider may then try to explain to you that you have:

  • Degenerative lumbar foraminal stenosis or lateral stenosis or Neural foraminal stenosis.
    • The diagnosis names listed above all refer to the most common type of lumbar spinal stenosis.
    • The nerves that leave your spinal cord and travel around the body have to pass through a gap or opening in the spine’s facet joints, the foramen. When that space is compromised or made smaller by bone spurs, herniated or bulging disc, facet joint osteoarthritis, and inflammation,  the nerve gets “pinched.”
  • Central spinal stenosis 
    • This is the diagnosis when the central canal, where the spinal cord rests within the spine is closing in on the spinal cord.

If you are reading this article it is very likely that you and your doctors have already made a valiant try to keep you away from surgery with a steady dose of medications, cortisone or epidural injections, physical therapy, and chiropractic. The recommendation to get surgery is coming closer and closer if it has not already been suggested to you. Some of you reading this article may already have a surgical date.

In some people, the state of their stenosis has made them a walking MRI interpretation. Maybe this is like you. You have been contacting doctor’s offices and simply emailing your MRI results to see if that doctor can help. We have been helping people coming up on three decades. While an MRI can be helpful in understanding someone’s problem, it may not truly represent the patient’s pain. This is why there is a problem with failed back surgery syndrome. The pain remains after surgery. The surgery was addressing the MRI and may have missed the true cause of the patient’s problem. One thing the MRI could miss is spinal ligament laxity. Which we will explain below.

Many people suffering from spinal stenosis do very well with surgery. The majority of patients have a great deal of pain relief. These are not the patients that we see at our center. We see the patients who have had surgery and now in some cases have been recommended to spinal fusion surgery. These people we see would like to see if avoiding that surgery is possible.


In this video, Ross Hauser, MD, discusses the difference between Dynamic Spinal Stenosis and Static Spinal Stenosis and who should get surgery and who can benefit without surgery

These are some learning points from the video:

  • Spinal Stenosis is the result of degenerative arthritis. The earlier you treat the osteoarthritis of the spine, the less stenosis risk factor.
  • When I was a medical student thirty years ago, the traditional treatment for spinal stenosis was a laminectomy surgery. The idea was that by cutting away the bone the spinal cord would have more room or not be compressed. Unfortunately, years later, many of these surgical patients would develop worsening spinal arthritis and would have worse symptoms than those that sent them to the original surgery. This is why surgeons are more careful in who they offer this surgery to. The surgery of choice now is decompression fusion.
  • In decompression fusion, the spinal cord is given its room and the vertebrae are fused to prevent future stenosis at that segment level. Because there is a fusion to stabilize the vertebrae, this gives us the understanding that the cause of stenosis is spinal instability.

How do we determine in the office who needs surgery and who doesn’t?

  • We examine the symptoms the patient is experiencing.
    • When a person walks a short distance or stands for some time, and they develop terrible back pain and they have to sit down because of the pain and because their legs feel heavy, and, if the person does not have back pain or little back pain and no leg pain when they sit down and the symptoms go away. This person would likely not need surgery.
    • The pain this person is suffering from is related to certain positions, standing as opposed to sitting for example. We know that this is being caused by an instability problem, we can treat this with Prolotherapy injections. (This is explained below). We call this a problem of dynamic spinal instability or dynamic spinal stenosis.
    • Sometimes we have to do nerve regeneration therapy with Prolotherapy. This is typical in a person who has pain relief when they sit but the pain does not go away completely. This can mean that there’s a part of the nerve that’s actually injured or the sheath that surrounds the nerve is damaged inject platelet-rich plasma or bone marrow cells on to the nerve to stimulate repair.
    • If someone has leg pain all the time, there is no alleviation from sitting or standing, this is what we call Static Spinal Stenosis, and those are the cases we typically recommend decompression fusion surgery.
This picture describes how classical spinal canal stenosis can compress the spinal cord, whereas intervertebral neural foraminal stenosis impinges on the nerve root.

This picture describes how classical spinal canal stenosis can compress the spinal cord, whereas intervertebral neural foraminal stenosis impinges on the nerve root.

The Lumbar spinal stenosis treatment journey – from diagnosis to surgery

Your lumbar stenosis journey typically began one day when your back pain became significant enough that you could no longer self-manage it on a daily basis. You may have been self-medicating with over-the-counter medications and anti-inflammatories, you may have even gone online for yoga or back stretching exercises to help you. But now the pain is worse and it is now moving down your hip and into your legs.

The problems of spinal stenosis are a long journey. Your story may sound very similar to this one:

For the last few years, my back pain has been slowly getting worse. I have had a few diagnoses, hip bursitis was one, sacroiliitis was another. I was finally diagnosed with lumbar foraminal spinal stenosis (L5/S1). I have a bulging disc and arthritis in my spine. The degenerative disc disease I have is worse on the right side which correlates with the symptoms I have, primarily sciatica which radiates into my right leg down into my foot. It’s “better,” on the left side. The sciatica pain only goes to my knee.

Sometimes when I walk I have to be careful on inclines, slopes, or stairs as this will cause a very sharp pain in my back. 

I am told I will need surgery. Not now but sometime in the future. I basically have to wait for my condition to get worse. I do not want surgery but I do not know what else to do. 

First stop: the x-ray or MRI


The dangers of stenosis diagnosis based on MRI

The MRI came back: Your doctor read the report to you

  • Degenerative disc disease causing pressure on the spinal nerves
  • You have spinal arthritis
  • You have bone spurs on the vertebrae closing the spinal canals through which nerves pass-through
  • You have problems with the ligamentum flavum. The big ligament that holds your spine together.

Is this report correct? Maybe not the MRI reading can be wrong.

We have written extensively on the over-reliance of MRIs in determining back pain treatment and the great concern that the MRI is sending a patient for a surgery they do not need, will not help them, and may make the patient’s situation worse. Please see our article: MRIs causing spinal surgery patients don’t need. In this article, you will see

  • Radiologists publishing research saying that doctors are ordering too many inappropriate MRIs.
  • MRI interpretations vary widely, you may get multiple interpretations from different radiologists.
  • Surgeons saying these problems may lead to unnecessary and unsuccessful spinal surgery.

Conservative Care before surgery

If you are diagnosed with lumbar stenosis, there is a good chance surgery will be recommended. But before the surgery, there is usually a long period of conservative care options. Usually, a  patient will be happy to try these treatments as surgery is something they would like to consider last.

What is conservative care? Conservative means non-surgical.

Research: Is conservative care for lumbar stenosis a waste of time and resources?

For some people the answer appears to be yes: But what kind of people should just move forward with the surgery? Smokers; type 2 diabetics; and obese people.

This is a March 2019 study from the Departments of Neurosurgery at Rush University Medical Center, the University of Texas South Western Medical Center, and the University of Cincinnati Medical Center. It was published in the medical journal Spine. (1)

Here are the learning points:

  • The study examined 4133 patients who underwent 1, 2, or 3-level posterior lumbar instrumented fusion.
    • 20.8% of patients were smokers
    • 44.5% had type II diabetes,
    • 38.2% were obese
  • The patients had long-term nonoperative therapy that included:
    • 66.7% used nonsteroidal anti-inflammatory drugs (NSAIDs),
    • 84.4% used opioids,
    • 58.6% used muscle relaxants,
    • 65.5% received lumbar epidural steroid injections,
    • 24.9% received chiropractor treatments

The point of the study was that these patients who went to surgery anyway spent a lot of money and healthcare resources on treatments that would not help them. We are going to review the treatments that did not help them.

Is conservative care a waste of time and money for women?

The same research team published these findings in the December 2018 journal World Neurosurgery. (2)

  • A total of 4133 patients (58.5% women) underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion.
  • A significantly greater percentage of female patients used nonsteroidal anti-inflammatory drugs, lumbar epidural steroid injections, physical and/or occupational therapy, and muscle relaxants.
  • Female patients used more nonsteroidal anti-inflammatory drugs, opioids, and muscle relaxants and yet still went to surgery.

Physical therapy for lumbar spinal stenosis

  • We are going to discuss a bit more about physical therapy here: A January 2019 study from the Department of Neurosurgery, University of Texas Southwestern Medical Center at Dallas made these remarks about physical therapy. This study was published in the biomedical journal F1000 Research. (3)
    • “Physical therapy for lumbar spinal stenosis usually involves some combination of core strengthening, flexibility training, and stability exercises. The optimal combination of these exercises and their frequency, duration, and the appropriate setting is not clear at this time.”
    • “The evidence of benefit from physical therapy alone is not clear. However, a limited course of physical therapy should still be considered as part of the initial treatment discussion and conservative measures.”
  • What makes physical therapy and its frequent companion treatment chiropractic manipulation dangerous is that they were given to patients who could not benefit.
    • But it wasn’t the physical therapy that was dangerous, it was the failure to achieve pain relief from it that created the danger for patients.
    • When these patients went back to the orthopedist and reported a lack of success in physical therapy, chiropractic, massage, yoga, etc., the failure of these treatments were used as justification to send that patient to possible unnecessary spinal surgery. That is the danger of the failure of these treatments.”
    • In our article, mentioned above, how physical therapy will not help certain people, we wrote: “Physical therapy is a major component of the orthopedist’s “conservative” approach to low back pain relief. The Caring Medical experience is that the results of PT are often disappointing. Disappointing may not be the right word, perhaps dangerous would be better.

Epidural injections for lumbar spinal stenosis

  • Epidural injections

Our opinions are based on over 25 years of empirical and clinical observation of how treatments help or not help lumbar stenosis patients. In our articles, we also like to bring in the opinion of specialists. Here is what pain management specialists offer as an opinion to conservative care options for lumbar spinal stenosis:

Treatment with Epidural injections is a frequent question we receive at our clinics: In our article Alternatives to Epidural Steroid Injections | why do patients still get epidurals? We answer common patient questions about epidurals and provide the research as to why we do not offer this treatment as a standard of care.

A brief discussion on epidural steroid injections for lumbar spinal stenosis – the news is not good


Little improvement, more complicated surgeries, and longer hospital stays, especially if you are over 60.

Research:

  • Patients receiving epidural steroid injections for lumbar spinal stenosis had less improvement and greater need for surgery
    • Research: What should a patient expect from epidural steroid injections for lumbar spinal stenosis? Little improvement, more complicated surgeries, and longer hospital stays, especially if you are over 60.
    • Research: Epidural steroid injections are low-value health care

When discussing the use of epidural steroid injections, it is always best to bring in an orthopedic opinion.

The first study is from the Department of Orthopaedics, Wexner Medical Center, Ohio State University, and Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois. This research was published in the International Journal of Spinal Surgery, August 2018. (4)

Highlights: Attention Medicare People

  • Epidural steroid injections are widely used but have come under increased scrutiny
  • If you are over 65 and on Medicare you were more likely to get an Epidural than if you had private insurance
  • If you were on Medicare you had a higher risk of going to surgery

This new study agrees with research published in the medical journal Spine, suggesting that the Epidural steroid injections were associated with significantly less improvement at four years among all patients with spinal stenosis…Furthermore, epidural steroid injections were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with Epidural steroid injections. . . ”(5)

Research: Findings warn doctors to stop doing certain spinal surgeries


Research: Findings warn doctors to stop doing certain spinal surgeries

“The benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive”

In the medical journal Current Opinion in Anaesthesiology, (6pain management doctors discuss the latest trends in lumbar spinal stenosis treatments, this includes a rundown of the conservative non-surgical treatments. Here is what the researchers said:

“Our review of current literature within the past 12–24 months for the treatment of lumbar spinal stenosis serves to update providers on recent advances and comparisons regarding therapy spanning lifestyle modification, pharmacologic therapy, minimally invasive interventions, and surgical interventions.

  • Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin (anti-seizure medications used for nerve pain) within an initial treatment regimen has been positive.
  • A recent randomized, double-blinded clinical trial of adding calcitonin (a protein hormone) to epidural steroid injections has shown improvement in pain and function for up to 1 year.
  • The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function.
  • Spinal cord stimulation (SCS) may have a role in select patients with lumbar spinal stenosis.

Finally,

  • the benefits of surgical treatment versus nonsurgical treatment for lumbar spinal stenosis is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of lumbar spinal stenosis, and a lack of standardized treatment guidelines.
  • long-term research with validated, objective measurements for the aforementioned treatments is needed to draw any definitive conclusions for clinical practice.

In the British Medical Journal, (7) doctors looked at the options in conservative care. This is what they found:

“The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high-quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment.”

  • In this study, the spinal injections were cortisone and epidurals.

In the medical journal Best Practice and Research. Clinical Rheumatology, (8) doctors wrote:

“Analgesics (painkillers), NSAIDs, muscle relaxants, and opioids are commonly used in patients with lumbar spinal stenosis although their use is extrapolated (taken) from studies of patients with non-specific low back pain. Each of these medication classes poses risks to patients, especially among older individuals.”

More studies: No clear benefits were observed with surgery versus non-surgical treatment in patients with lumbar stenosis. The one benefit conservative care offers – no immediate side-effects.

Doctors at the Italian Scientific Spine Institute published their research in the Cochrane Database of Systematic Reviews which gave this warning to patients considering surgery for spinal stenosis. To be fair, we should point out that the Italian Scientific Spine Institute specializes in the non-surgical treatment of spinal diseases.

  • We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. No clear benefits were observed with surgery versus non-surgical treatment.
  • However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment.
  • These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. (9)

” 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery”

A November 2019 study (10) that combined patient outcomes at 13 medical universities, hospitals, and spine centers in Canada, Australia, and Denmark that included the University of Toronto, the University of Ottawa, the University of Calgary, Murdoch University, University of Southern Denmark, and McGill University Health Centre among others, examined patient groups following surgery for degenerative lumbar spinal stenosis. The research simply sought to see who the surgery would help and who it would not.

Study learning points:

  • Patients with degenerative lumbar spinal stenosis were deemed to be surgical candidates.
  • The study examined:
    • Leg pain and back pain before and after surgery. After surgery at 3, 12, and 24 months.
    • Data from 548 patients ( average age 66.7 years old 46% female) were included.
  • Outcomes after surgery:
    • leg pain (excellent outcome = 14.4%, good outcome = 49.5%, poor outcome = 36.1%),
    • back pain (excellent outcome = 13.1%, good outcome = 45.0%, poor outcome = 41.9%),
    • and disability (excellent outcome = 30.8%, fair outcome = 40.1%, poor outcome = 29.1%).

Conclusion: “Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.”

The different types of surgeries for lumbar spinal stenosis

Surgeons writing in the medical journal Pain Medicine (11) gave an excellent rundown of surgical procedures that someone with lumbar spinal stenosis can explore. Here is a brief summary of their learning points and some explanatory notes.

Surgical options range from minimally invasive decompression surgery for indirect lateral and central stenosis using interspinous spacers to more conventional invasive decompression surgery, either with or without fusion. Here are brief descriptions.

  • Using interspinous spacers
    •  If you have been researching or contemplating this type of surgery, you know that a spacer is inserted into the rear portion of the vertebrae to hold them apart. For instance, a spacer is placed between L3 and L4 if that is where your stenosis is. The spacer will help alleviate pressure.
      • The study authors note that: “Stand-alone interspinous spacers are designed for the treatment of symptoms of intermittent neurogenic claudication, (pain, pins and needle sensation, numbness, back to legs spasming) that are brought on by moderate lumbar spinal stenosis.” The benefit of this type of surgery is that it avoids getting near the spinal canal. You are not getting fused and some degree of flexibility can be maintained. The downside is higher complication rates have been reported. The authors again note: “Not all patients are suitable for treatment with an interspinous spacer. Patients with osteoporosis (risk of spinous process fracture) and spondylolisthesis with dynamic instability (risk of posterior migration of implant) are not appropriate candidates for interspinous spacers.”

Minimally Invasive Lumbar Decompression

  • If you have been researching or contemplating this type of surgery, you know that this is a multipart surgery. It is considered minimally invasive because of the size of the surgical entrance.  The idea of using minimal invasive lumbar decompression surgery rests with the notion that it will do less damage to the surrounding tissue in the spine. In open surgery, muscles have to be moved out of the way often damaging the muscles and the connective tissue such as tendons and spinal ligaments. Using smaller holes and cameras, surgeons can effectively repair minimally damaging the surrounding tissue. Typically in this surgery, the central stenosis is addressed. A laminotomy is performed, that is the cutting away of the bone towards the rear of the vertebrae, the lamina and the ligamentum flavum, the long ligament that runs the length of the spine from C2-S1 and is offered hypertrophied in cases of spinal instability- that is thickened because of stress to help hold the spine together, is shaved down to prevent it from compressing nerves roots.

Endoscopic Decompression (for Foraminal Stenosis)

  • If you have been researching or contemplating this type of surgery, you know that this surgery is perhaps the least invasive. A small incision is made at the point of the problem’s disc area. The surgeon goes through this incision and removes the piece of disc or cuts away the piece of the vertebrae that is pressing on the nerves. The surgeon can also cut away or use radiofrequency to make the compressed passages such as in the foramen bigger. While many people can get benefit from this surgery, researchers have questioned the long-term results.

Invasive Open Decompression Surgery

  • If you have been researching or contemplating this type of surgery, you know that this surgery is the big incision surgery, that is why it is called open and invasive. As in the minimally invasive surgery, a laminotomy is performed, the ligamentum flavum is shaved down to prevent it from compressing nerve roots. The reason open invasive is chosen is that a Laminectomy and fusion need to be performed.
    • The authors of this research study cited above say: “Laminectomy has been the standard surgical treatment for lumbar spinal stenosis, demonstrating significant improvement in symptoms and functioning. Laminectomy can be either with or without fusion, depending on the disease characteristics and surgeon preference. Different studies have found conflicting results, with some reporting a more favorable outcome of decompression surgery alone and others reporting the opposite. In general, treatment with decompression alone without fusion was shown to be effective in 80% of patients with severe symptoms of lumbar spinal stenosis. The primary goal of spinal fusion would be to improve regional back pain and improve stability.”

Limited vs Multilevel Decompression Surgery

  • If you have multi-level problems in your spine your surgeon may recommend a multi-level procedure, getting to all the problem discs at once. This would require open spinal surgery with a big incision.
    • The authors of this research study cited above say: “Limited open decompression may be performed when one to three affected segments are involved. However, there remains controversy concerning how many levels need to be operated on in the case of multilevel lumbar spinal stenosis for the best clinical outcome.”
    • They also note “patient satisfaction at two years was higher in patients that had single-level decompression and fusion.”

Risks 

  • The authors of this research study cited above say: “In general, although open decompression surgery allows for direct visualization of the decompression site and has been shown to be safe and effective in the majority of patients, the procedure is also associated with higher morbidity (adverse effects), secondary spinal instability, longer recovery time, and more risks and might be less tolerated in patients with advanced age.
  • The decision of whether to perform decompression surgery alone or to combine with fusion is largely based on the clinical judgment of the surgeon. Generally, multilevel spinal stenosis involving foraminal and lateral stenosis with significant central canal stenosis, compounded with multilevel spondylosis with significant segmental dynamic instability, will require extensive multilevel decompression including medial facetectomy and multilevel spinal fusion.”

The bone is closing in all around the nerves. Understanding what causes spinal stenosis and the “narrowing of the spine” may help you avoid surgery.

Bone spurs form as a result of microinstability of the spine. Bone spurs are an “inner cast” that the body forms to help hold the spine in its correct position. Unfortunately, bone overgrowth also causes problems of reduced mobility and eventual nerve compression.

  • Our body has a difficult decision to make:
    • Bone spurs and narrowing of the spine limit the destructive spinal motion that causing pressure on the nerve (bone spurs limit spinal instability).
    • Allow the spine to move without restriction and cause possible damage to the spinal cord.
    • The body has to make the choice between the lesser of the two evils. Usually, the body generates the bone spurs or the narrowing of the spinal canal.

Questioning surgery: No association has been found between the severity of pain and the degree of stenosis

  • The hallmark symptom of spinal stenosis is neurogenic claudication, which is neurologically-based pain that occurs upon walking; other common symptoms include:
    • sensory disturbances in the legs,
    • low back pain,
    • weakness, and
    • pain relief upon bending forward.
  • No association has been found between the severity of pain and the degree of stenosis, although patients who are symptomatic tend to have narrower spine openings than asymptomatic patients.
  • Making a diagnosis of spinal stenosis based on the absolute size of the spinal canal also has its drawbacks since it does not indicate whether or not there is impingement or distortion of either the spinal cord or nerve roots. Impingement or encroachment of the spinal cord by bone is called myelomalacia; impingement of the spinal nerve roots is called radiculopathy.

In their study, surgeons from the Rothman Institute at Thomas Jefferson University wrote of the problem of correctly classifying patients with lumbar stenosis for the purpose of increasing the effectiveness of treatments.

While surgery may be effective for some, the surgical techniques vary widely from a decompression procedure to a spinal fusion procedure. This variation in technique and what the researchers call the “lack of an accepted classification system,” can lead to problems for patients with complications. (12)

We describe many spinal surgery techniques and their independent medical reviews in supportive research on this website including our articles:

Research: “Spine surgeons should be increasingly asked why they are offering these operations to their patients?”

Nancy Epstein of Winthrop University Hospital wrote in the medical journal Surgical Neurology International.

The incidence of nerve root injuries following any of the multiple MIS lumbar surgical techniques transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusions (ALIF), extreme lumbar interbody fusions (XLIF) resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques.

“Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?”(13)

Research: Findings warn doctors to stop doing certain spinal surgeries

Diagnosing stenosis as the cause of a patient’s pain is very problematic. We are going to the following problems that may lead to failed back surgery due to surgery not addressing the true cause of the patient’s pain.

  • No association has been found between the severity of pain and the degree of stenosis, although patients who are symptomatic tend to have narrower spines than asymptomatic patients.
  • Studies have found that diagnosing spinal stenosis with 10 mm as the sagittal diameter (the amount of space) alone produces false-positive rates approaching 50%.
  • Making a diagnosis of spinal stenosis based on the absolute size of the spinal canal also has its drawbacks since it does not indicate whether or not there is impingement or distortion of either the spinal cord or nerve roots. Impingement or encroachment of the spinal cord by bone is called myelomalacia; impingement of the spinal nerve roots is called radiculopathy.

One more time: Back to questioning the MRI


Research: “Spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis.”

Above we discussed problems with the MRI and the over-reliance of surgeons on recommending surgery to their patients.

Published in the medical journal Osteoarthritis and Cartilage researchers at one of Japan’s leading medical research centers, Wakayama Medical University Hospital, discovered something unsettling for the diagnosed stenosis patient. It seems that many asymptomatic individuals (patients with no complaints or symptoms) have radiographic lumbar spinal stenosis.

  • There seems then to be confusion if the patient is not complaining of back pain, but the MRI says it is stenosis, does the patient has a problem that needs to be operated on?

So in 938 patients with an average age of about 66, they found when they did an MRI, Lumbar Spinal Stenosis was very prevalent. But when they asked the patient if they had back pain or other spinal problems, spinal stenosis complaint was uncommon. (14) 

In recent research, surgeons in Mexico publishing in the Spanish language medical journal Cirugía y Cirujanos (Surgeons and surgery) say that spinal surgery failure for spinal stenosis patients is due mainly (61%) to surgical error and nearly 55% from misdiagnosis. (15)


YET, patients are convinced to have the surgery anyway

More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms”(16), according to research in the Journal of Neurosurgery from Wayne State University School of Medicine

Our option to Surgery and Conservative Care – Prolotherapy injections

In the research above we highlighted the research that suggests:

  • Conservative care options for lumbar spinal stenosis has limited success
  • Surgical outcomes, both open and minimally invasive surgery, are not as successful as one would think
  • MRIs can reveal stenosis that causes no pain
  • MRI can reveal stenosis in a situation where back pain exists BUT it may not be the stenosis causing the pain.

So if in your instance, it is not the stenosis causing pain as we outlined above, something else has to be responsible for the back pain or leg pain in diagnosed cases of spinal stenosis. What is it? How do you find out?

Treating the spinal ligaments may be the answer to stenosis


The examination of the patient with a stenosis diagnosis not responding to conservative care

When we examine a patient who has a big medical chart with x-rays, MRIs, treatment recommendations, surgeon recommendations, we usually start with: “When does your back hurt?”

  • Most people will refer to some motion, often one of combined flexion (bending) and rotation that they performed before developing certain positional symptoms.
  • For instance, symptoms that are worse with one position or motion (for example, walking or standing) then improve with spinal flexion (for example, sitting).

Based on our experience and the observations of thousands of patients, this presents us with a clue that the spinal ligaments are loose and causing symptoms based on the patient’s position.

Our patients are people who want to avoid surgery for their lumbar spinal stenosis. They are also people that have exhausted all or most options on the conservative care side. They come to our clinics looking for the realistic possibility that simple dextrose injections (Prolotherapy) will help them achieve their goal of reducing or being pain-free without surgery and continuous treatments. Typically, in all their treatments, very few will have had any discussion with their health care provider about the role of spinal ligaments in spinal instability as the cause of their problems.

This picture describes degenerative progression of the lower spine.

 

In approximately 90% of patients, low back pain is mechanical in nature, typically originating from overuse, straining, lifting, or bending that results in ligament sprains, muscle pulls, or disc herniation. The popular understanding of back pain is disc herniation as a frequent cause, but to a much greater extent, ligament injury forms the underlying basis. Ligaments hold the disk in place, and with ligament weakness, the disk is more likely to herniate.

The first step in determining whether Prolotherapy will be an effective treatment for the patient is to determine the extent of ligament laxity or instability in the lower back by physical examination. The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain. Pain here is an indicator that Prolotherapy can be very effective for the patient.

Treating the spinal ligaments may be the answer

This is why giving Comprehensive Prolotherapy to stabilize the ligaments is often the ideal treatment, even in patients who have been diagnosed with spinal stenosis. Many times a patient will find it hard to believe that dextrose injections, sometimes dextrose injections plus concentrated blood platelet healing factors (Platelet Rich Plasma therapy) will help them even after his/her doctor told them only surgery can help. These patients also find it hard to believe that after their Prolotherapy treatments that they do not have to go to surgery.

Research: Prolotherapy for back pain

There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.

  • Research from the University of Manitoba, The Journal of Alternative and Complementary Medicine.(17)  
    • 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
  • Harold Wilkinson MD, in the journal The Pain Physician (18)
    • Prolotherapy can provide significant relief of axial pain (soft tissue damage) and tenderness combined with functional improvement, even in “failed back syndrome” patients.

Citing our own Caring Medical published research in which we followed 145 patients who had suffered from back pain on average of 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. (19)

If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.

Prolotherapy for patients who had longstanding and often severe pain and disability

In other Prolotherapy research published in the journal International Musculoskeletal Medicine (20), researchers in the United Kingdom explored the use of Prolotherapy in patients who had failed to respond to conservative approaches including spinal manipulation and physiotherapy. These patients had longstanding and often severe pain and disability. Utilizing only treatments that included 3 injections over a 3 to 5 week period, they confirmed that 91% of respondents were better or not worse off after 12 months.

Prolotherapy injections for chronic low-back pain


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 repair of the ligament attachment to the bone.
  • We treat the whole low back area to include 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.

Pinched nerve or lumbar radiculopathy in cases of stenosis

If you have ever experienced a pinched nerve or lumbar radiculopathy, you know the pain is excruciating. Burning pain zooming down an extremity can cause such blinding pain, it will stop anyone in their tracks. But even in cases of acute pain, we have to ask why this problem started in the first place. The answer is ligament laxity, which causes the vertebrae to slip out of place and pinch the nerve.

In our office, people with a pinched nerve or lumbar radiculopathy are cases are often seen as needing a two-part solution.

  • First, we have to work to get the patient out of acute pain. Nerve blocks utilizing a 70.0% Sarapin and 0.6% lidocaine solution are often given, in addition to Prolotherapy. The nerve block provides initial pain relief, so the person is able to rest and repair while the Prolotherapy begins to work. Upon nerve relaxation, the vertebrae will realign and the nerve compression will cease. Even in cases of such extreme pain as a pinched nerve, the pain is typically positional. This means that it gets more intense when a person gets into certain positions. For example, if someone has unbearable pain upon sitting or kneeling, but is relieved somewhat while standing or lying flat, this means certain positions are causing the vertebrae to slip and pinch on the nerve. This also should be the point where someone should be contacting us for a Prolotherapy treatment.
  • In our in-house analysis of consecutive patients treated for radiculopathy with Prolotherapy, the average starting pain level in patients treated for lumbar radiculopathy was 6.3, and the ending pain level was 2.5 (VAS 0-10). In this same radiculopathy data, we looked at cervical radiculopathy patient outcomes as well. They were equally impressive with an average starting pain level of 5.6 and an ending pain level of 1.
  • Prolotherapy proved to be an excellent non-surgical option for the unrelenting pain characteristic of radiculopathy. Whether the spine or other joints, positional pain is indicative of joint instability and an ideal application for Prolotherapy!
This picture illustrates how a Prolotherapy injection can tighten the spinal ligaments and provide relief through providing vertebral alignment therapy. This will help alleviate the pressure caused by pinched nerves and herniated discs.

This picture illustrates how a Prolotherapy injection can tighten the spinal ligaments and provide relief through providing vertebral alignment therapy. This will help alleviate the pressure caused by pinched nerves and herniated discs.

Spinal Stenosis at Rest, Spinal Stenosis with Activity – when should you consider surgery, when should you consider Prolotherapy?

We can think of spinal stenosis as two different disorders, one needs surgery and the other Prolotherapy. There are SSAR and SSWA which stand for Spinal Stenosis At Rest and then Spinal Stenosis With Activity. (See Figure)

This picture illustrates the severity of symptoms that can occur in situations referred to as Spinal Stenosis At Rest and Spinal Stenosis With Activity. It also explains when surgery will likely be recommended for Stenosis At Rest and when surgery can be avoided in cases of Stenosis With Activity.

This picture illustrates the severity of symptoms that can occur in situations referred to as Spinal Stenosis At Rest and Spinal Stenosis With Activity. It also explains when surgery will likely be recommended for Stenosis At Rest and when surgery can be avoided in cases of Stenosis With Activity.

Surgery is needed for Spinal Stenosis At Rest but Prolotherapy resolves Spinal Stenosis With Activity.

They are differentiated on symptoms and a test called electromyography/nerve conduction studies (EMG/ NCV). The patient who has severe pain, especially nerve irritation down the leg at rest has a narrowing of the space for the nerves that are not affected by activity. It means that there just is never enough room for the nerve, even at rest. In these instances, a lot of nerve damage or irritation is present on an EMG/NCV test. This patient would be referred for a surgical decompressive surgery, where the surgeon makes more room for the nerve. Any residual pain after the surgery can then be treated with Prolotherapy.

However, almost all the cases of spinal stenosis fall into the second category, Spinal Stenosis With Activity.

These are patients who have no symptoms when they are sitting and laying recumbent and resting. But upon standing or walking for too long, they develop back pain, buttock pain, and pain down the leg. In other words, the symptoms are only precipitated by movement or change in position. This means that the nerves have enough room at rest, but the room for the nerve is decreased with standing or walking. The symptoms are dependent on position. Positional pain is a hallmark feature of conditions that respond to Prolotherapy, in the spine and any joint of the body!

When presented with all this information, on a patient’s first visit, he/she is sometimes disbelieving that Prolotherapy or Prolotherapy in conjunction with Platelet Rich Plasma Therapy can provide benefit and help relieve the pain of spinal stenosis, yet, the answer to their commonly asked questions can be found in the above research.

If this article has helped you understand problems of lumbar stenosis and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists.

Research citations:

1 Adogwa O, Davison MA, Vuong VD, Khalid S, Lilly DT, Desai SA, Moreno J, Cheng J, Bagley C. Long Term Costs of Maximum Non-Operative Treatments in Patients with Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery: A Five-Year Cost Analysis. Spine. 2018 Aug. [Google Scholar]
2 Davison MA, Vuong VD, Lilly DT, Desai SA, Moreno J, Cheng J, Bagley C, Adogwa O. Gender Differences in Use of Prolonged Nonoperative Therapies Before Index Lumbar Surgery. World Neurosurgery. 2018 Dec 1;120:e580-92. [Google Scholar]
3 Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun S, El Ahmadieh T. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Research. 2019 Jan 31;8. [Google Scholar]
4 Virk SS, Phillips FM, Khan SN. Factors Affecting Utilization of Steroid Injections in the Treatment of Lumbosacral Degenerative Conditions in the United States. International Journal of Spine Surgery. 2018 May 1:5021. [Google Scholar]
5 Radcliff K, Kepler C, Hilibrand A, Rihn J, Zhao W, Lurie J, Tosteson T, Albert T, Weinstein J. Epidural Steroid Injections Are Associated with Less Improvement in the Treatment of Lumbar Spinal Stenosis: A subgroup analysis of the SPORT. Spine (Phila Pa 1976). 2012 Dec 12.  [Google Scholar]
6 Patel J, Osburn I, Wanaselja A, Nobles R. Optimal treatment for lumbar spinal stenosis: an update. Current Opinion in Anesthesiology. 2017 Oct 1;30(5):598-603. [Google Scholar]
7 Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 4;352:h6234. [Google Scholar]
8 Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010;24(2):253-65. [Google Scholar]
9 Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Jan 29;(1): [Google Scholar]
10 Hebert JJ, Abraham E, Wedderkopp N, Bigney E, Richardson E, Darling M, Hall H, Fisher CG, Rampersaud YR, Thomas KC, Jacobs B. Patients undergoing surgery for lumbar spinal stenosis experience unique courses of pain and disability: A group-based trajectory analysis. PloS one. 2019;14(11):e0224200-.
11 Diwan S, Sayed D, Deer TR, Salomons A, Liang K. An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach. Pain Medicine. 2019 Dec 1;20(Supplement_2):S23-31. [Google Scholar]
12 Schroeder GD, Kurd MF, Vaccaro AR. Lumbar Spinal Stenosis: How Is It Classified? J Am Acad Orthop Surg. 2016 Dec;24(12):843-852.  [Google Scholar]
13 Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let’s tell someone. Surg Neurol Int. 2016 Jan 25;7(Suppl 3):S96-S101.  [Google Scholar]
14 Ishimoto† Y, Noriko Y, Shigeyuki M, Hiroshi Y, et al. Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: The Wakayama Spine Study. Osteoarthritis Cartilage. 2013 Mar 5. pii: S1063-4584(13)00706-1. doi: 10.1016/j.joca.2013.02.656.  [Google Scholar]
15 Romero-Vargas S, Obil-Chavarria C, Zárate-Kalfopolus B, Rosales-Olivares LM, Alpizar-Aguirre A, Reyes-Sánchez AA. [Profile of the patient with lumbar failed surgery syndrome at National Institute of Rehabilitation. Comparative analysis]. Cir Cir. 2015 May 15.  [Google Scholar]
16. Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. [Google Scholar]
17. 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]
18. 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]
19. Hauser R, Hauser M. Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study. Journal of Prolotherapy. 2009;1(3):145-155.
20. Jacks A, Barling T. Lumbosacral prolotherapy: a before-and-after study in an NHS setting. International Musculoskeletal Medicine. 2012 Apr 1;34(1):7-12.  [Google Scholar]

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