Non-surgical treatment options and surgery outcomes in lumbar spinal stenosis

Ross Hauser, MD., Danielle Matias, PA-C

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

If you are like many people that we see at our clinic, you have had recurring and chronic back pain for some time. Sometimes this back pain flares up and becomes almost intolerable for you. But, you have to go to work or continue on with your daily routine activities so this pain needs to be managed. Eventually, you will make appointments with a few or many different health care professionals and during one of these trips to the doctor or health care provider, it will be revealed to you that you have a diagnosis of lumbar spinal stenosis. Now your medical journey will probably be filled with diagnoses 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:

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.

Discussion points of this article.

Waiting for surgery because surgery is the only answer? The rate of side effects ranged from 10% to 24% in surgical cases

In this article, we will present research and clinical observations that for some people, there can be other options beyond being pain managed with medications until they can get a lumbar spinal stenosis surgery. We will take the path from pain to MRI to the surgical recommendation and show how in some people, not all, lumbar spinal stenosis surgery can be avoided and the suffering of waiting for surgery can be eliminated.

There is a great debate in medicine as to which path of treatment to pursue in patients suffering from lumbar spinal stenosis. In December 2016, researchers led by the Italian Scientific Spine Institute looked at nearly 13,000 previous published research studies and narrowed down this list to 24 extensive papers that could be used to debate which treatment options would be most beneficial to which patients. (1) This is what they concluded:

“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. 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. No clear benefits were observed with surgery versus non-surgical 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.”

This 2016 paper’s guidelines on conservative care treatment has been cited by 76 other publications including a July 2022 paper in the journal BioMed Central musculoskeletal disorders (2) which found “supervised physical therapy yielded similar effects to lumbar surgery.” Further, “These results suggest that supervised physical therapy is preferred over surgery as first-choice treatment, to prevent complications and to minimize health care costs, especially in mild to moderate cases of lumbar spinal stenosis.”

Throughout the course of this article we will see various comparison studies citing surgery is superior to conservative care treatments or that surgery is no better than conservative care treatment and surgery has its own complications. Many people do have very successful surgeries. Others do not. In this next section we will explore why your MRI may have lead you to a surgery failure.

Did the MRI interpretation scare the patient into a surgery they did not need?

In my article Is your MRI sending you to a back surgery you do not need because of fear and panic? I discuss many research studies, one was July 2021 when two surgeons and a radiologist published a randomized control trial study in the European Spine Journal. (3) The basis of this study was, did the MRI interpretation scare the patient into a surgery they did not need? Further, did the patient have poor surgical outcomes because their MRI report sent them into “catastrophic thought?”

Another study from July 2021 (4) cited an epidemic of unnecessary MRIs sending people to unnecessary surgery and worsening the patient’s condition by creating “failed back surgery syndrome” in many of them. In this paper, researchers expressed concerns over how many MRIs were being ordered by general practitioners for musculoskeletal problems in the United Kingdom. The researchers note phenomena found here in the United States as well that there is limited supporting evidence that these MRIs will be helpful to the patient and worse there is the potential for patient harms from early imaging overuse.

Summary of this and other related research:

The MRI

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 addressed 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.

The dangers of stenosis diagnosis based on MRI

In brief summary, the MRI came back: Your doctor read the report to you or maybe you were just given the MRI report with no explanation. What you read then seems to suggest:

Many times a patient will come in with the diagnosis of lumbar stenosis and scans and images to support the diagnosis. But their doctors are not sure what to do about.

Many times a patient will come in with the diagnosis of lumbar stenosis and scans and images to support the diagnosis. But their doctors are not sure that what to do about. A December 2021 study in the journal Orthopedic Reviews (5) examined and described the different aspects of patient suffering related to lumbar spinal stenosis and how suffering is managed before lumbar spinal stenosis surgery. In this paper, researchers talked to 18 patients on the waiting list for lumbar spinal stenosis surgery. They basically asked: “How do you feel?” The researchers then took all the answers and come up with an analysis. See if this sounds like you.

Patients struggling to be believed and taken seriously

“The suffering from lumbar spinal stenosis before surgery included the main theme of experiencing an impaired physical and social life and struggling to be believed and taken seriously. This had coping strategies to manage symptoms before surgery: a good physician-patient relationship alleviates the burden of long waiting times; ways to manage pain and disability; ambiguous expectations and hope for recovery, and; ways to handle concerns before surgery).

Conclusion: Being a person with lumbar spinal stenosis includes suffering and a possibility to discover coping abilities or having support structures for doing so. (This) study emphasizes the importance of a supportive dialogue, where physicians and patients make the suffering from lumbar spinal stenosis and care before lumbar spinal stenosis surgery more comprehensible and manageable.”

What the researchers here are suggesting is that not enough is being done to ease patient suffering before they can get to surgery. But what is it that patients are not getting enough of? What aren’t you getting enough of?

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:

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

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. 

Conservative Care before surgery: Researchers ask: Is conservative care for lumbar stenosis a waste of time and resources? When is surgery not indicated?

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 are non-surgical.

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

Three years later, many patients who chose not to have spinal surgery for stenosis are doing good.

Not everyone will need a stenosis surgery. A May 2022 paper published in JAMA, the Journal of the American Medical Association (6) writes about a “series of patients with lumbar spinal stenosis followed up for up to three years without operative intervention.” In this group of patients:

Further,

However, surgery needs to be carefully recommended. The researchers note:

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.

Ten years later, spinal stenosis did not progress to a level requiring surgery

In October 2022, doctors writing in the Journal of Clinical Medicine (7) looked at the ten year follow ups of 1862 patients initially diagnosed with lumbar spinal stenosis. The doctors were looking for the outcomes of patients who did not have surgery. How did they fare? The age of the patients ranged from 19 to 93 years old at the time of diagnosis. What the doctors found was that  62% of the patients of this study, who initially were diagnosed with lumbar spinal stenosis did not have or showed significantly less symptoms ten year later.  Overall, about 60% of people recovered from lumbar spinal stenosis symptoms after 10 years, and younger people were particularly likely to recover from lumbar spinal stenosis symptoms.

The study doctors also noted that it would be expected that the condition would worsen over time. Many people we see who had a diagnosis of lumbar spinal stenosis had it suggested to them that their situation would probably get worse.  However, the researchers noted, the frequency of lumbar spinal stenosis symptoms switching from bad to good (or bad to better) at the 10-year follow-up support the description of North American Spine Society Evidence-Based Clinical Guidelines which states “the natural history of patients with clinically mild to moderately symptomatic degenerative lumbar stenosis can be favorable in about one-third to one-half of patients”  even with a 10-year follow-up period.

What could make lumbar spinal stenosis worse was other conditions the patient suffered from such as hypertension, diabetes mellitus, osteoarthritis and depressive symptoms.

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. (8)

Here are the learning points:

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. (9)

Taking this research further, a March 2021 paper (10) found that even though men and women reported the same symptom severity for their lumbar spinal stenosis, female patients had more disability and depression.

Chiropractic care in patients over 80

A small study on twelve patients published in October 2022 in the Journal of bodywork and movement therapies (11) evaluated chiropractic care including flexion distraction spinal manipulation for improving function, symptoms and performance-based mobility in patients with lumbar spinal stenosis.

Results: Twelve patients  completed the average midpoint visit at 9 visits and the final visit at 13.7 visits.

Conclusion: Significant improvement in objective and subjective outcomes were found after a pragmatic course of care including spinal manipulation in lumbar spinal stenosis patients.

Physical therapy for lumbar spinal stenosis

Epidural injections for lumbar spinal stenosis

Our opinions are based on over 25 years of empirical and clinical observation of how treatments help or do 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.

Neurogenic claudication

Bone spurs form as a result of microinstability of the spine, as the body attempts to stabilize the unstable spine, which can eventually narrow the spinal canal and cause resultant spinal stenosis. Spinal stenosis is defined as a specific type and amount of narrowing of the spinal canal, nerve root canals, or intervertebral foramina and can be either congenital or developmental or be acquired from degenerative changes.

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. Segmental instability is thought to be a source of the low back 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.

A January 2022 study (13) led by the University of Toronto examined the growing older adult health problem of neurogenic claudication. They found: “There is moderate-quality evidence from (previously published studies) that: Manual therapy and exercise provides a superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education, and exercise delivered using a cognitive-behavioral approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term.”

Conclusions: There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of lumbar spinal stenosis with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness.

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


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

Research:

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. (14)

Highlights: Attention Medicare People

This 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 a longer duration of surgery and longer hospital stay. There was no improvement in outcome with Epidural steroid injections. . . ”(15)

A February 2021 paper published in the Brazilian Journal of Orthopaedics (16) offered a review assessment of conservative care treatments for lumbar stenosis up to the point. In reviewing previously published literature the researchers pointed out the following:

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, (17pain 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.

Finally,

In the British Medical Journal, (18) 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 the medical journal Best Practice and Research. Clinical Rheumatology, (19) 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.”

33% of the patients reported failure, and 22% reported worsening of pain and disability

A February 2023 study in The spine journal (20) comes to us from the Norwegian University of Science and Technology, Akershus University Hospital and Oslo University Hospital. In this study, the Norwegian doctors explored why some patients do not improve after lumbar spinal stenosis surgery and why the surgery may increase risk for complications and spine deterioration in some patients.

In this study, 8919 lumbar stenosis surgical patients, average age about 67 and 52% being female, were assessed 12 months after surgery.

Here are the findings:

Twelve months after surgery, the average  Oswestry Disability Index (ODI)  score was 23.9 (low end moderate disability), however 2950 patients (33.2%) were classified as surgical failures and 1921 (21.6%) were classified as worse off.

The conclusion of this research was: “After surgery for lumbar spinal stenosis, 33% of the patients reported failure, and 22% reported worsening as assessed by Oswestry Disability Index. Preoperative duration of back pain for longer than 12 months, former spinal surgery, and age above 70 years were the strongest predictors for increased odds of failure and worsening after surgery.”

” 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 (21) 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:

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 (22) 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.

Minimally Invasive Lumbar Decompression

Endoscopic Decompression (for Foraminal Stenosis)

Invasive Open Decompression Surgery

Limited vs Multilevel Decompression Surgery

Risks 

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 the 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.

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

Is it canal narrowing or wearing away of the vertebrae endplates that are causing pain attributed to lumbar spinal stenosis

A September 2021 study in The Spine Journal (23) addressed the controversy as to whether lumbar spinal stenosis itself contributes to low back pain. What these researchers are suggesting is that even when an MRI shows stenosis, that may not be what is causing the patient’s problems. The researchers write: “Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to low back pain. However, whether these factors cause low back pain in patients with lumbar spinal stenosis is unclear.” To then answer this question, the researchers looked at 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication (neurologic symptoms going from numbness to possibly bladder dysfunction) caused by lumbar spinal stenosis. What did they find? The presence of erosive endplate defects. . . These results suggest that low back pain in patients with lumbar spinal stenosis should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.”

What are endplate defects?

The endplates are the rim of the vertebrae, endplate defects represent the wearing away or dissolving of the rim of the vertebrae. This can occur from spinal instability which allows the bones to become hypermobile and bang and wear against each other  The damage to the endplate can not only result in the flattening of the disc and disc herniation, but modic changes as well (damage to the bone marrow within the vertebrae causing bone marrow edema or inflammation).

What are we seeing in this image? The caption reads: MRI of the lower back demonstrating Modic changes in several lumbar vertabrae. The person in this image suffers from degenerative Modic Type 1 endplate bone marrow signal changes at L3-L4 (signifying lesions and other damage). In this case, the patient was treated with Prolotherapy injections which helped stabilize the spine.

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. (24)

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?”(25)

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.

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.

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. (26) 

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. (27)

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”(28), 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:

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?”

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 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.

Citing our own Caring Medical published research in which we followed 145 patients who had suffered from back pain on average for nearly five years, we examined not only the physical aspect of Prolotherapy but the mental aspect of treatment as well.

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 (32), 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

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.

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 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!

The issue of pain catastrophizing and walking after stenosis surgery

A December 2022 study in the journal BioMed Central musculoskeletal disorders (33) examined whether walking speed is associated with postoperative pain catastrophizing in patients with lumbar spinal stenosis. In other words, do people who walk more slowly have worse surgical outcomes because of pain catastrophizing? In this study, the researcheres assessed the medical records and outcomes of consecutive patients with clinically and radiologically defined lumbar spinal stenosis who underwent surgical treatment (decompression, or posterolateral or transforaminal lumbar interbody fusion). Various pain and function scoring systems, including a pain catastrophizing scale, were used preoperatively and at three, six, and 12 months postoperatively.

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.

For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.

Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your back problems and spinal instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

Subscribe to our newsletter 

Research citations:

1 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]
2 Minetama M, Kawakami M, Teraguchi M, Enyo Y, Nakagawa M, Yamamoto Y, Matsuo S, Nakatani T, Sakon N, Nakagawa Y. Supervised physical therapy versus surgery for patients with lumbar spinal stenosis: a propensity score-matched analysis. BMC Musculoskeletal Disorders. 2022 Jul 11;23(1):658. [Google Scholar].
3 Rajasekaran S, Pushpa BT, Ananda KB, Prasad A, Rishi MK. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of’clinical reporting’: results from an RCT and blinded trials. European Spine Journal: Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2021 Mar 21. [Google Scholar]
4 Sajid IM, Parkunan A, Frost K. Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care. BMJ open quality. 2021 Jul 1;10(3):e001287. [Google Scholar]
Knutsson B, Jong M, Sayed-Noor A, Sjödén G, Augutis M. Waiting for lumbar spinal stenosis surgery: suffering and a possibility to discover coping abilities. Orthopedic Reviews. 2021 Dec 10:30716. [Google Scholar]
6 Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022 May 3;327(17):1688-99. [Google Scholar]
7 Igari T, Otani K, Sekiguchi M, Konno SI. Epidemiological Study of Lumbar Spinal Stenosis Symptoms: 10-Year Follow-Up in the Community. Journal of Clinical Medicine. 2022 Oct 7;11(19):5911. [Google Scholar]
8 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]
9 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]
10 Peteler R, Schmitz P, Loher M, Jansen P, Grifka J, Benditz A. Sex-Dependent Differences in Symptom-Related Disability Due to Lumbar Spinal Stenosis. Journal of Pain research. 2021 Mar 16:747-55. [Google Scholar]
11 Smith DL, Olding K, Malaya CA, McCarty M, Haworth J, Pohlman KA. The influence of flexion distraction spinal manipulation on patients with lumbar spinal stenosis: A prospective, open-label, single-arm, pilot study. Journal of Bodywork and Movement Therapies. 2022 May 18. [Google Scholar]
12 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]
13. Ammendolia C, Hofkirchner C, Plener J, Bussières A, Schneider MJ, Young JJ, Furlan AD, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. BMJ open. 2022 Jan 1;12(1):e057724. [Google Scholar]
14 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]
15 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]
16 Hennemann S, Abreu MR. Degenerative Lumbar Spinal Stenosis. Revista Brasileira de Ortopedia. 2021 Apr 5;56:9-17.
17 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]
18 Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 4;352:h6234. [Google Scholar]
19 Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010;24(2):253-65. [Google Scholar]
20 Alhaug OK, Dolatowski FC, Solberg TK, Lønne G. Predictors for failure after surgery for lumbar spinal stenosis, a prospective observational study. The Spine Journal. 2022 Nov 5. [Google Scholar]
21 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-.
22 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]
23 Minetama M, Kawakami M, Teraguchi M, Matsuo S, Sumiya T, Nakagawa M, Yamamoto Y, Nakatani T, Nagata W, Nakagawa Y. Endplate defects, not the severity of spinal stenosis, contribute to low back pain in patients with lumbar spinal stenosis. The Spine Journal. 2021 Sep 30. [Google Scholar]
24 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]
25 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]
26 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]
27 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]
28 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]
29 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]
30 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]
31 Hauser R, Hauser M. Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study. Journal of Prolotherapy. 2009;1(3):145-155.
32 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]
33 Wada T, Tanishima S, Kitsuda Y, Osaki M, Nagashima H, Noma H, Hagino H. Walking speed is associated with postoperative pain catastrophizing in patients with lumbar spinal stenosis: a prospective observational study. BMC Musculoskeletal Disorders. 2022 Dec;23(1):1-6. [Google Scholar]

This article was update December 22, 2022

Make an Appointment |

Subscribe to E-Newsletter |

Print Friendly, PDF & Email
SEARCH
for your symptoms
Prolotherapy, an alternative to surgery
Were you recommended SURGERY?
Get a 2nd opinion now!
WHY TO AVOID:
★ ★ ★ ★ ★We pride ourselves on 5-Star Patient Service!See why patients travel from all
over the world to visit our center.
Current Patients
Become a New Patient

Caring Medical Florida
9738 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax

Hauser Neck Center
9734 Commerce Center Ct.
Fort Myers, FL 33908
(239) 308-4701 Phone
(855) 779-1950 Fax
We are an out-of-network provider. Treatments discussed on this site may or may not work for your specific condition.
© 2023 | All Rights Reserved | Disclaimer