Spinal instability and back pain
Spinal instability can be at the root of many back pain conditions but the cause of the spinal instability can be confusing and complex.
- Before you read on, if you have questions about back pain, you can get help and information from our Caring Medical staff
In this article we will provide information on:
- failed back surgery syndrome,
- non-surgical treatment of lumbar radiculopathy,
- lumbar disc herniation,
- sacroiliac joint pain treatment,
- as well as discussing the challenges of identifying spinal instability caused by spinal ligaments.
Symptoms of Spinal Instability
- Giving way or back giving out, feeling of instability
- Need to frequently crack or pop the back to reduced symptoms
- Frequent bouts or episodes of symptoms (recurrence, not first episode)
- History of painful catching or locking during trunk motions
- Pain during transitional activities
- Greater pain returning to erect position from flexion
- Pain increased with sudden, trivial, or mild movements
- Difficulty with unsupported sitting and better with supported backrest
- Worse with sustained postures or a decreased likelihood of reported static position that is not painful
- Condition is progressively worsening
- Long-term, chronic disorder
- Temporary relief with back brace or corset
- Frequent episodes of muscle spasm
- Rotational symptoms, different symptoms on different days
Identifying spinal instability in nonspecific back pain
Spinal instability begins when the stabilizing structures of the spine, especially the ligaments can no longer hold adjacent bones together. When present, this is termed mechanical instability.
The term functional instability is used when the mechanical instability causes symptoms with a certain function or activity.
- Many people are walking around with mechanical instability but are asymptomatic because the force required to perform current normal activities is not beyond the tissue strength.
- Problems arise when the mechanical instability worsens when patients overdo an activity or start a new exercise program.
- Thus the patient may have symptoms only when performing a certain activity, such as back pain with running.
- From the patient’s perspective, pain symptoms do not exist during any other activities.
- This is called functional spinal instability with running and mechanical instability of the entire low back.
- Functional instability, or symptomatic instability with movement, occurs with mechanical failure of the spinal ligaments and the subsequent excessive motion of adjacent bones. This can be caused by trauma, disease, surgery, or any combination thereof to one or more regions of the spine.
Chronic back pain is caused by difficulty in understanding what is causing it.
Recently researchers in Germany writing in the medical journal Clinical rheumatology discussed the problems of assessing the true cause of back pain. To summarize their findings, the researchers noted that:
- The most examined spinal problem is low back pain.
- Low back pain for the most part is caused by a nonspecific problem that is difficult to diagnosis. (Note: This is not very reassuring to patients that the most chronic back pain problem is difficult to understand. This is also why the rush to lumbar surgery is so troubling.)
- Inflammation of the spine is not as widespread.
- Only a small amount of patients have axial (low back sacroiliac joint) inflammation as the major cause of their back complaints with chronic inflammatory back pain as the most prominent clinical feature of spondyloarthritis (inflammatory/rheumatoid arthritis). (Note: This is also troubling to patients as if inflammation is not the problem, as patients are being put on long-term anti-inflammatory treatment plans.)
- Numerous diseases such as:
- degenerative disc disease,
- degenerative changes in the intervertebral (facet) joints and the associated ligaments,
- spinal instability,
- herniation of the intervertebral disc,
- and spinal stenosis have to be differentiated in interpreting imaging of the spine.
- (Ross Hauser MD has written on article on this site on how the MRI is a risk factor for failed back surgery)1
In our opinion, most health care providers rely too heavily on diagnostic tests, especially for low back problems. Consequently, many who suffer from low back pain do not find relief.
The typical scenario is as follows:
- A person complains to a physician about low back pain that radiates down the leg.
- The physician orders x-rays and an MRI.
- The scan reveals an abnormality in the disc—such as a herniated, bulging, or degenerated disc.
- Unfortunately for the patient, this finding usually has nothing to do with the pain.
When a patient comes into Caring Medical we look for the familiar characteristic features of a patient with spinal instability. This helps us determine the role of discs and ligaments in the patient’s complaint of spinal instability.
1. The patient reports their back cracks a lot
Typically a patient will report that they hear a crack every time they turn over in bed or stretch out their back. This can be a tell tale sign of spinal instability. With regular movements such as these, it isn’t normal for vertebrae to shift enough to make a cracking sound, also known as crepitation.
2. Patient reports that they get frequent chiropractic adjustments
Needing frequent chiropractic treatments or therapy to relieve chronic pain is not typical. This means that the patient is suffering from constant dislocations of the vertebrae. It is likely that the reason the vertebrae continue to move out of position is ligament laxity, or the inability of ligaments to hold the spine in place. This is typical of any joint instability and degenerative joint disease caused by ligament laxity.
When capsular ligaments and other soft tissues along your spine stretch out, the vertebrae are able shift out of alignment. Even if you have them put back in place through repeated care and adjustments, the ligaments still remain loose and can allow for repeated shifting.
3. Patient continuously self-manipulates
Self-manipulation of the spine is very abnormal finding, yet is a common thing that we see. Whenever a new patient comes to Caring Medical for neck or low back pain, it is highly likely that they will tell us they crack their back or neck habitually.
Self or chiropractic manipulation has the potential to further loosen the spinal ligaments and cause more instability.
4. Intermittent pain down the arm or leg
Spinal subluxations (slipped/herniated disc) can pinch on nerves as they exit the spinal cord. The pain of the pinched nerve is not constant but instead only occurs when the vertebrae shift and pinch on the nerve. This is usually a good prognostic indicator for ligament damage as the cause of spinal instability.
5. Tightness or spasm in the neck and back muscles, even at rest
What causes muscle spasms in the back? It isn’t normal to get knots, trigger points, or tender points in muscles. Neck, upper back, or lower back muscle spasms are a sign of spinal instability. The reason these painful spasms do not go away is because they are trying to stabilize the spine. The tightness and spasm are a clue that the ligaments have become weakened and injured. When there is ligament instability there is spinal instability the surrounding muscles contract as a way to help keep stability.
What are the treatment options patients with back pain?
A recent paper from doctors at the University of Georgia and McGill University in Montreal published in the American family physician examined the top 20 research studies of 2015 that had the most impact on family practice doctors. Among the top 20 was:
- avoiding early imaging (MRIs et al)
- Do not add cyclobenzaprine or oxycodone to naproxen for patients with acute low back pain
- encourage patients with chronic or recurrent low back pain to walk.”2
At Caring Medical we have to agree that concerns about treatment plans including back surgery based on MRIs, painkillers and lack of movement in patients would back pain is something that needs to be looked into and corrected.
In a recent study from Vanderbilt University Medical Center published in the Journal of Neurosurgery, researchers followed:
- Fifty patients with lumbar spondylolisthesis,
- Fifty patients with stenosis, and
- Fifty patients with disc herniation who had symptoms persisting after 6 weeks of medical management and who were eligible for surgical treatment were followed after deciding on nonsurgical treatment.
The non-surgical treatment was:
- Spinal steroid injections,
- physical therapy,
- muscle relaxants,
- anti-inflammatory medication,
- and narcotic oral agents.
The maximum health gain in back pain, leg pain, disability, quality of life, depression, and general health state did not achieve statistical significance by 2 years of medical management, except for pain and disability in patients with disc herniation and back pain in patients with lumbar stenosis.
- Eighteen patients (36%) with spondylolisthesis,
- 11 (22%) with stenosis, and
- 17 (34%) with disc herniation eventually required surgical management due to lack of improvement.
The Vanderbilt researchers concluded that: In all cases, comprehensive medical management included spinal steroid injections, physical therapy, muscle relaxants, anti-inflammatory medication, and narcotic oral agents was not cost effective and the patients went on to surgery.3
Sometimes a patient will come in with a list of muscle relaxers they have been prescribed. The more common names and types they come in with are: Diazepam (Valium), Carisoprodol (Soma), which is habit forming. These and other drugs given for muscle spasms/relaxation are part of a class of drugs known as Benzodiazepines – anxiety medication / tranquilizers.
In research lead by doctors at the University of Sydney in Australia, the doctors found that muscle relaxants do provide temporary benefit for acute back pain. But for long-term chronic low back pain problems – there is no evidence for the efficacy of benzodiazepines.4
In their review of the pharmacological treatment of back pain, Oregon Health & Science University researchers also noted muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation.5 There is an old adage in medicine that is fortunately being erased, it goes something like this: “I can’t fix your problem so let me put you to sleep.”)
Physical therapy for low back pain
Physical therapy is the major component of the conservative approach to low back pain. The Caring Medical experience is that the results are often disappointing.
Doctors at the University of Warwick in the United Kingdom came to a similar conclusion when they could not find clinical research evidence that physical therapy (therapist-delivered interventions) provided more than little to moderate benefits.6
Many acute back injuries get better by themselves. Many of these patients do take some PT, whether formally at a Physical therapy facility, or more haphazardly at a chiropractor’s office, but it’s difficult to tell whether the results are any better or faster than they would be without the PT. Cases in which there is muscle weakness should have a prescribed regular program of strengthening exercises.
Physical therapists may suggest the balance ball, yoga, and pilates which placing stress on healing low back ligaments. Prolotherapy doctors usually recommend exercises such as side plank, supine plank, and regular planks. In these, as in holding yoga poses, there is no movement that stress the spinal ligaments.
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.
- University of Manitoba, Winnipeg, Manitoba, Canada. The journal of alternative and complementary medicine
- 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.7
- Harold Wilkinson MD, in the journal The Pain Physician
- Prolotherapy can provide significant relief of axial pain (soft tissue damage) and tenderness combined with functional improvement, even in “failed back syndrome” patients.8
Citing our own Caring Medical and Rehabilitation Services 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 who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who 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.9
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.
The first step in determining in whether Prolotherapy will be an effective treatment for you
The first step in determining in 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.
When identified as a problem of ligament weakness causing instability, low back pain is one of the easiest conditions to treat with Prolotherapy. Ninety-five percent of low back pain is located in a 6-by-4 inch area, the weakest link in the vertebral-pelvis complex.
At the end of the spine, four structures connect in a very small space which happens to be the 6-by-4 inch area. The fifth lumbar vertebrae connects with the base of the sacrum This is held together by the lumbosacral ligaments. The sacrum is connected on its sides to the ilium and iliac crest. This is held together by the sacroiliac ligaments. The lumbar vertebrae is held to the iliac crest and ilium by the iliolumbar ligaments. This is typically the area treated with Prolotherapy for chronic low back pain.
The diagnosis of ligament laxity in the lower back can be made relatively easily.
Typical referral pain patterns are elicited when gently pressed, for instance:
- the sacroiliac ligaments refer pain down the back of the thigh and the outside of the foot
- the sacrotuberous and sacrospinous ligaments refer pain to the heel.
- the iliolumbar ligament refers pain into the groin or vagina.
- Iliolumbar ligament sprain should be considered for any unexplained vaginal, testicular, or groin pain. Please see our companion article which talks about non-surgical treatment of lumbar radiculopathy.
The most common cause of unresolved chronic low back pain is injury to the sacroiliac ligaments which typically occurs from bending over and twisting with the knees in a locked, extended position. This maneuver stretches the sacroiliac ligaments, placing them in a vulnerable position.
Prolotherapy injections for chronic low-back pain
If you have questions about back pain, Get help and information from our Caring Medical staff
References for this article.
1 Braun J, Baraliakos X, Regel A, Kiltz U. Assessment of spinal pain. Best Pract Res Clin Rheumatol. 2014 Dec;28(6):875-87. doi: 10.1016/j.berh.2015.04.031.
2 Ebell MH, Grad R. Top 20 research studies of 2015 for primary care physicians. Am Fam Physician. 2016 May 1;93(9):756-62.
3. Parker SL, Godil SS, Mendenhall SK, Zuckerman SL, Shau DN, McGirt MJ. Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life: clinical article.
4 Abdel Shaheed C, Maher CG, Williams KA, McLachlan AJ. Efficacy and tolerability of muscle relaxants for low back pain: Systematic review and meta-analysis. Eur J Pain. 2016 Jun 22.
5. Chou R, Deyo R, Friedly J, Skelly A, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S. Systemic Pharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline Systemic Pharmacologic Therapies for Low Back Pain. Annals of internal medicine. 2017 Apr 4;166(7):480-92.
6. Mistry D, Patel S, Hee SW, Stallard N, Underwood M. Evaluating the quality of subgroup analyses in randomized controlled trials of therapist-delivered interventions for nonspecific low back pain: a systematic review. Spine (Phila Pa 1976). 2014 Apr 1;39(7):618-29.
7. 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.
8. 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. [Pubmed] [Google Scholar Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”]
9. Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155. [JOP/CMRS]