Caring Medical - Where the world comes for ProlotherapyProlotherapy and stem cells as an alternative to degenerative disc disease surgery

Unnecessary back surgery?

Ross Hauser, MD

In this article, Ross Hauser, MD discusses non-surgical alternative treatments for degenerative disc disease.

We have seen many people in our 25 years of service who went to surgery for degenerative disc disease.

  • Why do we see them? Because the surgery failed to correct the person’s problem and in many cases made it worse.

How can this be?

  • Because the surgery was performed with the idea that it was the discs that were causing the person’s problems.

The surgery failed because it was not the discs by themselves, but spinal instability caused by weakened degenerated ligaments.

The teaching point of this article is, before consenting to spinal surgery, explore your back problem as a problem beyond just the disc

In the April 2018 edition of the medical journal Insights Imaging doctors from Mercy Catholic Medical Center published a paper entitled the “ABCs of the degenerative spine.” This paper was written for the benefit of radiology residents.

  • What is so fascinating about this very detailed paper is that the authors set out to tell the residents that they need to recognize that degenerative disc disease is far from only a problem of the disc. That the disc itself sits within a complete spinal unit that consists of the adjacent vertebrae, the intervertebral disc itself, the spinal ligaments and the facet joints.
  • Further, degenerative disc disease is not really a degenerative disease but the result of continued insults (injuries) that makes the disc vulnerable to flattening out.(1)

I like to call these “insults” or injuries, the excessive load and destructive joint forces caused by damaged, weakened spinal ligaments. This is explained further below.

Disc degeneration is seldom the of the cause of pain – but frequently the reason for surgery

Degenerative Cascade


Here are some signs/symptoms that may lead a doctor to believe that pain is not coming from the disc problem and that disc surgery may not be the right option

Most patients who come to Caring Medical with low back or lumbar disc disease, thoracic or neck (cervical) pain have MRI’s that show disc degeneration. On examination, we find that the MRI’s disc degeneration is seldom what is causing their pain. Here are some signs/symptoms that may lead a doctor to believe that pain is not coming from the disc problem :

  • Pain on either side of the spine not on the midline
  • Sensation is intact
  • Muscle strength is fine
  • Pain upon lying down
  • Pain is not worse with sitting
  • Pain is not worse with bending over
  • Numbiness (tingling down the arm but sensation is ok)
  • Cracking

All of the above symptoms suggest ligament laxity of spine or sacroiliac ligament problems. Disc problems are more indicative if the person has low back pain for instance that is:

  • Central
  • Sitting makes it worse
  • Standing (compared to lying) makes it worse
  • Bending over while standing increases the central pain.

Spinal ligaments as the main culprit behind back pain

Progression of Degeneration of Lower Back

The many complexities of the spine and the spinal ligaments can be seen at the intervertebral joints – where vertebrae connect to each other.

  • Here the interspinous ligament weaves between the spinous processes connecting the back of the vertebrae bony processes.
  • The supraspinous ligament connects the spinous processes. Running towards the cervical spine it forms the nuchal ligament.
  • The intertransverse ligaments connect the adjacent transverse processes, and the ligamentum flavum connects the laminae of adjoining vertebrae.

It should be clear that the spinal ligaments are key factors in spinal stability and instability which can lead to degenerative disc and possible nerve compression at the facet joints in flexion or extension, and at the lower back ligaments of the sacroiliac joints.

In other words, back pain can be due to an unstable disc problem, facet joint locking, or sacroiliac dysfunction caused by problems of the spinal ligaments.

The spine relies heavily on the supporting ligaments to hold itself together

The opening statement of a recent research article from doctors at the Mayo Clinic brings all these concerns together when the researchers state: “Understanding spinal kinematics (the movement of the spine)  is essential for distinguishing between pathological conditions of spine disorders, which ultimately lead to low back pain.

It is of high importance to understand how changes in mechanical properties affect the response of the lumbar spine, specifically in an effort to differentiate those associated with disc degeneration from ligamentous changes (problems of the spinal ligaments), allowing for more precise treatment strategies.”(5)

In April 2016 doctors from the Hospital for Special Surgery in New York, University of Southern California, and the University of Virginia published their findings that acknowledged Degenerative Disc Disease is just that, a problem of degeneration and aging and that the vertebrae and facet joints of the spine represent a three joint complex that relies heavily on their supporting ligaments to hold the joint together.(6

Is medical research suddenly discovering that the spinal ligaments are important, actually crucial in determining back pain problems?

Listen to the opening of this research review, this is from Batson Children’s Hospital, University of Mississippi Medical Center: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.”(7)

There is a recent cluster of research on understanding the spinal ligaments and their crucial role in healing degenerative disc disease.

The ligaments of the spine as the key to degenerative disc disease

In one study doctors from Brigham Young University even suggest that the ligaments may be the key to degenerative disc disease and spinal degenerative changes. The researchers suggest that it is hard for doctors and MRIs to figure out the pain sources in low back pain, and that even when people have it, there are no symptoms for it, yet eventually it will develop into worsening low back pain and disc problems.

But, these researchers also say that there are “patterns” of disc degeneration that may provide insight into where the pain is coming from and that by addressing these patterns – further disc degeneration can be managed, What do doctors need to address? Spinal ligaments.

Specifically, individuals with contiguous multi-level disc degeneration have been shown to exhibit higher presence and severity of low back pain as compared to patients with skipped-level disc degeneration (i.e. healthy discs located in between degenerated discs).

Here is the reason: Stresses on the surrounding ligaments, facets, and pedicles (the area of the vertebrae where many spinal procedures begin) at vertebral levels where there was no degeneration of the spine were generally lower than where degeneration occurred.(8)

It should be obvious that stable ligaments equal stable spines – unstable ligaments – unstable spines.

Unnecessary surgery for degenerative disc disease leads to Failed back Surgery Syndrome

Duke University researchers wrote in the medical journal Neuromodulation, just how big a problem Failed Back Surgery Syndrome is:

  • Failed back surgery syndrome affects 40% of patients following spine surgery with estimated costs of $20 billion to the US health care system.”(1)

For 40% of patients, spinal surgery was unnecessary because it made their condition worse and cost them extra out of pocket expense.

Minimally Invasive Surgery results in failed back surgery too

In 2016, researcher Nancy Epstein of the Department of Winthrop NeuroScience, Winthrop University Hospital wrote in the prestigious journal Surgical neurology international:

“The incidence of nerve root injuries following any of the multiple Minimally Invasive Surgery lumbar surgical techniques 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?”(2)

From conservative care to spinal surgery

In the next series of studies we will examine, researchers will make a comparison of surgery versus non-surgical options for back pain. The Non-surgical options they examine are not Prolotherapy based treatments that may include stem cells for degenerative disc disease or Platelet Rich Plasma preparations.

We have already discussed research above which found patients did just as well with conservative care as with a spinal surgery. Here we will get a little more detailed.

The conservative care non-surgical options include:

Writing in the Journal of physical therapy science, doctors explored the problems of failed back surgery and compared it to the problems of conservative care. Here is what they wrote:

  • Surgical treatment of back pain is a treatment option for patients who remain severely symptomatic after a course of conservative treatment.
  • However, patients who have chronic, disabling low-back pain after one or more spinal surgeries are said to have failed back surgery syndrome which has a prevalence of 10–40% (depending on the studies). If these estimates are correct, there may be over 80,000 “failed” back surgeries per year in the United States.
  • The factors that cause failed back surgery syndrome are foraminal stenosis, pseudo-arthrosis, neuropathic pain, recurrent disc herniation, sacroiliac joint pain, spinal instability, and psychological problems as seen in post-laminectomy syndrome.

The authors also suggest, that going back to the hospital for another back surgery are considered extremely depressive and pain provoking, resulting in behavioral and cognitive problems that can have far-reaching effects on recovery.(3)

Canadian doctors, published in the Spine Journal in trying to predict which patients will benefit the most from spinal surgery for degenerative disc disease found that the worse the patient’s symptoms are – the less likely the surgery will succeed. Equally – it seems that the amount of disc herniation does not affect surgical outcomes negatively or positively.(4)

What does this mean?

  • It is not the discs causing the problem. Back pain can be caused by many reasons. One of the challenges in fact in treating back pain is making an accurate diagnosis.

For many, doctors and patients alike, it is hard not to see failed back surgery syndrome as a complication of an unnecessary procedure. This is seen in the research.

Prolotherapy’s role in treating the ligaments of Degenerative Disc Disease

In the Journal of Prolotherapy, James Inklebarger, MD and  Simon Petrides, MD wrote: “Prolotherapy injections produce an inflammatory response, which can augment collagen fibre and ligament structure regeneration, resulting in tightening and strengthening of spinal ligaments, thereby reducing the incidence of discogenic low back pain by improving intersegmental stability.”(9)

Caring Medical Research

Citing our own 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.(10)

By correcting the instability of the lumbar spine at an early stage, Prolotherapy will cause less stress to be imposed on the disc and less degeneration to occur at the disc.

Do you have a question about surgery for degenerative disc disease? Ask us You can get help and information from our Caring Medical staff.

 

1 Elsamadicy AA, Farber SH, Yang S, Hussaini SM, Murphy KR, Sergesketter A, Suryadevara CM, Pagadala P, Parente B, Xie J, Lad SP. Impact of Insurance Provider on Overall Costs in Failed Back Surgery Syndrome: A Cost Study of 122,827 Patients. Neuromodulation: Technology at the Neural Interface. 2017 Mar 1. [Google Scholar]
2 Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let’s tell someone. Surgical Neurology International. 2016;7(Suppl 3):S96-S101. doi:10.4103/2152-7806.174896. [Google Scholar]
3 Sahin N, Karahan AY, Devrimsel G, Gezer IA. Comparison among pain, depression, and quality of life in cases with failed back surgery syndrome and non-specific chronic back pain. Journal of Physical Therapy Science. 2017;29(5):891-5. [Google Scholar]
Wilson CA, Roffey DM, Chow D, Alkherayf F, Wai EK. A systematic review of pre-operative predictors for post-operative clinical outcomes following lumbar discectomy. Spine J. 2016 Aug 4. [Google Scholar]
Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2015 Sep 24:1-10. [Google Scholar]
Iorio JA, Jakoi AM, Singla A. Biomechanics of Degenerative Spinal Disorders. Asian Spine J. 2016 Apr;10(2):377-84. doi: 10.4184/asj.2016.10.2.377. [Google Scholar]
Butt AM, Gill C, Demerdash A, Watanabe K, Loukas M, Rozzelle CJ, Tubbs RS. A comprehensive review of the sub-axial ligaments of the vertebral column: part I anatomy and function. Childs Nerv Syst. 2015 May 1. [Google Scholar]
8 Von Forell GA, Stephens TK, Samartzis D, Bowden AE. Low back pain: A biomechanical rationale based on “patterns” of disc degeneration. Spine (Phila Pa 1976). 2015 May 20. [Google Scholar]
9 Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [Google Scholar]
10 Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155.

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