Non-Surgical treatment options for Lumbar Spondylolisthesis

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida
David N. Woznica, MD. Caring Medical Regenerative Medicine Clinics, Oak Park, IL

Treatment options for Lumbar Spondylolisthesis

Lumbar spondylolisthesis impacts the pelvic structure causing problems of “Lumbar lordosis (loss of natural curve) and pelvic dumping phenomenon (pelvic tilt).” Lumbar facet joint degeneration and lumbar intervertebral disc degeneration are mutually promoted, and lumbar spondylolisthesis aggravates intervertebral disc and facet joint degeneration.”

What is being suggested is that lumbar spondylolisthesis is caused by spinal and pelvic instability and then itself causes advances and accelerated lumbar and pelvic instability.

In the most simplest terms, once started, lumbar degeneration picks up a momentum of destruction that can be difficult to stop and repair short of major surgery.

In our clinics, we see lumbar spondylolisthesis occurring as the result of spinal instability brought on by stretched and damaged spinal ligaments. How? Stretched and damaged spinal ligaments cannot do the job they were intended to do, which is to keep your spine and vertebrae in its natural shape and position. If the spinal ligaments are too weak to maintain the integrity of your spine, the vertebrae start falling or slipping out of place. Once they start slipping out of alignment, the vertebrae become vulnerable to unnatural spinal motion and stressors and may develop cracks or a pars interarticularis stress fracture also referred to as a pars defect and Spondylolysis. The continuing degenerative progression of spinal injury and degenerative disease will continue on to Lumbar Spondylolisthesis and a possible recommendation to spinal fusion.

We see many patients who have been to many specialists looking for help with their problem of spondylolisthesis or “slipped disc.” While spinal surgery can help a lot of people with spondylolisthesis, the people we see are the people for whom the surgery did not help or made the patient’s situation worse, We also see the people who are not good surgical candidates or are on a waiting list to get a surgery, or simply want to explore all options before they consent to surgery.

The stories that these people tell us go something like this:

I am on a “stand by,” or waiting list for surgery. I do not know when I may get it so I am exploring other treatments. I have a lot of pain, I have advancing Spondylolisthesis, grade 2 and problems at the L4/L5. I am looking at a decompression and open fusion surgery as a minimally invasive procedure has been ruled out for me. I do very demanding work, I have to be very careful not to “throw out” my back or I get terrible acute pain. I am on painkillers when needed and I only take them when needed. I am thinking about the surgery because when I get the acute pain I cannot function. I am here because by teh time I get the surgery and the recovery period, even if all goes well, I may be dealing with all this for a year or two more.

Lumbar spinal fusion is commonly performed for spondylolisthesis because a permanent bonding or fusing of several vertebral segments is seen as the only way to prevent a disc from continually slipping out of place. There is of course a price to pay for this treatment. Fusing the segments of the spine will decrease mobility and increase stress on the areas above and below the fused segment. While fusion is sometimes a necessary surgery, the long-term consequences should be known and all conservative efforts tried first.

Multi-level forward slippage of the vertebra is known as anterolisthesis. This condition occurs because the posterior spinal ligaments cannot control the motion of the lumbar vertebrae. This inability to control the vertebrae movement is spinal instability that leads to slipped, herniated and bulging discs and degenerative disc disease. Prolotherapy is an injection of simple dextrose that can help treat this condition by strengthening the ligaments and tendon enthesis (or the attachments) surrounding and attached to the slipped vertebrae. As the ligaments and tendons are strengthened, spinal stability is restored, pain is alleviated.

Multi-level forward slippage of the vertebra is known as anterolisthesis. This condition occurs because the posterior spinal ligaments cannot control the motion of the lumbar vertebrae. This inability to control the vertebrae movement is spinal instability that leads to slipped, herniated and bulging discs and degenerative disc disease. Prolotherapy is an injection of simple dextrose that can help treat this condition by strengthening the ligaments and tendon enthesis (or the attachments) surrounding and attached to the slipped vertebrae. As the ligaments and tendons are strengthened, spinal stability is restored, pain is alleviated.

I am waiting for surgery. I have grade 2 spondylolisthesis at L4-L5 with a pars defect in each.

For many people, lumbar spondylolisthesis is a very painful and life-altering problem made worse by the seemingly years of active treatments that have not been helping. This is reflected in the many stories we hear from our patients. They go something like this:

I am waiting for surgery. I have grade 2 spondylolisthesis at L4-L5 with a pars defect in each. I have pain and numbness that comes and goes into my legs. I can alleviate some of the numbness and pain by leaning one way or another. I guess I am changing positions enough to find the right spot for pain relief. I had an MRI it showed the spondylolisthesis. My doctor wanted to try conservative care first and put me on physical therapy. I was all for that, I did not want surgery. In addition to the therapy, I was given painkillers and anti-inflammatory prescriptions. I tried not to use them at first.

I was not getting good results from the therapy and some days I felt much worse. The next step was the facet injections. First I had them with painkillers then I progressed to steroid injection. Initially, the first injections worked well. I had to progress to steroids because the effect was diminished from injection to injection. Finally, I stopped the injections as they were no longer helping me.

I am waiting for surgery, but, I am here, I guess exploring one last try to avoid it. Everything is getting worse, the pain, the numbness, everything. The medications are of no help I stopped taking them. All I can see is surgery unless you have something that can help me.

The lure of surgery based on MRI

The problem of spondylolisthesis is that your vertebrae are sliding forward and out of alignment. This, you have been told, is the cause of all your problems. For many people, it is the cause of all their problems. However, a patient will come into the office with an MRI interpretation that goes something like this and is in agreement with the agressive degeneation we spoke about at the beginning of this article.

Male patient 61 years old.

  • Facet arthropathy at L4-5 and L5-S1  worse on the right side. (This is reduced cartilage between the facet joints from degenerative breakdown).
  • Spondylolisthesis at L4-5 due to the facet arthropathy.
  • Combination of Facet arthropathy and Spondylolisthesis causing axial pain, pain when walking.
  • Leg (posterior tibial ) and hip muscles
  • Hip abductor muscles appear atrophied and this is leading to the problem of Trochanteric Bursitis.
  • Combined these problems are leading to mechanical stress in the patient’s legs and the cause of the patient’s leg pains.

Now this would sound like a lot to anyone for surgery or any treatment to fix. But a July 2020 study in the medical journal Spine (2) offers an optimistic viewpoint of surgical success.

“This study confirms that surgical intervention for degenerative spondylolisthesis is effective at reducing disability, back and leg pain, demoralization, kinesiophobia (fear of movement), and fear-avoidance beliefs related to physical activity in patients with degenerative lumbar spondylolisthesi. Furthermore, such patients exhibit a significantly more stable stance after surgery. However, balance parameters did not completely normalize by 3 months postoperatively.”

Many people do benefit from surgery. It can take some time. Many people however, do not benefit from surgery. Many people also have unrealistic expectations of what surgery can do. When we ask a patient who did not have a successful surgery why did they consider the surgery in the first place? They usually say something like: “I thought it would cure me.” We are seeing these patients because the surgery did not cure them. Please see our article: Failed Back Surgery Syndrome treatment options – the new research.

Even though the surgery was successful, 24% of people did not go back to work

If you are facing surgery, you know what the fears are. If they surround your ability to work, they are “When can I get back to work? How long is the recovery period? etc. These are obviously leading concerns for many.

In a May 2020 study, doctors writing in the journal Neurosurgical focus (3) made these observations:

  • Of 292 patients in the study group who had lumbar spondylolisthesis and who were asked about both surgical satisfaction and return to work status. Of these, 249 (85.3%) were satisfied with surgery and 224 (76.7%) did return to work after surgery.
  • Of the 68 patients who did not return to work after surgery, 49 (72.1%) were still satisfied with surgery.
  • Of the 224 patients who did return to work, 24 (10.7%) were unsatisfied with surgery

Treatment of spondylolisthesis is controversial because few things work

Many patients do very well with spondylolisthesis surgery long-term. These are usually the patients we do not see. We see the patients for who surgery has already failed, or did not provide long-term results, or the patient who is not a good surgical candidate because of other health concerns or the condition of their spine.

The treatment of spondylolisthesis is controversial because there is no traditional standard of care. In the below research evidence is given that surgery should only be offered in certain cases. Research is also offered that the surgery itself can cause a worsening of spondylolisthesis. Finally, research is offered that other factors can cause the surgery to be less than successful. Later in this article, we will offer evidence that regenerative medicine injections that can strengthen the spinal ligaments may be a viable option for many people and possibly an alternative conservative care answer for you.

“the preferred treatment is conservative. Surgery is only an option if patients have persistent/progressive leg pain”

Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.

In July 2019, researchers from the University of California at San Francisco wrote in the journal Neurosurgery clinics of North America.(4)

“Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population. Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.” Surgical management to include, Spinal decompression, Spinal fusion, and Spinal laminectomy.

In September 2019, Dutch researchers from Maastricht University in the Netherlands examined the role, or actually the need for surgery in cases of lumbar spondylolisthesis. Here is their research findings:(5)

  • Lumbar spondylolisthesis is usually asymptomatic. However, symptomatic spondylolisthesis results in back and/or leg pain such as radicular syndrome or neurogenic claudication (pinching or impingement or inflammation of the nerves coming out of the spinal cord. This is a common symptom in lumbar spinal stenosis.)
  • Variation in symptoms is caused by different types of spondylolisthesis.
    • Lytic spondylolisthesis, most common at L5-S1, is caused by spondylolysis of the pars interarticularis. This results in foraminal nerve compression and radicular symptoms. (You may have been diagnosed with spondylolysis and your doctor may have referred to this problem as a pars defect or Spondylolysis. Most commonly there is a stress fracture in the pars interarticularis of lumbar vertebrae. The pars interarticularis is a thin bone that joins two vertebrae. The pars interarticularis is especially vulnerable to a stress fracture in younger patients involved in high-level sports.)
    • Degenerative spondylolisthesis, most common at L4-L5 in patients who are more than 50 years old, is caused by slippage of the vertebral body and lamina, resulting in lumbar spinal stenosis and neurogenic claudication. (In your treatments and through visiting varying doctors you may have heard the term “slipped,” used as a description of your problem. The slip refers to the vertebrae, such as the L4, sliding out over the L5. This abnormal alignment traps and compresses the nerves.)
    • Iatrogenic spondylolisthesis can develop in 1.6-32.0% of patients after decompression surgery, causing recurrent neurogenic symptoms.
  • The researchers concluded:
    • “It is important to understand the main symptoms patients experience: back or leg pain. In both cases, the preferred treatment is conservative. Surgery is only an option if patients have persistent/progressive leg pain. Shared decision-making is necessary to select the most accurate surgery for each individual patient while also taking into account age, comorbidities and symptoms. Further research is necessary to determine the advantages of each surgery in order to improve advice to patients.”

“The rate of recurrence was 27%”

In November 2019, doctors wrote in the journal Orthopedic Research and Reviews, (6) about when and which surgery may offer benefit to the patient. One point they made is that there are a lot of surgeries available to choose from.

“For the small number of patients with severe, recalcitrant pain, lumbar fusion may be required, particularly when concomitant leg pain or deformity is present. Lumbar interbody fusion surgery is the usual treatment for degenerative lumbar disease, but it requires a long recovery period. Many surgical techniques have been described in the literature for spondylolisthesis. The main objective is to create interbody fusion, decompression of normal structures and stable vertebrae. . . Methods such as TLIF (Transforaminal Lumbar Interbody), posterior lumbar interbody fusion (PLIF), anterior lumbar interbody fusion (ALIF), and lateral lumbar interbody fusion (LLIF) are also available for interbody fusion. The advantages of these procedures in each other should be discussed in the literature (and with the patient.)”

The researchers continue: “In degenerative lumbar disc herniation treated with microdiscectomy without fusion, recurrence rates are high in the literature. The rate of recurrence was 27%, especially in patients with more than 6 mm annular defects.  Achieving a stable spine after surgery will minimize recurrence rates. So a lot of fusion technique has been developed.”

“No evidence for adding fusion to the decompression”

A 2020 study (7) from Swedish medical university researchers at Uppsala University, the Karolinska University Hospital and the Clinic of Spinal Surgery questioned whether fusion surgery did actually help a patient as suggested in other surgical research. One of the concerns pointed out in this research is the recommendation that the patient undergoing surgery for degenerative spondylolisthesis should have a fusion in addition to the decompression surgery. The thought being is that the patient, following decompression, may be at further risk for slippage of the vertebrae and a fusion would hold everything in place.

What these researchers found was the vertebrae had an equal chance of slipping after a decompression surgery alone or a decompression with fusion surgery. The implication being: “Our results provide no evidence for adding fusion to the decompression.”

Spondylolysis and Spondylolisthesis. Common at L5 The vertebrae now, slipping out of alignment, and under unnatural stressors may develop cracks or a pars interarticularis stress fracture also referred to as a pars defect and Spondylolysis.

Spondylolysis and Spondylolisthesis. Common at L5, pars interarticularis stress fracture also referred to as a pars defect and Spondylolysis.


Prolotherapy: A simple injection treatment supported by research

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.

The concept behind this treatment and Lumbar Spondylolisthesis is that in Grade 1 and Grade 2 Spondylolisthesis, Prolotherapy injections may be able to help pull the vertebrae back into alignment. Grade 3 and Grade 4 Spondylolisthesis may benefit from Prolotherapy but results are challenging and surgery may be needed.

Demonstration of how spondylolisthesis is graded: This patient is a Grade 2 https://radiopaedia.org/cases/spondylolisthesis-grade-ii-4?lang=gb

from Demonstration of how spondylolisthesis is graded: This patient is a Grade 2 https://radiopaedia.org/

Spondylolisthesis grading is based on the amount of “slippage.” Slippage can also tell us how weak the spinal ligaments are.

Ligaments are the connective tissue that holds the vertebrae in place. When you have slippage, it is because the strong bands of ligaments are no longer strong enough to hold the vertebrae in place. Generally speaking, the more slippage the weaker the connective tissue.

  • grade I: 0-25% slippage – can be repaired with Prolotherapy
  • grade II: 26-50% – can be repaired with Prolotherapy
  • grade III: 51-75% – Prolotherapy may offer pain benefits, surgery may be more realistic
  • grade IV: 76-100% – Prolotherapy may offer pain benefits, surgery may be more realistic
  • grade V (spondyloptosis): >100%

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.

“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).”

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.”(8)

In April 2016 doctors from the Hospital for Special Surgery in New York, the 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. (9

When spinal ligaments become loose, they can no longer do the job they were intended to do, hold your spine in proper alignment. When the spine becomes unstable, vertebrae move. When the vertebrae move, they can slip out of place and cause Lumbar Spondylolisthesis.

When spinal ligaments become loose, they can no longer do the job they were intended to do, hold your spine in proper alignment. When the spine becomes unstable, the vertebrae move. When the vertebrae move, they can slip out of place and cause Lumbar Spondylolisthesis.

The ligaments of the spine as the key to spinal instability

In one study doctors from Brigham Young University (10) 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.

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

 

The Spinal ligament repair injection treatment option Prolotherapy

In this video Danielle R. Steilen-Matias, MMS, PA-C ., explains and demonstrates a Prolotherapy treatment into the lumbar spine.

Video Summary and Learning Points

  • 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. I am treating the sacroiliac area to make sure that I get the ligament insertions and attachments of the SI joint in the low back.
  • I’ve marked with a black crayon all down the midline of this patient’s back  and then I have a horizontal line drawn where her pain stops.
  • It’s important to note that this particular patient is actually not sedated in any way so even though it is a lot of shots and a lot of injections through the skin which can be painful, patients tend to tolerate it really well the whole procedure goes relatively quickly
  • At 2:20 I’m just making sure that I get the sacroiliac or SI ligaments as well as the iliolumbar ligament to help strengthen the low back.
  • 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.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on research and clinical results, H3 Prolotherapy (H3 is a type of Prolotherapy named after three of its leading physician innovators Hackett-Hemwall-Hauser) is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle.

Formation of bone spurs in the spine

Understanding how to determine and even treat or prevent worsening spondyloarthritis is discussed by Italy’s University of Foggia Medical School researchers. (11) In their study in the Annals of Medicine the Italian researchers say: Despite intensive research into what causes slipped discs, some important questions still remain unanswered, particularly concerning formation of bone spurs in the spine.

Several studies suggest that spondyloarthritis pathogenesis prevalently occurs by endochondral ossification (a process of bone growth involving the cartilage), however it remains to identify factors that can induce and influence its initiation and progression.

The researchers end their paper by saying: Complete understanding of spondyloarthritis pathophysiology requires insights into inflammation, bone destruction and bone formation, which are all located in entheses and lead all together to ankylosis (fusion) and functional disability.

Comprehensive Prolotherapy which includes the use of stem cell therapy can be an ideal treatment for patient with developing spondylolisthesis because it strengthens the ligaments and tendon enthesis surrounding and attached to the slipped vertebrae. As the ligaments and tendons are strengthened spinal stability is restored.

Treatments are given to the ligaments on the back of the spine.  By tightening the ligaments in the back of the spine Prolotherapy helps stabilize the area thereby giving pain relief and allowing for other structures to heal. Typically a patient will require 3-6 visits, although some patients require more visits depending on their overall health status and the extent of their injury.

“Prolotherapy injections produce an inflammatory response, which can augment collagen fibre and ligament structure regeneration.”

In the Journal of Prolotherapy(12) 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.”

They concluded their research by suggesting: “There are currently few treatment choices other than surgical fusion for intractable lumbar discogenic pain and instability. Prolotherapy may offer a minimally invasive, cost-effective, and safe management option for these patients.

The findings in this study are in keeping with conclusions of other studies in that Prolotherapy, in conjunction with rehabilitation, would appear to be an effective intervention for the treatment of discogenic lower back pain associated with degenerative disc disease of the lumbar spine.

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.(13)

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.

We concluded this research by suggesting that in this study on the use of  Prolotherapy, patients with over four years of unresolved low back pain were shown to improve their pain, stiffness, range of motion, and quality of life measures even 12 months subsequent to their last Prolotherapy session. This pilot study shows that Prolotherapy is a treatment that should be considered and further studied for people suffering from unresolved low back pain.

Is this treatment right for you?

It may be difficult for some people to think that Prolotherapy may offer them an option when so many treatments before have failed. It may be hard for some patients to ignore strong recommenders to consider a spinal surgery that may or may not help and may or may not make their situation worse than it is today. Is this treatment right for you? Would you be a good candidate? Ask us.

If you have questions about Spinal fusion surgery complications, Get help and information from our Caring Medical staff

1 Zhou LJ, Yang M, Zheng WW, Zhang JY. Analysis of characteristics of lumbar spine-pelvic structural parameters in degenerative lumbar spondylolisthesis. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2020 Sep 25;33(9):862-6. [Google Scholar]
2 Haddas R, Lieberman I, Block A, Derman P. The effect of surgical decompression and fusion on functional balance in patients with degenerative lumbar spondylolisthesis. Spine. 2020 Jul 15;45(14):E878-84. [Google Scholar]
3 DiGiorgio AM, Mummaneni PV, Park P, Chan AK, Bisson EF, Bydon M, Foley KT, Glassman SD, Shaffrey CI, Potts EA, Shaffrey ME. Correlation of return to work with patient satisfaction after surgery for lumbar spondylolisthesis: an analysis of the Quality Outcomes Database. Neurosurgical Focus. 2020 May 1;48(5):E5. [Google Scholar]
4 Chan AK, Sharma V, Robinson LC, Mummaneni PV. Summary of Guidelines for the Treatment of Lumbar Spondylolisthesis. Neurosurgery Clinics. 2019 Jul 1;30(3):353-64. [Google Scholar]
5 Caelers IJ, Rijkers K. Lumbar spondylolisthesis; common, but surgery is rarely needed. Nederlands tijdschrift voor geneeskunde. 2019 Sep;163. [Google Scholar]
6 Nyström B, Jin S, Schillberg B, Moström U, Lundin P, Taube A. Are degenerative spondylolisthesis and further slippage postoperatively really issues in spinal stenosis surgery?. Scandinavian Journal of Pain. 2020 Jan 13. [Google Scholar]
7 Uçar BY, Özcan Ç, Polat Ö, Aman T. Transforaminal Lumbar Interbody Fusion For Lumbar Degenerative Disease: Patient Selection And Perspectives. Orthopedic Research and Reviews. 2019;11:183. [Google Scholar]
8 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. 2016;19(9):1009-18. doi: 10.1080/10255842.2015.1088524. Epub 2015 Sep 24. PMID: 26404463; PMCID: PMC4808500. [Google Scholar]
9 Iorio JA, Jakoi AM, Singla A. Biomechanics of degenerative spinal disorders. Asian spine journal. 2016 Apr;10(2):377. [Google Scholar]
10 Von Forell GA, Stephens TK, Samartzis D, Bowden AE. Low back pain: a biomechanical rationale based on “patterns” of disc degeneration. Spine. 2015 Aug 1;40(15):1165-72. [Google Scholar]
11 Neve A, Maruotti N, Corrado A, Cantatore FP. Pathogenesis of ligaments ossification in spondyloarthritis: insights and doubts. Ann Med. 2017 May;49(3):196-205. [Pubmed]
12 Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [Google Scholar]
13 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]

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