Treatment options for Lumbar Spondylolisthesis
Ross Hauser, MD. Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD. Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C . Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
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.
I am thinking about surgery. I have grade 2 spondylolisthesis at L4-L5 with a pars defect in each.
For many people, this 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 thinking about 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 can home and 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 thinking about 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.
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.(1)
“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:(2)
- 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.”
“a lot of fusion technique has been developed”
In November 2019, doctors wrote in the journal Orthopedic Research and Reviews, (3) 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 (4) 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.”
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.
Spondyloliosthesis 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.”(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)
The ligaments of the spine as the key to spinal instability
In one study doctors from Brigham Young University (7) 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.
“Prolotherapy injections produce an inflammatory response, which can augment collagen fibre and ligament structure regeneration.”
In the Journal of Prolotherapy, (8) 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,
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
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