Non-Surgical treatment options for Lumbar Spondylolisthesis
Ross A. Hauser, MD., Danielle R. Steilen-Matias, PA-C.
Treatment options for Lumbar Spondylolisthesis
As you have found this article it is very likely that you have continued or worsened symptoms of lumbar spondylolisthesis and you have been given a recommendation for surgery or you had a surgery and you have continued pain and functional difficulties.
- Back pain, especially when bending over.
- You have a numbness or “pins and needles” sensation.
- Muscle spasms in the back and in thighs
- Your back is stiff, sometimes locking up or “seizing” on you.
- Walking, gait and balance are problems, especially if you are on your feet for extended periods.
Discussion and treatment research covered in this article:
- Lumbar spondylolisthesis occurs as the result of spinal instability.
- I am on a “stand by” or waiting list for Lumbar spondylolisthesis surgery.
- Once started, lumbar degeneration and lumbar spondylolisthesis pick up momentum and start rolling down its destructive path, it can be difficult to stop and repair short of major surgery.
- An introduction to non-surgical options for lumbar spondylolisthesis.
- I am waiting for surgery. I have grade 2 spondylolisthesis at L4-L5 with a pars defect in each.
- What are we seeing in this image? Multi-level forward slippage of the vertebra is known as anterolisthesis.
- The lure of lumbar spondylolisthesis surgery based on MRI.
- Case history: Male patient 61 years old.
- Even though the lumbar spondylolisthesis surgery was successful, 24% of people did not go back to work.
- If you have a job and had previous successful surgeries, it is likely that your next surgery will be successful too.
- Treatment of spondylolisthesis is controversial because few things work.
- I had lumbar spondylolisthesis surgery, now I need another.
- “The preferred treatment is conservative. Surgery is only an option if patients have persistent/progressive leg pain.”
- “The rate of recurrence was 27%”
- “No evidence for adding fusion to the decompression.”
- Degenerative Spondylolisthesis Surgical comparisons.
- Acupuncture and nerve blocks for lumbar spondylolisthesis.
- Does Radiofrequency ablation make lumbar spondylolisthesis worse? Researchers are asking.
- Prolotherapy: A simple injection treatment supported by research.
- Spondylolisthesis grading is based on the amount of “slippage.” Slippage can also tell us how weak the spinal ligaments are.
- “An effort to differentiate (diagnose) those associated with disc degeneration from ligamentous changes (problems of the spinal ligaments).”
- The ligaments of the spine as the key to spinal instability.
- Formation of bone spurs in the spine.
- “Prolotherapy injections produce an inflammatory response, which can augment collagen fiber and ligament structure regeneration.”
- Caring Medical Research.
Lumbar spondylolisthesis occurs as the result of spinal instability
In our clinic, 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 their 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.
I am on a “stand by” or waiting list for Lumbar spondylolisthesis 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 decompression and open fusion surgery as a minimally invasive procedure that 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 acute pain I cannot function. I am here because by the 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.
Once started, lumbar degeneration and lumbar spondylolisthesis pick up momentum and start rolling down its destructive path, it can be difficult to stop and repair short of major surgery
A September 2020 study (1) suggests that in the simplest terms, once started, lumbar degeneration picks up momentum and starts rolling down its destructive path, it can be difficult to stop and repair short of major surgery. So let’s look at what these researchers said:
“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 causes advances and accelerated lumbar and pelvic instability. As stated above. Once it starts it is very difficult to stop.
This is why in our searchers of the current medical literature on recent developments in lumbar spondylolisthesis, much of the research centers around, why the surgery failed and new procedures that may not fail as much. It should be understood that many people have very successful surgeries for their back pain attributed to problems of lumbar spondylolisthesis. These are not the people we see at our center. We see the people who were told that surgery may not help them or the people who had the surgery and are now looking for answers as to why their pain is worse or they have had one pain fixed but now have a different and new back pain that they need help with.
Here is an example of what we are talking about in medical research. Here is a January 2021 study in the journal Spine. (2) The researchers write that the purpose of their study was to “identify preoperative factors that predict poor postoperative outcomes and define clinically important abnormal instabilities in degenerative lumbar spondylolisthesis.” Why chose this subject? “Current evidence regarding prognostic factors affecting clinical outcomes after surgery for degenerative lumbar spondylolisthesis is still limited. Moreover, there is no consensus regarding parameters that define clinically important abnormal instability in patients with degenerative lumbar spondylolisthesis.”
Your surgery can fail for many reasons.
An introduction to non-surgical options for lumbar spondylolisthesis
Most people who read our papers and articles are searching for non-surgical options. Whether these are treatment options to avoid a surgery or treatment options to avoid another surgery, the fact is, these people are looking for alternatives and very many of them have been down the conservative pain management path for years and yet here they are exploring non-surgical options. We want to remind the reader at this point and other points throughout this article, that for many people, surgery can be very successful. We just don’t see those success stories at our center.
An August 2021 study comes to us from a combined research project out of the University of Bologna in Italy and George Mason University in Virginia. Published in the Archives of Physiotherapy (3) the researchers here offered guidelines for when surgery should and should not be considered. Here is what they wrote:
“The presence of a lumbar spondylolisthesis on imaging without relevant risks related to the slipping is not an indication for surgery, and conservative treatment is always preferable. Despite the absence of consensus on the role of non-operative versus surgical care surgical indications are dependent on symptoms or other associated pathologic conditions rather than the severity/type of vertebral slippage.”
Let’s stop here for a brief explanatory note: The severity of the slippage is revealed on MRI. What the researchers are suggesting is that no matter what the MRI says, it is the patient’s symptoms or neurologic degeneration (burning pain, difficulty walking, problems urinating) that should dictate the surgery. Asymptotic people with “bad” MRIs should not be thrown into surgery based on the MRI.
“Actually, taking into consideration the lack of association between low back pain and lumbar spondylolysis (with or without lumbar spondylolisthesis), surgical intervention for the adult general population in which spondylolysis/lumbar spondylolisthesis provokes non-radicular low back pain should be reconsidered.”
Again, let’s stop here to emphasize one point: “non-radicular low back pain should be reconsidered”
“According to a consensus conference on conservative treatment for degenerative lumbar spinal stenosis (including lumbar spondylolisthesis), a conservative approach based on at least three weeks of therapeutic exercise may be the first therapeutic choice in non-severe clinical conditions. This same consensus conference concluded that physical therapy should use a multimodal approach and surgery should be considered if the clinical condition does not change during 3 months or in presence of severe complications, e.g. lumbar radiculopathy or cauda equina syndrome.”
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 in 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.
What are we seeing in this image? Multi-level forward slippage of the vertebra is known as anterolisthesis.
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, and pain is alleviated.
The lure of lumbar spondylolisthesis surgery based on MRI
The problem with 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 aggressive degeneration we spoke about at the beginning of this article.
A July 2022 commentary in the Journal of the American Medical Association (JAMA) wrote: (22) Surgical decompression is recommended in carefully selected patients who do not improve after nonsurgical care. The use of additional fusion in surgery for degenerative spondylolisthesis has been a controversial issue. Arguments for fusion have included the assumption that pain arises from abnormal movement in the slipped segment and that this problem might worsen after decompression. In the past 3 decades, decompression with fusion has been the gold standard for treatment of patients with spinal stenosis with spondylolisthesis as well as for many patients without spondylolisthesis. However, current evidence indicates that the more invasive fusion procedure is associated with increased costs but not clinical benefits
Case history: Male patient 61 years old
- Facet arthropathy at L4-5 and L5-S1 is worse on the right side. (This is reduced cartilage between the facet joints from degenerative breakdown).
- Spondylolisthesis at L4-5 due to facet arthropathy.
- A combination of Facet arthropathy and Spondylolisthesis causes 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 (4) 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 spondylolisthesis. 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 lumbar spondylolisthesis 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 (5) 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 the 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 the surgery.
- Of the 224 patients who did return to work, 24 (10.7%) were unsatisfied with surgery.
If you have a job and had previous successful surgeries, it is likely that your next surgery will be successful too.
Remember again that the majority of research surrounding lumbar spondylolisthesis is rooted in trying to predict who the surgery will work for and who it won’t. In a June 2020 study in the journal Neurosurgery (6) researchers wrote: “Preoperative employment and surgeries, including a fusion, were predictors of superior outcomes across the domains of disease-specific disability, back pain, leg pain, quality of life, and patient satisfaction. Increasing age was predictive of superior outcomes for leg pain improvement and satisfaction.”
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 whose 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.
I had lumbar spondylolisthesis surgery, now I need another
Frequently we will hear from someone who has a story that goes something like this:
I had been diagnosed with spondylolisthesis in L5-S1. My doctors convinced me and I decided to have spinal fusion through a minimally invasive Transforaminal Lumbar Interbody Fusion (TLIF) at the L5/s1 segment.
The first few months went well, but then I started having terrible pain and was told it was from sacroiliitis. (Inflammation in one or both sacroiliac joints). Now my doctors are telling me that my L4 is being affected by the lower fusion, (adjacent segment disease) so now I need to get another surgery. I did almost 50 sessions of physiotherapy to help with sacroiliitis, it did help but I still feel pain in the sacroiliitis. I am scared that if I go to surgery again it might not solve the problem.
“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. (7)
“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 includes 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 are their research findings:(8)
- 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, (9) 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 (10) 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 is: “Our results provide no evidence for adding fusion to the decompression.”
Degenerative Spondylolisthesis Surgical comparisons
A January 2022 paper (19) in the journal Acta Biomed offers a brief review of the treatments, including surgery for Degenerative Spondylolisthesis. “Most patients with symptomatic Degenerative Spondylolisthesis and absence of neurologic deficits should perform better with conservative treatment, whereas, patients with neurological symptoms, are more prone to undergo progressive functional deterioration without surgery. There is a lack of agreement on the best surgical management in patients with Degenerative Spondylolisthesis and symptomatic stenosis. There is contradictory data that does not permit for a recommendation for or against the addition of fusion to decompression. There is also controversy on which fusion technique is best. Spinal minimally invasive surgery is a promising approach for Degenerative Spondylolisthesis promoting early recovery and enhanced quality of life by reducing skin incision, muscular damage, and perioperative pain with significant improvements in clinical results and high satisfaction rates.”
A December 2021 study in the Journal of Neurosurgery. Spine. (20) In patients who underwent lumbar fusion for degenerative spinal disease, minimally invasive surgery was associated with higher odds of satisfaction at 3 months postoperatively. No difference was demonstrated at the 12-month follow-up. Minimally invasive surgery maintained a small, yet consistent, superiority in decreasing (disability) and back and leg pain, and minimally invasive surgery was associated with a lower reoperation rate.
Researchers from the Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne published these findings in May 2022 in the
Archives of orthopaedic and trauma surgery. (21)
“Lumbar spinal fusion surgery is a widely accepted surgical treatment in degenerative causes of lumbar spondylolisthesis. The benefit of reduction of anterior displacement (keeping the vertebrae from moving forward) and restoration of sagittal parameters (how far out of alignment or how much the malalignment of the spine was corrected) is still controversially debated.” To try to help answer this debate, the researchers then set out to analyze postoperative clinical outcome.
The researchers noted in study subjects that they “could observe a significant benefit in clinical outcome after lumbar fusion surgery in low-grade spondylolisthesis in . . . mid-term follow-up data including 32 patients. By surgical reduction, we could see significant restoration of anterior displacement and sagittal rotation. Interestingly, a significant correlation between restoration of both sagittal rotation and sacral inclination and clinical outcome score was observed in the 3-year follow-up.”
What are we seeing in this image?
If you have been diagnosed with lumbar spondylolisthesis or lumbar spondylolysis, it has probably been explained to you in a consultation where your spinal x-ray was being discussed that stress fractures are occurring in the pars interarticularis, the bone that joins the facet joints in the back of the spine. One way to address these stress fractures is to take the stress off the vertebrae and allow the stress fractures to heal. If you take the stress off the vertebrae you may prevent future stress fractures. If you take the stress off of these vertebrae you may also prevent further slippage and allow the vertebrae the stress-free environment they need to try to get themselves back into proper alignment. You may need treatments to do that. One treatment that may achieve both of these goals is Prolotherapy injections.
Acupuncture and nerve blocks
A July 2021 study (11) explored the clinical effect of acupuncture combined with nerve block treatment on Grade I lumbar spondylolisthesis. In this research:
- Patients with Grade I lumbar spondylolisthesis were randomly divided into a control group (70 patients) treated with only nerve block and an observation group (70 patients) treated with acupuncture based on the nerve block treatment in the control group.
- The researchers found “Acupuncture combined with nerve block can improve the efficacy rate of treatment of Grade I lumbar spondylolisthesis, relieve the pain of patients, restore their spinal functions and improve their quality of life, which is worthy of clinical promotion. “
Does Radiofrequency ablation make lumbar spondylolisthesis worse? Researchers are asking
A May 2021 paper in the Journal of Pain Research (12) explored the theory that Radiofrequency ablation may weaken paraspinal muscles that provide stability to the spine, the therapy can potentially contribute to progressive spinal instability. Here are their findings:
- Radiofrequency ablation (RFA) is a denervation therapy commonly performed for the pain of facet etiology (Commonly referred to as Facet syndrome, the facet etiology of pain develops when degenerative wear and tear thins out the cartilage of the facet joint and the joint becomes “bone on bone.”) This leads to inflammation and pressure on the nerves and discs.
- “Degenerative spondylolisthesis, a malalignment of the spinal vertebrae, maybe a co-existing condition contributing to pain; yet the effect of Radiofrequency ablation on advancing listhesis (a hypermobile vertabrae) is unknown. To the extent that denervating RFA may weaken paraspinal muscles that provide stability to the spine, the therapy can potentially contribute to progressive spinal instability.”
In this study, the researchers could not give evidence that Radiofrequency ablation advances spinal instability. They write: “Among patients with lumbar pain originating from facets in the setting of degenerative spondylolisthesis who underwent lumbar Radiofrequency ablation, the observed advancement of spondylolisthesis is clinically similar to the estimated maximum baseline of 2% per year change. The study findings did not find a destabilizing effect of lumbar Radiofrequency ablation in advancing spondylolisthesis in this patient population.”
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.
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.”(13)
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. (14)
What are we seeing in this image?
When spinal ligaments become loose because of wear and tear of acute injury, 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 (15) 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.
A Prolotherapy treatment into the lumbar spine.
- 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. In these images, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- The black crayon marks all down the midline of this patient’s back give guidance to where the injections should be placed. The horizontal line is drawn where the patient’s pain stops. This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- 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.
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. (16) 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 the 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.
- See what is occurring here. Doctors are unsure of the mechanism that causes spondyloarthritis. This research suggests that it may have something to do with the enthesis, the enthesis is where ligaments and tendons attach to muscle and bones. Bone spurs are forming at this juncture because the ligaments and tendons are causing spinal instability.
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 patients 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 fiber and ligament structure regeneration.”
In the Journal of Prolotherapy, (17) James Inklebarger, MD and Simon Petrides, MD wrote: “Prolotherapy injections produce an inflammatory response, which can augment collagen fiber 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 for 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 were told by their medical doctor(s) that there were no other treatment options for their pain, and a subset of 26 patients was 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. (18)
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.
For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.
Diagnosing lumbar instability & treatment with Prolotherapy, PRP, cortisone, nerve blocks
Ross Hauser, MD and Danielle Matias, PA-C discuss the types of cases we see at Caring Medical Florida for low back pain and spinal instability.
Summary: Is this treatment right for you?
To recap: Lumbar spinal fusion operations fuse together several segments of the vertebrae. Such an operation is commonly performed for spondylolisthesis to pull the vertabrae back into a natural alignment. While many people have successful surgeries many people can also suffer from post-operative back pain and adjacent segment disease or other complications caused by the surgery. After surgery, mobility can be decreased causing increased 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.
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.
Questions about our treatments?
If you have questions about non-surgical treatment options for Lumbar Spondylolisthesis and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
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This article was updated July 26, 2022