Over the years we have seen many patients with a long history of back pain. Most of the time it was nondescript back pain and no one was sure what was causing it. The problem, according to some patients, was the MRI did not show enough damage or irregularities to justify an aggressive surgical treatment. So the patient became “pain managed” with prescription medications, painkillers, anti-inflammatories, and possibly a few courses of physical therapy, possible chiropractic care, and then epidural steroid or cortisone injection. Eventually the patient will get a follow up MRI and one day, someone will find something on an their MRI that needs a spinal surgery.
Sometimes the person will tell me they are lucky, if they have to get the surgery, they will only need a Discectomy or a minimally invasive microdiscectomy. Same day surgery. Regardless of the procedure, this person is sitting in our exam room because they do not want the surgery no matter how minimally invasive it is. A surgery is still a surgery and you need to be under general anesthesia.
In talking to people like my example patient here, I can hear in their entire medical history, disc, disc, disc. Degenerative disc disease, herniated disc, bulging disc, how many millimeters the disc is sticking out, dis surgery. When I tell them that the size of their bulging disc may not matter they become puzzled. Some people will need a surgery if they have a significant and severe herniation. Some people who think they have a significant and severe herniation may not.
In my many books and for years on my radio show I have told readers and listeners that some people will have an MRI that will show a “massive” herniated disc and yet the person has no back pain. Other people will have an MRI that has a small herniated disc and will have terrible pain. It is not just me saying this.
An October 2020 study (1) examined the sizes of lumbar disc herniations. The theory the study authors were testing is if the size of the herniation (a big herniation) would not predict who would need a surgery and who would not within two years of the spinal MRI revealing this large herniation. Also, that this type of herniation could be treated surgically or non-surgically. Basically with the same results.
The 368 patients in this study had a primary lumbar radicular pain diagnosis. They also had an MRI showing a disc herniation. They had also just completed at least 6 weeks of conservative care management.
- Overall, 336 (91.3%) patients did not undergo surgery within 1 year of the lumbar disc herniation diagnosis.
- Patients who did not receive surgery had an average herniation size that occupied 31.2% of the canal, whereas patients who received surgery had disc herniations that occupied 31.5% of the canal on average.
How would something like this happen? Maybe in some people it is not the disc, it is the spinal ligaments.
Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients. Back pain may be a disc problem. Back pain may be a spinal ligament problem.
So when is it a disc problem that needs surgery and when is it a spinal ligament weakness problem that does not need surgery? Doctors at the Mayo Clinic (2) have published a paper entitled: Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. In this paper the Mayo Clinic researchers wanted to make a clear definition between two problems affecting low back pain patients.
- First, that pain could be coming from the discs.
- Second that pain could be coming from the spinal ligaments.
The Mayo researchers suggest that recognizing how the spine moves is essential for distinguishing between the many different types of spinal disorders, and a diagnosis which may ultimately, and erroneously lead to back surgery.
- If a patient has instability, excessive movement, and decreased stiffness, doctors should examine for ligament damage.
- If the opposite, less movement, more stiffness, the doctor should look for disc disease.
Damaged pelvic ligaments
In recent research, doctors may have found the culprit of back pain to be damaged pelvic ligaments. In research published in the medical journal Spine (3) a connection was made between pelvic instability caused by loose pelvic ligaments and low back pain. The research identified damaged pelvic ligaments as significantly contributing to pelvic instability and as generators of low back pain.
In the clinical setting, after a physical examination, we often find that the patient’s pain is from a ligament meaning they have a sprain. So when we check in the hip, pelvis, lower back we look for trigger points – areas of the body that when we press on them it makes and refers pain somewhere else in the body. You just can’t read an MRI to decide what is going on with a patient, you have to use your hands and do an examination.
A diagnosis which may ultimately, and erroneously lead to back surgery.
In our own published peer-review research appearing in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (4) we examined treating spinal ligaments with low back pain. Below is an explanatory adaption of the introductory paragraph of that study. It gives a good understanding of the importance of understanding that we should be looking at the ligament problems in back pain.
- An Orthopaedic Knowledge Update from the American Academy of Orthopedic Surgeons tells its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (5)
- Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for low back pain (6). This could be due to the overreliance of MRIs to guide physicians to correct diagnoses. They write: The influence of the posterior pelvic ring ligaments on pelvic stability is poorly understood. Low back pain and sacroiliac joint pain are described being related to these ligaments.When these ligaments are damaged or weakened, they serve as generators of low back pain.
- Two studies illustrate that patients without symptomatic back pain displayed MRI abnormalities including degenerative disc changes [7,8].
- In the first study researchers wrote that “imaging findings, including degenerative changes, reflect anatomic peculiarities or the normal aging process and turn out to be clinically irrelevant. . . Many treatments (therefore) have proven inefficacious, and some have proven counterproductive, (because of errounous interpretation)
- In the second study, researchers wrote that in making treatment decisions, “patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance.”
- Yet patients with these same diagnoses are recommended for surgery without a thorough understanding of their pain generator.
- Canadian researchers found that 55.7% of lumbar spine MRIs were considered inappropriate or of uncertain value to diagnosis .
What the research shows us is that surgeons to be on the look out, 97% of the time it is not the discs causing pain. The MRI can be misleading and send a patient to surgeon with a “disc problem.”
Damaged ligaments after surgery a cause of post-surgical pain
Researchers in Germany take the idea of discs vs ligaments a step further, they suggest that while surgery can repair the obvious problems of disc disease and be successful, the surgeon must be keenly aware that soft-tissue damage, the ligaments and supportive structures of the spine, can be significant and severe and the surgeons must balance surgical and non-surgical intervention to prevent surgical failure.(10)
The degenerative disease environment of the inner spine treated with stem cells and PRP injections
I have written many articles on stem cell therapy and how they may be able to change the degenerative disease environment of the inner spine to a healing environment. When stem cells are injected into the spine or joint they initially set up a line of communication with the native immune system and begin exchanging messages. It has been theorized in the medical literature that injected stem cells tell the immune cells to call healing factors to the site of spinal damage and to meet them at the points where repair is needed.
A recent paper (11) from Australian researchers explains how this change of environment works.
- When introduced into a diseased joint or spine, stem cells display plasticity and multipotency. This is the ability to change/morph into other cell types and multiply. They also signal the native stem cells and other growth factors to regroup and begin repairing damaged joints.
- Mesenchymal stem cell MSCs (connective tissue stem cells) suppress inflammatory T–cell proliferation and provide an anti-inflammatory effect. The treatment inhibits damaging chronic inflammation.
Doctors should think the patient only has a back sprain and not a disc related surgical condition
In these and other papers and studies I will cite below, the indirect injection treatment of a degenerative discs and resulting strengthening of the spinal ligaments and tendons suggest that maybe doctors should think the patient only has a back sprain and not a disc related surgical condition.
The chronic lower back pain patient typically experiences some type of trauma or overuse to the lower back that causes injury to the iliolumbar, interspinous, and supraspinous ligaments, the ligaments that hold the pelvis to the vertebrae and spinal processes in place.
Ligaments are designed to handle a normal amount of stress that stretches them to their natural limit, returning to their normal length once the stress is removed. If additional (traumatic) stress is applied, and this stretches the ligament beyond its natural range of extension, the ligament does not return to its normal length but instead remains permanently overstretched, diminishing its integrity and attachment to the bone.
Unlike muscle tissue, ligaments and tendons have a very limited circulatory system and a poor supply of blood to regenerate them. This is why ligaments may not heal and instead can remain in a weakened and irritable inflammatory state.
Here is a statement from the medical journal Spine:
“As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.”(12). In other words, very few doctors are looking for a back sprain as cause of chronic low back pain.
Stem cell injections and the herniated disc
Because these surgical procedures and MRIs deal with the problems of the spine as being disc related, there is an assumption that our regenerative non-surgical injections of Platelet Rich Plasma and stem cells are injected directly into the disc. This is not how our treatment works. Our treatment works by regenerating and repairing the damaged supportive tissue of the spine; the ligaments I mentioned above and the tendons at the enthesis. The enthesis is the special connective tissue that attaches the ligaments and tendons to the bones.When these supportive tissues are rebuilt, the spine sometimes does something really wonderful, it heals the pain by slowly pulling that vertebrae back into alignment and with it, the herniated bulging disc.
Research in the medical journal Stem cells translational medicine suggests that stem cells, without direct injection to the site of disc lesions in the spine, can repair disc lesions by changing the healing environment of the spine.
Highlights of this research:
- Stem cells are effective in inhibiting disc degeneration and disc herniation by way of the complex interplay between themselves and immune system cells in achieving successful disc tissue regeneration. The stem cells regenerated the outer tissue of the disc and contained and lessened the bulge.
- Remarkably, stem cells were able to bring more oxygen to the damaged disc and accelerate healing by reversing the low-oxygen (degenerative or dying) environment in the spine. Everything heals with more oxygen.
- Stem cells were able to reduce or prevent herniation by suppressing the non-healing inflammation.(13)
PRP for Back Pain
Research has shown Platelet-Rich Plasma Therapy (PRP) to be effective in treating degenerative disc disease by addressing the problems of spinal ligament instability and stimulating the regeneration of the discs indirectly (discs were not injected directly but showed an increase in disc height).
The same research cites that as in any medicine, the sooner the degeneration is addressed, the better the results in patient satisfaction. PRP is no exception. “The administration of PRP has a protective effect on damaged discs in the acute and delayed injection settings representing clinical treatment with PRP in the early versus late stages of the degenerative process. It appears that earlier intervention in the disease process would be more beneficial than PRP treatment of already severely degenerated discs.”(14)
In our research, Treatment of Chronic Low Back Pain with Platelet-Rich Plasma Injections, published in the journal Cogent Medicine (15) we wrote:
- Platelet-Rich Plasma (PRP) is a non-invasive modality that has been used to treat musculoskeletal conditions for the past two decades. Based on our research, there were no publications that studied the effect of PRP on unresolved lower back pain. The aim of this study was to report the clinical outcomes of patients who received PRP injections to treat unresolved lower back pain.
- 67 patients underwent a series one, two, or three PRP injections into the ligaments, muscle, and fascia surrounding the lumbar spine.
- Patients who received two treatments received injections a mean 24 days apart and patients who received three treatments received injections a mean 20.50 days apart.
- Baseline and posttreatment outcomes of resting pain, active pain, lower functionality scale, and overall improvement percentage were compared to baseline and between groups.
- Patients who received one PRP injection reported 36.33% overall improvement and experienced significant improvements in active pain relief.
- These same patients experienced improvements in resting pain and functionality score, yet these results were not statistically significant. Patients who received a series of two and three treatments experienced significant decreases in resting pain and active pain and reported 46.17% and 54.91% total overall improvement respectively. In addition, they were able to perform daily activities with less difficulty than prior to treatment.
You can read more about this paper and link to the study here: Darrow research study PRP back pain
Lidocaine and steroids
A May 2022 paper (16) compared lidocaine to steroids in Transforaminal Epidural Blocks for lumbar disc herniation.
In this study, the researchers noted: “Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation. The addition of steroids is more effective than local anesthetic alone in Lumbar transforaminal epidural block for patients with lumbar disc herniation. Moreover, the efficacy of Lumbar transforaminal epidural block (TFEB) has been reported to be positively correlated with the volume of injectate. . . This study compared the efficacy of high-volume Lumbar transforaminal epidural block (TFEB) with vs. without steroids for the management of the axial and radicular pain caused by lumbar disc herniation.”
- A total of 54 patients were randomly assigned to either a group who received lidocaine only or a group that received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone.
- The primary outcomes were pain intensity at baseline and 4 weeks after the procedure.
- The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects.
Results: Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after Lumbar transforaminal epidural block (TFEB). However, there were no significant differences between the groups in terms of changes in back pain or radicular pain. The conclusion was: “High-volume Lumbar transforaminal epidural block (TFEB) with and without steroid administration yielded similar significant pain reductions and functional improvements amonglumbar disc herniation patients 4 weeks after the procedure.
Do you have questions? Ask Dr. Darrow
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Stem cell and PRP injections for musculoskeletal conditions are not FDA approved.
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1 Gupta A, Upadhyaya S, Yeung CM, Ostergaard PJ, Fogel HA, Cha T, Schwab J, Bono C, Hershman S. Does size matter? An analysis of the effect of lumbar disc herniation size on the success of nonoperative treatment. Global Spine Journal. 2020 Oct;10(7):881-7.
2 Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2015 Sep 24:1-10.
3 Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. Spine J. 2013 Jun 5. pii: S1529-9430(13)00402-6. doi: 10.1016/j.spinee.2013.03.050. [Epub ahead of print]
4 Marc Darrow, Brent Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7(2)-2018. BJSTR. MS.ID.001461. DOI: 10.26717/ BJSTR.2018.07.001461. 5/
5 An HS, Jenis LG, Vaccaro AR (1999) Adult spine trauma. In Beaty JH (Eds.). Orthopaedic Knowledge Update 6. Rosemont, IL: American Academy of Orthopedic Surgeons pp. 653-671
6 Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J. Ligamentous influence in pelvic load distribution. Spine J. 2013 Jun 5. pii: S1529-9430(13)00402-6. doi: 10.1016/j.spinee.2013.03.050.
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11 Davatchi F, et al. Mesenchymal stem cell therapy for knee osteoarthritis: 5 years follow-up of three patients. Int J Rheum Dis. 2016 Mar;19(3):219-25
12 Von Forell GA, Stephens TK, Samartzis D, Bowden AE. Low back pain: A biomechanical rationale based on “patterns” of disc degeneration. Spine (Phila. Pa 1976). 2015 May 20.
13 Cunha C, Almeida CR, Almeida MI, Silva AM, Molinos M, Lamas S, Pereira CL, Teixeira GQ, Monteiro AT, Santos SG, Gonçalves RM, Barbosa MA. Systemic Delivery of Bone Marrow Mesenchymal Stem Cells for In Situ Intervertebral Disc Regeneration. Stem Cells Transl Med. 2016 Oct 11. pii: sctm.2016-0033.
14 Gullung GB1, Woodall JW, Tucci MA, James J, Black DA, McGuire RA. Platelet-rich plasma effects on degenerative disc disease: analysis of histology and imaging in an animal model. Evid Based Spine Care J. 2011 Nov;2(4):13-8. doi: 10.1055/s-0031-1274752. —2722
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16 Chae JS, Kim WJ, Choi SH. Effects of Local Anesthetics With or Without Steroids in High-Volume Transforaminal Epidural Blocks for Lumbar Disc Herniation: A Randomized, Double-Blind, Controlled Trial. Journal of Korean Medical Science. 2022 May 2;37(17).