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CHRONIC LOW BACK PAIN
Vladimir
Djuric, M.D.
Chronic
low back pain (CLBP) is defined as ongoing back and/or back-related leg symptoms
beyond three month’s duration. For those unfortunate individuals afflicted
with this condition, even simple daily rituals such as getting out of bed,
making breakfast, or doing laundry can be difficult tasks. Despite recent
medical advances in both the diagnosis and treatment of the condition, CLBP
remains the leading cause of pain and disability in developed countries.
In the past century there has been extensive deliberation regarding the specific
causes of CLBP. Imaging studies such as
x-rays, CT scans, and
MRI
have
successfully shed light on structural abnormalities, which may or may not be
contributing to the symptoms. The focus of both these and electrodiagnostic
studies (EMGs) are the intervertebral discs and their effect on the spinal
nerves. A herniated disc may either press against or inflame one of these
nerves, creating “sciatica”-type symptoms. This is a relatively
straight-forward problem with, in most cases, a similar straight forward
solution. Conservative treatment, including medications, PT, and epidural
steroid injections usually promote in resolution of symptoms.
In some instances, particularly when there is a danger of permanent neurologic
loss, surgical intervention is necessary and usually successful. Unfortunately,
this is where the simplicity ends. Primary back and buttock pain (as opposed to
primary leg pain, the most dominant symptoms found in sciatica) is another ball
game altogether. If usual conservative treatments such as medications,
physical
therapy, exercises, and chiropractic, fail to resolve or at least palliate
symptoms, the patient can get caught up in a complicated and frequently
frustrating whirl of diagnostic tests, referrals, more tests, and counter
referrals. As much as we physicians are reluctant to admit it, our understanding
of more complicated presentations of
back pain
remains inadequate. At times,
even though our understanding of the problem may be quite thorough, the
treatment options are poor.
Lumbar
degenerative disc disease
(DDD) is a common condition and considered to
be part of the normal aging process. However, we depart from normalcy when these
degenerative discs are the cause of severe pain. In spinal medicine, painful
lumbar degenerative disc disease has probably been given the lion’s share of
attention and research dollars. Surgical fusion with and without
instrumentation, fusion cages, and more recently, electrothermal annuloplasty (IDET)
are all procedures that can successfully treat the condition – sometimes. In
many instances, even though these high-tech interventions may be available, the
patient may not be a candidate.
Facet (zygapophyseal) joint dysfunction is another cause of chronic low back
pain. These small joints located in the back of the spinal canal help guide
segmental motion and to a lesser extent serve as weight bearing elements.
Especially with DJD,
Spondylolisthesis
(slipped vertebra) and trauma, these
structures can become sources of pain. Again, treatment choices are quite
limited. Steroid injections into these joints may provide substantial relief,
but the benefits are temporary and frequent injections are contraindicated.
Radiofrequency denervation, a procedure in which the nerves supplying the pain
fibers to the joint are destroyed has been of limited success in the lumbar
spine.
One of the more frequently overlooked source of back pain, especially in
instances where the pain was initiated by trauma, is the sacroiliac joint. These
relatively flat joints which flank either side of the tailbone (sacrum) are
susceptible to injury merely because of their nature and orientation. Being flat
allows for little intrinsic stability. In large part, the stability that is
present is provided by large
ligaments. Traumatic injury such as falling and
landing on the buttocks, lifting a heavy load, automobile accidents with the
right leg extended and firmly pressing on the brake and “missing a step” can
all result in a sacroiliac joint sprain and eventually lead to SI joint
dysfunciton. In many instances it is easily treated by a manual therapist or
chiropractor. However, if the ligaments become too lax, the joint can become
unstable. Activities such as bending, twisting, or even shifting positions can
cause the joint to “sublux” or shift out of position. When in the
“subluxed” position, the joint and associated ligaments become irritated,
causing pain. Various studies have implicated SI joint dysfunction as being
responsible for anywhere from 10% to 40% of chronic back complaints.
Extensive clinical research supports prolotherapy as a legitimate treatment for
CLBP. Ongley’s study, published in the journal "Lancet" in 1987,
showed significant improvements were realized by patients treated with
prolotherapy for nonspecific chronic back pain. Klein performed a similar study
which was published in the "Journal of Spinal Disorders" in 1993. It
also demonstrated a reduction in pain and disability in patients treated with
prolotherapy when compared to placebo. In other less “scientific” research
and the testimonials of countless prolotherapy patients and practitioners
similar results have been found.
After practicing prolotherapy for over seven years and in that time treating
hundreds of backs, I remain convinced that prolotherapy has a place in the
treatment of chronic back pain. Although by no means a cure in the general
sense, prolotherapy is usually successful in making the symptoms more manageable
and limiting the frequency, severity, and duration of exacerbations. Successful
outcome, measured in terms of not only pain relief, but also functional
improvement and a reduction in medication usage is more typical than not.
The condition of internal disc dysfunction (painful DDD) only indirectly
benefits from prolotherapy. Until recently, my personal success had been rather
limited in treating this population of patients. Over the past year, however,
intradiscal injection of a modified proliferant solution has been very effective
in some cases. Electrothermal annuloplasty, still in its investigational stages,
holds promise as an alternative to
spinal fusion in the treatment of this
difficult problem. Unfortunately, inclusion criteria for undergoing this
treatment are quite stringent. In more advanced stages of disc degeneration and
multi-level disc involvement, success rates fall dramatically.
Facet joint dysfunction and sacroiliac joint dysfunction are conditions for
which prolotherapy should be strongly considered. These problems are addressed
more directly with the injections. By stimulating
collagen
synthesis and
promoting joint stabilization, symptoms stemming from these conditions can be
greatly ameliorated. Although certainly not a panacea, prolotherapy stacks up
favorably when compared to most other treatments directed towards the treatment
of these very challenging conditions.
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