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PROLOTHERAPY
AND SPINE DISEASE
The orthopedic
surgeons' reliance and emphasis on
x-rays procedures and surgery by nature
makes him think of the spine as a focally or regionally injured organ.
Actually, it's rare for a spine injured by sudden
deceleration in an auto accident, lift or fall to receive its injury in one
area. The x-ray changes suggesting that simply show the peak of injury, not
the breadth. The patient frequently senses this better than the surgeon as
he/she notes pain in remote areas where x-rays appear normal.
The
Prolotherapist
like the
chiropractor and Osteopath sees the spine as an integral functioning
unit with varying degrees of injury. The surgeon during informed consent
cautions the patient that
surgical fusion at one level may cause the adjacent
disc space to degenerate. This is because the
ligaments in the next segment
are already injured and will now be put under even more movement and stress.
When a patient
undergoes disc removal and fusion (PILF) for leg and
back pain, the surgeon cautions that he may relieve the
leg pain and aggravate the back pain for leave it unchanged. This is because
the surgery has done nothing or weakened the back ligaments.
It was reported at
the World Spine Conference in Cincinnati, Ohio in 1991 that 40% of patients
undergoing PILF will suffer continued back pain because the surgeon failed to
recognize that the herniated disc was causing no symptoms. The back pain was
all coming from an unstable
sacroiliac joint better managed by chiropractic or
Prolotherapy.
The weakest point the
spinal ligament attachment is the delicate ligaments attaching the very heavy
skull to the delicate first and second cervical vertebrae. The surgeon is
little interested in this critical anatomy as it is a surgically inaccessible
area. Patients who undergo surgical fusion of the neck with relief of arm pain
frequently continue to complain of
headaches and neck fatigue plus symptoms of
Barre-Lieou syndrome
(see below) that can only be relieved by Prolotherapy. Low Back Pain
Lumbar disc disease
is the leading cause of disability in America Low back pain is the number one
cause of work loss from pain in the U.S. This is a combined effect of poor
work habits in the workplace, unsafe lifting techniques and vehicle trauma.
The fact that insurers and Workmen's Compensation will allow surgery and
physical
therapy and little other care causes patients to wax and wane trying
to avoid operation.
The principle problem
with low back pain management is failure to make an accurate diagnosis. There
are more than a dozen different causes of low back pain. Most patients suffer
from at least two or three causes confounding the therapy. The fact is that
ligament instability is a common factor to each every cause and it is the only
therapy that stands any chance to correct enough of the problems to get the
patient working with a permanently repaired back.
Intervertebral Disc
Bulging and Herniation is the best-recognized and most feared cause of back
pain by patients. This is so because it is the one disorder visible on
MRI
and
myelogram. This does not mean that it is the cause of the back pain. Pain
below the knee associated with back pain is almost always nerve root pressure
from a herniated disc.
Associated numbness
below the knee strongly supports the diagnosis. The cause of leg pain is not
simply herniated disc material pressing on the nerve. The narrowed disc leaves
the Intervertebral ligaments to long allowing abnormal movement that causes
the nerve to rub or chafe.
Correcting the
ligaments can improve range of motion, reduce leg pain and protect the disc
against further degeneration. Disc degeneration is a separate disorder. Many
older patients have dried brittle discs that have not bulged or herniated.
These discs may also lose their blood supply and undergo tissue death with
deterioration, fermentation and gas formation causing diskitis. This is
visible on plain x-ray as air inside the disc.
Facet arthritis is
wear,
cartilage loss and spur formation in the small gliding joints of each
vertebrae. This causes local back pain, stiffness and then swelling around the
nerve root aggravating otherwise tolerable disc herniation.
This chronic
arthritis causes the ligaments lining the spinal canal to over grow or
hypertrophy (ligamentum flavum hypertrophy). The resulting combinations of
hypertrophy, facet enlargement, disc bulge and swelling narrows the spinal
canal leaving little or no room for the spinal cord to pass. This disorder
called Spinal Stenosis is particularly frightening because surgery with it's
swelling and bone formation
aggravates the condition and once done cannot be reversed. Spine surgeons try
very hard not to operate for the first time on spinal stenosis.
The resulting
pressure puts pressure first on the arterial and venous blood supply of the
spinal cord and nerves. This causes a classic pain called claudication. The
patient with claudication has pain aggravated by standing and more commonly
walking that is relieved by rest. It is important in these patients to perform
doppler sound wave analysis of the arteries supplying the legs to make sure
the pain is from the back and not
from atherosclerosis or hardening of the arteries.
Spondylolisthesis is
perhaps the worst disorder of the lumbar spine. Two-five percent of all people
are born with a defect (spondylolysis) in the most important strut in the low
back at the last lumbar vertebrae. 50% of these people will fracture that
defect during their life and develop symptomatic spondylolisthesis. This
fracture results in the last lumbar vertebrae sliding forward on the sacrum
causing the spinal cord to be crushed. Surgery has a high failure rate because
of the massive forces of gravity
acting on the surgical site. This disorder is diagnosed by taking oblique (45
degree angle) x-rays of the back from both sides. Sacroiliac instability is
the most probable cause of pain in patients who have normal x-rays. These
patients eventually seek out chiropractors after their family doctor and
orthopedist fail to make the diagnosis.
Most patients with
back injury have some component of their pain stemming from their sacroiliac
joints. The sacroiliac joint is unique in its movement and attachments. It's
purpose is to take the force of gravity coming down the spine and send it at a
ninety degree angle out to the hip. The ilium stands much higher than the
sacrum causing the last lumbar vertebrae and disc to be buried deep between
the sacroiliac joints.
The pain of
sacroiliac is best characterized as off center in the low back radiating to
the
groin and anterior thigh. There is some numbness occasionally in the upper
leg but not below the knee. Difficulty descending stairs and standing after
riding in a car or sitting is typical of sacro-iliac pain. This joint may
occasionally pop or click when turning in bed or moving the hips. When
patients report their 'hip is out', they are having SI pain. There is no
surgical repair for the Sacro-iliac joint. There is a special Sacro-iliac
brace that can help patients walk and work. This joint is ideal for
Prolotherapy since is long, large and easily accessible.
The most difficult
diagnosis's are back and limb pains caused by nerve entrapment outside the
back. Gluteal nerve entrapment is a sciatica from the nerve being wrapped over
a protruding bone inside the buttocks.
Pyriformis syndrome is a mixture of
muscle spasm and nerve stretch caused by sacroiliac instability. Both can be
proven with temporary
nerve blocks.
Seven per cent of all
adults have some evidence of congenital variation on x-ray of the spine. This
means that they were born with a back constructed differently than the
average. If this is a symmetric variation, it may never be important. It is
common for adults to have four or six rather than five lumbar vertebrae. This
is little trouble unless it occurs on just one side. Sometimes the last disc
is quite narrow and serves as a poor cushion degenerating quickly. A large
percent of patients are born with one leg one to two centimeters shorter than
the other side causing pelvic tilt, scoliosis and sacroiliac pain. This is
important to discover using standing pelvis x-rays (ordered only by
chiropractors, MD's get their films lying down). A simple shoe lift can
relieve all back pain.
Patients with tight
hamstrings (the muscles in the back of the thigh) causing an extreme arch in
the back called hyperextension syndrome. Stretching and exercise can relieve
much of these patients' symptoms. A word about Gouty arthritis is important in
the discussion of back pain. Gout is caused by a genetic tendency to excrete
the breakdown of muscle tissue through the uric acid path rather than less
toxic alternatives. Normal uric acid is 3 to 7 mg/dl. True gout with a painful
toe and kidney stones occurs if the uric acid rises above 12 mg/dl.
Traditional medicine
considers the patient with a level between 7 and 12 to be symptom free. Many
family physicians treat these patients with a simple affordable once a day
drug called Zyloprim and low and behold, their back pain is resolved. The
facet joints appear to be the first joints in the body affected by gout. Some
patients with normal uric acid levels have very high 24 hour urine excretion
on testing. They also may benefit from treatment. If you have a positive
family history, use water pills or have past history of gout, this might be
worth a try.
Not all back pain is
caused by the spine. It is very important to rule out kidney stones or kidney
infection, prostatitis, chronic diverticulitis, cancer of the pelvis,
endometriosis, ovarian cysts, fibroid tumors, shingles and circulatory
deficiency from hardening of the arteries.
Scoliosis is an
abnormal curvature of the spine. The majority of these cases occur in
adolescence and resolve if not severe with exercise and growth. If the cause
is from injury, tumor, disc degeneration or congenital abnormalities, they
will persist and become more painful causing additional ligament injury
throughout life. There has been little luck correcting scoliosis with
Prolotherapy but it is possible to stop the progression of the disease and
correct some of the curvature.
Failed Back Syndrome
means that the surgeon operated and it didn't work or caused new problems.
These patients were misdiagnosed or the surgery had unexpected changes to
distant areas of the spine. The surgeon may offer more surgery. Think very
carefully! If he didn't know what was wrong the first time, what has changed?
Get an opinion from a major spine center. Failed backs almost always have
sacroiliac disease plus some other ligamentous failure and need to start all
over with a good medical work-up. Prolotherapy has a very high success rate at
reducing pain in post-op patients who fail. The spine surgeon who wrote the
text "The Failed Back" from Boston Mass. General Hospital considers
Prolotherapy the mainstay of treatment.
The following report
is from a patient with a fourth lumbar disc herniation and right leg pain who
awoke from surgery with no leg pain but now LEFT hip pain relieved by
chiropractic. The surgery was successful but the result was ligamentous
instability. All of the underlined areas are correct surgical procedures for a
laminectomy. In each step, ligament is cut, removed, scraped aside, stretched
or otherwise injured. The medial facetectomy means that a portion of the
gliding joint for that vertebrae was removed. None of these parts can be
repaired or replaced. Thoracic Spine Pain
As we move up the
spine, the next section is the thoracic spine defined as the area of vertebrae
that have attached ribs. The ribs serve a significant protective factor and
disc herniation is rare in this area. Degenerative arthritis with aging is
however almost the norm. Lifting injuries do not injure the disc as much as
the attachment of ribs to spine. This is the joint that cracks with
chiropractic manipulation and indeed chiropractic is the best management for
occasional pain. If however, this back pain requires constant manipulation,
this is a simple problem to solve with Prolotherapy.
Cervical Spine Pain
(Pain in the neck and arms) Just as the back is mostly a mixture of many
causes of pain, so it is true with the neck. Arthritis, disc injury,
herniation, facet arthritis are all co-mingled just as with the back.
Attention to the lower cervical disc narrowing with surgery is occasionally
fraught with failure to relieve pain though surgery in the neck is safer and
more effective than in the low back. When the neck is injured in an
extension/flexion injury such as
whiplash, the maximum disc injury is to the
lower cervical area where movement is maximum. For this reason, most neck
surgery occurs between C5C6 or C6C7. The maximum ligament injury occurs much
higher at the attachment of the skull to the first two vertebrae. Since the
nerves supplying the skin and muscle are at a minimum in this area, symptoms
tend to be headache and head heaviness rather than numbness and pain at a
distance.
More important, the
spinal cord and base of the brain lose protection and cause symptoms more
suggestive of other diseases such as Multiple Sclerosis or Migraine. This
syndrome called Barre'-Lieou is rarely diagnosed today. See the discussion
below. It is not possible to correct these delicate ligaments as they are
surgically inaccessible and fail to show on MRI.
Cervical Disc Disease
can cause herniation with nerve root pressure. The symptoms include numbness
and tingling of the forearm or part of the hand. This is true because three
separate nerves supply the arm. Pain from a C4C5 disc refers to the outside of
the shoulder. C5C6 affects the forearm and thumb. C6C7 refers to the hand.
These symptoms can be relieved with surgery, which is surprisingly simple. An
incision is made over the front of the neck just above the collarbone. No
serious structures are cut, rather they are moved aside. The vertebrae are
separated with a special clamp and the disc is removed. Donor bone is taken
from the iliac bone just below the boney prominence above the hip with a
device like a cookie cutter and placed in the gap. The bones then grow solid.
The patient complains more of hip than
neck pain post op. The biggest
complication of the surgery is that the fusion makes for a long segment of
immobile bone that now throws the movement into the next disc causing it to
deteriorate over years resulting in more surgery. Prolotherapy has the
advantage that it stabilizes the weak disc without limiting its movement. The
disc is still herniated but because the motion is more naturally, there is
less swelling and arthritis and subsequently less nerve pressure.
Degenerative disc disease is a hardening, narrowing and drying of the disc so it becomes
inflexible and breaks down. This may be a finding on x-ray in older patients
who have no symptoms and their only sign is poor range of motion. In other
patients, the narrowed disc throws pressure on the small gliding facet joints
in the vertebrae causing chronic neck pain. Partial relief can be achieved
with Prolotherapy. Surgeons consider this disorder inoperable. Sleeping in a
cervical foam collar can also relieve some pain.
Thoracic Outlet
Syndrome is a less common cause of arm and neck pain. Commonly associated with
degenerative disc disease, this disorder results from ligament injury to the
small ligaments holding the collarbone to the shoulder and shoulder blade.
This collapse narrows the space where the artery, vein and nerves to the hand
pass under the collarbone into the armpit. Because of the vascular pressure,
there occasionally is minor hand swelling as well. Typically, the arms become
tired when held above the head as when combing hair. A simple test, the
Adson's maneuver can suggest the disorder. The pulse is taken with the hand at
the side, then the arm is elevate as if the patient was taking a pledge and
the head is turned away from the side and a deep breath is taken. If the pulse
disappears or drops in volume, a doppler test will confirm the diagnosis. The
repair involves removing the first rib through the armpit or Prolotherapy can
stabilize the ligaments.
One in 100 patients
with neck pain has an extra set of ribs attached to the last neck vertebrae.
These short structures put abnormal pressure on the muscles and nerves passing
to the shoulder. There is not surgical or medical management of this disorder.
Exercises relief it briefly. Occipital neuralgia or Splenius Capitus syndrome
is really just a symptom collection complicating other injuries. The
attachment of the muscles at the nape of the neck become chronically inflamed
placing irritation around the first cervical nerve. This nerve causes
headaches at the back of the skull and above the eyes. Pushing on the nerve
causes the pain and ice to the neck relieves it. Severe cases may need the
nerve cut leaving the scalp numb. Repairing the posterior interspinous
ligament in the neck where it is torn resolves the pain. Barre'-Lieou Syndrome
named after two European physicians who described it simultaneously. Barre' is
famous for his work with Guillan-Barre' syndrome, the post viral paralysis
disorder. It was a common diagnosis until the discovery of Neurosurgery in the
1950's. Since there is no surgical or medical known management, it fell out of
the thought process of physicians and was forgotten. Chiropractors see the
syndrome very commonly since that is the best management of symptoms. Symptoms are many and varied and no patient has them all. The symptoms mostly arise because the nerves supplying the blood supply inside the skull become irritable from pinching at the base of the skull. The defect is weakness and hypermobility of the ligaments attaching the skull to the first two or three cervical vertebrae. Catapress, the blood pressure pill relieves some of the symptoms because it reduces the rate of firing of the alpha ganglionic nerves in the blood vessels. Symptoms from most common to least include headache, head heaviness, Temperomandibular Joint Syndrome (because the ligaments to the jaw were injured at the same time), eye heaviness, unsteady gait and vague imbalance, true vertigo with spinning, unexplained anxiety sometimes mis-diagnosed as panic disorder. Some patients complain of 'onion skinning' described, as a feeling that there is a layer of tight skin on the cheek or a feeling like a hair or insect is on the skin that can't be removed. These patients feel best when reclining in a pillow to take the weight off the ligaments. They may have minor swallowing problems. Symptoms at a distance include palpitations (heart skipping), difficulty with orgasm and incomplete emptying of the bladder. There are not tests to prove this disorder. Prolotherapy is the only known treatment in the literature.
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Prolotherapy is a medical
technique. As with any medical technique, results will vary among
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Prolotherapy may not work for you and as with all medical
procedures there are risks involved. These risks should be discussed with a qualified
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