Chronic Pain

A VIABLE TREATMENT FOR CHRONIC LOW BACK PAIN

By 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.