Low back pain is a widespread issue and a significant cause of disability in the US and globally. Most people will experience some significant back pain at some point in their lives. Fortunately, in most cases, it’s due to muscular strains that are temporary and self-limiting. However, over 50 million Americans suffer from more serious, chronic back pain that restricts their activities and affects their quality of life. This number is even higher when considering those with periodic, recurrent episodes of pain.
The Potential of Stem Cells in Treating Low Back Pain
In this blog, we’ll explore the regenerative approach, specifically how stem cells can be used to treat various conditions causing back pain. Notable athletes like Fred Couples and Rafael Nadal have used stem cell treatments to help heal their back pain, enabling them to return to their sports and perform at the highest levels.
From the very beginning, it’s crucial to find the real root cause of the pain. You can’t fix a problem without a clear understanding of what’s causing it. For low back pain, the right diagnosis and understanding of the pain mechanism are essential. Commonly diagnosed causes of back pain include degenerative disc disease, disc herniations, facet joint arthropathy (arthritis), spondylolysis (vertebral arthritis), and spondylolisthesis (vertebrae slipping forward on one another). These conditions are easily seen on X-ray and MRI imaging. However, just because an abnormality is seen on imaging doesn’t mean it’s the primary cause of the pain. Basic imaging often misses considerations of vertebral instability and ligament and tendon enthesopathy affecting the deep vertebral, lumbar, and pelvic connective tissues. If these ligaments and tendons are stretched or torn, they can generate significant pain. Differentiating radiological diagnoses from the actual root cause of the pain is crucial.
The Importance of a Comprehensive Diagnosis
Supporting this viewpoint 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.” This highlights that few doctors look for back sprain as a cause of chronic low back pain. Researchers suggest that ligamentous causes of pain are often neglected compared to other pathologies, likely due to the overuse of MRIs and overreliance on their results for diagnosis. Studies have shown that many patients without symptomatic back pain display MRI abnormalities, including moderate to severe degenerative disk changes. These MRI findings often lead to recommendations for surgery, which can result in catastrophic outcomes if the surgery addresses an abnormality that isn’t the real cause of the patient’s back pain.
A comment from the Journal of General Internal Medicine, December 2019, states: “Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded MRIs do not improve patient outcomes and lead to unnecessary surgeries and procedures.”
In conventional orthopedics, MRI is considered the gold standard for diagnosing low back issues. However, MRIs are often over-ordered and their findings only tell part of the story, sometimes misleading the diagnosis. MRI lacks specificity, as many imaging abnormalities may not actually be the true pathology. It also lacks sensitivity, potentially missing microtears at the entheses of the deep ligaments and tendons that stabilize the vertebral joints. Essentially, what an MRI or X-ray sees and picks up may not be the real cause of the pain, and what it doesn’t pick up may actually be the problem.
Classical vs. Regenerative Approaches to Back Pain
Classical approaches to back pain largely revolve around the MRI and the discs, often assuming that pain comes from discs unless proven otherwise. It’s common for MRIs to show degenerative discs, ranging from minor deformations to protrusions and herniations. Since many MRIs are ordered, numerous disc abnormalities are identified that may or may not be the actual cause of patients’ pain.
Spinal discs are soft, compressible structures that separate and cushion the vertebrae, acting as shock absorbers and allowing the spine to flex, bend, and twist. Pain from the discs is called discogenic pain. While disc degeneration and herniations in the lumbar spine are commonly blamed for low back pain, almost everyone over the age of 50 or 60 has some degree of disc degeneration visible on MRI. Many of these individuals do not experience pain. Because discs have no nerves, degeneration alone isn’t thought to directly cause pain.
However, disc degeneration can indirectly cause significant pain. As discs lose hydration and volume due to aging, wear and tear, or injury, or as spinal and deep lumbar ligaments stretch, resulting vertebral instability can cause pain. Stretched connective tissue can cause pain, and a loose vertebral joint may lead to disc rupture. A herniated disc, where the nucleus pulposus extrudes through the fibrous annular ring, can cause pain by mechanically pressing on the nerve root or chemically irritating sensitive nerve roots, leading to sciatica.
Facet Joint Sprain and Other Causes of Low Back Pain
Another frequent cause of low back pain is facet joint sprain, where the capsule around the apophyseal joints is stretched. The facet joints stabilize the vertebral bodies and counterbalance the intervertebral discs. These joints can be damaged like the meniscus in the knee and are prone to chronic degenerative arthritis. Pain from facet dysfunction typically affects the back of the lumbar spine, thoracic region, and neck, and is worsened with extension or rotation of the back. The diagnosis can be suspected based on imaging studies but should be confirmed with palpation interrogation of the lumbar spine.
The Regenerative Approach: Joint Stability and Connective Tissues
The focus of regenerative orthopedics is joint stability and connective tissues. For low back pain, the initial approach is to suspect connective tissue enthesopathy and vertebral instability, whether disc herniations are present or not. A comprehensive approach to vertebral instability considers all supporting connective tissue structures, including spinal ligaments and deep lumbar ligaments. The deep lumbar ligaments include the iliolumbar ligaments, sacroiliac ligaments, and lumbosacral ligaments. Pelvic tendon strain (gluteal enthesopathy) can also cause serious pain. All these structures are crucial for vertebral stability, and loosening them can lead to further pain and problems.
People with back pain often can’t pinpoint the exact source of their pain. Clues in the patient’s history can help identify the cause. For instance, pain that sets in after lifting something heavy and radiates down the leg could be true sciatica (disc herniation) or an acute sprain. Pain worsened by twisting suggests a facet joint sprain. Pain relieved by bending over a shopping cart might indicate vertebral instability causing spondylolisthesis. Pain worsened by getting up from a seated position could indicate vertebral instability or deep tissue enthesopathy. Difficulty standing or sitting for long periods suggests gluteal enthesopathy, known in regenerative circles as the “theater-cocktail syndrome.”
Deep lumbar ligaments have specific referral patterns that can be mistaken for sciatica and nerve root compression from a protruding disc. Sacroiliac ligaments refer pain down the posterior thigh and lateral foot. Sacrotuberous and sacrospinous ligaments refer pain to the heel. Iliolumbar ligament sprain should be considered for unexplained vaginal, testicular, or groin pain.
Comprehensive Diagnostic and Treatment Approach
Pelvic enthesopathy is common in patients with low back pain and can be either a primary pain generator or develop secondary to other deep lumbar instability. A thorough palpation interrogation exam often reveals a positive jump sign for gluteal attachments on the pelvis. Patients can’t differentiate this pain from discogenic or deep spinal or lumbar ligament sprains. Due to biotensegrity, these structures are interconnected, and it’s common to see several conditions coexist.
The approach for these conditions involves a comprehensive diagnostic exam and injections. Palpation interrogation testing checks the strength and integrity of all joints and supporting connective tissue structures in the back. Injections should target all these structures, sometimes requiring several sessions to ensure thorough treatment. As ligaments tighten and joints become stronger and more stable, pain often disappears.
The holistic regenerative approach to low back pain, which considers all connective tissue structures and vertebral stability, may yield superior results compared to classical reductionist approaches that focus mainly on the discs. The most common source of persistent low back pain is vertebral instability and ligament or tendon laxity. Traditional workups often rely on MRI findings, which may not always correlate with the actual cause of pain. For serious low back pain, finding a skilled regenerative doctor who can perform a thorough palpation interrogation exam and target the right structures with injections is crucial.
Many studies show that back surgery has only about a 30-40% success rate to heal the pain. For the right candidate, regenerative approaches are much more successful. For a good regenerative doctor who is trained and experienced with palpation interrogation techniques (and the proper diagnosis of the primary pain generators) and skilled in the selection and preparation of the most potent stem cell combinations, the success rate is about 85%. Even if a patient has had back surgery and still has pain (failed back surgery syndrome) it still may be very fruitful for that patient to consult with a good regenerative doctor as the problem may actually be in the pelvis and not due to disc issues, even though the MRI showed disc abnormalities.
Once we have properly diagnosed and prioritized the pain generators in a given patient, then we have to decide which combination of Stem Cells, PRP and Prolotherapy is the best choice for the various areas involved. Prolo primers can sometimes make a huge difference. In some cases Prolo as a stand alone treatment may be sufficient to heal a problem. In other cases, the degeneration is too severe and stem cells from a patient’s own abdominal fat, mixed in with PRP growth factors can be the fastest and most effective way to fix the problem. Of course in some cases, even if we use stem cells we may need a PRP booster to complete the job. This is particularly true when the patient has multiple areas that have substantial degeneration.
