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 their MRI that needs a spinal surgery.
Sometimes the person will tell us they are lucky, if they have to get the surgery, they will only need a discectomy or a minimally invasive microdiscectomy. 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, we can hear in their entire medical history that everything surrounds a problem of the disc. They know about degenerative disc disease, herniated disc, bulging disc, how many millimeters the disc is sticking out, disc surgery recommendations. When we 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.
For some people 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.
Do the sizes of lumbar disc herniations dictate surgery?
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 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.
The conclusion to the research was: “The percentage of the spinal canal occupied by a herniated disc does not predict which patients will fail nonoperative treatment and require surgery within 2 years after undergoing a lumbar spine MRI scan.”
How would something like this happen? Maybe in some people it is not the disc, it is the spinal ligaments.
Degeneration of the lumbar spine including the facet capsular ligament appears to be occurring as a whole joint phenomenon
In a May 2023 cadaver study (2) , researchers looked at causes of lumbar spine degeneration. “In particular, the mechanics of the facet capsular ligament (and how that) may contribute to low back pain. They found that the facet capsular ligament is caused by lumbar spine degeneration and causes lumbar spine degeneration. As the ligament gets weaker the spine gets weaker and the forces of the unstable spine’ Ligament and disc degeneration at the same time shows that degeneration of the lumbar spine including the facet capsular ligament appears to be occurring as a whole joint phenomenon.”
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.
In the image below the red tissue are the iliolumbar ligaments. It can be easy to mistake damage or injury to these ligaments as a disc disorder, especially if the MRI reveals degenerative disc disease.
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 (3) 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.
A June 2022 paper (4) examined facet capsular ligament function. Based on their analysis of the ligament tissue and previous tests on isolated lumbar facet capsular ligaments, they concluded that the normal state of the facet capsular ligament is in tension, and that the collagen in the ligament is likely uncrimped even when the spine is not loaded. (The ligament is always taut, under pressure, susceptible to strain).
Muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population
In our own published peer-review research appearing in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018, (5) 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 told its surgeon members that muscle strains, ligament sprains, and muscle contusions account for up to 97% of low back pain in the adult population (6)
- Additionally, researchers wrote in the Spine Journal that spinal ligaments are often neglected compared to other pathology that account for low back pain (7). 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.
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.”
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.”(8). In other words, very few doctors are looking for a back sprain as cause of chronic low back pain.
Lumbar radiculopathy or spinal ligament sprain?
Radicular pain or “radiculopathy” (sometimes also referred to as a “pinched nerve”) is often described by patients as a deep pain that travels down the leg. This pain is often accompanied by numbness or tingling, and muscle weakness in the limb.
The most common example of this type of problem is sciatica. This pain radiates down the leg along the sciatic nerve. Sciatica follows the path down the back of the thigh, into the calf and then into the foot via branches of the nerve.
Radicular pain may be caused by an injury to the spine. It may be from impact injuries that cause compression in the vertebrae, such as those in sports related injuries or motor vehicle accidents, i.e., disc herniation. Or it may be caused by a degenerative process discussed above such as stenosis or Degenerative Disc Disease. It is essential to perform a physical examination in cases of referred pain to isolate the problem.
A ligament injury that appears to be a nerve impingement
It may actually be a ligament injury that appears to be a nerve impingement and ligament trigger points may refer pain in a manner similar to radiculopathy.
This is why relying on an MRI as the sole diagnostic tool could lead to unnecessary surgery. An MRI may show a pre-existing condition that never caused pain. If surgery was performed to correct this condition and pain was actually generated by a ligament sprain, the surgery would fail.
A physical examination and conservative treatment will help determine if this is a ligament injury or a nerve problem.
It is important for the patient to know in cases of radiating pain that an MRI that indicates slippage of the vertebrae (Spondylolisthesis), an arthritic condition, or a bulging disc is NOT necessarily an indication that surgery is needed.
Regenerative non-surgical 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 bone marrow derived stem cells are injected directly into the disc. This is not always the case. These treatments may work 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 (9) 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.
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.”(10)
In our research, Treatment of Chronic Low Back Pain with Platelet-Rich Plasma Injections, published in the journal Cogent Medicine (11) 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
PRP on the iliolumbar ligament
A December 2020 study (12) “Ultrasound-guided diagnostic and therapeutic interventions using local anesthetic and PRP, respectively, were found to result in a specific diagnosis and remarkable recovery in the iliolumbar syndrome group of patients with nonspecific low back pain.” Out of 45 patients treated, 42 showed significant improvement – Visual Analogue Scale (1-10 score 10 being worst) score of less than 3 (mild pain). Many patient in the study showed a score of 8 or very severe pain at the initiation of treatment.
It has been suggested that a majority of lower back pain problems can be traced to problems of the ligaments. Why then aren’t most therapies geared to treating the ligaments? Because many physicians do not believe that the ligaments can be successfully treated. Why? Because ligaments have very poor circulation and therefore do not have the ability to heal. This is taught in basic anatomy. Muscles are big, red, and powerful because they are filled with blood. Ligaments and tendons are small and white because there is no blood in them. Research above has demonstrated elsewise.
Use the form below to ask Dr. Darrow a question about your low back pain
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 Middendorf JM, Budrow CJ, Ellingson AM, Barocas VH. The Lumbar Facet Capsular Ligament Becomes More Anisotropic and the Fibers Become Stiffer with Intervertebral Disc and Facet Joint Degeneration. Journal of biomechanical engineering. 2023 May 1;145(5):051004.
3 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.
4 Gacek E, Ellingson AM, Barocas VH. In situ lumbar facet capsular ligament strains due to joint pressure and residual strain. Journal of biomechanical engineering. 2022 Jun 1;144(6):061007.
5 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/
6 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
7 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]
8 Nayak BK, Singh DK, Kumar N, Jaiswal B. Recovering from nonspecific low back pain despair: Ultrasound-guided intervention in iliolumbar syndrome. Indian Journal of Radiology and Imaging. 2020 Oct;30(04):448-52. [Google Scholar]
9 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.
10 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
11 Darrow M, Shaw B, Nicholas S, Li X, Boeger G. Treatment of unresolved lower back pain with platelet-rich plasma injections. Cogent Medicine. 2019 Jan 1;6(1):1581449.
12 Nayak BK, Singh DK, Kumar N, Jaiswal B. Recovering from nonspecific low back pain despair: Ultrasound-guided intervention in iliolumbar syndrome. Indian Journal of Radiology and Imaging. 2020 Oct;30(04):448-52.