Avoiding back pain surgery – alternative treatment and therapies for back pain

Marc Darrow, MD, JD.

Many times I will see a patient in my office who has been recommended to some type of spinal surgery to relieve back pain. This person has tried many treatments and remedies to avoid the need for surgery, mostly conservative care measures that have not helped that failed them to reduce back pain. I see these people, in many cases, as the last chance, in their thinking, for a non-surgical option to finally treat back pain that has plagued them for years.

There are many options to explore when seeking treatment for your back pain. Most people I see have tried the majority if not all of these standard chronic back pain treatments.

Treating back pain with medications:

For most, medication use started on their own with over the counter Non-steroidal anti-inflammatory drugs (NSAIDs) therapy. As pain worsened and this person had to seek medical care, the pain medications increased to possibly include:

  • Painkillers including opioids.
  • COX-2 Inhibitors (Non-steroidal anti-inflammatory drugs).
  • Muscle relaxants therapy.
  • Anti-seizure medications.
  • Anti-Depressants therapy

A paper from 2018 (3) revealed something you may already know. Patients are for the most part dissatisfied with their back pain management when the primary treatment is pharmacology. These people do not want to be treated with medicine, they are looking for alternative therapies for healing their body. This is what the authors of the paper wrote: “Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of low back pain, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy.”

Exercise, Yoga and Physical Therapy

Many people can find success with Exercise, Yoga and Physical Therapy as treatment options for chronic back pain. Many do not. Why? Many people I see are athletes who are very familiar with the importance of building the core muscles for body posture. Despite this knowledge and an understanding of the need to exercise, they are here visiting me with constant lower and mid-back spasms and a radiating dull pain.

Physical therapy is a treatment that works by strengthening muscle and retraining muscles to be more effective. To do this physical therapy requires the muscle to get stronger through resistance training. If the tendon attachment to the bone is weak and stretched out, the necessary resistance will be very difficult to achieve. Our treatments help to strengthen this attachment and are explained below.

This is not to say yoga is not an effective treatment.  A January 2022 paper (1) investigated the effect of a stretch and strength-based yoga exercise program on neuropathic pain due to lumbar disc herniation. Here is the author’s opinion: ” lumbar disc herniation with neuropathic pain influences treatment outcomes negatively. Most yoga poses include the parameters of spinal training and help reduce pain and disability in patients with low back injuries. We hypothesized that yoga positively affects both lumbar disc herniation and neuropathic pain by increasing mobilization, core muscle strength, and spinal and hamstring flexibility.”

The patients in this study were taught yoga for 1 hour twice weekly for 12 weeks. Neuropathic pain, low back pain, disability, and function were measured blind before and at the 1-, 3-, and 6-month follow-ups. The “analysis showed a statistically significant difference in neuropathic pain, patient global assessment, low back pain, disability, and function in favor of the yoga group at post-treatment. The between-group effect sizes were moderate at 6-months follow-up. It was determined that the selected stretch and strength-based yoga exercise could be a promising treatment option for neuropathic pain due to low back pain.” For some this can be a helpful treatment. Yoga can help with stress and sleep. For others advancements in pain relief can be made, but as I will discuss below, those advancements can be lost as spinal ligaments and tendons continue to weaken and any gains in posture and pain relief can be lost.

MRI Is Sending People to Back Surgery Who Don’t Need It

Avoiding back pain surgery There is thinking in the medical community that if you want to avoid a back surgery, do not get an MRI. This is not a new thought, the controversies surrounding MRI interpretation sending people to a back surgery that they did not need has been going on for years. BUT, the patients think they need back pain surgery to get back pain relief.

All too frequently, a medical study comes across my desk that says patients are too often choosing to have elective orthopedic surgery to manage back pain. In a recent paper, doctors found that more than 50% of the patients would have a spinal surgery for their chronic back pain if their doctor told them they had an abnormal spinal MRI, even if they had no pain or restricted movement. The authors surmised that patients overemphasize the value of MRIs and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. (2)

In the 2018 paper (3)  I cited above about the concerns regarding pharmacotherapy, the authors also noted that “Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of low back pain in order to improve patient outcomes.” The patients in this study thought that the MRI was necessary to obtain true diagnosis and the proper treatment path.

A paper looked at the papers that spinal surgeons and specialist were accessing – the top paper was about magnetic resonance imaging (MRI) findings in individuals without back pain

In 2015, Doctors analyzed the most frequently cited papers in lumbar spine surgery and measured their impact on the entire lumbar spine literature. Here is what they found: The most cited paper was “the classic paper” from 1990 that described magnetic resonance imaging (MRI) findings in individuals without back pain, sciatica, and neurogenic claudication (impairment), showing that spinal stenosis and herniated discs can be incidentally found when scanning patients. (4)

In 2020, doctors again analyzed the most frequently cited papers in lumbar spine surgery and measured their impact on the entire lumbar spine literature. Here is what they found: The most cited paper was “the classic paper” from 1990 that described magnetic resonance imaging (MRI) findings in individuals without back pain, sciatica, and neurogenic claudication (impairment), showing that spinal stenosis and herniated discs can be incidentally found when scanning patients. (5)

The word “incidental” meant that the patient had no pain. The purpose of the paper was to examine why people with no back pain show abnormalities on MRI. More than a quarter of a century later, doctors are still citing the paper and asking the same question: “Why does this patient have clear problems on MRI but no back pain?” And the secondary question: “Should we send this patient to surgery?”

The second most cited (and far more recent) study similarly showed that patients who had no symptoms of back pain who underwent lumbar spine magnetic resonance imaging frequently had lumbar degeneration and disease.(6) The two most cited research papers in relationship to spinal surgery are studies on why patients had absolute and clear spinal problems on MRI and yet showed no signs of pain or expressed any problems.(7)

I often see patients who have severe back pain and show me an MRI, X-ray, and/or scan that was inconclusive.

I often see patients who have severe and chronic back pain and show me an MRI, X-ray, and/or scan that was inconclusive. For instance, a patient can have muscle spasm from a simple back strain, which can cause excruciating pain and may limit the ability to walk or even stand. Conversely, a large herniated disc may be completely painless. Yet the patient with the large herniated disc may be sent to surgery. Why do we see so many failed back surgery patients? Because lower back pain is one of the most difficult complaints to accurately diagnose and treat. The reason for the insurance diagnosis code of “Failed Back Surgery Syndrome” is that so many back surgeries fail.

As the research above has shown, magnetic resonance imaging (MRI) for back pain remains controversial because a considerable proportion of patients may be classified incorrectly by MRI for lumbar disc herniation and spinal stenosis.

Not only that, but doctors writing in the European Journal of Pain reported that while the importance of MRI findings remains controversial, best evidence does not support the use of any prognostic test in clinical practice in selecting patients for lumbar spinal fusion.

This supports recent findings that despite doctors frequently requesting MRIs for the lumbar spine, the imaging performs poorly and is not likely to identify the anatomical structures that are the
source of pain.(8) This is why a physical examination, not an MRI, is the main diagnostic tool I employ. While MRI is used as an ancillary confirmation, it is most often wrong when used solely on its own as a diagnostic tool.(9)

Recently, doctors in Canada found that more than half of lower-back MRIs ordered at two Canadian hospitals were either inappropriate or of questionable value for patients. And family doctors were more likely to order these unnecessary tests compared to other specialists. The findings are important, because in some parts of Canada, MRI tests for the lower back account for about
one-third of all MRI requests. Across the country, wait times for MRIs are long, and patient access is limited.(10)

From another study from the University of Connecticut Health Center: “More than 85% of patients seen at primary care practices have low back pain that cannot be attributed to a specific disease
or an anatomic abnormality, and it is well known that imaging of asymptomatic patients often reveals anatomic abnormalities, such as herniated discs. One of the risks of routinely imaging uncomplicated acute low back pain is patient ‘labeling’; no evidence exists that labeling patients with low back pain with a specific anatomic diagnosis improves outcomes.”(11)

This evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in patients with nonspecific, acute or subacute lower back pain with no indications of underlying serious conditions. Specific consideration of patient expectations about the value of imaging was not addressed here; however, this aspect must be considered to avoid unnecessary MRI imaging while also meeting patient expectations and increasing patient satisfaction.”(12) In another recent paper, researchers concluded that at present, best evidence does not support the use of any prognostic test in clinical practice in selecting patients for lumbar spinal fusion.(13)

MRI reports can catastrophize the patient’s back pain. Doctors are told to stop using potential catastrophizing terminologies

In July 2021 a study (14) suggested that when patients are given their MRI results, they can have catastrophic effect on the patient. According to this paper, it is a problem with the doctor’s “bedside manner.”

“Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain. (The researchers) probed the potential effects of a routine MRI report on the patient’s perception of his spine and functional outcome of treatment.”

How to deliver an MRI report to the patient:

Two groups of low back pain patients. One group (Group A) had their MRI read to them as you would get any MRI report. The second group (Group B) had their MRI report explained to them minimizing terminology that would concern the patient and all the while reassuring the patient that the MRI interpretation were normal of aging and degenerative changes.

  • Results: “Both groups were comparable initial by demographics and pain. After 6 weeks of treatment, Group A had a more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status. The alternate method of clinical reporting (Group B who had their MRI explained in more reassuring terms) had significant benefits in assessment of lesser severity of the disease, shift to lesser severity of intervention and surgery.”

Conclusion: “Routine MRI reports produce a negative perception and poor functional outcomes in low back pain. Focused clinical reporting had significant benefits, which calls for the need for ‘clinical reporting’ rather than ‘Image reporting’.”

But MRI Is Suggesting Fusion Surgery for Sacroiliac Joint Dysfunction—Shouldn’t I Get the Surgery?

In one research paper, doctors concluded that sacroiliac joint spinal fusion for the management of chronic lower back pain is “murky,” and that the consequences of the unsupported enthusiasm for surgical management of disc-related back pain negatively impacts the public perception of spinal surgeons.(15)

There is a further double jeopardy for patients—new research questions whether or not MRI has any value in determining sciatica treatment or diagnosis.(16) We now have a possibly misleading MRI sending a patient for a procedure that may not work, causing the patient more problems.

As noted in the above recent study, researchers have shown that diagnosis of sacroiliac joint dysfunction is flawed.(17, 18) This misdiagnosis is why doctors say that the sacroiliac joint spinal fusion for the management of chronic lower back pain is “murky” and can lead to Failed Back Surgery Syndrome.

One of my patients is a woman in her early seventies. She presented with her husband after not one, but two sacral fusions, one on the right and one on the left. You might be appalled if you saw the amount of metal that was used to do the fusion. Huge screws, too. Because of continued pain on the left side, her surgeon wanted her to redo the left fusion. She came to me for advice. During examination, I pressed on her gluteus muscles, away from the fusion site and she winced in pain. I immediately told her that her pain was not coming from the sacroiliac joint, and that she simply
had a strain where the muscles were attached to the pelvis. I asked her if the surgeon actually examined this area and to my astonishment, her answer was, “no.” She and her husband looked like deer in headlights, confused as to what I was telling them. How could her pain not be related to the joint, and the subsequent fusion, when she had surgery for that issue. I told them I was sorry, but the surgery never needed to be done if this is where the pain had been. It took about a half hour for them to digest this information, and we proceeded to inject PRP though the muscles down to the bone interface. We call that the enthesis. She returned two weeks later, and was about 50% better. I injected again, and expect full recovery with one more series of injections.

This is the most common scenario in my office. Not necessarily the same area, but almost all areas of the body. Please remember, elective surgery means you, the patient, get to elect whether or not to proceed to surgery. It is your body. You own it. You decide, not the doctor. Alternative treatments and alternative therapies are available.

If It Isn’t the Discs, Then What Is Causing Your Back Pain?

You have a sudden pain in your lower back area. A few days goes by and finally the pain has become sufficient enough to warrant a trip to your doctor. Many people think that chronic back pain can only come from discs. There are many structures in the low back that can cause severe pain. These include muscles, ligaments, tendons, bones, joints and discs. The outer rim of the disc can be a source of significant back pain due to its rich nerve supply and tendency towards injury.

Many people walk around every day with herniated or bulging discs. They suffer no pain because not every disc problem generates pain. But if an MRI is performed and these herniated discs are seen as the “probable” cause of the problem you have all the makings for a failed back surgery. A surgery is being performed based on an improper diagnosis.

So what is causing the pain? It is estimated that 70% of lower back pain is caused by ligament injury. In our chronic pain and sports injury clinic in Los Angeles, we would estimate this number to be even higher. Usually when a patient comes in with complaints of lower back pain, I physically examine and palipate the area above the pelvis, where the iliolumbar ligament is. This is the ligament that attaches the spine to the pelvis. If that area is sore, we can be confident that we can help this patient.

Back pain can be divided into three large classifications.

Back pain can be divided into three large classifications. The most common condition is known as axial, or mechanical back pain. It is estimated that 90% of low back pain is of this nature and stems from soft tissue sprains and strains and disc herniation from lifting, bending, or wear and tear.

This pain can run the gamut from a very sharp to a dull ache. It may occur all the time, or it may come and go. It also varies in intensity from very mild to extremely severe. One patient may report that his/ her lower back is only sore when having been seated for a long time, or after working in the garden. Another patient may report severe, debilitating pain and need assistance to walk or stand, or even to get up from a sitting position. While one patient is perfectly straight, the other is bent over and locked in a crooked posture. The one thing that is common in these conditions is that the pain is restricted to the lower back area.

This most common type of problem, mechanical back pain, is completely non-specific with regards to the injured structure or structures. Generally, the pain gets worse with certain activities or positions. It is usually relieved by rest or changing positions. Note, extended bed rest may aggravate this type of problem.

This condition responds extremely well to conservative care. At times, spinal manipulation alone is the “miracle” affording immediate relief. More often, the injury involves more than just a misalignment of a vertebrae or of your pelvis. nerves, muscles, tendons, ligaments and skin can all have an influence on the degree of discomfort. And each of these may need to be addressed to attain relief.

If you have multiple episodes of this type of pain, you will want to engage yourself in a rehabilitation program to help resolve the underlying causes of the problem. Here, the diagnosis goes farther than just finding out what is causing the pain, but additionally centers on what weakness or restriction you have that ultimately causes you to have an episode. Here again, we function much like a “coach”, finding the cause(s) and helping to direct you towards ways of avoiding and limiting future bouts with pain.

The most common type of back pain is known as referred pain.

The most common type of back pain is known as referred pain. Here, patients complain of having an achy, dull type of pain that seems to move around. The discomfort comes and goes and varies in intensity. This achy pain starts in the low back area and commonly spreads into the groin, buttocks and upper thighs.

The treatment options here are similar to those used in treating axial pain. Diagnostic and therapeutic measures are aimed at correcting abnormalities in the muscles, ligaments and small joints of the spine.

The last type of back pain is known as radicular pain. In this case, the pain is described as deep and usually constant. It follows the nerve down the leg and is often accompanied by numbness or tingling and muscle weakness.

The most common example of this type of problem is the sciatic pain that radiates along that sciatic nerve – down the back of the thigh and calf into the foot. This type of pain is caused by injury to a spinal nerve. Some of the possible causes of this are a disc protrusion or bulge, arthritic changes or a narrowing of the opening through which the nerve exits.

While a few of these cases will require surgery, most respond to conservative care. Here the care will consist of multiple therapies, all designed to reduce inflammation, balance your posture, strengthen supporting structures, attain normal motion and improve the health of the nerve that is involved.

In all types of back pain, your health habits play an important role. For example, there are certain foods that are high in the fats that cause more inflammation. Limiting intake of these animal fats and increasing your intake of the good fats that reduce inflammation may play an important role in your healing. Smoking is another health concern. Statistically, smokers are slow healers with respect to back pain.

An important part in prevention is keeping these back muscles active and in good tone.

One of the most important areas in chronic back pain management is the strength of your abdominal wall and your pelvic floor. There are three major abdominal muscles, each with small subdivisions. Any weakness in one of these sections can be the root cause of a chronic back problem. Weakness in these structures causes your back muscles to tighten and shorten. This adversely affects the lower back on the small joints and discs.

So was does the disc get so much attention? Because the disc can be easily seen on MRIs and ligament and tendon strains cannot.

A recent study in the medical journal Pain Medicine questions the prevailing thought that discs are a major culprit in back issues. The researchers wrote: “Between 26% and 42% of chronic low back pain is attributed to internal disc disruption of lumbar intervertebral discs (i.e., a disc problem in the lower back). These prevalence estimates and data characterizing discogenic pain originate largely from research conducted 20 years ago. With few studies since, their concordance with rates in community practice has rarely been addressed.”

The researchers had some doubts about these numbers. In conducting their own tests, they found that discogenic pain was not as prevalent but was still within the confidence intervals previously
reported (meaning in the ballpark), owing to the fact that they discovered discs as being responsible for pain 21% of the time.(19)

If this is the case, then it can be said that something else is causing your back pain 79% of the time. As we have discussed, one of the great challenges in treating back pain is identifying the source of the patient’s pain. As I indicated above, the majority of patients believe that the source of their pain has been identified by their MRI. However, in many patients the picture of disc degeneration is not an accurate profile of the cause of pain. Most often, I find that it is the spinal ligaments that are involved—in other words, the pain is being caused by a simple “sprain.” I ask patients whether they have ever had a sprained ankle. Most say yes, and that it hurt quite a bit. I then tell them that they have the equivalent of a sprained “ankle” in their back, and nothing more, regardless of what the MRI or other films show. Do people get surgery for a sprained ankle? Of course not!! This is not to say that surgery may be needed for a tendon or ligament rupture, or fracture.

This is difficult for people to understand, because they see their MRI with an apparently “obvious” abnormality that requires surgical intervention from their chronic back pain. However, once they have had a physical examination and are shown where the chronic back pain is being generated, patients come to understand that their back pain may be based on ligament irritation at the point where the ligaments attach to bone (enthesopathy). A treatment plan with realistic expectations can then be discussed using regenerative medicine injections.

Conservative care, many patients can avoid surgery

Fusion for Lumbar Stenosis

A May 2022 study (22) followed a group of patients diagnosed with lumbar spinal stenosis. Some of the patients had surgery, some avoided surgery. The two groups were observed for three years.  In the group of patients that did not have surgery the researchers reported that: “approximately one-third of patients reported improvement, approximately 50% reported no change in symptoms, and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse.”

Spinal injections therapy- Platelet Rich Plasma Therapy, Cortisone, Epidural and Transforaminal steroid injection, Bone Marrow Aspirate, Prolotherapy and Botox

Platelet Rich Plasma Therapy or more commonly referred to as PRP treatments are injections given into the area of spine to strengthen the spinal ligament attachments and help restore stability and prevent the vertebrae or the bones from slipping out of place causing herniated discs. The treatments are made from healing and growth factors found in your blood. These healing and growth factors are collected from a standard blood draw in the arm. The collected platelets are then concentrated and injected into the injured area of the back to stimulate healing and regeneration to the soft tissue structures that stabilize the spine. We do not inject into the spinal canal or directly into the discs with this therapy.

Orthopedics alternative treatments

Injecting directly into the disc was discussed in a 2019 paper (20) suggesting this treatment as a possible future therapy  once more studies were assessed. The researchers wrote: “PRP has great potential to stimulate cell proliferation and metabolic activity of IVD cells in a laboratory setting. Several animal studies have shown that the injection of PRP into degenerated IVDs is effective in restoring structural changes (IVD height) and improving the matrix integrity of degenerated IVDs as evaluated by magnetic resonance imaging (MRI) and histology. The results of this basic research have shown the great possibility that PRP has significant biological effects for tissue repair to counteract IVD degeneration. Clinical studies for evaluating the effects of the alternative treatments injection of PRP into degenerated IVDs for patients with discogenic LBP have been reviewed. Although there was only one double-blind randomized controlled trial, all the studies reported that PRP was safe and effective in reducing back pain. While the clinical evidence of tissue repair of IVDs by PRP treatment is currently lacking, there is a great possibility that the application of PRP has the potential to lead to a feasible intradiscal therapy for the treatment of degenerative disc diseases. Further large-scale studies may be required to confirm the clinical evidence of PRP for the treatment of discogenic LBP.”

Research has shown PRP to be effective in healing and treating degenerative disc disease (DDD) by addressing the problems of spinal ligament instability and by stimulating the regeneration of the discs indirectly (although discs were not directly injected, they showed an increase in disc height).(21)

Research showed that PRP therapy is able to recover the mechanical properties of denatured (worn-down) discs, thereby providing a promising effective therapeutic modality.(22) Although I don’t typically consider Degenerative disc disease to be a major player in neck or back pain, I do treat these areas daily. From my exam, it is typically not the discs that are the issue, but the ligaments at their connection to bone that cause the pain. This is called an enthesopathy. And typically, it is easy to heal with PRP. Please be very careful to not have surgery for areas that can heal with PRP. As you will read, areas in MRIs that show anatomical issues, may not be the pain generator.

In 2019 we published our study on the effectiveness of PRP treatments for the patient for chronic low back pain. The study appears in the journal Cogent Medicine.(23)

This research gives an insight into what level of treatment success we can have with certain back pain conditions and how many PRP treatments the patient should expect towards achieving their treatment goals.

Let’s get to our study:

In our research, Treatment of Chronic Low Back Pain with Platelet-Rich Plasma Injections, we wrote:

  • 67 patients underwent a treatment of one, two, or three PRP injections into the ligaments, muscle, and fascia surrounding the lumbar spine.
  • Patients who received two treatments received injections an average 24 days apart and patients who received three treatments received injections an average 20.5 days apart.
  • Baseline and post-treatment outcomes of resting pain, active pain, lower functionality scale, and overall improvement percentage were compared to baseline and between groups.

Results:

  • 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.

Transforaminal steroid injections are injected into the spine in the space between the spinal cord and the vertebrae. This treatment is designed as an anti-inflammatory measure to reduce pressure on the nerves that may come from inflammation from a herniated disc or spinal instability. Many doctors do not believe this is the best treatment option for patients with long standing back pain as will be demonstrated in the research below.

A June 2021 study (24) compered PRP injections to Transforaminal steroid injection. Here are the results: “Transforaminal steroid injection is extensively used as a treatment in cases of herniated disc, but it is associated with complications. In comparison, platelet-rich plasma (PRP) injection has been used in musculoskeletal disorders and could be another option . . . (for) patients who suffer from radicular pain due to lumbar disc herniation.” In this study the researchers substituted PRP for steroid, administered the injection in the same way and recorded that the PRP provided similar results. The authors concluded: “The results showed similar outcome for both transforaminal injections using PRP and steroid in the treatment of lumbar disc herniation, suggesting the possible application of PRP injection as a safer alternative.”

Medicine is showing that PRP can be among effective alternative therapies.

References for this article

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21 Gullung GB, 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.
22 Khalaf K, Nikkhoo M, Ya-Wen Kuo, Yu-Chun Hsu, Parnianpour M, Campbell-Kyureghyan N, Haghpanahi M, Jaw-Lin Wang. Recovering the mechanical properties of denatured intervertebral discs through Platelet-Rich Plasma therapy. Conf Proc IEEE Eng Med Biol Soc. 2015 Aug; 933-6. doi: 10.1109/EMBC.2015.7318516.
20 Xu Z, Wu S, Li X, Liu C, Fan S, Ma C. Ultrasound-Guided Transforaminal Injections of Platelet-Rich Plasma Compared with Steroid in Lumbar Disc Herniation: A Prospective, Randomized, Controlled Study. Neural Plasticity. 2021 May 27;2021.
21 Marc Darrow, Brent Shaw, Schmidt Nicholas, Xian Li & Gabby Boeger. Tsai-Ching Hsu (Reviewing editor:) (2019) Treatment of unresolved lower back pain with platelet-rich plasma injections, Cogent Medicine, DOI: 10.1080/2331205X.2019.1581449
22 Katz JN, Zimmerman ZE, Mass H, Makhni MC. Diagnosis and Management of Lumbar Spinal Stenosis: A Review. JAMA. 2022 May 3;327(17):1688-99.

 

 

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