In this article, Dr.Speciale updates information based on new research that the common problems of low back pain and sacroiliac (SI joint) pain can be treated successfully with injections of Prolotherapy, Platelet Rich Plasma Therapy, and Stem Cell Therapy. These treatments can be effective even in patients who had pain for decades and help them avoid unnecessary spinal surgery.
Why are doctors rushing to send their patients to spinal fusion surgery?
The diagnosis of Sacroiliac joint dysfunction and/or Sacroiliac joint (SI) pain is difficult. There is no consensus in the medical community based on recent research that can quantify the amount of pain sacroiliac joint dysfunction causes or the determination if that pain is in fact coming from the sacroiliac joint. If this sounds confusing listen to what researchers have to say:
In new research, doctors say to diagnose sacroiliac joint dysfunction as the cause of pain, you need to be able to treat and alleviate that pain. It sounds obvious but … “The degree of pain relief required to diagnose sacroiliac joint dysfunction following a diagnostic SIJ block (SIJB) is not known. No gold standard exists. . . “
Now why is the nerve block being given? If the doctors can prove that the pain is coming from sacroiliac joint – then they can proceed with surgery! This next part is unbelievable.
The research patients were given nerve block, but it could not predict if the source of pain was identified and whether or not surgical fusion would be beneficial.
These disappointing results of diagnosis by alleviating pain lead these researchers to conclude that “Using overly stringent selection criteria (the use of diagnostic steroid injection) to qualify patients for SIJF (Spinal Fusion) has no basis in evidence and would withhold a beneficial procedure from a substantial number of patients with SIJ dysfunction.” 1
Recommendation: Patients should get spinal fusion surgery even without clear evidence to suggest it would work. Please see Dr. Hauser’s article Failed Back Surgery Syndrome.
Yet, based on evidence like that above – Sacroiliac joint fusion surgery is becoming an increasingly popular treatment alternative for Sacroiliac joint dysfunction.2
Spinal surgery causes sacroiliac joint-related pain
Does surgery CREATE sacroiliac joint-related pain?
Doctors in Germany examined a potential connection between lumbar decompressive surgery and new onset of sacroiliac joint-related pain causing a diagnosis of “failed-back-surgery.”
Here is what they said in their published research:
Patients with lumbar stenosis do have substantially positive results from decompressive surgery. HOWEVER the change of body position and walking behavior after successful surgery might lead to changed force effects on the entire spine and on the sacroiliac joint. in the future.
In other words, lumbar decompression surgery changed the patient’s natural movement to one that irritated the and caused SIJ-related pain after surgery.
The doctors concluded that “Lumbar decompression patients should be informed about this possible condition to avoid uncertainty, discontent, unnecessary diagnostics and to induce a quick, specific treatment.” In other words a diagnosis of a “failed-back-surgery.”3
Did your spinal operation create a new pain condition?
Sacroiliac joint inflammation
- A patient suffering from Sacroiliac joint dysfunction symptoms may have pain from inflammation, sacroiliitis. Sacroiliitis is one cause of the broad picture of sacroiliac joint dysfunction degeneration.
Sacroiliac joint inflammation is a difficult to determine diagnosis as it may come from an infectious disease or be caused by a rheumatology disorder. For many patients inflammation of the sacroiliac joint is NOT caused by infectious disease but by chronic degenerative inflammation including ankylosing spondylitis. In some causes a rheumatologist will be consulted.
Sacroiliitis pain and symptoms include pain on one side of the lower back (unilateral sacroiliitis – one of the SI joints is inflamed) or both sides (bilateral sacroiliitis, both SI joints are inflamed).
Sacroiliitis can be brought on by wear and tear osteoarthritis, by impact or acute traumatic injury, pregnancy causing wear and tear and SI instability and as mentioned, the rare case infection.
The first thing the doctor may offer you is anti-inflammatory medications, a sacral belt (low spine support brace), and a recommendation to change your activities and/or lifestyle to avoid more stress on the sacroiliac joint.
However this approach may not be addressing the problems that weakened or damaged spinal ligaments are the cause of sacroiliac joint instability. This will be addressed below.
Making the case for treating spinal ligaments
Doctors writing in the European Spine Journal, said that referred pain from the sacroiliac joint can be isolated to the anterior ligament sacroiliac joint region, and that by treating the ligaments pain can be alleviated. 4
This clearly presents a solution in sacroiliac joint pain treatment where doctors say a solution does not exist. Recently, published research in the medical journal Pain Physician said:
- Doctors generally accept that approximately 10% to 25% of patients with persistent low back pain may have pain arising from the sacroiliac joints. Despite understanding this there are currently no definite conservative, interventional, or surgical management options for managing sacroiliac joint pain.5 To jump back to the top of this article for a moment – this is when new research suggests a spinal fusion, did this research from 2012 agree?
Here is their findings:They found that the evidence for:
- cooled radio frequency neurotomy in managing sacroiliac joint pain is fair.
- The evidence for effectiveness of intraarticular steroid injections is poor.
- The evidence for periarticular injections of local anesthetic and steroid or botulinum toxin is poor.
- The evidence for effectiveness of conventional radiofrequency neurotomy is poor.
- The evidence for pulsed radio frequency is poor.
- A lot of poor results.
But you can offer poor results more often!
Recently doctors said that image-guided injections of the epidural space and of the sacroiliac joints are effective techniques for the treatment of pain; their effectiveness is sometimes not lasting for long periods of time, but considering the low associated risk when performed by trained personnel, they can be easily repeated.6
Treating the ligaments in sacroiliac joint dysfunction
Ligaments are bands of fibrous tissue that connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis. The sacrum is the part of the spine below the fifth and last lumbar vertebrae and above the coccyx. The uppermost portion of our pelvis is called the ilium. The area that connects these structures is the sacroiliac joint (SI): sacro from the sacrum, iliac from the ilium.
There is an expansive mesh of ligaments that make up this sacroiliac joint which is frequently injured. The function of the SI ligaments and the ligaments of the spine is to provide stability to these bones while allowing normal motion to occur. The hub of many people’s back or pelvic pain is one of both SI joints. A problem here can affect the groin, pubis, hips and lower lumbar areas as well.
Returning to the opening of this article – the diagnosis of sacroiliac (SI) pain is tricky. Here is another new paper – listen to what it says: Although the prevalence of sacroiliac joint pain is relatively high there is no unambiguous reference standard to diagnose sacroiliac joint pain pain. Pressure tenderness (palpitation) in the sacroiliac joint pain region is used for diagnostic purposes and it appears to be a reliable method.7
You mean a physical examination? The prefered diagnostic method of a skilled Prolotherapist has always been palpitation – gently press down with your thumb to reproduce pain. “X” then makes that spot. See our article on the Accuracy of MRI for assessing treatment.
As far back as 2009, Caring Medical has published research on outcome results in patients receiving Prolotherapy for low back pain. Here is what was reported on findings of 145 patients with unresolved lower back pain in the Journal of Prolotherapy:
- One hundred forty-five patients, who had been in pain an average of four years and ten months, were treated quarterly with Prolotherapy.
- This included 55 patients who were told that there were no other treatment options for their pain and 26 patients who were told by their doctor(s) that surgery was their only option.
In these 145 low backs:
- pain levels decreased after Prolotherapy; 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability;
- 75% percent were able to completely stop taking pain medications.
The decrease in pain reached statistical significance for the 145 low backs, including the subset of patients who were told there was no other treatment options for their pain and those who were told surgery was their only treatment option.8
- Research appearing in the Journal of Alternative and Complementary Medicine stated that “Prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections”9
Prolotherapy Injections a non-surgical alternative for SI pain
Prolotherapy is an injection treatment that stimulates the repair of connective tissues such as tendons and ligaments. It causes a mild inflammatory response which initiates an immune response. This mimics what the body does naturally to heal soft tissue injuries.
We have found that it is fairly rare for people’s SI/back pain to be caused by a pinched nerve or by a slipped or herniated disc. Much more common is a ligament injury which caused ligament laxity or ‘looseness.’
In the scholarly journal Spine, a 1995 article written by A. Schwarzer wrote:
- “ligament laxity in the sacroiliac joint is the number one reason for ‘Sciatica’, or pain radiating down the side of the leg, and is one of the most common reasons for chronic low back pain.”10
Our clinical experience has been that if we treat back pain with Prolotherapy, administering injections into the lumbar and SI ligament attachments that exhibit tenderness, the pain and referred pain diminishes, even when MRI’s showed disc abnormalities. The injections are not given near the discs yet the back pain is completely healed.
Platelet Rich Plasma and Prolotherapy Injections a non-surgical alternative for SI pain and long-term results
Recent research says that “Despite widespread use of steroids to treat sacroiliac joint pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.”
In this research, Forty patients with chronic low back pain diagnosed as sacroiliac joint pain were divided into 2 groups, steroid group and PRP group.
- Intensity of pain was significantly lower in the PRP group 6 weeks after treatment as compared to the steroid group.
- The efficacy of steroid injection was reduced to 25% at 3 months while it was 90% in the PRP group.
- A strong association was observed in patients receiving PRP and showing a reduction in pain scores. The researchers concluded: The intra-articular PRP injection is an effective treatment modality in low back pain involving sacroiliac joint pain.”11
Doctors at the University of Toronto have published four case studies investigating the long-term benefit of platelet-rich plasma (PRP) injections reducing SI joint pain, improving quality of life, and maintaining a clinical effect.
At follow-up 12-months post-treatment, pooled data from all patients reported a marked improvement in joint stability, a statistically significant reduction in pain, and improvement in quality of life.
The clinical benefits of PRP were still significant at 4-years post-treatment. Platelet-rich plasma therapy exhibits clinical usefulness in both pain reduction and for functional improvement in patients with chronic SI joint pain. The improvement in joint stability and low back pain was maintained at 1- and 4-years post-treatment.12
1 Polly D, Cher D, Whang PG, Frank C, Sembrano J; INSITE Study Group. Does Level of Response to SI Joint Block Predict Response to SI Joint Fusion? Int J Spine Surg. 2016 Jan 21;10:4. doi: 10.14444/3004. eCollection 2016.
2 Carlson SW, Magee S, Carlson WO. An algorithm for the evaluation and treatment of sacroiliac joint dysfunction. S D Med. 2014 Nov;67(11):445-9, 451.
3. Schomacher M, Kunhardt O, Koeppen D, Moskopp D, Kienapfel H, Kroppenstedt S, Cabraja M. Transient sacroiliac joint-related pain is a common problem following lumbar decompressive surgery without instrumentation. Clin Neurol Neurosurg. 2015 Sep 11;139:81-85. doi: 10.1016/j.clineuro.2015.09.007. [Epub ahead of print]
4 Kurosawa D, Murakami E, Aizawa T. Referred pain location depends on the affected section of the sacroiliac joint. Eur Spine J. 2014 Oct 5. [Epub ahead of print]
5. Hansen H, Manchikanti L, Simopoulos TT, et al. A systematic evaluation of the therapeutic effectiveness of sacroiliac joint interventions. Pain Physician. 2012 May;15(3):E247-78.
6. D’Orazio F, Gregori LM, Gallucci M. Spine epidural and sacroiliac joints injections – when and how to perform. Eur J Radiol. 2014 Jun 7. pii: S0720-048X(14)00299-X. doi: 10.1016/j.ejrad.2014.05.039. [Epub ahead of print]
7 van Leeuwen RJ, Szadek K, de Vet H, Zuurmond W, Perez R. Pain Pressure Threshold in the Region of the Sacroiliac Joint in Patients Diagnosed with Sacroiliac Joint Pain. Pain Physician. 2016 Mar;19(3):147-54.
8. Hauser R, Hauser M, Dextrose Prolotherapy for Unresolved Low Back Pain: A Retrospective Case Series Study Journal of Prolotherapy. 2009;3:145-155.
9. Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain.J Altern Complement Med. 2010 Dec;16(12):1285-90.
10. Schwarzer AC, April CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine 1995;20:31-37
11. Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid versus Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain. Pain Pract. 2016 Sep 27.
12: Ko GD, Mindra S, Lawson GE, Whitmore S, Arseneau L. Case series of ultrasound-guided platelet-rich plasma injections for sacroiliac joint dysfunction. J Back Musculoskelet Rehabil. 2016 Jun 30.