Spine Prolotherapy

Spinal ProlotherapyA good Adjuvant in spine management

Mohamed Mohi EldinProfessor of Neurosurgery,

Cairo University, Egypt

The Neglected Ligaments

Ego (Brain, Cord, Spine Surgery) !!

No attraction

Left unrecognized or untreated,

Unfortunately, function of muscles is joint movement

and only incidentally joint stabilization.

Spinal Ligaments are there !!

Stores of elastic energy,

Plastic, semi elastic,

interwoven “collagen” threads

connecting bone to bone,

form joints in some regions.

Ligaments

Do not heal well ( lack of blood supply).

Ligaments bend, but do not stretch.

They have nerve endings sensitive to

stretching, tearing, pressure, etc.

Ligament damaged by

Trauma (Popping),

Degeneration (cracking), or

day-to-day wear & tear.

Ligaments TearLigaments heal in elongated, disorganized fashion

resulting in:

excessively mobile joint,

poorly supported by its ligaments and

dependent on muscles to maintain stability.

Ligament Laxity

Results in hypermobile joints

and segments causing:

Pain with activities

Grinding sensation

Numbness and pain in a non-dermatomal

pattern

Temporary benefit from bracing

Ligament Laxity

Spinal or arthritic

pain frequently

has a component

of ligament

laxity.

Distinct clinical characteristics

PosainPersistent pain

on maintaining one position

for a long time.

Distinct Referral Pattern

Nulliness– a numb-like feeling

– in the same distribution

as posain

– without neurologic

deficit.

Traumatic Ligament Laxity

Neck & Low back Scenario

Tear from microscopic to total disruption

Muscles goes into spasm, to protect the injured joint

Resulting in

aberrant positions, impairing circulation, limiting movement,

Ending in pain.

Degenerative Ligament Laxity

Neck & Low back Scenario

With age, poor posture, injuries and degeneration

Ligaments stretched and weak.

With destabilization of the vertebral column,

Muscles contract, locking the joints

Joints displaced horizontally in a non-physiologic lock

More pain, more spasm, PAIN.

Posterior Longitudinal Ligament

Anterolisthesis Scenario

Interspinous and Supraspinatous

Ligament Injury

Fanning of the Spinous Processes

Anterior Longitudinal Ligament

Anterior Disc Space Widening

ON EXTENSION

Anterior Longitudinal Ligament

Retrolisthesis

Facet Capsule Laxity

Facet Capsule and Many

LigamentsForaminal Enchroachment

Prolotherapy…The Idea

INFLAMMATION AND HEALING

Three overlapping stages

1. Inflammation phase: (4 days),

2. Granulation phase: (10-14 days),

3. Wound contraction phase: (3-6 Weeks)

Prolotherapy…The Idea

Fibroblasts (Ligamentous building blocks)

New collagen fibers organized into ligaments,

Winding, contracting, expressing fluid, becoming shorter

Tightening the support of the joint.

Typical Inflammatory Repair Response

Prolotherapy…The Definition

A form of injection aimed at the ligaments, inviting

inflammation, and aiming at healing

(proliferate, stimulate growth, regenerate, and rebuild)

Prolotherapy…The Definition

A natural healing stimulation of the body's own

temporary, controlled, gentle low-grade healing ability;

Through micro-injections of natural chemical and physical

irritants, to stimulate repair of, and strengthen damaged or

weakened tendons and ligaments

With minimal discomfort.

Regenerative Tissue Therapy

for strained ligaments

An elegant, Effective, Safe, Cost effective way

to treat neck and back pain

Prolotherapy…The Target

Ligaments returned to their normal length and

strength and

the joint to its normal function.

Reconstructive Ligament Therapy

Sacroiliac ligament biopsy(volunteers)

Increased cells and collagen deposited

baseline 3 months post injection

Early Inflammation is needed for

Healing

Hence for Prolotherapy

Anti-inflammatory agents interfere with the healing cascade

Prolotherapy…The History

First used in ancient times

Amenhotep III (Egypt) “…giving fire to his horses”.

Hippocrates around 400 B.C. described the insertion of hot needles into tissue to create small amounts of scar

tissue around.

Prolotherapy…The History

• Evolved in 1930s before modern surgical

techniques

• Dr. George Hackett, in1950s, refined the

procedure and described its use, causing a controlled rate of inflammation and

healing.

Prolotherapy…The Name

Old name Sclerotherapy evolved from

Scar Therapy;

However,

Modern Prolotherapy does not provoke scars.

Hypertrophy is achieved without scarring.

It is now called,

Reconstructive or Regenerative therapy.

Prolotherapy…Many Names

Nonsurgical reconstructive therapy,

Prolotherapy,

Proliferative therapy,

Regenerative ligament therapy,

Reconstructive ligament therapy

Reconstructive Ligament Therapy

Doesn't correct mechanical problems like spinal stenosis,

Nor does it reverse arthritic changes.

Prolotherapy… Indications

• Sacroiliac sprains or strains

• Hyperextension or hyperflexion

• Lumbar facet syndrome

• Failed back syndrome

• Straight back syndrome

• Regional myofascial pain syndrome

• Fibromyalgia

• Spondylolysis

• Spondylolisthesis

• Compression fractures

• Lumber enthesopathy

• Whiplash injury

Published Clinical Benefits

(in respected medical journals)

Spells RELIEF

For more than sixty years

With up to 85-90% good to excellent results

that a degree of enthusiasm was generated.

WHY NOT TO USE IT

We Believe ThatLigaments can hurt & are subject to overstrain

Irreversible ligaments strain, and laxity are important parts of

most spinal traumatic or degenerative pathologies.

Prolotherapy is noninvasive with minimal risk, provide pain

relief, and sometimes cure, for various forms of spinal pain.

Prolotherapy…

as a Mono or Adjuvant Therapy

Prolotherapy… Treatment Protocol

Ensure a true ligament insufficiency

Stimulate a limited inflammatory response,

Trigger the healing cascade

Increase fibroblastic activity & collagen deposition

Strengthen ligamentous structures

Relieve pain

Prolotherapy… Contraindications

• Immunocompromised,

• Smokers,

• Poor nutritional status,

• Insufficient conservative

treatment,

• Needle phobia,

• Allergy to proliferant

solution.

Prolotherapy… Preparation

No aspirin, anti-inflammatory or anticoagulant medications

for 3 days.

No pain medications prior to procedure.

It is important to be in pain at the time of the procedure.

Insulin & oral diabetes medications take usual dose. Patients

taking cardiac or blood pressure medications may take

usual dose.

Prolotherapy… The Procedure

Fluoroscopically Guided

The Procedure… Blind Technique

One of the commonly used is

high concentration

dextrose.

The injections may take many

sessions.

Prolotherapy… Procedure

Prolotherapy… Post-Procedure

No driving after the procedure.

No anti-inflammatory drugs for 5 days after injections.

Paracetamol is accepted.

Light activity for 3 days

Resume normal activities on day 4 following treatment

Patient may have increased soreness and stiffness averaging 2 days post

procedure.

Prolotherapy… Complications

• Increased pain

• Dizziness and nausea

• Numbness

• No scaring

• No infection

• No abscess

• No weakness

• No spinal headache

• No allergic reactions

• No other disability

Prolotherapy… Results

Significant and sustained reductions in neck & low

back pain were observed for 1 year follow up:

50% reported 85% improvement,

24% reported 75% improvement,

20% reported 60% improvement, and

6% reported no improvement.

Prolotherapy… Conclusions

A safe and effective treatment for spinal pain .

A superior treatment option compared to drugs

which interfere with the inflammatory pathways of

healing.

Should be considered a good tool in in the hand of

spine surgeons.

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