Re: 요추 인대(ligament laxicity) 프롤로, prp 증식치료 논문!! 2022

[문형철]

J Back Musculoskelet Rehabil

. 2022 Jul 4;35(4):701–712. doi: 10.3233/BMR-210097

Lumbar instability as an etiology of low back pain and its treatment by prolotherapy: A review

Ross A Hauser a,*, Danielle Matias a, David Woznica b, Benjamin Rawlings a, Barbara A Woldin a

• Author information
• Article notes
• Copyright and License information

PMCID: PMC9398090  PMID: 34957989

Abstract

BACKGROUND:

Low back pain is a significant spinal disorder that affects much of the population at some point during their lives.

OBJECTIVE:

While proper diagnosis is key, diagnosing the underlying cause of low back pain may often be unclear.

METHOD:

In this review article, we discuss lumbar instability as an etiology of low back pain and its treatment by prolotherapy.

RESULTS:

Spinal ligaments may be an underlying culprit in the development of lumbar instability with resultant low back pain and associated disorders.

CONCLUSION:

In these cases, adequate treatment consisting of non-biologic prolotherapy or cellular prolotherapy, including platelet rich plasma (PRP), can be beneficial in restoring spinal stability and resolving chronic low back pain.

초록
배경:
요통은 평생 동안 많은 사람들이 경험하는 주요 척추 질환 중 하나입니다.
목적:
정확한 진단이 중요하지만, 요통의 근본 원인을 진단하는 것은 종종 명확하지 않을 수 있습니다.
방법:

이 리뷰 논문에서는 요통의 원인으로서 

요추 불안정성과 

그 치료법으로 프로로테라피를 논의합니다.

결과
척추 인대는 

요추 불안정성의 근본적인 원인으로 작용하여 

요통 및 관련 질환을 유발할 수 있습니다.

결론
이러한 경우, 

비생물학적 프로로테라피 또는 세포 기반 프로로테라피(혈소판 풍부 플라즈마(PRP) 포함)를 포함한 적절한 치료는 

척추 안정성을 회복하고 만성 요통을 완화하는 데 유익할 수 있습니다.

Keywords: Lumbar instability, prolotherapy, low back pain, degenerative disc disease, sacroiliac joint, facet joint, spinal osteoarthritis

1. Introduction

1.1. Background

Low back pain is the most common spinal disorder, with more than one-half of the U.S. population living with chronic pain, and approximately 80% affected by chronic pain at some point in their lives [1, 2]. In the most recent Global Burden of Disease Study, low back pain was the leading cause of years lived with disability [1]. Those with acute low back pain who lack proper diagnosis and treatment are at risk for developing chronic pain, which predisposes them to high rates of disability, limiting their ability to participate in everyday activities and reducing their quality of life. About 20% of people who have had acute low back pain develop chronic low back pain when symptoms continue to persist at one year [3]. Low back pain is typically associated with spondylosis, an umbrella term that refers to the progressive degeneration of the spine and affects the joints, discs, and bones therein. Most low back pain is mechanical in nature and can be caused by any of the following conditions: sprains and strains, intervertebral disc degeneration, herniated or ruptured discs, radiculopathy, sciatica, spinal stenosis, spondylolisthesis, trauma, and scoliosis, as well as an abnormal lordotic curve [4].

In the United States, spinal problems of the back and neck are the most common musculoskeletal conditions to cause limitations in activities of daily living (ADL) in young adults [5]. The number of all-age years lived with disability (YLDs) attributable to low back pain has increased 17.5% since 2007. Low back pain was the leading cause of YLDs in 126 of the 195 countries and territories surveyed [6]. Such a high and sustained YLD figure for low back pain is becoming a cause of concern since it represents the potential loss of a functioning workforce and a greater population of non-wage earners [7]. Previously, the United States Bone and Joint Initiative had reported that nearly 26% of those adults (age 18 or older) who said they were unable to work due to a health condition also attributed it to chronic back or neck problems. In 2013, low back pain was the diagnosis recorded in nearly 62 million healthcare visits [8].

Although 3 out of 4 of these visits were to a physician’s office, more than 2.3 million patients with low back pain were hospitalized and almost 10 million were treated in the emergency department [ibid]. For the years 2012-2014, the annual direct medical costs for all persons with a back-related condition was estimated at $315 billion per year (in 2014 dollars), but this figure does not include costs associated with chiropractic care, physical therapy, alternative therapy (e.g., prolotherapy), or outpatient clinics, and is therefore grossly underestimated [1]. Globally, low back pain is ranked #1 as the leading cause of YLDs for both males and females, and has been so for the past 27 years, reflecting the lack of progress in addressing this type of pain [9, 10].

1. 서론

1.1. 배경

요통은 가장 흔한 척추 질환으로, 미국 인구의 절반 이상이 만성 통증을 겪고 있으며, 평생 동안 약 80%가 만성 통증을 경험합니다 [1, 2]. 최근 글로벌 질병 부담 연구에서 요통은 장애 조정 생명 연수(DALY)의 주요 원인으로 나타났습니다 [1]. 급성 요통을 겪은 후 적절한 진단과 치료를 받지 못한 환자는 만성 통증으로 발전할 위험이 높으며, 이는 장애 발생률 증가, 일상 활동 참여 능력 저하, 삶의 질 감소로 이어집니다.

급성 요통을 경험한 사람의 약 20%는

증상이 1년 이상 지속될 경우 만성 요통으로 발전합니다 [3].

요통은 척추의 진행성 퇴행을 의미하는 광범위한 용어인 척추증과 일반적으로 연관되어 있습니다.

이는 척추의 관절, 디스크, 뼈에 영향을 미칩니다.

대부분의 요통은 기계적 원인으로 발생하며,

다음 조건 중 하나 이상에 의해 유발될 수 있습니다:

염좌 및 긴장, 추간판 퇴행, 추간판 탈출 또는 파열, 신경근병증, 좌골신경통,

척추관 협착증, 척추전방전위증, 외상, 척추측만증, 그리고 비정상적인 요추 전만 곡선 [4].

미국에서 척추의 허리와 목 문제는

젊은 성인에서 일상 생활 활동(ADL)에 제한을 초래하는

가장 흔한 근골격계 질환입니다 [5].

요통으로 인한 장애 조정 생명 연수(YLD)는

2007년 이후 17.5% 증가했습니다.

years lived with disability

요통은

조사된 195개국 및 지역 중 126개국에서

YLD의 주요 원인으로 나타났습니다[6].

요통으로 인한 높은 YLD 수치는

기능적 노동력 손실과 비임금 근로자 인구 증가를 의미하기 때문에

우려의 대상이 되고 있습니다[7].

장애 및 조기 사망의 근본 원인별 인구 건강에 대한 상세하고 포괄적이며 시의적절한 보고는 시간 경과에 따라 연령층, 성별, 지역별로 복잡한 질병 및 부상 부담 패턴을 이해하고 대응하는 데 필수적입니다. 질병 부담 추정치의 가용성은 공중보건 연구자, 정책 입안자 및 기타 전문가들이 질병을 완화할 수 있는 전략을 구현하는 데 도움이 되는 근거 기반 개입을 촉진할 수 있습니다. 또한 지속 가능한 개발 목표(SDGs)와 같은 국가 및 국제 건강 목표 달성을 위한 진전 상황을 더 엄격하게 모니터링하는 데도 기여할 수 있습니다. 지난 30년간 글로벌 질병, 부상 및 위험 요인 부담 연구(GBD)는 이 필요를 충족시켜 왔습니다. GBD 2021의 제작에는 전 세계 협력 네트워크가 참여해 모든 이용 가능한 데이터를 제공, 검토, 분석했습니다. GBD 추정치는 추가 데이터와 개선된 분석 방법을 통해 정기적으로 업데이트됩니다. GBD 2021은 코로나19 팬데믹으로 인한 건강 손실 추정치를 처음으로 제시합니다. 방법 GBD 2021 질병 및 부상 부담 분석은 100,983개의 데이터 소스를 활용해 371개 질병 및 부상에 대한 장애 조정 생명 연수(YLD), 생명 손실 연수(YLL), 장애 조정 생명 연수(DALY), 건강한 기대 수명(HALE)을 추정했습니다. 데이터는 생명 등록 시스템, 구두 부검, 인구 조사, 가구 조사, 질병별 등록 시스템, 의료 서비스 접촉 데이터 및 기타 출처에서 추출되었습니다. YLD는 각 질병 및 부상에 대해 원인-연령-성별-지역-연도별 후유증 유병률에 해당 장애 가중치를 곱하여 계산되었습니다. YLL은 원인-연령-성별-지역-연도별 사망 수에 사망 시점의 표준 기대수명을 곱하여 계산되었습니다. DALY는 YLD와 YLL을 합산하여 계산되었습니다. HALE 추정은 인구당 YLD와 지역, 연령, 성별, 연도, 원인별 연령별 사망률 데이터를 사용하여 산출되었습니다. 모든 최종 추정치에 대해 95% 불확실성 구간(UI)은 500회 추출의 2.5%와 97.5% 백분위수 값으로 생성되었습니다. 불확실성은 추산 과정의 각 단계에서 전파되었습니다. 계수 및 연령 표준화율은 1990년부터 2021년까지 전 세계, 7개 초지역, 21개 지역, 204개 국가 및 지역(21개 국가의 하위 지역 포함), 811개 하위 지역별로 계산되었습니다. 여기서는 2010년부터 2021년까지의 데이터를 보고하여 지난 10년간의 질병 부담 추세와 COVID-19 팬데믹 첫 2년간의 추세를 강조합니다. 결과 전 세계 DALY는 2010년 26억 3천만(95% 신뢰구간 24억 4천만–28억 5천만)에서 2021년 28억 8천만(26억 4천만–31억 5천만)으로 증가했습니다. 이 DALY 수의 증가 대부분은 인구 증가와 고령화 때문으로, 2010년부터 2019년까지 전 세계 연령 표준화 전체 원인 DALY율이 14.2%(95% 신뢰구간 10.7–17.3) 감소한 것으로 나타났습니다. 그러나 주목할 점은 코로나19 팬데믹의 첫 2년 동안 이 비율이 역전되어, 2019년 이후 전 세계 연령 표준화 전체 원인 DALY 비율이 2020년에는 4.1%(1.8–6.3), 2021년에는 7.2%(4.7–10.0) 증가했습니다. 2021년 전 세계 DALY의 주요 원인은 코로나19(212.0백만 [198.0–234.5] DALYs), 이어 허혈성 심장 질환(188·3백만 [176·7–198·3]), 신생아 질환(186·3백만 [162·3–214·9]), 뇌졸중(160·4백만 [148·0–171·7])이 뒤를 이었습니다. 그러나 다른 주요 전염성, 모성, 신생아, 영양(CMNN) 질환에서는 눈에 띄는 건강 개선이 관찰되었습니다. 2010년부터 2021년까지 전 세계적으로 HIV/AIDS의 연령 표준화 DALY율은 47.8% (43.3–51.7) 감소했으며, 설사 질환의 DALY율은 47.0% (39.9–52.9) 감소했습니다.. 비전염성 질환은 2021년에 1.73억(95% 신뢰구간 1.54–1.94) DALY를 차지했으며, 2010년 이후 연령 표준화 DALY율이 6.4%(95% 신뢰구간 3.5–9.5) 감소했습니다. 2010년부터 2021년까지 3단계 주요 원인 중 상위 25개 원인에서 연령 표준화 DALY율은 불안 장애(16.7% [14.0–19.8]), 우울 장애(16.4% [11.9–21.3]), 당뇨병(14.0% [10.0–17.4])에서 가장 크게 증가했습니다. 부상으로 인한 연령 표준화 DALY율은 2010년부터 2021년까지 전 세계적으로 24.0%(20.7–27.2) 감소했으나, 지역, 연령, 성별에 따라 개선 정도는 일관되지 않았습니다. 전 세계적으로 출생 시 건강 기대 수명(HALE)은 2010년 61.3년(58.6–63.6)에서 2021년 62.2년(59.4–64.7)로 약간 개선되었습니다. 그러나 이 전체적인 증가에도 불구하고, 2019년부터 2021년까지 HALE은 2.2%(1.6–2.9) 감소했습니다. 해석 COVID-19 팬데믹을 건강 손실의 원인을 상호 배제적이고 포괄적인 목록에 포함시켜 이해하는 것은 그 영향을 파악하고, 비용 효과적이고 증거 기반의 개입을 통해 지역 및 글로벌 수준에서 건강 자금 지원과 정책이 필요를 충족시키도록 보장하는 데 필수적입니다. 글로벌 역학 전환은 여전히 진행 중입니다. 우리의 연구 결과는 비전염성 질환 예방 및 치료 정책의 우선순위화와 건강 시스템 강화가 여전히 극히 중요함을 시사합니다. CMNN 질환의 부담을 줄이는 진전은 멈춰서는 안 됩니다. 전 세계적 추세는 개선되고 있지만, CMNN 질환의 부담은 여전히 용납할 수 없을 정도로 높습니다. 근거 기반 개입은 전 세계 어린이와 어머니의 생명을 구하고 사회의 전반적인 건강과 경제적 조건을 개선하는 데 기여할 것입니다. 정부와 다자간 기관은 향후 수십 년간 자원을 압박할 질병과 부상의 부담을 줄이는 노력과 함께 팬데믹 대비 계획 수립을 우선순위로 삼아야 합니다.

배경 2019년 호주에서 모든 근골격계 질환 및 요통(LBP)에 대한 전국적 유병률, 장애 조정 생명 연수(YLDs) 및 귀인 위험 요인을 보고하고, 근골격계 질환과 다른 건강 상태 간의 장애 부담을 비교하는 것을 목적으로 합니다. 방법 Global Burden of Disease (GBD) 2019 연구의 모든 근골격계 질환 및 LBP에 대한 메타데이터를 접근하고 통합했습니다. 유병률, YLD 및 귀인 위험 요인에 대한 성별 및 모든 연령층별 계수 및 연령 표준화율을 보고합니다. 결과 2019년 호주에서 근골격계 질환은 YLD의 주요 원인(20.1%)으로 추정되었습니다. 근골격계 질환의 유병 사례는 7,219,894.5건(95% 신뢰구간: 6,847,113–7,616,567)이며, 근골격계 질환으로 인한 YLD는 685,363건(95% 신뢰구간: 487,722–921,471)으로 추정되었습니다. 요통(LBP)의 유병 사례는 2,676,192건(95% 신뢰구간: 2,339,327–3,061,066)이었으며, 요통으로 인한 YLD는 298,624건(95% 신뢰구간: 209,364–402,395)이었습니다. 요통은 근골격계 질환으로 인한 YLD의 44%를 차지했습니다. 2019년 근골격계 질환으로 인한 YLD의 22.3%와 요통으로 인한 YLD의 39.8%는 수정 가능한 GBD 위험 요인에 기인했습니다. 결론 근골격계 질환으로 인한 지속적인 높은 부담은 호주인의 생애 전반에 걸쳐 영향을 미치며, 특히 여성과 노인층에서 두드러집니다. 호주 의료 시스템에서의 통합적 및 조직적 개입 전략은 고가치 의료 서비스를 지원하고 장애의 주요 수정 가능한 위험 요인(예: 흡연, 직업적 인체공학적 요인, 비만)을 해결해야 합니다.

이전에는 미국 뼈와 관절 이니셔티브(United States Bone and Joint Initiative)가 건강 문제로 인해 일할 수 없다고 응답한 18세 이상 성인 중 약 26%가 만성 요통이나 목 통증을 그 원인으로 지목했다고 보고했습니다. 2013년에는 요통이 약 6200만 건의 의료 방문 기록에 진단으로 기재되었습니다.

이 중 4명 중 3명은 의사 진료소를 방문했지만,

요통으로 입원된 환자는 230만 명 이상이었고

응급실에서 치료받은 환자는 거의 1천만 명에 달했습니다[ibid].

2012년부터 2014년까지 척추 관련 질환을 가진 모든 사람의 연간 직접 의료 비용은

2014년 달러 기준으로 연간 $315억으로 추산되었으나,

이 수치는

척추 교정 치료, 물리 치료, 대체 치료(예: 프로로테라피), 외

래 클리닉 비용을 포함하지 않아 크게 과소 추산되었습니다 [1].

전 세계적으로 요통은 남녀 모두에서 YLD의 주요 원인 1위로,

지난 27년간 이 순위를 유지해 왔으며,

이는 이 유형의 통증 관리에 대한 진전이 부족함을 반영합니다 [9, 10].

1.2. Stabilizers of the lumbar spine

The spine acquires its stability from the intervertebral discs (IVDs), and the surrounding ligaments and muscles, with the discs and ligaments providing intrinsic stability, and the muscles, extrinsic support. In the lumbar spine, there are 5 vertebrae (L1–L5); rarely, some people have 6. The lower back is formed by the lumbar spine and the beginning of the sacral spine (S1), which is why it is important to examine the sacroiliac joints when a patient complains of persistent low back pain.

The Denis model divides the spine into 3 columns. The first column is made up of the anterior longitudinal ligament and the front half of the vertebral body and disc; the middle column consists of the back half of the vertebral body and disc, plus the posterior longitudinal ligament; and the third (posterior) column is made up of the facet joints, the ligamentum flavum, and the interconnecting ligaments of the posterior elements (see Fig. 1). The sacrum and its surrounding ligaments form a foundation of structural integrity for both the lumbar spine and posterior pelvic ring, allowing a seamless transition of force from the upper body to the lower extremities [11]. Although the spine is still usually considered stable when only one of the columns has been disrupted, this may not remain so because any looseness of the ligaments in the posterior column can act as a springboard for degeneration of a second column.

1.2. 요추의 안정화 구조

척추는 추간판(IVDs)과 주변 인대 및 근육으로부터 안정성을 얻으며,

추간판과 인대는 내재적 안정성을,

근육은 외재적 지원을 제공합니다.

요추에는 5개의 척추체(L1–L5)가 있으며,

드물게 6개를 가진 경우도 있습니다.

하부 요추는 요추와 천추의 시작 부분(S1)으로 구성되어 있으며,

이 때문에 환자가 지속적인 요통을 호소할 경우

천추골반 관절을 검사하는 것이 중요합니다.

Denis 모델은

척추를 3개의 기둥으로 나누습니다.

첫 번째 기둥은 전방 장골 인대와 척추체의 앞쪽 반쪽 및 디스크로 구성되며,

중간 기둥은 척추체의 뒤쪽 반쪽과 디스크, 후방 장골 인대로 이루어집니다.

세 번째(후방) 기둥은 관절면 관절, 황색 인대, 후방 요소 간의 연결 인대로 구성됩니다(그림 1 참조).

천골과 그 주변 인대는

요추 척추와 후방 골반 고리의 구조적 안정성의 기반을 형성하며,

상체에서 하체로 힘의 원활한 전달을 가능하게 합니다 [

Figure 1.

Open in a new tab

The Denis model of the lumbar spine divides the spine into 3 columns.

Activity- and age-related low back problems do not typically arise immediately after a traumatic event, but instead begin to develop once ligaments start to creep (tendency to slowly elongate) after prolonged stretching. This creeping behavior is the result of the forward motions engrained in the human lifestyle. Our days are spent bending to tie our shoes or pick items up, lifting to carry objects or hold our children, twisting to play sports or go skiing, and sitting (or slouching) to drive, read, talk, or text on cell phones, and use computers at work and home. We all either perform or assume these everyday motions and stationary postures without giving them a second thought, but they can lead to gradual loosening of the posterior ligamentous complex (PLC) over time.

What then are the overriding effects of gradual loosening of the ligaments in the lower back? Our bodies are remarkably intuitive in sensing when something has gone awry, especially when it concerns a vital structure like the spine, and responds by adopting other measures to maintain the spine’s stability. Muscle spasms may develop along the spine generated by the ligamento-muscular reflex, whereby the stretched ligaments rapidly react by signaling the muscles over top of them to squeeze and spasm to prevent the spine from destabilizing. The body also responds to joint instability by causing joint swelling, paraspinal muscle tightening or osteophytes (bone spurs), all of which may help to decrease the force per unit area on the (facet) joints. By doing so, the body temporarily stabilizes the joints. With this said, the body’s overall reaction to the worsening of ligament laxity and instability in the lower spine is to initiate both degenerative and growth mechanisms (balance of anabolic and catabolic events) as protective measures.

데니스 모델에 따르면

요추는 3개의 기둥으로 나뉩니다.

활동 및 연령과 관련된 요통은

일반적으로 외상 사건 직후에 발생하지 않으며,

대신 인대가 장기간의 스트레칭 후 서서히 길어지는 경향(크리핑)이 시작되면서 점차적으로 발생합니다.

이 크리핑 현상은

인간의 생활 방식에 내재된 전방 움직임의 결과입니다.

우리는

신발을 묶거나 물건을 주우려고 몸을 구부리고, 물건을 들어 올리거나 아이를 안기 위해 들어올리며,

스포츠를 하거나 스키를 타기 위해 몸을 비틀고, 운전하거나 책을 읽거나 휴대폰으로 대화하거나 텍스트를 보내거나,

직장이나 집에서 컴퓨터를 사용할 때 앉아 있거나(또는 구부정하게 앉아) 시간을 보냅니다.

우리는

이러한 일상적인 동작과 정적 자세를 의식하지 않고 수행하거나 유지하지만,

시간이 지나면 후방 인대 복합체(PLC)의 점진적인 이완으로 이어질 수 있습니다.

그렇다면

척추의 인대가 점차 느슨해지는 것의 주요 영향은 무엇일까요?

우리 몸은

특히 척추와 같은 중요한 구조물에 문제가 생겼을 때 이를 감지하는 데 매우 직관적이며,

척추의 안정성을 유지하기 위해 다른 조치를 취합니다.

인대-근육 반사 작용에 의해 척추를 따라

근육 경련이 발생할 수 있습니다.

ligamento-muscular reflex

이 과정에서 늘어난 인대가

위쪽의 근육에 신호를 보내 수축하고 경련을 일으켜 척추의 불안정을 방지합니다.

목적 등측방 인대(DRL)는 첫 번째 손목관절(CMC1)의 안정성에 필수적이며, 관절 proprioception에 기여하는 것으로 알려진 신경 말단과 기계수용체를 포함하고 있습니다. 이러한 신경 말단이 CMC1의 신경근육적 안정성에 미치는 영향은 아직 알려지지 않았습니다. 본 연구는 DRL과 CMC1 근육 사이에 인대-근육 반사 경로가 존재하는지 조사했습니다. 방법 건강한 10명(여성 5명, 남성 5명, 평균 연령 28세; 범위 24–37세)이 포함되었습니다. CMC1을 안정화하는 주요 4개 근육을 조사했습니다: 장지신근(extensor pollicis longus), 장지외전근(abductor pollicis longus, APL), 단지외전근(abductor pollicis brevis), 첫 번째 등측 간골근(first dorsal interosseous). 바늘 전극을 각 근육에 삽입하고 DRL에 미세 와이어 전극을 삽입했습니다. DRL을 200 MHz로 자극하며 등척성 팁, 키, 팔마르 핀치 자세에서 근전도 활동을 기록했습니다. 평균 근전도 값을 분석하여 자극 전(t1)과 자극 후(t2) 활동을 비교했습니다. 결과 자극 후 변화는 모든 4개 근육과 3개 자세에서 관찰되었습니다. 팁 핀치 시 모든 근육의 진폭 감소와 함께 대량 억제가 관찰되었습니다. 키 핀치 시 빠른 공동 수축 반응이 관찰되었습니다. 손바닥 핀치 시 대항 근육의 빠른 억제 반응이 관찰되었습니다. APL은 자극 후 20ms 이내에 반응한 유일한 근육이었습니다. 결론 우리는 CMC1 인대-근육 반사 반응을 확인했습니다. 팁 핀치 동안 관찰된 활동의 대량 억제는 모든 4개 근육에 영향을 미치는 보호적 인대-근육 관계를 나타냅니다. 관찰된 동시 수축은 관절 안정성을 촉진합니다. APL의 빠른 반응은 DRL과의 신경해부학적 근접성과 결합되어 CMC1 proprioception에 특별한 역할을 시사합니다.

몸은 관절 불안정에 대응해

관절 부종, 척추 주변 근육 긴장 또는 골극(뼈 돌기)을 유발할 수 있으며,

이는 모두 (면관절) 관절당 단위 면적에 가해지는 힘을 감소시키는 데 도움을 줄 수 있습니다.

The body also responds to joint instability by causing

joint swelling,

paraspinal muscle tightening or

osteophytes (bone spurs),

all of which may help to

decrease the force per unit area on the (facet) joints.

이 과정에서 신체는

관절을 일시적으로 안정화시킵니다.

이와 같이,

하부 척추의 인대 이완과 불안정성이 악화될 때

신체의 전반적인 반응은 퇴행성 및 성장 메커니즘(동화 및 이화 과정의 균형)을

활성화하는 보호 조치로 이어집니다.

1.3. 요통의 원인

비특이적 요통은 전 세계적으로 질병 부담의 주요 원인 중 하나이며 모든 연령층에 영향을 미칩니다 [12]. 통증의 원인이 불명확하거나 잘못된 진단을 받은 경우, 불필요한 척추 수술이나 침습적 시술이 발생할 가능성이 높으며, 오피오이드 과다 사용과 영상 검사의 남용은 계속해서 심각한 문제로 남아 있을 것입니다. 지난 10년간의 비용 분석은 이 사실을 입증했으며, 메디케어 지출에서 경막외 스테로이드 주사 비용이 629% 증가; 요통 관련 아편류 약물 지출이 423% 증가; 메디케어 수혜자 중 요추 MRI 검사 건수가 307% 증가; 척추 융합 수술률이 220% 증가했다는 엄청난 수치를 보여주었습니다 [13]. 요추 통증을 진단하는 것은 요추 척추 자체가 몸과 마찬가지로 통증을 유발할 수 있는 많은 구성 요소로 이루어져 있으며, 복잡한 통증 패턴을 통해 통증을 유발하기 때문에 어려울 수 있습니다 [14].

프로로테라피라는 용어를 창안한 조지 해켓(George Hackett) 박사는 천장관절 인대 손상으로 인한 통증 패턴이 좌골신경통과 유사하다는 것을 최초로 설명했습니다(그림 2 참조). 천장관절의 안정화는 프로로테라피가 만성 요통을 치료하는 성공적인 방법 중 하나입니다. 현대 의학은 만성 요통에 대해 통증을 가리는 데만 효과적인 약물을 처방하는 경우가 많습니다. 디스크 퇴화 관련 체계적 문헌 고찰에서 필립스(Phillips)와 동료들은 이 전략을 비판하며, “요통의 원인은 거의 다루어지지 않는다”고 지적했습니다[15]. 우리는 저자들이 정확히 지적했다고 믿으며, 척추 척추 운동 단위가 기능 장애를 일으키고 만성 통증이 발생할 경우, 이는 거의 항상 인대 이완으로 인한 불안정성 때문이며, 이는 포괄적 또는 세포 수준 프로로테라피로 해결될 수 있다고 주장합니다.

1.3. Causes of low back pain

Non-specific low back pain is a leading contributor to disease burden worldwide and affects people of all ages [12]. When the etiology of the pain is unknown, or a person is given an inaccurate diagnosis, unnecessary spinal surgeries or other invasive procedures are more likely to occur, and the overuse of opioids and imaging will continue to be a widespread problem. Cost analyses over the last decade have born this out with monumental figures, indicating a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids related to back pain; a 307% increase in the number of lumbar MRIs among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates [13]. Diagnosing a person’s low back pain can be difficult to determine since the lumbar spine, like the body itself, consists of many components capable of generating pain and does so via a set of complex pain patterns [14].

George Hackett, MD, who coined the term prolotherapy, was the first to describe the referral pain patterns of injury to the sacroiliac ligaments, which mimicked those of sciatica (see Fig. 2). Stabilization of the sacroiliac joints is one of the successful ways that prolotherapy treats chronic low back pain. Modern medicine typically prescribes medications for chronic back ailments that only serve to mask the pain instead. In a systematic review of disc degeneration, Phillips and colleagues have questioned this tactic, countering back by stating, “The causes of lower back pain are rarely addressed” [15]. We believe the authors were right on target and contend that when a spinal vertebral motion segment becomes dysfunctional and chronic pain develops, it is almost always due to instability caused by ligament laxity, which could be resolved with either comprehensive or cellular prolotherapy.

1.3. 요통의 원인

비특이적 요통은

전 세계적으로 질병 부담의 주요 원인 중 하나이며

모든 연령층에 영향을 미칩니다 [12].

통증의 원인이 불명확하거나 잘못된 진단을 받은 경우,

불필요한 척추 수술이나 침습적 시술이 발생할 가능성이 높으며,

오피오이드 과다 사용과 영상 검사의 남용은

계속해서 심각한 문제로 남아 있을 것입니다.

지난 10년간의 비용 분석은 이 사실을 입증했으며,

메디케어 지출에서 경막외 스테로이드 주사 비용이 629% 증가;

요통 관련 아편류 약물 지출이 423% 증가;

메디케어 수혜자 중 요추 MRI 검사 건수가 307% 증가;

척추 융합 수술률이 220% 증가했다는 엄청난 수치를 보여주었습니다 [13].

요추 통증을 진단하는 것은

요추 척추 자체가 몸과 마찬가지로 통증을 유발할 수 있는 많은 구성 요소로 이루어져 있으며,

복잡한 통증 패턴을 통해 통증을 유발하기 때문에 어려울 수 있습니다 [14].

프로로테라피라는 용어를 창안한

조지 해켓(George Hackett) 박사는

천장관절 인대 손상으로 인한 통증 패턴이

좌골신경통과 유사하다는 것을 최초로 설명했습니다(그림 2 참조).

천장관절의 안정화는

프로로테라피가 만성 요통을 치료하는 성공적인 방법 중 하나입니다.

현대 의학은

만성 요통에 대해 통증을 가리는 데만

효과적인 약물을 처방하는 경우가 많습니다.

디스크 퇴화 관련 체계적 문헌 고찰에서 필립스(Phillips)와 동료들은 이 전략을 비판하며,

“요통의 원인은 거의 다루어지지 않는다”고 지적했습니다[15].

우리는 저자들이 정확히 지적했다고 믿으며,

척추 척추 운동 단위가 기능 장애를 일으키고 만성 통증이 발생할 경우,

이는 거의 항상 인대 이완으로 인한 불안정성 때문이며,

이는 포괄적 또는 세포 수준 프로로테라피로 해결될 수 있다고 주장합니다.

Figure 2.

Open in a new tab

Ligament referral pain patterns from structures in the lower back and hip.

2. Method

2.1. Prolotherapy

Prolotherapy is a regenerative injection treatment that uses various biological substances to initiate an inflammatory healing cascade, mimicking the body’s own response to repairing musculoskeletal injuries. Prolotherapy treatments can be either non-cellular based (d-glucose/hypertonic dextrose) or cellular-based (platelet rich plasma [PRP] and mesenchymal signaling cells/stem cells), the former of which is obtained via a venous blood draw, and the latter via a small volume liposuction or bone marrow harvesting. In the United States, the practice of regenerative medicine, including prolotherapy, is currently limited to using autologous mesenchymal stem cells, which must be obtained and used during the same procedure with little manipulation [16]. Generally, cellular-based prolotherapy is reserved for more severe cases of ligament damage/instability and spinal joint degeneration.

Various methods of prolotherapy can be used to treat lumbar instability and its consequent pain syndromes; to provide relief expeditiously, however, the administered treatment should be tailored to each individual patient, depending upon confirmation of their diagnosis and primary pain generator. Pain sources include the lumbar facet joints and their capsular ligaments, over-pressured or deranged intervertebral discs resulting from lumbar instability, and sacroiliac and iliolumbar ligaments (see Fig. 3).

2. 방법

2.1. 프로로테라피

프로로테라피는

다양한 생물학적 물질을 사용하여 염증성 치유 반응을 유발해

근골격계 손상의 자연적 치유 과정을 모방하는 재생 주사 치료법입니다.

프로로테라피 치료는

비세포 기반(d-글루코스/고장성 덱스트로스) 또는

세포 기반(혈소판 풍부 플라즈마 [PRP] 및 중간엽 신호 세포/줄기 세포)로 구분되며,

전자는 정맥 혈액 채취를 통해, 후자는 소량 지방 흡입 또는 골수 채취를 통해 얻어집니다.

미국에서 재생 의학,

특히 프로로테라피의 적용은 현재 자가 중간엽 줄기세포의 사용으로 제한되어 있으며,

이는 동일한 절차 내에서 최소한의 조작으로 채취 및 사용되어야 합니다[16].

일반적으로

세포 기반 프로로테라피는

인대 손상/불안정성이나 척추 관절 퇴행과 같은 중증 사례에 제한적으로 적용됩니다.

요추 불안정성과 그로 인한 통증 증후군을 치료하기 위해

다양한 프로로테라피 방법이 사용될 수 있습니다.

그러나 신속한 통증 완화를 위해 투여되는 치료는 환자의 진단 확인과 주요 통증 원인을 고려해 각 환자에게 맞춤형으로 조정되어야 합니다. 통증의 원천에는 요추 관절면 관절과 그 캡슐 인대, 요추 불안정성으로 인한 과도한 압력이나 변형된 추간판, 그리고 천장관절과 요천관절 인대가 포함됩니다(그림 3 참조).

Figure 3.

Open in a new tab

Prolotherapy treatment for the low back may involve injections to the capsular, sacroiliac, and/or other ligaments and entheses.

2.2. Facet joints and their contribution to lumbar instability and low back pain

The facet joints are considered a crucial anatomic region and stabilizer of the spine because they play an important role in load transmission, acting as the posterior load-bearing component for stabilizing the motion segment in flexion and extension while restricting axial rotation. Together with the intervertebral disc, the facet joints transfer loads and guide and constrain motions in the spine. This mechanical behavior and its specialized geometry and biomechanics are meant to ensure the normal health and function of the spine during physiologic loading, but this behavior can lead to joint dysfunction if the tissues within the facet joints are altered by injury, degeneration, or spinal surgery (e.g., disc repair or replacement), which can disrupt facet responses [17]. Typical degenerative changes that occur in response to ligament injuries in the facet joints include cartilage degradation followed by joint space narrowing and sclerosis of the subchondral bone [18].

The lumbar spine is considered unstable if abnormal strains or excessive motion develop in the functional spinal unit, a structure that contains the bodies of the upper and lower vertebrae and the IVD between them, as well as the facet joints, which join the vertebrae together. The functional spinal unit is surrounded by ligaments, including the PLC, which are crucial for maintaining spinal stability. The PLC is made up of the supraspinous ligament, interspinous ligament, ligamentum flavum, and the facet capsule ligaments. The roles of the PLC are to limit excess motion and resist bending and compressive forces. This second function is particularly important, as demonstrated in a study that found intradiscal pressure increases greatly during sitting, lifting, or forward leaning, alone or with twisting, the latter of which involves shear forces that the PLC is ill-equipped to handle. All these motions were found to trigger the loading of such forces onto the PLC [19]. Should the PLC become injured or unable to resist those forces, the lumbar disc would become a pain generator. Other important ligaments surrounding the functional spinal unit are the intertransverse ligament, the anterior longitudinal ligament, and the posterior longitudinal ligament.

Studies have eval‎uated the effects when various ligaments of the PLC become dysfunctional. For instance, the removal of the facet joint capsular ligaments in the lower lumbar spine causes a large increase in pressure within an otherwise healthy lumbar disc, [20] and cutting these ligaments in the upper lumbar spine causes an increase in side-to-side bending motion [21]. While the lumbar disc and the facet joints are both common pain generators, the facet joint capsular ligaments are arguably the most critical starting point in the development of lower back disorders. This is so because their injury would result in increases in shear forces (side-to-side motion), thereby increasing the likelihood that instability would occur, along with subsequent facet joints and lumbar disc degeneration. It should be noted that the facet joints and interspinous ligaments are the first to be injured under degenerative conditions (see Fig. 4). While the entire PLC is treated in comprehensive prolotherapy, it is the lumbar facet joint capsular ligaments that are targeted.

Figure 4.

Open in a new tab

Capsular ligament injury leads to the development of spinal instability, which can give rise to disc protrusions and eventual disc degeneration in the process.

Although facet joint pain can account for up to 45% of low back pain [18], there are few randomized controlled studies in the literature on the use of comprehensive or cellular prolotherapy for treating this type of pain. Narrative and systematic reviews, as well as meta-analysis, noted overall positive results, especially with cellular prolotherapy, but mixed with noncellular prolotherapy for chronic low back pain [22, 23, 24, 25]. Currently, standard medical care remains focused on masking facet joint pain instead of diagnosing and treating the real cause, which is joint instability. Historically, treatment options have included oral NSAIDs and physical therapy, as well as more invasive interventions such as facet joint corticosteroid injections, diagnostic nerve blocks to the facet joints, and radiofrequency ablation of the sensory nerves supplying the joints if the diagnostic block is positive.

3. Results3.1. Prolotherapy and PRP for facet joint pain

A single-blind, randomized, crossover study eval‎uated the effectiveness of injection therapy in 35 patients diagnosed as having painful enthesopathies as a major pain generator. Of the patients studied, 86% had undergone prior spinal surgery, and all had been referred to a neurosurgeon to see if more surgery was needed. Patients were injected with either anesthetics alone or with anesthetics combined with a phenol-glycerol proliferant (prolotherapy), for a total of 86 injections. Out of this group, 39 patients were treated with local anesthetics alone, and 47 with prolotherapy. Outcomes were done clinically at regular follow-ups, and subjectively by a series of questionnaires. Clinical assessment revealed 80% of patients had excellent to good relief of pain and tenderness when prolotherapy injections were given, but only 47% of patients given anesthetics alone had the same amount of pain relief. Of the questionnaire responses, 66% reported excellent to good pain relief after prolotherapy vs. 34% after anesthetics alone. Patients in both groups reported improvements in work capacity and social functioning, but patients who received prolotherapy injections had a greater reduction in focal pain intensity than those with anesthetics alone. In the crossover portion of the study, patients who had been in the anesthetics alone group reported they had much better pain relief after getting prolotherapy injections. Those who had been in the initial prolotherapy group said the anesthetic-only injections failed to provide as much pain relief. The authors concluded that prolotherapy injections to painful enthesopathies provide substantial relief from axial pain and tenderness along with functional improvement, even in cases of “failed back [surgery] syndrome” [26].

A study into the use of PRP for facet joint pain examined the results of guided injections of PRP into the lumbar facet joints of 19 patients. The study found that PRP had beneficial effects which improved over time, with 15 of the 19 patients experiencing significant pain reduction by 3 months [21]. In a subsequent randomized prospective study with a larger cohort of 46 subjects, the same lead author compared the results of facet joint injections using either PRP or anesthetic and corticosteroid. At the 1-month mark, 80% of subjects in the corticosteroid group were satisfied with the results of the procedure, but this declined to between 20% and 50% after 6 months. Conversely, the subjects in the PRP group had an increase in satisfaction over time, leading the authors to conclude that PRP was the superior treatment [22]. As the facet joint capsular ligaments loosen, the spinal segments begin to flex (bend forward) more, though imperceptibly to us, when a person leans forward, sits, or lifts. Over time, this results in several possible adaptations, the first of which is disc degeneration (see Fig. 5).

Figure 5.

Open in a new tab

As the facet joint capsular ligaments loosen, the spinal segments begin to flex more during normal motions. Over time, this will increase pressure in the facet joint(s), as well as accelerate degeneration of the intervertebral disc(s).

3.1.1. Disc degeneration as a consequence of lumbar instability

According to the National Institutes of Health (NIH), disc degeneration remains a key cause of chronic low back pain [3] and is thought to be the initiator of degeneration in the spine. This process is believed to result in segmental instability, which in turn increases the load on the facet joints and leads to cartilage alterations. On the reverse, when there is too much motion (due to joint hypermobility or instability from ligament laxity) in the posterior pillar at the facet joints, undue pressure will be exerted on the disc, potentially leading to disc herniation or degeneration.

When the spine is axially loaded, the exterior rim of the IVD can bulge at the periphery. If a person is bending forward, the disc normally bulges posteriorly, but if the person is leaning toward the right, the disc bulges laterally to the left. In other words, the disc bulges normally with movement and thus is not painful. When an MRI shows bulging discs as the main finding, it usually has no clinical significance. If the axial forces are applied over too long a period, however, the disc will not regain its original length and width, even when accounting for recovery time. This could happen, should the PLC become loose due to creep. Every time the person bends or sits thereafter, the loosened ligaments will cause the bony vertebrae to slip or tilt forward and squeeze the front of the lumbar disc more than usual, resulting in a backward bulge [27]. It should therefore be unsurprising that disc pressures are higher when spinal instability is present. When the disc degeneration is long-standing and severe, it can put even more stress on the facet joints, worsening the spinal instability, and ultimately becoming a causative factor in the development of spinal osteoarthritis (see Fig. 6).

Figure 6.

Open in a new tab

The progression of degeneration in the lower back starts with an initial injury to one or more spinal ligaments. Over time, the process progresses to involve more spinal segments. Eventually, unresolved spinal instability can cause multi-level degeneration of the lumbar spine.

Discogenic back pain is without a clear source, although it is thought to originate from the intravertebral disc and the associated structures of the motion segment (i.e., facet joints, ligaments, and spinal muscles). The degenerative changes that occur in the disc and the structural defects that ensue in surrounding tissues result in biomechanical instability and inflammation.

Although many treatments and interventions have been explored for disc degeneration, all have had drawbacks. Treatment options such as pain medications, steroid injections, discectomies, and spinal fusion surgeries only address symptoms but do little to stop the degeneration process. Regenerative medicine, including cellular therapies, focuses instead on the biological repair or regeneration of the IVD and surrounding facet joints, posterior ligaments, etc. This has many advantages over current therapies and regenerative treatments that are coming of age in the treatment of discogenic back pain. These therapies include non-cellular and cellular prolotherapy (mesenchymal stem cells or bone marrow aspirate, PRP) and offer the most promise, as they have the potential to provide meaningful pain relief and functional restoration to the spinal ligaments and IVD [28].

3.2. Dextrose and cellular prolotherapy for disc degeneration and pain

Degenerated discs are believed to produce nerve root pain either mechanically or chemically. In the case of advanced disc degeneration, this type of pain has a history of being symptomatically resistant to peridural steroids, intra-discal electrothermoplasty, and direct surgical intervention, while also being difficult to resolve. However, exposure of irritated nerves to hypertonic dextrose prolotherapy is thought to have chemoneuromodulatory potential. Sustained pain reduction has been demonstrated in a prospective consecutive patient series in which the effects of disc space injections of hypertonic dextrose were assessed in patients with chronic advanced degenerative discogenic leg pain, with or without low back pain, including those with moderate to severe disc degeneration and concordant pain reproduction with CT discography. Patients underwent bi-weekly disc space injections of a solution consisting of 50% dextrose and 0.25% bupivacaine in the affected disc(s). Each patient was injected an average of 3.5 times. Overall, 43.4% of patients achieved sustained improvement as shown by average changes in numeric pain scores of 71% between pretreatment and 18-month measurements. The authors concluded that intradiscal injection of hypertonic dextrose has promise as a treatment for managing the pain of advanced lumbar disc degeneration [29].

In a retrospective case series of 21 patients with MRI-confirmed lumbar disc degeneration and refractory low back pain/non-radicular low back pain, 18 (86%) of patients experienced 70% or greater improvements in pain and function [30] at 1-year follow up. Patients underwent 3 prolotherapy treatment sessions at 1–3 weeks apart, which included injections at the ligamento-periosteal junctions at the origin and insertion of the posterior sacroiliac ligaments, iliolumbar ligaments, facet joint capsules, and supraspinous and interspinous ligaments (all bilaterally). Injections were done under fluoroscopic guidance.

A small case series of 4 patients [31] with low back pain also proved successful in treating those with disc herniations with prolotherapy. Patients underwent 3–9 prolotherapy sessions to the ligaments of the low back (almost all 1 month apart) with all patients experiencing 95–100% pain relief and increase in function, including the ability to return to work.

Intervertebral discs can, to a limited extent, exhibit regenerative properties themselves. While some interventions focus on controlling pain intensity, other more invasive interventions try to stabilize the disc through fusion surgery, which permanently “freezes” that level of the spine and often leads to adjacent segment disease. Cellular prolotherapy, however, focuses on both resolving the pain and stabilizing the disc. Ligamentous and disc regenerative approaches aim at halting or reversing spinal degeneration. As Huang, et al. state, “Existing treatment options…only address symptoms whilst doing little to halt the degeneration process…new therapies focus on the biological repair or regeneration of the nucleus pulposus (NP) and annulus fibrosus (AF) and can be especially promising when applied to an early stage of disc degeneration” [32].

3.2.1. Sacroiliac joint-mediated pain

The sacroiliac joint is often described as a large, auricular-shaped synovial joint. Only one-third of the joint, however, is a true synovial joint; the remainder of the sacroiliac joint is made up of an intricate set of ligamentous connections [33]. This strong ligamentous architecture provides stability to the sacroiliac joints. Loss of ligamentous integrity to these joints can result in sacroiliac joint instability and chronic pain (see Fig. 7).

Figure 7.

Open in a new tab

Ligaments of the low back, including those of the sacroiliac joint.

A prospective, randomized, controlled trial was conducted to eval‎uate the efficacy and long-term effectiveness of intra-articular prolotherapy in relieving sacroiliac joint pain, compared with intra-articular steroid injection. At 15 months, 58% of the patients treated with prolotherapy reported that more than half of their pain was relieved, which was statistically significant (log-rank 𝑝< 0.005), compared with only 10% in the corticosteroid group who reported that same level of pain relief [34].

Another randomized clinical trial eval‎uated the efficacy of injections of a dextrose-glycerin-phenol proliferant in treating 79 patients with chronic low back pain who had failed to respond to previous conservative care. Patients were randomly assigned to receive a double-blind series of 6 injections at weekly intervals of either a xylocaine/proliferant or a xylocaine/saline solution into the posterior sacroiliac and interspinous ligaments, fascia, and joint capsules of the lower back from L4 to the sacrum. Of the 39 patients assigned to the proliferant group, 30 achieved a 50% or greater reduction in both pain and disability scores at 6 months compared with 21 of 40 in the group receiving the saline solution (𝑝= 0.042). The proliferant group also achieved greater improvements on the visual analog, pain, and disability scales [35].

A prospective study was conducted to determine whether prolotherapy is effective in the treatment of deficient load transfer of the sacroiliac joint in 25 patients. In this study, 3 injections at 6-week intervals of a hypertonic dextrose solution were given into the dorsal interosseous ligament of the affected sacroiliac joint of each patient. Outcome measures included the Quebec Back Pain Disability Scale, Roland-Morris 24, and Roland-Morris 24 Multiform questionnaires, and independent clinical examination by 2 authors. Clinical scores were obtained using the t-test for matched pairs and showed there were significant improvements from baseline to follow-ups at 3, 12, and 24 months (𝑝< 0.001). The authors concluded that prolotherapy treatment provided positive clinical outcomes for 76% of the patients at the 3-month and 12-month follow-up visit, and 32% at 24 months. Functional questionnaires also demonstrated significant improvements for those followed up at 3, 12, and 24 months (𝑝< 0.05) [36].

In an audit of conservative treatments for low back pain, patients who were diagnosed with sacroiliac pain via diagnostic block were treated either by corticosteroid injection to the sacroiliac joint or by prolotherapy to the sacroiliac ligaments. Long-term improvement was assessed at 6 months, after which 63% of the prolotherapy group reported a substantial drop in pain severity compared with only 33% in the corticosteroid group [37].

The use of PRP for treating musculoskeletal conditions is growing, and studies specific to sacroiliac mediated pain have found that PRP provides favorable outcomes. In one randomized, controlled trial of PRP vs. corticosteroid injection, 90% of subjects treated with PRP to the sacroiliac joint were satisfied at the 3-month follow-up compared with only 25% of those who were treated with the steroid [38]. In 2 small case series, PRP was used to treat a total of 14 patients with chronic sacroiliac joint pain, the first of which involved administering a fluoroscopically guided single injection of 4 ml autologous PRP into the sacroiliac joint of 10 patients who had failed other conservative treatments. After 4 follow-up sessions at 3-month intervals, verbal analog scale scores for pain of all 10 patients had decreased more than 50% by the 12th month; better functioning had also returned by that time [39]. In the second case series, 4 female patients with sacroiliac joint instability and severe chronic low back pain were successfully treated with PRP injections after having been refractory to other treatment modalities. At follow-up 12 months after treatment with PRP, pooled data from the 4 patients reported a clinically and statistically significant reduction in pain, noticeable improvements in joint stability, and higher quality of life, as evidenced by a 93%, 88%, and 75% reduction in the mean scores for SFM (𝑝< 0.0001), NRS (𝑝< 0.001) and Oswestry Low Back Pain and Disability (𝑝< 0.0001), respectively [40].

3.2.2. Spinal osteoarthritis

Spinal OA (also known as lumbar spine OA) has a complex association with chronic low back pain and affects approximately 80% of the population aged 40 and over, according to 2013–2015 statistics. The authors further reported that low back pain was self-reported at the highest rate (35%) by people in the 45- to 64-year age group, and that this group also underwent the most spinal procedures (47%). Self-reported limitations in performing ADL affect about 10% of people who have OA in their back or neck [41].

Spinal OA is characterized by facet OA, disc space narrowing (DSN), and osteophyte formation (OST) at the same vertebral level and belongs to a group of spinal disorders called spondylosis. In one study, evidence of DSN and OST in the lumbar spine was obtained radiographically from a community-based population, indicating that the preval‎ence of spinal OA may be as high as 50% to 64% for DSN and 75% to 94% for OST [42].

An important orthopedic principle to consider regarding osteophyte formation is Wolff’s Law, which states that, in humans, any bone will adapt to the stresses put upon it. In the case of instability, those stressors are the loosened ligaments that have been repeatedly pulling on their bony attachments, causing the bone to adapt itself so it can resist this force. This typically results in what is known as bony hypertrophy (bony growth). In the spine, this can be referred to as spurring (osteophyte formation) or facet arthrosis (arthritis) but is more generally known as spondylosis. As the bone grows out further and reaches the area where the ligament(s) is pulling, it can cause a compressive effect and squash the nerve coming through the foramina. In advanced cases, nerve root compression may require treatment with decompression surgery (foraminotomy). In cases of intermittent radiculopathy (meaning the radicular symptoms are not constant), lumbar instability with or without spurring may be a culprit due to excess motion of the vertebrae and IVD narrowing the neural foramina. In cases of back pain with numbness down the leg, prompt medical attention should be sought out so that the instability causing damage to a nerve can be rectified. This even applies to younger people who usually have thick and healthy discs, because they would experience the same type of pain signal should a segment of their spines become injured. A medical practitioner (ideally, a Prolotherapist) can determine at which level that injury occurred and then address the instability before the pain becomes chronic. All too often, patients who feel pain due to unstable facet joints are given passive treatments and told the pain will subside. These conventional treatments (e.g., NSAIDs, cortisone shots, ice, rest), however, are short-lived and put patients at risk for further instability issues and more intense chronic pain as they age.

4. Discussion4.1. Diagnostic clues to utilize prolotherapy in a patient with chronic low back pain

In an editorial, a board-certified physician in family medicine whose specialty is pain management made several points about treatment of low back pain with prolotherapy [43]:

• •
• •
• •
• •
• •

4.1.1. Adverse effects

The current status of the literature suggests that non-cellular (including dextrose) and cellular prolotherapy are well tolerated, safe, and reasonably effective. The most frequent adverse events are the expected short-term increase in pain from the interventions and increased risk of infection. Pain and swelling at the injection site(s) are typically short-lived, with patients recovering within several days. Dextrose, a common ingredient in non-cellular prolotherapy, is extremely safe (even in intravenous use) and in 1998, the FDA documented that no adverse outcomes had been reported for 25% intravenous dextrose solution in 60 years [44, 45].

Adverse events with spinal prolotherapy exist and include spinal headache, nerve damage, non-severe spinal cord insult, and disc injury. Prolotherapy performed by an experienced Prolotherapist can mitigate these risks [46] and these events are no more common in prolotherapy procedures than for other spinal injection interventions [47].

Throughout the literature, complications of PRP injections, including infections, are extremely rare. Additionally, PRP has been thought to have anti-microbial properties, thus further lowering risk of infection [48, 49]. It also may have a role in preventing infection, given a recent study that found antimicrobial activity was greatest when a leukocyte-rich PRP was used in conjunction with a mixed antibiotic [50]. As PRP involves the use of the patient’s own blood product, the chance of allergic reaction is quite low.

5. Conclusion

Given the widespread preval‎ence of spinal disorders, clinicians should understand ligaments as a causative factor for lumbar spinal instability resulting in chronic and worsening low back pain. Degenerative spine conditions are initiated by the development of instability within the PLC, most notably the facet joint capsular ligaments. In response, the body makes adaptations trying to stabilize the spine, which are initially protective but eventually become harmful (e.g., bone spurs). Without addressing the instability, progression of degenerative spinal conditions with low back pain will continue.

Clinically speaking, spinal stability is the ability of the spine to maintain its alignment during loading, and to protect the neural structures it encloses without causing pain. It is the collective job of the bones, muscles, discs, and ligaments to maintain their alignment of the spinal column so the spinal cord and nerves remain protected. If the spine no longer has properly functioning biomechanical properties, however, clinical stability is lost, giving rise to spinal instability and pain.

Prolotherapy is a regenerative treatment option for those suffering from low back pain and associated conditions related to joint and spinal instability. Regenerative treatment to injured ligaments has the potential and ability to strengthen the PLC, and thus relieve both chronic and acute low back pain.

Conflict of interest

None to report.

Ethical declaration

Ethical review was not necessary for this study, as no human subjects were included, and only publicly available data were used.

References

• [1]. Weinstein SI, Yelin EH, Watkins-Castillo SI. The big picture. United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), 4th; ed. United States Bone and Joint Initiative (USBJI) (Internet). [Accessed 2021 July 26]. Available from: https//www.boneandjointburden.org/fourth-edition/i1/big-picture. [Google Scholar]
• [2]. Chaib F. Musculoskeletal conditions affect millions. World Health Organization (WHO) (Internet). 2003; Oct 27. [Accessed 2021 July 26]. Available from: https//www.who.int/news/item/27-10-2003-musculoskeletal-conditions-affect-millions. [Google Scholar]
• [3]. National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke. Low back pain fact sheet (Internet). 2020. Mar. [Accessed 2021 July 26]. Available from: https//www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet.