Prolotherapy for spinal conditions

1. Spinal Prolotherapy
A good Adjuvant in spine management
Mohamed Mohi Eldin
Professor of Neurosurgery,
Cairo University, Egypt

2. 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.

3. Spinal Ligaments are there !!
Stores of elastic energy,
Plastic, semi elastic,
interwoven “collagen” threads
connecting bone to bone,
form joints in some regions.

4. 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.

5. Ligament damaged by
Trauma (Popping),
Degeneration (cracking), or
day-to-day wear & tear.

6. Ligaments Tear
Ligaments heal in elongated, disorganized fashion
resulting in:
excessively mobile joint,
poorly supported by its ligaments and
dependent on muscles to maintain stability.

7. 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

8. Ligament Laxity
Spinal or arthritic
pain frequently
has a component
of ligament
laxity.

9. Distinct clinical characteristics
Posain
Persistent pain
on maintaining one position
for a long time.

10. Distinct Referral Pattern
Nulliness
– a numb-like feeling
– in the same distribution
as posain
– without neurologic
deficit.

11. 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.

12. 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.

13. Posterior Longitudinal Ligament
Anterolisthesis Scenario

14. Interspinous and Supraspinatous
Ligament Injury
Fanning of the Spinous Processes

15. Anterior Longitudinal Ligament
Anterior Disc Space Widening
ON EXTENSION

16. Anterior Longitudinal Ligament
Retrolisthesis

17. Facet Capsule Laxity

18. Facet Capsule and Many
Ligaments
Foraminal Enchroachment

19. 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)

20. 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

21. Prolotherapy…The Definition
A form of injection aimed at the ligaments, inviting
inflammation, and aiming at healing
(proliferate, stimulate growth, regenerate, and rebuild)

22. 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.

23. Regenerative Tissue Therapy
for strained ligaments
An elegant, Effective, Safe, Cost effective way
to treat neck and back pain

24. Prolotherapy…The Target
Ligaments returned to their normal length and
strength and
the joint to its normal function.
Reconstructive Ligament Therapy

25. Sacroiliac ligament biopsy
(volunteers)
Increased cells and collagen deposited
baseline 3 months post injection

26. Early Inflammation is needed for
Healing
Hence for Prolotherapy
Anti-inflammatory agents interfere with the healing cascade

28. 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.

29. Prolotherapy…The History
• Evolved in 1930s before
modern surgical
techniques
• Dr. George Hackett, in
1950s, refined the
procedure and described
its use, causing a
controlled rate of
inflammation and
healing.

30. 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.

31. Prolotherapy…Many Names
Nonsurgical reconstructive therapy,
Prolotherapy,
Proliferative therapy,
Regenerative ligament therapy,
Reconstructive ligament therapy

33. Reconstructive Ligament Therapy
Doesn't correct mechanical problems like spinal stenosis,
Nor does it reverse arthritic changes.

34. 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

35. 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

36. We Believe That
Ligaments 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.

37. Prolotherapy…
as a Mono or Adjuvant Therapy

38. 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

39. Prolotherapy… Contraindications
• Immunocompromised,
• Smokers,
• Poor nutritional status,
• Insufficient conservative
treatment,
• Needle phobia,
• Allergy to proliferant
solution.

40. 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.

41. Prolotherapy… The Procedure
Fluoroscopically Guided

42. The Procedure… Blind Technique
One of the commonly used is
high concentration
dextrose.
The injections may take many
sessions.

43. Prolotherapy… Procedure

44. 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.

45. 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

46. 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.

47. 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.

48. mmohi63@yahoo.com
mohamedmohieldin.com
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