BACK PAIN-WHAT EXACTLY IS THE DIAGNOSIS? 
Ross Hauser, M.D.

People are confused because doctors, most commonly orthopedic surgeons, give them diagnoses that they do not understand. In one study, 51 surgeons were asked to give the four most common diagnoses used for patients with low back pain and a total of 50 different terms were used. Some of the diagnoses were the following: facet syndrome, mechanical low back pain, degenerative disc syndrome, arthritis, degenerative instability, central stenosis, failed low back syndrome, radiculopathy, herniated disc, spondylosis, sprain, fibromyositis, and about 35 other terms. (Fardon, D. Terms used for diagnosis by English speaking spine surgeons. Spine. 1993; 18:274-277.) This study was done in 1993, so there are probably another 10 terms by now! By and large, however, the terms used were just variations on the condition of the disc. The main focus in orthopedic surgery, as it relates to neck and low back pain, is that the source of the pain evolves from disc deterioration. Most surgeons would say the majority of pain complaints in the neck, mid back, and low back are from problems in the discs. This is why so many MRIs and surgeries are performed. Prolotherapists do not have to argue this point. Even if this was the case (which we do not think), then the best treatment is still to strengthen the ligamentous support around the disc so it does not have to bear as much weight. Even if the discs are the cause of the pain, the treatment required is still Prolotherapy.

Back Braces? Support or Folly?
Over the years, numerous studies have been done to see what would happen if workers wore back supports, belts, or braces. Would these help, hinder, or have no effect on the worker developing back pain? One study, for instance, took 312 workers at a major Dutch airline whose jobs included loading and unloading cargo pallets both manually and with a forklift truck.

These workers were randomized into one of four groups: lumbar support and education, education only, lumbar support only, and no intervention. The education involved three classes on proper lifting technique. Those in the lumbar support groups were to wear the lumbar supports at all times during working hours.

What happened? Thirty-five percent of workers experienced an episode of low back pain during the intervention period and 10 percent took sick leave because of low back pain. The study found no statistically significant differences among the groups. The back supports did not prevent the development of back pain in these workers. (Van Poppel, M. Lumbar supports and education for the prevention of low back pain in industry. JAMA. 1998; 279:1789-1794)

One commentary on this study stated the following, "This is the fourth randomized controlled trial (the standard of modern medicine) to assess the role of lumbar supports in preventing low back pain in the workplace, and the third to show no effect. While an observational study has shown a benefit, the preponderance of evidence argues against the routine use of lumbar supports, particularly since compliance with their use, even in this setting, is so low. This study also raises the question of whether the use of lumbar supports in workers without back pain may actually increase sick leave. (Mitchell, L. Effectiveness and cost effectiveness of employer-issued back belts in areas of high risk for back injury. Journal of Occupational Medicine. 1994; January: 90-94.)

What about back surgery?
Nearly 95 percent of all the low back pain occurs in a six by four inch area. This is the place where the fifth lumbar vertebra connects with the base of the sacrum and they both connect to the pelvis by various ligaments.

Specifically, the lumbar vertebrae connect to the sacrum by the lumbosacral ligaments, the sacrum to the iliac crests by the sacroiliac ligaments, and the lumbar vertebrae to the iliac crests by the iliolumbar ligaments. This is the most common area in the back treated by Prolotherapy.

Patients often come in to our clinic with detailed stories about how an orthopedist performed a discogram and CT scan, MRI, and various other x-rays, and is confident that they have disc problems. It is sad to say, but many patients who have been to orthopedic or neurosurgeons tell us that the doctor never even touched them when making the diagnosis that the pain was caused by a herniated disc or pinched nerve. Many patients who have all kinds of disc abnormalities that show up on MRI and CT scan, say they didn't even know because they had no symptoms! Scott Boden, M.D., found that nearly 100 percent of people he tested, over age 60, with no symptoms had abnormal findings in their lumbar spines on MRI scans. Maureen Jensen, M.D. and associates published in The New England Journal of Medicine the fact that only 36 percent of people with no back pain had normal MRI scans of the back. The conclusion to the study stated, "Because bulges and protrusions on MRI scans in people with low back pain or even radiculopathy may be coincidental, a patient's clinical situation must be carefully evaluated in conjunction with the results of MRI studies." In other words, DO NOT cut on a person based on MRI studies. Likewise, CT scans find a lot of abnormalities on people who have no back pain symptoms.

The Long Term Risks of Surgery 
The back is a weight-bearing structure. It means that when any tissue is removed, whether it is bone or disc tissue, the likelihood of further long-term pain and arthritis is increased. The patient will often undergo a stabilization procedure with rods or bony fusion, including the areas above or below a previously operated on vertebral segment, because the area has become lax and degenerated. Prolotherapy cures the back pain because it addresses the root cause of back pain-ligament laxity.