ProloTherapy of the Low Back (including Sacroiliac Areas)

Arden Andersen, D.O.
AOA Convention, October 2012,
San Diego, CA

The lumbar spine and sacral-iliac carry the
weight of the body and payload, maintain the
scaffolding for the body core muscles and
allow humans to stand erect.

One of the most common areas of pain,
injury, invasive and non-invasive therapy
from steroid injections to decompression,
from OMT to laser spine surgery
One of the most amenable areas to successful
prolotherapy
One of the easiest areas to inject as a
beginner and gain success and confidence

Low back injury at age 18, perhaps before as well
on the farm, chiropractic relieved/saved me from
exploratory surgery
During medical school had significant pain,
disability treated 5 days per week with OMT,
cranio-sacral and exercises without resolution.
Finally had prolotherapy at AOAPRM seminars
and got resolution of pain for over 5 years,
reinjured/Levaquin and now getting prolotherapy
again with improvement
Nothing has been as effective as prolotherapy

‣ OMT/chiropractic doesn’t hold
‣ Ligament structure are tender to exam
‣ Ilio lumbar attachments to iliac area are tender
‣ Inter spinous ligaments origin/insertion is
tender, painful to touch
‣ Pain’s less when mobile. (The patient is in less
pain while in motion, but hurts more when still or
on arising in the morning.)
‣ Local Anesthetic is diagnostic if all or most
symptoms are gone by 10-15 minutes after the
areas to receive prolo have been anesthetized.
(thus ruling out pain from non-ligament causes)

Rule Out: – lose style points for missing these
◦ neoplasm
aneurism
appendicitis
peritonitis
kidney infection
shingles
bladder infection
failed surgery
infectious processes

Any pain not of fibrous tissue enthesitis
origin
Nerve root impingement due to disc
fragmentation which compresses a nerve root
True spinal stenosis – relative as they may
still benefit from prolotherapy before or after
surgical intervention
Muscle atrophy of either lower extremities
Keep in mind that patient may have already
exhausted other options or refuses to go
anywhere else – YOU are it!

‣ A preponderance of pain receptors are
located in or on ligamentous tissue.
‣ When a legamentous area is tender upon
palpitation, it is due to the pain receptors on
the remaining intact fibers being over
stretched. For example, apply a pull on a
patch of scalp hair containing 100 or more
hairs. Then apply the same force on 10 hairs.
The ten hairs represent the weakened
ligament. This usually is well accepted by the
patient.

Why are we doing this?
What is our goal?
◦ Full disclosure and signed consent form
◦ What is the patient to expect over the next few days
◦ Is patient allergic to anything? Specifically local
anesthetics, corn, oils, etc.
◦ Are we merely giving local blocks to determine
diagnosis with actual treatment later?
• Depends upon time allotted for appointment
• Patient expectations or apprehensions

Study !

Study !
Study !

Study !
Study !
Study !

Ask
the
patient
where
is the
pain?

Sclerotomes
vs.
Dermatomes

“Sclerotomal” pain in the lower extremities may be
noted- study the “old” sclerotome charts which
show referred pain of ligament (not nerve root)
origin.

Take a
good
history

And ASK

And
TOUCH
the
patient!!

More
study! =

More
Success

KNOW
THY
ANATOMY

Special Points

Additional
points of
interest

Know
This
By Heart

I prefer to mark the patient’s land marks
◦ Locate the iliac crest bilaterally and mark L4
spinous process, the remainder of the lumbar and
sacral spinous processes, SI joints and iliac borders
◦ You can mark the key Hackett points A, B, C, D

The most important aspect is to inject the painful
areas of ligamentous injury/laxity. Many doctors
do not pre-anesthetize and most doctors have
their patients lie down for injections.
I prefer to pre-anesthetize the spine area and
knees and I have the patients sitting up. That is
my comfort, yours may be different – get
comfortable.
Observe various practioners and develop the
techniques that work best for you in your
practice.

Locate the SP with palpation and insert the
needle to bone, inject ¼ - ½ cc while
retracting the needle and reinsert the needle
through the interspinous ligament to contact
on the top of the spinous process below;
inject ½ to 1cc while retracting the needle
Repeat this process for each vertebra
Inject over the SI joints, PSIS and other painful
areas.

Locate the SP with palpation and insert the needle
to bone, inject ¼ - ½ cc while retracting the needle
just off the bone and reinsert the needle through
the interspinous ligament to contact on the top of
the spinous process below; inject ½ to 1cc while
retracting the needle within the ligament. One can
slide the needle down the side of the spinous
process to the lamina and inject ¼ to ½ cc of prolo
solution.
Repeat this process for each vertebra
If needed one can inject on the transverse process if
the pain pattern dictates such a need.

Lady just over 5’ and near 300 lbs.
◦ Needed a 2” needle to contact the SP
◦ Had nearly as much cleavage in back as in front
◦ Thoracic and LS pain complaints
◦ Good improvement with just SP and Interspinous
ligament injections in the thoracic and lumbar plus
ilio-lumbar ligament injection bilaterally using 4”
22ga. needle

Needle point
traverses
interspinous
space/ligament

Anesthetic
needle
contacts bone
or desired
depth

Inject 1cc
anesthetic
with slow
withdrawal of
needle

Continue flow
of anesthetic
until needle is
sub-Q

Deposit 0.5cc
prolo-solution

Inadvertent
ontact of needle
point against
spinal cord

Deposition of solution –
lamina

Needle point
on fascet

Inject with Bone
Contact

Optioninject
segment
below

Injection
Point

Review
Review

L/S- S/I injection

L5 transverse process

Sacral Base

L5 fascet

Iliac crest

Iliac crest, lower

Iliac crest, upper S/I

Mid S/I

Needle
point on
ilium

Needle
point on
lower ilium

Needle point on lower sacral
enthesis area

12 cc syringe
Xylo 2% w epi- 2cc
Pumice Solution 4cc
50% Dextrose 4cc
PQU 1cc
Q.S. Sterile Water to 12-13 cc total volume12 cc syringe
Xylo 2% w epi- 2cc
Pumice Solution 4cc
50% Dextrose 4cc
PQU 1cc
Q.S. Sterile Water to 12-13 cc total volume

Keep syringe horizontal as able…
Keep syringe in motion(rotation)
Retract plunger before every point injected
Point needle upwards between punctures
Change needle if retraction x 3 does not reestablish
flow of medication

12 cc syringe
50% Dextrose 4cc
Pumice-Lidocaine Solution 6 cc
PQU ½ cc
Sodium Moruate ½ cc
B-complex 1 cc (address the stress of the procedure on the
person)
Q.S. Sterile Water to 12-13 cc total volume12 cc syringe

I explain to patients they will need 3 to 5 sessions before we make the
decision about results.
They must have protein before the procedure. Ex: N/V after injections
Many patients only need 3 sessions for significant to complete pain
relief. (not usually true with lidocaine and glucose alone)
Each session I chase the painful points and end when their painful
points are no longer. I will use two syringes of solution on the typical
low back.
I alter the mix as I deem necessary, e.g. lighten it up for some patients.
Suggest 2 to 4 weeks between sessions.
I use PRP for hip and knee joint internal injections and suggest 4 to 6
weeks between sessions.
There is also a tincture called Dull-It I have used at times to temper the
pain and reduce the cortisol spike induced by the injection process.

Direct needle to area out side area of “pocket” of CSF
Inject 0.5 cc prolo-solution into 4-6 areas (left, right,
above, below + areas posterior to the pocket)
Place patient prone and “head down” at 10-15 degrees
After 15 minutes, then finish treatment
Return to prone position x 30 minutes
Send home “horizontal”
Lie flat or Trundelenburg until 9am next day
Report any subsequent headache symptoms
This prevents 99% of spinal headaches and seals off the
defect in 1-3 treatments.
May need “spinal headache” treatment IV
Can’t do blood patch if don’t know where leak occurs.

Find the iliac crest laterally and midline should be
the L4 spinous process
Mark off the SP’s of the lumbar spine and S1
Locate the PSIS and SI joint and mark it
Palpate along the posterior and lateral iliac spine,
perhaps the ASIS
L4 and L5 TP are attachments of ilio-lumbar
ligaments bilaterally – these are the “money”
points for injection
Follow the pain with each session and from
session to session
◦ Patients come in due to pain, injecting abnormalities,
though justifiable, don’t guarantee resolution of the pain
– personal example of my shoulder

Some days we just don’t hit the point, after 3
attempts, leave it for another day
Know when to refer to other prolotherapists
◦ I refer to Dr. Whitfield for delicate/precarious
injection points. Ex. Cranial/anterior cervicals,
abdominals. ER doc.
◦ I refer to Dr. Sessions if I feel he has better
experience than I. Ex. Anterior cervicals and
hernias. FP surgeon as is Dr. Hull.

I personally pre-anesthetize spine, hip and knee
I personally set the patient up
I don’t use US, don’t find the need to use US. I
can recount only one or two patients where US
might have been a benefit for the injection
process which is not enough to justify the cost in
my practice. If needed I can refer for this rare
event.
◦ Pain doesn’t necessarily show up on US, XR, CT or MRI
◦ My patients pay cash so US charges where I can palpate
the anatomy are not an option. I prefer their cash go
toward therapy over studies. I recognize that some
practices are geared around the US with great success.
Good luck with Obama(don’t)care “free” health insurance
and that billing in the future.

I have a nurse with the patient at all times.
We give the patient apple juice and insist they
have eaten protein at most recent meal or we
give them a protein bar before the procedure.
I have the patient wait in the office for 15
minutes after every injection session whether
the first or 100 th .

Questions?