Prolotherapy for the treatment of interspinous ligament injury: A case report

Case/Program Description: Patient is a 38-year-old man referred for chronic mid to low back pain. He denied history of trauma but endorsed past exertional back strains. His symptoms were primarily axial, localized to the lower thoracic and lumbar regions without radiation to the limbs. Exam showed tenderness to palpation midline, between the spinous processes in the thoracic and lumbar spine, worse with flexion. Lumbar plain films were normal. Magnetic resonance imaging (MRI) showed mild disc bulge along the L5-S1 level with mass effect upon the left S1 nerve root. Setting: Tertiary Care Hospital. Results: A course of anti-inflammatory medications and physical therapy did not improve his symptoms. Epidural injections were not indicated due to lack of limb symptoms. Patient received a trial of three dextrose prolotherapy injections, each 2 months apart, to the lower thoracic and upper lumbar interspinous ligaments. This reduced his pain significantly and allowed him to return to function. Discussion: Interspinous ligament injury is an under recognized etiology of back pain. Cadaveric studies have demonstrated that interspinous ligaments are the weakest of the spinal ligaments and are subjected to the greatest strain during flexion and extension of the spine. The diagnosis is largely clinical as imaging modalities such as MRI have shown varying reliability. Prolotherapy, or proliferative therapy, is gaining recognition as a treatment modality for tendin-opathy as well as ligamentous laxity but its use for the treatment of interspinous ligament injury is poorly described. Further studies are warranted to explore the presentation and diagnosis of interspinous ligament injury and the use of dextrose prolotherapy in its treatment. Conclusions: Physiatrists should recognize interspinous ligament injury as a potential source of chronic back pain in conjunction with or separate from other diagnoses, such as degenerative disc disease or radiculopathy. Prolotherapy injections may be beneficial as both an adjuvant and primary treatment modality.