Disc Prolapse/ Spondylosis/ Spondylolisthesis

The Spine comprises of 33 individual spinal bones called vertebrae arranged one on top of the other with intervening cushions between each of the vertebrae called intervertebral discs which consist of a central gel like fluid zone surrounded by a peripheral ring shaped annular ligament. The disc provides flexibility and strength to the spine. Various factors including age related conditions, overweight, sedentary lifestyle, trauma or certain motions can cause wear and tear or damage to the spinal vertebrae. Some of the major conditions that affect the functioning and strength of the spine are discussed here.

Disc prolapse: This condition occurs when the gel-like fluid in the spinal disc pushes through a crack in the tougher exterior casing. Some herniated discs cause no symptoms. When the displaced disc tissue press against nearby muscles, ligaments and nerves it may cause pain, weakness, numbness and unexplained muscle aching which may worsen without treatment and develops quickly.


Spondylosis:   Osteoarthritic/ degenerative changes of the spine are termed Spondylosis more simply put it is arthritis; which if occurs in the facet joints, it is called as facet syndrome.

Spondylolisthesis: A spinal disorder in which one bone (vertebra) slips forward onto the bone below it. If the vertebra slips further, it may cause compression or irritation of the nerves and cause severe back pain or nerve crowding that produces leg pain or numbness.

The doctor is able to diagnose the spinal diseases through a meticulous history taking and a thorough clinical examination to understand the source of pain and discomfort and may check the nerve & muscle function as well as may prescribe imaging tests like X-ray and/or MRI Scan to understand in detail the source of discomfort and identify any damaged areas.

Conventional treatment methods include exercises for strengthening the lower back muscles, over-the-counter pain relievers, Spine Surgery, wearing a back brace and epidural steroid injections.


The root cause of chronic lower back pain including disc prolapse is mostly Spinal Instability. The stable spine behaves like a see saw with its fulcrum at the facet joint. The disc in front is balanced by ligaments and muscles at the back. If there is damage to the ligaments/muscles in the form of strain, more weight is transferred to the disc region in the front which may lead to disc prolapse. In Dr Tejaz John’s experience Platelet Rich Plasma Prolotherapy and Dextrose Prolotherapy offer the best results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region.



Symptoms caused by Spinal Instability

  • Progressively worsening symptoms.
  • Pain on unsupported sitting which improves with supported backrest.
  • Frequent recurrence of long term pain, catching/ locking & muscle spasms.
  • Feeling of spine instability or giving way.
  • Pain on rising up from sitting position.
  • Need to crack or click the spine frequently to reduce symptoms.
  • Temporary relief with spinal support/ brace or corset.
  • Worse with standing for long.

Chronic Conditions caused by Spinal Instability: Radiculopathy, Spinal Canal Stenosis, Degenerative disc disease, Herniated disc, Sciatica, Spondylolisthesis, Spondylosis, Bulging disc and facet joint Subluxations.

Many times a patient with back pain and/or accompanying hip pain; despite various treatments which may include epidural steroid injection, the patient still has pain and now has been recommended a spine surgery procedure because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”

Patients who are in severe back pain usually bring an MRI/ X-ray and/or scan that may show an inaccurate picture of what is causing their pain. In a landmark study by Boden et al in the Journal of Bone and Joint Surgery (Am) 1990, which has been quoted by nearly 2700 other articles Dr Boden does MRI scans of the Lower Back for people who have no lower back pain, sciatica or neural claudication in lower limbs. He gets neuro-radiologists to interpret the MRI without them being told the history and examination findings. He found that 57% of apparently “normal” people above the age of 60 years without any backache or nerve symptoms in legs had “abnormal” MRI changes with 36% having Disc prolapse and 21% having Spinal Canal Stenosis. If 57% of apparently normal people have abnormal Spine MRI, how can we be sure that when a patient presents with back pain, that his pain is actually related to the bulging disc, when that disc bulge could certainly be asymptomatic. The MRI cannot show muscle spasms from a simple cervical/ lumbar strain which can cause excruciating pain. Neither can it detect microstructural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.

Here is a statement from the medical journal Childs Nerv Syst. 2015: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic neck/lower back pain patient may have history of trauma or overuse to the neck/ lower back that result in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent spinal instability.

PRP for Back Pain Research studies have shown that Platelet-Rich Plasma (PRP) Therapy by addressing the problems of spinal ligament instability is effective in treating the degenerative spine. The sooner the spinal ligament instability is treated, the better the results and patient satisfaction. In fact, many doctors now think that stress on the ligaments may be the cause for most pain in degenerative disc disease. PRP is an effective means of alleviating back pain because it eliminates pain by stimulating the local immune response to heal the underlying tissues and may help avoid surgery in cases of spinal ligament instability.

PRP prolotherapy is a combination treatment where PRP is injected into region of the joint and dextrose prolotherapy is given to the ligaments of the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Platelet-Derived Growth Factor (PDGF)

Attracts cells of the immune system to the site and stimulates their proliferation. Also shown to assist in healing of ligaments and tendons.

Transforming Growth Factor-ß (TGF-ß)

Similar affects as PDGF. It is Secreted by all major cell types involved in healing.

Vascular Endothelial Growth Factor (VEGF)

Helps in formation of new blood vessel, thereby increasing vascularity in injured areas.

Fibroblast Growth Factor (FGF)

Promotes the growth of the cells involved in collagen and cartilage formation.

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the joints and soft tissues in the lower back. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.

Prolotherapy for Back Pain - Neck and Lower Back pain is one of the leading causes of disability, yet most of the people suffering from it do not know that Spinal instability is most likely the real cause of the problem! We see, most patients take pain tablets and muscle relaxers to cover the pain, which only masks further degeneration and leads to an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability.


Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the cervical/ lumbar spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome.

Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint/ entheses. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. In Dr Tejaz John’s experience, Prolotherapy is an effective non surgical treatment method used successfully in Spinal instability. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous attachments in the Spine. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles in the chronic degenerated Spine. We treat patients who have been diagnosed with bulging discs, spinal stenosis, degenerative disc disease, spondylolisthesis, failed back surgery syndrome, sciatica, and more by Prolotherapy, which can yield a more desirable pain-relief outcome.

Patient Benefits of PRP Prolotherapy and Prolotherapy:

  • Minimally invasive treatment method
  • Almost painless injection technique using very thin needles under local
  • For those who wish to avoid if not delay Surgery
  • Significantly reduces the symptoms associated with Backache
  • Reduced risk of adverse events
  • Repairs and tightens ligaments improving spine stability and ease of standing, sitting & walking
  • Safe and effective treatment method
  • Faster healing and recovery
  • PRP Prolotherapy results in safe, significant, effective, progressive improvement of back pain, function and reduction of stiffness.

At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of minimally invasive treatment options for patients suffering from various spinal disorder conditions. To know more Disc Prolapse/ Spondylosis/ Spondylolisthesis treatment plans and cost, book an appointment now.


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Dr. Tejaz Koshy John

Consultant for Orthobiologics, Regenerative & Interventional Orthopaedics

MBBS, MS Ortho (Christian Medical College, Ludhiana), Joint Replacement Fellowship (HOSMAT Hospital, Bangalore), Orthopaedic Trauma Fellowship (Hebrew University Hospital, Jerusalem, Israel)

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