Non-specific Low Back Pain

Solutions for non specific low back pain

In Switzerland, 25 years ago, a surgical intervention was successful in 100% of patients. Why hasn't it been used since?

In Switzerland between 1990 and 1995, Dr Markwalder, a spinal surgeon, used Graf ligaments to “fix” painful intervertebral joints in full extension. The result was either excellent or moderate in all cases with no failures. (M)

At seven year follow up, 75% reported excellent to fair. (It seems likely that most of the remaining 25% suffered from the well-known “adjacent segment syndrome.”)

  • 1. Why isn’t this procedure still being used?
  • 2. Why was it so successful?
  • 3. Is there a therapy corresponding to this interpretation?
  • 4. Could the 1990’s surgical procedure be used in the future?
  • 5. What is the pain causing mechanism?
  • 6. Why isn’t this pain universal when we sit or bend?
  • 7. Why is the pain so severe and persistent?
  • 8. Why does pain spread to the pelvis and leg (Sciatica)?
  • 9. What is it in our lifestyle that causes hyperflexion or distortion in the lower spine?
  • 10. How can we modify civilised sitting habits to avoid this “disease of civilisation”?
  • 11. Why isn’t the spine straight? Vertical columns should be straight!
  • 12. Is there a published technical paper putting the whole of this argument?
At that time (ca 1990) it was commonly believed that trauma of the facet joints was a major source of low back pain. It was hoped that immobilisation would allow recovery. Although the operation was very successful it was generally accepted by about 2000 that the facet joints were not a common source of low back pain. Because of this there was no rationale for the surgical intervention and it was not continued. (It is also relevant that the surgeons moved on in their careers. This info from personal visit to authors in Switzerland)
Because the wedge shape of the disk in full extension squeezed the nucleus of the disk to the anterior of the disk and away from the nerves in the posterio-lateral corners of the disk. This was so widely accepted by 2007, that the following was the introductory sentence of a paper in Spine in that year; “Intervertebral disc problems, principally excessive migration of the nucleus pulposus, ------ are generally accepted to be one of the main causes of nonspecific back pain” (A).
Mackenzie stretch

The therapy, which corresponds most closely to this interpretation of the problem, is the McKenzie Therapy. This is taught inside the physiotherapy profession. Robin McKenzie was a physiotherapist. His book “Treat Your Own Back” is well known to all those treating back pain. This shows the typical exercise of the McKenzie system.

This will tend to restore the wedge shape of the lowest lumbar discs where this has been lost for whatever reason. I look upon this as a very important bit of evidence. Although I am qualified as a chiropractor, I am trained in Mackenzie by the Mackenzie Institute UK and I used it in most acute back pain cases of recent onset. In the trial published in the British Medical Journal in 1990, neither manipulative physiotherapy nor chiropractic was particularly effective in the early stages of an acute LBP attack. This is exactly when Mackenzie is most effective. It can completely stop the attack in its tracks. If the person is careful with sitting and uses my pelvic supports (O) when driving they can be back to square one quite quickly. My interpretation is that the Mackenzie extension exercise squeezes the nucleus back to the anterior of the disk where it should be all the time in L 4/5 or 5/S.

Yes. But in a much less invasive way. The intention previously was to immobilise the joint in extension so that any trauma in the facet joint capsules could recover. If it is understood that the real criterion is that the joint should not flex beyond parallel sided, (see Q6) then the problem becomes much easier to solve. A prosthetic ligament can be built up between the sacrum and the existing supraspinous ligament at the spinous process of L4. This must not stretch plastically, as natural ligament would, but can stretch elastically. Also, it must cover joints at least up to the spinous process of L4 and be strongly integrated with the existing supra-spinous ligament so that the “adjacent segment syndrome” does not occur. A very preliminary proposal is at Natural Joint

“Intervertebral disc problems, principally excessive migration of the nucleus pulposus, ---- are generally accepted to be one of the main causes of nonspecific back pain” This is the opening paragraph of a 2007 paper in “Spine” (A) from Aberdeen And Robert Gordon Universities in Scotland based on upright MRI scans. By 2007 this was more or less generally accepted. (E)

But what is meant by “excessive” in this quote? My answer to this is in Q6.

Because these two joints, L4/5 and L5/S, do not flex, even in full flexion, beyond the angle, at which the two endplates are parallel. Hence the nucleus always stays anterior in these two disks and there is no posterior migration of the nucleus at all, let alone “excessive” migration. (This, of course, refers to the natural, pain free spine! For so many people, pain on sitting or bending is exactly what happens!)

This fact “that the lowest two disks should not flex beyond the shape when the endplates are parallel” is totally unrecognised in medicine and low back pain research.

This statement relies on three pieces of published research which are fortunately from very different populations; white English males (B), black male and female South Africans (C), and male and female Iranians (D).

Despite the very large variation in sacral and spinal shapes, the criterion above was the one fact that was universal. The MRI research at Aberdeen (A) shows that this will keep the nucleus away from the pain-triggering nerves in the postero-lateral annulus.

To protect the spine from disk prolapse.

Evolution is design. Very good design by the simple process of killing off bad design. A climbing ape becoming a good biped, and fast enough runner to survive on the savannahs of East Africa, needed redesign (evolution) of everything from the occiput in the skull to the big toe.

In the pelvis, there was one of those difficult design decisions that every engineer has met. Bringing the vertical column forwards over the hip joint and keeping it straight, (as vertical weight bearing columns should be,) leaves no birth canal. Bit of a non-starter that! The opposite solution of keeping the whole spinal column behind the centre of the body just requires too much muscular effort and bulk in the spine, resulting in slow running. Not a good solution with lions around!

The design chosen by evolution is to place most of the spine above the hip joint and to have a sharp “double bend” in the lowest two spinal joints and the sacrum. (Lordotic at the L4/5joint, the L5 wedge shaped vertebra and L5/S joint. Kyphotic sacral shape.) All of this inside the pelvis; “the pelvic spine.”

And the resulting prominence of the sacrum solves another problem at the same time. When the body is not upright but nearer to horizontal for lifting, the bending forces near the base of the spine are very high; tension in the muscles and compression in the disks and vertebrae. These forces are reduced if the muscle is offset further behind the vertebrae and the muscular structure that is most posterior and has the widest connection at origin and insertions is the erector spinae aponeurosis. (F) This makes a direct connection from the thorax to the most prominent part of the sacrum (and also to the posterior iliac spines) and is as vital, and does the same job as, the top cable in this picture of a building site crane.

industrial crane

But there is a problem here. The spine isn’t as rigid as a building site crane and the prominence of the sacrum is below the flexible part of the spine. This means that the advantage of the prominent sacrum can actually be reversed by hyperflexion. The whole structure is an “over-centre mechanism”. It can collapse. And if it does it will burst the disk in exactly the way demonstrated in vitro by Adams and Hutton in 1984 (G). Back Pain is Nature’s way of telling us that we are flexing the spine past a safe limit. To ensure that we don’t ignore this warning, it is severe and persistent as so many back-pain sufferers will recognise! And all that is necessary to trigger this severe pain is for the nucleus of one of the lowest two disks to migrate to the posterior of the disk. This will happen if either of these disks flexes beyond the vertebral endplates being parallel. This mechanical point is explained with diagrams at Natural Joint

To maximise the pain and inhibit any action, such as bending and lifting, which might cause prolapse.

In explaining how most sciatica is a part of low back pain, I can’t do better than the start of chapter 2.2 of my book, “The Evolution of Low Back Pain” written in 1992 after five years in chiropractic, (two after qualification.) My experience after twenty-five years as a chiropractor confirms this interpretation but there is no medical research that I know of other than that mentioned in this chapter. In fact, as I have written elsewhere “there is no medical understanding of the problems caused by tight muscles”.

An example of this is to be found in the conclusion of Nikolai Bogduk’s Chapter 13, “Low Back Pain” where he writes “There are no data on underlying pathology that justify the belief that muscles can be a source of chronic low back pain.” (I) As I wrote earlier, medics think that pain must be caused by pathology and have no understanding of the problems caused by tight muscles. I also repeat another of my comments “the whole of alternative medicine is different ways of loosening tight muscles.” In total contradiction to Nicolai Bogduk’s statement, tight muscles are the source of most chronic back pain including sacro-iliac pain and sciatica (as well as being the source of most of the income of most chiropractors!)

“The Sublesation. Chapter 2.2 of The Evolution of Low Back Pain (H).

Although the idea of a warning pain explains some aspects of back pain it does not explain the muscular spasms that are so often associated with back pain.

It seems very likely that these muscular effects are associated with a phenomenon that occurs in the spine of any animal that I shall refer to as a sublesation. The chiropractor refers to this effect as a “chiropractic subluxation” and the osteopath refers to it as an “osteopathic lesion”. I shall avoid both terms because in medical terms it is neither a subluxation nor a lesion because it is within the normal range of joint mobility and because there is no associated tissue damage. I have also avoided the word “fixation” because this includes cases where the joint is “fixed” by adhesions following trauma. The word sublesation should avoid all these ambiguities because it doesn't exist. It is a combination of the chiropractic term subluxation and the osteopathic term lesion. I hope that sublesation will eventually be accepted by both professions and also by the medical profession so that this important phenomenon can receive the recognition and research effort that it deserves. (Note; this was written in 1992. Progress so far? Less than zero. Most chiropractors don’t even use the word subluxation anymore because of medical opposition.)

In a sublesation, local muscles around a joint are permanently energised by nerves that are in some way excited by the clamping effect of the muscles. Thus, the effect is self-perpetuating. The mobility of the joint is greatly reduced and it is distorted asymmetrically because the muscle in spasm is only on one side. The osteopath and chiropractor both recognise the characteristics of the sublesation as asymmetry, loss of mobility and local muscle abnormality. The effect can occur in any spinal joint of any animal and has probably evolved in order to allow an injured joint to recover. (This phenomenon is the central point of chiropractic and is also central to osteopathy.)

When the warning pain has been triggered and there is disc damage or potential disc damage, the sublesation is ideally suited to provide muscular immobilisation of the vulnerable part of the spine. It seems likely that the phenomenon of the sublesation has evolved to be a very much more powerful effect in the human lumbo-sacral area. It also seems likely that evolution has used sublesations in the pelvis and sacro-iliac joints to cause muscle contraction in many of the muscles of the lumbar region.” End of quote.

This muscle spasm is what so many back-pain sufferers will recognise. It has to be powerful and painful because it has evolved to stop any very determined proto-human in the last five million years from continuing the activity that is likely to result in a prolapse from the disk straight onto the spinal cord or nerve roots.

The phenomenon of the sublesation applies at all spinal joints, including the four or five sacral joints that are no longer mobile joints. Any nerves exiting the spine can also be affected, so the nerve signal that initially comes from the disk can switch on sublesations in local lumbar or sacral segments. These can cause pain and muscle spasm in any tissues that get their innervation from the relevant segment. Hence sciatica without any physical nerve impingement. Evolution has incorporated all of this into a pain to protect the actual disk; a pain that even a determined proto-person can’t ignore. And all of this occurs without any pathology!

Just one more anecdotal point; frequently the sacro-iliac pain persists long after the initial low back pain. If the initial pain signal from the disk has died away over time, then the sacro iliac locking and pain can persist. If so, it is easy for the osteopath or chiropractor to release the sublesation and “cure” the pain. I always say that most osteopaths and chiropractors make most of their money, and reputation, by releasing the sacro-iliac joints. It is therefore not surprising that many osteopaths and chiropractors believe that the real cause of low back pain lies in the pelvis.

lumbar support distortion

Civilised ways of sitting. Particularly the car seat.

This was clear in the tabulations in the seminal 1979 paper in Spine (J) which was meant to show that lumbar support maintained the standing shape of the spine. In fact, the tables clearly showed the distortion that is obvious in this diagram. Although the standing position of the pelvis is maintained, and lordosis is increased in “depth”, the critical joints near the lumbo-sacral junction are flexed!

The lowest lumbar joints, the source of low back pain, are flexed by support of the lumbar spine by a backrest while upper lumbar joints are hyperextended. X-rays were taken of subjects sitting with variable lumbar support. This is exactly what was shown by the tabulations in the paper although not recognised by the authors. For analysis see (K).

This and all other forms of civilised sitting are analysed in my 1992 book “The Evolution of Low Back Pain.” (H) Usually the standing position of the pelvis is not maintained in sitting but this was the aim in the research referred to here. (J) The paper, and the diagram above, clearly show the universal effect of sitting with a backrest.

This is not going to be easy! The only truly “natural” way of sitting is sitting on the ground. This has been part of our evolution and lifestyle for millions of years. I refer to this as “Slumped sitting” where much of the upper body weight is supported by the abdomen.

As soon as we sit on a surface at about knee height, as most chairs are, we adopt a different body shape. The lower lumbar joints are flexed and joints near the lumbar-thoracic junction are extended or hyperextended. This habit develops very early in life. Dr Mandal, a Danish surgeon, wrote his book “Homo Sedens” in the 1970’s.(N) He looked particularly at schoolchildren and showed how most of them distorted the spine in this way when asked to “sit up straight”. The lumbar lordosis was in the lower thoracics!

One therapy that seeks to correct this is the Alexander Technique. Pupils are taught to sit on a chair without a backrest in a posture that avoids this distortion. Unfortunately, the time and effort required in learning this do rather emphasise the difficulty in making this universal.

It is interesting to note that this distortion, with flexion of the lowest lumbar joints and hyperextension of joints higher up is exactly the same as the distortion caused by any backrest. This is accentuated if the backrest is shaped for lumbar support as in a car seat.

It is in vehicle seats and driving where the greatest statistical association with back pain is to be found and where there is a solution in replacing lumbar support with pelvic support. Paper giving full argument and references at (P)

Pictured here are examples of seating products incorporating pelvic support produced by Pelvic Posture Ltd and Gorman Design Ltd between 1987 and 2005.

mondeo car seat

Pelvic Support Car Seat. In production 2002.

pelvis on seat

Prototype adjustable pelvic supports. This shows how the iliac crest is supported at its highest points by bringing the support round the sides of the body.

poschair 1998

Pelvic support office chair. Showing support for the iliac crest to stop the pelvis rolling backwards, which normally flexes the lowest lumbar spinal joints excessively.

This is answered in the Answer to Q7. In a nutshell, it is the need to maintain a birth canal while evolving to be bipedal four or five million years ago. When the spine was moved forward in the body to be over the hip joint, a straight lumbar spinal column (columns are straight! Ask the ancient Greeks!) would have left no birth canal! “The Obstetric Dilemma” as the Cambridge anthropologist Jay Stock described it. (L)
No. However my unpublished paper “The Obstetric Reason for Lordosis and the Implications for Lifting and Low Back Pain” is available on this website at (P). This paper was rejected by “Spine” in 1987, by The Journal of Biomedical Engineering (UK) in 1998 and, with a few updates, by Science Advances in 2016. Covering letter is at (Q)
Adjacent Segment Syndrome
The term “Adjacent Segment Syndrome” refers to the frequent failure of the intervertebral joint adjacent to a joint that has been immobilised by fusion or artificial ligament, eg Graf ligament. A good example is at Spine In that case the subsequent failure is at L3/4 which shows that even the presence of a supra spinous ligament is not able to prevent the hypermobility of an adjacent segment. Most commonly the adjacent segment is either L5/S or L4/5 where there is no supra-spinous ligament. When one of these two joints is fused or otherwise immobilised it seems obvious that the other will eventually become hypermobile.

References & Links

Note; References (eg A) in this website go directly to the relevant paper if this is available on the web. If not, the link is to the list of references in this website.

Several of the references are to the book “The Clinical Anatomy of the Lumbar Spine” by Nikolai Bogduk. I consider this to be the only comprehensive book on the anatomical detail and research on the spine. There are five editions. The first was 1987. The fifth was 2014/15.

  1. The Response of the Nucleus Pulposus of the Lumbar Intervertebral Discs to Functionally Loaded Positions Alexander et al SPINE Volume 32, Number 14, 2007) Welcome Back Centre
  2. Pearcy MJ, Portek I, Shepherd J Three dimensional X-ray analysis of normal movement in the lumbar spine. Spine 9: 294-297, 1984
  3. Jonck LM, van Niekerk JM A roentgenological study of the motion of the lumbar spine of the Bantu. South African J Lab Clin Med 2: 67-71, 1961.
  4. Kamali N. Evaluation of Total and Segmental Lumbar Lordosis Using Radiographic. Babol University of Medical Sciences. Quarterly Journal Summer 2003, Volume 5, Number 3
  5. Bogduk 4th Edition. Page195-200
  6. Bogduk. Multiple references to erector spinae aponeurosis in index of all editions. (Under “muscles” in 4th edition index.)
  7. Adams MA, Hutton WC Prolapsed intervertebral disc. A hyperflexion injury Spine 7: 184-191, 1982
  8. Gorman J The Evolution of Low Back Pain (book) 1992 available as free download at
  9. Bogduk p205 4th Edition.
  10. Anderson GBJ, Murphy RW, Ortengren R, Nachemson AL The influence of backrest inclination and lumbar support on lumbar lordosis Spine 4: 52-58, 1979.
  11. comments on paper at (J)
  12. Wells J, DeSilva J, Stock J The Obstetric Dilemma. American Journal of Physical Anthropology. Nov 2012
  13. Markwalder TM1, Dubach R, Braun M Soft system stabilization of the lumbar spine as an alternative surgical modality to lumbar arthrodesis in the facet syndrome and here also.
  14. The Seated Man. (Homo Sedens) Dr A C Mandal. Dafnia Publications. Denmark. Pub 1980 approx.
  15. Current information can be found here on Pelvic supports, portable for car seat. Sold from 1983 till 2015.
  16. Academic paper “The Obstetric Reason for Lordosis and the Implications for lifting and Low Back Pain”.
  17. Covering Letter for submission of Academic Paper to Science (P)