Your low back pain started gradually over the last several years. Now it is constant and limiting your activity. Physical therapy, chiropractic care, and medications have failed to provide relief. Your x-ray and MRI are reported to be normal. Your doctor is baffled. What is the Multifidus? Why is the Multifidus muscle important? What is Multifidus atrophy? How to treat Multifidus pain and atrophy? Is PRP effective for low back pain? Are there any current studies available? Let’s dig in.
What Is the Multifidus? ( A Muscle)
The Multifidus muscle is a small yet important muscle located deep in the spine. It runs along the entire length of the spine but is most developed in the lumbar area. There is a right and left Multifidus muscle in the low back. Unlike the superficial back muscles that help you move your back around, the Multifidus works at a much deeper level, functioning as a major stabilized of the spine. To learn more please click on the video below.
Why Is the Multifidus Muscle Important? (Key Stabilizer)
It is an important stabilizer of the lumbar spine. Specifically, it reinforces the normal curve in your low back and limits how far forward one can bend (1). This small yet mightly muscle stabilizes the boney low back building blocks (vertebral bodies), discs, joints, and ligaments.
What Is Multifidus Muscle Atrophy? (Shrinking)
Muscle atrophy is when the muscle shrinks or wastes away. Like many things in medicine, atrophy is graded according to its severity. The scale is referred to as the Kader scale which is depicted below. The images are axial MRI slices of the low back. An axial image is a cross-section. The Multifidus muscle is outlined by the white ovals. Mild atrophy shown below on the left has very few fatty infiltrates (white in color). The muscle is dark in color much like a steak that you would buy at the grocery store. In moderate atrophy, the dark Multifidus muscle is infiltrated by fat which is white in color. With severe atrophy, the amount of fat within the Multifidus muscle has increased. The amount of white in the muscle (fat) defines the level of atrophy. Meaning the more fat in the muscle, the more it’s having problems stabilizing your spine.
Why Is This important?
Multifidus muscle atrophy has been associated with low back pain (2). Low back pain has profound social and economic implications. Low back pain has a very high incidence rate with a lifetime prevalence of up to 84% (3). There are a large number of studies highlighting the importance of the Multifidus muscle. Several key studies include:
Hildebrandt demonstrated a direct correlation between the amount of fat infiltration in the lumbar Multifidus muscle and decreased range of motion of lumbar flexion. (4)
The fatty composition of the Multifidus muscles in back pain was directly correlated to poor physical function. (5)
Increased fat in Multifidus muscle is associated with increased levels of inflammatory chemicals and impaired cellular cleanup. (6)
Regrettably, your doctor rarely discusses this important stabilizing muscle that may be the source of your ongoing pain. To compound matters, the radiologist who reads and provides a formal MRI report rarely mentions the quality of the Multifidus muscle. Go check your report and prove me wrong.
Treatment for Multifidus Pain and Dysfunction?
Conservative care when appropriate should always be first-line treatment. Core stabilization exercise programs have been effective in increasing the Multifidus muscle cross-sectional area in patients with chronic low back pain (7). A number of different exercises are effective which include:
2 Leg Bridge
Bridge & March
Bird Dog
Modified Side Plank
Regenerative Option for Multifidus Pain and Chronic Low Back Pain?
Absolutely! Hussein et al demonstrated that the injection of PRP into the atrophied lumbar muscles provided significant clinical benefit in low back symptoms (8). Platelets contain growth factors that are powerhouses for tackling inflammation and promoting healing. White blood cells otherwise known as leukocytes remove tissue debris and also secrete important growth factors such as ILGF.
The study recruited 115 individuals with a history of low back pain and Multifidus muscle atrophy on MRI. Patients were treated weekly with WBC-rich PRP for six weeks and then followed for 24 months. Pain scores, functional assessment, and patient satisfaction were evaluated. A follow-up MRI was performed at 12 months after treatment. No serious complications occurred. The results at 18 months were impressive.
- The success rate was 71.2%
- 60% of patients reported excellent outcomes
- Increase in cross-sectional area and decreased fatty degeneration in Multifidus muscle on follow up MRI
The Centeno-Schultz Clinic: A New Free Study for Patients with Ongoing Low Back Pain
At the Centeno-Schultz Clinic, we are committed to advancing the science and clinical practice of Orthobiologics. We have published extensively on the use of bone marrow concentrate which contains stem cells and PRP for common orthopedic conditions. A list of our publications is available here.
We are excited to announce a new study to further evaluate the use of PRP in patients with low back pain and Multifidus atrophy. Here is a condensed summary of the study, its inclusion, exclusions, and contact information.
Multifidus Study Requirements
The patient must be willing to come to the Broomfield or Lone Tree clinic for an initial evaluation to make a final determination of study eligibility. A current lumbar spine MRI within the last 6 months is required. All treatment visits occur at the Broomfield Centeno-Schultz Clinic. Treatments occur once a week for 6 weeks and involve a peripheral blood draw. Patients will be randomized to one of three groups:
- Group 1: Platelet poor plasma injected to the Multifidus muscle
- Group 2: Platelet rich plasma injected into the Multifidus muscle
- Group 3: Platelet rich plasma injected into the Multifidus and other structures
Inclusion Criteria
- Male or female ages 18-75
- Axial low back pain for a minimum of 3 months
- Recent MRI (within last 6 months) consistent Kader grade 2 or 3 Multifidus atrophy at 1 or 2 levels
Exclusion Criteria
- Mild Multifidus atrophy Kader grade 1 only
- Symptomatic spinal stenosis
- Sciatica
- Fracture previous spine surgery, neuromuscular disease of the trunk, malignancy, infection, or pregnancy
- Burning of Nerves: Radiofrequency Ablation (RFA) within the previous 12 months
- Corticosteroid injection
- Worker’s compensation case
- Currently involved in a health-related litigation procedure
- Bleeding disorders
- Chronic opioid
- Documented history of drug abuse
In Conclusion
- The Multifidus is a small muscle located deep in the spine
- The Multifidus muscle is a critical stabilizer of the low back
- Muscle atrophy is when the muscle shrinks or wastes away
- Multifidus muscle atrophy has been associated with low back pain
- Conservative treatment for Multifidus pain and atrophy involves core stabilization programs
- Injection of PRP into atrophied Multifidus muscles resulted in a reduction in low back pain symptoms and improved muscle health.
- The Centeno-Schultz Clinic is offering a new study further studying the effects on PRP in patients with low back pain and Multifidus atrophy
If you would like to find out if you are a candidate, please contact Ehren Dodson, PhD at 720-287-7199 or email at [email protected]
1. Bogduk N. Clinical Anatomy of the Lumbar Spine and Sacrum, Fourth edition. Philadelphia: Elsevier; 2005. ISBN 0-443-10119-1.
2. Goubert D, Oosterwijck JV, Meeus M, Danneels L. Structural Changes of Lumbar Muscles in Non-specific Low Back Pain: A Systematic Review. Pain Physician. 2016 Sep-Oct;19(7):E985-E1000. PMID: 27676689.
3.Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G; COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006 Mar;15 Suppl 2(Suppl 2):S192-300. doi: 10.1007/s00586-006-1072-1. PMID: 16550448; PMCID: PMC3454542.
4.Hildebrandt M, Fankhauser G, Meichtry A, Luomajoki H. Correlation between lumbar dysfunction and fat infiltration in lumbar multifidus muscles in patients with low back pain. BMC Musculoskelet Disord. 2017;18(1):12. Published 2017 Jan 10. doi:10.1186/s12891-016-1376-1.
5.Sions JM, Coyle PC, Velasco TO, Elliott JM, Hicks GE. Multifidi Muscle Characteristics and Physical Function Among Older Adults With and Without Chronic Low Back Pain. Arch Phys Med Rehabil. 2017 Jan;98(1):51-57. doi: 10.1016/j.apmr.2016.07.027. Epub 2016 Aug 30. PMID: 27590444; PMCID: PMC5183461.
6.James, G., Chen, X., Diwan, A. et al. Fat infiltration in the multifidus muscle is related to inflammatory cytokine expression in the muscle and epidural adipose tissue in individuals undergoing surgery for intervertebral disc herniation. Eur Spine J 30, 837–845 (2021). https://doi.org/10.1007/s00586-020-06514-
7.Kliziene I, Sipaviciene S, Klizas S, Imbrasiene D. Effects of core stability exercises on multifidus muscles in healthy women and women with chronic low-back pain. J Back Musculoskelet Rehabil. 2015;28(4):841-7. doi: 10.3233/BMR-150596. PMID: 25881694.
8. Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. SICOT J. 2016;2:12. Published 2016 Mar 22. doi:10.1051/sicotj/2016002.
