Stemcelldoc's Weblog

December 31, 2012

Lumbar Disc Surgery Update: Disappointing

spine surgery

At the Centeno-Schultz Clinic we acknowledge that ow back and leg pain secondary to lumbar disc disease can be disabling. Stem cell therapy is an alternative to traditional back surgery.

Regenexx PL-Disc utilizes platelet growth factors to enhance blood flow and reduce inflammation at affected disc level and adjacent nerve roots. 

PL stands for ‘Platelet Lysate”.  We take our novel Super Concentrated Platelet (SCP) mix and break open all of the platelets to get the growth factors out.  Why?  Just like an immediate release pill, it is sometimes better to have more growth factors available to help stimulate cells towards repair.  So while SCP is like a time released pill which releases growth factors slowly, PL is like an immediate release pill.  Our experience dating back to 2005 has demonstrated that PL works best around nerves.

Poor blood supply is at the heart of why many patients with chronically pinched low back nerves fail to heal.  Regenexx PL-Disc is an out-patient “walk-in/walk-out” injection procedure where patients can immediately return to activity as tolerated.  Blood is drawn from your arm, processed in our lab and the separated platelets are concentrated and injected into the lumbar spine. Unlike conventional PRP injections (platelet rich plasma) PL quickly accelerates stem cell growth. This is because all of the growth factors in the platelets become immediately available to the local stem cells.

Success to date:

http://www.regenexx.com/2011/02/regenexx-pl-disc-works-in-this-patient-when-steroid-epidurals-fail/

http://www.regenexx.com/2012/12/epidural-steroid-injection-reviews-heres-a-patient-who-has-tried-both-steroids-and-using-his-own-growth-factors/

Lumbar surgery has been utilized for the treatment of low back pain and sciatica.

Results?

http://www.regenexx.com/2012/12/epidural-steroid-injection-reviews-heres-a-patient-who-has-tried-both-steroids-and-using-his-own-growth-factors/

Jacobs et al conducted a systematic literature review on the effect of surgical techniques for sciatica due to disc herniation to update the Cochrane review of 2007. Sixteen studies were included: seven from the original review and nine additional studies.

No conclusions can be drawn with regard to the comparative efficacy of open, microscopic, and tubular discectomy surgical techniques to treat sciatica due to a herniated disc.   There was no clinically relevant superiority of either technique.

2013:  Patients beware.  Explore treatment recommendations and ensure that none limit future options.

December 30, 2012

Epidural Steroid Injections: Risks

epidural-steroid-injections
At the Centeno-Schultz Clinic we acknowledge the pain, frustration and restriction in activity associated lumbar and cervical degenerative disc disease. Advanced treatment options include Regenexx PL where platelet growth factors are injected into the epidural space at the level of the degeneration or injury. The platelet growth factors increase the blood flow and increase inflammation.

High dose epidural steroids are utilized to treat lumbar and cervical disc disorders. Unfortunately the number of complications and risks associated with epidural steroids continues to increase.
Risks:
significant bone loss

suppression of hypothalamus-pituitary-adrenal (HPA) axis

elevation of blood glucose in diabetic patients

breakdown of  cartilage in animal studies

– ligament failure and breakdown.

In addition there is a signficant increase in the incidence of bone osteonecrosis in patients taking oral steroids.

In 2013 consider the risks associated with steroid injections and investigate the option of platelet derived growth factors.

October 6, 2012

Sacroiliac Joint Ligaments: Importance of Stability

In a previous blog, the sacroiliac joint has been discussed as a source of lower back, buttock and posterior leg pain.

The importance of stability has been discussed in Ortho 2.0.  There are 4 central components:  Stability, Articulation (joint), Neuromuscular, and Symmetry (SANS).

Treatment options of sacroiliac joint dysfunction at the Centeno-Schultz Clinic include prolotherapy, PRP, IMS and autologous stem cell therapy.

The stability of the SI joint is dependent upon the integrity of the supporting ligaments.

These ligament include:

Dorsal  sacroiliac ligament:  joins the sacrum and the ilium and is composed of the long and short posterior SI ligaments.

iliolumbar ligament:    stretches from the transverse process of  L5 to iliac crest.

sacrospinous ligament:   triangular in shape attached by its apex to the ischial spine and medially, by its broad base, to the lateral margins of the  sacrum and coccyx.

sacrococcygeal ligaments:  stretches from the sacrum to the coccyx and thus dorsally across the sacrococcygeal symphysis.

Sacrotuberous ligament:  stretches from sacrum to the tuberosity of the ischium.

September 22, 2012

Sacroiliac Joint Dysfunction: A Cause of Back, buttock and Leg Pain

At the Centeno-Schultz Clinic we acknowledge that sacroiliac joint can be a cause of lower back and buttock pain.

The sacroiliac joint (SIJ) is the joint between the sacrum and the ilium of the pelvis.  It is a  synovial joint characterized by a capsule surrounding the articulating surfaces and synovial fluid.  The stability of the SI joint is maintained through an extensive number of ligaments.  Stability is critical as discussed in Ortho 2.0.

The function of the SIJ is to dissipate loads of the torso through the pelvis to the lower extremities.

Clinical presentation varies but commonly involves unilateral back and buttock pain  originating at the PSIS which can be dull ,sharp, stabbing, or knife-like

Slipman demonstrated pain in various areas including lower back (72%), buttock (94%) and lower leg (50%).

Causes of SI joint dysfunction include mechanical dysfunction, inflammation, lumbar fusion, trauma, degeneration and pregnancy.

 A comprehensive study at Hopkins demonstrated the incidence of sacroiliac joint pain is between 15% to 25% in patients with axial low back pain.

Diagnosis can be made by provocative physical examination manuevers which include Gaenslen and FABER test.

The gold standard is injecting SIJ under intermittent x-ray with local anesthetic and steroid with the patient reporting signficant reduction in pain.

Treatment options include physical therapy, IMS, prolotherapy, PRP and autologous stem cells.

September 16, 2012

Prolotherapy: Creating Stability

At the Centeno-Schultz Clinic stability is a central theme.  The importance of stability is discussed in Ortho 2.0.   The integrity of a joint is directly related to its stability.  Joint instability predisposes to additional injury and acceleration of the degenerative process.

Stability is the foundation or structural support of a joint.  A crumbling or weak foundation can not support a tall structure.   Instability can not support an active, healthy joint.

At the Centeno-Schultz Clinic prolotherapy is an effective treatment for joint instability.  Prolotherapy is regenerative injection procedure where a chemical irritant is used to cause a chemical micro-injury.  The irritant stimulates the body’s healing mechanism to repair and strengthen the degenerative and weakened tissues.  Prolotherapy initiates a three stage healing process:

Inflammatory:  occurs within the first week characterized by increased blood flow and swelling.

Fibroblastic:  1-6 weeks with fbroblasts creating new collagen and repairing injured tissue.

Maturation:  after 6 weeks characterized by stronger, more organized tissue.

Clinical examples where prolotherapy can be used to create stability include:

Supra and interspinous ligaments in lumbar spine.

Tendinosis & tendonitis of rotator cuff.

Lateral and medial epicondylitis.

Ankle sprains.

Antibiotic induced tendon damage.

ACL laxity or small tears.  Autologous stem cell therapy has been successfully used in full thickness tears in the ACL.

Stability is critical and prolotherapy is an effective therapy to stabilize a joint.

January 9, 2012

Narcotic Risk: FDA issues public health advisory

The Centeno-Schultz Clinic acknowledges the dangers of utilizing narcotics in managing chronic spine pain.  These include addiction, tolerance requiring escalating doses. cognitive and behaviour changes and death.  The Centeno-Schultz Clinic offers comprehensive spine care including facet and epidural injectionsunder x-raySI joint injections, prolotherapy and radiofrequencyStem cell therapy is an alternative to traditional spinal surgeryRegenexx PL utilities platelet derived growth factors to enhance blood flow and reduce inflammation. Previous blogs have discussed the successful use of stem cells for spine pain.

Medication mix ups or mislabeled has potentially serious consequences.

Today the FDA has issued a warning that pills, tablets, or caplets of Percocet and eight other opioid products packaged by Novartis for Endo Pharmaceuticals may have been mixed up, with one drug being packaged as another.

Patients beware!

December 30, 2011

Low Back Pain: Cluneal Nerve Entrapment

At the Centeno-Schultz Clinic we acknowledge that low back pain can arise from the lumbar facets, intervertebral disc and the sacroiliac joint.

An overlooked cause of low back pain is entrapment of the superior cluneal nerve.

The cluneal nerve is compromised of the posterior rami of L1, L2 and L3 and provides sensation to the upper buttocks.

Three distributions of the cutaneous branches of the nerve exist.   Lu et al described the anatomical relationship of the superior cluneal nerve to the posterior iliac crest.  The medial branch of the superior cluneal nerve is confined within a tunnel consisting of fascia and the superior rim of the iliac crest.    The location is 7-8 cm lateral to the spinous process on the iliac crest.  It is lateral and superior to the posterior superior iliac spine.

The nerve can be entrapped between the fascia and the iliac crest causing pain and restriction in motion.  This is similar to carpal tunnel syndrome where the fascia constricts the median nerve.

Case reports  have documented the entrapment of the superior cluneal nerve as a cause of unilateral back and buttock pain.  Patients who have undergone iliac crest bone grafts for lumbar fusions are at risk for entrapment.  Stem cell therapy is an alternative to spinal surgery and fusions.

The Centeno-Schultz Clinic is committed to establishing an accurate diagnosis so effective treatment can be started and you can return to your passions.

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December 26, 2011

Low Back Pain: Think Lumbar Facet

At the Centeno-Schultz Clinic we are committed to identifying the source of a given patient’s pain.  Back pain can arise from many sources which include dysfunctional muscles, structural instability, facet joint, sacroiliac joint and  disc degeneration.  Ortho 2.0 details the importance of function and stability.

The lumbar facet joint is a small joint in the posterior portion of the spine that is composed of the superior articular process of one vertebrae and the inferior articular process of vertebrae directly below it.  Similar to the knee-joint,  the facet joint is lined with cartilage which allows for  smooth and  painless motion.  It functions to limit the movement of each spinal  motion segment.  Trauma, instability and degeneration can cause damage to the cartilage lined joint resulting in pain.  Conventional radio-graphic studies often times fail to demonstrate facet injury.  Diagnosis is made by injection of local anesthetic into the joint (intra-articular facet injections) or medial branch blocks.

AB is 36 y/o patient with 10year history of low back pain, constant in duration, progressive in nature over the last 11 months, localized in lumbar region right>left with radiations into hips.  Pain was sharp and throbbing.  Aggravating factors included prolonged walking, sitting and running.

Alleviating factors:  percoset, ice and rest.

Treatment to date included PT, chiropractic care, oral narcotics and muscles relaxants.  Patient had undergone two  lumber epidural steroid injections without significant benefit.

MRI of lumbar spine was significant for mild disc degeneration at L4/5, L5/S1 and facet degeneration at L4/5 and L5/S1.

Patient presented to Centeno-Schultz Clinic frustrated with the treatment to date and lack of  improvement.  She underwent x-ray guided injection into the lumbar facet joints which has provided her significant and sustained benefit.

Rather than relying exclusively on the MRI which demonstrated degeneration of the lumbar discs we took history and performed a thorough physical examination which was significant for lumbar facet dysfunction.

Comprehensive care is our commitment at the Centeno-Schultz Clinic.  In order to save a joint not only do you need to know how to help that joint, but you also need to know how it got that way in the first place.

September 30, 2011

Epidural Fat and Resultant Narrowing of the Lumbar Canal: A Complication of Epidrual Steroids

Epidural steroid injections are a common treatment for back and extremity pain.  Steroid injections have been associated with complications with include  changes in blood glucose and cortisol levels, infection. apotosis( programmed cellular death), damage to cartilage and the development of  avascular necrosis .   At the Centeno-Schultz Clinic platelet derived growth factors are been used  successfully in the treatment of cervical and lumbar pain.  A  patient who failed traditional epidural steroidshad signficant improvement after Regenexx PL epidural injections.

accumulation of fat around the epidural space can occur as the result of epidural steroid injections.  Narrowing the canal can cause  compression of spinal nerves with resultant pain and restriction in level of activity,

Tok reported a case where a patient developed neurologic symptoms secondary to abnormal epidural fat after a single epidural injection. Sandberg reports symptomatic compression of the neural elements from  excessive epidural fat after repeated epidural steroid injections.

 McCullen reported a similar case   after multiple steroid injections.

Fogel in at literature review and meta analysis demonstrated that exogenous steroid use, obesity and endogenous steroid excess are all associated with symptomatic epidural fat accumulation.

RW is a 45 y/o patient with chronic lower back pain who had received a larger number of lumbar epidural steroid injections from a local pain practice.  He transferred his care to the Centeno-Schultz Clinic.   RW’s lower back pain had escalated in severity.  His most recent lumbar spine MRI was significant for two level narrowing of the spinal canal in part due to a large accumulation of  epidural fat which was not present years prior.  The image below is RW’s most recent MRI.  The blue arrow identities the narrowing of the spinal canal at the L5/S1 level due to multiple steroid injections.

July 13, 2011

Lumbar Fusion: Adjacent Level Degeneration

Lumbar fusion is surgical procedure whereby the interverbral discs are fused in an effort to relieve pain.  The lumbar discs function as a shock absorber to absorb the forces of daily activity.

Do lumbar fusions impact the way in which our bodies manage the forces and stresses of daily activity?    Do they alter the body’s biomechanics?

Yes!

In a previous blog I have discussed the increased forces placed on the SI joint after lumbar fusion.  Clinically this often results in SI joint dysfunction and buttock and leg pain.

Are the discs above and below the fusion segment at risk for degeneration?

Ghiselli demonstrated the rate of symptomatic degeneration at an adjacent segment was 16.5% at five years and 36.1 at ten years.  The study involved 215 patients who had undergone lumbar fusion.  The average duration of followup was 6.7 years.

Bottom Line:  Lumbar fusion places you at risk for future surgeries.  Ghiselli demonstrated that at 10 years over 1/3 of  patients who underwent lumbar fusion had subsequent lumbar decompression or fusion at ten years.

BG is a case in point.  He is a 57 y/o patient who underwent L5/S1 fusion in 1992.  In 2005 the fusion was extended to L3/4 and L4/5 due to pain.  In 2008 a third fusion performed which involved the L2/3.   This month he presented to clinic with severe back and groin pain with an MRI significant for advanced degeneration at the L1/2 disc level with disc herniation.  He is tentatively scheduled for his fourth fusion.

The Centeno-Schultz Clinic offers non surgical alternatives for the treatment of lumbar degnerative disc and leg pain.

 

 

 

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