Stemcelldoc's Weblog

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.

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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.

August 12, 2011

Sacroiliac Joint Pain: Not limited to Back and Buttock

The sacroiliac joint (SI) is the joint between the sacrum, the base of the spine, and the ilium of the pelvis. 

Frequently it is a cause of pain in patients who have undergone lumbar fusions and traumatic injuries.

ST is 47 y/o active patient with 4 year history of left buttock pain which was constant in duration, progressive in nature with radiations into the left lateral thigh extending down calf and into the fourth and fifth digits of left foot.  Buttock pain was aching and throbbing whereas  the leg pain is ‘nerve’ like with intermittent sharp electrical sensations. Patient is active in volleyball and cycling.  Physical examination was significant for positive  Fortin test and patrick test.

ST was surprised of by the diagnosis of SI joint dysfunction.  Surely this was irritation of the nerve root caused by a protruding lumbar disc.

Can SI joint be responsible for lower extremity pain?

Yes !

Slipman demonstrated that SI joint pain is not limited to the lumbar region and buttock.  50 patients were evaluated who had confirmed Si joint dysfunction. 94 % of patient described buttock pain whereas 50% of patients had lower extremity pain, 28% had leg pain distal to the knee and 14% reported foot pain.

Not all lower back, buttock and leg pain arises from disc disease.

At the Centeno-Schultz Clinic we are committed to making the correct diagnosis.  Treatment options for sacroiliac joint dysfunction includes prolotherapy, PRP and bone marrrow derived stem cells.

July 7, 2011

Buttock Pain After Lumbar Fusion

Fusion of the lumbar spine is commonly performed for low back and leg pain. Pain relief varies from minor to moderate.  Unfortunately  fusion of the lumbar spine can result in complications or the development of a new type of pain.

 EB is a case in point.  EB is a 50y/o patient who underwent two level fusion for severe lower back and leg pain which was refractory to conservative therapy.  While her leg pain improved her lower back pain remained unchanged and she developed new buttock pain which was constant in duration, progressive in nature, localized deep in her buttock with radiations into the posterior thigh.  Physical examination was significant for tenderness over the PSIS and a  positive Patrick’s test. EB  had developed sacroiliac joint dysfunction as a result of her lumbar fusion.

The sacroiliac Joint (SI) is the joint in the bony pelvis between the sacrum and the ilium.  It functions as a major shock absorpter for the spine.  Removal of some of the shock absorbers of the spine puts additional forces and strain on the SI jont leading to pain and dysfunction.

The SI joint, its anatomy, physiology and clinical significance is well documented.

Symptoms: Unilateral pain which if severe enought can refer into hip, groin and down the posterior thigh.

Engineeers have demonstrated increased stresses and motion in SI joint following lumbar fusion.

Katz demonstrated that SI joint dysfunction was a cause of pain in 32% of patients with low back pain after lumbar fusion.

At the Centeno-Schultz Clinic EB underwent x-ray guided injections of the prolotherapy into the joint and supporting ligaments with greater than 75% benefit.   Patients unresponsive to prolotherapy have undergone SI injections with Regenexx SCP, Regenexx SD and Regenexx PL with good success.

March 13, 2011

Nutrition and Stem Cell Therapy

Is there a correlation between nutrition and osteoarthritis?

Yes!

At the Centeno-Schultz Clinic and Regenexx we acknowledge the critical role between the two.

1 in 5 patients have metabolic syndrome characterized by central obesity, hypertension and elevated lipids and serum glucose. This syndrome results in the release of detrimental chemicals into the joints which can lead to the breakdown of cartilage matrix.

These same patients do poorly with knee and hip replacements due principally to the systemic proinflammatory state.

Obesity and hyperglycemia are associated with increased infection rates after knee replacements.

Diets rich in carbohydrates, refined sugar and processed food can promote a pre-diabetic state.   SIRT-1 gene expression plays an important role in circulating blood sugars levels and joint health.   Activation of SIRT-1 gene by dietary restriction and Resveratrol is associated with healthy cartilage.  Inactivation of SIRT-1 gene, commonly seen with aging and diets high in refined sugar and carbohydrates results in increased body fat, decreased energy and cartilage cells becoming less stable.  This can become the perfect storm for the onset of osteoarthritis.

In counseling deconditioned and overweight patients with osteoarthritic and musculoskeletal injuries, the Centeno-Schultz Clinic recommends at a minimum diet modification and increased activity levels.  These efforts are taken in an effort to optimize clinical outcomes from Regenexx SD, Regenexx AD and Regenexx SCP therapies.

May 31, 2010

Essential Differences in PRP Therapies

Platelet rich plasma (PRP) therapy is the use of a patient’s own platelets to accelerate healing.  It is termed rich because the platelets are concentrated, typically 5-10x above the concentration that is circulating in your blood.

PRP therapy has been used for a number of different indications  including wound healing in surgery,tendinitis, cardiac care and dental health.

Platelet-rich plasma (PRP) therapy made headlines following the Super Bowl, when it was revealed that Pittsburgh Steelers Hines Ward and Troy Polamalu had undergone PRP injections in the days leading up to the game.

Are all PRP therapies the same?

NO.

There are distinct differences in platelet rich plasma .

Most PRP is created by a bedside machine that creates a platelet concentrate by spinning (centrifuge) the blood thereby separating the platelets from the other blood products.

A cell biologist in a laboratory, however,  is able to separate the platelet from other blood products and so much more.

A cell biologist can create PRP that is pure and free of any red or white blood cells.  A machine cannot.

A cell biologist can create PRP in a specific concentration for specific indications.  A machine cannot.

A cell biologist can make PRP that has a very high levels of specific, naturally occurring growth factors such as VGEF, vascular  growth endothelial factor.  A machine cannot.

At the  Centeno-Schultz Clinic we are not reliant on a machine.  Rather through the use of a state of the art lab with full-time cell biologists we are able to provide our patients with customized PRP therapies that are specifically designed for them.  This is the critical difference which translates to improved outcome.

January 26, 2010

New Perspective: Ortho 2.0

Everyone told Christopher Columbus that the world was flat.   

 Friends told the Wright brothers that birds were the only creatures capable of flight.  

    

A paradigm shift was required.  This also applies to medicine. The time has come to focus not on joint replacement but on joint restoration and repair.     Dr. Centeno has termed this Ortho 2.o.   Ortho 2.0 has a bigger focus beyond just fixing one part of the musculoskeletal system (bone, joints, muscles, tendon, and ligaments).   When the focus shifts to repair, the amount one needs to know about the joint increases exponentially.  There are four principal elements which are addressed when evaluating a gvien joint: (S.A.N.A.)   

ORTHO 2.0 : S.A.N.A.

  S: stabilization   

A: articulation   

 N: neurologic   

 A: alignment   

 Injection of magic stem cells alone is not sufficient for joint restoration.  Multiple studies have shown that just injecting stem cells into a joint blindly is not that effective.  For the best clinical outcomes, each of the factors listed above must be evaluated and treated. At Regenerative Sciences and The Centeno-Schultz Clinic this is the standard.  Case examples utilizing the S.A.N.A. paradigm will be in future blogs.   

It is truly a new day:)    

November 29, 2009

MISLEADING MRI: The picture does not tell the whole story

In a previous blog, I have discussed the limitations of MRI’s in identifying the source of a given patient’s pain.  A clinical evaluation today illustrates this point.

35y/o athletic patient presented with a 4 year history of lower back pain, constant in duration, 6/10 in severity, progressive in nature, localized in left lower back and buttock area without any radiations into his leg.  Pain which was aching in character was aggravated by prolonged sitting, standing and twisting.

Treatment to date had included massage, chiropractic care, physical therapy, trial of anti-inflammatory agents, narcotics and a surgical evaluation.

Physical examination was significant for tenderness in the left lower spine and buttocks with no neurologic abnormalities.  Direct pressure applied to the mid-buttock was painful.

MRI of the lumbar spine was significant for advanced degeneration of the L5/S1 disc and bone swelling.

The patient was convinced that his pain was arising from the degenerative lumbar disc.  Family members, his primary care physician and surgeon endorsed this view.  The surgeon had recommended lumbar fusion to relieve his pain.

Low back pain can arise from many structures including muscle, ligament, facet, disc and sacro-illac joint (SI). Evaluation to determine the source of the pain had not been performed.  At the Centeno-Schultz Clinic this is achieved by injecting a small volume of local anesthetic under x-ray into a specific targeted tissue.  If the pain is significantly relieved from the injection, the pain generator has been identified and an appropriate treatment plan can be created.  Often without such diagnostic evaluations, the source of a given patient’s pain cannot be established and therefore the patient is at risk for incorrect diagnosis and therapy.

November 10, 2009

Regenerative Sciences Heads to South America

peru-machu-picchu

Regenerative Sciences, a Colorado based autologous mesenchymal stem cell therapy clinic focused on orthopedic applications, signed a licensing agreement with industry leader Stematix to bring the Regenexx procedure to various parts of South america.  From the press release:

David C. Bonner, Ph.D., Chairman and CEO of Stematix, said, “We at Stematix are excited to be working with Regenexx, the leaders in applied regenerative medicine for orthopedic. We anticipate that this cutting edge, proven treatment will provide needed care for many patients in clinics established in Latin America. We are working toward a first clinic in Argentina during 2010. The expertise and experience of Dr. Centeno and Dr. Schulz will be invaluable in establishing our clinic in Argentina, and we look forward to incorporating advances in the treatment methodology that the Regenexx clinic in Denver will lead. “

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