Stem Cell Therapy for Lumbar Degenerative Disc Disease: Update

Low back pain is a common problem.  Episodic discomfort following purposeful activity is typically self-limited.

The problem is when that knife in your back, that lancinating pain that takes your breath away with minor motion becomes chronic. Physical therapy and myofascial deactivation are often helpful in breaking that cycle.  At the Centeno-Schultz Clinic, when conservative therapies fail, x-ray guided epidural  injections of low dose corticosteroid or platelet derived growth factors are used and can be beneficial.  Unfortunately some patients do not respond to conservative therapy.

NQ is a 39 y/o patient with 3 yr history of lower back pain who failed to respond to conservative and injection therapy.  She declined surgery and opted for the Regenexx procedure which afforded her the opportunity to use her own stem cells.  NQ had her own mesenchymal stem cells injected into the posterior aspect of her L5/S1 disc on .

 NQ returned to clinic today, 4 months post injection reporting  50% improvement in her lower back pain.  She has been able to increase her level of activity and is enjoying the summer with her family.

This corresponds with her postprocedure MRI which is below.  There is a reduction in the size of the disc bulge which is identified by the red arrows.  The diameter of the spinal canal is increased from 0.9cm preprocedure to 1.1cm postprocedure due to a reduction in the size of the disc protrusion.   Stem cell therapy for lumbar degenerative disc disease holds great promise as it eliminates the risks of anesthesia/surgery and the often profound biomechanical changes that occur as a result of cutting through and compromising the integrity of supporting ligaments, muscle and fascia.

Low Back and Leg Pain Successfully Treated with Stem Cells

A disc protrusion can cause severe lower back and leg pain.  Treatment options vary from conservative to surgical.  Conservative therapies often include physical therapy, the use of muscle relaxants, non-steroidal anti-inflammatory medications and narcotics.  Surgical options include trimming the protruding disc through a large incision, a small incision with the assistance of a microscope or laser.  Some studies have demonstrated that surgical repair of a disc protrusion places the patient at increased risk for subsequent back problems in the future.

NQ is a 30+ y/o patient who has a long-standing history of lower back and leg pain.  She had undone conservative therapy in addition to epidural steroid injections with little sustained benefit.  She elected to undergo the Regenexx procedure where she used her own culture expanded cells to treat her back and leg pain.  Her own bone marrow derived stem cells were grown in a state of the art lab and then injected under x-ray into the disc protrusion.  thirty days after injection NQ reports a 90% reduction in her leg back and 40% improvement in her low back pain.   Her lumbar spine MRI shows improvement as illustrated below.    Two matching slices from several months before the procedure (on the left) and two from one month after the procedure (on the right). These are side views of the spine and since MRI’s literally slice across an area, I have included two slices to be as accurate as possible. The images are on an ultra high field magnet (3.0 T) and are also closely matched for imaging parameters (Before=Sag STIR: ET-12, TR-4166.7, TE-37.3; After=ET-12, TR-4166.7, TE-37.3). Note the red arrows in the before images show a large disc bulge that the yellow arrows in the after images show has been reduced.

She has been able to increase her level of activity and is enjoying this Memorial Day weekend with her family.

Theraupatic Lumbar Discogram?

Lumbar discography is procedure in which a needle is placed into the disc at two or more levels to determine whether of not a specific disc is the  source of pain.  Is the pain coming from the L4/5 disc or the L5/S1 disc?  The procedure is performed with intermittent x-ray.  Once the needles are in the center of each disc,  contrast is injected into the disc.   A patient’s response is graded as follows:

P0:  no pain:  a common response in a healthy disc

P1:  painful, but not identical in quality or location to the patient’s daily pain.

P2:  painful, identical in character, quality and location.

Discograms are strictly a pre-surigcal procedure which tells the surgeon which level to operate.  They have no therapeutic benefit.  I have had two discograms and they HURT!

A recent study demonstrated that lumbar discograms accelerate disc degneration.

Patients are often  misinformed about discograms.

AJ was a 23y/o with 6 month history of low back pain following a rear-end motor vehicle injury.  Pain was constant in duration, 6/10 in severity, progressive in nature and  localized in her lower back, right =left with radiations into her buttocks.  MRI was significant for mild degeneration of the L5/S1 disc. Physical examination was significant for tenderness in the lower lumbar spine with extension and rotation.  She had no treatment to date:  no physical therapy, chiropractic care, trial of good quality fish oil, massage or evaluation by a pain specialist.  Her PCP referred her to a surgeon for evaluation of her back pain.  She was scheduled for a discogram which she thought was going to help here back pain.

 Evaluation of all possible sources of pain is essential.  For lumbar back pain common causes include:

myofascial: dysfunctional muscles 

facet dysfunction:

ligamental dysfunction: treated with proloterhapy

SI joint dysfunction:

Disc dysfunction.

The Centeno-Schultz Clinic is committed to identifying the cause of a patient’s pain and designing an proper treatment plan utilizing state of the art therapies.

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.

Another FDA Recall

Today the FDA recalled Synex II vertebral implants.  The implants were recalled because they pose an imminent  health hazard.  Six adverse event reports have been  filed to date which demonstrated moderate to severe loss of vertebral body replacement height. Other potential complications included neural injury, increased pain and need for reoperation/revision surgery. Synthes had a previous recall in Feb 2009.

In a press release Synthes advised: “that surgeons and hospitals in possession of the subject devices must stop implanting them immediately.”

Vertebral implants are utilized in lumbar spine surgery and were thought to have a potential advantage over conventional fusion techniques.

Vertebral Implant

Surgery is a one way door:  once undertaken one can only move forward.  Complications are part of the risks of surgery. Removal of the disc, which functions as a shock absorber, can result in pressure overload in adjacent levels thereby advancing the degenerative casade.

A non-surgical option for the treatment of lumbar disc disease is the use of your own stem cells.  Utilizing the Regenexx procedure, patients have had reduction in their back and leg pain.

Epidural Steroids Injections and Strokes

Epidural steroid injection are commonly used to treat lumbar degenerative disc disease, lumbar disc protrusions and herniations.

The epidural space contains fat, blood vessels and lymphatics.

 

Steroid injections into the epidural space can inadvertently reach the blood vessels.

The significant is twofold.  First the patient is unlikely to get clinical relief of their pain since the injection went into the blood vessels instead of  the intended target:  the nerve root and disc.

The second is more concerning. Injection of steroids into the artery can result in stroke and death.  Dawley recently demonstrated the  arterial injection of steroids lead to cerebral hemorrhage by obstructing the microvasculture as well as the toxicity of the steroid.

I have previously blogged on the mounting concerns over steroid injections.

Alternative  therapies for spine and joint pain include PRP, activated PRP, prolotherapy and autologous stem cell therapy.

PRP Therapy for Lumbar Disc Protrusion

The  lumbar disc is composed of two principal parts: the inner jelly(nucleus pulposis) and the outer side wall(annulus).  The annulus provides support similar to that of the side wall of your tire.  If the side wall (annulus) becomes weakened, it can bow out.  When this occurs it is referred to as a disc protrusion, herniation or extrusion depending upon how far it protrudes  outwardly.  The protruding disc can be painful itself or it can press upon a nerve root causing leg pain.

Steroid injections have been use for lumbar disc protrusions however there is concern over the side-effects of high dose steroids as  previously discussed.

PRP injections are rich in platelet derived growth factors which have the potential of  increasing blood flow and therefore healing of the disc.

 The Centeno-Schultz utilizes various types of PRP to treat lumbar disc disease.   Examples  include platelet poor plasma, plasma lysate and activated PRP.  Patient specific platelet rich plasma injections created in a state of the art lab as opposed to those created by portable centrifuge units   are just another example of how theCenteno-Schultz Clinic distinguishes itself.

Understanding Your Lumbar Spine MRI

The lumbar spine is compromised of several principal elements:  the vertebral bodies, discs, spinal cord and spinal fluid.

All these structures can be identified on a schematic as well as an MRI of the spine.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 The vertebral bodies are the building blocks of the spine. There are 5 lumbar vertebral bodies

The disc is a shock absorber that is positioned between each disc.  A normal disc is contains water and therefore is bright white in color on certain types of MRI images (T2 images).

The spinal cord is a long thin bundle of nervous tissue that conducts information from the brain to the peripheral nervous system.

The spinal fluid bathes the spinal cord in fluid.

Injury to the disc can result in disc protrusions, tears in the outer fibers of the disc, reduction in disc height and pain.  At the Centeno-Schultz Clinic it is our goal to identify the source of a patient’s pain.  Regenerative therapies include prolotherapy, PRP and injection of autologous mesenchymal stem cells utilizing the Regenexx procedure.

Stem Cell Therapy for Lumbar Disc Protrusions

Lumbar disc protrusions can cause lower back and leg pain which can vary from mild to severe.

Today in clinic, I had the opportunity to followup with a patient who underwent autologous stem cell therapy using the Regenexx procedure.  He has kindly allowed me to share his experience. Patient is a 37-year-old male with longstanding lower back and leg pain.  The back pain was sharp in character, constant in duration, progressive in nature and aggravated by coughing, sneezing and flexion.  He would experience episodic pain which would incapacitate him.  Physical examination was significant for lower back pain aggravated by flexion, extension and straight leg raise.

Micro-discectomy and other surgical treatments were dismissed by the patient and his family.

 4 weeks after having his own stem cells injected into the L5/S1 disc along with platelet derived growth factors, the patient had significant reduction in his back and leg pain.  MRI prior to and after stem cell therapy was significant for a reduction in the L5/S1 protrusion which is illustrated below.

 

 

 

 

 

 

 

 

 

 

 

MRI of Lumbar Spine: Stem Cell Therapy

The lumbar disc functions as a shock absorber.  There is a lumbar disc between each lumbar vertebral body.

Lumbar discs are compromised of a supportive side-wall called the annulus fibrous and the inner gel referred to as the nucleus pulposus.  With degeneration there is weakening of the side wall with bulging of the disc.  The disc itself also looses height and brightness.  On the MRI, the disc will be shorter and darker.

To strengthen the side wall, patients can undergo the Regenexx  procedure where their own  mesenchymal stem cells are injected into the disc. This regenerative in design as opposed a    microdiscectomy where a “nip and tuck” is performed on disc protrusion.  This latter procedure disrupts the integrity of the disc and increases risk of degeneration and recurrent protrusion or herniation.

On Left Note L5/S1 Protrusion which significantly resolved after Regenexx Therapy