Let It Grow: The Role of VEGF

 

 

Everyone knows that a seed will not grow without sufficient nutrients and water.

So to with stem cells when implanted in an area that is low or deficient in nutrients.  Blood flow is the key to cellular growth.  No blood flow, no growth.

Lumbar discs have poor blood supply.  One of the growth factors derived from platelets has been utilized to enhance blood flow to lumbar disc and the stem cells which have been implanted in them.  The growth factor is VEGF :Vascular Endothelial Growth Factor.  It has the capacity to create new blood vessels (angiogensis) thereby enhancing nutrient flow.

A case series of patients who underwent implantation of autologous mesenchymal stem cells into the symptomic disc had injections of concentrated VEGF.  66% of patients had a significant reduction in pain.  The before and after stem cell therapy MRI’s clearly demonstrate a reduction in the size of the disc protrusions.

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The Importance of Blood Supply

Blood supply to a given structure provides essential nutrients for growth, maintenance and repair.  Some structures such as the heart have a rich blood supply with multiple arteries.  Other structures have a very limited, tenuous blood supply which places them at risk for impaired growth, repair and potential cellular death. The lumbar intervertebral disc is such a structure.  While it is the cornerstone of our spine and bears the weight of our bodies as we walk, its blood supply is extremely limited.

What does this mean?  If injuries occur the lumbar disc has limited capability of repairing itself due to its very limited blood supply.  The result is a slow insidious degeneration of the lumbar disc characterized by reduction in disc height and signal.  The MRI  below on the left illustrates a degenerative L5/S1 disc.  The blue arrow identifies the spinal cord, the red arrow is pointing to the cerebral spinal fluid and the black arrow identifies the L3/4 disc.  Note the L3/4 disc has a white signal within the disc which represents hydration.  It also is identical in height and brightness to the disc above it.  Both of these discs are normal.  The white arrow identifies a degenerative L5/S1 disc which is black in color with reduction in height in comparison to the adjacent discs.

Degeneration of lumbar spine

 With injury there is also a propensity to develop bulges since the integrity of the side wall (annulus fibrosis) is compromised. 

Disc Bulge

 If sufficient damage occurs, a disc bulge can progresses to a disc herniation where an portion of  the inner contents of the disc (nucleus pulposus) are extruded.

Lumbar Disc Herniation

In a previous blog I discussed the importance of platelets and the four major growth factors they contain:   Platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-b), vascular endothelial growth factor (VEGF) and epithelial growth factor (EGF). Vascular endothelial factor is responsible for angiogenesis (the creation of  new blood vessels).  These new blood vessels can provide essential nutrients to repair damaged tissue.  At Regenexx we injected concentrated VEGF adjacent a degenerative disc with the hope of improving blood flow and initiating repair.  Please see MRI results below.  On the left are MRI images of the L5/S1 disc prior to therapy.  Note there is a reduction in height and brightness of the L5/S1 disc.  On the right are MRI images of the same L5/S1 disc after therapy.  Note an increase in the height and the signal of the disc.  There is significant improvement in the disc height and signal.  What is the significance?  This is a patient who despite prior back surgery continued to have pain.  After therapy at Regenexx the patient had near complete resolution of pain as well as MRI evidence of lumbar disc repair.

Before and after therapy of L5/S1 Disc

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Lumbar Epidural Steroid Injections

Lumbar epidural steroid injections are a common therapy for patients with lower back and leg pain as  a result of a disc bulge or herniation.   If the disc is bulging or herniated it can compress the nerve root causing leg pain and or weakness.

The epidural space is a area around the spinal cord and is adjacent to the disc.

Injection into this space allows medication to bathe the irritated nerve root and disc.   One can think of an epidural steroid injection as putting water on a large fire.  At the Centeno-Schultz Clinic all epidural steroid injections are performed under x-ray to ensure accurate placement of medication.  Unlike other clinics,  we do not use the conventional high concentrations of steroids.  For example most epidural steroid injections use  4 or more milligrams of steroids.  At the Centeno-Schultz Clinic we use only nano-grams concentrations because it is closer to the dose that the body uses naturally.  It also avoids the adverse effects of steroids which include suppression of immune and renal function, itching, increase in epidural fat, deterioration of the outer annuls of the disc, insomnia and weight gain.  If steroid therapy is not effective or not attractive to the patient,  through Regenexx we have the ability to inject natural growth factors  such as platelet lysate of VEGF supernatant into the epidural space.  These factors not only provide an anti-inflammatory effect for the irritated nerve and disc but they also promote increased blood blow to the disc and therefore healing.

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