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One Year Post Op on a Low Back Disc Bulge Treated with Stem Cell Injection

Wednesday, February 3rd, 2010

One of the problems with damaged discs is that they tend to go one direction, they degenerate with time. This is one of the big issues for most patients who have low back surgery (laser spine surgery included, micro surgeries, minimally invasive low back surgery, to the disc it’s all the same). Since the surgeon removes parts and pieces of the disc (again doesn’t matter if it’s vaporized with a laser or pulled out with a surgical instrument), the disc continues to collapse in height and lose water (likely at a faster pace due to the surgery). We get a short term gain (less pressure on a nerve) and create a bigger long-term problem (the disc now degenerates faster) As it does this and the years pass, more arthritis forms and this can press on more nerves. In the end, the cells inside the disc die off with time. Not so long ago, I blogged on an animal paper which showed that mesenchymal stem cells, when re-implanted into a degenerated disc, stopped the progression of degeneration in it’s tracks. Yesterday, we got one year follow-up films back on an a study patient who had her large L5-S1 disc bulge treated by injecting stem cells into the bulge, rather than surgery. The films below show that the disc bulge is still smaller than it was before the stem cell injection and perhaps getting a bit smaller:

stem cell injection into low back disc to avoid low back surgery

If you look at the before image to the left (above), the disc bulge is bigger before stem cell injection, the one year follow-up after stem cell injection on the right shows a smaller bulge. While that’s great news, the more interesting issue is what happened to the non-treated L4-L5 disc. This disc serves as a control, meaning what happens to it is what the treated disc should be doing if it continued to degenerate. What’s happening to the non-treated disc above the treated disc?

stem cell injection to avoid low back surgery

The untreated disc (L4-L5) has indeed continued to degenerate as expected. In the MRI’s above, it’s lost 1 mm in height and has a bigger bulge as well as seems to be holding onto less water (darker on MRI). What happened to the treated disc during this time? No loss in height, no loss in water content, disc bulge size is still smaller than pre-treatment. This is interesting, as it may mean that the normal degenerative process (discs get darker, lose height, and bulge more over time) has been slowed or possibly stopped for now.

Tags: avoid, buldge, bulge, disc, don't want, injection, low back, stem cell, surgery, therapy, Treatment, treatments
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Ortho 2.0 and a facet cyst causing a low back problem…

Monday, November 2nd, 2009

To further synthesize more concepts of why it’s important to figure out how the musculoskeletal system failed in order to strategize how it can be fixed, I present this am an interesting case of a patient from Boston who had a serious fall from a bike about three years ago. He injured his shoulder, kidney, and hip. When he was first evaluated for stem cell treatment of his hip, I was concerned about his low back. While stem cells in the hip helped the hip pain (he now now walk faster through an airport), over the ensuing year he continued to develop problems in his low back and leg. He was finally was diagnosed with a cyst on his right L4-L5 facet joint, which was pressing on a nerve and giving him pain down the leg. The facet joints are small joints in the back, and sometimes arthritis of the joints can result in a cyst (just like a swollen knee joint can develop a Baker’s cyst). These cysts can press on spinal nerves, so they can be a double whammy for the patient. In Boston, he had the facet cyst treated with a steroid injection to pop the cyst. This helped some of the leg symptoims and severe nerve pain, but by the time I re-examined him recently, his back was pretty bad (unable to stand straight). This was impacting his work as a university physician. While knowing he has a facet cyst is a good strat to helping, asking the question of how he got that way is important if this is going to be sucessfully treated with surgical fusion of this level. His case is a good example of the ortho 2.0 concept. Consider the ortho 2.0 pyramid below, in which I’ve filled in various portions:

ortho-20-facet-cyst

To better explain, more discussion and pictures are needed. On his flexion-extension views, it was noted that he had the L4 vertebra slipping forward on the L5 vertebra. This forward slippage was at the same level as his facet cyst. Coincidence? Likely not. The way to understand this problem involves some ligaments in the back of the spine that act as the major duct tape that help keep the spine aligned. These ligaments are the supraspinous and interspinous ligaments. The image below shows the ligaments (red lines) in the back of the spine.

supraspinous-interspinous-ligaments

So before his bike accident, these ligaments are doing their job, helping to hold the spine in alignment. After the accident, this is what I believe happened:

l4l5-spondylolisthesis-due-to-interspinous-and-supraspinous-ligament-injury

Note that after the bike crash, the injury and tearing of these ligaments allow the L4 vertebra to move forward on the L5 vertebra. This causes the facet joints (above red star, there are two at each level) to get compressed, which ultimately leads to excess wear and tear of these joints. Is there another part of this puzzle? Well an interesting observation as he lies prone on the table is below:

abdominal-wall

What gives with the severe bulging of left abdominal wall? Further questioning of the patient reveals that he also injured his kidney in the bike accident and had surgery on the left. The scar can be seen in the picture above. An important stabilizer of the back is the transversus abdominus. This muscle was likely cut through to get at the kidney, resulting in the muscle weakness you see above on the left side (inability to hold in the abdominal contents). This resulted in the following analysis:

ortho-2o-weakness-in-unilateral-transversus-abdominus

The transversus abdominus is a muscle that’s the deepest of the abdominal wall. It attaches to the thoracodorsal fascia and pulling on this muscle on both sides helps to allow the buoyancy of the abdominal contents to assist in off loading the wieght of the upper body by literally floating it on the abdominal contents. It’s also a major low back stabilizer all by itself. The picture below shows that it attaches to fascia that then attaches to the back of the vertebra on both sides (spinous process). This axial view (saw you in half view) shows that if the pull is equal on both sides, this helps to keep the vertebra straight.

transversus-abdominus-normal-thoracodorsal-fascia-attachments-to-vertebra

However, if we cut one side of the transversus abdominus muscle (for example to get to a damaged kidney), the forces on the vertebra will be unequal, causing it to have a slight tendency to rotate (in this case to the left). This forces on the right facet joint will increase, causing more wear and tear forces on that side.

Below is an actual axial MRI image which shows the abnormal pull to the right by the transversus abdominus muscles (orange arrows) causing extra force on the right facet joint (yellow star). This is where the facet cyst is located.

axial-facet-cyst-mri

So in summary, we believe that the damage to the ligaments in the back (supraspinous and interspinous ligaments) as well as this abnormal pull of one transversus abdominus over the other, have caused the facet joints to wear out. Their response on the right (the side where we would predict the most force) is to swell to try and keep up with the wear and tear. This lead to a facet cyst and then ultimately pressure on the spinal nerve. We are now designing a treatment plan for this gentleman, but I think this case illustrates the importance of piecing together all of the parts and pieces of what caused the musculosketal system to fail. Many times treating patients with musculoskeletal problems is as simple as a quick fix (in this case popping a facet cyst with a facet injection), othertimes it takes considerably more analysis.

Tags: cystfacet, facet cyst, low back, pain, surgery
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Resolution of Large Disc Bulge / Herniation with Stem Cells

Tuesday, September 29th, 2009

LM is a 39 year old male with a 16 year history of back and progressive leg pain after a lifting injury. He had tried chiropractic for years, but over the last few years his pain worsened despite treatment. His pre-op MRI showed a very large disc bulge/herniation contained by the ligament near the back of the discs (Posterior Longitudinal Ligament or PLL-acts like duct tape to hold the back part of the disc ). The technical term for this is a sub-ligamentous disc herniation. LM was entered into one our our disc studies and his sagittal MRI’s are below. Instead of surgery, we injected his own stem cells into the disc herniation area and followed the Regenexx Disc protocol.

L5-S1 disc bulge treated without surgery with an injection of stem cells

Notice the large disc bulge/herniation in the red dotted circle on this sagittal MRI view above. The matching 4 week post-procedure film on the right shows that the size of this disc bulge has been remarkably reduced (less disc material to the right of the dashed white line). How about the other view (axial)? This is below:

L5-S1 disc bulge treated without surgery with an injection of stem cells

The red arrow in the before treatment image points to the large right sided disc bulge/herniation which compresses the right S1 nerve root (causing sciatica). Note that the disc bulge is the part of the disc that is beyond the disc margin (marked by the white dashed circle). The one month post stem cell injection image uses the yellow arrow to point to the much improved disc bulge/herniation that is no longer near the nerve. I have included a magnification of this area below. The patient reported good resolution of his back and leg pain. Again, it’s important to note that without this stem cell injection, he would have been looking at a major back surgery where this disc material would have to removed (thus weakening the disc).

Magnification of L5-S1 disc bulge treated without surgery with an injection of stem cells

Tags: avoid surgery, bulge, busted disc, herniated, injection, low back surgery, slipped, stem cells
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Mesenchymal Stem Cells Arrest the Progression of Degenerative Disc Disease

Monday, August 31st, 2009

A while back I blogged on the research paper title I have used for the title of this blog. The focus of this blog was that mesenchymal stem cells were capable of stopping degenerative disc disease from it’s usual steady progression. This morning I’d like to present an interesting 3 year plus MRI of an early study patient. WB is a very active early 50’s female runner with a severely degenerated L2-L3 disc. She was first entered into a disc study in early 2006. She received a very early iteration of the Regenexx disc procedure, well before any of the refinements that we later saw as necessary. However, she did receive mesenchymal stem cells into the disc, so her 3 year plus follow-up STIR MRI’s are interesting. In this case, the interest is more on what’s happening with the disc above and below the treated disc. On the left is a May 2006 MRI and on the right is a June 2009 picture. The discs circled in the red dashes were not treated, the one in the yellow dashed circles was treated. The untreated red dashed circle discs show significant progression of degenerative disc disease, with the red disc above now showing a bulge and decreased disc height. The red dashed disc below has also lost height. The treated yellow dashed circle does not look like it has progressed, if anything it looks a bit better in the three years (more defined disc space). We had previously confirmed that most of her pain was in fact coming from the L2-L3 disc. So how does the patient feel three years plus after treatment? She reports about 60% improvement with the ability to do more with less pain.

This is just one case at 3+ years after treatment. One could argue that the L2-L3 disc is so severely degenerated to begin with that it doesn’t have far to go until it’s completely obliterated, while the discs above and below are just beginning that degenerative cascade. On the converse, we should be seeing larger bone spurs at the L2-L3 disc by this time with no defined disc space and advancing pain. A case of one patient is just that, one person’s long-term experience. Will keep you updated as we get more long-term data on disc patients, especially those that have received newer iterations of the Regenexx disc procedure.

Tags: back, bulge, degenerated, degenerative, disc, low back, lumbar, slipped, stem cells
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New Research on Stem Cells and Degenerated Discs

Monday, July 13th, 2009

The title of the paper kind of hits you, “Mesenchymal Stem Cells Arrest Intervertebral Disc Degeneration…”. This past week Chinese researchers published a paper showing that the same stem cell line being used in the Regenexx disc procedure can stop the natural progression of spinal discs from degenerating. This is similar to other papers showing that show that low back disc regeneration is also possible. You see, once a disc is injured, it invariably seems to become worse and worse (degeneration). First it looses it’s ability to hold onto water, going from bright on T2 MRI images to dark. After this, it eventually starts to collapse, so that at some point it’s “bone on bone”. The Chinese showed that an injection of stem cells into the disc stopped this “sure thing” worsening (Intervertebral Disc Degeneration). We also had some results this past week that would support this Chinese finding. We have known for some time that we can help many patients get rid of disc bulges that are pressing on nerves by injecting their stem cells into the disc. However, we have always limited our patients to those where the disc had yet to collapse (good disc height). In February we treated a patient with an old 2007 MRI showing a dark, dried out disc with reasonable disc height and a disc bulge. By the time of her stem cell reinjection, it was clear on the fluoroscopy image that her disc had progressed and collapsed. Dr. Schultz and the patient decided to proceed with the stem cell injection as she wanted to try to save the disc and didn’t want surgery. She reported excellent relief of her back and leg pain, so we were curious to see what had happened with that collapsed disc.

ddd-rehydration

The pictures above are all “AFTER” images (we usually show before and after). Her old films are only in hard copy, so I haven’t been able to pull those yet. In addition, they wouldn’t help much, as they show a dark disc with better disc height two years before the stem cell injection, before it had collapsed. What’s exciting is the white area inside the L5-S1 disc that shows that this disc is now holding onto water. Why is this important? As stated above, low back discs are living tissue that have cells that produce chemicals that hold onto water. It’s these chemicals that allow the low back discs to act as shock absorbers. Think of those super absorbent baby diaper chemicals that can hold many times their weight in water. Once those cells start to die off, they aren’t there to produce the chemicals to hold onto water and the disc gets dark on this type of MRI (look at the dark, untreated disc above the one with the dashed circle). These dried out and dark discs are really bad shock absorbers, so the surrounding bone gets beat up and in response, your body adds bone spurs. Once your body adds bone spurs to shore up the beat up bone, these spurs can press on nerves and then it’s big surgery (foraminotomy and/or laminectomy). So the fact that her problem disc is now holding onto water, means that this disc may be able to act as a shock absorber to prevent the formation of bone spurs. This is exciting stuff. Note that we didn’t recreate a brand new disc, so there is still the need to treat patients early before the disc collapses. However, the fact that we could likely add some function back to a collapsed disc means that for these patients, all hope may not be lost.

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Spinal Fusion?

Friday, July 10th, 2009

xray

Interesting article today on health care costs. As interventional pain physicians, we see many patients who have received un-needed spinal fusions. The issue is that these surgeries are very invasive with high complication rates. They are also famous for overloading the levels above and below the fusion (causing new painful areas). While we see a few severe patients a year who might benefit, the number of these surgeries performed is likely 10 times what’s needed. Best to quote the article:

Spinal-fusion surgery

A February 2004 analysis of spinal-fusion surgery published in NEJM concluded that its efficacy for the most common indications remains unclear.

Health : This type of back surgery leads to more complications than other types of spinal surgery.

Cost: Inappropriate spinal-fusion surgeries account for approximately $11.1 billion of waste in health care spending a year. There were over 303,000 spinal-fusion surgeries in 2004, and the average hospital bill is over $34,000, not including professional fees. What’s more, the amount Medicare spends on fusion surgeries has risen 500 percent over a decade and now represents nearly half of the $1 billion that Medicare spends on all spine surgeries.

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Employee Benefits or We Wouldn’t do Anything on You We Don’t Do on Ourselves

Tuesday, May 19th, 2009

as-axial

Late last year we hired a new cell biologist. After a few weeks on the job, it was clear that her back was killing her and her leg was numb. She was miserable and having trouble sitting in front of the sterile hoods. As she tells the story, “I was getting up from the kitchen table and my legs just went out from under me and I was in excruciating pain. I had tingling in my legs and was very numb, especially in my right leg. At its worst, the pain was at a 10 and I had lost all feeling in my right leg, all the way down to my foot and through my toes. ” We tried traditional then specialized epidurals to help her pain, but she would only get temporary relief. Her MRI showed a fairly good sized right sided disc bulge at L5-S1 with a large tear in the back of the disc. It was either surgery to cut out the back of the disc and lose her to months of rehab or offer to try the same stem cells she was culturing everyday. She chose to have the Regenexx procedure and here is her result:

“The pain gradually decreased in intensity over a period of about 6 months but was still present at the time of my re-injection. At the time of my re-injection in January, my pain was at about a 5-7 and I felt relief within the 1st week of treatment. My pain at its worst now is a 1 or 2 and it’s rare that I have any pain at all. I have regained all feeling in my right leg and foot as well. “

Her films above show how the disc has decreased in size. The films above are the axial slices (you saw in half view). The top row above shows the disc in the white dashed circles, before on the left and after on the right. The bottom row of pictures above is an additional close up on the disc with the little double arrow measuring the extent of the disc.

The films below are matched sagittal slices, where the body is split from front to back. The white dashed circle shows the disc bulge which is easily seen in the left before picture, but not in the right after picture.

In conclusion, we practice what we preach, meaning we feel confident about the safety and efficacy of the Regenexx procedure to help treat disc bulges without surgery, so much that the people growing the cells don’t hesitate to use those cells to fix their own problems! As discussed in other blogs, the problem with surgically removing the back of this disc would mean that the disc would be weakened. We believe the Regenexx procedure allows us to strengthen the back of the disc while getting rid of the disc bulge.

sag-as

Tags: cell biologist, disc bulge, Regenexx, Surgery alternative
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Surgical Complications and Two Colleagues

Tuesday, May 12th, 2009

surgical-robots_html_m83df9ee-300x273

As I have said here before, we have a good number of health care providers as patients. As an example, yesterday I performed a stem cell re-implant on a dentist from Hawaii. The reason I’ve usually given is that these medical providers know the other side of the big surgical procedure coin. They have seen the complications of surgical procedures, treated these patients or been involved in treating the complications. So when it comes time for these medical providers to get a knee replacement or major orthopedic procedure, they go looking for other alternatives. I’d like to highlight two colleagues who have contacted me in the past week who went through with big orthopedic surgeries and lived to tell the tale (one only barely). This is not to say that many times big orthopedic procedures don’t change lives for the better, they do so everyday. However, the bigger and more invasive the procedure, the bigger the chance for significant complications.

The first is a doctor who had a benign tumor on his spine. It definitely needed to be taken out. He scoured our local area for a neurosurgeon who had experience in taking out this particular type of tumor (a tall task). It was an 11 hour surgery where the surgical site became infected. He is now on IV antibiotics, had a second surgery where they were forced to remove the hardware and “power wash” the area. Thank God this wasn’t MRSA, as he likely wouldn’t have lived to tell the tale. This of course led to protracted inactivity, a deep venous thrombosis, which led to a pulmonary embolus, and finally the placement of a filter in one of his major veins (to catch the little blood clots). What started as a simple removal of a benign tumor led to him almost loosing his life to surgical complications. Complications like this are not uncommon in spine surgery, with most studies quoting a 2-5% serious complication rate.

The second story that I’ve heard this past week is another colleague who went in for routine arthroscopic shoulder surgery for rotator cuff repair. The surgeon may have speared one of the major nerves of the shoulder with the scope which has led to atrophy in the surrounding shoulder muscles and adhesive capsulitis in the shoulder. It’s also possible that the traction used to pull on his arm during surgery caused the nerve injury. He now is forced to leave practice as a chiropractor as he has no strength in the arm. How often do serious complication occur in shoulder arthroscopy? Several studies quote about 10%, but reading between the lines, the rate of serious complications is likely lower, about 5%.

Many pundits have written about the possible horrible complications that could befall anybody who tries stem cell therapy. I have written on this topic in the past. To recap, the safest option for treatment at this point is the patent’s own adult stem cells, as they are used everyday by the body to repair and maintain many tissues. However, the surgical complications of the procedures that stem cell therapy would replace make any possible complications from the patent’s own adult stem cells look mild. This is ultimately why we see so many health care providers, they simply weigh both of these things and opt for the much less invasive stem cell treatment.

Tags: centeno, Regenexx, stem cell, surgery alternatives, surgery complications
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Making the Grade…

Friday, May 8th, 2009

Like any procedure, the Regenexx procedure works better in some patients than in others. We have always provided prospective grading of candidacy. What does this mean? It means that we obtain basic information about the patient and ask to review films to determine the severity of their disease. We compare that severity to our clinical experience with that specific procedure and place the patient in a GOOD, FAIR, or POOR category. We believe this is an important part of any stem cell based procedure. What this means practically is that about 1/4 of the patients get put into the GOOD category, 1/2 in the FAIR category, and about 1/4 in the POOR category. In addition, this stem cell procedure grading is different for each procedure. As examples:

-For peripheral joints (knee, hip, shoulder, ankle, etc…) the grading depends on severity of the arthritis. We feel GOOD candidates have a limited amount of cartilage loss or an “OCD”. FAIR candidates have one compartment cartilage loss (like medial or lateral side) without major bony structural changes and POOR candidates generally have significant structural changes in the bone (huge bone spurs) that cause significant loss of range of motion.

-For ligaments and tendons the grading depends on the integrity of the structure. GOOD candidates have a partial thickness tear or a small full thickness tear where the tendon or ligament is still intact. At this point we can’t treat full thickness and retracted tears in ligaments or tendons, so these are placed in a “we can’t treat you” category. This is because the ends of the tears need to be surgically brought back together before any injection based therapy is likely to help.

-For bone problems (fracture non-union and AVN) our grading is based on the amount of damage. AVN is graded on a scale (we use ARCO) and stage 1-2 (without structural collapse of the bone) are GOOD candidates, yet stages 3 and above are considered FAIR-POOR candidates (we discourage these patients from trying our non-surgical stem cell treatment). For fracture non-unions, the fracture site must be stable for the patient to be a GOOD candidate, the fracture site should have all areas in relatively close approximation (we have filled in up to a 1 cm gap), and the fracture within 1-2 yerars old. Large areas of loss of bone may place you in the FAIR or POOR categories. In addition, if the fracture has been there many years (more than 1-2), this may also make the procedure much less effective. The good news is that we have seen healing in smokers and patients that have failed a bone stimulator, patients who are usually notoriously difficult to heal.

-Low back discs are graded on their severity and degree of collapse. GOOD candidates are patients with at least 75% of disc height preserved, can have a dark disc, have a contained disc bulge or subligamentous herniation (herniated disc where the herniated material hasn’t pushed past the posterior longitudinal ligament). If the disc is collapsed and has lost most of it’s disc height, our procedure is unlikely to help.

There are also other factors outside of disease severity that make up our grading. These include age vs. sex (male vs. female), number and type of prescription medications, activity level, body mass index, overall physical health, etc… Even though we prospectively grade candidates for the Regenexx procedure, we have been surprised. Despite our grading system we have had poor candidates show up from time to time and do well with treatment (the vast majority of these are knee arthritis patients). In summary, we believe that any valid medical or surgical procedure needs to grade patients up front to let them know their basic candidacy. In addition, whether or not they are allowed to try to the procedure despite being warned of being a POOR candidate should be directly related to the degree of complications associated with the procedure. Since we have had no significant stem cell related complications in about 450 patients in the last 4 years and have been surprised in knees, we do allow primarily knee patients to try the procedure even if they are not ideal candidates. However, we will not see late stage AVN patients, disc patients whose disc has already collapsed, unstable fractures, etc…

Tags: Ankle, back, candidate rating, disc, Knee, ligament, Regenexx, Shoulder, Thumb
Posted in Ankle, Back/lumbar, Hip, Knee, Ligament/tendon, Medical alternatives, Shoulder, Surgery alternative, Thumb, stem cell | No Comments »

Disc Repair Update

Tuesday, April 14th, 2009

Just saw the disc rehydration patient back in follow-up who is the subject of this post. It’s important to note that this is a patient who at the time of her Regenexx procedure had already failed lumbar discectomy, epidurals, acupuncture, physical therapy, etc…

She’s still doing very well. Thought I would give a list of her reported improvements at about 3-4 months post procedure:

1. More mobility, she can now bend all the way forward.

2. More ability to exercise without pain.

3. No more leg pain, weakness, numbness.

4. Elimination of upper back and neck pain. She believes this was all compensating for her low back.

Her back pain is down more than 90%. She has now decided to go back to acting and modeling due to her new ability to exercise and stand for long periods.

I think this patient as well as others we have treated for lumbar disc hernations and buldges represents and new era in pain management. For the most part, we pain doctors and surgeons have only been able to manage people’s disc problems. Even when we surgically trim the disc, we’re not fixing anything, just buying some time by getting pressure off of a nerve. The disc never goes back to it’s old self of being a good shock absorber, at worst it’s just waiting to fail at a later date or at best slowly deterioarting and contining to lose it’s ability to protect the surrounding bone, joints, and nerves. However, the ability to fix discs opens up a whole new world for both doctors and patients. You want to know what pain was coming from the bad disc? Fix it and see what’s left. Novel concept.

Tags: bad disc, cell, cells, centeno, disc, disc buldge, disc bulge, herniated disc, low back pain, pain, painful, Regenexx, slipped disc, stem, stem cells
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