I’m blogging from Rome where the Vatican stem cell conference begins tomorrow. My initial plan was to lay off the blogging this week and take a much needed break, but I just saw the MedPage article on BMP’s and cancer and thought it was too interesting to pass up. As a disclaimer, there’s been no research that the spinal fusion procedure causes cancer (although there’s quite a bit of research that fusion is dramatically less safe than a routine spinal surgery). However, many spinal fusion surgeries are now using Bone Morphogenic Proteins (BMPs) to promote fusion which are associated themselves with more complications. In a recent study, 1 in 4 surgeries by 2006 used these artificial growth factors to grow bone and in women patients the use was nearly 50%. The overall BMP use in fusion surgeries is likely significantly higher now as use of BMPs had exploded from 2002 onward. Besides having a higher rate of complications and side effects, BMP use has now been linked to cancer. How much does your cancer risk go up if your surgeon uses BMPs? 3-5 times! Add this to recent data showing that certain knee replacement prostheses may increase your cancer rate and it all adds up to concerns that placing artificial items in the body may be a bigger risk than once thought. The upshot? Based on the dramatically increased risk of complications over traditional back or spine surgery, spinal fusion should be a surgery of last resort and not a routinely considered procedure for patients with chronic back or neck pain. In addition, if you do need to have back or neck surgery, consider the use of your own concentrated stem cells (many surgeons are spinning down stem cells at the bedside to place them in the fusion mass) rather than using BMPs!

We are pleased to announce the acceptance for presentation of another paper at the Orthopedic Research Society this coming January. The paper is entitled: Safety and Complications Reporting Update on the Re-Implantation of Culture-Expanded Mesenchymal Stem Cells Using Autologous Platelet Lysate Technique. This is a 4 year study of 339 patients showing that the complications from stem cell injections (Regenexx-C) were far lower than those experienced by patients undergoing traditional orthopedic surgeries such as knee replacement. Knee outcome data will also be presented. This follows our presentation at ORS on orthopedic stem cells last year. We’re proud that the Centeno-Schultz clinic has again been chosen by the prestigious research organization to present our clinic’s data on this promising technique!

AE is a 36 year old white female who was first seen in Sept of 2009 with a 2.5 year history of back and leg pain (7/10 moderately severe pain).  Most importantly, she had failed physical therapy, IDET (a procedure where a catheter is inserted in the low back disc to burn away painful nerves), epidural steroid injections, facet injections, and trigger point injections. She did get some relief from a prior laminectomy, but still had significant pain. Her MRI showed reactive bone swelling in the vertebrae with compression of the left S1 nerve root. We first performed a selective nerve root block at L5-S1 to make 100% sure that treating that disc would relive symptoms. When she reported short-term good relief from a diagnostic block at that level, in October of 2009 her own specially cultured stem cells were injected into the L5-S1 low back disc using an exacting technique (Regenexx-C). Here is her report from this week (from the ICMS treatment registry):

Overall, how do you feel now compared to prior to the procedure?

-Good-noticeable improvement

She also reports that despite starting with moderately severe 7/10 pain prior to the procedure that she now only has mild pain, her range of motion has increased, and she can do more since the procedure. She also writes-”Much more active and back to a normal life!”

The upshot? Despite AE failing just about every existing conservative low back injection therapy and surgery, she responded well to the exacting injection of her own specially cultured stem cells into the L5-S1 disc. While we can’t claim that every patient can achieve these same results, we’re proud to have helped AE get back to a more normal life!

Is LASER surgery a back surgery alternative? The picture above of Dr. Evil is arguably the world’s most famous air quote. He does this as he describes the laser he has placed on the moon to disintegrate the earth. I feel a little like making this air quote as I speak to some patients about “LASER” Spine surgery as an alternative to traditional back surgery. This LASER surgery is widely promoted as the holy grail for patients with disc problems, yet I continue to see many patients who benefit about as much from this expensive surgery as they do with a traditional low back surgery, which is not much. I recently saw a patient from the south who underwent laser spine surgery as an alternative to the usual type of back surgery, only to get much worse. While this can happen to any patient, I was curious to see how the surgery was documented via the notes. Looking at these operative notes, the disc was bathed in high dose steroids as the surgeon exited the area. The goal of this seems to be to reduce local swelling caused by the high temperatures generated by the LASER. The problem is that the outer disc is composed of fibrocyte cells that make fibrous tissue. For the surgery to be successful, these fibrocytes and other fibroblast cells in the back of the disc need to heal the area cut out by the LASER. What happens to fibroblasts when they’re blasted by high doses of steroids? They die off, just like many cells that are treated with high dose steroids. Since the goal of the surgery is to “repair” the disc, adding high dose steroids is likely doing the opposite, reducing the already weak healing properties of the disc. So why use a LASER at all? Your guess is a good as mine, as I can’t come up with a reason why a LASER would be any better than a scalpel or other cutting device, other than it’s sounds really cool. The upshot? LASER in my opinion isn’t a viable alternative to traditional low back surgery. In fact, I now have to give the above air quote when I talk about “LASER” spine surgery with my patients. Save your money and seek out non-surgical alternatives.

As you know, we’re big advocates for the concept of the “hip bone’s connected to the back bone, and the leg bone’s connected to the knee bone…” We often see patients who have both hip and back pain and many assume that their back pain is a result of them walking funny due to pain. However, we have also frequently observed that fixing the low back in many of these patients often takes their hip pain away, especially if you catch them early in this cycle (before severe hip arthritis sets in). We often observe the same thing with low back and knee pain. Why? Some of the nerves in the low back can shoot pain to the hip. In addition, recent studies have started to show the inter-relationship between pain, nerves, and arthritis. A recent study supports this concept, finding that almost 50% of patients undergoing total hip replacement had low back pain. The rest of the study shows a complex inter-relationship between the hip and low back. For example, about 2/3′rds of patients had their back pain resolve after hip replacement surgery (which begs the question if 1/3 of these patients actually had their low back leading to most of their hip pain) and 20% had back pain develop after their hip replacement (which begs the question of if their hip pain was really a sentinel of their low back problem). The upshot? If you have low back and hip pain consider asking your doctor for a simple diagnostic test known as a “diagnostic block” of the hip. I would make sure the doctor that performs the block doesn’t use steroids as the high doses commonly used may make your back feel better even though the medications are being placed in your hip. In this procedure, the doctor will only numb the hip to ensure that all of your pain goes away. If all of your back and hip doesn’t go away, a doctor needs to take a closer look at your low back.

Medpage has recently run an interesting series on spinal fusions and the use of BMP’s to promote fusion. I have blogged on some of the problems with these new BMP drugs used to promote low back fusion.  They also recently highlighted a patient with severe pain following such a low back fusion that I think brings up an important point. As I’ve blogged before, spinal fusions artifically limit normal spinal motion and overload the vertebral segments above and below the fusion. This often leads to new areas of spinal degeneration above and below the area of fusion and new area of pain generation. In fact, the first thing I think about when I see a post low back fusion patient in pain is if the facet joints or nerves above or below the fusion are involved. In general these patients tend to do well right after surgery, but then are in pain again within the first few months after surgery. Having said all of this, fusion is still a viable option for those patients who are severely unstable or for whom there is no other option, however, we no longer consider it to be routine appropriate next step for patients who have failed conservative care, but rather a giant leap into an unknown therapy.

JS is a patient we treated two years ago with the Regenexx-C procedure which involved injecting his own cultured stem cells into his bulging low back disc. Before we tried this, he was being treated several times a year with epidural injections, which gave him some relief, but this was more of a stop gap measure to manage his disc bulge rather than a fix. After his stem cell injection, the patient had great results as shown on his MRI, with a dramatic reduction in his low back disc bulge size. I got this unsolicited text on Friday, so I thought I’d share it:

Dr. Centeno, it is [JS].  Sorry to invade your space, but today is the 2 year anniversary of the last procedure I had.  I want tell you that my life is a different life. I live today free of pain killers, & only need to medicate rarely. You have truly changed my entire family’s lives.  I live a normal life that j never thought I would see. My family thanks you for continuing to push that envelope & never giving up. Thanks to you & your entire wonderful team.

While we can’t fix everyone with a low back disc bulge and our procedure isn’t magic in that it has a success and failure rate, it’s messages like this from patients that make us doctors smile.

Can stem cells be used to help low back facet joint pain? The answer is that it depends. If the facet joint was damaged due to trauma (more common with neck facet joints) then we’ve seen good results. However, much of low back facet pain is degenerative and thus due to longstanding wear forces. To review, the facets in the low back are the joints that help to connect the back of the vertebrae at each level. The normal curvature in the back helps distribute the load of the body evenly between the front of the spine (discs) and the back of the spine (facet joints). If you look at the drawing above, notice the facet joints are in the back of the spine (front is to the left in this picture).  Recently I examined a patient in clinic who had 6 months of relief from traditional steroid facet injections that were performed because his MRI showed swollen facet joints. This worked very well for awhile, but then the pain came back with a vengeance. Why? Well the first reason is simple, while steroids are potent anti-inflammatories, they also chew up cartilage, so when the anti-inflammatory effect wore off, the facet joints were likely worse off because of the steroid. The second reason the pain returned may not be as readily apparent, but gets down to the basics of our orthopedics 2.0 approach (see our practice’s e-book for more information). Notice above that this patient’s spine looks more like the one on the right, where there’s a high sacral angle. This means that his sacrum (the triangle at the bottom of the spine) is oriented more horizontally than most. This can happen when the psoas muscles are too tight or for any number of other reasons. As a result, his spine bends backward on itself, trying to compensate. This causes more pressure on the facet joints which are wearing out. So if we place magic stem cells in these facet joints, even if they work to shore up his degenerating cartilage, the patient’s pain will just come back because we did nothing to help his high sacral angle. While we’re just getting started with this patient, the implications of his bio-mechanics on what we can do for him with stem cells is clear. 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.

Low Back pain causing Knee Pain? One of the more common misdiagnoses we see on a day to day basis is a patient with minimal back pain and knee pain, but whose knee pain is really being caused by a pinched nerve in the back. What? Is it possible that a patient with a pinched nerve in the back doesn’t have much back pain? Isn’t it the knee causing the back to be sore? Sometimes. The nerves in the low back go to the legs, so if I were to reach into your back right now and pinch a nerve, you’d feel it somewhere in your thigh, knee, leg, or foot and likely not much in your low back. Most doctors have been tranined to diagnose picnhed nerves in the back only when there’s numbness or tingling down the leg (sciatica), but to ignore the back when there’s just pain someplace in the leg. As an example, take this patient of Dr. Hanson’s who was seen yesterday. The patient had severe arthritis of both knees and was deemed a candidate for a Regenexx-AD stem cell procedure because of his displaced meniscus tissue from prior meniscus “chop” surgeries. He denied any back issues at the time. He obtained only minimal improvement with the stem cell procedure for the knee arthritis, so Dr. Hanson went digging deeper. Turns out the patient did have some off/on back issues through the years and sure enough, his exam and later his MRI showed that he had an L5-S1 disc bulge pressing on a spinal nerve. Dr. Hanson treated the disc bulge with the Regenexx-PL-Disc procedure and now his knee pain is 60% better as a result of the low back treatment. We see this all the time. As a result, we can’t stress enough that a thorough vetting of your low back is critical if you have hip, knee, ankle, or foot pain. As another example, read this blog post about a  rock climber who was told he had severe intractable plantar fascititis but really had a low back problem. Another patient that comes to mind was a late 30′s mother of two who was told she needed a hip replacement because her MRI showed a congenitally short hip socket and mild arthritis, but who really had a disc bulge irritating the S1 nerve. We treated her S1 nerve problem with the Regenexx-PL-Disc procedure and her hip pain went away. You might be saying to yourself about now, “But my doctor said I have ___ arthritis (insert hip, knee, ankle in the blank) so that must be what’s causing my pain!” While your arthritis may need to be treated as well, it may not be the main cause of why you hurt. Recent research showing that some patients still have severe knee pain after a knee replacement only strengthens the argument that we need to be doing more to identify the source of knee pain before major surgery to chop out the joint. To learn more about the science behind these concepts, see our practice’s e-book, Orthopedics 2.0. For a shorter discussion of the science, see this post where recent research connects nerve problems with arthritic pain.

Interesting article this week posted at MSNBC.com about a recent study of patients undergoing low back surgery. The study demonstrated that of those patients who opted for back surgery, only 26% went back to work compared to 67% of the patients who didn’t get surgery. There was also an increase in the use of pain medications after surgery. As we have always said, for a very few patients, low back surgery can be a godsend. However, that’s only about 1-2 in 10 (IMHO) of the patients currently undergoing back surgery. The problem with conventional low back surgery is that it either cuts out parts of the disc or fuses together vertebral segments that were built to move. By taking out parts of the disc, the surgery weakens the disc and makes it more likely to fail. To understand this phenomenon, think of the low back disc like a bicycle tire. As illustrated above, the thick outer rubber tube can develop cracks and tears which let the inner tube bulge out (just like a disc bulge). Rather than fixing the cracked outer rubber part, our current surgical approach just lops off a piece of the outer rubber tube (the part pressing on a nerve), making the tire less durable and more likely to fail. Low back surgery does the same thing, no matter if it’s through a scalpel or a laser. In the case of the low back, the outer rubber tube is the disc annulus (outer part of the disc) and the inner tube is the nucleus pulposis (inner rubbery gel part). Is there a better way? We believe in either injecting substances to help the disc area heal (like the Regenexx-PL-Disc procedure) or to help heal the cracks (like the Regenexx-C-Disc stem cell procedure). We’ve seen significant improvement in low back discs by simply injecting the patient’s own specially grown stem cells into these tears. The upshot? Looking at the bicycle example, it’s no wonder why disc surgery often fails miserably.