Laser is arguably (like stem cells) a cool word.  Who could forget Dr. Evil’s infamous “Laser” talk with hand parentheses!  We often get asked by patients about “Laser” (hand parentheses included) low back surgery.  We tell them that when you have a disc bulge pressing on a nerve, removing disc tissue is removing disc tissue, it doesn’t matter how it’s removed: with a scalpel, a surgical device, a needle based coblation tool, or a “Laser”.  The removal of the back wall of the annulus fibrosis (the thick outer covering of the disc) weakens the back part of the disc and thus makes the disc more likely to fail.  Discs don’t heal well, so unlike some areas of the body where removing a small amount of tissue might cause more to grow back, this generally doesn’t happen in the spine.  In addition, disrupting important blood supply for this part of the outer disc can also have long-term adverse consequences on the long-term health of the disc.  So using a laser to vaporize this disc tissue is no different than using anything else to remove it, the tissue is still removed and the disc is weakened.  Our approach (and we believe the approach of all future biologic applications for the disc) is to rebuild the back of the disc by trying to get it to heal.  We have seen evidence on MRI of healing of low back discs and reduction in the size of disc bulges. In summary, “Laser” low back surgery is all the rage, but still involves weakening the structure of the disc.

Interesting story out this week on Medtronic’s Bone Morphogenic Protien (BMP) device used to promote spinal fusion-Amplify.  Spinal fusion is when a surgeon does something to cause one vertebra to fuse to the other (grow together).  Lumbar fusions are big surgeries with big risks.  BMP-2 is used by surgeons to stimulate two bones that normally wouldn’t grow together to fuse. We have published with CSU on the use of BMP-2, so we have some knowledge of it’s properties. One of the concerns we’ve seen clinically is that when used in fusions, it seems to really irritate spinal nerves and lead to significant radiculopathy.  Now this article raises concerns about it possibly leading to a higher rate of cancer. This may make some sense and this is one of the reasons we have always avoided using recombinant growth factors with our stem cell procedure. The concern is that these growth factors can be given at doses many, many times their normal physiologic ranges to “whip” cells into doing certain things.  This extra stimulus may promote tumors, as cells are cycling much faster than their design specifications.  As an alternative, we have always used the patient’s own growth factors from blood platelets to grow cells, as the levels of growth factors are more physiologic.  The jury is still out on the cancer risks of this device, so only time will tell.

MF is a young active man from South America who has a L4-L5 disc bulge that causes leg symptoms and back pain.  He wanted to avoid surgery for the disc bulge, so he sought out the Regenexx Disc treatment, where we cultured his own stem cells to get greater numbers and then used imaging guidance to inject these into specific parts of his lumbar disc.  It’s important for any clinic offering investigational care to discuss it’s successes and it’s cases that didn’t quite get there (at least on the first try).  For MF, 4 months out form the procedure he’s only had a small improvement in symptoms and this is consistent with his pre and post MRI’s of the low back.  The images above are side views (sagittals) of his low back, showing some decrease in size of the disc bulge, but only by 20% or so.  The axial images below (top down view) again show a small decrease in size of the disc.  The reason he may not have gotten more relief may be because this L4-L5 disc is bulging both in the middle and out to the side, partially obstructing the foramen (the hole where the nerve exits).  We have recommended a second procedure for MF, as we believe that we have demonstrated some effect based on objective MRI imaging and believe that it may be possible to decrease the size of the bulge in this other sideways direction (into the foramen).

Every few months it’s helpful for me to take a “day in the life” snapshot of long-term and short-term follow-up exams or reports of patients treated with their own cultured stem cells for arthritis.  Today’s installment involves several patients treated for thumb/knee arthritis (blackberry thumb), SI joint arthrits/injury, a knee osteochondral defect, and a hip arthritis patient.  BS is 50ish female with chronic right knee arthritis pain who was unable to hike and had severe right thumb pain at the CMC joint (blackberry thumb or texting thumb) that didn’t permit her to pick up samples as an interior designer.  We injected her own cultured stem cells into the knee and into the thumb about two years ago.  Both areas are significantly better still, she now hikes and lifts samples without issue.  The patient returns to get the other side done (left knee and left thumb joint, as over time they are becoming more arthritic).

SM is a twenty something college graduate student who was involved in a car crash, injuring her sacroiliac joint.  We had tried traditional cortisone injections into the SI with only temporay relief.  We tried prolotherapy which didn’t halp long-term.  We then tried injecting her own cultured stem cells into the joint.  Low back pain went from a constant 5/10 to 0/10.  She was unable to run before the injection of her own stem cells and had gained weight.  Now about 6 months after the procedure, she went for a 6.5 mile run yesterday.

SP is a thirty something personal trainer from out of town with a large osteochondral defect in his trochlear groove of the knee (pot hole in the cartilage).  He was offered micro fracture, but literally couldn’t afford (financially) being out of commission on crutches and in a brace for 6-12 weels or laid up in bed on a CPM machine.  We injected his cultured stem cells into his OCD under MRI planned x-ray guidance and he is now about 3-4 months out form the procedure and reports about 70-80% improvement in pain and function.  He was here for a “booster shot” to see if we could get him a little further down the recovery curve.

I try to also include patients who fail the procedure in these updates.  RD is a fifty something year old patient with moderate hip arthritis who was told he was a FAIR candidate (meaning there was a significant chance the procedure may fail).  He is now a few months out from the procedure, which was the injection of his own stem cells into the weight beraring area of the hip under x-ray guidance.  RD hasn’t noted any improvement.  Why?  One reason may be that we were not able to grow as many cells as we would like for RD, which does happen.  The ability to grow stem cells in culture is as variable as one patient’s healing response vs. another patient’s healing response.  For RD, the procedure clearly looks like a failure.

NQ is a middle aged woman with a multiple year history of low back pain and sciatica (lumbar radiculopathy) who we treated for about a year with intermittant epidurals. She had only transient relief from those injections, at best a few weeks of remission. She failed physical therapy as well as other alternative medicine modalities. The patient was facing a discectomy surgery where the back part of the disc would be removed. It really didn’t matter how that was to be done: through a big surgical approach with instruments, through a laser, through a smaller incision, through a needle-the end result would be the same, the back wall of the disc would be weakened without much ability to heal. Instead of these approaches, she decided to have her own cultured stem cells placed into the disc through and injection. Other than post-op soreness, she wore no brace and had none of the big down-time and recovery that would have been needed if she had traditional low back surgery. She is now about a month post the injection, reporting about 90% improvement in left and right leg pain and numbness and 40% improvement in low back pain. The MRI images above are 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. The images below simply the above MRI images, showing that the disc bulge has a “High Intensity Zone” or HIZ. This is an area of bright signal that gives the disc bulge the appearance of a balloon that’s being expanded. This is was bad news for the patient, as this means the back fibers of the disc are literally coming apart and separating. However, by the after image they have mended.

JS is a 43 year old who I have seen for may years to treat low back pain from a car accident about 10 years ago.  We settled into a pattern of treating his low back disc bulge and nerve root irritation (lumbar radiculopathy / sciatica) with steroid epidurals 3-4 times a year.  Using these treatments, he would get temporary relief lasting a few weeks to a few months, but he still needed to take narcotics.  More recently, with the passage of Colorado’s medical marijuana law, he became my only patient (out of about 1,000 active patients) that I trusted enough to fill out his state form.  He thus transitioned from narcotics to medical marijuana, which helped, but left him a bit “unfocused”.  Finally, 9 months ago, he wanted off this treadmill and had seem some of the sucess we were having with implanting the patient’s own stem cells into the low back discs to treat disc bulges.  He signed up for that procedure and was a GOOD-FAIR candidate.  Nine months later, he was seen this morning and has had a dramatic reduction in his pain and increase in his function.  He also dramatically reduced his medical marijuana, which was clear just from speaking with him.  He doesn’t need epidurals at this point and told me he has increased his work hours by 25% as an accountant.  He also just spent his recent vacation jet skiing through 9 foot swells.  I think JS is a good story to tell, because unlike many other patients who we see for stem cell injections into the lumbar discs, I have personally had extensive history with him.  I knew what worked to manage his pain and saw that I could help, but only in short spurts and little bits.  While we able to keep him away from surgery before the stem cells, it was only through repetitive procedures and tons of medication that reduced his ability to earn a living.  After the procedure, he’s a different patient.

low back fusion, lumbar, surgery

Interesting study out this week concerning low back fusion surgery risks. It discusses how the surgery rate for low back fusion has jumped 1,500% from 2002 to 2007.  It also discusses how the risk of a serious complication like a stroke is 5% with low back fusion surgery, versus 2% with a surgical laminectomy (decompression surgery) .  It also discusses that hardware manufacturers have been using aggressive financial incentives to doctors to promote fusion over other types of surgeries.  Finally, the article also brings up that there is no evidence that fusion works.

As physicians working everyday in this area, what do we think?  Fusion can be a valuable tool in the toolbox for helping a limited number of patients with significant instability in the spine.  Having said that, we would agree with the article concerning the sky rocketed rate of fusion in the past 5 years.  I think most patients believe that this surgery will fix their back, but our interventional pain practice is made up of patients who quickly suffer side effects from the fusion.  The biggest is that once you stop one vertebra from moving, the vertebrae above or below must compensate by moving more.  So this eventually leads to more pain and degeneration above and below the fusion site.  In addition, many of these patients end up needing a second or third surgery to fuse these levels.  Do we recommend fusions?  Yes, rarely, when there is no other good way to treat a patient with an unstable spinal level that is causing neurologic problems, we will recommend fusion.  Out of 1,000 patients with severe spinal pain seeking an interventional pain physician, in our practice, this is about 10/1,000 or 1% or less.  The conclusion, fusion is a two edged sword that can help certain patients who can’t otherwise be helped, while for most patients, it causes more problems that it solves.

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.