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 fusions are a big problem. While a few patients who get their back fused really need the procedure to control serious instability, most patients get their back fused to help control pain. Recent controversies surrounding things like BMP drugs to promote fusion (which cause sterility in men), the fact that we American doctors fuse far too many low backs, and the complications associated with low back fusion surgery all make the topic important if you’re considering spinal fusion surgery. For those patients who decide on a low back fusion because of pain, a recent study demonstrated that in many patients, the SI joint is being made painful by fusing the low back. Why? Your back bones are built to move. When one of them is artificially stopped from normal motion by fusion, the adjacent levels get overloaded, leading these levels to become degenerated at a faster pace. In one study, 16.5% of the patients who had their low back fused at 5 years and about 1/3 of patients at 10 years needed additional surgery to correct spinal degeneration caused by the fusion.The SI joint study above demonstrated the same phenomenon, but with the next joint down from the lumbar spine, which is the SI joint. This has become such a common area of pain in post fusion low back patients in our practice that it’s almost automatic that someone who has had their low back fused and who is experiencing pain in the back of the hip will undergo an interventional pain (read injection) work-up for SI joint syndrome. Just this last week I saw an unfortunate patient who had a 5 level low back fusion and ended up with more pain than before the fusion, this time above and below the fusion. The upshot? If there’s another way to manage your low back pain, don’t get your low back fused! Artificially stopping normal motion has unintended consequences and complications.