Stem Cells Lower Back Pain: Confused?
POSTED ON 1/18/2015 IN Spine BY Christopher Centeno
Are you confused by the information you find when you search for "stem cells lower back pain"? You're not alone. I see many patients these days that are bewildered by the claims of various providers that offer stem cells for low back disc bulges or other disc problems. Being the only physician on earth with a decade of experience injecting stem cells into discs, I'll try to clear that up today.
To understand this topic, you first have to know how the disc is built and what can go wrong. Your low back has spine bones called vertebrae that are separated by cushions called discs. The discs have an outer tough covering called the annulus fibrosis and an inside gel like material called the nucleus pulposis. The inside gel is important, as it has chemicals that are very good at holding onto water, which provides the mechanics for the disc to function as a cushion and shock absorber. The spinal nerves that power the back, hips and leg muscles and take feeling back from these areas to the brain come out near the disc, two at each level. There are 5 lumbar levels, labelled L1-L5, which sit atop a sacrum or tailbone, which is typically labeled S1-S4.
Let's place what can go wrong into categories to better understand what might be treated with stem cells: 1. Herniated Disc-(disc extrusion, disc herniation, sequestered disc, or a free fragment)- The inner gel-like disc material can rupture through the tough outer covering. This material can piss off the nerves that come out at each level, leading to numbness, tinging, burning, cramping, or pain in the back, hip, thigh, knee, calf, ankle, or foot. 2. A Torn and Painful Disc-The disc still has good or pretty good height (isn't a degenerated disc that has collapsed), but due to some trauma, the tough outer covering of the disc has become torn and painful. The patient often has only back pain, or if the disc also has a bulge pressing on a nerve or leaks, then back and leg pain. 3. Disc bulge (disc protrusion, protruded disc, bulging disc, prolapsed disc)-The disc still has good or pretty good height (isn't a degenerated disc that has collapsed), but the tough outer covering has been damaged and the inner gel puts pressure on it to cause it to bulge. This can then put pressure on a nerve, leading to numbness, tinging, burning, cramping, or pain in the back, hip, thigh, knee, calf, ankle, or foot. 4. Degenerated Disc (degenerative disc disease, DDD): The inner gel-like material can lose it's ability to hold onto water and become dried out and the tough outer covering can become beat up due to wear and tear. The disc loses height and begins to collapse, causing more pressure on the bones which leads to bone spurs. At the same time, the whole spinal segment around the disc becomes sloppy and moves too much (degenerative instability). This last part accelerates the bone spurs and can cause the ligament inside the spinal canal (ligamentum flavum) to get bigger and compress nerves (spinal stenosis).
All of this can be painful, mostly due to the extra motion and pressure on nerves and the joints in the back of the spine called the facets (which happens due to the decreased disc height). While the disc itself can be torn and painful like #2 above, that's usually the least of the patient's problems. The disc can also bulge and press on nerves, so sometimes this can be a big problem. Before I get into how each of these are treated with regenerative medicine (stem cells and the like), it's important to note that there many other structures in the spine that can cause pain like the facet joints, SI joints, ligaments, tendons, and muscles. Figuring out where the pain is coming from can often take time, so to the extent that a doctor spent 5 minutes with you performing an exam and looking at your MRI and concluded that your back or leg problems were due to a disc problem, the likelihood that you have a bad diagnosis is real. In addition, as a consumer and patient, you need to understand that "nilly willy" injection of stem cells or anything else into the disc is a bad idea. Why? Just poking a hole in the disc can cause that disc to degenerate further or cause a serious infection (discitis) that can result in the need for big surgery. So while there are some cases above where stem cell injections into the disc can be useful if all else fails (i.e. better than fusion surgery), every attempt should be made to avoid injection inside the disc first.
If we look at the list above, a herniated disc (#1), while a painful experience when it's happening, is the easiest to treat. If left alone, the research shows that the body will remove the gel like material that's pissing off the nerve. This can take time, so for many years epidural steroids were injected. The downside of this approach is that the steroids injected were toxic to local tissues. As a result, we instead inject our 3rd generation platelet lysate into the area around the nerve. There is usually no need for stem cells to be injected into the disc. Number 2 above (a torn and painful disc), may well be the "killer app" for stem cell or platelet injections inside the disc, but that's based on very early clinical data that isn't yet conclusive. One study that has yet to be published, but was very well done, showed that in these cases, a simple platelet rich plasma injection could help the pain that comes from the disc and possibly heal the tear.
A second small study using stem cells was seriously flawed, but did seem to show some pain relief linked to the dose of cells. Both of these studies fit with our general decade long experience. However, before you go sign up for someone to inject platelets or stem cells into your disc, this type of procedure is only likely to work if you have disc pain and there are many other things that can cause back pain. So unless you've had a thorough examination with at least 20-30 minutes hands on exam by a physician and other injections into the facet joints, SI joints, muscle/ligaments/tendons that have failed, it isn't good medicine to inject platelets or stem cells into the disc.
Number 3 above can be either easy or hard to treat. In our decade long experience, most disc bulges can be managed without ever getting a needle into the disc. Injections of our 3rd generation platelet lysate usually work well to calm down the pissed off nerve. Having said that, sometimes the disc bulge is placing too much mechanical pressure on the nerve. In these cases, the only technology that we've seen with MRI evidence that shows a reduction in the size of the bulge is our Regenexx-C procedure where specially cultured cells are placed into the disc using a specialized technique. In addition, a "buyer beware" warning is critical here, in that we've seen physicians using "stem cells" from any number of sources who believe that they can get the same results we've published on-line and offer patients a platelet or stem cell injection for a disc bulge.
This is despite the fact that the cultured disc stem cell technique is unique and a typical same day stem cell injection won't work to help a disc bulge. Number 4 above (a degenerated disc) is the holy grail of spine medicine-meaning the concept that you can inject stem cells into a collapsed and degenerated disc and have that disc regrow "good as new". However, nobody has demonstrated that this can be accomplished in humans, with all major trials failing to date. Having said that, this is what most patients who sign up for disc stem cell therapies believe they're getting. In particular, the small disc study I referenced above only showed a very slight improvement in stem cell injected discs that may or may not have been an artifact of the MRIs that were taken. In addition, a company trying to get FDA approval on a stem cell drug has also failed to demonstrate that this product can regrow discs.
Our approach here is to recognize that while it may be nifty to regrow the disc, the cause of most of the pain and disability is actually the degenerative instability and that these patients often hurt because of painful and irritated nerves and facet joints caused by lax ligaments. Hence our Regenexx-DDD procedure is used. The upshot? Most patients searching for stem cell cures for their low back disc problems aren't quite clear on what kind of disc issue they have. I hope this article clears that up and helps patients avoid the numerous stem cell disc scams that are out there right now!
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