Treating the Whole Spine with Orthobiologics
POSTED ON 4/26/2018 IN Spine BY Christopher Centeno
If you visit a doctor who injects the spine, it's highly likely that he or she will focus on finding one spot that's causing most of your pain. However, is that the best approach to trying to help your back pain? This morning I'd like to show you some data from our registry that argues that this approach, even when orthobiologics, like PRP, replace harmful steroids, may not be the best we have to offer patients. Instead, a more wholistic spine-injection approach may give you better results. Let me explain.
What Is the Pain Generator Approach?
A couple of weeks ago, I blogged on the functional spinal unit (FSU) and getting rid of the pain generator. Today I want to expand on why we may need to move away from the pain generator approach and start treating the whole spine. Let's review the pain generator approach. In defining the concept of the pain generator, first, the pain generator is the primary, or sole, cause of the patient's pain. You may be experiencing back pain, but where is the pain generating from? A spinal nerve? An injured disc? The spinal facet joint? So the pain generator is the pathoanatomic site, or pathologic structure, from where the back pain is originating. So the basic approach is to identify the source, the pain generator, and treat it. When this approach first became popular, it was revolutionary in that it focused physicians on moving away from the silly notion that all "back pain" was the same. Hence, this was a huge advance. Why? Because we now understood that some patients had pain primarily in their SI joint while others had a different problem and had pain coming from their facet joints. Hence, it makes common sense that interventional pain management physicians, who are doctors who do injections throughout the spine, are taught to find the one thing that's causing most of the pain and then inject that structure. That one thing is the pain generator. However, is this the best way to optimize outcomes in an age of orthobiologics?
What Are Orthobiologics?
If you read this blog regularly, you likely understand that the world of spinal-pain treatment has shifted radically in the last few years. While we at Regenexx began to use stem cells and PRP to treat the spine way back in 2005, when it was considered quackery, over the last few years, many traditional physicians have seen the wisdom of ditching harmful steroid injections and adopting orthobiologics. These are substances like PRP and stem cells and many other things that can help enhance healing. Other things on this list include cytokine-enriched serums, ECM products like amnion, and new biologic drugs that are working their way through the FDA approval process now.
Injecting Orthobiologics in the Spine Using the Pain Generator Approach
The problem that I see today is that interventional pain management physicians who are adding PRP and stem cells to their practices are really just adding these orthobiologics using the same pain generator approach, just injecting the one thing in the spine. However, is injecting this one structure the best way to apply orthobiologics to the spine, or are they missing a key concept by not treating the whole spine?
We May Be Missing Something if We're Injecting Only the Pain Generator
The pain generator approach, like many things in medicine, is really just reductionist thinking. In other words, it's trying to solve a problem by identifying and focusing on its parts rather than treating the whole organ. The spine isn't just a collection of parts and pieces; it's a whole functional spinal unit (FSU), meaning all of its parts work together as one unit to withstand loads and protect the body. So treating one part, just the pain generator, ignores any other part that might be impacting the functioning of the whole unit. Let's see what our registry data says...
Show Me the Data: Treating the Pain Generator vs. Treating the Whole Spine
Our former Centeno-Schultz Clinic fellow Chris Williams, MD, who is a brilliant interventional orthopedic physician and now opening his own practice in Atlanta, pulled together this data-driven registry project. The patient registry data he pulled included the following:
- High-dose LP-PRP injected into facets under fluoro guidance with contrast confirmation
- Platelet lysate mixed with 12.5% dextrose and ropiviciane injected into ligaments
- Platelet lysate mixed with nanogram dexamethasone and ropivacaine was injected via fluoro-guided transforaminal epidurals with contrast confirmation.
To see this data, please watch the video above. Let's first discuss the data on fluoroscopy-guided lumbar facet-only injections (number 1 above). This is the "pain generator" approach where we injected just the facet joint that was causing the most pain. Meaning, these are the patients who have back pain due to facet joint arthritis. What was interesting here was that for the pain and function scores, there was no statistically significant improvement at many of the time points (at 1, 3, 6, 12, 18, and 24 months) after the facet injection with the PRP. Again, watch the video for graphs illustrating all of this data. Now let's see what happens when we examine data on both facet and ligament injections (fluoroscopy-guided lumbar facet and ligament injections). These structures comprise two components of the FSU (numbers 1 and 2 above). Looking at both pain and function, we see something completely different: all time points in both pain and function now demonstrate statistically significant improvements. We see the same thing when we add fluoroscopy-guided treatments on the facet and ligament plus the epidural injections (numbers 1, 2, and 3 above). Statistical significance in both metrics. This is in contrast to the one structure pain generator approach, showing the opposite. In summary, treating two or three structures in the FSU has greater improvements in pain and function than only treating the pain generator.
Getting Most Physicians to Shift Away from the Pain Generator Approach Will Take a While
First, I would estimate that 95% of the doctors out there who can use guidance to inject PRP or stem cells into specific parts of the spine have no idea how to diagnose a problem with the functional spinal unit or inject its other parts, like the ligaments and stabilizing muscles (multifidus). Hence, this will be a huge educational process. In addition, please note that things are even worse at the average chiropractor's office offering fake amniotic and umbilical cord "stem cell" therapy. Here, they just blindly inject the muscle trigger points, completely missing almost all of the FSU. The upshot? This registry data supports that treating the whole spine (injecting the full FSU) with orthobiologics produces better results than just injecting a single structure. Is it time to get rid of the pain generator approach? More research will need to be done. However, based on what I've observed through the years, IMHO, it's time to crown a new king. The king is dead, long live the king.
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