Frankly, until we became the first in the world to inject stem cells into discs, discography never made much sense to me. I would tell patients, “I’m going to poke a hole in your disc to see if there’s a hole in your disc.” However, when we began to see that platelet rich plasma and stem cells could heal disc tears on MRI, discography made sense. Now you could poke a hole in the disc to see if there’s a hole in the disc that needs to be repaired. While we’ve been using what I call “biologic discography” for many years, this morning I’d like to put a name on it and challenge my colleagues.
Between your vertebrae, or spinal bones, there are cushioning, shock-absorbing structures called intervertebral discs. They have a tough outer covering that is fibrous (annulus) and an inner gel that is like hard toothpaste (nucleus pulposus). The disc annulus can become painful or torn, and a discography test may be necessary to pinpoint the specific offending disc in the painful area.
A discography procedure uses fluoroscopic (X-ray) guidance to inject contrast dye into the discs to pressurize the discs and test for pain as well as ferret out the architecture (i.e., are tears present). As each disc is pressurized, the patient is then asked to describe his or her pain level to the physician, and to compare it to the pain the patient has been experiencing. The diagnostic goals of discography are to determine if the disc is causing back pain and, if so, which disc is the source and also to determine if there are any tears or holes in the disc.
Can’t an MRI give us this information? The problem with an MRI is that just because a tear is seen on MRI, this doesn’t mean the tear is the source of the pain. Wear-and-tear trauma can occur naturally, especially with age, so the only reliable way to determine if a tear is the pain source is to perform a discography test. Watch the video below for more information on this:
Discography, however, also isn’t without its problems. Because a hole is poked in the disc to deliver the contrast material to pressurize the disc, discography side effects can occur. These include the following:
In other words, discography can cause good discs to go bad. This is especially true when discography is combined with steroids and certain anesthetics. Just because an epidural steroid injection is a nonsurgical procedure doesn’t mean it’s good for you. In fact, it’s the opposite; steroids are toxic to cartilage and are riddled with side effects. We’ve even found that certain local anesthetics are toxic to cells. Discography side effects can make the disc pain or injury worse.
Biologic discography, used not only to diagnose but also to regeneratively treat the disc, can be an answer to avoiding discography side effects. It avoids harmful steroids and anesthetics and substitutes solutions that have been shown in clinical or animal studies to help the disc heal.
Biologic discography involves not only diagnosing the problem disc but also precisely injecting a regenerative substance, rather than toxic steroids, to address disc pain and facilitate disc healing. Regenerative substances can include the patient’s own platelet rich plasma (PRP) or even stem cells, and we have high-quality clinical research that supports the use of PRP, as well as some research supporting stem cells, to help disc healing. So after contrast-dye injection, PRP, for example, would also be injected. The reason behind biologic discography is really quite simple—why damage the disc by poking a hole in it (discography) if you’re not leaving something behind (regenerative substance) to address the damage?
There are some technical differences between the traditional and the biologic technique. First, we tend to use much less contrast dye since we’re also injecting a substance to treat the disc at the same time. Watch the video below to see Dr. Pitts performing an actual disc stem cell treatment:
Second, we avoid injecting harmful steroids and anesthetics into the disc. Third, biologics are injected into the disc tears seen and into the annulus as the needle is removed, to cover the needle track made by the discogram.
Injecting anything into the disc is one of the most invasive spinal procedures that can be done using a needle. For the right patient, biologic discography works well and is very helpful; however, a disc injection is always a higher-risk procedure. As such, we do not believe that everyone with back pain is a good candidate for orthobiologic injections directly into the disc space. Many patients can be treated, depending on the spinal condition (e.g., herniated discs, tweaked spinal nerves, loose spinal ligaments, etc.), with a lower risk procedure that does not involve entering the disc itself. A potentially good candidate for a biologic discography would be, for example, someone with a disc tear that is definitely causing pain or if chemicals are leaking out of the disc and onto the nerve, causing irritation. A poor candidate, for example, would be someone with severe degenerative disc disease with a collapsed disc as disc injections are not an appropriate nor an effective therapy for this condition.
For a thorough review of spine conditions and how they can be treated nonsurgically with advanced biologics, watch this video:
Beware of any clinic willing to inject stem cells into any type of disc condition and in any type of patient—every patient simply is not a good candidate for a disc injection procedure (ask these 10 questions before you let a clinic inject your disc). Beware of clinics whose providers learned how to inject stem cells into discs via a weekend course as extensive experience is imperative for these injection procedures.
Finally, we’ll finish with a big beware label. You may see fibrin treatment being pushed for back pain, which is a rubber-cement-like substance injected to seal a degenerated disc. These sealants quickly break down, usually within a week or two, returning the disc to its prior collapsed state. To date, we have no compelling evidence that fibrin helps degenerated discs. In fact, we have one randomized controlled trial that it was ineffective.
The upshot? First, hopefully, biologic discography will replace standard discography over the next decade. It just makes more common sense. In the meantime, I’d like to challenge my colleagues to, as much as feasible, not poke holes in discs unless you’re leaving at least PRP behind.
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About the Author
Christopher J. Centeno, M.D. is an international expert and specialist in regenerative medicine and the clinical use of mesenchymal stem cells in orthopedics. He is board certified in physical medicine as well as rehabilitation and in pain management through The American Board of Physical Medicine and Rehabilitation.…