This past month I had an interesting back-and-forth with an interventional spine physician about interventional orthopedics. This dialogue brought up an important issue that I think most interventional spine physicians don’t yet understand. While they have the requisite skills to start training in interventional orthopedics, they don’t have the skills needed to practice the specialty. In fact, they are sorely undertrained. Let me explain.
I was asked to write a book chapter by a specialty society for interventional spine physicians. This work would have been my seventh or eighth on regenerative orthopedics, but I said yes and got to work. The last several chapters I’ve written have all clustered around the theme that interventional orthopedics (IO) is an emerging specialty. Also, while stem cells and PRP allow IO to have great tools to help patients, the real magic is in rethinking orthopedics as an interventional (i.e., precise injection-based) specialty rather than a surgical one. Much to my surprise, the word came back from on high that my book chapter couldn’t be about interventional orthopedics. I got the distinct sense that the editors felt that it was not in keeping with their messaging that regenerative medicine for interventional spine physicians was more about using PRP and stem cells as just another injectate (i.e., something that is injected). I also got a distinct sense that the editors didn’t know what they didn’t know, hence this blog.
Interventional spine and IPM have changed the world for patients with spinal pain for the better. We have lots of physicians to thank for that specialty, which was birthed in just a few private practices around the country rather than in a university. This all happened because of physicians like Charlie April, Rick Derby, the Saal brothers, Paul Dreyfus, and Lax Manchicanti. When I began residency in the late ’80s, these giants were just starting to learn how precise steroid injections could reduce spine-surgery rates. Millions of patients who didn’t get back or neck surgery since the 1990s onward owe their thanks to these doctors. They then went out and trained crew after crew of physicians through a few different organizations, and I was one of those doctors who eventually learned how to perform these procedures.
I remember way back in 2004 that my practice had hit a wall. While I loved the fact that precisely injecting steroids into the neck and low back of my patients could help them, most of the relief was temporary, and sometimes the pain returned with a vengeance. As I began adding the simplest type of regenerative medicine in the form of prolotherapy injections, I noticed that this often worked better than steroid shots. It was those observations that caused me to get into stem cells in 2005, at a time when nobody else in the U.S. was doing that type of work.
I’ve noticed of late that a few IPM societies have begun offering regen med courses. The offerings are often a little amusing for me, as it’s clear that they view orthobiologics as just another injectate. Something to be bolted onto their current routine of spinal injections or just added to simple joint injections. Regrettably, these physicians are missing the whole point of IO.
While IO is about precise injections of orthobiologics, it also opens up a whole new world where orthopedic treatments can be rethought from the ground up. This idea is likely invisible to most IPM physicians because they don’t know what they don’t know. Let me explain.
Let’s take the example of a posterior shoulder labral tear. The patient shows up to the IPM physician with shoulder pain. Not having much training in how to correctly perform a shoulder exam (because his or her fellowship focused on spine injections), the IPM physician doesn’t know where to begin. So a cursory shoulder exam is performed and a quick guided PRP shot is delivered into the joint. The patient doesn’t get much better, so an MRI is ordered, which shows a posterior labral tear. This is where our IPM physician hits his or her first roadblock. The course that was given by the specialty society only focused on simple inside-the-joint shoulder injections. How to precisely inject a posterior labrum with ultrasound wasn’t taught, and while the IPM doctor bought an ultrasound machine, he or she doesn’t actually know more than the basics.
Let’s say for argument’s sake that our IPM doctor figures out how to inject the posterior labral tear with some PRP and manages through some miracle to get it close to the tear. The patient reports some improvement but is back the next year with the same problem. The IPM doctor is stumped and refers the patient for surgery.
If this IPM physician knew anything about IO, not only would he or she be an expert on how to get platelets or stem cells to this spot, but even more importantly, the doctor would know that a posterior labral tear is often caused by glenohumeral instability in the posterior direction. The doctor could have checked for that instability using stress ultrasound and if found, could have easily targeted the specific lax ligaments leading to that instability. If the IPM doctor had known how to diagnose and treat what was actually wrong, the patient would never have been referred to the surgeon.
While I tried to explain the example above to the IPM doctors who felt threatened by the idea of IO, it seems to have sailed over their collective heads. I can’t say that I blame them as when I was a practicing IPM physician, it would have also sailed over my head. So the purpose of this post is to say to all IPM doctors, “You’re not qualified to practice IO, but you sure could be with the proper training.” That’s more than the weekend courses being taught by IPM organizations. It requires a staged and structured educational program.
The upshot? IPM doctors, I have a challenge for you. Up your game substantially as you learn how to use these new tools. Your patients will thank you, and, hopefully, a whole new world of how to prevent knee, hip, shoulder, foot/ankle, and hand/wrist surgery will open up for you!
*DISCLAIMER: Like all medical procedures, Regenexx® Procedures have a success and failure rate. Patient reviews and testimonials on this site should not be interpreted as a statement on the effectiveness of our treatments for anyone else.
Providers listed on the Regenexx website are for informational purposes only and are not a recommendation from Regenexx for a specific provider or a guarantee of the outcome of any treatment you receive.
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.…