Today I examined a patient who was planning an L5-S1 low back fusion, but received a back fusion denial from his insurance company. This may have saved his back! As a result of the back fusion denial he was forced to do some more homework on the internet, ultimately finding out that there were serious problems with low back fusion including male sterility caused by the BMP drugs now used to promote fusion, serious low back fusion complications, and overload and advanced degeneration of the levels above and below the low back fusion levels. The patient has pain in the left low back and his MRI and CT-Myeogram were essentially normal. What was interesting was that instead of investigating the other causes of low back pain like the SI joint, facet joints, ligaments, or muscles the last clinic jumped directly to a discogram. While a discogram can be helpful, it’s putting a hole in the disc to see if there’s a hole in the disc. Based on his exam and history (despite his “positive discogram”) this patient likely has an SI joint problem that was causing pain. A simple injection under x-ray guidance that’s much less invasive than a discogram and should be able to confirm that the SI joint is causing his pain and not the degenerated low back disc. So what started out as life changing back fusion surgery, ended up as a simple SI joint injection. In this case, a back fusion denial by the man’s insurance company may be the best thing that ever happened to him!
It’s been known for sometime that adult stem cells (the type in your body) can repair your low back discs (at least in animals). While surgery will only weaken these discs, stem cells can repair them? A few years ago we undertook research to see if this would work in people. We first tried the type of stem cells that you can get from a bedside centrifuge machine (BMAC), didn’t work. It likely didn’t work because the number of stem cells you can get in this type of same day procedure is just not enough. So we then did what they did in the research and started to grow the cells in culture to bigger numbers. After figuring out the specifics, we had it working inside of a year. Now the FDA is claiming these stem cells in your body that can be used to fix your back are drugs? What are your stem cells drugs? No reason given. Recently patients have banded together to oppose the FDA on this issue as well.
Adult stem cells live in all of us. They come in various types, the most commonly mentioned in therapy being hematopoetic and mesenchymal stem cells. Mesenchymal stem cells are released by your body in many different types of injury. If you break a bone or tear ligament, cartilage, or tendon tissue, these cells spring into action as reapir cells. Your body will even increase the amount locally, say in a knee injury through “culture expansion”, meaning your body grows more when it needs them. The Regenexx procedure mimics this process by growing more of these mesnechymal stem cells to use in the culture process. The FDA contends that the Regenexx procedure constitues a drug. But is this a drug? Since the function of the tissue is not changed, this type of minimal culture expansion doesn’t create something new. Does the research show that there are risks to this process? No the research is clear that limited growing of these cells likely poses no new risks. So why the argument between the Regenexx procedure and the FDA? In a phrase, “big pharma”. The big pharma business plan for adult cells requires that they be classified as drugs, or else the business model is broken. Physicians and patients have come together to support doctors in using these minimal culture procedures to treat a variety of diseases. Let the drug companies heavily modify cells as drugs by inserting new genes and reversing adult cells back to embryonic cells, let doctors practice medicine by using the patients own adult stem cells to treat disease.
As a doctor who treats patients with back pain and sciatica all day, lumbar epidural injections + fish oil is a great and powerful combination that I use on my own intermittent left S1 disc/nerve problem. Why do I use this combination on my own problem? First, epidural injections can be a great way to calm down an inflamed spinal nerve when the fire just gets too much to manage. I consider this like putting allot of water on a really big nerve fire. In addition, we stay away from very high dose steroids in our epidurals and have replaced the milligrams with nano-grams of steroid. This is because this is closer to the dose range that the body uses naturally. In addition, since we have our own stem cell culture lab, we add in platelet lysate or a VEGF rich supernatant from cultured platelets. What’s all that mean? These natural preparations made from the patient’s own blood platelets bring natural growth factors to bear to help the disc bulges heal themselves. Fish oil is a natural management tool for the day to day inflamed spinal nerves (sciatica) many of us get form sitting too long or just chronic bulges. Our friend Joe Maroon (a Neurosurgeon at the University of Pittsburgh) conducted a study where he was able to get about 60% of his patients off of NSAID’s like Motrin by substituting a high quality fish oil loaded with Omega 3 fatty acids. We personally use the same brand he uses, which is Nordic Naturals. Too often fish oil is made from oxidized and cheap junk fish, while these guys do the processing right. What to do when the epidurals and fish oil no longer work well? We use the patient’s own stem cells injected into the disc tears that are causing the bulges (to help heal the tears and reduce the size of the disc bulges). This method usually helps our patients avoid low back surgeries (where the disc is too often weakened by cutting off the disc bulge). Repair is better than cutting out-at least that’s what we believe at The Centeno-Schultz Clinic.
Epidural steroid injections have become a mainstay of treating herniated discs (sciatica). As a interventional pain specialist I’ve seen them work well to avoid surgery hundreds of times. However, there can be adverse effects from epidural steroid injections. These side effects are generally much less than surgery. The side effects from epidural steroid injections can be: increased pain or numbness, an increase in epidural fat causing pressure on the nerve, immune and repair function suppression, just to name a few. In our clinic, we consider that the most concerning of these side effects of epidural spinal shots for pain are caused by the extremely high doses of steroids commonly used. Steroids are a two edged sword (like cortisone). They do bring down swelling around the nerve. However, for an unknown reason (likely due to medical tradition and certainly not medical science), most physicians use about a million times more steroid than your body uses on a day to day basis. We’ve found that lowering the dose of steroids from the milligram range to the nano-gram range doesn’t diminish the anti-inflammatory effect, just the side effects. This is because your body naturally produces it’s own steroids in nano-grams (one billionth of a gram) and not milligrams (one thousandth of a gram). We also commonly add in platelet lysate (growth factors isolated from the patients blood and processed in a our cell culture lab). These growth factors (especially VEGF) can help bring in much needed extra blood supply to the poorly vascularized and nutritionally challenged disc, helping the disc heal itself. We can also create a VEGF rich supernatant (we call it super VEG) by culturing the patient’s blood platelets. What if the disc/nerve (sciatica) problem still persists? We then turn to using the patient’s own stem cells to heal the tears in the disc and get rid of the bulge. For more information, click the link in the last sentence or check out the video below:
The low back has disks that act as cushions between the back bones. In order to fix back disks without surgery, the disk has to be repairedin some way. This is because as we ageor the disks are injured, they can bulge and press on spinal nerves, causing sciatica. Many things have been tried through the years, including spinal decompression therapy. This newer form of traction is interesting, but in our clinic we have not seen a significant benefit over traditional traction to justify it’s high price. Instead of this modality, consider an inversion table, which you can use at home. Other non-surgical options haven’t existed until recently. A new procedure injects your own adult stem cells into the low back disks to repair damage. This can help repair the tears in the disc that caused the disk to bulge (which then presses on the exiting spinal nerves). This new procedure can be performed through a needle, without the need for surgery or big recovery times. A video that helps to explain how to fix back disks without surgery can be found at this link. This video reviews how traditional low surgery removes the bulging part of the disc, which can weaken the disk and lead to more complications such as a re-herniation of the disk. A case report with an MRI is discussed.
Mid back pain is defined as pain in the thoracic spine. The causes of mid back pain are very similar to the causes of low back pain. As a result, many of the treatment options are similar. These include epidural steroid injections, facet injections, trigger point injections, prolotherapy, and physical therapy. Mid back pain is different in that surgical options become much more dangerous, as the lungs are in the way and commonly have to be deflated. In addition, mid back pain can also involve pain coming from the ribs and the joints that attach the ribs to the spine. Upper extremity numbness due to changes in the shape of the ribs can also accompany mid back pain. Scoliosis or an abnormal curvature of the spine can also cause mid back pain. Like the low back, some of the causes of mid back pain can be treated with injections of stem cells.
Chronic back pain has multiple causes. Often these patients are placed on narcotic medications to treat chronic back pain. Other common options offered to chronic back pain sufferers include low back surgery. Regrettably, both of these options used to treat chronic back pain can often make the problem worse. Again, finding a specific cause of the chronic back pain is an important part of planning treatment. For example, chronic back pain due to a disc bulge pressing on a nerve or the dura can often be treated sucessfully with a stem cell injection into the disc. Other treatment options for chronic back pain include epidural steroid injections, facet injections, trigger point injections, prolotherapy, and physical therapy.
Back pain relief strats with a specific diagnosis. You can’t get back pain relief without knowing what’s causing the back pain. Once the structure causing the back pain is known, back pain relief is the next step. If you have a disc problem, the cutting out a piece of the disc or fusion is rarely a way to get back pain releif. Other options for disc related back pain relief include stem cell injections. If you have a facet joint problem, back pain relief may be gained with either the injection of stem cells into the joint or facet joint radiofrequency. SI joint problems can also cause back pain and injecting the SI joint with anti-inflammatories or stem cells may allow for back pain relief. Prolotherapy may also provide back pain relief. Other options for back pain relief include: acupuncture and acupressure , epidurals , physical therapy , and massage therapy.
As a physician who has seen thousands of patients with back pain, there are many causes. These include disc problems where the disc is painful or can be damaged causing a bulge or herniation. Back pain can also be caused by a disc placing pressure on a nerve. If this is the case, newer stem cell procedures can repair the disc bulge. Back pain can also be caused by irritated or damaged facet joints. Yet another cause of back pain is the SI or sacroliliac joint. Muscles and ligaments being overloaded or injured can also lead to significant back pain. Back pain can also be due to occult problems like vertebral compression fractures, cancer, a balooning out of the aorta, etc…
The most important part of a back pain work-up is identifying a specific strutcure that is causing the pain. Just throwing narcotics or other medications at the problem is extremely counter-productive. Too often back surgery is the conclusion when the cause of back pain goes undiagnosed. This can cause significant complications.