Your low back pain is getting worse. Each morning it is a struggle to get up. One wrong move and your body locks up. You know that you may need surgery, only you know you should avoid surgery at all costs. But you know there’s only a couple options
Do injections for back pain work? The short answer: it depends on who is doing the procedure. Let’s dig in.
The Wild Wild West and Stem Cell Therapy for Back Pain
Unfortunately for the consumer, there is little uniformity or consistency in injections for low back pain. There are “experts” with different backgrounds and training in different parts of the globe all offering a cure. A helpful guide to navigating the important difference in stem cell treatments begins with 4 questions.
- Who is providing the injection?
- What is being injected?
- Where is it being injected?
- How is it being injected?
Understanding each of these questions will help you and your loved one identify legitimate, well-trained physicians and avoid the con artists interesting in taking your hard-earned money.
Who Is Providing the Injection?
The evaluation and management of low back pain and its causes require dedicated study and years of training (1). Additional training and certification are required to inject cells into the various structures in the low back that may be causing the pain. These structures include the disc, facets, ligaments, tendons, and muscles. Physicians trained in anesthesiology and physical medicine (PM &R) typically have learned these skills during their 4 years of residency.
Nurses are often used in chiropractic clinics to perform injections. This is because chiropractors are not allowed by law to perform injections. Nurses do not have the training, certification, or expertise to inject stem cells into the different structures in the low back. The same applies to retired rheumatologists, dermatologists, or surgeons who have opted to embark on a part-time second career.
If you are scheduled for injections of bone marrow concentrate for low back pain ask specifically who is performing the injections and their credentials.
What Is Being Injected?
Orthobiologics are biological substances naturally found in the body that are used to promote quicker healing of muscle, tendon, and bone injuries. I discussed in depth what Orthobiologics are and why you should care in a previous blog. There are many different types of Orthobiolgics. The most common that are used in the treatment of low back pain are:
PRP (platelet-rich plasma)
This involves drawing a patient’s blood and processing the blood whereby the white and red blood cells are removed. The platelets are increased in concentration many times their normal concentration. PRP is rich in growth factors which can increase the blood flow and decrease inflammation.
Autologous Stem Cells
“Autologous” is an important word to know and understand. It refers to the source of the cells. Autologous cells are cells from your own body. They are yours. The most common type of stem cells used for low back pain is autologous bone-derived stem cells. These are cells taken from your hip bone during a bone marrow aspiration. Autologous fat-derived stem cells are often advertised by clinics but are not legal in the United States.
Allogenic Birth Tissue-Derived “Stem Cells”
Allogenic refers to the fact that these cells are from a different patient or pool of patients. They are not your own. Birth tissue products are heavily advertised and promoted. Examples include Wharton’s Jelly and Amniotic fluid. I placed the word stem cells in quotes. This is to reflect the fact that despite the claims birth products do NOT contain any living stem cells. This has been confirmed in multiple clinical laboratories (2-4). In July the FDA provided a consumer warning letter..
To learn more about Orthobiolgics please click on the video below.
Where Is It Being Injected?
In real estate experts know that location is KEY. So too with stem cell injections for low back pain. It is important to understand that there are multiple structures in the low back that can be a source of pain. Each of these needs to be evaluated and possibly injected to provide the best clinical outcome. The list includes:
- Lumbar Disc: The gelatinous structure sandwiched between the spinal bones which functions as an important shock absorber.
- Facet Joint: A pair of small cartilage lined joints located at the backside of the spine. These joints are susceptible to injury from trauma, poor posture, degeneration, and spinal surgery.
- Ligaments: Thick pieces of connective tissue that connect bone to bone. They play a critical role in the stability of the spine.
- Muscles: The multifidus muscle is a core stabilizer of the spine. It is often ignored and can be injured thereby compromising spinal stability.
- Exiting Nerves: At each level of the spine, nerves exit from the spinal cord transmitting important information to the rest of the body.
- Fascia: a thin band of connective tissue that surrounds and holders organs, blood vessels, and muscles in place.
Few physicians can skillfully inject stem cells into all the areas listed above. Significant skill, training, and dedication is required. Hundreds of hours of dedicated study and practice is required. This training is available through the IOF.
How Is It Being Injected?
This refers to how the stem are placed into the damaged structure or structures in the low back. There are three options.
Blind
Similar to the antics of childhood birthday parties with a blindfolded child swinging at the suspended pinata. The physician simply touches the back and advances a needle without any guidance or visualization of the structures. Often times these injections are simply into the muscle. Discs, facets joints, and specific ligaments can not successfully be injected blindly. Blind injections are not advanced treatments and can not target important structures in your back that may be causing your pain.
Ultrasound
Ultrasound is an imaging method that uses high-frequency sound waves to produce images of different parts of the body. The most common use of ultrasound is in the evaluation of a growing baby during pregnancy. It is also useful in musculoskeletal medicine. It is a fantastic imaging tool for visualizing superficial tissues like muscles, tendons, and ligaments in the knee and ankle. In the spine, some of the potential pain-generating structures can be injected such as the ligaments, muscles, and facets. Ultrasound also allows for visualization of the needle as it is advanced towards the targeted structure. Ultrasound is better than blind injections but has limited use for injections into the disc particularly in larger patients.
X-ray
Fluoroscopy is an imaging method that uses intermittent x-ray. Fluoroscopy is used in various medical procedures including Interventional Orthopedics, Pain Management, and Interventional Cardiology. It involves a large C-shaped machine that can take x-ray from different angles. It is the gold standard in advanced spine injections. In addition, fluoroscopy also allows for the use of a dye. The dye is called contrast and it confirms accurate needle placement. Fluoroscopy allows the successful injection of superficial and deeper structures alike. The downside is the expense and the steep learning curve. Fluoroscopy is very expensive to purchase and maintain. The average cost for a new fluoroscopy unit exceeds $300,000 The learning curve is steep and takes years to master as one must be able to create a mental 3-D image using 2-D x-ray images.
To watch injections into the lumbar discs under x-ray please click on the video below. The injections are performed by Dr. Pitts at the Centeno-Schultz Clinic. Please note the use of dye which confirms accurate placement of the injected stem cells.
Do Injections of Bone Marrow Concentrate Work for Low Back Pain?
Medical research examining the effectiveness of Orthobiologics continues at a rapid pace. Here is the brief summary:
PRP can help various causes of low back pain. A recent study demonstrated PRP injected into the disc can reduce pain and increase function (5). At the Centeno Schultz Clinic, we published results that demonstrated an advanced PRP called Platelet Lysate is effective in reducing sciatica caused by bulged and herniated disc (6). PRP also can reduce the shrinkage of important spinal stabilizing muscles (7). Finally, PRP has been shown to be more effective than steroids in the treatment of sacroiliac (SI) joint problems (8).
Autologous bone marrow stem cells have been effective in the treatment of painful discs (9). The first stem cell injection into the disc was performed at the Centeno-Schultz Clinic in 2005. Our 2016 study demonstrated the safety and feasibility of bone marrow stem cells injected into discs for low back pain (10). Our 2017 study demonstrated a mean improvement of 60% at three years post-treatment in patients who had stem cell injections into the lumbar disc (11).
What medical research does not support is the use of exosomes, amniotic, or umbilical cord products. Said another way there are NO human studies supporting the use of these products for low back pain.
To learn more about stem cell treatment options for spine problems, please click here to download Dr. Centeno’s Spine Owner’s Manual.
Are Injections Covered by Insurance?
Regrettably, for most patients, injections for back pain are not covered by major health insurers, Medicare, or Medicaid. However, Regenexx has had success in getting full coverage from various self-funded health plans. Click here to learn more about getting your employer to cover these procedures.
In Conclusion
Injections for low back pain vary significantly from highly skilled physicians to con artists. 4 questions can assist you and your loved one in identifying highly skilled physicians from con artists. The questions are: Who is providing the injection? What is being injected? Where is it being injected? How is it being injected? PRP and bone marrow-derived stem cells have been demonstrated to be effective in the treatment of low back pain. There are No human studies published on the use of exosomes, umbilical, or amniotic products for low back pain. There are significant differences in the use of stem cells in the treatment of the low back. Do your homework, and be aware and question high pressured sales tactics used by many clinics.
In 2005 The Centeno-Schultz Clinic became the first clinic in the world to inject stem cells into the disc, a procedure called Perc-FSU. Fifteen years later we continue to innovate and advance stem cell injections of low back pain. We offer Telemedicine consultations with fellowship-trained physicians who can identify your candidacy and the best treatment option for your low back pain. Stop the pain today.
References
1.Allegri M, Montella S, Salici F, et al. Mechanisms of low back pain: a guide for diagnosis and therapy. F1000Res. 2016;5:F1000 Faculty Rev-1530. Published 2016 Jun 28. doi:10.12688/f1000research.8105.2
2. Berger D, Lyons N, Steinmetz, N. In Vitro Evaluation of Injectable, Placental Tissue-Derived Products for Interventional Orthopedics. Interventional Orthopedics Foundation Annual Meeting. Denver, 2015. https://interventionalorthopedics.org/wp-content/uploads/2017/08/AmnioProducts-Poster.pdf
3.Becktell L, Matuska A, Hon S, Delco M, Cole B, Fortier L. Proteomic analysis and cell viability of nine amnion-derived biologics. Orthopedic Research Society Annual Meeting, New Orleans, 2018. https://app.box.com/s/vcx7uw17gupg9ki06i57lno1tbjmzwaf
4.Panero, A, Hirahara, A., Andersen, W, Rothenberg J, Fierro, F. Are Amniotic Fluid Products Stem Cell Therapies? A Study of Amniotic Fluid Preparations for Mesenchymal Stem Cells With Bone Marrow Comparison. The American Journal of Sports Medicine, 2019 47(5), 1230–1235. https://doi.org/10.1177/0363546519829034
5. Monfett M, Harrison J, Boachie-Adjei K, Lutz G. Intradiscal platelet-rich plasma (PRP) injections for discogenic low back pain: an update. Int Orthop. 2016 Jun;40(6):1321-8. doi: 10.1007/s00264-016-3178-3.
6.Centeno C, Markle J, Dodson E, et al. The use of lumbar epidural injection of platelet lysate for treatment of radicular pain. J Exp Orthop. 2017;4(1):38. Published 2017 Nov 25. doi:10.1186/s40634-017-0113-5
7. Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. SICOT J. 2016;2:12. Published 2016 Mar 22. doi:10.1051/sicotj/2016002
8. Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid vs. Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain. Pain Pract. 2017 Jul;17(6):782-791. doi: 10.1111/papr.12526
9.Pettine KA, Suzuki RK, Sand TT, Murphy MB. Autologous bone marrow concentrate intradiscal injection for the treatment of degenerative disc disease with three-year follow-up. Int Orthop. 2017 Oct;41(10):2097-2103. doi: 10.1007/s00264-017-3560-9.
10. Elabd C, Centeno CJ, Schultz JR, Lutz G, Ichim T, Silva FJ. Intra-discal injection of autologous, hypoxic cultured bone marrow-derived mesenchymal stem cells in five patients with chronic lower back pain: a long-term safety and feasibility study. J Transl Med. 2016;14(1):253. Published 2016 Sep 1. doi:10.1186/s12967-016-1015-5.
11.Centeno C, Markle J, Dodson E, et al. Treatment of lumbar degenerative disc disease-associated radicular pain with culture-expanded autologous mesenchymal stem cells: a pilot study on safety and efficacy. J Transl Med. 2017;15(1):197. Published 2017 Sep 22. doi:10.1186/s12967-017-1300-y
