Prolotherapy For Thoracic Pain

Prolotherapy is an injection based regenerative therapy used in the treatment of ligament, tendon, muscle and spine injuries. It is minimally invasive and  involves the injection of an irritant such as dextrose into the damaged or painful area.  

The injected irritant stimulates a delayed or frozen healing cycle thereby increasing blood flow and tissue healing.

Where In The Thoracic Spine Does It Hurt?

The thoracic spine is that section of the spine that is below the neck and above the low back.  It is also referred to as the mid back. 

It has multiple components that include:

• Vertebral Bodies: Boney building blocks that stack one upon another. 12 in number
• Thoracic Disc: Shock absorber sandwiched between the vertebral bodies
• Thoracic Joints: 3 major types of joints: Facet, costotransverse, and costovertebral joints
• Thoracic Muscles: 3 principal layers: superficial, immediate and deep
• Thoracic Ligaments: Thick pieces of connective tissue that connect bone to bone. They provide important stability and support to the thoracic spine.
• Thoracic Nerves
• Thoracic Tendons: connective tissue that connects muscle to bone

Thoracic Spinal Cord:  susceptible to irritation and injury which can cause upper and lower extremity weakness, numbness and difficulty with walking

Potential Conditions That Cause Thoracic Spine Pain

Herniated Or Slipped Thoracic Discs 

Thoracic discs are important shock absorbers that are sandwiched between the vertebral bodies.  They provide a critical role in maintaining spinal alignment, absorbing the forces of daily living and providing space for the existing nerve roots. 

Thoracic discs are susceptible to injury and degeneration which can lead to a number of different conditions that include: disc protrusion, disc herniation, disc extrusion, disc collapse.  These conditions can cause pain, restriction in range of motion and nerve compression.

Degenerative Disc Disease 

A clinical condition that refers to the gradual deterioration of the discs in the thoracic spine.  Pain, weakness and limited movement are common symptoms. The gradual deterioration of the thoracic  discs can lead to facet arthritis, ligament laxity, nerve root irritation and possible irritation or compression of the spinal cord. 

Thoracic Radiculopathy 

Nerves exit from every level of the spine. They exit through a boney doorway referred to as the neuroforamen. This boney doorway may become narrowed by a number of different factors that include: facet overgrowth, disc protrusion, disc herniation, ligament overgrowth and bone spurs.  

This can cause irritation or compression of the existing nerve root resulting in pain which can be electrical in nature and can extend down the extremities and or abdomen. 

Sudden Sprain Or Strain From Injuries 

A sprain is stretch or tear of a ligament whereas a strain is an injury to the muscle.  Both can cause pain, swelling and restriction in range of motion. 

Spinal Infection 

Infection can occur in different parts of the spine.  When the infection is in the bone it is referred to as osteomyelitis whereas when it involves the disc it is referred to as discitis.  Infection can also occur in the muscle, tendons or ligaments.  Common symptoms include pain, fever, fatigue and limited movement. 

Osteoporosis 

A medical condition characterized by loss of bone mass and deterioration of bone tissue which can lead to fracture.

Osteoarthritis 

The most common form of arthritis is also referred to as a degenerative joint disease or “ wear and tear” arthritis. It affects any or all the thoracic spine joints including the facet, costotransverse and costovertebral joint leading to pain and restricted range of motion. 

Shingles 

also known as herpes zoster, is a viral infection that can cause a painful rash that commonly appears as a band or strip of blisters.  The rash and blisters occur along the pain of the affected nerve.  Burning, tingling and itching are common symptoms. 

Inflammation Of The Vertebral Joints  

All joints in the thoracic spine are susceptible to injury and inflammation causing pain.

Fractures In The Vertebrae  

The boney building blocks of the spine also known as vertebrae are susceptible to injury including fracture. Osteoporosis is the most common cause of vertebral fractures (1). Other causes include trauma, cancer, chemotherapy, long term steroid use and infection. 

Spinal Tumors 

Tumors in the thoracic spine can cause pain and restricted movement. Spine tumors can arise within or surrounding the spinal cord and or spinall column.  They may be benign or malignant. Tumors outside the dural sac referred to as extradural are the most common type of tumor in the spine (2). 

Conventional Treatment For Pain In The Thoracic Spine

Steroid Injections

When conservative treatment fails, patients may be referred for steroid epidural injections. Steroids are powerful anti-inflammatory medications that reduce swelling and pain. They are associated with significant negative effects which have been discussed in a previous post.

Surgery

Surgery should be the last treatment option for thoracic spine pain unless there is significant spinal instability or progression of neurologic symptoms such as weakness, numbness or loss of bowel and bladder control. 
The specific type of surgery will be dependent upon many factors that include site of injury, presence or absence of neural compression, symptoms and underlying medical conditions. The three most common thoracic spine surgeries are: thoracic fusion, thoracic laminectomy and discectomy. 

What Is Prolotherapy For The Thoracic Spine?

Prolotherapy is an injection based regenerative therapy that can be used to treat thoracic spine ligament and tendon injuries. It is minimally invasive and Injections are performed under x-ray or ultrasound guidance to ensure that  the prolotherapy reaches its specific target and  avoids critical structures such as blood vessels, nerves and organs such as the lungs. 

The anatomy of the thoracic spine is complex and significant complications can occur if guidance is not used.                         

How Does Prolotherapy Work For Thoracic Pain?

Prolotherapy has been used in clinical practice for more than 90 years.  The earliest form of prolotherapy was used by the Egyptians to treat lame animals with “hot iron cautery”. In the 1950 Dr, George Hackett formalized prolotherapy as a treatment option for ligamentous laxity and arthritic conditions (3)

Dextrose is the most common prolotherapy agent. The exact mechanism of action is not completely understood. It is thought that the hypertonic dextrose causes trauma to local cells which in turn stimulates a healing cycle.

In vitro studies have demonstrated that human fibroblast and chondrocytes(cells that make cartilage) when exposed to hypertonic dextrose trigger an increase in the number of growth factors.  These growth factors are critical to repair and growth of tendon, ligament and cartilage (4). 

In humans the injection of hypertonic dextrose has been found to stimulate the inflammatory response, ligament size (5) and increase tendon growth.(6)

What Does The Research Say About Prolotherapy?

There are an extensive number of publications examining the effectiveness of prolotherapy for different clinical conditions. Study design, number of patients and demographics vary significantly in the studies.

The most compelling data supports the use of prolotherapy in the treatment of tendinopathies (8). A tendon is the connective tissue that connects a muscle to the bone. In the thoracic spine there are a large number of both large and small muscles and tendons that are susceptible to injury. 

There is also strong evidence to support the use of prolotherapy in the treatment of osteoarthritis and degenerative joint conditions (9). The thoracic spine has a large number of small joints that are susceptible to injury, inflammation and pain that include thoracic facets and costotransverse joints.

How Does It Differ From Other Regenerative Therapies?

Prolotherapy is an effective injection based regenerative therapy for tendon and osteoarthritis and degenerative joint conditions. It uses an irritant to stimulate healing and repair. 

Dextrose is the most common irritant used. It is readily available, low cost, and does not require refrigeration for storage. It can be stored in a clinic or warehouse.  It is commonly mixed with a local anesthetic and saline. It can be used in any clinic or ambulatory surgery setting.  

PRP and bone marrow concentrate are significantly different as each requires the following:

• Removing blood or bone marrow under sterile conditions prior to the actual procedure. Typically a patient has a blood draw or bone marrow aspirate several hours prior to the procedure. Why? So that the PRP and bone marrow can be processed and concentrated. 

• Processing of the blood or bone marrow by bedside centrifuge or cell laboratory. 

The latter is the standard of care at the Centeno-Schultz Clinic that allows one to customize the PRP and bone marrow for each patient. A 65 year patient has much different needs than a 25 year old. 

For best clinical outcome, personal customization of both PRP and bone marrow concentrate is best. Few clinics have this capability and are reliant on bedside centrifuges with the philosophy that one size fits all. 

• Storage: processed PRP and bone marrow must be refrigerated  under strict guidelines so as to maintain the integrity of the platelets and cells. Otherwise, the stem cells within the bone marrow concentrate or the growth factors in the PRP are compromised. 

This in turn directly affects clinical outcome. Poor processing and storage can lead to poor outcomes.

Prognosis For Prolotherapy

Prolotherapy is an injection based, regenerative treatment that starts with the creation of an injury followed by inflammation. There are three distinct phases of healing.

• Inflammation: 1-2 weeks caused by the trauma of the needle and the hypertonic dextrose solution.
• Proliferation:  2-6 weeks: The fibroblasts and progenitor cells begin laying down new disorganized tissue.
• Maturation or Remodeling Phase: 6 weeks to 6 months: The disorganized collagen reorganizes to strong, stable ligaments.  

To learn more and what patients may experience during the three phases of healing please click on the video below. Please note that the video discusses ligament healing after PRP and stem cell injections, the concepts and recovery are very similar with prolotherapy.

Why Regenexx PRP Is Superior

There are a number of significant differences between Regenexx and other regenerative clinics.

• Centeno-Schultz Clinic performed this first orthopedic stem cell procedure in the United States. We have over 15 years of clinical experience and as of May 2017 have performed over 46,000 procedures.

• All providers are board certified, fellowship trained physicians. There are no mid-level extenders such as PA or NP’s at the Centeno-Schultz Clinic.

• University Level Cell Processing Lab that allows for customization of PRP and bone marrow concentrate treatments. 

• Two distinctly different types of PRP: Platelet Lysate and PRP. To learn more please click on video below. 

• Ability to count the number of cells in bone marrow concentrate.  Through extensive research we know how many cells it takes to help one or more joints.  To learn more please click on the video below.

• Publication of our outcome and safety data.  We are transparent with our results and update this information regularly. 

• Our patented technique allows us to concentrate bone marrow 5-6 times more than other clinics.  Our method has been verified in the lab.

To better understand how the Centeno-Schultz Clinic and Regenexx are very different from other clinics please click on the video below:

Know Your Options In Treating Thoracic Spine Pain

Pain in the thoracic spine is poorly understood and treated for a number of reasons including the complex nature of anatomy. Oftentimes it is misdiagnosed or disregarded. 

The Centeno-Schultz Clinic are experts in the evaluation and treatment of thoracic spine disorders. Securing an accurate diagnosis is paramount for best clinical outcome. 

Possible sources of pain in the thoracic spine include thoracic discs, facet joints, costotransverse joints, ligaments, muscles, tendons and nerves. All must be considered and evaluated for best clincial outcome. 

If you are suffering from thoracic spine pain, proper diagnosis is critical in ensuring that you undergo the right treatment plan. Read about how how we do it at Centeno-Schultz Clinic.

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References:

1. Ralston SH, Fraser J. Diagnosis and management of osteoporosis. Practitioner. 2015 Dec;259(1788):15-9, 2. PMID: 26882774.

2. Kumar N, Tan WLB, Wei W, Vellayappan BA. An overview of the tumors affecting the spine-inside to out. Neurooncol Pract. 2020 Nov 18;7(Suppl 1):i10-i17. doi: 10.1093/nop/npaa049. PMID: 33299569; PMCID: PMC7705529.

3. Nair LS. Prolotherapy for tissue repair. Transl Res. 2011 Sep;158(3):129-31. doi: 10.1016/j.trsl.2011.05.001. Epub 2011 May 31. PMID: 21867977.

4. Tang JB, Xu Y, Ding F, Wang XT. Tendon healing in vitro: promotion of collagen gene expression by bFGF with NF-kappaB gene activation. J Hand Surg Am. 2003 Mar;28(2):215-20. doi: 10.1053/jhsu.2003.50052. PMID: 12671851.

5. Tabata Y. Tissue regeneration based on growth factor release. Tissue Eng. 2003;9 Suppl 1:S5-15. doi: 10.1089/10763270360696941. PMID: 14511467.

6. Jensen KT, Rabago DP, Best TM, Patterson JJ, Vanderby R Jr. Early inflammatory response of knee ligaments to prolotherapy in a rat model. J Orthop Res. 2008 Jun;26(6):816-23. doi: 10.1002/jor.20600. PMID: 18240327; PMCID: PMC2755507.

7. Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil. 2004 May;83(5):379-89. doi: 10.1097/01.phm.0000124443.31707.74. PMID: 15100629.

8. Kim SR, Stitik TP, Foye PM, Greenwald BD, Campagnolo DI. Critical review of prolotherapy for osteoarthritis, low back pain, and other musculoskeletal conditions: a physiatric perspective. Am J Phys Med Rehabil. 2004 May;83(5):379-89. doi: 10.1097/01.phm.0000124443.31707.74. PMID: 15100629.

9. Rabago D, Patterson JJ, Mundt M, Kijowski R, Grettie J, Segal NA, Zgierska A. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013 May-Jun;11(3):229-37. doi: 10.1370/afm.1504. Erratum in: Ann Fam Med. 2013 Sep-Oct;11(5):480. PMID: 23690322; PMCID: PMC3659139.