Before you consider surgery for degenerative disc disease
In this article, Tim Speciale, DO discusses non-surgical alternative treatments for degenerative disc disease including new research on stem cells and disc height and Prolotherapy for spinal instability.
Canadian doctors are trying to predict which patients will benefit the most from spinal surgery for degenerative disc disease. Here is a startling finding: the worse the patient’s symptoms are – the less likely the surgery will succeed. Equally – it seems that the amount of disc herniation does not affect surgical outcomes negatively or positively.1
What does this mean? It is not the discs causing the problem. Back pain can be caused by many reasons. One of the challenges in fact in treating back pain is making an accurate diagnosis.
Disc degeneration is seldom the pain cause – but frequently the reason for surgery
Most patients who come to Caring Medical with low back or lumbar disc disease, thoracic or neck (cervical) pain have MRI’s that show disc degeneration. On examination we find that the MRI’s disc degeneration is seldom what is causing their pain. Here are some signs/symptoms that may lead a doctor to believe that pain is not coming from the disc problem :
- Pain on either side of the spine not on the midline
- Sensation is intact
- Muscle strength is fine
- Pain upon lying down
- Pain is not worse with sitting
- Pain is not worse with bending over
- Numbiness (tingling down the arm but sensation is ok)
All of the above symptoms suggest ligament laxity of spine or sacroiliac ligament problems. Disc problems are more indicative if the person has low back pain for instance that is:
- Sitting makes it worse
- Standing (compared to lying) makes it worse
- Bending over while standing increases the central pain.
Spinal ligaments as main culprit behind back pain
The many complexities of the spine and the spinal ligaments can be seen at the intervertebral joints – where vertebrae connect to each other.
Here the interspinous ligament weaves between the spinous processes connecting the back of the vertebrae bony processes.
The supraspinous ligament connects the spinous processes. Running towards the cervical spine it forms the nuchal ligament.
The intertransverse ligaments connect the adjacent transverse processes, and the ligamentum flavum connects the laminae of adjoining vertebrae.
It should be clear that the spinal ligaments are key factors in spinal stability and instability which can lead to degenerative disc and possible nerve compression at the facet joints in flexion or extension, and at the lower back ligaments of the sacroiliac joints.
In other words, back pain can be due to an unstable disc problem, facet joint locking, or sacroiliac dysfunction caused by problems of the spinal ligaments.
The spine relies heavily on the supporting ligaments to hold itself together
The opening statement of a recent research article brings all these concerns together when the researchers state: “Understanding spinal kinematics (the movement of the spine) is essential for distinguishing between pathological conditions of spine disorders, which ultimately lead to low back pain.
It is of high importance to understand how changes in mechanical properties affect the response of the lumbar spine, specifically in an effort to differentiate those associated with disc degeneration from ligamentous changes (problems of the spinal ligaments), allowing for more precise treatment strategies.”2
In April 2016 doctors published their findings that acknowledged Degenerative Disc Disease is just that, a problem of degeneration and aging and that the vertebrae and facet joints of the spine represent a three joint complex that relies heavily on their supporting ligaments to hold the joint together.3
Is medical research suddenly discovering that the spinal ligaments are important, actually crucial in determining back pain problems?
Listen to the opening of this research review: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.”4
There is a new cluster of research on understanding the spinal ligaments and their crucial role in healing degenerative disc disease. In one remarkable study doctors even suggest that the ligaments may be the key to degenerative disc disease and spinal degenerative changes.
The ligaments of the spine as the key to degenerative disc disease
The researchers suggest that it is hard for doctors and MRIs to figure out the pain sources in low back pain, and that even when people have it, there are no symptoms for it, yet eventually it will develop into worsening low back pain and disc problems.
But, these researchers also say that there are “patterns” of disc degeneration that may provide insight into where the pain is coming from and that by addressing these patterns – further disc degeneration can be managed, What do doctors need to address? Spinal ligaments.
Specifically, individuals with contiguous multi-level disc degeneration have been shown to exhibit higher presence and severity of low back pain as compared to patients with skipped-level disc degeneration (i.e. healthy discs located in between degenerated discs).
Here is the reason: Stresses on the surrounding ligaments, facets, and pedicles (the area of the vertebrae where many spinal procedures begin) at vertebral levels where there was no degeneration of the spine were generally lower than where degeneration occurred.5
That should be obvious that stable ligaments equal stable spines – unstable ligaments – unstable spines.
Stem cell therapy was viable and effective in halting or reversing degenerative disc disease
Last year, the Mayo Clinic released animal study findings that suggested that stem cell therapy was viable and effective in halting or reversing degenerative disc disease of the spine. In fact, they called it a “landmark study.” Since the release of this study, numerous papers have come out trying to assess the role of stem cells in regenerating the innards of degenerated discs.6,7 What they are finding is based on new and old research they cannot come up with a conclusive opinion. The problem is the quality of the studies they are examining.
However sometimes in medicine, the true study result is the patient outcome. Is the disc innards the only cause of back pain? No according to the research presented above and other supporting research on the problem of ligaments.
Degenerative disc disease (DDD). This is a common form of Osteoarthritis in the back. A degenerated disc is one that has lost some water innards and as a result loses height and flattens.
One of the challenges of being a clinic that offers stem cell therapy, is not the procedure itself, but keeping patients informed of the nearly daily updates in the science and research that supports and sometimes does not support the use of stem cell therapy in back pain problems.
A common question we receive via email is will stem cell therapy work for me and my disc problems?
My doctor says it wont, how do you respond?
Here is what recent investigators concluded:
“If cell therapy for treatment of disc-related disorders is to enter the clinic as a routine treatment, investigations must examine the questions related to patient selection and the feasibility of achieving the desired repair in an acceptable time frame.”8
In other words, and we agree stem cell therapy will not work for everyone, HOWEVER, our empirical results speak for themselves Stem Cell Therapy for back pain works for many, many people. What is a success? The success or non-success of stem cell therapy is best decided after a physical examination and a conversation with the patient as to what are the goals of the treatment. Many times a patient will receive Prolotherapy, or Platelet Rich Plasma Therapy, or Stem Cells and pronounce that they do not work without questioning if their particular treatment plan was appropriate to them. Sometimes however, the treatment may not work at all, in this case the doctor explores other options.
Remarkably, in a paper from February 2015, doctors questioned whether stem cell therapy would be effective for disc repair because they could not see how to control the inflammation factors and the effects of the inflammatory response on stem cells.9 Perhaps the opinion of a doctor well experienced in using inflammation as a tool for healing as in Prolotherapy may have helped.
Stem cell injection’s role in back pain
Two research papers 10 suggests that stem cell injections may provide the answer as a treatment for degenerative disc disease because the treatment rebuilds ligaments. As mentioned in the research above – ligaments become injured or overstretched and spinal instability causes the chronic problems associated with degenerative disc disease.
In one paper, researchers found results for treating the ligaments with stem cell therapy so striking that the doctors noted pain relief and minimal side effects and the evidence convincingly showed the safety and effectiveness of stem cell therapy in the non-surgical treatment of back pain and degenerative disc disease.11
Equally, doctors warn that the treatment has to be done right.
Doctors wanted to know if the medical research supported the idea that stem cell injections could regenerate damaged discs. They explored all printed research and demonstrated that stem cells derived from bone marrow, fat cells, or synovial fluid showed successful inhibition of disc degeneration.
- Bone-marrow-derived stem cells demonstrated superior quality of repair compared with other stem cell treatments.
However, as great as these results were study design, doctor method, and other inconsistencies in the way the stem cell therapy was provided lead way for them to recommend that further studies be made to improve efficacy, reduce potential complications, and standardize techniques.12
This research continues to support recent findings that stem cell therapy is an effective treatment for back pain in the hands of skilled physicians. Recently at the 2013 annual meeting of the American Academy of Pain Medicine in Fort Lauderdale, pain specialists at Columbia Interventional Pain Center in St. Louis, studied the cases of 24 patients who received autologous bone marrow injections for their chronic back pain. The results were promising. Half of the patients did not have any other treatment after the bone marrow injections, 10 of the these 12 reported pain relief at four months and eight reported continued pain relief at one year. All of the patients showed signs of disc degeneration prior to the bone marrow injections.
Prolotherapy’s role in Degenerative Disc Disease
In the Journal of Prolotherapy, James Inklebarger, MD and Simon Petrides, MD wrote: “Prolotherapy injections produce an inflammatory response, which can augment collagen fibre and ligament structure regeneration, resulting in tightening and strengthening of spinal ligaments, thereby reducing the incidence of discogenic low back pain by improving intersegmental stability.”
By correcting the instability of the lumbar spine at an early stage, Prolotherapy will cause less stress to be imposed on the disc and less degeneration to occur at the disc.
Any doctor experienced with Prolotherapy who has used stem cell therapy knows the excellent results it can provide for people with injuries and pain involving severe cartilage defects. Recently we published a new article on degenerative disc disease after surgery and the possible solutions offered by stem cell therapy.
Please see our article Prolotherapy for chronic back pain and instability to continue this discussion on treatment options.
References for this article
1 Wilson CA, Roffey DM, Chow D, Alkherayf F, Wai EK. A systematic review of pre-operative predictors for post-operative clinical outcomes following lumbar discectomy. Spine J. 2016 Aug 4. [Pubmed]
2. Ellingson AM, Shaw MN, Giambini H, An KN. Comparative role of disc degeneration and ligament failure on functional mechanics of the lumbar spine. Comput Methods Biomech Biomed Engin. 2015 Sep 24:1-10. [Pubmed]
3. Iorio JA, Jakoi AM, Singla A. Biomechanics of Degenerative Spinal Disorders. Asian Spine J. 2016 Apr;10(2):377-84. doi: 10.4184/asj.2016.10.2.377. Epub 2016 Apr 15. Review. [Pubmed]
4. Butt AM, Gill C, Demerdash A, Watanabe K, Loukas M, Rozzelle CJ, Tubbs RS. A comprehensive review of the sub-axial ligaments of the vertebral column: part I anatomy and function. Childs Nerv Syst. 2015 May 1. [Pubmed]
5. Von Forell GA, Stephens TK, Samartzis D, Bowden AE. Low back pain: A biomechanical rationale based on “patterns” of disc degeneration. Spine (Phila Pa 1976). 2015 May 20. [Pubmed]
6. Li Z, Peroglio M, Alini M, Grad S.Potential and Limitations of Intervertebral Disc Endogenous Repair. Curr Stem Cell Res Ther. 2015 Mar 4. [Pubmed]
7. Wang Z, Perez-Terzic CM, Smith J, et al. Efficacy of intervertebral disc regeneration with stem cells – A systematic review and meta-analysis of animal controlled trials. Gene. 2015 Jun 10;564(1):1-8. doi: 10.1016/j.gene.2015.03.022. Epub 2015 Mar 19. [Pubmed]
8. Tibiletti M1, Kregar Velikonja N, Urban JP, Fairbank JC. Disc cell therapies: critical issues. Eur Spine J. 2014 Jun;23 Suppl 3:S375-84. doi: 10.1007/s00586-014-3177-2. Epub 2014 Feb 8.
9. Krock E, Rosenzweig DH, Haglund L. The Inflammatory Milieu of the Degenerate Disc: is Mesenchymal Stem Cell-Based Therapy for Intervertebral Disc Repair a Feasible Approach? Curr Stem Cell Res Ther. 2015 Feb 11. [Pubmed]
10. Handley C, Goldschlager T, Oehme D, Ghosh P, Jenkin G. Mesenchymal stem cell tracking in the intervertebral disc. World J Stem Cells. 2015 Jan 26;7(1):65-74. doi: 10.4252/wjsc.v7.i1.65.
11. Pettine KA, Murphy MB, Suzuki RK, Sand TT. Percutaneous injection of autologous bone marrow concentrate cells significantly reduces lumbar discogenic pain through 12 months. Stem Cells. 2014 Sep 3. doi: 10.1002/stem.1845.
12. Yim RL, Lee JT, Bow CH, Meij B, Leung V, Cheung KM, Vavken P, Samartzis D. A systematic review of the safety and efficacy of mesenchymal stem cells for disc degeneration: insights and future directions for regenerative therapeutics. Stem Cells Dev. 2014 Nov 1;23(21):2553-67. doi: 10.1089/scd.2014.0203. Epub 2014 Sep 11.
13. Inklebarger J, Petrides S, Prolotherapy for Lumbar Segmental Instability Associated with Degenerative Disc Disease. Journal of Prolotherapy. 2016;8:e971-e977. [JOP Citation]
New information added to this article 1-16-17