Stem Cell Therapy for Back Pain
Table Of Contents
Low back pain is a widespread issue and a significant cause of disability in the US and globally. Most people will experience some significant back pain at some point in their lives. Fortunately, in most cases, it’s due to muscular strains that are temporary and self-limiting. However, over 50 million Americans suffer from more serious, chronic back pain that restricts their activities and affects their quality of life. This number is even higher when considering those with periodic, recurrent episodes of pain.
Supporting this viewpoint, a statement from the medical journal Spine highlights the lack of detailed literature on vertebral ligament anatomy and function. This suggests that ligamentous causes of pain are often neglected, likely due to an over reliance on MRI results for diagnosis. Studies have shown that many patients without symptomatic back pain display MRI abnormalities, which can lead to unnecessary surgeries if misinterpreted.
MRI is frequently used to assess low back pain in conventional orthopedics, but it is often over-ordered. While it provides valuable information, MRI findings should be correlated with a thorough physical exam to ensure an accurate diagnosis. MRI lacks specificity and may not detect micro tears in the deep ligaments and tendons stabilizing the vertebral joints, which can be the true source of pain.
Doctors often assume that back pain comes from discs unless proven otherwise. While disc abnormalities are common, they are not always the primary cause of pain. Spinal discs are shock absorbers that allow the spine to flex, bend, and twist. Pain from discs, known as discogenic pain, is commonly blamed for low back pain. However, disc degeneration seen on MRI does not necessarily cause pain, as many people with disc degeneration do not experience discomfort.
Indirectly, disc degeneration can cause major pain by leading to vertebral instability, stretched connective tissue, and possible disc rupture. When a disc herniates, the nucleus pulposus can put pressure on nerve roots and cause chemical irritation, resulting in serious pain radiating down the leg (sciatica).
Facet joint sprain is another frequent cause of low bWhat is missing from this description and what is clear to me as a regenerative orthopedic specialist, is that most of these chronic cases are due tears and microtears in the major ligaments that surround the vertebrae and anchor the vertebrae to the pelvis or tears/microtears in the gluteal muscle attachments in the pelvis. These are by far the major cause of persistent low back pain. Ligaments and tendons are tough, whitish tissues which, unlike muscles (which are red), don’t have a lot of blood flow. This is why these connective tissues, when sprained or strained, form tears which might not heal. And this applies to you whether you are thirty or 70 and whether you’ve had this pain for one month or twenty years. If these structures get damaged, either through injury or by wear and tear degeneration and if they don’t heal by themselves within about eight weeks or so, they are likely never to heal.
The only way to heal these tears is with regenerative injections. For milder cases, four or five sessions of Prolotherapy might do the trick (over 80% will achieve 80% improvement). If the damage is more serious, more powerful regenerative solutions like stem cells and PRP are called for and will work faster and better than Prolo or PRP alone.
What is the Root-Cause of the Low Back Pain? The Limitations of MRI
As with all the other areas of the body we discuss, it’s crucial to properly diagnose the real root-cause of the problem and understand the mechanism of the pain. As we have seen in the sections on the knee, shoulder and other parts of the body, you can’t fix a problem without a clear understanding of what’s causing it. Commonly diagnosed causes of back pain include degenerative disc disease, disc herniations, facet joint arthropathy (arthritis), spondylolysis (vertebral arthritis), and spondylolisthesis (vertebrae slipping forward on one another). These conditions are easily seen on X-ray and MRI imaging. However, just because an abnormality is seen on imaging doesn’t mean it’s the primary cause of the pain. Basic imaging often misses considerations of vertebral instability and subtle ligament and tendon enthesopathy that affects the deep vertebral, lumbar, and pelvic connective tissues. If these ligaments and tendons are stretched or torn, they can generate significant pain. It is crucial to understand that just because an abnormality shows up on x-ray or MRI, it may not necessarily be the real primary root cause of the pain.
Supporting this viewpoint that the connective tissue, which may or may not show up on MRI, may be a major pain generator is supported by a statement recently made in the surgical journal Spine: “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.” This highlights that few doctors look for ligament and tendon sprain/strain as a cause of chronic low back pain. Researchers suggest that ligamentous and tendinous causes of pain are often neglected compared to other pathologies, likely due to the overuse of MRIs and overreliance on their results for diagnosis. Studies have shown that if you did MRIs on a group of normal people without symptomatic back pain, many of them have abnormalities, including moderate to severe degenerative disk changes. Unfortunately, such abnormal MRI findings, if accompanied by symptomatic pain, often lead to recommendations for surgery. As you can well imagine, the outcome can be disastrous if the basic diagnosis is wrong and patients undergo a surgery that is addressing an imaging abnormality that isn’t the real cause of the patient’s back pain.
Another comment from the prestigious medical “Journal of General Internal Medicine”, December 2019, states: “Clinical practice guidelines suggest that magnetic resonance imaging of the lumbar spine is unneeded during the first 6 weeks of acute, uncomplicated low-back pain. Unneeded MRIs do not improve patient outcomes and lead to unnecessary surgeries and procedures.”
In conventional surgical orthopedics, everyone considers the MRI as the gold standard for diagnosing low back issues. MRIs are often over-ordered and the whole approach to back pain largely revolves around the MRI findings. It’s common for MRIs to show degenerative discs, and other abnormalities ranging from minor deformations to protrusions and herniations. Spinal discs are soft, compressible structures that separate and cushion the vertebrae, acting as shock absorbers and allowing the spine to flex, bend, and twist. Pain from the discs is called discogenic pain. While disc degeneration and herniations in the lumbar spine are commonly blamed for low back pain, almost everyone over the age of 50 or 60 has some degree of disc degeneration visible on MRI. Many of these individuals do not experience pain because discs have no nerves. Degeneration alone isn’t thought to directly cause pain, however they can indirectly cause significant pain. As discs lose hydration and volume due to aging, wear and tear, or injury, or as spinal and deep lumbar ligaments stretch, resulting vertebral instability can cause pain. Stretched connective tissue can cause pain, and a loose vertebral joint may lead to disc rupture. A herniated disc, where the nucleus pulposus extrudes through the fibrous annular ring, can cause pain by mechanically pressing on the nerve root or chemically irritating sensitive nerve roots, leading to sciatica. In standard orthopedic practice there is often an assumption that the pain comes from discs and the mechanism of pain is as we just described, unless proven otherwise.
Unfortunately. MRI findings only tell part of the story, sometimes misleading doctors to make the wrong diagnosis. MRI lacks specificity, as many imaging abnormalities may not actually be the true pathology. It also lacks sensitivity, potentially missing microtears at the attachments of the deep ligaments and tendons that stabilize the vertebral joints. Essentially, what an MRI or X-ray sees and picks up is interesting and possibly the problem but it also may not be the real cause of the pain. It may be a “red herring”.
Facet Joint Sprain
Another fairly frequent cause of low back pain is facet joint sprain, where the capsule around the apophyseal joints is stretched. The facet joints stabilize the vertebral bodies and counterbalance the intervertebral discs. These joints can be damaged like the meniscus in the knee and are prone to chronic degenerative arthritis. Pain from facet dysfunction typically affects the back of the lumbar spine, thoracic region, and neck, and is worsened with extension or rotation of the back. The diagnosis can be suspected based on imaging studies but should be confirmed with palpation interrogation of the lumbar spine.
Sacro-Iliac instability
Every now and then I see a patient who presents with a diagnosis of sacro-iliac dysfunction. The surgical solution for this which is screwing down the pelvis (ilium) to the sacrum is ridiculous and gives a poor result. What is needed is to tighten and strengthen the sacroiliac ligaments with regenerative injections. Regenerative injections of Prolo, PRP and or stem cells is by far the treatment of choice and a much more direct and elegant way to fix the problem. If ligaments fail, we have the technology to rebuild them and that applies from the range of damage being mild stretching to severe tears. Our success rate for this problem exceeds 80%.
It should also be noted that many of these patients will also have associated gluteal damage and other ligament tears since the body tries to compensate by spreading the load to all surrounding structures. The body will recruit the surrounding gluteal muscles to try and splint the area and help stabilize the sacroiliac ligaments. In a regenerative workup all surrounding structures need to be checked with palpation interrogation and all weakened and damaged tissues should be injected at every session.
Stem Cell Therapy for Back Pain: Regenerative Healing versus Surgery
The focus of regenerative medicine (I prefer the term regenerative orthopedics) is the connective tissues and joint stability. For low back pain, the initial approach is to suspect connective tissue enthesopathy and vertebral instability, whether discopathy is present on MRI or not. Since the majority of patients will have connective pain and injecting and healing ligament and tendon tears with stem cells is relatively easy and very safe, it makes sense to fix this first i.e. fix the easy stuff first. God forbid the patient does actually have significant discopathy pain as a major pain generator, you can deal with this after and consider the more invasive techniques of surgical orthopedics as a backup plan.
A comprehensive approach to vertebral instability includes palpation interrogation of all supporting connective tissue structures, including spinal ligaments and deep lumbar ligaments. The deep lumbar ligaments include the iliolumbar ligaments, sacroiliac ligaments, and lumbosacral ligaments. Pelvic tendon strain (gluteal enthesopathy) is an extremely common finding in patients with low back pain and can cause serious pain. In regenerative orthopedics it is well known that patients with back pain usually can’t pinpoint the exact source of their pain. Gluteal tears can easily masquerade as a disc problem and may present identically. Clues in the patient’s history can help identify the cause. For instance, pain that sets in after lifting something heavy and radiates down the leg could be true sciatica (disc herniation) or an acute strain and microtears at the insertion of the gluteal muscles in the pelvis. Pain worsened by twisting suggests a facet joint sprain. Pain relieved by bending over a shopping cart might indicate vertebral instability causing spondylolisthesis. Pain worsened by getting up from a seated position could indicate vertebral instability or deep tissue enthesopathy. Difficulty standing or sitting for long periods suggests gluteal enthesopathy, known in regenerative circles as the “theater-cocktail syndrome.”
Deep lumbar ligaments have specific referral patterns that can easily be mistaken for sciatica and nerve root compression from a protruding disc. Sacroiliac ligaments refer pain down the posterior thigh and lateral foot. Sacrotuberous and sacrospinous ligaments refer pain to the heel. Iliolumbar ligament sprain should be considered for unexplained groin pain.
Many studies show that back surgery (particularly lumbar vertebrae fusion) has only about a 30-40% success rate to heal the pain. The reason, in my view, is they have failed to diagnose the real root cause of pain. It’s probably not the discs at all, but ligament and tendon tears. For most patients, regenerative approaches are much more successful. For a good regenerative doctor who is trained and experienced with palpation interrogation techniques and the proper diagnosis of the primary pain generators, experienced in the selection and preparation of the most potent stem cell combinations and skilled in precise, palpation-guided injections, the success rate is about 85%. This means that approximately 85% of candidates will have at least an 80% improvement by the end of their program.
Even if a patient has had back surgery and still has pain (failed back surgery syndrome) it still may be fruitful for that patient to consult a good regenerative doctor as the problem may actually be in the pelvis and not due to disc issues at all, even though the MRI may show significant disc abnormalities. We will not inject the direct area where the patient had their surgery but we certainly can inject surrounding structures such as the pelvis and sacroiliac ligaments
The Stem Cell Option: A Comprehensive Diagnostic and Treatment Approach
Let’s review how stem cells and PRP can be used to treat various conditions causing back pain. Notable athletes like Fred Couples and Rafael Nadal have used stem cell treatments to help heal their back pain, enabling them to return to their sports and perform at the highest levels.
In my opinion, a wholistic regenerative approach to low back pain, which considers all connective tissue structures and vertebral stability, yields far superior results when compared to a classical reductionist approach that focuses mainly on the discs. Symptomatically, patients can’t differentiate gluteal strain pain from discogenic or deep spinal or lumbar ligament sprains. Even if the discs are a major pain generator they can heal themselves if you stabilize the vertebral segments around the disc. The most common source of persistent low back pain is vertebral instability and ligament or tendon laxity. Due to biotensegrity, these structures are all interconnected, and it’s common that patients have multiple regions of ligament laxity. The regenerative healing approach involves comprehensive palpation interrogation testing that checks the strength and integrity of all joints and supporting connective tissue structures in the back. Injections should target all the damaged structures, prioritizing and paying special attention to the regions where the jump signs were most prominent (i.e. the epicenters of pain).
Pelvic enthesopathy is a very common finding in patients with low back pain and can be either a primary pain generator or develop secondary to other deep lumbar instability. A thorough palpation interrogation exam often reveals a positive jump sign for gluteal attachments on the pelvis. I can’t tell you how many patients I’ve seen over the years who present with chronic, severe low back pain and have a marked “jump sign” in the pelvis. Although many have seen many doctors who may or may not have recommended surgery, they usually report that no doctor ever examined them in that fashion and palpated those structures. What a huge oversight in the orthopedic community that doctors are not even aware of the huge importance of the connective tissues in orthopedic pain and how easily they can be evaluated!
Once we have properly diagnosed and prioritized the pain generators in a given patient, then we have to decide which combination of Stem Cells, PRP and Prolotherapy is the best choice for the various areas involved. Prolo primers can sometimes make a huge difference. In mild cases Prolo as a stand alone treatment may be sufficient to heal a problem. In other cases, the degeneration is more severe and stem cells from a patient’s own abdominal fat, mixed in with PRP growth factors is the fastest and most effective way to fix the problem.
Some patients will improve within a few days to a couple of weeks after the injections. Others may take five or six weeks before they improve. As the ligaments and tendons heal, the patient’s pain disappears. If the patient improves within a few days after the injections, this is likely due to the tightening phase of healing that can begin almost immediately after injections. Healing is a process and sometimes Mother Nature takes her time. If the patient’s improvements take longer to kick in it is likely due to the time it takes for the stem cells to differentiate into the type of cells required and rebuild the required type of tissue. After about 6-8 weeks if a patient still has sluggish results they may require a PRP booster to get the optimal results. The stem cells remain alive for 4 to 5 months so they can benefit from a PRP booster to reignite healing. This is particularly true when the patient had multiple areas of degeneration that were injected.
Our philosophy is to fix the easy stuff first. If the patient’s pain persists we can reevaluate and look more closely. Maybe the discs are the problem! Only then should more invasive pain management and surgical approaches be considered. Usually we do a stem cell/PRP treatment and patients improve dramatically, confirming to them that we have the right diagnosis of the primary pain generators. The proof is in the pudding.
As always with regenerative healing, rehabilitation needs to be active. Ligamentous tissue needs to move in its normal range of motion to heal properly. Not with load of course, at least initially, but it does need to move. For rehab of the low back region, I recommend walking but I like to make sure the patient has optimal orthotics to optimize their gait and biomechanics so as not to put undue stress on the ligaments that are in the process of regenerating and healing. I’m fortunate to have Boris at my offices in Sarasota. Boris is a master Orthotist and highly specialized in making custom fitted orthotics for my patients. I consider Boris as one of the top orthotic specialists in Southwest Florida and have entrusted my patients to his care for many years. I believe his work has helped my back, knee, hip and ankle patients recover faster and maintain and protect the healing that stem cells achieve. In addition, swimming and aqua therapy (after the first 10 days once the keyhole incision for fat extraction is healed) can also be very useful for rehab. Hot tubs with jets are great for relieving spasm and encouraging new blood flow to tissues.
