Back pain is a huge problem in the U.S. Most of us will experience it in our lifetime. For a small percentage, but a substantial number, of cases the problems can become persistent and severely debilitating. Unfortunately, the conventional orthopedic approach based on MRI’s and invasive back surgery has largely failed to resolve these problems. Thankfully, there have been two major advances in technology in the last few years that have led to better, more effective, more elegant ways to heal persistent back pain. The first is the Discseel approach, invented by Dr. Kevin Pauza. The second important advent comes from the exciting new field of stem cell orthopedics.
Good medicine starts with the right diagnosis. The more precise the diagnosis of the root cause of the problem, and the more focused the treatment, the better the chance for a successful outcome. In the case of Discseel, the key understanding is that pain doesn’t come from disc bulges and herniations but rather from disc leaks. It is the chemical irritation of the disc leaks, not just the mechanical pressure of a disc herniation, that produces the pain. This explains why MRI findings may correlate poorly with the clinical picture. Some patients have significant herniations with minimal or no symptoms while others have a fairly benign appearing MRI and severe symptoms. According to Dr. Pauza, a key factor is whether the disc is leaking or not. Unfortunately, MRI is unable to pick up disc leaks. To make a more precise diagnosis of the pain generators, Dr. Pauza’s Discseel system calls for an annulogram that has fewer adverse effects than a discogram yet is more detailed and able to identify disc leaks. With this guidance, he is then able to pinpoint and fix the disc leak by injecting fibrin into the damaged disc. Pretty cool if you ask me.
In stem cell orthopedics, the key understanding is that instability of vertebral segments (and shear force) may be the root cause of discopathy in the first place and that by correcting and tightening the ligaments and tendons that hold the vertebrae in place, you can improve symptoms (and even help protect a Discseel repair from reinjury). Also, in regenerative orthopedics, we are aware of and look for tears and microtears at the attachments of stabilizing ligaments and tendons. These attachments are highly innervated and can often become major pain generators. Since these tears are often too small to be seen on ultrasound or MRI, the only reliable way to verify and prioritize pain generators at the attachments of key structures is by a specific technique called palpation interrogation. Using your thumb, if you palpate a specific structure with 20-30 pounds of pressure and elicit the “jump sign” you have diagnosed and confirmed a specific pain generator and a source of the pain.
One needs to bear in mind that the myofascia connects the whole body and should be considered as a whole. For example, if a patient has discogenic pain due to a leaky disc, the whole myofascia of the low back is under stress and muscles go into spasm to splint the damaged area. Therefore if a patient has significant back pain it is worthwhile to check the whole region for primary and secondary pain generators. There are about 40-50 common trigger points in the major ligament and tendon attachments in the lower back. Key structures include the supra-spinous ligaments, facet joints, transverse process, sacroiliac, gluteal attachments in the pelvis, hip capsules and the IT bands. It takes an experienced regenerative specialist about 15 or 20 minutes to test all of these structures and identify and prioritize any major “epicenters” of pain generation. Any structure that is positive for the “jump sign” can then be earmarked for repair which is done by peppering the attachments with injections of prolotherapy (dextrose), PRP or a PRP/stem cells combo depending on the severity of the degeneration and the particular case.
As we saw with the Discseel approach, MRI also misses key details for the stem cell orthopedic system. In this case, MRI gives a “still” picture and is unable to gauge instability of joints under movement or stress. It is this subluxation of “loose” joints (and pulling on the capsular attachments) that can often be so painful. In addition, connective tissue damage at the site of attachments of supporting ligaments and tendons is often in the form of micro-tears which are too small to be seen on MRI. Once again, MRI misses critical details and we can readily understand why an over-reliance on MRI findings alone can be dangerously misleading.
Now that we have a basic understanding of the Discseel and the stem cell orthopedic systems, we can begin to appreciate why conventional back surgery approaches such as fusion have been so unsuccessful. It’s not that the surgeons are technically lacking. It is a basic misdiagnosis and misunderstanding of the primary pain generators. The problem starts with an over reliance on MRI and an assumption that, in a patient with significant back pain who also has significant MRI abnormalities such as disc herniations, that those abnormalities must be the root of the pain. Don’t get me wrong. They may be causal, but to proceed to a very invasive surgery without fully exploring simple, minimally invasive testing is a mistake and can lead to serious consequences. It is a relatively easy thing to do an annulograms on suitable candidates or to evaluate major structures in the low back with a basic palpation interrogation scan. It is vital that these simple yet detailed tests are not overlooked as they may often yield critical information regarding the true root-causes of the back pain.
I should add a caveat to the principle of striving to make the most precise diagnosis possible. First, do no harm! Always start with the safest, least invasive approach first. When it comes to human beings and medicine, nothing is a 100%. If, for any reason, an approach fails to resolve a problem, the potential adverse effects and risks are directly proportional to the invasiveness of the approach. I therefore recommend that patients only consider the option of invasive back surgery if all other reasonable, nonsurgical options have been fully explored and have failed.
Now that we understand the limitations of basing a diagnosis and treatment plan solely on MRI findings, and have additional tools to evaluate the root-causes of back pain more precisely, we can develop a less invasive and much better approach. If patients have severe symptoms that appear discogenic, I would recommend that they explore the Discseel option (and potentially be evaluated with annulograms for discseel repair if indicated). In addition, as an adjunct to Discseel, I would recommend that all patients with significant pain consider the option of evaluation and potential treatment by a good regenerative orthopedic specialist. An experienced regenerative expert can evaluate all the key structures for weakness with a basic palpation interrogation scan that takes less than 20 minutes. If the scan yields positive “jump signs”, the affected structures should be properly addressed with regenerative injections of prolotherapy, PRP or a PRP/stem cell combo. If we choose to use stem cells, only autologous tissues are used i.e. from the patients own blood or tissues, as this is safest and DNA matched stem cells are most effective. The regenerative injections can be started as a primer prior to Discseel treatment or given as boosters in the weeks/months after treatment. (Note* Depending on the severity of the damage and how fast patients heal, cases may require two to four sessions of injections for complete resolution of the back pain.) Improvements can sometimes occur very quickly because tightening can occur almost right away although other improvements based on tissue regeneration can take 6 weeks or more.
Discseel and regenerative orthopedics, together, present a minimally invasive yet powerful approach to back pain. If used properly I believe these strategies can be synergistic and yield a success rate in excess of 85%. Importantly, I believe these approaches can improve the quality of life for many patients and help many avoid the need for back surgery altogether. In addition, since both approaches are regenerative and structural in nature, there is every reason to believe that positive results would likely be long-lasting. Downtime for both approaches is minimal and patients can return to activities of daily living almost immediately.
About Mark Walter M.D.
Dr. Walter is one of Florida’s top experts in stem cell orthopedics and has pioneered the field for over 20 years. He is author of Stem Cell Orthopedics: The new Field of Regenerative Orthopedics (available on amazon). Dr. Walter trained at McGill (1980) and has a background in family practice and sports medicine. He completed most of his postgraduate work in regenerative orthopedics through the University of Wisconsin system. Over the years, Dr. Walter has treated several thousand patients with low back pain, and is currently researching how regenerative orthopedics could be used as an adjunct to Discseel in healing back pain.