I was recently contacted by a patient about a back stem cell treatment. A young man in his twenties wanted to know whether his MRI and his history were a good fit for the multiple therapies offered by clinics hawking stem cells to treat back pain. After looking at his MRI, my first response was, “Are you kidding me?” Let me explain.
Stem cell treatments for back pain have burst on the scene this last few years largely based on very promising animal models. In a rat or or a rabbit, stem cells seemingly regenerate the disc. When we first tried this on patients with moderate to severe degenerative disc disease in 2005/2006, it was a miserable failure in all bit one patient, who had an obvious tear in his otherwise good disc. The patients with more severe disease all failed. We quickly moved on from simple same day therapies to more advanced cultured stem cells and found that we could reliably get rid a disc bulge with very specialized treatment of the cells and hyper-precise targeting one area of the disc. We still offer that treatment in Grand Cayman and continue to treat patients with the right kind of disc tears here in Colorado with same day therapies.
The patient in question had called a clinic offering disc stem cell treatments and with a glance of his MRI they said he was a good candidate. He felt the whole thing was bit hokey, so he did his research and found that we had more experience with stem cells and low back discs than anyone in the world. When I first looked at his MRI before the phone call, I literally said, “Are you kidding me?.” His MRI showed a pretty normal looking disc for his age, perhaps with some lost ability to hold onto water (the disc wasn’t quite as bright as it’s neighbors). There were no obvious tears in the disc. Based on a slight bulge and the status of his stabilizing muscles, he could have been getting some irritation of the nerves (sciatica) and he had some symptoms that matched. I was floored to learn that outside of some meds and therapy, he had never even had a lumbar epidural to see if this would all go away. He was about as far from a candidate for injecting same day stem cells in his disc as I could imagine.
To better understand why I thought he was a poor candidate for a disc treatment with stem cells, let me compare and contrast him with another patient who was a good candidate in terms of risk/benefit. While our young patient (we’ll call him patient A) had never had basic and less invasive injections to calm down irritated nerves (epidurals), the other patient (we’ll call him patient B) is older and has been successfully managed for 5 years by using his own platelet growth factors injected into his facet joints and epidural. He then had a new injury with a new MRI showing a disc tear and after that he no longer responded to the same less invasive treatments.
First, it’s important to understand that there are stark risk differences between the more common injections like epidurals and injecting a disc. For disc injections, a rare, but very serious complication is discitis-basically an infection of the disc. It’s a big deal involving IV antibiotics where a catheter is placed near heart and one or more big surgeries. In addition, recent research has suggested that just just poking a hole in the disc can cause it to degenerate (see here, here, and here). So based on all of this information, we know two things:
1. You should have a good reason to poke a hole in the disc (i.e. if there’s a less invasive procedure that may help you should pursue it)
2. You should have some evidence that what you’re injecting can counter the degenerative effects of poking a hole in the disc (which must do in the injection of stem cells)
So what’s the evidence that stem cells can regenerate a degenerated disc? Pretty weak. So far cultured stem cells placed into the disc through an off the shelf product (Mesoblast’s Degenerative Disc Disease Trial) have failed to show regeneration. In addition, for same day stem cells taken from the patient, we have only one tiny pilot trial, which has problems. As discussed in prior blogs, it’s ability to prove that anything positive happened in any of the discs injected is very limited. So we don’t have good evidence right now that stem cells can regenerate a disc.
If we apply all of this to patient A:
1. He has had no injections such as placing his own platelet growth factors epidural, which for him would likely have a high success rate and would be much less risky than injecting the disc
2. His disc doesn’t have a tear or isn’t degenerated enough to consider risking an injection of stem cells into the disc
3. He has a bulge irritating a nerve and if he had failed all other less invasive treatments, the only stem cell therapy with MRI evidence that suggests that it can reduce the size of disc bulges is the Regenexx-C procedure we perform down in Grand Cayman
If we apply all of the above to patient B:
1. He has failed less invasive therapies because of the new injury
2. His disc is torn and has good disc height
3. He’s left without other good options
I would be nuts to recommend that patient A get stem cells injected into this disc. Patient B did get same day stem cells (Regenexx-SD) in his disc and had a nice recovery.
The upshot? All of this stuff is very confusing for patients. It’s one thing to offer a patient with severe degenerative disc disease a stem cell procedure (which won’t work to regenerate his disc in our experience), in that this patient has no other options. Are stem cells the right move for that patient… not really. However, the clinic that offered this young man a stem cell injection as a solution should be ashamed, as there is absolutely no credible rational for offering this more invasive therapy!
The Regenexx-C procedure is not approved by the US FDA and is only offered in countries via license where culture expanded autologous cells are permitted via local regulations.