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©Regenexx

Above is a collection of sunsets from this past two weeks here in Grand Cayman. Today I head back to the states, and as I thought about the blog this morning, I thought I’d bring you into the complexity of what happens down here relative to all of the stem cell scams worldwide and back in the states. After all, some of our most medically complex cases end up here.

Distilling What We Do into Its Most Simple Form

One of the things that always blows me away is how faux stem cell clinics have become expert at taking the complex things we do with imaging guidance and needles and boiling them down to their simplest form until what’s done no longer bears any resemblance to the original article. When I was a kid, we would call this a smolex. Meaning, we would buy these watches that were Rolex knockoffs at the local flea market. They would look good but would last maybe a few weeks before they fell apart. Turns out that for $20, what’s inside was nothing like what’s in a real Rolex. The problem of course with fake stem cell clinic offerings is that they aren’t charging $20, but oftentimes as much or more than the real McCoy.

To show you what we do and why it’s so different, let me walk you through it.

The BMA

You may have heard the phrase “garbage in, garbage out.” In a stem cell procedure, that applies to when the stem cells are harvested. For us, this takes 30–40 minutes; for most clinics, it’s 5–10 minutes. This is called a bone marrow aspiration (BMA), and it’s when the doctor uses a needle to “aspirate” the liquid portion of bone marrow from the back of the hip.

The issue is that you need to take as little volume from as many sites as possible to up the number of stem cells. So all week, I have drawn 5 ml from as few as 24 sites on both sides to as many as 36 sites. A site is noted as changing location or depth of the needle and drawing something out. In addition, these are bone sites, so there is only one skin site on each side. Despite this, most patients feel very little discomfort because of the way I numb the area.

Compare this to the smolex version, which is to take all bone marrow from a single site. This takes just a few minutes and sacrifices stem cell yield in exchange for maximizing doctor convenience and time. Basically, garbage in and garbage out, meaning fewer stem cells.

For info on a BMA, see my video below:

Growing Cells

Unlike in Colorado and elsewhere in our network, the Grand Cayman site has a culture-expansion license. This means that they can grow cells in culture to larger numbers. This is also a labor-intensive process that takes weeks. There is a large lab staff in a several-thousand square foot clean room that spends tens of hours with each sample, coaxing as many stem cells to grow as feasible. Believe me, this is both science and a high art, as these cells are living things that must be cared for carefully to be able to grow to their full potential.

For more info, see my video below:

Injecting Cells

It’s always bizarre for me to compare what we do to precisely place cells into the musculoskeletal system with the scam clinics. Your average faux stem cell venture uses a nurse to do this, as that’s far cheaper for the clinic. So what you get is simply someone who blindly sticks a needle into your knee, hoping that something makes it into the joint. Or if there’s a doctor involved, for example in many Banana Republic clinics, you get the same blind injection. Or if there’s a doctor who uses ultrasound, you get the simplest injection inside the joint that takes a few minutes.

As my back ached yesterday from being in a lead apron all week, I thought about how my stem cell reinjects lasted from an hour and a half to a length of three hours this week. Almost everyone took the time allotted, so I wasn’t twiddling my thumbs. Why? Let me walk you through a few of the complexities…

Bones, Bones, and More Bones

This past two weeks, off the top of my head, I injected intraosseous (into bone) in 4–5 hips, a shoulder, a few knees, two ankles, and a foot. This is because there was MRI evidence in these patients that the bone was dying off, and we’ve seen much better results when we treat those dying areas directly. Better, in fact, than when you just inject into a joint. Each of these procedures requires a full surgical prep, and the patients get sedated. Each must be precisely guided using C-arm fluoroscopy. Each requires that I document exactly where the cells will go using contrast flow before I can place the stem cells into the bone. For more on how difficult this can be, see my video below:

To see what these procedures look like, see our video below:

Tendons R Us

This past two weeks, I have injected about 100 specific tendons. Why? We have seen that many of our patients with low back, neck, shoulder, knee, hip, or ankle pain have tendons that are inflamed, degenerated, or partially torn. Hence, these need to be precisely injected using ultrasound imaging. Again, it’s labor intensive as each different tendon (there are hundreds in the body) requires a different setup for the nurses and obviously a unique injection approach for the doctor.

This is what the rotator cuff procedure looks like when I’m guiding the needle via ultrasound:

Ligaments Galore

Many of our patients also have subclinical instability. Meaning the ligaments that hold the joint together are loose and degenerated, leading to more wear and tear on the structure. Hence, injecting stem cells into a joint where the excessive forces due to instability will just chew up the joint again makes little sense. Hence, each area of instability in each joint needed to be mapped and targeted using ultrasound guidance, or for deeper ligaments like ACL in the knee, using fluoroscopy.

To see just how complex all of this can be, please take a few minutes to watch my video below on shoulder instability:

This is Dr. Markle injecting a torn ACL ligament using fluoroscopy:

Don’t Forget Muscles

Many of our patients show up with damaged or atrophied muscles. Just like the tendons and the ligaments, these must also be precisely targeted. A good example is atrophied multifidus muscles in the low back, which cause instability and add to degenerative disc disease. For more info, take a look at my video below:

How About Nerves?

If you have low back pain and knee pain, it’s likely that one problem is feeding off the other or even making the other area worse. So treating just the knee doesn’t maximize results. The same goes for neck pain and shoulder, elbow, or wrist/hand issues. In many of these patients, there are bulging discs or irritated nerves that need to be treated at the same time.

To understand more about this connection, watch my video below:

At Last, Joints!

Finally, we get to the part that most people think will be injected. Yes, we see patients who have arthritis, so we precisely inject the joint. However, even this can get complex. Take a knee, for example; it may have lost cartilage on the inside, but the meniscus has been operated and becomes mushy and unstable and is extruding out of joint. This needs to first be identified on stress ultrasound imaging, and then the ligament structures that stabilize the meniscus must also be targeted along with the meniscus itself, all using precise ultrasound guidance.

To see how a knee joint is injected using the simplest possible ultrasound technique, see below:

To understand what can happen to a meniscus after knee surgery, spend a few minutes watching my video below:

Even a simple joint injection is often not simple. For example, several times these past two weeks, based on the anatomy and the body habitus of the patient, I had to switch from one imaging technology to another. For example, yesterday in a patient who was larger, I could be certain I was in the joint on one side using ultrasound, but only 90% sure on the other side. Rather than risk injecting these precious stem cells outside the joint, even with a 10% chance I was wrong, I switched to C-arm fluoroscopy guidance so I could be 100% certain.

The upshot? As I say farewell to Cayman for another few months (I’m back in November and March), I wanted you to get a peek into why my back aches by the end of the two weeks. Unlike the faux stem cell clinics in the states and the Banana Republics, we work hard here precisely identifying all of the issues that are causing our patients to hurt and then meticulously addressing each one. That can mean hours upon hours of standing in lead or hunched over an ultrasound machine, which means that by the end of my stay, my own back is letting me know that it’s time to head back home to Colorado!

The Regenexx-C procedure is not approved by the USFDA and is only offered in countries via license where culture-expanded autologous cells are permitted via local regulations. 

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile