The Differences Between Real Regen Med and Pain Management
This week, we began our fellow interviews for the 2021 year. The first interviewee was at our site yesterday and speaking with him during procedures reminded me of how far apart Regenexx is from the rest of the world. Let me explain.
What Is a Fellow?
A fellow is a doctor who has completed medical school and residency training in a medical specialty and who wants to continue his or her education. We run a fellowship program at our Colorado HQ site and usually train from 1-3 fellows a year. This next year in 2021, we’ll take 2 fellows.
That Doctor’s Academic Pain Management World
The doctor I was speaking to yesterday is currently in a fellowship program for outpatient pain management, so if accepted into our program, he’ll spend another year focusing only on regenerative medicine. What was fascinating about our conversations is that he is in the thick right now of traditional spine interventionalist training. What’s that?
If you have back or neck pain and you fail physical therapy or chiropractic care, you’re likely to see a doctor who specializes in interventional pain management. This is a medical specialty that largely uses steroid injections, diagnostic numbing injections, radiofrequency ablation, stimulators, and the like to help patients control pain. I know it well because it’s what I used to practice 15 years ago before I started Regenexx.
How Behind Are Our Academic Pain Management Programs?
We often think of academic medical centers as cutting edge. In many ways that’s true, but not when it comes to image-guided injection treatment of the spine. Let’s dive in.
The first thing that the fellow candidate asked was what I was injecting inside a patient’s disc and why. In his fellowship program, all that ever gets injected inside someone’s disc is large amounts of radiographic contrast and steroid. I quipped that this was a great way to kill disc cells. Meaning that by injecting large amounts of contrast (the stuff that you can see on x-ray guidance or fluoroscopy), his attendings (the name for a senior doctor in a medical education program) were killing disc cells. We’ve known this since about 2012 (1,2). In addition, by injecting steroids into the disc, this was also killing the cells inside the disc (2).
So what did I do differently? I used a tiny amount of contrast to confirm that I was actually inside the disc (0.05 ml or less). This is the opposite of what he’s being taught because his attendings routinely inject 20-40 times more. I then didn’t inject high dose steroids into the disc, but platelet-rich plasma (PRP), which is concentrated platelets from the patient’s blood. This has been shown to help the disc cells survive (3,4). I also injected differently. While a traditional pain management doctor would want only to inject something inside the disc in a place called the nucleus pulposis, I spent quite a bit of time injecting both the right and left annulus fibrosis (the outer covering of the disc). Why? Because this patient’s MRI showed damage to that structure. Hence, the purpose of my injection was to achieve functional repair of the disc rather than to determine if it was causing pain (discography).
This doctor’s next question came when I was injecting the same patient’s epidural space. That means that I was injecting around irritated spinal nerves. His attendings would only ever inject long-acting anesthetics and high dose steroids into this space. I then told him that this again was a great way to hurt the nerve cells (5-9). So what did I do differently? I injected platelet lysate because it contains nerve growth factor and other elements which can help nerve cells (10-12).
RFA vs High-Dose PRP Injections
Another topic that came up was how interventional pain management doctors are much more interested in radiofrequency ablation (RFA) of the facet joints and I was injecting them with PRP. RFA is a procedure where the doctor uses electrical energy to burn the nerves that take the pain signals from the low back joints to the spinal cord and brain. The problem? That same nerve also supplies critical stabilizing muscles which then die off as well (13,14). This results in instability in the spine. So RFA helps one problem and creates another. Instead of killing critical nerves, my approach was to inject a high dose PRP into these damaged joints (15).
Another big observation that the fellow candidate made was the pace of what we were doing. In his current program, the pain management attendings are required to turn over 20-40 different patients a day. Basically, it’s assembly line, high-volume care. Each patient gets a one or two-level quick injection procedure and then is pushed out the door as quickly as possible. In contrast, I spent a full two hours on one patient performing many different injections in many different parts of the low back and neck.
After a few hours of discussion over my patient procedures, the fellow candidate finally concluded that the main salient difference between where he’s working now and our clinic was outcomes. Our focus is on how can we use the best stuff in the best way to give the patient the best chance of success. Regrettably, in his current fellowship, the data is clear that many procedures they perform don’t help patients in the long-run and some things clearly hurt patients. Meaning it’s more about checking the boxes than what’s best for the patient.
When Will Academic Centers Catch Up?
What was the most interesting was how behind the times academic centers still are in moving from destructive spine care to regenerative spine care. This is a hard one for most patients to understand, as they have the sense that the local, big-name academic medical center is at the cutting edge of research. While in many ways that’s true, not when it comes to regenerative spine injections.
Why is this case? These academic medical centers are also businesses. Without widespread insurance coverage for these newer approaches, they can’t pull the trigger and allow their doctors to widely adopt them. So in the meantime, they continue to treaty spine patients like it’s 1999.
The upshot? Regenerative spine care is here to stay and destructive spine care needs to be shown the door. Having a fellow candidate around just serves to remind me of how far ahead Regenexx is when compared to what patients can access at their local university hospital. We await the day when the academic medical centers finally catch up!
(1) Gruber HE, Rhyne AL 3rd, Hansen KJ, Phillips RC, Hoelscher GL, Ingram JA, Norton HJ, Hanley EN Jr. Deleterious effects of discography radiocontrast solution on human annulus cell in vitro: changes in cell viability, proliferation, and apoptosis in exposed cells. Spine J. 2012 Apr;12(4):329-35. doi: 10.1016/j.spinee.2012.02.003. Epub 2012 Mar 16. PMID: 22424848.
(2) Eder C, Pinsger A, Schildboeck S, Falkner E, Becker P, Ogon M. Influence of intradiscal medication on nucleus pulposus cells. Spine J. 2013 Nov;13(11):1556-62. doi: 10.1016/j.spinee.2013.03.021. Epub 2013 Apr 19. PMID: 23608563.
(3) Kim HJ, Yeom JS, Koh YG, Yeo JE, Kang KT, Kang YM, Chang BS, Lee CK. Anti-inflammatory effect of platelet-rich plasma on nucleus pulposus cells with response of TNF-α and IL-1. J Orthop Res. 2014 Apr;32(4):551-6. doi: 10.1002/jor.22532. Epub 2013 Dec 11. PMID: 24338609.
(4) Akeda K, An HS, Pichika R, Attawia M, Thonar EJ, Lenz ME, Uchida A, Masuda K. Platelet-rich plasma (PRP) stimulates the extracellular matrix metabolism of porcine nucleus pulposus and anulus fibrosus cells cultured in alginate beads. Spine (Phila Pa 1976). 2006 Apr 20;31(9):959-66. doi: 10.1097/01.brs.0000214942.78119.24. PMID: 16641770.
(5) Markova L, Umek N, Horvat S, Hadžić A, Kuroda M, Pintarič TS, Mrak V, Cvetko E. Neurotoxicity of bupivacaine and liposome bupivacaine after sciatic nerve block in healthy and streptozotocin-induced diabetic mice. BMC Vet Res. 2020 Jul 17;16(1):247. doi: 10.1186/s12917-020-02459-4. PMID: 32680505; PMCID: PMC7367396.
(6) Verlinde M, Hollmann MW, Stevens MF, Hermanns H, Werdehausen R, Lirk P. Local Anesthetic-Induced Neurotoxicity. Int J Mol Sci. 2016;17(3):339. Published 2016 Mar 4. doi:10.3390/ijms17030339
(7) Wang PH, Tsai CL, Lee JS, Wu KC, Cheng KI, Jou IM. Effects of topical corticosteroids on the sciatic nerve: an experimental study to adduce the safety in treating carpal tunnel syndrome. J Hand Surg Eur Vol. 2011 Mar;36(3):236-43. doi: 10.1177/1753193410390760. Epub 2011 Jan 31. PMID: 21282223.
(8) Shishido H, Kikuchi S, Heckman H, Myers RR. Dexamethasone decreases blood flow in normal nerves and dorsal root ganglia. Spine (Phila Pa 1976). 2002 Mar 15;27(6):581-6. doi: 10.1097/00007632-200203150-00005. PMID: 11884905.
(9) Mackinnon SE, Hudson AR, Gentili F, Kline DG, Hunter D. Peripheral nerve injection injury with steroid agents. Plast Reconstr Surg. 1982 Mar;69(3):482-90. doi: 10.1097/00006534-198203000-00014. PMID: 7063571.
(10) Kokkalas N, Kokotis P, Diamantopoulou K, Galanos A, Lelovas P, Papachristou DJ, Dontas IA, Triantafyllopoulos IK. Platelet-rich Plasma and Mesenchymal Stem Cells Local Infiltration Promote Functional Recovery and Histological Repair of Experimentally Transected Sciatic Nerves in Rats. Cureus. 2020 May 24;12(5):e8262. doi: 10.7759/cureus.8262. PMID: 32596080; PMCID: PMC7313431.
(11) Torul D, Bereket MC, Onger ME, Altun G. Comparison of the Regenerative Effects of Platelet-Rich Fibrin and Plasma Rich in Growth Factors on Injured Peripheral Nerve: An Experimental Study. J Oral Maxillofac Surg. 2018 Aug;76(8):1823.e1-1823.e12. doi: 10.1016/j.joms.2018.04.012. Epub 2018 Apr 20. PMID: 29763577.
(12) Ikumi A, Hara Y, Yoshioka T, Kanamori A, Yamazaki M. Effect of local administration of platelet-rich plasma (PRP) on peripheral nerve regeneration: An experimental study in the rabbit model. Microsurgery. 2018 Mar;38(3):300-309. doi: 10.1002/micr.30263. Epub 2017 Nov 2. PMID: 29094404.10
(13) Kanchiku T, Imajo Y, Suzuki H, Yoshida Y, Nishida N, Taguchi T. Percutaneous radiofrequency facet joint denervation with monitoring of compound muscle action potential of the multifidus muscle group for treating chronic low back pain: a preliminary report. J Spinal Disord Tech. 2014 Oct;27(7):E262-7. doi: 10.1097/BSD.0000000000000107. PMID: 25137144.
(14) Smuck M, Crisostomo RA, Demirjian R, Fitch DS, Kennedy DJ, Geisser ME. Morphologic changes in the lumbar spine after lumbar medial branch radiofrequency neurotomy: a quantitative radiological study. Spine J. 2015 Jun 1;15(6):1415-21. doi: 10.1016/j.spinee.2013.06.096. Epub 2013 Nov 14. PMID: 24239488.
(15) Wu J, Zhou J, Liu C, Zhang J, Xiong W, Lv Y, Liu R, Wang R, Du Z, Zhang G, Liu Q. A Prospective Study Comparing Platelet-Rich Plasma and Local Anesthetic (LA)/Corticosteroid in Intra-Articular Injection for the Treatment of Lumbar Facet Joint Syndrome. Pain Pract. 2017 Sep;17(7):914-924. doi: 10.1111/papr.12544. Epub 2017 Feb 22. PMID: 27989008.