Joint Preservation Blog

October 1, 2010

Pudendal Nerve Entrapment and Pelvic Ligament Problems

Filed under: Back/Lumbar, ligament/tendon — D @ 8:03 pm

 

RD is a middle-aged ex-fireman who injured his hip and sacro-iliac joint in a fall. We treated his pain with SI joint injections and epidurals, but recently he began to talk about sexual dysfunction. He consulted multiple specialists without any answers. He finally asked me if it could be due to his back. His MRI showed no severe issues that could cause sexual dysfunction, so we began looking for other sources. In particular, he was very tender over the sacrospinous ligament, which travels from the bottom of the tailbone (sacrum) to the bottom part of the pelvic bone. Once I looked it up, it became clear that the pudendal nerve (that supplies the penis) travels under this ligament (ligament in red above, star shape at site where nerve gets entrapped). It was worth a shot (literally) as he had no other options and cutting the ligament would destabilize his pelvis and SI joint complex. Under ultrasound guidance we localized his sacrospinous ligament and injected a small amount of anti-inflammatory. When I saw him two weeks later, his sexual dysfunction was gone, meaning that it’s likely the nerve was getting entrapped. While this may be a rare problem, the solution in this one patient was simple.

February 12, 2009

Bone Marrow Nucleated Cell Concentrate (BMAC): Is it Concentrated Enough?

 

bmac machine

bmac machine

 

In 2005-2006 we mixed up BMAC in our cell biology lab.  It was easy to create from a marrow aspirate.  We performed some basic MRI studies with pre and post 3.0T high field studies and ran outcome questionnaires for knee and hip arthritis patients.  We were unimpressed by the results and because of this experience moved on to culture expanded mesenchymal stem cells.  

 

BMAC has become popular of late. In this procedure, a physician takes a bone marrow aspirate, places it in a specially designed centrifuge and pulls out a concentrate of bone marrow nucleated cells. This has been billed as a stem cell concentrate, but the stem cells that are concentrated in reasonable numbers tend to be CD34+ heme progenitors (stem cells that make new blood) and not MSC’s (Mesenchymal Stem Cells). Since MSC’s are the MVP of the adult stem cell mix available in a bone marrow concentrate, their concentration is very important to the success of such a treatment. A recent study on bedside bone marrow concentrate machines for MSC’s (BMAC) determined what concentrations were possible from a commercially available centrifuge unit. Using this study to calculate MSC numbers, a 60 ml bone marrow draw would produce 70,000-90,000 MSC’s. The Regenexx procedure yields after culture expansion are in the 5M-100M range. Based on this data, the Regenexx procedure produces approximately 100-1,000 times more cells than you can obtain with BMAC bedside systems. Based on this and other data, our best estimate is that the average micro fracture procedure would release 5-10 ml of un-concentrated marrow, so about 500-1,000 MSC’s into the defect site. Our own dosing data and the copious animal research would suggest that for appropriate cartilage, tendon, ligament, muscle repair the necessary MSC dose is in the millions range. Obtaining that amount of MSC’s from a BMAC system would require unacceptably high volumes of whole marrow from the patient. The conclusion, while very convienent, BMAC doesn’t have the right stuff.

For more information on different stem cell types, I’ve posted a video below:

January 13, 2009

Steroid Shots

Steroid shots have become a mainstay of modern orthopedic medicine.  Relief from a cortisone shotis due to powerful anti-inflammatory effects of the corticosteroid medication.  You body uses this same chemical daily to modulate inflammation and help control tissue repair (generally to put the brakes on an inflammatory injury response).  In very low doses (about 1,000,000 times less than is used by most doctors) these natural steroids help to reduce swelling and help the joint produce growth factors like TGF-beta which can help heal local tissues.  However, in the high doses commonly used in orthopedics (milligrams or bout 1,000,000 times more than the nano-grams used naturally), steroids can be a big sledge hammer to the system, stamping out bad inflammation and good tissue repair with equal force.  A steroid shot for sciatica is common these days, as doctors often use these to decrease swelling around swollen nerve roots that lead to back and leg pain.  however, the same issues as above apply, the dose if often too high.  Our own experience with out own patients shows that relief from a cortison shot can be obtained with a low nono-gram dose approximately 1,000,000 times less than the commonly used milligram dose.  This also prevents many of the body wide side effects that can seen from high dose milligram cortisone shots, such as weight gain, changes in blood sugar, and moodiness.  Cortisone shots before surgery (the higher milligram dose) will generally reduce the effectivness of healing, as they tend to supress the healing immune system response including knocking down critical repair responses and adult stem cells.  Concerned about high milligram dose cortisone shots?  Alternatives treatments include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the inflammation short term.

Cortisone Shot Flare

 

cortisone shot flare

cortisone shot flare

As a pain management doctor who performs procedures all day, I have seen Cortisone shot flares in the office.  Cortisone is a corticosteroid, which is a fancy way of saying that it’s a very strong anti-inflammatory which can bring down swelling.  Cortisone is actually an older brand name, newer brand names more commonly used today include Depomedrol and Celestone.  One of the biggest problems that we see in our office is that the commonly dose used of Cortisone is in the milligram range (thousandth of a gram).  While this may not sound like much, for orthopedic applications like sciatica, back pain, knee pain, shoulder pain, elbow pain, and other peripheral joints, this dose is about 100,000 to 1,000,000 times more than your body naturally uses to control swelling.  As an example, if the 50 nano-gram dose that your joint would use on it’s own to control inflammation is the height of a book of matches, the height of the usual dose used by most physicians to control swelling is the height of the Empire State Building.  Why? Unknown, as the science would support that the nano-gram (billionth of a gram) dose is good for the joint, while the milligram dose causes all natural repair function to cease.  This is why too many of these very high dose Cortisone shots can cause a joint to degrade.  Think of it as you can put in a finish nail with a sledgehammer (the milligram dose), but it isn’t pretty.   Steroid shots for sciatica are common, and we only use the giant milligram dose in certain circumstances where we need a huge effect to help the patient, otherwise we have moved to the lower doses.  So what’s the biggest cause of a Cortisone shot flare? While the high dose may be an issue, it’s usually the needle.  To inject joints, most syringes come loaded with a 20 gauge needle.  While this makes drawing up meds very fast and is great for pulling fluid out of a joint (aspirate), its way to large for putting cortisone into a joint.  A 27 gauge needle is a better choice and less likely to cause a cortisone shot flare.  So to avoid a Cortisone shot flare, make sure your doctor uses a smaller needle (25 or 27 gauge).  In addition, we find that cold spray on the skin can help patients tolerate the shot better.  In addition, having the doctor wiggle or put allot of pressure on the area to be injected can help reduce the sensation of the needle stick.  What if don’t want Cortisone?  Alternatives include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the swelling short term.

January 8, 2009

Bone Stimulators

As a doctor, patients with a fracture that won’t heal can be in quite a pickle. There are many bone stimulators on the market including the Exogen, the Symphony bone growth stimulator, and the mbi bone growth stimulator. How does a bone stimulator work ? There are two main types, ultrasound based and an electrical bone stimulator. The ultrasound type works by emitting a pulsed low intensity ultrasound signal (PLIUS). This has been shown to stimulate mesenchymal stem cells which turn into osteoblasts which are cells that make new bone. An electrical bone growth stimulator works in much the same way. It’s usually worth using one of these units for 6-12 weeks. What if using a bone stimulator doesn’t work? Bone grafting is one option, but a big surgery. Is there another way? Yes, newer stem cell based injection methods can avoid the surgery and use your own stem cells to heal the fracture. I’ve posted two videos below on the subject:

electrical stimulation for fracture healing

As a doctor, one of the most difficult problems a patient can face is is a bone that won’t  heal.  One of the most miserable patients I can rememeber was a little old lady with a sacral fracture who at three months after her fracture couldn’t even go to physical therapy because the fracture wasn’t healing.  She had tried electrical stimulation for fracture healing, but this failed.  Other patients who come to mind are a thirty something smoker with an non-healing humerus fracture and a 60 something geologist with a leg fracture (tib-fib non-union).  They all had one thing in common, they could barely do anything.  What other options are there for these patients?  One option is as we’ve discussed, electrical stimulation for fracture healing.  There are also other types of fracture healing assist devices, including PLIUS or Pulsed Low Intensity Ultrasound.  These units can help, but what to do when they fail?  The issue is often a poor blood supply to the fracture.  As a result, surgeons traditionally try a bone graft with it’s own blood supply.  However, this is a very big surgery.  Is there another way to heal these fractures that won’t heal on their own?  Yes, recent research into adult stem cells have shown them capable of fracture repair.  How did we heal up the three fractures described above?  By injecting the patient’s own adult stem cells into the fracture lines (without bone graft surgery).  The little old lady?  Independent in 6 weeks with a healed scaral compression fracture.  The smoker?  Healed in 6 weeks and had full function of her arm.  The 60 some year old geologist with the tib-fib non-union?  Same.  All without surgery.  Below is a video that explains more:

January 3, 2009

video’s of low back surgery

Video’s of low back surgery. Low back surgery for a bulging disc cuts off the back part of the disc, making it weaker and more prone to failure. Below is a video showing a new method of treating a disc bulge, whereby the tear in the low back disc is repaired with an injection of the patient’s own stem cells

December 2, 2008

Back Pain and Stem Cells

Filed under: Back/Lumbar — Tags: , , , , , , , — D @ 9:23 pm

Three years ago, using guidance from the animal research, we got together with one of the local universities and tried placing bone marrow derived, mesenchymal stem cells into degenerated lumbar discs to treat back pain.  This was an IRB approved study and a spectacular failure, meaning we saw little changes in the discs on MRI and most patients reported little relief of back pain.  This past year we then set out to understand why this worked so well in animals, but failed to work in people.  First, degenerated discs in people that cause back pain have really poor nutrition and oxygen supply, not so in the animals being treated without back pain.  So we made a series of changes to technique and cell preparation to get around these issues.  We are happy to say that after several years of learning how to make this work , we can report good, reliable results in treating back pain with stem cells.  We can reduce the size of disc bulges and contained herniations by repairing the back of the disc with adult stem cells. This is using highly specialized techniques to place the cells via fluoroscopy without the need for surgery.

August 21, 2008

What is joint preservation?

Joint preservation is both an unknown and new medical science.  It literally means what it sounds like, preserving a joint via a number of tools rather than replacing all or part of that joint.  So instead of a total knee replacement, fixing as many issues as possible to make sure the joint still functions.  Why do this?  Joint replacement is big surgery with big risks, so many of us would like to avoid these risks.  In addition, from a psychological perspective, one knows they are truly “old” when a surgeon cuts out what used to a perfectly good joint and replaces that with metal and plastic.  So this blog is dedicated to my clinical experience and the tools I use to save joints, hence joint preservation.

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