Posts Tagged ‘Back and Spine’
The 5 things you should know about chronic pain from BecomePainFree.com
Only sufferers of chronic pain know the implications of pain in every aspect of life. Family members and friends of someone with chronic pain may sympathize to some extent, but it’s difficult to truly understand how chronic pain affects someone. If you have a friend or family member suffering from chronic pain — whether caused by an accident or injury, or another health condition such asfibromyalgia — use these tips to understanding chronic pain to help you be most supportive to your loved one.
1.Don’t pass chronic pain off as “all in your head.” People who suffer from chronic pain are rarely fabricating or exaggerating their symptoms. Conditions causing chronic pain can make an individual truly miserable. Many cases of chronic pain are difficult to diagnose, and thus management and treatment is far more challenging than in cases of acute pain, where the source of pain is easily diagnosed.
2.Chronic pain is different from acute pain. Acute pain lasts for a brief period of time, perhaps following an injury or accident. Chronic pain, on the other hand, is persistent and can even be permanent. We have all felt acute pain at some point in time, but only those with chronic pain know what it is to be in pain constantly.
3.Chronic pain may be caused by or the cause of other health conditions. Difficulty sleeping and depression are two conditions that often plague sufferers of chronic pain. Chronic pain can create a vicious cycle for the sufferer, for example: chronic pain leads to sleep disturbances, whereas lack of sleep can exacerbate chronic pain. The same is true of depression; it can be caused by or the cause of some chronic pain symptoms.
4.Every person’s pain is different. We all experience and express pain differently. Some people may be more tolerant of pain in specific parts of the body, while other people may express discomfort with pain in the same area or caused by the same condition.
5.Chronic pain is emotionally exhausting. Imagine that you are in pain or don’t feel good for months or years on end, with no relief. Constant pain wears on the emotions and can lead to depression and anger. Treatment for chronic pain often means treating each symptom and effect of that pain, including mental health issues such as depression.
Chronic pain is a lonely condition. If someone you know or love is suffering from chronic pain, don’t try to compare their pain to your own experiences, or assume their pain is all made up. Rather, offer your care and support. Be willing to listen when they need to talk and supportive throughout treatment programs.
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How to Prevent Migraines
Throbbing headache. Blurred vision. Sensitivity to light and sound. Nausea. Sound familiar? At least 16 to 17 percent of the world’s population will experience a migraine at some point in their lives, but for many, migraines are a part of daily life.
A migraine can be simply debilitating, when all you can think about is getting to a dark, quiet place to lie down and rest. Migraines can mean missing work or school, and even missing out on important, they-only-happen-once, life events.
There are some medications that can reduce the number and severity of migraines, but lifestyle changes are also strongly recommended to help prevent and/or alleviate the pain associated with migraines. If you suffer from migraines, try these migraine prevention tips.
- Get regular exercise. Aerobic exercise helps to reduce tension and prevent migraines. Choose a form of exercise you enjoy — walking, swimming or cycling or even dancing. Make time for 30 minutes of aerobic exercise every day. Exercise also aids weight loss, which may also help to prevent migraines.
- Avoid migraine triggers. For many people, migraines are triggered by certain food or scents. If you notice that a specific food or scent has triggered migraines in the past, try to avoid them.
- Get plenty of rest. Regular sleep patterns can help to reduce tension and stress that lead to migraines. Establish a regular sleep pattern means going to bed and getting up at the same time, every day. To help yourself sleep, turn off all electronics at least an hour before your bedtime, turn down the lights and allow yourself to relax.
- Reduce stress. Stress is a common cause of migraines. Find ways to reduce your stress, whether through exercise, meditation or simply relaxing at home.
- Reduce estrogen levels. For some women, estrogen can induce migraine headaches or make them work. If this is the case for you, avoid medications such as birth control and other hormone pills that contain estrogen.
If you suffer from chronic migraines, talk with your doctor about pain management and lifestyle changes that may help reduce your headache main.
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LIVING WITH BACK PAIN
In most instances, individuals with low back pain will improve over a two- to six-week period. The goal is to minimize recurrences and, while being in good physical condition does not prevent all back pain episodes, it will make the resolution of those episodes easier. If you smoke, stop. Smoking is a predisposing factor for back pain. If you are overweight, get into shape. Obesity does not cause back pain, but it does make it harder to heal. (No particular diet is known to prevent episodes of low back pain.) Bottom line, pay attention to your body and exercise, eat right and maintain a healthy life style.
POINTS TO REMEMBER
- Low back pain is a common problem and rarely associated with a severe illness.
- The vast majority of individuals heal back pain by remaining active and taking pain-relieving drugs.
- About 50 percent of individuals are healed in a week or two; over 90 percent are resolved in eight weeks.
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San Antonio Spine Surgeon, San Antonio Back Doctor, Mayo Clinic Trained Spine Surgeon, Bexar County Orthopedic Surgeon
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Spine Surgeon Fort Worth Texas, Spine Surgeon Tarrant County, Texas Back Institute, TBI, Shawn Henry DO
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Spine Surgeon Dallas, Mayo Clinic Trained Spine Surgeon, Back Doctor, Spine Pain Doctor
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Stem Cells for Spine Surgery: 7 Points
Written by Laura Miller | May 23, 2012
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How we got here
Dr. Hynes was one of the many spine surgeons who participated in Medtronic’s original trials for BMP-2 in the 1990’s. While scientists have known about the ability of stem cells and BMP to generate bone for several years, Medtronic was the first company to develop a safe and effective molecule to stimulate cell growth. After completing the pre-market approval trials, the Food and Drug Administration granted approval for the BMP-2 product, Infuse, in 2002 for creating fusion in the Lumbar Spine placed through an anterior approach in a LT cage.
“In the original study, I experienced 100 percent of enrolled patients in my Practice achieving bone growth when combining BMP with the local cells that were already there,” says Dr. Hynes. “Local ‘stem cells’ respond to BMP and become activated thereby creating bone. When I saw it worked in 100 percent of my enrolled patients, I was a true believer. I have used it in my practice since the study and FDA approval going back greater than 10 years.”
What has changed is our ability to concentrate stem cells; Dr. Hynes harvests the stem cells from the iliac crest to combine with the BMP. It takes less than five minutes for his physician’s assistant to harvest the cells, which are spun in a centrifuge while he begins the operation. After 10-15 minutes, the cells are ready and Dr. Hynes adds a small amount to the surgical field along with the BMP. The collagen sponge is placed within an interbody LT cage to keep the material from migrating.
“This has been an effective Bone Graft method and it has been an advantage for my patients who can avoid Iliac Bone Graft surgery and Donor Bone issues and cost,” says Dr. Hynes. “It doesn’t add to my usual procedure time. It does add a small cost, but I find it’s worth the value proposition.”
Since its inception and release, surgeons have been experimenting with its use in several different capacities, on- and off-label. However, articles published in The Spine Journal in July 2011 suggest complication rates may be higher than the original studies reported. Several physicians have reported positive and negative events based on individual practice date, and further research into its use will be necessary going forward. As with all products, on label and off label use is routine practice and common place. When used correctly, minimal side effects of swelling, seroma and osteolysis occur.
What the research says
There have been several clinical studies and basic science research projects published in professional journals discussing the efficacy of using BMP with local stem cells to enhance fusion. However, research on the impact of increasing the number of stem cells is still lacking. Dr. Hynes’ current clinical work focuses on whether there is a better chance of achieving fusion with a higher concentration of stem cells.
He harvests stem cells from the iliac crest, percutaneously and painlessly, or vertebral body and extract about 60-80 ccs of blood. The desired stem cells are concentrated to a few ccs with centrifugation and has about a 50,000 cell count per “Spine Smith research data.”
“We already know the mechanism by which BMP-2 activates stem cells. The stem cells are already very effective,” says Dr. Hynes. “If we add to the population of stem cells that are already there that are available to regenerate new bone, it could make the procedure even better. Anecdotally, I have a high fusion rate for my spine patient population even before adding the extra concentration of stem cells. With the additional stem cells, I hope to achieve fusion at almost any level no matter how many levels are needed such as in degenerative scoliosis. In osteoporosis and aging spine patients, this has been extremely beneficial when compared to poor iliac crest from bone harvest.
Dr. Hynes’ ethereal practice goal is to someday be able to “guarantee” that they will achieve fusion for every patient who undergoes surgery. This means stabilization. However, fusion does not guarantee “success” of the surgery but increases odds of the surgical success. At this point, he is close, with approximately a 95 percent fusion rate. “What I want to do before I retire is to be able to guarantee a fusion,” he says. “I can’t guarantee pain relief or other clinical outcomes, but I want to be able to confidently guarantee the fusion or stabilization component.”
Options for harvesting stem cells
There are several bone graft options spine surgeons can choose from to achieve a fusion, and in the wake of recent controversies some surgeons are looking for an alternative to using BMP. Surgeons can go back to the traditional fusion method – the iliac crest – or using an allograft. Dr. Hynes says harvesting bone from the iliac crest can leave 30 percent of patients in more pain and add significant surgical time in the OR with increased blood loss. Allografts also have downsides, including graft consistency, quality, processing issues and less potential to achieve fusion than iliac crest or autogenous grafting methods.
“The bone for allografts may not be prepared correctly,” says Dr. Hynes. “We don’t always know the quality or consistency of the allograft compared to the patient’s natural bone. If I’m putting a piece of bone in patients, it’s better if it comes from their own bodies. That way, you can’t tell the difference between the bone you grow and the natural bone. (What we are doing is creating a nice bone graft that balances the biomechanics of the fusion construct better than the allograft.)”
In some cases, the allograft bone could migrate or fracture or reabsorb after the procedure, which can cause significant pain and complications, often resulting in revision procedures. By using the combination of BMP and stem cells in an interbody device, Dr. Hynes is able to avoid most of those complications because the cells are attracted to the BMP, which is restrained in the cage.
Patients should have the final say – “Informed Consent”!
Like many surgeons, Dr. Hynes describes the different fusion options to his patients and allows them to choose which procedure they feel most comfortable with. He discusses the pros and cons of each technique, including the most recent concerns about BMP, as well as his personal outcomes. He says patients often choose BMP combined with stem cells because they like the idea of regenerating their own bone naturally, avoiding the extra surgery and potential pain of iliac crest bone grafts and decreased potential or effect of donor allograft bone.
“The psychology of healing is part of this,” says Dr. Hynes. “Patients understand the procedure and like the idea of using their own cells as healing factors. People are very positive about that process because they feel like they are doing something natural instead of synthetic. Healing and surgery isn’t just biomechanics and science; it’s psychological as well. Successful outcomes of surgery depend on subjective relief as well as objective factors.”
In his practice, Dr. Hynes says a significant number of his patients chose the BMP and stem cell combination with given the option. However, when the patients choose a different option, he performs the other procedures as well. “It’s our duty to give patients their choice,” he says. “I’m not always smart enough to know what the best choice is for any one individual, but I’ve practiced many years and learned that if you take time to educate patients to all the reasonable options, they will make good decisions and take responsibility for them.”
Deciphering the complications
While Dr. Hynes hasn’t experienced significant complications among his patients, it’s clear that other surgeons have reported complications when they perform spinal fusions using BMPs. One reason for the discrepancy could be the dosage; well-documented evidence suggests that a higher dosage of BMP could cause swelling complications when used in the cervical spine. By using low doses of BMP and a pre and post-surgical protocol, swelling is completely avoidable in the cervical spine. Another factor is the surgical approach; Dr. Hynes says retrograde ejaculation (“RE”) – one of the severe complications mentioned in the studies this past summer – is a complication risk of any anterior spine surgery and not related to use of BMP. “I have performed thousands of anterior procedures before and after approval of BMP for anterior lumbar surgery and I find no difference in RE noted in my patients.”
“Every spine surgeon knows RE is a risk during anterior procedures and it usually will reverse on its own,” says Dr. Hynes. “RE occurs in an extremely low frequency. RE occurs because of disruption ‘surgically’ of small nerves to a sphincterine the bladder. BMP does not cause this effect, but the use of the electrocautery tool, during surgery, likely does. Use a small dose of BMP and a cage as well.”
In his practice, Dr. Hynes has never experienced a critical airway complication using cervical BMP. In early years, too high a dose would lead to swelling but not airway compromise which more commonly occurs with hematoma or blood clot, says Dr. Hynes. Papers published in The Spine Journal also mention cancer as an associated complication, which is something he hasn’t necessarily noted either. “I haven’t seen a rash of cancer in my patients, but I haven’t been surveying for it either,” he says.
He is currently going through his patient base to determine whether he can detect any cancer cases that could be associated with the procedure.
Whether to use BMPs
As surgeons report different findings based on their individual practice data, many of the studies and discrepancies have been reported in the media. However, full understanding of these complex issues is often lost in news reports. “I hate to see some of the surgeons and journals duking it out in the media,” says Dr. Hynes. “That isn’t the place to argue over the efficacy of stem cells and BMPs. We have to do it in the meetings where people understand the context. To lay this out in the newspapers exacerbates political agendas and confuses our patients. We need to speak honestly with each other about this at professional and scientific meetings, not in the press.”
This controversy isn’t the first time new spinal technology and procedures have been under attack. For a period of time, pedicle screws – which are a standard of care now – were under the microscope because complications were reported. In some instances, surgeons were sued and restricted from use at their hospitals for their alleged unfavorable outcomes. Now pedicle screws are the mainstay of spinal fusion procedures.
“At the time, there was only approval that pedicle screws could be used on single-level surgeries,” says Dr. Hynes. “Now we use them at multi-levels. The pedicle screws ultimately won the day, but with public stimulation ‘in the news’ in the early 1990s, we almost lost the ability to use them. This was a public attack on the advent of a new fusion technology, and now we are seeing similar phenomenon’s with BMP and other medical products.”
Covering the cost of BMP
In some cases, surgeons may have a difficult time receiving reimbursement for BMP products because they were more expensive in the past. Dr. Hynes and his colleagues have worked with hospitals and surgery centers to cover the cost in both out-of-network and in-network contracts. In some cases, patients are willing to cover the cost of using stem cells with BMP. Due to the success and demand, the cost has now become competitive considering operative costs of iliac bone surgery or allograft. “The increased volume of use and effectiveness has caused a dramatic decrease in cost,” says Dr. Hynes.
“I see patients from out of the Country and they are usually cash pay patients,” says Dr. Hynes. “We have to line item every part of the procedure to show the actual cost and there is almost no increased cost for the use of low concentrated BMP compared to iliac bone grafts or allograft when taking OR time, surgeon’s time and other OR costs into consideration.”
Fortunately, the hospitals in Dr. Hynes’ community allowed him to use BMP and conduct the clinical studies there. “We have more experience in our community with the benefits of this technology because we started so early,” he says. “Our surgeries are very efficient and our operative time is less because of our long-term experience with the procedure using stem cells and BMP.”
However, in some cases Dr. Hynes has made sacrifices to mitigate these costs. “I think about what I could live without and forego those expenses for stem cells and BMP,” he says. “I might use less expensive blades or a new set of tools for the next year. I might continue to use my old led apron or do surgery without a super drape. I’m there to give patients a better outcome and I want to make sure they have the opportunity to have the stem cells.”
More Articles on Spine Surgeons:
8 Spine Surgeons on the Future of Spinal Fusions
6 Spine Surgeons on How Young Surgeons Can Position Themselves for Success in the Future
What Percentage of Your Spine Practice is Medicare Patients?
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Kyphoplasty Surgery, Kyphoplasty, Kypho, Vertebroplasty, Back Surgery, Spine Surgery
What is Vertebroplasty & Kyphoplasty?
Vertebroplasty and kyphoplasty are minimally invasive procedures for the treatment of vertebral compression fractures (VCF), which are fractures involving the vertebral bodies that make up the spinal column.
When a vertebral body fractures, the usual rectangular shape of the bone becomes compressed, causing pain. These compression fractures may involve the collapse of one or more vertebrae in the spine and are a common result of osteoporosis. Osteoporosis is a disease that results in a loss of normal bone density, mass and strength, leading to a condition in which bones are increasingly porous, and vulnerable to breaking. Vertebrae may also become weakened by cancer.
In vertebroplasty, physicians use image guidance to inject a cement mixture into the fractured bone through a hollow needle. In kyphohplasty, a balloon is first inserted into the fractured bone through the hollow needle to create a cavity or space. The cement is injected into the cavity once the balloon is removed.
Performing Kyphoplasty Surgery
- During kyphoplasty surgery, a small incision is made in the back through which the doctor places a narrow tube. Using fluoroscopy to guide it to the correct position, the tube creates a path through the back into the fractured area through the pedicle of the involved vertebrae.
- Using X-ray images, the doctor inserts a special balloon through the tube and into the vertebrae, then gently and carefully inflates it. As the balloon inflates, it elevates the fracture, returning the pieces to a more normal position. It also compacts the soft inner bone to create a cavity inside the vertebrae.
- The balloon is removed and the doctor uses specially designed instruments under low pressure to fill the cavity with a cement-like material called polymethylmethacrylate (PMMA). After being injected, the pasty material hardens quickly, stabilizing the bone.
Kyphoplasty surgery to treat a fracture from osteoporosis is performed at a hospital under local or general anesthesia. Other logistics for a typical kyphoplasty procedure are:
- The kyphoplasty procedure takes about one hour for each vertebra involved
- Patients will be observed closely in the recovery room immediately following the kyphoplasty procedure
- Patients may spend one day in the hospital after the kyphoplasty procedure
Patients should not drive until they are given approval by their doctor. If they are released the day of the kyphoplasty surgery, they will need to arrange for transportation home from the hospital.
Recovery from Kyphoplasty
Pain relief will be immediate for some patients. In others, elimination or reduction of pain is reported within two days. At home, patients can return to their normal daily activities, although strenuous exertion, such as heavy lifting, should be avoided for at least six weeks.
Candidates for Kyphoplasty
Kyphoplasty cannot correct an established deformity of the spine, and certain patients with osteoporosis are not candidates for this treatment. Patients experiencing painful symptoms or spinal deformities from recent osteoporotic compression fractures are likely candidates for kyphoplasty. The procedure should be completed within 8 weeks of when the fracture occurs for the highest probability of restoring height.
It is not known whether kyphoplasty or vertebroplasty will increase the number of fractures at adjacent levels of the spine. Bench studies on treated bone have shown that inserting PMMA does not change the stiffness of the bone, but human studies have not been done. Osteoporosis is a chronic, progressive disease. As stated earlier, patients who have sustained fractures from osteoporosis are at an increased risk for additional fractures due to the loss of bone strength caused by osteoporosis.
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Regenerative Medicine
Administering undifferentiated stem cells to an injured disc has made adult stem cell regenerative medicine in spine a reality. Adult stem cell regenerative medicine holds the promise of stabilizing or even reversing the degenerative changes associated with aging or following traumatic injury. Current clinical use of stem cells is very limited, in part by the cumbersome approval process. The use of concentrated bone marrow aspirate (BMC) as a “stem cell” preparation is currently the simplest and safest way of utilizing the regenerative potential for mesenchymal stem cells (MSCs) to promote tissue regeneration. In fact, stem cells concentrated from bone marrow have been shown to stimulate the formation of bone, cartilage, ligament and tendon, and dermal tissues.
Conservative treatment options for lumbar and cervical pain associated with discogenic disc disease (Pfirrmann Grades 3-6) are limited. Treatment options include pain medication, steroids, physical therapy, and chiropractic care. Reversal of disc pathology has not been achieved with current available treatment modalities. Failure of these nonoperative treatments may leave surgical intervention as a treatment option.
The goal of utilizing MSCs is to not only potentially provide pain relief from the painful degenerative disc, but to reverse the degenerative process. There are three methods for placing MSCs into the painful nucleus pulposus.
The use of allogeneic mesenchymal precursor cells (MPCs) is currently being evaluated as a part of an FDA Phase I clinical trial. Extracted from donors and expanded in number by tissue culture, this process isolates and grows the stem cells into pure MPCs which are injected into the nucleus pulposus. This technology does not have FDA approval.
Utilizing expanded, autologous MSCs for injection into the painful disc is the second method. Federal regulations require the approval of an Investigational New Drug application supported by prospective, randomized clinical trials for the use of expanded autologous MSCs. The FDA has not approved this technology.
The third method involves autologous point of care therapy. This technology does not require FDA approval. The patient’s own MSCs are directly injected into the nucleus pulposus of the symptomatic degenerated disc(s) using standardized two needle discography technique. This requires fluoroscopic visualization and 2-3cc of MSCs are slowly injected into the symptomatic nucleus pulposus.
There have been no complications associated with the iliac crest aspiration or disc injection. Thus far no patient in the study has undergone spine surgery following treatment. Results obtained with this technique suggest its potential clinical efficacy in the treatment of moderate to severe degenerative disc disease. These results require verification with longer follow-up and randomized prospective studies.
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Adult Stem Cell Therapy to Treat Back Pain, Stem Cell, Spine Stem Cells, Stem Cell Treatment
Adult Stem Cell Therapy that doesn’t require FDA approval to treat lumbar and cervical spine conditions resulting from injury or aging, and is also involved with an FDA clinical trial investigating the use of Adult Stem Cells.
Stem Cell
These stem cells are autologous – they are taken from an adult patient and returned to that same patient in a concentrated form to the damaged area in a 30-minute procedure. This type of adult stem cell therapy does not require FDA approval to administer.
When it comes to stem cells, there is often a lot of mystique surrounding them. We hear from the media that we can create a human being out of a bundle of cells, which is not necessarily true. We also tend to look at embryonic stem cells as being the only type of stem cell. With these types of embryonic stem cells, one idea is to be able to create a liver or kidney in a Petri dish, which is not controllable or feasible at this point, and the work being done by the BecomePainFree.com medical group.
When we look at stem cell types, we have embryonic stem cells on one hand and adult stem cells on the other. The characteristics of each of these are not like other cells. For instance, a liver cell can divide but it will only ever be a liver cell. These stem cells, both embryonic and adult, can turn into different types of cells. The embryonic stem cells can really turn into any cell type, but adult stem cells are limited as far as the cells they can turn into. This depends upon environment or niche and what they are already programmed to become. A lot of people think there is a lot of promise with embryonic stem cells and there is, although we are not quite there yet.
We are still at the forefront of stem cell technology and embryonic stem cells in particular. With those cells, we do not have the ability to control what types of tissue they turn into. For example, we could be trying to manipulate these cells to turn into kidneys, but they might start to develop as pancreatic cells, which is troublesome. Another key with all stem cells is that they can proliferate quite a bit, usually at a higher rate than just a regular somatic cell. Although this sounds good at first glance, the issue with this, particularly with embryonic stem cells, is we cannot control that division. Hence, these cells can keep going and going without dying. In the normal bodily process, cells are programmed to die after a certain time, but these embryonic stem cells can evade that action and continue dividing, which takes on the characteristic of cancer cells. In some animal studies, an issue that keeps arising is development of tumors in some of these animals. It is difficult to predict if tumors are going to form when using some sort of embryonic stem cell treatment. This is still a scary area through which we are still trying to navigate.
However, the focus of the BecomePainFree.com medical group is on adult mesenchymal stem cells. On the whole, the media does not give a lot of attention to these kinds of stem cells, as using them avoids any kind of ethical or controversial issues. There is a great amount of research being done on adult mesenchymal stem cells, however, because they are very powerful.
First off, we can control what cell type they turn into much more easily. For example, the treatment used by the BecomePainFree.com medical group focuses on Mesenchymal precursor cells (MPC). Mesenchymal means these cells are not going to turn into any kind of blood product such as a red blood cell or white blood cell, although they are derived from bone marrow. The fact that they are precursor cells means these MPCs are only going to differentiate into one of a few cell types. They are either going to become bone cells, i.e., osteoblasts, or chondrocytes, i.e., cartilaginous tissue such that we see in intervertebral discs and joints, etc. All of that really depends on the environment in which we place these adult stem cells where it is well suited to do this. For example, we can inject these MPCs into a bone fracture, and because the cells are surrounded by bone tissue, these cells will receive signals from the surrounding cells that tell them to turn into bone. However, the cells we use will be injected into a disc or joint, and the cells composing the disc and joint tissue will signal the stem cells to develop into similar tissue. Again, there is no chance of any sort of pancreatic cell or nerve cell type spontaneously forming because we are using certain adult stem cell types, which are limited and cannot turn into anything like that. In addition, as the tissue surrounding the disc and joint is relatively avascular, there is not really any worry of these cells migrating through the blood stream to somewhere else in the body and causing any sort of problem. As far as the proliferation issue with embryonic stem cells, we have not seen this issue with adult stem cells in terms of dividing exponentially without ceasing. There is almost a preset limit to how many times these adult stem cells will divide.
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Become Pain Free, Pain, Back Pain, Spine Pain, Spine Surgery, Chronic Pain 