Marc Darrow MD,JD

There are many types, causes and diagnosis of low back pain. Equally there are many types of treatments including many types of surgery. In this article I will discuss with you treatment options including the use of bone marrow aspirate concentrates or commonly bone marrow stem cell therapy for back pain.

The different types of back pain

Back pain comes with many different diagnosis. In many patients they have multiple diagnoses.

  • Spondylolysis and Spondylolisthesis
  • Lumbar radiculopathy or sciatica
  • Intervertebral disc degeneration

A spinal ligament injury or nerve impingement?

The cause of low back pain can be identified as spinal instability. Spinal instability can be caused by loose, lax, or damaged spinal ligaments. Spinal ligaments hold the vertebrae in place. When they are loose or stretched out the vertebrae start moving out of alignment. The confusion in the proper diagnosis of back pain can also be traced to MRI imaging. The cause of failed back surgery may also be traced to MRI imaging as an MRI may show a pre-existing condition that is asymptomatic and not reveal a new or worsening injury that is causing the pain.

In many cases of radiating pain, where MRI indicates a slippage of the vertebrae (Spondylolisthesis), a degenerative osteoarthritis condition, or a bulging disc, the MRI is not necessarily an indication that surgery is needed. Researchers have suggested that lower back pain can be caused by weak spinal ligaments.

MRI is not necessarily an indication that surgery is needed

Doctors in a 2021 paper (7) recommended that when health professionals discuss MRI results with patients, the way the results are given can have catastrophic effect on the patient. According to this paper, “Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain.  . . Routine MRI reports produce a negative perception and poor functional outcomes in low back pain.” In other words, many patients are inadvertently scared into surgery .

Spondylolysis and Spondylolisthesis

These are diagnosis that typically improve with conservative care and patients would, more the most part, be considered appropriate candidates for regenerative medicine treatments.

Spondylolysis is a stress fracture in the vertebrae’s pars interarticularis. In younger or athletic patients this can result from traumatic injury. In older patients, the cause of spondylolysis can be suspected degenerative wear and tear. Eventually the injury can cause the vertebrae to slide out of place and overhang the vertebrae below it. This is the diagnosis of spondylolisthesis. Spondylolisthesis will be suspected if the patient describes pain radiating through the buttocks into the hips and legs.

Many people can have Spondylolysis. They may not even know it as it can be asymptomatic. In some people, pain is felt when they are involved at physically demanding work, sport or other activity. Most will feel it most when they arch their spine or bend backwards. It is only when back pain becomes chronic and is focused on a specific segment of the lumbar spine does the  spondylolysis diagnosis come into play. An X-ray is may be called for to detect a stress fracture in the vertebrae.

If you have been treated for spondylolysis or you have advanced to degenerative Spondylolisthesis  your conservative care options may have included:

  • Rest and activity avoidance which would aggravate your situation.
  • Over the counter or prescription nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Physical therapy.
  • Immobilization with a back braces.

Spondylolisthesis can be treated non-surgically. However, if neurological problems develop and a loss of function occurs, surgery will be recommended.

Below in the case histories we present in the medical literature, we describe a patient with:

  • A radiograph of his lumbar spine demonstrated narrowing at L5-S1 and L3-L4 as well as grade I spondylolisthesis, of L5 on S1.

Lumbar radiculopathy or sciatica

Lumbar radiculopathy or sciatica is a symptom of spinal instability and disc and nerve compression. It is the numbing pain that works its way down the leg. This pain is sometimes accompanied by leg weakness. As this pain radiates down the leg along the sciatic nerve it is referred to as Sciatica.

Failed back surgery syndrome

We are often asked can stem cell therapy help patients with failed back surgery syndrome. The answer is many people can be helped, other cannot be. If the problems of pain are related to hardware mispositioning, bent screws or plates, stem cell therapy cannot help. For others there can be a problems of adjacent segment disease, spinal degeneration above and/or below the site of a fusion. These people may be offered another surgery to extend the fused elements or unto rounds of physical therapy, stronger painkillers, and, or a spinal cord stimulator. Sometimes these treatments work, sometimes they do not.

An October 2021 paper wrote (11) : “Spinal fusion is the most widely accepted treatment for lumbar disc degenerative disease. However, it has been associated with adjacent segment degeneration as a potential long-term (complication) especially in those with preoperative risk factors, which may cause aberrant (excessive) stress forces in these segments and lead to adjacent level degeneration.  . . there are a few reports considering reoperation rate as being the most reliable parameter to define adjacent segment disease, despite clinical symptoms.”

Darrow Stem Cell Institute research article

This is a Darrow Stem Cell Institute research article published in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018. This article presents highlighted portions of that research. For the full article please visit this link.

You can ask me your questions about bone marrow concentrate (stem cell) injections by using the form below.

Cite this article: Marc Darrow, Brent Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7(2)-2018. BJSTR. MS.ID.001461. DOI: 10.26717/ BJSTR.2018.07.001461. 4/6

Information references. 

This article discusses the injection of bone marrow concentrate (BMC). Bone marrow concentrate is also considered stem cell therapy as bone marrow derived stem cells (mesenchymal stem cells) are taken from the iliac crest and then the stem cells are concentrated as stem cell therapy or stem cell treatment. These are adult stem cells.

Article abstract

  • Lower back pain can be a debilitating condition that is often caused by ligament and fascial sprains in the spine, and muscle strains.
  • Even though the diagnosis may be a herniated disc, facet arthropathy, degenerative disc disease, spinal stenosis, scoliosis, spondylosis, spondylolisthesis, or other pathology, we have found for the past twenty years, with thousands of successfully treated patients, that the actual pain generator may not even be noted in the diagnosis.
  • With the risk of adverse complications of surgery and ineffectiveness of epidural injections, bone marrow concentrate (BMC) offers a promising treatment to treat lower back pain. Bone marrow concentrate contains mesenchymal stem cells that have the ability to differentiate into muscle, cartilage, and bone, in addition to releasing trophic factors that enhance tissue regeneration.
  • The four patients included in this study underwent at least one treatment of bone marrow concentrate injection to the entheses of muscles, fascia, and ligaments surrounding the lumbar spine.
  • At one-year follow-up all four patients experienced a decrease in resting and active pain. Patients also reported a mean 80% total overall improvement and were able to perform daily activities with less difficulty.
  • These encouraging results warrant further investigation of the full potential of BMC injections for treatment of spine and lower back pain.

Information clarification:

Mesenchymal stem cells are multipotent adult stem cells. This means that they are self-renewing, can multiple, and more importantly can differentiate or change themselves into the building blocks of bone, cartilage, muscle, fat, and connective tissue i.e, the ligaments, tendons and fascia. The idea of the treatment in medicine is to take stem cells from the bone marrow, concentrate them, and inject the cells into the low back.

Spinal muscle strains and Spinal ligament sprains often neglected in lower back pain diagnosis

In medicine, muscle strains, ligament sprains, and muscle contusions account for up to 97% of lower back pain in the adult population. Additionally, researchers state that the ligaments of the spine are often neglected compared to other pathology that account for lower back pain. This could be due to the overreliance of MRIs to guide physicians to correct diagnoses. Two studies illustrate that patients without symptomatic back pain displayed MRI abnormalities including degenerative disk changes [1,2]. Yet patients with these same diagnoses are recommended for surgery without a thorough understanding of their pain generator. Canadian researchers found that 55.7% of lumbar spine MRIs were not a good medicine and considered them inappropriate or of uncertain value to diagnosis [3].

Bone Marrow Concentrate (BMC) is a potential therapy to improve lower back patients’ quality of life

  • BMC stem cells is a solution that contains many cytokines (cartilage building blocks) and growth factors but most notably contains platelets and mesenchymal stem cells (MSCs),
  • Mesenchymal stem cells are adult multipotent stem cells that have the ability to differentiate into different cell types such, cartilage, bone, and muscle.
  • This is a promising solution to tissue regeneration including regeneration of muscles and ligaments
  • Mesenchymal stem cells also secrete trophic factors which stimulates and has anti-inflammatory properties and have been shown to promote muscle healing and growth through myogenesis of muscle progenitor stem cells.

Recently, MSCs were injected into patients with degenerative disc disease with reported improvement in disc quality, pain, and quality of life variables [4,5,6].

The patients in the present study were injected with bone marrow concentrate stem cells into the muscles, fascia, and ligaments surrounding the lumbar spine. It has been well documented in literature that MSCs and platelets enhance tendon and ligament healing [8,9].

In patients who were diagnosed with ligament and fascial sprains, we hypothesize that we can reduce patients’ low back pain by strengthening these anatomical areas.

Patient Case 1 stem cell therapy


The first patient was a 65 year-old male with a seven-year history of lower back pain.

  • His pain first occurred when he experienced intense cramping in his lower back while playing tennis.
  • At one point because of difficulty walking, he went to the emergency room.
  • His back pain was most prevalent when running and sitting for extended periods of time.
  • A radiograph of his lumbar spine demonstrated narrowing at L5-S1 and L3-L4 as well as grade I spondylolisthesis, of L5 on S1. However, after physical examination, the physician diagnosed the patient with a lumbosacral sprain.
    • The patient had undergone physical therapy, chiropractic adjustments, massage, and acupuncture that provided minimal pain relief.
    • The lack of a conservative treatment had caused him to consider back surgery.
    • His baseline characteristics were:
      • resting pain of 2/10,
      • an active pain of 9/10,
      • and a functionality score of 20/40.

The patient underwent 2 BMC treatments in 21 days.

  • At short-term follow-up after the second treatment, the patient reported 60% total improvement, stating that he was in less pain and able to swim without difficulty. However, he continued to
    experience occasional stiffness.
  • At the annual follow-up, patient reported a significant decrease in pain and was able to perform activities more easily.
  • His final resting and active pain levels were 1/10.
  • He reported 80% total overall improvement, with a functionality score of 33/40.

Patient Case 2 Stem Cell Injections after PRP


The second patient was a 37-year-old male with a two and half year history of lower back pain.

  • The patient had undergone chiropractic adjustments and massage therapy all of which provided only temporary relief.
  • He underwent 4 Platelet-Rich Plasma (PRP) injections at another private practice, a year prior to BMC stem cells injection. The PRP injections provided no relief.
  • It was then recommended that patient undergo surgery.
  • Radiographic imaging of the patient’s lumbar spine demonstrated disc bulges at L3-L4, L4-L5, and L5-S1, in addition to mild bilateral facet joint and ligamentum flavum hypertrophy – Intervertebral disc degeneration
  • The pain was described as constant tightness that worsened when sitting for long periods or sleeping on his right side.
  • After palpation of his lower back, it was clear that the pain was generated from a lumbosacral sprain.
    • His baseline resting, and active low back pain were 4/10 and functionality score
      was 28/40.
    • The patient underwent two bone marrow aspirate concentrate stem cells treatments in 37 days.
    • At the short-term follow-up after treatment, the patient reported a 60% overall improvement. He experienced increased flexibility, less pain, and was able to sleep better at night.
    • A follow up was given a year after the conclusion of treatment and the patient continued to experience 60% improvement.
    • His resting pain was 1/10, active pain was 2/10, and functionality was 32/40.

Case 3 – Patient had four stem cell therapies


The third patient was a 56-year-old male who had a two-year history of lower back pain.

  • The patient reported pain that was most prominent when sitting or lying on his stomach.
  • MRI of his lumbar spine demonstrated moderate L3-L4 central stenosis due to a broad based disc bulge and facet degenerative change with hypertrophy.
  • He underwent an epidural injection, physical therapy, and massage therapy none of which provided consistent pain relief.
    • His resting back pain was 3/10, active back pain was 6/10, and functionality score was 17/40 at baseline.
    • When our physician examined his lower back, the patient was diagnosed with a lumbosacral sprain.
    • The patient underwent four BMC treatments in a 146-day period.
      • He experienced a minor improvement after the first treatment, reporting only dull aches with less frequency and stretching his lower back reduced the pain.
      • After the third treatment, he reported improved ability to perform daily activities with less pain. At the short-term follow-up after the fourth treatment he experienced
        the most symptomatic relief, reporting a 75% total overall improvement.
      • Another follow-up was administered approximately a year and half post-treatment, and his overall improvement increased to 90%.
      • Additionally, his resting pain was 0/10, his lower back active pain was 2/10, and his lower back functionality score increased to 34/40 after therapies.

Case 4


The fourth patient was a 77 year-old female with a 20-year history of lower back pain, which had progressed with age.

  • The patient wore a back brace to attempt to reduce the stiffness and pain when standing or sitting for extended periods of time.
  • Radiographic assessment of her lumbar spine showed mild dextroscoliosis and mild narrowing of L1-L2, L3-L4 and moderately severe narrowing of L5-S1.
    • Her baseline resting and active pain prior to treatment was 1/10 and 5/10 respectively, and a 33/40 functionality score.
    • After physical assessment of her lower back, our physician determined her pain was generated from a lumbosacral sprain.
    • She had one BMC treatment and at first follow up two weeks after the injections, the patient experienced no pain or stiffness and reported 90% total improvement.
    • Approximately a year after treatment, she felt even better, and stated that she was able to perform aerobics and line dancing for an hour and a half a day with no pain.
    • She reported infrequent stiffness, but not as severe as it was prior to treatment. Her resting and active pain were 0/10 and functionality score was 39/40.

What did we learn from these case studies of low back pain treated with bone marrow concentrate

This is the first reported study treating low back with BMC injections to the ligaments, fascia, and muscles surrounding the lumbar spine. It is promising that at one-year follow-up, 100% of patients in this study experienced a decrease in resting and active pain in addition to performing daily activities with less difficulty.

  • All four patients experienced sustained or increased improvement at annual follow-up compared to short-term follow-up.
  • On average, patients reported:
    • 80% decrease in resting pain,
    • 78% decrease in active pain,
    • and a 41% increase in functionality score.
  • Additionally, patients reported a mean 80% total overall improvement following
    treatment.
  • The two patients who considered surgery prior to BMC treatment no longer felt the need for it.
  • These results provide evidence that appropriately chosen patients with low back pain may find relief with BMC injections.

Other research on bone marrow mesenchymal stem cells for back pain

A March 2022 paper (10) examined the effectiveness of bone marrow mesenchymal stem cells in the treatment of chronic low back pain due to severe lumbar spinal degeneration. The study authors wrote: “Regenerative medicine interventions are applied to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous/allogenic biologics and it continues to expand.” The authors note: “The anti-inflammatory, immunomodulatory, and regenerative properties of bone marrow mesenchymal stem cells, and investigation into their therapeutic efficacy and safety in patients with severe chronic low back pain, have not been demonstrated in controlled studies. Multiple pain generators have been hypothesized to be responsible in severe spinal degeneration and it is difficult to identify a single pain generator; consequently, resulting in inadequate therapeutic results.”

To answer these questions this study was undertaken to evaluate the effectiveness of autologous bone marrow MSCs in the treatment of chronic low back pain due to severe lumbar spinal degeneration with involvement of multiple structures.

  • Methods: The treatment group patients received a one-time bone marrow concentrate injection into spinal structures (i.e., discs, facets, spinal nerves, and sacroiliac joints), along with conventional treatment, whereas, the control group received conventional treatment with nonsteroid anti-inflammatory drugs, over-the-counter drugs, structured exercise programs, physical therapy, spinal injections and opioids, etc., as indicated.
  • Results: Significant improvement was achieved in functional status measured by disability scores and pain relief.
  • The results showed significant improvements at 12-month follow-up with 67% of the patients in the study group achieving a minimum clinical difference in better function and reduced pain as compared to 8% in the control group.
  • Opioid use decreased in the investigational group, whereas, there was a slight increase in the control group.

Do you have questions? Ask Dr. Darrow

 


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References are from the following journals of medicine.

1 Kovacs FM, Arana E. Degenerative disease of the lumbar spine. Radiologia. 2016 Feb 10;58:26-34.
2 Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. Journal of Neurosurgery: Spine. 2015 May 1;22(5):496-502.
3 Emery DJ, Shojania KG, Forster AJ, Mojaverian N, Feasby TE. Overuse of magnetic resonance imaging. JAMA internal medicine. 2013 May 13;173(9):823-5.
4 Elabd C, Centeno CJ, Schultz JR, Lutz G, Ichim T, Silva FJ. Intra-discal injection of autologous, hypoxic cultured bone marrow-derived mesenchymal stem cells in five patients with chronic lower back pain: a long-term safety and feasibility study. Journal of translational medicine. 2016 Dec;14(1):1-9.
5 Pettine K, Suzuki R, Sand T, Murphy M. Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up. International orthopaedics. 2016 Jan;40(1):135-40.
6 Centeno C, Markle J, Dodson E, Stemper I, Williams CJ, Hyzy M, Ichim T, Freeman M. Treatment of lumbar degenerative disc disease-associated radicular pain with culture-expanded autologous mesenchymal stem cells: a pilot study on safety and efficacy. Journal of Translational Medicine. 2017 Dec;15(1):1-2.
7 Rajasekaran S, Raja SD, Pushpa BT, Ananda KB, Prasad SA, Rishi MK. The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. European Spine Journal. 2021 Mar 21:1-3.
8 Chamberlain CS, Saether EE, Aktas E, Vanderby R. Mesenchymal stem cell therapy on tendon/ligament healing. Journal of cytokine biology. 2017 May;2(1).
9 Chen X, Jones IA, Park C, Vangsness Jr CT. The efficacy of platelet-rich plasma on tendon and ligament healing: a systematic review and meta-analysis with bias assessment. The American journal of sports medicine. 2018 Jul;46(8):2020-32.
10 Atluri S, Murphy MB, Dragella R, Herrera J, Boachie-Adjei K, Bhati S, Manocha V, Boddu N, Yerramsetty P, Syed Z, Ganjam M. Evaluation of the Effectiveness of Autologous Bone Marrow Mesenchymal Stem Cells in the Treatment of Chronic Low Back Pain Due to Severe Lumbar Spinal Degeneration: A 12-Month, Open-Label, Prospective Controlled Trial. Pain Physician. 2022 Mar 1;25(2):193-207.
11 Pinto EM, Teixeira A, Frada R, Atilano P, Miranda A. Surgical risk factors associated with the development of adjacent segment pathology in the lumbar spine. EFORT Open Reviews. 2021 Oct;6(10):966-72.

3252 = 212

 

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