Health Letter – Main Line Spine

There is no single magic treatment that works for all forms of chronic low back pain. The first key in successfully treating it is to determine the source and cause. Then with a diagnosis, your medical professional can evaluate appropriate alternatives to relieve the symptoms.

Until about 20 years ago, the medical community believed there were only three primary sources for low back pain. Today, doctors recognize a fourth source of low back pain that involves damaged vertebral endplates.

We’ll bring you up to speed on what you should know about this pain source and a treatment option to consider if you are suffering from it.

What are three of the sources of low back pain?

For years, medical specialists believed the sources of low back pain were rooted in three spine structural components:

The zygapophyseal joints. These both allow and limit rotation and bending movements in the spine. Degenerative changes in the facet joints can lead to low back pain.
The sacroiliac joints. These joints link the hip and the lower spine. Low back pain can result from joint damage or injury.
The intervertebral discs. These provide cushioning and flexibility for the spinal column during everyday activities. Disc degeneration can pinch spinal nerves, leading to low back pain that may radiate into the legs.

There are many different conditions across these three sources that can cause problems for patients. The complexity of diagnosing them usually requires an in-depth examination by a medical professional.

What is a fourth source of low back pain?

The more recenlty discovered fourth source of low back pain can arise from a damaged vertebral endplate.

What are vertebral endplates?

The spine has a series of stacked small bones called vertebrae that form the spinal canal. Between adjacent vertebrae are intervertebral discs that provide cushioning and flexibility.

At the top and bottom of each vertebra are vertebral endplates. These endplates serve as the interface between each vertebra and the adjacent disc. (In the image below, the vertebral endplates are illustratated by the lighter yellow rings).

What is vertebrogenic pain?

As intervertebral discs deteriorate with wear and tear with age, stress occurs on the vertebral endplates. With this stress, the endplates may become damaged.

Damaged vertebral endplates can become inflamed, leading to vertebrogenic pain. The basivertebral nerve (BSN) transmits pain signals to the brain from the endplates.

What are the symptoms of a damaged vertebral endplate?

The symptoms of a damaged vertebral endplate are similar to that of a damaged intervertebral disc.

In both cases, patients describe:

The source of the pain is in the middle of the low back.
Pain that worsens with physical activity, prolonged sitting, bending, and lifting.

This similarity presents a challenge when identifying the difference between the two. A damaged vertebral endplate requires distinctly different treatments than a damaged intervertebral disc.

So how do doctors determine if a patient has vertebrogenic pain? They use an MRI to look for specific changes that occur with vertebral endplate inflammation, called Modic changes. Depending on what they find in the imaging, it may indicate that the endplate is indeed damaged.

The Intracept Procedure

The Intracept Procedure for back pain targets the basivertebral nerve to relieve chronic vertebrogenic low back pain. It may be considered after other conservative options fail to relieve pain.

A doctor uses fluoroscopic guidance to target a radiofrequency probe. The probe heats the basivertebral nerve, stopping it from sending pain signals to the brain.
The Intracept procedure typically lasts an hour and takes place in an outpatient surgery center using local anesthetic and light sedation.
The Intracept back procedure is minimally invasive and preserves the overall structure of the spine.
The Intracept procedure recovery time, when most patients feel pain relief, is within two weeks after the procedure.

What’s the Intracept Procedure success rate? A recent study on Intracept showed function and pain relief improvements that lasted more than five years¹.

Wrapping it up, there are two key takeways if you have lower back pain:

Vertebral endplate damage should always be considered as a possible alternate pain source in addition to spinal disc degeneration.
For appropriate patients with vertebrogenic low back pain, the Intracept Procedure can be an effective option.

Reference

Fischgrund J. Ryne A. Macadaeg K. et al. Long-term outcomes following intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: 5-year treatment arm results from a prospective randomized, double-blind sham-controlled multi-center study. Eur Spine J. 2020 Aug;29(8):1925-1934. doi: 10.1007/s00586-020-06448-x [PubMed]

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It’s normal to experience aches and pains in our back, particularly as we get older. Roughly 75 to 85% of adults in the U.S. experience back pain sometime in their lifetime.

Our back pain may be a simple sign of an aging spine. Or sometimes, it may indicate we have a disease or injury. A visit to our doctor can help sort through what is normal from what may be a problem.

One common back pain progression begins with age-related degeneration of the spine. Spondylosis is a broad term that encompasses different types of spine degeneration.

“Over time, spondylosis in the lower back can cause lumbar spinal stenosis,” says Farzad Karkvandeian, DO. Dr. Karkvandeian is a doctor at the Philadelphia region’s Main Line Spine medical practice.

He continued, “The mild procedure can relieve lumbar spinal stenosis back pain for some patients who don’t respond to traditional conservative treatments.”

What Is Spondylosis?

Spondylosis results from normal “wear and tear” degeneration of soft structures and bones in our spine. It can appear in any part of the spine. However, it is most commonly observed in the neck (cervical) and lower back (lumbar) regions.

“Osteoarthritis of the spine” is an alternative name for spondylosis.

Patients with this degenerative condition may or may not experience symptoms. Most people don’t experience significant pain or other issues related to these arthritic changes, Dr. Karkvandeian noted. Spondylosis frequently evades detection until a patient undergoes an imaging scan triggered by a different condition.

“Nevertheless, some individuals experience a decline that ultimately results in discogenic pain,” he added. “This can limit a patient’s range of motion. In the lower back, it also indicates a patient may have lumber spinal stenosis.”

Research indicates that spondylosis affects approximately 90% of individuals aged 60 and above. Lumbar spinal stenosis is present in about 20% of this same population in the United States.

What Is Lumbar Spinal Stenosis?

Lumbar spinal stenosis (LSS) usually occurs from an injury or changes in the spine as we age. It can cause the spinal canal in the lower part of the back to narrow.

This narrowing can create pressure on nerves running through the hollow space in the center of the spine’s vertebrae. The pressure may lead to a set of lumbar spinal stenosis symptoms called pseudoclaudication, also called neurogenic claudication.

“When lumbar spinal stenosis occurs, it typically impacts the lower L3 to L5 levels of the spine,” Dr. Karkvandeian noted. “When patients have lumbar spinal stenosis, their legs will often feel heavy. Some describe it as if they were walking in cement.”

Other early symptoms may include cramping or discomfort in the leg(s) after a long walk. Those with the condition may also feel leg numbness or achiness after prolonged standing. In the later stages, pseudoclaudication may progress into even more severe leg pain that worsens when walking.

Illustration of lower spine S1 and L5 to L1 and spinal canal — Illustration of the lower portion of the spine from S1, L5 to L1, and illustration of the spinal canal.

Back Pain Relief with the mild Spine Procedure

According to Dr. Karkvandeian, one of the major causes of lumbar spinal stenosis is the presence of excess ligament tissue. This usually develops on the spine with spondylosis.

Over time, the strong ligament cords that help hold the spine’s bones together can become thick and stiff. As this happens, these thick ligaments can push into the spinal canal.

Spondylosis and lumbar spinal stenosis are not one in the same and shouldn’t be confused for each other. But Dr. Karkvandeian emphasized that it would be uncommon to find thickened ligaments and LSS without the presense of spondylosis.

“The mild procedure provides us with a minimally invasive way to remove that excess ligament tissue,” Dr. Karkvandeian says. “By doing that, we can restore space in the spinal canal. This relieves pressure on spinal nerves and the associated low back pain.”

Mild stands for minimally invasive lumbar decompression.

The mild back surgery procedure typically takes less than an hour. It is performed with specialized instruments through a single, tiny incision that measures less than the diameter of a baby aspirin (5.1 mm). mild® is normally completed in an outpatient surgery center using local anesthetic and light sedation.

“It’s important to remove the excess ligament tissue from both sides of the spinal segment during the procedure,” Dr. Karkvandeian emphasized. “There are no half-measures that are adequate when you want to maximize the long-term outcome for a patient.”

mild Procedure Durability

“Every patient is different, and the outcomes have varied,” says Dr. Karkvandeian. “We have witnessed individuals transition from experiencing extreme pain levels of 10 out of 10 to complete pain relief. When the procedure works well, it is an extremely gratifying experience for our patients and medical team.”

“Like with all procedures of this kind,” Dr. Karkvandeian added with caution, “it doesn’t work for everyone.” “However, a study of the five-year follow-up of Cleveland Clinic mild procedures shows encouraging results.”

Seventy-five individuals received mild® treatment at the Cleveland Clinic between 2010 and 2015. Of that group, only 9 needed additional lumbar surgical decompression during a 5-year follow-up afterwards¹.

“We will continue to learn more from clinical studies that will follow this one,” Dr. Karkvandeian said. “But for now, Cleveland Clinic’s experience provides an objective record of long-term success with mild. Our own direct experience with mild procedure outcomes with our patients remains positive.”

Reference

Mekhail N, Costandi S, Nageeb G, Ekladios C, Saied O. The durability of minimally invasive lumbar decompression procedure in patients with symptomatic lumbar spinal stenosis: Long-term follow-up. Pain Pract. 2021 Nov; 21(8): 826-835 [PubMed]

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Complex regional pain syndrome (CRPS) is a chronic and painful condition usually affecting the arms or lower extremities. The impacted extremity may involve the pelvis, groin, hip, knee, ankle, or foot. It can develop due to an injury, surgery, stroke, or heart attack. In some cases, it can occur without an apparent cause.

Those suffering from CRPS often have pain far out of proportion to whatever caused it. In addition to burning or throbbing pain, symptoms may include swelling, joint stiffness, muscle spasms, temperature sensitivity, and skin changes.

It is important to begin treatment of CRPS early. When it first appears, it presents the easiest opportunity to improve symptoms. But this condition can be a challenge to treat.

Some conservative treatments, including physical therapy, medications, and sympathetic nerve blocks, can be effective. But these options may fail to provide adequate results. Patients will often then consider neurostimulation to avoid more aggressive surgical alternatives.

Spinal Cord Stimulation (SCS) Therapy as an Alternative for Chronic Regional Pain Syndrome

Traditional spinal cord stimulation (SCS) is a neurostimulation therapy used to manage chronic, severe pain. It has been in use for over 40 years.

Around the world, tens of thousands of patients undergo spinal cord stimulator implants each year. Spinal cord stimulation delivers mild electrical stimulation to nerves along the spinal column. This modifies nerve activity to minimize the sensation of pain signals reaching the brain.

SCS therapy is now significantly improved and refined since its first routine use. Advances have continued to enable better personalization and effectiveness for each patient’s needs.

However, chronic regional pain syndrome usually involves specific extremities such as the pelvis, groin, hip, knee, ankle, or foot. For some CRPS pain sufferers, spinal cord stimulation doesn’t provide the kind of specific extremity targeting needed for pain relief.

Dorsal Root Ganglion (DRG) Stimulation as an Alternative Chronic Regional Pain Syndrome Therapy

Dorsal root ganglion (DRG) stimulation provides targeted neurostimulation pain relief to the lower extremities. The FDA has approved it for patients with complex regional pain syndrome (CRPS I and II). DRG stimulation has shown to be effective for CRPS when SCS isn’t a viable option.

It works by targeting neurostimulation at the dorsal root ganglion.

What Is a Dorsal Root Ganglion?

The nervous system in our bodies has two components: the central nervous system (CNS) and the peripheral nervous system (PNS). The central nervous system consists primarily of the brain and spinal cord. The peripheral nervous system consists of nerves and ganglia outside the brain and spinal cord.

For clarity, the definition of “ganglia” is the plural form of “ganglion.”

The peripheral nervous system’s job is to connect the central nervous system to the limbs and organs. It serves as a relay between the brain, spinal cord, and the rest of the body.

The dorsal root ganglia are clusters of neurons on the back root of spinal nerves. They act as peripheral nervous system “gates” controlling our perception. Everything we sense must pass through a dorsal root ganglion before entering the spinal cord. Those sensory signals then pass from spinal cord nerves to the brain.

Spinal cord cross-section illustration showing dorsal root ganglion — An illustration of a cross-section of the spinal cord showing the dorsal root ganglion.

How Does Dorsal Root Ganglion Stimulation Work?

Dorsal root ganglion stimulation is similar to traditional spinal cord stimulation. Both systems use a small neurostimulator implant pulse generator. And both use small, insulated wires called leads to direct stimulation to their targets.

The major difference between the two is the target. In spinal cord stimulation, the leads directly target spinal nerves. However, with dorsal root ganglion stimulation, the leads target dorsal root ganglia on the posterior root of spinal nerves.

When active, DRG stimulation delivers tiny electrical pulses to the dorsal root ganglia. These impulses mask the feeling of pain traveling to the brain.

The stimulator does not eliminate a patient’s pain but changes how their brain perceives it.

Why Is DRG Stimulation More Effective than Spinal Cord Stimulation for Treating CRPS?

Spinal cord stimulation blocks pain signals from broad areas of the body.

In comparison, dorsal root ganglion stimulation is tightly focused on the nerves associated with a specific area of pain. This makes it more effective in masking pain from one particular extremity.

In addition, DRG requires only about 10% of the energy used by SCS, which minimizes the paresthesia-tingling sensation during use. It also means that the batteries of the system last far longer.

A Physician’s First-Hand Perspective on DRG Stimulation

Dr. Jeffery Rowe is a physician at Main Line Spine, a physiatry specialized medical practice, who is an expert in the DRG procedure. Abbott notes that he has implanted more dorsal root ganglion stimulators than any other doctor in the United States. He is also one of the country’s top spinal cord stimulation physicians.

“I continue to see very encouraging results from DRG stimulation procedures,” says Dr. Rowe. “It has been a game-changer for treating chronic regional pain syndrome and other challenging conditions.”

Dr. Rowe has helped to train more than 2,000 doctors in the procedure at Abbott’s Texas facility. He was part of the Neuromodulation Appropriateness Consensus Committee (NACC) that developed the best practices consensus document on DRG stimulation.

“We see individuals who’ve had chronic pain for 20 years, and they think they’ve tried everything,’ says Dr. Rowe. “Or they may have had a spinal cord stimulation trial ten years ago. They’ll tell us that it didn’t help them much.”

“However, DRG stimulation provides a truly unique alternative. And neurostimulation has evolved significantly over the years,” he continued, “the technology is vastly different today. The differences over time are like comparing apples to oranges.”

Dr. Rowe reflected on what he believes is one of the major keys to success with the procedure. “It’s vital to devote enough time to place and anchor the leads properly,” he says. “It’s important to follow rigorous protocols to optimize lead placement.”

He encourages patients with CRPS who haven’t had success with conservative treatments to consider the procedure. Dr. Rowe says, “A DRG stimulation trial could be a first step to life with chronic pain in control.”

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Chronic knee pain affects one in four people aged 55 and older. For many, the symptoms are mild to moderate. However, when it is severe, it can be debilitating.

Ongoing knee pain can also occur after knee replacement or ACL surgery. The triggers and causes of this kind of knee pain are complex and can be related to many different factors.

If you suffer from severe knee pain, it can make the simplest tasks seem almost impossible. Everything from walking to sitting down can be painful. Coping with chronic knee pain without seeking treatment can make the situation even worse.

We’ll look at the major possible causes of severe chronic knee pain along with leading options to treat it.

The Knee Is a Highly Vulnerable Joint

The knee is the joint that connects your thigh to your lower leg. It’s the biggest joint in your body. Like all joints, your knees are part of the bones in your skeletal system. Your knees also contain cartilage, muscles, ligaments, and nerves – all of which are vulnerable to damage.

Trauma

The knee bears a great deal of stress from everyday activities, such as walking, lifting, and kneeling, and from high-impact activities, such as running, jumping sports, and aerobics. Pain and damage from traumatic injuries and overuse are common

Arthritis

Knee pain can also result from different types of arthritis including osteoarthritis, rheumatoid arthritis, gout, pseudogout, and septic arthritis. Osteoarthritis of the knee is very common, with 46% of people developing it at some point in their lifetimes.

Post-Knee Replacement Pain

Although uncommon, a small percentage of knee replacement patients continue to have chronic pain on the outer sides of the knee after surgery. This is where the surviving knee ligaments and tendons are located. Most often these connective tissues are damaged either by the surgery or new stresses placed on them by the implant.

A number of other knee replacement patients have nerve irritations. This nerve irritation can be below or above the knee or within the kneecap. Other people become hypersensitive to pain after surgery, experiencing more pain than they should.

Preventing Knee Pain

Although it’s not always possible to prevent knee pain, there are some things you can do to ward off injuries and slow joint deterioration.

Maintain a Healthy Weight and Keep Extra Pounds Off

It’s one of the best things you can do for your knees. Every extra pound puts additional strain on your joints, increasing the risk of injuries and osteoarthritis.

Regularly Exercise to Be Strong and Flexible

Strong muscles will help stabilize and protect your knee joints and muscle flexibility can help you achieve a full range of motion. Prepare for the jumps and pivots of sports like basketball with good hip control by building glute strength. Work on normal ankle mobility to decrease unnecessary stress on the knee.

Use good cushioning shoes and focus on form when running or jogging to minimize pounding on the knees. And approach repetitive work knee stress in jobs such as construction or farming by preparing with exercises to strengthen impacted muscles.

Seeking Medical Help for Chronic Knee Pain

If knee pain persists and impacts the quality of your life, you should see a qualified medical professional to evaluate your condition. Putting off an appointment to address your chronic knee pain issues when they become critical will often allow things to further deteriorate and get worse.

There are a variety of treatments that may be appropriate for each individual situation. They include:

Physical therapy can help strengthen the muscles around your knee and make it more stable.
Medications can be prescribed to relieve pain and address the symptoms causing it.
Corticosteroids can be injected into your knee joint and may help reduce the symptoms of an arthritis flare and provide pain relief that may last a few weeks to a few months.
Hyaluronic acid is a natural substance found in joints. It is a viscous, gel-like substance. A treatment called viscosupplementation injects it to augment the fluid that naturally lubricates your knee joints. This may reduce friction within the joint, thereby reducing pain and stiffness, and preventing the loss of cartilage and bone.
Platelet-rich plasma (PRP) injections may benefit certain people with osteoarthritis with a PRP concentration of many different growth factors that appear to reduce inflammation and promote healing.

But what if these options aren’t sufficiently effective? Or if you want to avoid prolonged use of pain medications? What additional options are there short of surgery?

Peripheral nerve stimulation may be an answer for some patients. Itpresents a drug-free alternative that has proven to be highly effective to control chronic knee pain in appropriate cases.

Peripheral Nerve Stimulation

Neurostimulation has been used successfully to manage intractable chronic pain for over 40 years.

You may have heard of spinal cord stimulation (SMS) which was the first therapeutic approach that used neurostimulation. This therapy uses gentle electrical impulses to interrupt pain signals before they reach your brain. SMS offers a drug-free approach that does not require drugs or physical therapy to work.

Peripheral Nerve Stimulation (PNS) describes a localized and miniaturized approach to using neurostimulation. Peripheral nerve stimulation is different from spinal cord stimulation because it places the stimulating device directly over the nerve at the targeted pain area, not on the spinal cord where the nerve originates.

There are several medical device manufacturers that offer variations of peripheral nerve stimulation devices. Some of these devices are designed for a course of treatment that is 60 days or less. Others are designed for longer term use. Doctors will select specific devices based on each individual patient’s situation.

These PNS devices are small in size, minimally invasive, discreet, and upgradeable. The diameter of the leads implanted to provide stimulation is smaller than the size of a thin strand of spaghetti. There are both temporary and permanent PNS therapy options. They can be removed by your doctor if you decide to discontinue the therapy.

Peripheral Nerve Stimulation and Knee Pain

Peripheral nerve stimulation devices are increasingly used to help patients control their chronic knee pain. Very small electrodes are implanted next to the nerves involved, which can then be stimulated with the goal of relieving knee pain. Control of applying that stimulation is in the hands of the patient when they need it.

Appropriate candidates for peripheral nerve stimulation should have exhausted more conservative treatments without adequate improvement.

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When you are in pain – particularly if it’s low back pain – your initial reaction may be to stop all activity and rest. In fact, however, the opposite is often true.

Let’s stop for a moment and not get ahead of ourselves. If you have back problems, you should first see a medical professional for diagnosis and guidance before following any treatment protocols. But after you do, your doctor will often recommend that you work to move and stay active, despite the pain.

a woman participates in gentle exercise with others — A woman participates with others in gentle exercise to increase flexibility and strength and improve cardiovascular fitness

Lower Back Pain Is Often Persistent

When you have an acute musculoskeletal injury, it’s important to get pain, swelling, and inflammation under control as soon as possible. One recommended treatment approach to do so is RICE:

Rest
Ice
Compression
Elevation

However, this kind of “take it easy” approach is normally only recommended for a period of 48 to 72 hours. If your pain persists after that, you should be seeing a doctor to find out why.

Low back pain is often chronic. However, it can come and go on an ongoing basis at different levels of severity. ICE, heat and taking over-the-counter anti-inflammatories may help – but you need to do more to help yourself for the long term. You need to move.

Mechanical Pain

80% of all back problems are mechanical in nature. This means that these problems will respond best if you keep moving – even if your pain is persistent.

Your spine is made up of a series of joints. Mechanical pain occurs when anything happens that restricts the movement of one or more of those joints. This is why back pain is also accompanied by stiffness. A bulging disk, ligament issue, or forms of arthritis can create obstructions within the structure of your spine.

If you move the right way as your medical professional has recommended to you, you can release those obstructions. And as they are released, stiffness is reduced, and you usually will experience less pain.

Sitting Too Long and the Pain-Spasm-Pain Cycle

Most of us know that sitting too long can be bad for our health. However, it also can be a cause of back pain. When you sit too long, your joints aren’t being used. The area of your low back is a nerve-dense location, and with the immobility of sitting too much, it can start what’s known as the pain-spasm-pain cycle – where a skeletal muscle spasm causes pain in your spine.

The pain-spasm-pain cycle can first be triggered from an underlying condition such as a herniated disc, arthritic joint or bulging disc. When that happens, usually without warning, one of these conditions suddenly triggers a muscle spasm in your spine.

In turn, the triggered muscle spasm causes ischemia, which is a lack of blood flow in and around the muscle. The ischemia then causes pain. The muscle sees that pain as a threat to the spine – and reacts in an effort to protect it with another new spasm.

As a result, you can get locked into a never-ending back pain-spasm-pain cycle.

The good news is that your medical professional can help you break this cycle with therapies that will release and reset the affected muscle.

Diagram illustration of how a trigger can start an ongoing pain-spasm-pain cycle — A muscle spasm triggered by an underlying back condition can start a never-ending pain-spasm-pain cycle.

Get Moving!

One of the most important things that people with low back pain can do is to stay as physically active as possible in daily life and exercise regularly. Not moving enough can weaken your core muscles, make the pain worse over the long term, and lead to other health problems. It’s a fact that regular physical exercise has been shown to reduce pain – but do it after reviewing your plans with your doctor.

If you have low back pain, it’s a good idea to go about your daily life as normally as possible, and not to let the pain limit your activities too much. Don’t isolate yourself but get out and do the things you enjoy. This will make it easier for you to cope with your back pain.

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VIA Disc is a minimally invasive outpatient procedure intended for patients with degenerated lumbar intervertebral discs. It helps to rebuild discs biologically. But before getting into the specifics of the procedure, we need to start with the condition that it targets for treatment.

What Is Degenerative Disc Disease?

The discs in your spine are rubbery cushions between the bones in your spinal column. These bones are known as vertebrae. These discs act as shock absorbers. As you move, bend or twist, your discs enable you to do that comfortably. When they are healthy, discs act as a structural cushion to help distribute shocks and pressures to your spine evenly.

The biomechanical ability to cushion shocks and pressures is enabled by a disc’s ability to absorb and retain water. Water within the disc generates a swelling pressure that resists loads and maintains the height of the disc.

After the age of 40, our discs can begin to degenerate. This is known as degenerative disc disease. Wear and tear of our intervertebral disks causes a loss of hydration – the ability we’ve discussed to absorb and retain water – along with degeneration of the discs themselves.

For many, as this degeneration occurs, we don’t develop any symptoms. But for about 5% of us, this disc degeneration prevents discs from doing their job properly. When this happens, it leads to back pain.

Illustration of intervertebral disc functioning with natural cushioning — Illustration of an intervertebral disc functioning with natural cushioning

Managing and Treating Degenerative Disc Disease

There are noninvasive treatment options available for degenerative disc disease, such as physical therapy, medications, steroid injections, radiofrequency neurotomies, or even spinal cord stimulation. But until recently, when these alternatives weren’t sufficient, major spine surgery was the only other option.

A new nonsurgical option is now available. It is called VIA Disc and is designed to rebuild damaged discs biologically.

The VIA Disc procedure is an allograft. An “allograft” is a tissue graft. The treatment is designed to help a disc regain and preserve its ability to absorb water and repair disc damage.

What Are Regenerative Biotherapeutics and Orthobiologic Medicine?

What do we mean about rebuilding discs biologically? The human body has the natural ability to heal itself in many ways. Cuts to the skin repair themselves, broken bones mend and a living-donor’s liver regenerates in a few weeks.

Regenerative Biotherapeutics includes therapies that support the body in repairing, regenerating and restoring itself – taking our natural healing ability and helping it along. These therapies prompt the body to enact a self-healing response.

Popular uses of regenerative biotherapeutics today include treatments from Non-Hodgkin’s Lymphoma and Leukemia to Osteoarthritis and Rheumatoid Arthritis, and many other conditions in between. Variations of regenerative biotherapeutics use therapies such as platelet rich plasma (PRP) and stem cells. When regenerative biotherapeutics is used to help heal musculoskeletal conditions it is also commonly referred to as orthobiologic medicine.

What Is VIA Disc?

VIA Disc is an orthobiologic regenerative therapy that seeks to reverse the age-related wear and tear of intervertebral discs – along with the degeneration and loss of hydration that results with this deterioration.

This treatment uses biologic growth factors and cytokines extracted from intervertebral discs. This extraction is enhanced with additional solutions to promote this therapy’s effectiveness.

During an outpatient, non-surgical procedure, this mixture is injected into the damaged disc. The strategy behind it is that by supplementing disc tissue, it seeks to enhance the biomechanics of the damaged disc. This in turn overcomes the imbalance that has occurred from degenerative tissue loss.

In more simple terms, the ability of a disc to cushion is regained. And its deterioration is halted and reversed. And with that, associated pain is reduced.

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Driving can be a stressful experience. The daily traffic on the Schuylkill Expressway. Drivers who dart in front of you without the courtesy of a turning signal. The challenge of successfully clearing center-city traffic light cameras. The short fuse of fellow drivers exacerbated by traffic jams.

But this isn’t the worst of it. If you have neck, back or shoulder issues, sitting in a car for an extended period can be excruciating. Even without back problems, sitting in a car’s seat for a long drive can lead to discomfort and soreness.

Typical seat design doesn’t help. Many car seats are designed for average body types. The problem is that many of us are constructed differently than that ‘average.’ If we are taller, shorter, wider or more slender than the averages that auto manufacturers refer to as ‘norms’, we’ll have a harder time comfortably fitting into seats designed for those average dimensions.

Which brings us to one of the most important things to keep in mind. All our bodies are different. So although we’ll provide you with some tips to alleviate your back pain when driving, you’ll need to find a mix of those tips that works best for your own uniqueness.

man intently looking forward, driving a car

1. Your Seating Positions and Seat Adjustments Should Promote an Upright Spine

If you want to avoid back pain when driving, keep the thought of maintaining a good posture in mind.

Before you start driving, get comfortable. Pull your wallet, cell phone and other bulky items out of your pockets. Position yourself properly with your back fully against the back of your seat.

Adjust your seat back or forward, up or down so that you aren’t up too close or have to strain forward to see. Your seat height should be as high as your knees – and there should be a gap between the back of your knees and the front of the seat to promote healthy circulation.

When your seat is reclined to about a 30-degree angle, it normally will support the least amount of lower back disc pressure.

2. Hold Your Steering Wheel Properly

Relax your arms so that you have a gentle bend at your elbows. Place your hands so that they are at the 9 o’clock and 3 o’clock position which will allow you to rest your elbows on the vehicle’s armrests to alleviate stress and pain on your upper back.

3. Adjust Your Headrest and Keep Your Head Back

If your head rest can tilt forward, adjust it so that you can drive with your head touching it with your chin level and your shoulders back. Don’t force your head backward however if you can’t adjust it forward enough so your head touches – what is most important is maintaining good posture.

The top of the headrest should be no lower than your eye level.

4. Use Your Car Seat’s Lumbar Support Correctly

If your car has a lumbar support, adjust its depth by moving it from flat until it comfortably fills the arch of your back. When set correctly, you should feel an even pressure from your hips to your shoulders.

If your car doesn’t have adjustable lumbar support, you can use a lumbar pillow. These are widely available from a range of providers.

5. Adjust Your Mirrors

Prevent neck strain by making sure your rear-view and side mirrors are properly adjusted. External mirrors can be adjusted horizontally and vertically.

It’s easy to check you’ve got this right: you should be able to see the traffic behind you without having to crane your neck. Once adjusted properly, if you find yourself wanting to adjust the mirror during your drive, it may be a sign that you are starting to slump in the seat.

6. Use Cruise Control

If your car has a cruise control option, use it whenever possible. By using cruise control, your legs can be bent and help support some of your body weight. This takes some of the load off your spine and reduces your chances of developing back pain while driving.

7. Shift Your Position Periodically

When possible, try to move a little in your seat. Even 10 seconds of movement and stretching is better than sitting still. At a minimum, adjust your seat and change your position slightly every 15 to 20 minutes. Pump your ankles to keep the blood flowing and provide a slight stretch in your hamstring muscles. Any movement that is safe to do in the car will help you out.

8. Take Frequent Breaks During Long Drives

Stopping frequently while on a long road trip may not be ideal but it can help reduce the stress on your spine. At each stop make sure you get out, walk around and stretch before getting back on the road again.

Sitting in one position in a car will stiffen up your back muscles and can lead to achiness and possibly muscle spasm. Everyone should ideally take at least a 15-minute break for every 2 hours of driving. If you’re prone to back pain, you may want to take breaks more frequently, such as every 30 to 60 minutes.

9. Apply Heat to Your Back

If your car has a heated seat, turning it on can bring some relief. If you don’t have heated seats, there are heated seat covers available on the market that sit on top of your car’s seat. Heat can help loosen your muscles and joints and possibly reduce your back pain.

It Will Take Some Time to Find the Adjustments that Work Best for You

Setting up your car seat so that it works best for you as an individual will take a bit of trial and error. Start with the suggestions that we have provided and try it for a few days – and then start to make small gradual adjustments one at a time.

You’ll eventually find the right combination of adjustments that minimizes the stress on your back and which provides you with the most comfortable driving position possible for your unique body.

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Reports show that 50 to 85% of adults experience back pain at some point, with a high prevalence in adults who are 65 years of age and older. One widely used treatment for low back and leg pain has been fluoroscopically guided epidural steroid injections (ESIs).

In basic terms, an epidural corticosteroid injection is a minimally invasive way to deliver anesthetic and anti-inflammatory medication into the body with a syringe. The medication is injected into the epidural space around the inflamed spinal nerves.

bThe level and length of pain relief can vary widely from patient to patient.

Illustration of the human back spine and rib cage, broken into puzzle pieces with one piece missing

Looking at an Epidural Corticosteroid Injection in More Depth

Epidural corticosteroid injections inject a small dose of anti-inflammatory medication, called a corticosteroid, into the lower back to relieve pain in your lower back or legs. The medication is injected into an area surrounding the nerves in the spine called the epidural space. The medication acts to reduce inflammation, and in doing so, it can help to relieve pain.

In addition to being a treatment, epidural corticosteroid injections can be used by your doctor to identify and diagnose specific nerve root problems.

What Are Steroids?

There are two kinds of steroids. One kind are chemicals, often hormones, that your body makes naturally. They help your organs, tissues and cells do their jobs.

There is also a class of man-made medicines called steroids. The two main types of the second kind of man-made steroids are corticosteroids and anabolic-androgenic steroids (or “anabolics”).

Corticosteroids are medicines that quickly fight inflammation in your body. These lab-made steroids work like natural hormone cortisol that is made by our adrenal glands. Cortisol keeps our immune systems from making substances that cause inflammation. Corticosteroid medicines work in a similar way. They slow or stop the immune system processes that trigger inflammation.

Limiting the Use of Corticosteroids

For some patients, epidural corticosteroid injections provide thankful pain relief. But they are usually limited to just a few a year because there’s a chance for systemic side effects. These can include skin thinning, facial flushing, insomnia, moodiness, and high blood sugar. In addition, it’s important that after injections you have enough of a break so that your body can return to its normal balance.

For these reasons your doctor will carefully weigh the scheduling of any successive corticosteroid injections.

The Epidural Corticosteroid Injection Procedure

An epidural corticosteroid injection is done on an outpatient basis. It takes approximately 10 to 30 minutes and patients are lying face down during the procedure.

The medicine is injected into the epidural space in your spine using x-ray moving image guidance (using a fluoroscope) on a screen so that it can be targeted precisely. A local anesthetic is also used to help with pain relief.

After the Procedure

After the procedure is completed, you can return home. Normally you can resume normal activities the following day. The corticosteroid usually starts working within 2 to 5 days, although you may need up to a week to feel the full benefits of the procedure.

Many people experience many months of pain relief and improved function after an injection. However, if you don’t experience pain relief you should contact your health care provider as this may be a sign that your pain is arising from other conditions.

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You may have heard of ‘degenerative disc disease.’ This term doesn’t actually refer to a disease, but instead to a condition in which a damaged spinal disc causes pain.

A Quick Review of Spine Anatomy

What role do discs play in our spines? Your spine is made up of a series of bones that run from the top to bottom of your back. Discs sit between each of these bones. They serve as shock absorbers and provide flexibility for your spinal column. Normally, each of your discs is directly adjacent to your spinal nerves.

Facet joints also play a key role in the spine. They are the connections between the bones of the spine. Thus, the spinal bones, discs, facet joints and nerves all function together to enable our mobility along with far more complex body functions.

What Is Degenerative Disc Disease?

With that quick spine anatomy review in-hand, we can now look at what exactly is degenerative disc disease. This condition is the progressive deterioration of spinal discs and arthritic changes in facet joints due to wear and tear with aging.

Bone spur overgrowth is related to degenerative disc disease. It can also cause a narrowing of the spinal canal, resulting in spinal stenosis, where the nerves running up that canal are compressed. This causes pain, numbness, and weakness in the legs.

There are a host of additional conditions associated with degenerative disc disease, including lumbar radiculopathy (also known as sciatica), neurologic claudication, and degenerative spondylolisthesis. They all are part of the challenges we face with our spine as we age and strive to remain active in our lives.

Illustration of lower back (lumbar) disc degeneration — Illustration of a spine with degenerative disc disease.

Non-Surgical and Minimally-Invasive Treatments for Degenerative Disc Disease

In most cases, the initial preferred path to treat degenerative disc disease are non-surgical and minimally-invasive options. These include:

Medications: Over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs) can help control the inflammation, swelling and pain symptoms.
Physical Therapy: Some individuals experience disc problems due to excessive sitting or poor muscle development in the back. Physical therapy can help to improve and balance muscle mass, lower pressure on your back, and improve posture.
Weight Loss: If you are overweight, reducing your BMI can help significantly improve stress on discs and the spine, and reduce pain.
Epidural Steroid Injections: Flouroscopic-guided epidural steroid injections, precisely targeted near spinal nerves, discs, or joints, can reduce inflammation or pain.
Radiofrequency Neurotomy: This procedure uses radiofrequency waves to generate heat to target specific nerves. It temporarily disables those nerves’ ability to send pain signals. For some patients, radiofrequency ablation may reduce or eliminate pain for months.
Spinal Cord Stimulation: Spinal cord stimulators are medical devices that a doctor can implant in your body to manage chronic pain. They deliver electrical stimulation through thin leads to nerves along the spinal column. This modifies or blocks nerve activity to minimize the sensation of pain reaching the brain. A patient directly controls this stimulation activity by using a small external remote.

But what happens if these options prove to be ineffective or inappropriate for a patient?

Traditional Surgical Treatments for Degenerative Disc Disease

Until recently, the only options to treat degenerative disc disease other than non-surgical and minimally-invasive pain management have been surgical intervention and artificial disc replacement. Given the serious nature of this kind of back surgery, they traditionally are recommended only when all other alternatives have been exhausted.

Discectomy and Laminectomy Surgery

One of the first procedures developed for degenerative disc disease are a discectomy and laminectomy. In this surgery, a surgeon removes part of the bulging disc and part of the bone around the spinal canal.

There are two issues however that can result from this procedure. First, the removal of the disc material weakens the disc, so there is a risk for the disc to re-herniate. And second, the removal of bone can make the spine segment more unstable. As a result, pain can return in some instances. When it does, the resulting condition is called “Failed Back Surgery Syndrome.”

Spinal Fusion

In order to try to fix issues associated with discetomies and laminetomies, surgeons developed a procedure called spinal fusion. They targeted the issue of pain often being caused by spine instability. And spine instability was due to degeneration along with a loss of the height of a disc.

In the spinal fusion procedure, a spacer along with hardware is inserted to prop the disc up. The goal is to aleviate pain by preventing the degenerated spine segment from being able to move at all.

However, after spinal fusion, when one segment no longer can move, more force is exerted on other parts of the spine to compensate. As a result, new spine problems and sources of pain can crop up along adjacent parts of the spine due to the increased stress.

Artificial Disc Replacement (ADR)

To solve these problems, artificial disc replacement (ADR) emerged as an alternative. Rather than fuse two spine segments, the concept is to implant an artificial disc between them. This allows motion and props up disc height, alleviating the problems with fusion.

The artificial disc replacement technique however can have post-operative issues similar to that of spinal fusion surgery. In part, this is because the motion of an artificial disc joint isn’t natural. Stress on adjacent spine segments can still occur.

The Case for Surgical Spine Intervention and Artificial Disc Replacement

Despite the issues we’ve raised, there are circumstances where spine surgery is the most effective treatment to reduce pain and relieve symptoms. While spine surgery may limit flexibility, it can be successful in arresting pain.

If a medical professional or spine surgeon has recommended spine surgery to you, you should certainly consider it. Doctors evaluate many factors, and spine surgery may be the only viable alternative for a particular patient.

Physical Medicine and Rehabilitation doctors will normally recommend a spine surgeon when non-surgical and minimally-invasive spine pain management alternatives have been exhausted.

New, Non-Surgical Alternatives to Spine Surgery

Against this backdrop, two new alternatives to spine surgery have emerged: VIA Disc and the Intracept Procedure. These may be options for some patients seeking back pain relief and for who other non-surgical approaches have been ineffective or inappropriate.

What Is VIA Disc?

VIA Disc is a novel approach to address degenerated discs is to rebuild the disc biologically. In recent years, advances in regenerative medicine have advanced dramatically. They have taken their cue from the fact that the human body has a natural ability to heal itself in many ways. For example, skin cuts repair themselves, broken bones mend, and donated liver transplants regenerate.

Orthobiologic regenerative medicine is focused on taking this natural ability, directing it, and helping it along. The VIA Disc procedure uses biologic growth factors and cytokines extracted from intervertebral discs. These are enhanced with additional solutions to promote this therapy’s effectiveness. This procedure supplements tissue and cell loss that is associated with degenerative disc disease in the lower back.

During an outpatient, non-surgical procedure, this growth factor and cytokine mixture is injected into degenerated discs under imaging guidance with moderate sedation. The goal is for this supplement to stimulate the regeneration of the disc itself – and improve its functionality.

Studies have shown that those undergoing this procedure showed pain and function improvements that continued to be evident 12 months after the treatment.

What Is the Intracept Procedure?

Another option that has recently emerged is the Intracept Procedure.

Referencing back to our opening discussion about spine anatomy, at the point where discs meet the vertebrae bone is a layer called the vertebral endplate. This endplate is a mix of cartilage and bone that separates these two elements of your spine.

Research has shown that for some, back pain specifically originates in one or more of these endplates. If this is the source of your back pain, there is a new innovative way to treat it that doesn’t disturb the delicate function of your discs.

There is a nerve called the basivertebral nerve that interfaces with your vertebral endplates. The Intracept Procedure is a minimally invasive procedure that targets the basivertebral nerve to provide relief from chronic how back pain that originates in the endplate.

Prior to recommending the procedure, doctors who suspect the basivertebral nerve is the source of a patient’s pain will conduct a special imaging test to confirm their diagnosis.

This outpatient procedure is implant-free and preserves the structure of the spine. It ablates the basivertibral nerve with a radiofrequency probe to provide lasting pain relief.

Are You a Candidate for the Via Disc or Intracept Procedures?

While both VIA Disc and the Intracept Procedure show promise to address chronic back pain developed as a result of degenerative disc disease, they are only appropriate for some patients. You should discuss both options with your healthcare provider if you believe they may be appropriate options for your back pain.

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Sports medicine doctors focus on treating musculoskeletal injuries resulting from the active lifestyles of athletes and non-athletes alike.

Most sport medicine healthcare providers have certifications in other specialties, such as Physical Medicine and Rehabilitation, Family Medicine, Internal Medicine, Emergency Medicine, and Pediatrics. As a practitioner of sports medicine, they have have additional training in helping people improve their athletic performance, recover from injury, and prevent future injuries.

Sports medicine is focused on caring for athletes of all levels, from amateur weekend warriors to professionals, adults who exercise for physical fitness to student athletes, and people with physically demanding jobs, such as construction workers. They often provide coordinated care with other medical specialists to get an individual back to the sports they love or to their vocations.

athlete performing vertical jumping exercises

Sports Medicine Conditions

Sports medicine primarily focuses on nonsurgical treatments. In fact, according to statistics from the American Medical Society for Sports Medicine, roughly 90 percent of all sports injuries do not require surgery. Instead, it focuses on maximizing the benefits of nonsurgical options, which can help patients recover faster. However, sports medicine doctors will refer a patient to an orthopedic surgeon if they determine it is appropriate.

What are the most common sports medicine injuries? They include:

Ankle issues
Anterior cruciate ligament (ACL) injuries
Concussions
Dislocations
Fractures or breaks
Frozen shoulder
Hip pain
Joint injuries or pain (shoulder or knee)
Muscle strains
Overuse injuries (rotator cuff or stress fractures)
Posterior cruciate ligament (PCL) injuries
Shin splints
Shoulder dislocation
Sprains
Tennis and golfer’s elbow
Tendonitis

Sports Medicine Treatments

When sports injuries occur, sports medicine doctors use a variety of diagnostic techniques and treatment options to help accelerate and optimize recovery. These options and treatments include:

Medical History and Physical Examination
Imaging Techniques (X-Rays, MRIs, CT Scans, Ultrasound)
Physical Therapy
Activity Modification
Anti-Inflammatory Medications
Cortisone Injections
Orthobiologic Regenerative Medicine (Including PRP)

What Are Frozen Shoulders?

Frozen shoulder affects about 2 percent of the U.S. population and is one of the conditions that Sports Medicine doctors focus on.

Frozen shoulder is medically known as adhesive capsulitis. It is a common cause of shoulder pain and loss of motion in those who are in their 40’s or older. Unfortunately, it can result in a considerable disruption to any sports activity, especially given how long it usually takes to resolve.

A frozen shoulder is a condition where the shoulder’s joint capsule becomes inflamed or sticky. This makes the whole joint stiff, and difficult and painful to move. As the joint capsule becomes inflamed, scar tissue forms, which causes pain and leaves less room for the shoulder to move through its normal full range of motion.

This condition can be challenging to diagnose in its early stages, as it can appear to be similar to other common shoulder disorders. Where there are questions about its diagnosis from initial medical examination, an MRI or ultrasound examination is often required to detect the thickening in the joint capsule that is one of the indicators of this condition.

Frozen Shoulder Treatment

Conservative treatments begin with the use of non-steroidal anti-inflammatory medication (NSAIDs) and physical therapy. However, when this approach is unsuccessful, steroid injections may be appropriate.

For many patients, resting the shoulder over a long period under the supervision of a doctor is what is required for recovery. It’s a frustrating path for impatient athletes, but it is the reality of the road to recovery for most who have this condition.

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