Healing better, faster and what was thought to be impossible.
For every problem we first try to think of causes. For instance, for many young and middle-aged people with low back pain, the discs are the source. Prolonged sitting and driving – and we encourage people to choose where they live on the basis of how easy it is for them to live an active lifestyle, ideally walking or biking to school, work, or shopping – increases the rate of wear and tear on the discs and psychological distress. If the rate of disc repair can be improved through education, changes in posture, relaxation, better food and sleep, the discs may recover and the pain may go away. We discourage use of NSAIDs because they reduce the blood flow to the intervertebral discs, the knee meniscus and other places. While “proper posture” reduces pressure on the discs, if the discs are not the source of pain, sitting straight for too long causes muscle fatigue and pain. We encourage people to vary their posture, lean back, allow their muscles to relax, or even slouch like teenagers if it feels good (but not all the time!).
Heavy weight low repetition exercise can reverse tendinosis or tendon degeneration. Anaerobic exercise stimulates growth hormone (GH) and brain derived neurotrophic factor (BDNF), improving memory and brain plasticity. Aerobic exercise strengthens the heart and lungs. Deep water stimulates lymphatic flow and inhibits anti-diuretic hormone (ADH). When possible, we try to use exercise to treat medical problems. For foot and ankle pain in children (Sever’s Disease), we came up with a new theory on the disease, then developed a cure for it using a specific exercise protocol as opposed to rest and immobilization.
Platelet Rich Plasma (PRP)
Platelets were the first to evolve with the circulatory system and serve to form clots and stabilize areas of damage.
Musculoskeletal injuries often involve tears of the collagen. When platelets encounter torn collagen, they activate, adhere to and pull it together, working like nanorobots or nanosurgeons. They form a sticky fibrin matrix, secrete growth factors and recruit stem cells.
Platelets and platelet rich plasma (PRP) are obtained from a patient’s own blood using a series of steps involving centrifuges. There are different types of PRP, with concentrations ranging from 2.5 to over 20 times that of platelets in blood, and with or without white cells. Some types of PRP are effective for certain problems and some are not. For each patient we do a complete blood count and PRP analysis using a Horiba ABx Micros 60 hematology analyzer.
There have been 8 Level I studies (double-blind randomized controlled trials) showing leukocyte rich PRP to be effective for improvement of pain and restoration of function in chronic tendon disorders, and 6 Level I studies showing leukocyte poor PRP to be effective for osteoarthritis of the knee.
We have found PRP to be highly effective for chronic ligament and fibrocartilage tears, such as for the hip labrum, the knee meniscus, or triangular fibrocartilage in the wrist. It is imperative that the injection be precisely delivered to the actual defect using high-frequency diagnostic ultrasound.
In 2014, we published a scientific rationale and case series using PRP for low back pain caused by intervertebral disc tears. In 2015, Greg Lutz MD and associates published a double-blind randomized controlled trial showing sustained improvement at 1 year and beyond in patients whose discs they injected with PRP compared to controls. Recently, following 6 months of experiments in pig discs and using human stem cells and PRP, we have determined the optimum combination for disc repair and recovery.
We have treated over 380 patients and 750 discs in the cervical, lumbar and thoracic spine since 2012. Successfully treated patients have ranged in age from 14 to 75 years old. Approximately 60-70% of patients respond positively, half of which experience substantial reduction of pain and improvement of function and half near complete resolution of pain and resumption of normal activities at 8 weeks following a single procedure. Of these, 90% have experienced sustained improvement and 10% have had to have the procedure repeated at 1-2 years.
At our practice we use the most powerful ultrasound imaging technology (and large machines are much better than small ones) to optimally visualize small difficult to find injuries which can cause a great deal of pain and disability. Our first hip labrum patient had symptoms for years following a car accident and despite arthroscopic surgery. We were able to find a persistent defect in the labrum and treat it with PRP, resulting in permanent relief of pain.
For patients with chronic neck pain as a result of whiplash or high-velocity trauma, we developed a hybrid ultrasound and fluoroscopy-guided technique to inject the cervical facet joints, which have been found to have capsular ruptures on post-mortem studies not evident on MRI. The procedure can be done in the office in a few minutes using a 0.3 mm diameter needle, with only a fraction of the radiation exposure and an accuracy of 97%, higher than the best reported rate of 91% reported with fluoroscopy.
Bone Marrow Aspirate Concentrate (BMAC)
Bone marrow is active throughout life as the factory for platelets, red blood cells and white blood cells. Bone marrow also contains small concentrations of mesenchymal stem cells (MSCs). In the lab these cells can become muscle, tendon, ligament, cartilage and bone cells, but we don’t have evidence this happens in the body. When injected into degenerating arthritic joints, tendons and ligaments, bone marrow aspirate concentrate (BMAC) reduces inflammation and stimulates the repair process, typically more effectively than leukocyte-poor PRP, which in turn has been shown to be more effective than viscosupplement or cortisone injections in randomized controlled trials.
The BMAC procedure is done using local anesthesia on the iliac crest (back of the pelvic bone) from which bone marrow is aspirated and then processed in the lab using centrifuges. For every procedure, we count the total number of nucleated cells using fluorescent microscopy, a small fraction of which are MSCs. How exactly BMAC works to reduce inflammation and pain long-term (on the order of 1 to 3 years) in many patients is not known, but may involve stimulation of repair and regenerative mechanisms and reduction of unnecessary immune and defense mechanisms. Unlike for PRP, there have been no randomized placebo-controlled trials for BMAC for joints. A 2016 review by Chahla et al in the Orthopedic Journal of Sports Medicine concluded that the available evidence shows BMAC to be safe and effective for treatment of knee osteoarthritis.
Ultra-Minimally Invasive Surgery
The original operations for carpal tunnel syndrome were done with an open surgical approach and general anesthesia. Arthroscopic techniques were then developed using regional anesthesia. At present the procedure can be done with the “camera” outside the body and the incision as small as 1 mm.
Rojo-Manaute and associates did a randomized controlled study of ultrasound-guided versus mini-open (<2 cm incision) carpal tunnel release and found 2 to 3 times better function and lower pain scores at 1 week and 6 months with the ultrasound technique. We have done over 150 of these operations without significant complications. Patients are typically able to return to work in 3 days. We have done ultrasound-guided surgery for a variety of other problems, ranging from removal of osteophytes in the knee, calcium deposits in the hip, release of tendon contractures and decompression of the anterior and lateral leg fascia for compartment syndrome.
Frequently Asked Questions
1) Bodor M, Toy A, Aufiero D: Disc Regeneration with Growth Factors. In: Lana, JF, editor. Platelet Rich Plasma. Berlin: Springer Verlag, 2014.
2) Tuakli-Wosornu YA et al. Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study. PMR. 2015 Aug 24.
3) Bodor M, Dregalla R, Uribe Y: PRP: History, Mechanism of Action, Preparation and Clinical Applications. In: Manchikanti L and Navani A. Essentials of Regenerative Medicine in Interventional Pain Management, 2019.
4) Chahla J et al. Concentrated Bone Marrow Aspirate for the Treatment of Chondral Injuries and Osteoarthritis of the Knee: A Systematic Review of Outcomes. Orthop J Sports Med. 2016
5) Buncke G, McCormack B, Bodor M. Ultrasound-guided carpal tunnel release using the manos CTR system. Microsurgery. 2013 Feb 18.
6) Rojo-Manaute JM, Capa-Grasa A et al. Ultra-Minimally Invasive Ultrasound-Guided Carpal Tunnel Release: A Randomized Clinical Trial. J Ultrasound Med. 2016 Jun;35(6):1149-57.