PRP has been used in musculoskeletal medicine as early as the 1990’s, and since the 1980’s in surgical and dental procedures.  Uses for PRP in musculoskeletal medicine include treatment of tendonopathy, tendonosis, acute and chronic muscle strain, ligament sprains and intra-articular injuries and joint pain.  This modality may be used for chronic neck and low back pain (including post surgical pain). Joint conditions may include shoulder arthropathy, tennis elbow, degenerative or meniscal knee abnormalities or foot pain (including plantar fasciitis).

Blood is made of RBC (Red Blood Cells), WBC (White Blood Cells), Plasma, and Platelets.  When in their resting state, platelets look like sea sponges and when activated form branches.  Platelets were initially known to be responsible for blood clotting.  In the last 20 years we have learned that when activated in the body, platelets release healing proteins called growth factors.  There are many growth factors with varying responsibilities, however cumulatively they accelerate tissue and wound healing.  Therefore after increasing the baseline concentration of these platelets, we are able to deliver a powerful cocktail of growth factors that can dramatically enhance tissue recovery.  Most enticing, is that the technique appears to help regenerate ligament and tendon fibers.

The procedure is strikingly straightforward.  First, a small amount of blood is drawn from the patient’s arm.  The blood is then placed in a centrifuge that spins the blood for approximately 15minutes.  This step removes the unwanted components of blood that are not primarily responsible for healing including:  plasma. WBC’s and RBC’s.  What remains is an increased concentration of up to 10x above baseline of platelets. 

Under fluoroscopy the area of injury is properly identified and marked.  The physician then performs the injection.  The patient rests afterward for 5 to 10 minutes and is then discharged home with post procedural instructions.  Patients are encouraged to participate in physical therapy following the injection which enhances recovery.

Because this substance is injected where blood would rarely go otherwise, it can deliver the healing instincts of platelets without triggering the clotting response for which platelets are typically known.  This method is excellent for areas that are not well vascularized, like ligaments and tendons.

The benefits and socio-economic implications are obvious.  Besides reducing pain and returning the patient to functionality more quickly, this procedure is a first option before surgery and may even obviate the need for surgery.  There is little chance for rejection or allergic reaction because the substance is autologous, meaning it comes from the patient’s own body.  The injection carries far less chance for infection than an incision.  Of note, recent research suggests that PRP may have an anit-bacterial property which protects against possible infection.  The procedure leaves no scar and takes only about 20 minutes, with a considerably shorter recovery time than after surgery.  There is no down time for the patient.  PRP therapy may replace cortisone shots which may cause damage over time.  One study has shown that when comparing PRP and cortisone shots after 6 months those treated with PRP had less pain and gained more function.

Journel of Orthopaedic Trauma, July 2008 vol 22 No 6.  “Platelet Rich Concentrate:  Basic Science and Current Clinical Applications”

The Americal Journal of Sports Medicine, 009, Vol.37, No.6 “Use of Autologous Platelet-Rich Plasma to Treat Muscle Strain Injuries”

Jounal of the Americal Academy of Orthopaedic Surgeons, Oc.t 2009, Vol 17, No. 10 “Platelet-Rich Plasma:  Current Concepts and Applications in Sports Medicine”

The American Journal of Sports Medicine. October 2009,Vo1.34, No. 11, “Treatment of Chronic Elbow Tendinosis with Buffered Platelet-Rich Plasma”

New York Presbyterian Hospital, October 15, 2009 “Platelet-Rich Plasma Therapy to Treat Sports Injuries.

New York Presbyterian Hospital, October 13, 2009 “Platelet-Rich Plasma Therapy Speeds Healing”

Unfortunately, an MRI study may be incorrect in determining the condition about 40% of the time. An MRI study is a picture at a static moment in time, done with a patient in a stationary position. Studies have been done where asymptomatic patients (no complaints of back pain) were revealed to have positive MRI findings (disk degeneration, bulges or even herniations) even though they never had a history of back pain – false positive findings. Conversely, discography has shown multiple times there can be painful disks even with a lack of MRI findings – false negative findings. Therefore, it is paramount to determine the true etiology of the condition before more aggressive treatments are undergone.

While no study, including discography, is perfect, it gives much more information than a MRI alone. There are two components: the provocative component, and the radiological component. This test helps determine if the neck or back pain is being caused by one or more of the intervertebral disks. It is used by pain physicians and surgeons to determine the correct treatment for the patient, whether that be a laser (percutaneous) diskectomy, endoscopic assisted diskectomy, or open surgical microdiskectomy or even fusion operation.

The procedure involves placing needles, under anesthesia, into the discs. The patient is then awoken, and conversive. A small amount of contrast is injected under pressure and responses are noted. First, this produces a real time fluoroscopic image of the disk, and the contrast can reveal abnormalities (annular tears etc.) that the MRI may not have been sensitive enough to pick up. Second, as a result of the increased pressure within the disc, the patient may experience pain. Most important is not only that pain may be reproduced, but whether or not it is similar to the usual pain that the patient has been experiencing. The patient, while briefly awake, is given analgesics so as to lessen any negative experience, and some are amnestic as well (don’t remember being awake at all).

Nonetheless, patients undergo this test because it gives invaluable information as part of their care. The test is much more sensitive than an MRI for determining the integrity of the disks, and can determine which disks are provoking pain, something an MRI cannot do. Many times subtle internal diskogenic abnormalities are not visualized on an MRI, but dye leakage out of the disks cannot be missed. Usually a CT scan is then performed, as fluoroscopy is limited in viewing the internal structure of the disks, and where dye leakage has occurred.

In conclusion, provocative discography is an invaluable component of a pain specialist in the workup of a patient with ongoing neck and back pain. It gives real time information utilizing patient feedback, in helping to determine if one or more intervertebral disk are abnormal and symptomatic. The information obtained can either help a patient avoid surgery, or determine what minimally invasive or surgical treatment is most appropriate. It is recommended by many pain specialists and surgeons in the care of their patients.

Spinal cord involves placing permanent electrodes in the spinal column as a long relieving modality.  It is theorized to work by blocking the transmission of pain sensation to the brain.  There is a similarity to transcutaneous electrical nerve stimulation (TENS) whereby electrical current is passed through surface electrodes in the region of ongoing pain thereby reducing that pain.  However, spinal cord stimulation or more correctly dorsal column stimulation is a more effective and applicatable modality in the treatment of chronic daily pain.  This technology has been around since the early 1970s and has helped thousands of patients in the treatment of various pain conditions.

The spinal cord stimulation system consists of one or two spinal leads and an implantable generator.  If the patient is deemed a good candidate by their pain physician, the first step is to perform a trail of the stimulation.  This involves placing one or two small leads in the spinal canal.  The leads are secured to the patient’s back to an external generator.

A trial may go one for several days up to one week, but no longer due to the risks of infection (you don’t want to have leads entering the spinal region from the outside for too long a period of time).

A trial would be deemed successful if the following occur:

1. Is the correct area of pain “covered”.
2. Does the patient not find the sensation unpleasant?
3. Does the stimulation alleviate a majority of the pain?

If all three questions are answered “Yes” then permanent implantation of the device can be performed.  This would involve a second procedure whereas incisions are made to implant the entire system (leads in the spinal canal and the generator in subcutaneous tissue).

I have treated many patients with this device for both chronic neck and low back pain of various causes, with or without upper and lower extremity pain.  Appropriate candidates are ones where conservative treatments, both medications and injection therapy, have failed; where surgery would not be beneficial;  or where the patient is attempting to avoid surgery.  Contraindications include patients with coagulation disorders or the use of blood thinners, for example.

Indications include patients with various conditions of the spinal column and nerves including such as degenerative disk disease, spinal stenosis, disk herniations with nerve impingement, vertebrogenic pain, reflex sympathetic dystrophy, or patients who have failed back surgery (so called “post-laminectomy pain syndrome”).

The advantages of this modality are that during the trial period the patient can see what the device “feels like” and how much pain is alleviated before entertaining permanent placement.  This is opposed to surgery where once you’ve had it, you can’t take it back.  Additionally, the device is 100% reversible.  So even if you’ve had it for a time, the device can be removed at any time thereafter and you’re back to square one.  It is safe for long term use and can improve patient’s pain, function, and quality of life.  The device is controlled with an external patient programmer.  Recently the device has become more sophisticated such that different programs can be set for different types of pain the patient may experiences at various times.  For example there may be times that greater back pain is experienced, and others where leg pain occurs, and the stimulation can be changed by the patient to meet him/her needs in a dynamic fashion.  Lastly, the device does not utilize medications and therefore there are no drug side effects such as drowsiness, disorientation, nausea or other problems such as drug addiction.  It treats the specific are of pain without affecting the entire body.

Short term risks of both trial and permanent placement include infection, bleeding, headaches, failure to relieve pain, issues with the hardware, and nerve injury.  Long term complications can involve device failure either involving a mal-position of the spinal leads leading to a lack of proper stimulation, or damage or other malfunction to the generator.  Presently, there is a rechargeable battery which as a reported life span of nine years.  Thereafter replacement of the generator through a minor surgical procedure is required.  It must be realized that spinal cord stimulation is a palliative treatment in that it does not eliminate the source of pain but reduces the pain the patient experiences.  There is no way of predicting who will receive benefit and who will not, which is why a trial is performed.

In conclusion, in the appropriate patient, spinal cord stimulation can be a very good pain relieving modality as part of an overall comprehensive pain management program.  It is a very good treatment option in patients with conditions refractory to more conservative treatments and who wish to avoid or have failed surgery.  I have personally used this to treat many patients improving their ability to function, perform various activities, and lead a more normal life.

The management of chronic pain with opoid medication was highly regarded in the last decade.  But the pendulum has swung the other way during the last few years.  There is unfortunately a lot of drug diversion and abuse occurring today.  This therefore puts a physician who prescribes pain medication under some scrutiny, and can put patients on the defensive.  Of course the best defense is a good offense. 

I do practice medical management for chronic pain.  This has led me to adopt a strict philosophy and office policy.  The optimum patient will say “do whatever you can do to help me with my pain”.  I have had patients who have trialed interventions that I have recommended, but still have a degree of pain.  In these patients, if other options are limited or risky, I will discuss medications (even if they have never asked about it).  I hate to fail in treating someone.  So I will do whatever it takes, including prescribe medication.  Sometimes this is successful, and does improve their pain and quality of life (the goals of all therapies).  I have also seen patients only seeking someone who will prescribe pain medications for them.  In some I have told that there may be treatments which can help them besides pills.  But if a patient blatantly refuses what may be beneficial treatments, it makes them not seemingly genuine in wanting to get better.  Nevertheless, a good physician must also take patient’s needs and desires into account, when coming up with a treatment plan.

A chronic pain patient must be prepared to undergo several steps before obtaining medication.  He/she must obtain at least several months of previous notes from previously treating physicians.  It should be expected that those physicians will be contacted.  Also, they will need to undergo both physiologic and psychological testing.  This is recommending in the field, to evaluate for depression and other ailments related to chronic pain.  Only after such testing has been completed, may pain medication be prescribed.  However, I never prescribe such medication on the first visit.

I am dedicated to treating all patients in pain.  However, one must realize that such a relationship is a partnership, whereas both doctor and patient must understand each others issues and desires.  Medical management of chronic pain is not popular (no one advertises this), is somewhat controversial, and is certainly labor intensive.  However, it remains an important treatment in patients who otherwise have limited options.

So what are some of these treatments which exist?  There are several ablation techniques,  they are:  cryoablation (cold), radiofrequency ablation (heat), or chemical ablation.  The latter are less commonly utilized.  However one example is the use of Botulism Toxin for chronic muscle (myofascial) pain.

Botox “permanently” [nerve tend to regenerate over six months] prevents firing at the neuromuscular junction (where the nerve innervates the muscle).  It therefore can be used for chronic muscle pain, and has in the last few years been used to treat chronic muscle tension headaches with very good success.

I have used Cryoablation, the freezing of tissue for many different ailments.  It can be used in any soft tissue.  I have successfully treated pain from muscles, ligaments and joints.  Applicable areas include neck, shoulder, inguinal (groin), knee and ankle pain.  The joint pain must be determined to be extra-articular (not due to a problem within the joint).  But for example, I’ve had patients who have had knee and ankle surgery, with persistent pain, who benefited from freezing of the painful areas around the joint.

Finally radiofrequency ablation is the most common treatment utilized by pain interventionalists.  It uses heat generated through a fine needle to ablate localized areas.  It is most utilized for painful joint conditions in the spine.  The facet and sacroiliac joint are the amenable treatments to this technique.  I also used it for shoulder and hip conditions which successfully prevented the patients from having to undergo surgery.  Other technologies do exist which can help treat degenerative disk abnormalities.

The goal of these treatments is to find out what is causing the pain (the “pain generator), and use minimally invasive therapies to result if a long lasting benefit to the patient.

The next picture depicts one vertebral body on top of another.  In the front (left side) you see the intervertebral disk between the two bones.  The disk is made up of the Nucleus Pulposus surrounded by the Annulus Fibrosus.  This acts as a cushion between the vertebral bodies.  Just to the right of the disk is the neuroforamen.  This is the hole that the nerves exit to travel to the lower extremity.  Anything that puts pressure on the nerve (here labeled the Dorsal Root Ganglion) will produce pain down the leg.  This can involve the disk pressing on the nerve, the ligamentum flavum (which are ligaments behind the nerve) or the facet joint (labeled Articular capsule).

These diagrams again show how the disk in the front, the spinal cord and nerves just behind it, and the ligaments and bones in the back.  You see how the nerves exit the bones, and how any surrounding structures could pinch the nerves, causing pain.

This picture shows how disks are tested to determine if they are causing the pain.  This is called a diagnostic lumbar discography.

All of the various structures of the spine can be tested to determine if they are causing the pain.  These tests are much better and more sensitive than MRIs because they are dynamic (the patient reports a response) as opposed to an MRI which is just a static picture.  It is this which gives pain physicians a powerful tool to diagnose and treat patients who are suffering from neck or back pain, as well as other ailments.

For my first blog I want to try to explain what when and why you might need to seek care with an interventional pain physician.  As the most common treatments are for low back pain, this is what I will be talking about here.  I really believe in what I do, as I’ve helped thousands of patients throughout my fifteen years of practice.  It is a wonderful thing to have a patient return after a treatment and reports that they are feeling better.  Most people whom I have treated have benefited from these therapies.

There is no exact science to the treatment of back pain.  What I have always found to be pecular is that ten different people with the exact same problem can go to ten different physicians and each prescribed a different type of treatment!  This may involve chiropractic manipulation, physicial therepy, exercise, medications, accupuncture, back interventions, or even surgery.  Nonetheless, a steadfast rule is to try more conservative treatments first, and more aggresive treatments afterward.

When are such interventions appropriate?

If more conservative therapies have failed, and you have had pain for at least several months, then you may be a candidate for these treatments.  Many of you may have had MRI and EMG testing, and these test can certainly help determine what is causing the pain, but many times they only tell part of the story.  My philosophy is to use these therapies to also help determine what is causing the pain.  There are many parts that make up the spine that can cause pain.  I can anesthesthetize (ie numb) them with a type of novocaine, to figure out what causing the pain (for example:  disks, joints, nerves, muscles etc).  This approach has led me to be very successful in treating patients with back pain.

Why undergo back interventions?

If you’re reading this, then you’ve probably have tried different therapies and still have back pain.  Many people are hesitant about having an injection in their back, and may have heard negative things.  While any treatment has risks associated with it, these treatments truly can only make you better.  The worst case scenario is simply that it didn’t work.  Of course many patients have also been cured.  My goal is to get my patient better and prevent them from having to entertain other treatments, such as surgery.  While Epidural injections are the most common treatments that doctors in my specialty perform, it is also the most basic.  Many more sophisticated therapies now exist, which can cure disk herniations without surgery.  Two such treatments which I perform more and more are percutaneous disk (laser) decompression, and endoscopic diskectomies.  These are “minimally invasive therapies” which permanently treat disk hernations.

Therefore, if you are still having back pain dispite having had physicial therapy or other treatments, and the pain has persisted, you may benefit from these treatments.  Even if you’ve already had Epidural injections, many other treatments exist which could be beneficial.  There’s very little down side to trying these treatments:  They are extremely simply, done as outpatient procedures, and can be highly beneficial.  I am very lucky to have chosen a profession where I help people every day!