Journal Club January 2016: Cellular Supplementation Technologies for Painful Spine Disorders

Article title: Cellular Supplementation Technologies for Painful Spine Disorders

Author: Michael J. DePalma, MD, Justin J. Gasper, DO

Journal: PM&R 7 (2015) S19-S25

Discussion:

Chronic low back pain (CLBP) is one of the most common complaints for which people seek medical attention. Although it is often not easy to diagnose the etiology of the back pain, doing so can have immense benefits in terms of targeted therapy. Some of the more common places of origin for CLBP include the intervertebral disk, facet joints, and sacroiliac joints. Unfortunately, none of the current therapies have proven to be very effective, but cellular supplementation techniques have shown promise.

In regards to the pathophysiology of disk degeneration, some of the treatment goals include either (1) increasing the amount of extracellular matrix available to promote disk regeneration via dehydration or (2) inhibit cytokines that degrade proteoglycans to try to reverse the degenerative process. However, intradiskal treatments will need to address not just the degenerative changes, but the non-healing annular fissure as well. The treatment that is most supported by current data involves cellular supplementation.

Cellular supplementation to treat diskogenic LBP involves the introduction of cells that can potentially regenerate disk tissue. One of the possible sources includes autologous human disk cells, but obtaining pure cells free of other cells provides its own set of challenges. As a result, there must be a clonal expansion of these cells once they are obtained and purified, which is both expensive and not yet FDA-approved for clinical use. The use of allogeneic stem cells is another intriguing possibility that may be more cost-effective and increase cell survival rates even more than using autologous disk cells, according to an FDA-regulated phase 2, randomized, controlled study. Other sources of cellular supplementation include juvenile and adult chondrocytes, but not enough research has been done yet to determine their efficacy.

Painful facet and SI joints are another common cause of CLBP. In osteoarthritis, disk degeneration leads to loss of disk height, which increases the compressive load and causes the synovial membrane, joint capsule, and cartilage to transmit pain via nociceptive type C fibers. A classic feature of OA involves an imbalance between matrix degradation and synthesis, leading to increased catabolism of hyaluronic acid and a decrease in the lubricating properties of the joint space.

Treatment for painful facet and SI joints is far more limited compared to diskogenic LBP due to the relative dearth of research available. A promising treatment involves intra-articular injections of exogenous hyaluronic acid, but more research needs to be done.

Discussion Points:

  1. What are the most common causes of chronic low back pain? Which causes are more prevalent in the elderly population (age > 65)?
  2. What therapeutic objectives should techniques for diskogenic low back pain aim to achieve?
  3. Describe some of the current limitations regarding cellular supplementation techniques.
  4. Regarding future research, what are some osteopathic techniques for the treatment of low back pain that should be explored further?
  5. Besides chronic low back pain, in what other conditions might you see cellular supplementation techniques eventually becoming successful mainstays of therapy?

LEARN MORE by downloading the article and discussion below:

Article - Link to Full Article

Discussion - AOCPMR Journal Article Summary - January 2016