Although further research is needed to determine the safety and efficacy of regenerative procedures in the spine, the potential of many of these therapies — such as stem cells, platelet-rich plasma and bone marrow aspirate — is considerable.
Three spine surgeons discuss regenerative therapies that excite them and whether these products will become more widespread in the next decade.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
Next week's question: Is there a danger of the next generation of spine surgeons becoming too dependent on enabling technologies?
Please send responses to Alan Condon at email@example.com by 5 p.m. CDT Wednesday, June 8.
Editor's note: Responses were lightly edited for clarity and length.
Question: In 10 years, will regenerative medicine become more mainstream in spine?
Colin Haines, MD. Virginia Spine Institute (Reston): The field of regenerative medicine will continue to grow. In general, spine surgeons have been slow to adopt new technology. Less invasive approaches to surgical solutions became widespread much faster in many other areas of the body. Similarly, regenerative medicine has hit the ground running more rapidly in spine care than in fields such as orthopedics and sports medicine. There are randomized controlled trials that show the benefit of [platelet-rich plasma] in the extremities, so I imagine similar studies will be upcoming soon in the spine.
At my practice, we utilize regenerative medicine as one of many tools to restore function and eliminate pain for discogenic pain, facetogenic pain, sacroiliac dysfunction and even radicular pain. Our prospective data has also been presented at peer-reviewed meetings as well. While randomized and blinded studies will need to be conducted, the reality is that regenerative medicine has significant potential to improve our patients in a nonsurgical manner. And as our patients continue to be more and more informed about this field, its utilization will continue to grow.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Regenerative medicine is already quite mainstream in orthopedic circles. Many NBA and NFL athletes receive regenerative medicine treatments. The next step is to figure out what to put and where to put it. Although the spine is somewhat still of a black box for many people, studies such as SPECT-CT may help localize targets for treatment. It is very exciting to think we are getting closer and closer to mapping pain generators to help better treat patients not just with surgery, but also other current and future therapeutics in the quiver. I look forward to learning more about plasma-rich proteins, stem cells and new therapeutics and how they can play a role in the care of the spine patient.
Michael Gordon, MD. Hoag Orthopedic Institute (Irvine, Calif.): The central tenet of regenerative medicine is the notion that cells from human tissue lines can be manipulated or transformed in a manner that can improve or supersede the body's natural self-healing mechanisms. More often, the promise is that, with injection of fat cells, concentrated bone marrow cells or centrifuged-whole blood concentrates of platelets, new tissue growth can occur in areas where disease or age has rendered existing cell lines incapable of that task. The "stem cells" that live in these tissues are expected to fulfill this task. This idea has captivated physicians and patients alike with boundless promises of cell regrowth, tissue rejuvenation and restoration of youthful strength, vitality and beauty.
Look no further than the internet for breathless promises online. The problem of course is the complete lack of level 1 research data to support these claims (and for that matter, the lack of any prospective research in human trials). Existing numbers of actual live, effective pluripotential mesenchymal stem cells in the human tissue are very small, and their numbers in concentrated tissues are currently unmeasurable.
Since 2004, more than $4 billion in California has been invested privately in stem cell research, and more than $8 billion in government funding. Despite this huge push, with improvements in treatments for diabetes, breast cancer, colon cancer and lung cancer, disease modification in the spine is lacking. Before regenerative medicine arrives in spine, several daunting hurdles must be surmounted.
Cell lines that can actually regenerate disc cartilage, one of the most challenging cellular environments in the body, must be discovered, grown, manipulated and tested in humans. The appropriate dosing, administration, follow-up and diagnostic imaging proof of cell-line propagation must be described. Clinical outcome analysis must be provided showing benefit in humans that is long term and self-propagating.
A common refrain in stem cell research is as follows: Picture landing a brigade of 10,000 well-supplied soldiers into the middle of a desert with only the water, food, fuel and housing they carry with them sufficient for four months. What are the chances that in 12 months they will have built a thriving city with shelter, food, water, energy supplies and population growth with nothing but the sand around them. That is the challenge facing a stem cell injection in the degenerative disc. Ten years is a very short time to achieve all of this, but as they say about the U.S. men's soccer team, "their future is bright and it always has been."