CLSCS score
Treatment received within 1 year
Surgery (n = 171)
Nonsurgery (n = 186)
p-value
Grade 0
0
88
<0.001
Grade 1
9
94
<0.001
Grade 2
113
4
<0.001
Grade 3
49
0
<0.001
If we take as a base the statistics of lumbar stenosis prevalence and the increase of the disease in the course of aging, it is the most common spinal surgeries in elderly patients, and the most common cause is degenerative disc disease, facet, ligaments and joint. Regenerative medicine through PRP and BMAC scientific evidence has shown increasing promise in application to the spine. Also, the therapeutic success of the surgery depends on the degree of the stenosis involvement which is very clear that the new classification on cases of grade 0 and 1 benefits from conservative treatment and grades 2 and 3 of the surgical treatment [84]. Yes, we can offer regenerative therapy with the use of PRP and/or BMAC for preventive/early treatment of patients with a family history, symptoms, and initial radiological signs of spinal degeneration. Even the advanced cases of lumbar stenosis such as in osteoarthritis of the knees could try cell therapy (regenerative medicine) using PRP/BMAC as a minimally invasive alternative with very little risk to patients before spinal surgery, except in cases of clear segmental instability.
48.1.10 Spinal Scapular Humeral Pain
Spinal scapular humeral pain may be defined as a pain in the shoulder girdle and in the cervical region, and the first origin may be correlated to changes in all three regions, either together or alone. Because it is a region of complex anatomy, the exact location of pain and correct diagnosis are key for the successful treatment. In this aspect, it is essential to have a holistic view of medicine and the use of all the available methods for biological, morphological, physiological, and functional assessments of pain picture.
The dyskinesia or weakness of the spinal scapular humeral muscles is one of the main hypotheses for this phenomenon; however, other predisposing factors can be pointed out, such as stress, chronic pain, trauma, psychosomatic factors, sleep disorders, and hyperlaxity, as a mechanism of joint overload by increased tone muscle, genetic changes, and a greater predilection for females ([86–90].
The definition of the underlying cause is very important since it will determine an effective approach to the therapeutic action, usually multimodal and multidisciplinary. It is important to know that non-identified pain cannot be treated, and performing procedures without a proper diagnostic reasoning can lead to iatrogenic actions. In this context, the knowledge of many pathologies that can follow this pattern cannot be denied, such as functional and structural changes in the cervical spine, shoulder girdle, as well as specific changes of the shoulder joint. We must always take into consideration factors such as the age, life conditions, stress level, and comorbidities, so we can reach all the possible diseases during treatment.
Among the most common causes are the degenerative changes in the cervical spine affecting discs, ligaments, and facets (most common cause) [91]. Scapular pain may precede within 3 months signs of tingling in the hands, motor deficiency, and cervical pain in patients with primary cervical spine disease [92]. Since 1973, Murphey et al. show that 70% of the patients had this phenomenon and that the location of the scapular pain helps in the diagnosis of the affected root [93]. Mizutamari et al. showed after a cadaveric and clinic study that the roots of C5 (n = 18) and C8 (n = 8) send cutaneous roots; however, C6 and C7 did not, this being one of the reasons for patients with C6 and C7 impairment not presenting pain during superficial palpation. On the other hand, the most persistent pain after treatment is in the suprascapular region (C5) and nape (surgical trauma), which is less common in the interscapular and scapular regions and the posterior shoulder’s face (C6 and C7) [94].
The tools for diagnosis are a careful clinical examination, laboratory exams, ultrasonography, digital thermography, and MRI, according to the needs of each person. The ultrasonography is a technique in ascending progression in the diagnostic and treatment aid that allows a superficial and deep structure evaluation, which increases diagnostic accuracy, therapy optimization, and clinical response improvement. The digital infrared thermography is a technique that helps not only the topographic diagnosis but also analyzes, through the emission of the body’s heat, thermal changes that allow to distinguish an inflammatory, neuropathic, myofascial, or articular pain, which results in a better understanding of the pain’s physiology and topography, besides being able to demonstrate sympathetic disturbs, circulatory changes, and endocrine dysfunctions (mainly thyroid dysfunctions) [95]. Thus, aggregating all biomechanical, social, morphological, and physiological parameters, it is possible to indicate a more appropriate treatment for each type of pain, in the most biological way possible.
The basis of conservative biological treatment is to be individualized and based on the correct diagnosis of pain and related disorders, so that the well-directed multidisciplinary and multimodal approach has good results [96, 97].
Several authors, specially Gleitz, had published several papers showing the efficacy of the shockwave therapy in spinal scapular humeral pain treatment, basically in myofascial pains, rotator cuff tendinopathy, and adhesive capsulitis [98–102];. In 2011, Gleitz published a protocol using shockwave therapy in patients with myofascial pain and fibromyalgia. He suggested that these patients were treated with low and medium energy, recommending radial waves (2 bar, 10 Hz) from 1000 to 2000 pulses/myofascial point. It is also suggested a protocol with focal waves depending on the muscle’s size and generator of – 1000–2000 pulses/point) 4 Hz, 0,1 mj/mm2.
The prolotherapy and regenerative medicine has been gaining ground in the last years as a treatment option with interesting results. The treatment with regenerative medicine aims to strengthen or repair musculoskeletal injuries including ligaments, bone, and cartilage through injections with stimulating solutions and stimulating biological properties (named by Friebergh of regenerative injection treatments) [103]. A paper published in 2015 with PRP application in facet joints and ligaments guided by ultrasound with follow-up of 6–12 months (n = 6) concluded that PRP represents a potential effective and viable treatment for spinal pain related with the facets, capsules, and ligaments [104]. Obata et al. after drilling discs in rabbits (n = 12) and injected intradiscal PRP demonstrated restoration of disc’s height and more expression of chondrocyte-like cells [105].
In 2014, Kim et al. demonstrated anti-inflammatory effect of PRP in the collagen matrix of the nucleus pulposus in response to inflammatory cytokines inducing its degradation [106]. Papers were also published with intradiscal infiltration of PRP in humans showing satisfactory results within pain and functional improvement in more than 70% of the patients [107].
Articular, tendinosis, ligament, or functional shoulder pain as the origin of the spinal scapular humeral syndrome has also been approached by regenerative medicine [108, 109]. A paper published by Jo et al. in 2011 with PRP infiltration after repair of extensive rotator cuff lesions demonstrated a lower re-rupture rate [110].
Papers using hyaluronic acid in order to avoid adherence after repair of the rotator cuff demonstrated good results when compared to the control group [111]. In addition, hyaluronic acid has a positive effect on tendon regeneration, antinociceptive properties, and clinical results superior to corticoid in the medium term in rotator cuff tendinosis and improvement of functional scores in glenohumeral arthrosis specially using a high molecular weight product [112–118].
48.1.11 Spino-pelvic Pain
The spino-pelvic pain is characterized by pain involving the lower lumbar region and the pelvic girdle, being able to have as a source of pain the spine, the hip, or both. In acute cases, the diagnosis of its primary origin tends to be easier and direct, while in chronic cases, the pain loses the anatomical reference, and it becomes diffuse, which often makes diagnosis difficult and leads to the treatment of a secondary site. Chronic pain in the hip, groin, and buttocks is a frequent presentation and represents 10% of the sports physicians [119].
As a source of low back pain radiating to the upper gluteal region, we have incarceration of the cluneal nerves, superior gluteal neuralgia, iliolumbar ligament syndrome, facet arthritis, and discopathy. The superior cluneal nerves originate from the roots of T12, L1, L2, and L3, in which incarceration causes symptoms in the upper gluteal region and palpation of the iliac crest. The medial clavicular nerves originate from the root of S1 and S3, and the lower ones are branches of the sacral plexus and innervate the lower gluteal region (Fig. 48.1) [120].
Fig. 48.1
1 superior cluneal nerves (L1–L3), 2 middle cluneal nerves (S1–S3), 3 inferior cluneal nerves (from branches of sacral plexus)
The iliolumbar ligament syndrome [121] is an often neglected condition, which manifests with low back pain and the iliac crest posteromedially triggered by physical activities involving the upward movement of weight with lateral rotation of the trunk (workers, golfers, etc.). The treatment is done with direct blocking of the ultrasound-guided ligament (Fig. 48.2).
Fig. 48.2
(a) Anatomy of the iliolumbar ligament (T transverse process of L5, I iliac crest); (b) approach for left iliolumbar ligament block, laterally medially guided by ultrasonography; (c) ultrasonography image: SC subcutaneous, ES spinal erector muscle, IL iliolumbar ligament, TP transverse process of L5, L vertebral blade
From the lumbosacral plexus and its branches, the iliohypogastric nerve (branches of L1 and L2) is responsible for the sensitivity of a small territory in the near-lateral gluteal region immediately distal to the anterolateral portion of the iliac crest and the motor part of the abdominal wall musculature (Fig. 48.3). The ilioinguinal nerve, also originating from the branches of L1 and L2, is responsible for the motor part of the most distal musculature of the internal transverse and obliquely abdominal muscles. Its sensitive part inverts the region corresponding to the iliac crest, inguinal ligament, proximal-medial region of the thigh, and base of the genitalia. The genitofemoral nerve, also originating from the branches of L1 and L2, has no motor function; it is purely sensory, of the anterior region of the thigh and lateral of the genitalia.
Fig. 48.3
Sensitive sensory dermatomes of the lumbosacral and sacral plexus nerves
The lateral cutaneous nerve of the thigh is a branch of L2 and L3, has no motor function, and is only sensitive in the anterolateral region of the thigh. The obturator nerve originates from the branches of L2, L3, and L4, dividing after passing through the osteofibrous tunnel under the pubic branch in two beams: anterior and posterior. It has motor action of the adductor muscles, long, short, magnus, pectineus, and external obturator. Its sensitive territory corresponds to the medial portion of the knee, lympho-femoral and medial-distal joint of the thigh. The femoral nerve also originates from the branches of L2, L3, and L4, exerts motor function in the quadriceps, and is sensitive in the anterior region of the thigh.
From the sacral plexus, the pudendal nerve is the main perineal nerve and originates from the branches of S2, S3, and S4, being responsible for all the motor and sensory part of the perineum. The posterior cutaneous nerve of the thigh is also from the branches of S1, S2, and S3, has no motor function, and is only sensitive in the inferior gluteal region, posterior of the thigh, and perineum.
The upper and lower gluteal nerve also emerges from the sacral plexus, the gluteal nerve being the branch of the L4, L5, and S1 roots and the gluteal nerve of L5, S1, and S2. It exercises only motor function of the maximal, medial, and minimum gluteus musculature and tensor of the fascia lata, having no sensitive function.
Piriformis syndrome is described as the source of deep pain in the gluteal and the posterior region of the thigh due to the mechanical compression of the sciatica. The muscle has its origin from the second to fourth sacral segments with its tendon portion inserting into the piriform fossa. Its distal edge is in intimate contact with the sciatic and twin and inner obturator muscles [119].
X-ray imaging and magnetic resonance imaging indicate anatomical tissue changes, when available. However, not always the lesion identified represents exactly the primary point of pain. Thermography is a functional examination capable of showing early changes, even before the alterations detected by the MRI, besides helping to evaluate and identify secondary sites of pain or compensation (Fig. 48.4). The diagnostic block guided by ultrasonography confirms the site to be treated.
Fig. 48.4
(a) Magnetic resonance of the right hip showing tendinopathy of the middle gluteus (white arrow); (b) thermographic examination showing a hyporradic point in the peritrochanteric region of the gluteus medius (red arrow) associated with lumbar compensation (white arrow) (Picture provided by Dr Marcos Brioschi, available in: http://www.abraterm.com.br)
The use of PRP applied directly to the lesion site favors improvement in pain and healing and tissue repair [122, 123].
In the pelvic girdle, the most prevalent pathology in the young adult is the femoro-acetabular impact syndrome [124] also recognized as one of the main causes of hip arthrosis. The most frequent manifestation is groin pain (88%), followed by hip lateral pain (67%) and pain in the anterior thigh (35%), gluteal (29%), and low back region (23%) [125]. The energy dissipated at the time of the impact of the transition from the head to the acetabular ridge can be divided into two vectors: anterior and posterior in the pelvic ring.
The anterior vector is a frequent source of pain in the pubic sinfise (pubalgia) and the posterior vector in the sacroiliac joint and facets of L5–S1, manifesting as low back pain.
The diagnostic block of the lumbar-femoral hip joint guided by ultrasonography in patients with low back pain, carriers of radiographic signs of the femoro-acetabular impact without the typical clinical picture of groin or hip lateral pain, is a safe way of making an accurate diagnosis of this disease [126].
The treatment of the mechanical alteration of the femoro-acetabular impact is by videoarthroscopy of the hip, and the treatment of the chondral and labral damages can be reinforced with the application of growth factors obtained by PRP and hematopoietic stem cells concentrated from bone marrow aspirate and hyaluronic acid and medicated with losartan and vitamin D and fish oil supplementation [127, 128].
The use of bone marrow aspirate concentrate is safe for intra-articular use. In a meta-analysis, with the review of 3012 procedures using BMAC, Centeno et al. found the least number of complications with BMAC alone proving their safety and low incidence of adverse events11. The mesenchymal cells still exercise an analgesic and immunomodulatory effect on the joint with chondral damage. The MRI follow-up has been shown to reduce subchondral bone edema and joint cartilage repair resulting in improved quality of life scores, reduction in VAS, and improvement in functional tests (Roghayeh et al. 2015).
48.1.12 PRP, BMAC, and BIOFAT Production
Recently, the most current biological treatments in use for clinical trials is the BMAC, BIOFAT and PRP. According to the literature there are different in house methods for its production. The figure 48.5 represents the PRP preparation method. The figure 48.6 represents the BMAC preparation methods. The figure 48.7 showed the BIOFAT preparation method.
Fig. 48.5
PRP production; (a) blood harvesting with 21G from peripheral vein; (b) 6 ACD tubes collected (1 kit); (c) blood at first centrifugation at 300 × g for 5 min; (d) collection of buffy coat; (e) plasma after second centrifugation at 700 × g for 17 min; (f) PRP resuspension ready for application
Fig. 48.6
BMAC preparation; (a) preparing the area, posterior iliac crest due to higher amount of stem cells; (b) surgical instruments and syringes for harvest; (c) applying local anesthesia; (d) insertion of the specific needle to bone marrow harvesting; (e) collecting bone marrow; (f) placing the bone marrow in sterile tubes; (g) bone marrow after first centrifugation at 40 × g for 20 min; (h) collection of buffy coat; (i) plasma after second centrifugation at 800 × g for 10 min; (j) cell pellet resuspension; (k) BMAC ready for application
Fig. 48.7
BIOFAT production; (a) fat harvesting from flank region; (b) fat and blood harvested; (c) placing the material into sterile tubes; (d) fat after centrifugation at 900 × g for 15 min; (e) blood collection with 14G needle; (f) fat homogenization with 14G Abbocath; (g) add fat in a 3 mL syringe; (h) fat ready for application
Conclusions
The pain is dynamic and adaptively modulated by a complicated and integrated neural network system that facilitator ties and inhibitors continuously modify the nociceptive signal processing. The spine disorders trigger an immune response mediated by a pro-inflammatory signaling generated by the anatomic lesion or by immune cells, causing pain by physically touching it, by interfering, or by chemically stimulating the nerve roots related with the disorder. Therefore, the interaction between the nervous and the immune system is considered an essential factor in the development and perpetuation of the pain.
The regenerative medicine and cell therapy demonstrate a promising strategy within the multidisciplinary treatment of patients with chronic pain. Possible mechanisms such as elimination of local nociceptive stimulation, modulation of central sensitization, and somatosensory neuroprotection can prevail over the recomposition of the structure.
The search for therapies that control the degenerative process has increased, and several approaches have been proposed. The use of PRP, BMAC, fresh, or cultivated cells is, nowadays, already a reality, and the stimulus of healing and tissue regeneration has given space to several treatment proposals with encouraging outcomes.
The treatment with regenerative medicine aims to strengthen or repair musculoskeletal injuries including ligaments, bone, and cartilage through injections with stimulating solutions and stimulating biological properties.
References
1.
Atlas LY, Wager TD. How expectations shape pain. Neurosci Lett. 2012;520:140–8.PubMed
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