04/27/2017 1 Bio-Cellular Disc Interventions: The Evidence Carlos J. Garcia, MD The Regenerative Spine and Joint Institute “I am sorry my granddaddy had to cancel Nemacolin last year. I had a little surprise for him”. Gabriella Maree April 6, 2016 Disclosures NONE Carlos J. Garcia, MD The Regenerative Spine and Joint Institute
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04272017
1
Bio-CellularDisc Interventions
The Evidence
Carlos J Garcia MDThe Regenerative Spine and Joint Institute
ldquoI am sorry my granddaddy had to cancel Nemacolin last year I had a little surprise for himrdquo Gabriella Maree April 6 2016
Disclosures
NONE
Carlos J Garcia MDThe Regenerative Spine and Joint Institute
04272017
2
Disclaimers
Bio-Cellular Disc Interventions (BDI) are not designed as stand alone therapies
Some of the BDI may considered investigational and proper consents should be obtained
Consult with your State Medical Board and the FDA for regulatory guidance
BDI should only be performed by practitioners with significant expertise in interventional spine techniques
BDI should only be considered when reasonable conservative therapies have failed or conservative treatment is not feasible
Definitions
Regenerative Medicine
Multi Disciplinary approach in which different therapeutic interventions are utilized in order to induce biologic enhancement of tissue repair regeneration and functional restoration
Bio-Cellular Disc Interventions
Interventions in which growth factors scaffolds and cells are utilized in order to induce biologic enhancement of tissue repair regeneration and functional restoration of the intervertebral disc complex
Definitions
Tissue Engineering
The first definition of tissue engineering is attributed to Drs Langer and Vacanti who stated it to be an interdisciplinary field that applies the principles of engineering and life sciences towards the development of biological substitutes that restore maintain or improve tissue function or a whole organ
04272017
3
Spine Related Conditions
DISC
Symptomatic DDD
Symptomatic Herniated Discs
NERVE ROOTS
Compressive Lesions
Inflammatory Lesions
Neuropathic Lesions
)
Spine Related Disorders
FACET JOINTS
Degenerative
Ankylosing
Traumatic
PARTS DEFECT
LIGAMENTS and MUSCLES
Degenerative Disc Disease Is a chronic progressive degenerative condition with no known
cure
High prevalence and frequently symptomatic
It is associated with the normal aging process and is influenced by many factors known and unknown
The hallmark change is reduced disc height due to loss of extracellular matrix and cell death resulting in decrease capacity of the IVD to absorb water
The condition can deteriorate and cause pain motion instability and ultimately collapse of the IVD
It affects the Annulus Fibrosis Nucleus Cartilaginous End Plate and Vertebral Bone Marrow
04272017
4
Bio-Molecular Pathways
Cellular Respiration
Dysfunction
NADNADH
Mitochondrial Dysfunction
Citric Acid Cycle
Glycolytic Pathways
ATP Production
Oxidative Stress
Alteration Gene Expression
Cytokine Imbalance
Alteration Cell Hemostasis
Decrease ECM
Increase Apoptosis
Inflammatory Cytokines
Bio-Mechanical Pathways
Resulting in annular tears end plate sclerosis herniated discs spondylo-arthorpathy and spinal stenosis
Cell death fibrosis catabolic cytokines and proteases creating structural failure
Mechanical dysfunction of the annulus nucleus and end plate
Reduction in cell density proteoglycan collagen (IIIX) water binding capacity axial loading function
Ref 16-23
Intervertebral Disc Complex
IVD Collagen Type
Proteoglycan(Type and
wt)
Cell Density
Water(wt)
Cell Type Function Structure
Nucleus Type IIIVIIXXI
5-10
25-60AggrecanDecorinbiglycanFibromodulinversican
Low 70-90 Chondrocyte Compressive CELLECMGAG
Annulus Type III VIIXXI
10-15
10-35AggrecanDecorinbiglycanFibromodulinversican
High 65-80 Fibroblast Tensile Lamellarconcentric
End plate Type X
20-25
5-10AggrecanDecorinbiglycanFibromodulinversican
Low 50-60 Chondrocyte Nutrition CELLECMGAG
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5
IVD Cell Types
Cell Density and Aging
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland Paper No 305 bull 55th Annual Meeting of the Orthopaedic Research Society
Immune Privilege
bull Certain sites of the human body have immune privilege meaning they are able to tolerate the introduction of antigens without eliciting an inflammatory immune response
bull Tissue grafts are normally recognised as foreign antigen by the body and attacked by the immune system
bull Brain Eye Testes Placenta Disc
04272017
6
Immune Privilege
Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege It has been demonstrated that the expression of the Fasligand is decreased in degenerated discs
The Journal of Japanese Society of Lumbar Spine DisordersVol 14(2008) No 1 P 50-57 The relationship between immune privilege of the disc and low back pain Kotaro NISHIDA1)
Immune Privilege
TGF-beta
Suppresses Mitogen and antigen-driven T cells
Suppresses mediators released by neutrophils
Suppresses nitric oxide produced by macrophages
Blocks the actions of Natural killer cells
Degenerative Cascade
Synovitis Hypomobility
Degenration
Capsular Laxity
Subluxation
Arthropathy
Zygaphophyseal Joints
Disc Resorption
Internal Disruption
Radiall Tears
CircumfentialTears
Osteophytes
Intervertebral Disc
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7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
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8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
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9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
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10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
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11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
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Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
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13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
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14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
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15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
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16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
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Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
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Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
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Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
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20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
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21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
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Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
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23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
2
Disclaimers
Bio-Cellular Disc Interventions (BDI) are not designed as stand alone therapies
Some of the BDI may considered investigational and proper consents should be obtained
Consult with your State Medical Board and the FDA for regulatory guidance
BDI should only be performed by practitioners with significant expertise in interventional spine techniques
BDI should only be considered when reasonable conservative therapies have failed or conservative treatment is not feasible
Definitions
Regenerative Medicine
Multi Disciplinary approach in which different therapeutic interventions are utilized in order to induce biologic enhancement of tissue repair regeneration and functional restoration
Bio-Cellular Disc Interventions
Interventions in which growth factors scaffolds and cells are utilized in order to induce biologic enhancement of tissue repair regeneration and functional restoration of the intervertebral disc complex
Definitions
Tissue Engineering
The first definition of tissue engineering is attributed to Drs Langer and Vacanti who stated it to be an interdisciplinary field that applies the principles of engineering and life sciences towards the development of biological substitutes that restore maintain or improve tissue function or a whole organ
04272017
3
Spine Related Conditions
DISC
Symptomatic DDD
Symptomatic Herniated Discs
NERVE ROOTS
Compressive Lesions
Inflammatory Lesions
Neuropathic Lesions
)
Spine Related Disorders
FACET JOINTS
Degenerative
Ankylosing
Traumatic
PARTS DEFECT
LIGAMENTS and MUSCLES
Degenerative Disc Disease Is a chronic progressive degenerative condition with no known
cure
High prevalence and frequently symptomatic
It is associated with the normal aging process and is influenced by many factors known and unknown
The hallmark change is reduced disc height due to loss of extracellular matrix and cell death resulting in decrease capacity of the IVD to absorb water
The condition can deteriorate and cause pain motion instability and ultimately collapse of the IVD
It affects the Annulus Fibrosis Nucleus Cartilaginous End Plate and Vertebral Bone Marrow
04272017
4
Bio-Molecular Pathways
Cellular Respiration
Dysfunction
NADNADH
Mitochondrial Dysfunction
Citric Acid Cycle
Glycolytic Pathways
ATP Production
Oxidative Stress
Alteration Gene Expression
Cytokine Imbalance
Alteration Cell Hemostasis
Decrease ECM
Increase Apoptosis
Inflammatory Cytokines
Bio-Mechanical Pathways
Resulting in annular tears end plate sclerosis herniated discs spondylo-arthorpathy and spinal stenosis
Cell death fibrosis catabolic cytokines and proteases creating structural failure
Mechanical dysfunction of the annulus nucleus and end plate
Reduction in cell density proteoglycan collagen (IIIX) water binding capacity axial loading function
Ref 16-23
Intervertebral Disc Complex
IVD Collagen Type
Proteoglycan(Type and
wt)
Cell Density
Water(wt)
Cell Type Function Structure
Nucleus Type IIIVIIXXI
5-10
25-60AggrecanDecorinbiglycanFibromodulinversican
Low 70-90 Chondrocyte Compressive CELLECMGAG
Annulus Type III VIIXXI
10-15
10-35AggrecanDecorinbiglycanFibromodulinversican
High 65-80 Fibroblast Tensile Lamellarconcentric
End plate Type X
20-25
5-10AggrecanDecorinbiglycanFibromodulinversican
Low 50-60 Chondrocyte Nutrition CELLECMGAG
04272017
5
IVD Cell Types
Cell Density and Aging
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland Paper No 305 bull 55th Annual Meeting of the Orthopaedic Research Society
Immune Privilege
bull Certain sites of the human body have immune privilege meaning they are able to tolerate the introduction of antigens without eliciting an inflammatory immune response
bull Tissue grafts are normally recognised as foreign antigen by the body and attacked by the immune system
bull Brain Eye Testes Placenta Disc
04272017
6
Immune Privilege
Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege It has been demonstrated that the expression of the Fasligand is decreased in degenerated discs
The Journal of Japanese Society of Lumbar Spine DisordersVol 14(2008) No 1 P 50-57 The relationship between immune privilege of the disc and low back pain Kotaro NISHIDA1)
Immune Privilege
TGF-beta
Suppresses Mitogen and antigen-driven T cells
Suppresses mediators released by neutrophils
Suppresses nitric oxide produced by macrophages
Blocks the actions of Natural killer cells
Degenerative Cascade
Synovitis Hypomobility
Degenration
Capsular Laxity
Subluxation
Arthropathy
Zygaphophyseal Joints
Disc Resorption
Internal Disruption
Radiall Tears
CircumfentialTears
Osteophytes
Intervertebral Disc
04272017
7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
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16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
3
Spine Related Conditions
DISC
Symptomatic DDD
Symptomatic Herniated Discs
NERVE ROOTS
Compressive Lesions
Inflammatory Lesions
Neuropathic Lesions
)
Spine Related Disorders
FACET JOINTS
Degenerative
Ankylosing
Traumatic
PARTS DEFECT
LIGAMENTS and MUSCLES
Degenerative Disc Disease Is a chronic progressive degenerative condition with no known
cure
High prevalence and frequently symptomatic
It is associated with the normal aging process and is influenced by many factors known and unknown
The hallmark change is reduced disc height due to loss of extracellular matrix and cell death resulting in decrease capacity of the IVD to absorb water
The condition can deteriorate and cause pain motion instability and ultimately collapse of the IVD
It affects the Annulus Fibrosis Nucleus Cartilaginous End Plate and Vertebral Bone Marrow
04272017
4
Bio-Molecular Pathways
Cellular Respiration
Dysfunction
NADNADH
Mitochondrial Dysfunction
Citric Acid Cycle
Glycolytic Pathways
ATP Production
Oxidative Stress
Alteration Gene Expression
Cytokine Imbalance
Alteration Cell Hemostasis
Decrease ECM
Increase Apoptosis
Inflammatory Cytokines
Bio-Mechanical Pathways
Resulting in annular tears end plate sclerosis herniated discs spondylo-arthorpathy and spinal stenosis
Cell death fibrosis catabolic cytokines and proteases creating structural failure
Mechanical dysfunction of the annulus nucleus and end plate
Reduction in cell density proteoglycan collagen (IIIX) water binding capacity axial loading function
Ref 16-23
Intervertebral Disc Complex
IVD Collagen Type
Proteoglycan(Type and
wt)
Cell Density
Water(wt)
Cell Type Function Structure
Nucleus Type IIIVIIXXI
5-10
25-60AggrecanDecorinbiglycanFibromodulinversican
Low 70-90 Chondrocyte Compressive CELLECMGAG
Annulus Type III VIIXXI
10-15
10-35AggrecanDecorinbiglycanFibromodulinversican
High 65-80 Fibroblast Tensile Lamellarconcentric
End plate Type X
20-25
5-10AggrecanDecorinbiglycanFibromodulinversican
Low 50-60 Chondrocyte Nutrition CELLECMGAG
04272017
5
IVD Cell Types
Cell Density and Aging
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland Paper No 305 bull 55th Annual Meeting of the Orthopaedic Research Society
Immune Privilege
bull Certain sites of the human body have immune privilege meaning they are able to tolerate the introduction of antigens without eliciting an inflammatory immune response
bull Tissue grafts are normally recognised as foreign antigen by the body and attacked by the immune system
bull Brain Eye Testes Placenta Disc
04272017
6
Immune Privilege
Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege It has been demonstrated that the expression of the Fasligand is decreased in degenerated discs
The Journal of Japanese Society of Lumbar Spine DisordersVol 14(2008) No 1 P 50-57 The relationship between immune privilege of the disc and low back pain Kotaro NISHIDA1)
Immune Privilege
TGF-beta
Suppresses Mitogen and antigen-driven T cells
Suppresses mediators released by neutrophils
Suppresses nitric oxide produced by macrophages
Blocks the actions of Natural killer cells
Degenerative Cascade
Synovitis Hypomobility
Degenration
Capsular Laxity
Subluxation
Arthropathy
Zygaphophyseal Joints
Disc Resorption
Internal Disruption
Radiall Tears
CircumfentialTears
Osteophytes
Intervertebral Disc
04272017
7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
4
Bio-Molecular Pathways
Cellular Respiration
Dysfunction
NADNADH
Mitochondrial Dysfunction
Citric Acid Cycle
Glycolytic Pathways
ATP Production
Oxidative Stress
Alteration Gene Expression
Cytokine Imbalance
Alteration Cell Hemostasis
Decrease ECM
Increase Apoptosis
Inflammatory Cytokines
Bio-Mechanical Pathways
Resulting in annular tears end plate sclerosis herniated discs spondylo-arthorpathy and spinal stenosis
Cell death fibrosis catabolic cytokines and proteases creating structural failure
Mechanical dysfunction of the annulus nucleus and end plate
Reduction in cell density proteoglycan collagen (IIIX) water binding capacity axial loading function
Ref 16-23
Intervertebral Disc Complex
IVD Collagen Type
Proteoglycan(Type and
wt)
Cell Density
Water(wt)
Cell Type Function Structure
Nucleus Type IIIVIIXXI
5-10
25-60AggrecanDecorinbiglycanFibromodulinversican
Low 70-90 Chondrocyte Compressive CELLECMGAG
Annulus Type III VIIXXI
10-15
10-35AggrecanDecorinbiglycanFibromodulinversican
High 65-80 Fibroblast Tensile Lamellarconcentric
End plate Type X
20-25
5-10AggrecanDecorinbiglycanFibromodulinversican
Low 50-60 Chondrocyte Nutrition CELLECMGAG
04272017
5
IVD Cell Types
Cell Density and Aging
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland Paper No 305 bull 55th Annual Meeting of the Orthopaedic Research Society
Immune Privilege
bull Certain sites of the human body have immune privilege meaning they are able to tolerate the introduction of antigens without eliciting an inflammatory immune response
bull Tissue grafts are normally recognised as foreign antigen by the body and attacked by the immune system
bull Brain Eye Testes Placenta Disc
04272017
6
Immune Privilege
Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege It has been demonstrated that the expression of the Fasligand is decreased in degenerated discs
The Journal of Japanese Society of Lumbar Spine DisordersVol 14(2008) No 1 P 50-57 The relationship between immune privilege of the disc and low back pain Kotaro NISHIDA1)
Immune Privilege
TGF-beta
Suppresses Mitogen and antigen-driven T cells
Suppresses mediators released by neutrophils
Suppresses nitric oxide produced by macrophages
Blocks the actions of Natural killer cells
Degenerative Cascade
Synovitis Hypomobility
Degenration
Capsular Laxity
Subluxation
Arthropathy
Zygaphophyseal Joints
Disc Resorption
Internal Disruption
Radiall Tears
CircumfentialTears
Osteophytes
Intervertebral Disc
04272017
7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
5
IVD Cell Types
Cell Density and Aging
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland
Liebscher T Wuertz K Haefeli M Nerlich A Boos N University Hospital Balgrist University of Zurich Zurich Switzerland Paper No 305 bull 55th Annual Meeting of the Orthopaedic Research Society
Immune Privilege
bull Certain sites of the human body have immune privilege meaning they are able to tolerate the introduction of antigens without eliciting an inflammatory immune response
bull Tissue grafts are normally recognised as foreign antigen by the body and attacked by the immune system
bull Brain Eye Testes Placenta Disc
04272017
6
Immune Privilege
Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege It has been demonstrated that the expression of the Fasligand is decreased in degenerated discs
The Journal of Japanese Society of Lumbar Spine DisordersVol 14(2008) No 1 P 50-57 The relationship between immune privilege of the disc and low back pain Kotaro NISHIDA1)
Immune Privilege
TGF-beta
Suppresses Mitogen and antigen-driven T cells
Suppresses mediators released by neutrophils
Suppresses nitric oxide produced by macrophages
Blocks the actions of Natural killer cells
Degenerative Cascade
Synovitis Hypomobility
Degenration
Capsular Laxity
Subluxation
Arthropathy
Zygaphophyseal Joints
Disc Resorption
Internal Disruption
Radiall Tears
CircumfentialTears
Osteophytes
Intervertebral Disc
04272017
7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
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Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
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13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
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16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
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17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
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18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
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22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
6
Immune Privilege
Recent report showed that the disc is an immune-privileged organ and Fas ligand expression may play important roles to maintain the immune privilege It has been demonstrated that the expression of the Fasligand is decreased in degenerated discs
The Journal of Japanese Society of Lumbar Spine DisordersVol 14(2008) No 1 P 50-57 The relationship between immune privilege of the disc and low back pain Kotaro NISHIDA1)
Immune Privilege
TGF-beta
Suppresses Mitogen and antigen-driven T cells
Suppresses mediators released by neutrophils
Suppresses nitric oxide produced by macrophages
Blocks the actions of Natural killer cells
Degenerative Cascade
Synovitis Hypomobility
Degenration
Capsular Laxity
Subluxation
Arthropathy
Zygaphophyseal Joints
Disc Resorption
Internal Disruption
Radiall Tears
CircumfentialTears
Osteophytes
Intervertebral Disc
04272017
7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
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Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
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13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
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16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
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Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
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20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
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22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
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23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
7
Stages of DDD
EARLY MODERATE ADVANCED
Infectious IDD
Of the 61 patients undergoing surgery for extruded disc
herniation in their series in 46 of specimens growth of
Proprionibacterium Acnes [PA] was observed and this
correlated with a greater frequency of MC type I
Albert HB et al Does nuclear tissue infected with bacteria following disc herniationsl ead to Modic changes in the adjacent vertebrae EurSpine J 201322690ndash6
Symptomatic DDDTreatment Challenges
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
8
Symptomatic DDDTreatment Challenges
Lack of adequate animal model with symptomatic chronic degenerative disc disease
Symptomatic DDDTreatment Challenges
Multifactorial Etiology
Presence of systemic pro-inflammatory conditions modulating pain pathways Obesity RA SLE DM Diets
Lack of specific biologic markers
Lack of correlation significant between diagnostic imaging and pain
Non-specific symptoms and non-specific physical findings
Diagnostic test such as provocative discography and MRI considered the ldquogold standardsrdquo have concerns with specificity and sensitivity
Lack of consensus
Lack of an Integrated Regenerative Approach
Pain can not be imaged Maybe
Degenerative Disc Disease
STAGING
RSJI STAGING SYSTEM Evaluation tool designed to standardized evaluation of symptomatic DDD from a regenerative perspective
It is utilized to assist in biologic tool selection and intervention prognosis
Utilizes four imaging classifications MRI Pffirmann (MRI) Modic (MRI X rays) Dynamic Video Discography
Co-Morbidity factors assessment that affect the overall cell function
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
9
Dynamic Video Discography
Utilizes real time video recording during discography
Allows to evaluation of contrast flow analysis based on volume not pressure
Provides critical information regarding volumetric capacity of the IVD
Better assessment of annular tear dynamics
Essential in designing tissue engineering constructs
Discography
WARNING
Spine (Phila Pa 1976) 2009 Oct 134(21)2338-45 doi 101097BRS0b013e3181ab5432
2009 ISSLS Prize Winner Does discography cause accelerated progression of degeneration changes in the lumbar disc a ten-year matched cohort study
Carragee EJ1 Don AS Hurwitz EL Cuellar JM Carrino JA Herzog R
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
10
Modic ClassificationType I
T1 Hypo-intense signal
T2 Hyper-intense signal
Bone marrow edema and inflammation
Type II
T1 Hyper-intense
T2 Iso or Hyper-intense
Often represents normal red haematopoietic
bone marrow conversion into yellow fatty
marrow as a result of marrow ischemia
Type III
T1 Hypointense
T2 Hypointense
Often represents sub-chondral bone sclerosis
Modic MT Steinberg PM Ross JS et al Degenerative disk disease assessment of changes in vertebral body marrow with MR imaging Radiology 1988166193ndash99
Pffirmann Magnetic Resonance Classification Intervertebral Disc Degeneration
Pffriman AW Magnetic Resonance Classification of Lumbar Intervertebral Disc Degeneration Spine Volume 26 Number 17 pp 1873ndash1878 copy2001
Grade StructureDistinction of
Annulus-Nucleus
Signal Intensity Intervertebral DiscHeight
I Homogeneous bright white Clear Hyperintense Isointenseto CSF
Normal
II Inhomogeneous ww0 horizontal bands
Clear Hyperintense Isointenseto CSF
Normal
III Inhomogeneous gray Unclear Intermediate Normal to slightly decreased
IV Inhomogeneous gray to black
Lost Intermediate to Hypointense
Normal to moderately decreased
V Inhomogeneous black Lost Hypointense Collapsed
Class I Inner third annulus
Class 2Outer third annulus
Class 3Through annulus
Class 4Annular Tear 30
Class 5Epidural extravasation
Dallas CT DiscogramClassification
Sachs BL et al Dallas discogram description A new classification of CTdiscography in low-back disordersSpine (Phila Pa 1976) 1987 Apr12(3)287-94
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
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16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
11
CO-MORBIDITY FACTORS
Translational Instability
Poor Core Biomechanics
Advanced Auto Immune Diseases
Nutritional Depletion
Severe Systemic Diseases
Morbid Obesity
Substance Abuse
Psychological Dysfunction
Prior Back Surgery
Chronic Infections
CO-MORBIDITY FACTORS
Greater than 2 symptomatic discs
Chronic Neuropathic Pain
Smoking History
Non-ambulatory
Failed Spinal Cord Stimulation
Failed Intra Thecal Therapies
Disability Seeking Behavior
Hormonal Deficiencies
Regenerative Disc ClassificationStage I
DHR 0 -25 Herniation 0-3mm Stenosis- None
Pfirman III
Modic O
Discography Pain-Concordant Grade 1-3
Pain Location- Mainly back Intensity Mild-Moderate
Instability None Co-Morbidities None-Mild
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
12
Regenerative Disc ClassificationStage II
DHR 0 -50 Herniation 0-6mm Stenosis- None
Pfirman III
Modic O-I
Discography Pain-Concordant Grade 1-5
Pain Location Backgt leg Intensity Mild-Moderate
Instability None Facet Hypertrophy ndash Hypo-Hyper Mobility
Co-Morbidities None-Moderate
Regenerative Disc ClassificationStage III
DHR gt50 Herniation gt6mm Stenosis- Mild-Moderate
Pfirman III-IV
Modic I-III
Discography Pain-Concordant Grade 1-5
Pain Location Back gt Legs Intensity Moderate
Instability Spondylolisthesis I Co-Morbidities Mild-Severe
Regenerative Disc ClassificationStage IV
DHR gt80 Herniation gt6mm Stenosis- Mod-Severe
Pfirman IV-V
Modic III
Discography Not indicated
Pain Location LeggtBack
Intensity Severe
Instability Spondylolisthesis I-II
Mod-Severe Co-Morbidities
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
13
Bio-Regenerative Index Prognostic Model
Stage I Very Good ndash Excellent
Stage II Good ndash Very Good
Stage III Fair ndash Good
Stage IV Poor
At this time there is not enough clinical data to validate this prognostic model
Biologic Tools
CELLS
GROWTH FACTORSSignaling Molecules
SCAFFOLDS
Polypeptides found in tissue extracts such a blood synovial fluid cells etc involved in stimulation of cell proliferation migration modulation differentiation and matrix synthesis and degradation
Essential in stimulating cells such as chondrocytes fibroblasts endothelial cells needed for connective tissue repair
Found in small concentration in tissue extracts
Can be genetically engineered
Growth FactorsBiologic Signaling Molecules
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
14
Autologous
Synthetic
Allogeneic
Growth Factors(Signaling Molecules)
PRP
Imbedded in Scaffolds Amniotic
Tissue
GDF-5BMP-2 Peptides (IGF-1)
Types of Growth Factors
Anabolic Regulators
Up regulation of cell proliferation gene expression of proteoglycan aggrecan collagen and extracellular matrix
Insulin Like Growth Factor IGF-1
Transforming Growth Factor TGF-B
Bone Morphogenic Protein BMP-2
Types of Growth Factors
Catabolic Regulators
Secreted by macrophages infiltrated in granulation tissue and apoptotic cells Metalloproteinases MMP and Aggrecanaseecreate loss of matrixTNF alpha Interleukin-1 (IL-1)PG inhibition at low concentration and aggrecan degradation at higher concentration
Interleukin-1 (IL-1)
Metalloproteinases MMP
Aggracanases
24 Dingle JTet al The sensitivity of synthesis of human cartilage matrix to inhibition by IL-1 Cell Biochem Funct 1991 999-102
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
15
Endocrine Affect multiple distant tissues usually carried in the blood
Paracrine Cells are the source of growth factors usually close contact
Autocrine Cell produces growth factors which act on the same cell
Growth Factors Mechanism of Action
Scaffolds
Scaffolds provide a provisional matrix in a three-dimensionalmicroenvironment to localize cells for cellular and molecular interactions appropriate for cell survival and differentiation
Scaffolds
Low immunogenicity
Bio-degradable and Bio-compatible
Optimal Mechanical and Architectural Properties
Non toxic
Preferably hydrophilic
Kuo CK Li WJ Mauck RL et al (2006) Cartilage tissue engineering its potential and uses Curr Opin Rheumatol
1864ndash73
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
16
Autologous
Synthetic
Allogeneic
TISSUE SCAFFOLDS
Adipose Fibrin (PPP)
CollagenAmniotic BM
Fibrin
Alginates Polymer Nano Hyaluronic Acid
Scaffold Types
Hyaluronic Acid HydrogelsA normal constituent of both connective tissue matrix and synovial fluid is a large mucopolysaccharids produced by synoviocytes and chondrocytes respectively Large molecular weight with cross-linking are preferable (Synvisc)
Fibrin GelFibrin Glue contains large amounts of fibrinogen and thrombinIdeal for growth factor delivery Autologous processed from PRP
CollagenSponges micronized allogeneic most effective with cell therapy
Human Amniotic MembraneDe-cellurized basement membrane from the innermost placental layer `composed of a thick basement membrane avascular stroma
Scaffold Types
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
17
Cell Based Therapies Treatment in which stem cells are induced to differentiate into
the specific cell type required to repair damaged or destroyed cells or tissues
Produce significant growth factors to induced stimulate endogenous stem cell population
Successful cell to cell interaction with the Niche
Survive in the recipient after transplant
Engraft into the surrounding tissue after transplant
Produce enough trophic growth factors to achieve desired effect
Avoid harming the recipient in any way
Cell Based Therapy
Coheim a German pathologist almost 130 years ago proposed the existence of non-hematopoietic stem cells He suggested that bone marrow cells can assist in the repair of process of various peripheral tissues
In 1970 Friedenstein discovered that bone marrow contained fibroblastoid cells with clonogenic potential in vitro capable of forming colonies CFU-F He was able to regenerate heterotopic bone tissue in different transplants Thus providing evidence of cell renewal potential of these cells
Friedstein AJ et al The development of fibroblast colonies in monolayer cultures of guinea-pig bone marrow and spleen cells Cell Tissue Kinet 1970 3(4)393-403
Autologous
Point of Care
Cell-Based Therapies
BMAC (Bone Marrow Aspirate Concentrate)
ADSVF (Adipose Derived Stromal Vascular Fraction)
Ex-Vivo Expansion
BMMSC (Bone Marrow Mesenchymal Stem Cells)
ADMSC (Adipose Derived Mesenchymal Stem Cells)
UCMSC (Umbilical Cord Mesenchymal Stem Cells)
OTHER TISSUES ( MUSCLE SYNOVIUM MENSTRUAL BLOOD ETC)
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
18
Cell Based Therapy
Bone Marrow Aspirate Concentrate (BMAC)Non hematopoietic fraction composed of endothelial
progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) platelets lymphocytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population less than 01-002 of total nucleated cells
Current clinical trials critical limb ischemia trials cardiac (ischemia and heart failure) stroke diabetes (III) autoimmune etc
Cell Based Therapy
Adipose Derived Stromal Vascular Fraction (ADSVF)
Endothelial progenitor cells (EPC) mesenchymal stem cells (MSC) very small embryonic like cell (VSEL) lymphocytes pericytes growth factors and other extracellular matrix factors
Mesenchymal stem cell population 5-10 of total nucleated cells
Current clinical trials graft vs host tissue reconstruction cosmetic surgery orthopedics spinal cord injury RA SLE etc
Peripheral Blood
Epiblast-like Stem Cells (ELSC)
Blastomere-like Stem Cells (BLSC)
Two distinct populations of stem cells from adult tissues Ihathave pluripotent (epiblast-like stem cells) and to- lipotetit(blastotnere-Iike stem cells [BLSCs]) capabili- ties for differentiation sitnilar to that of embryonic stem cells^^
Their identification was based on cell size cell surface markers trypan blue staining pattern and differentiation potentials^
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
19
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Epiblast-like Stem Cells (ELSC)Blastomere-like Stem Cells (BLSC)
Umbilical Cord Umbilical Cord Blood
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
20
Placental-Newborn Sources
Amniotic Fluid (Growth Factors)
Placental Tissue (Growth Factors Scaffolds)
Whartonrsquos Jelly (Scaffold Growth Factors)
Umbilical Cord (Cells MSC)
Umbilical Cord Blood ( Cells HSC)
Integrated Regenerative Approach Degenerative Disc Disease
All StagesBio-Mechanical
Core strengthening
Weight reduction
Exercise
PT Chiropractic Acupuncture Low level laser Yoga Bio feedback TENS
Nutritional Optimization
Anti-inflammatory Diet
Supplements
Hormonal Optimization
Cortisol testosterone progesterone Thyroid Estrogen
Stage I
Stage III
Stage II
Biologic Applications
Growth Factors
Growth Factors
Growth Factors
Cell Therapy
Cell Therapy
Scaffold
Stage IV Operative Care (SVF+GF+ Scaffold)
a
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
21
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage I DDD
Biologic Tools Growth Factors (PRP)
Peptides (P)
Technique Intra-Discal Injection Peri-annular
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage II DDD
Biologic Tools BMAC (CBT) + HA (S) +Peptides (GF)
Amniotic (CBT) + HA (S) +- Peptides (GF)
ADSVF (CBT) + AF (S)
Technique Intra-Discal Injection Lipoaspirate or Bone Marrow Aspirate
Interventional Regenerative Approach Degenerative Disc Disease
Diagnosis Stage III DDD
Biologic Tool ADSVF + - BMAC
HA Collagen Fibrin
Technique Lipoaspirate (50-100cc)+ Bone Marrow Aspirate
Intra-discal Injection Transpedicular
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
22
Interventional Regenerative Approach Degenerative Disc Disease
Stage IV Severe
Complex Spine Operative Care
Main role as enhancement of tissue repair
Growth Factors (PRPBMP-2 GDF-5)
Scaffolds (Amniotic BM Bone-Allografts DBMHyaluronic Acid)
Cell Therapy (ADSVF BMSVF Expanded MSC)
Intradiscal PRP
Intradiscal Injection of Autologous Platelet-Rich Plasma releasate for the Treatment of Discogenic Low Back Pain-Preliminary Prospective Clinical Trial of 12 cases
Akeda K et Al Poster presentation ORS 2013
bull Type Open Non Randomized Single ARM Patients 12
bull Diagnosis Symptomatic DDD Mainly back pain discography MRI
bull Pfirrmannrsquos Grade III- IV Grade IV- 4
PRPbull Outcome Measures VAS RDQX ray
bull MRI (4 12 months) DHI
bull Source Autologous PRP Autolgous Fibrin from coagulated whole blood and Ca Cl2
bull Type Growth factors Fibrin Sealant
bull Results Average Follow Up 11 months
bull VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
bull MRI DHI unchanged T 2 mean values unchanged
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
23
PRP
Akeda K et Al
Results Average Follow Up 11 months
VAS PRE- 77 POST 31 (+- 32) RDQ PRE- 135 POST-29 (+- 42)
DHI unchanged T 2 mean values unchanged
Intradiscal PRP
Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections A Prospective Double-Blind Randomized Controlled Study Original research PMR 2015 XXX 1-10
Yetsa A Tuakli-Wosornu MD MPH Alon Terry MD Kwadwo Boachie-Adjei BS CPHJulian R Harrison BS Caitlin K Gribbin BA Elizabeth E LaSalle BSJoseph T Nguyen MPH Jennifer L Solomon MD Gregory E Lutz MD
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
24
Intradiscal PRP
Conclusion Participants who received intradiskal PRP showed significant improvements in FRI NRS Best Pain and NASS patient satisfaction scores over 8 weeks compared with controls
Those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up Although these results are promising further studies are needed to define the subsetof participants most likely to respond to biologic intradiskal treatment and the ideal cellular characteristics of the intradiskal PRP
IntradiscalAllogeneic Fibrin Biostat
Intradiscal Injection of Fibrin Sealant for a the Treatment of Symptomatic Lumbar Internal Disc Disruption Results of a Prospective Multicenter Pilot Study with a 24-MonthFollow Up
Yin Wet al Pain Medicine 2013
bull Content Human Fibrin Sealant Bovine Thrombin Calcium Choride Synthetic Aprotinin Acetate
bull Device Biostat Biologx
bull Proposed Mechanism of ActionDown regulation of pro-inflammatory Cytokines (Interleukin 1B IL-68 TNF Proteolytic Enzymes MMP-3MMP1Upregulation of Anabolic cytokines- IL -4
bull End Point Up to 4ml or 100mmHg psi
bull Device 18g Intradiscal Trochar
bull Follow UP for 2 years
bull No new disc bulges greater than 4 cm One case of discitis 3 cases of asymptomatic reactive changes (ModicIII)
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
25
bull Most subjects had improvement in pain and function in 4 weeks Significant pain relief defined as gt 30 improvement 86 at 6 months
bull Improvement in function (gt30) 73 at 6 months
bull No change in reduction of medication use
bull No changes in T image or disc height
Intra-discal BMAC
BMAC
One-Year Results of the Use of Autologous Point-of-Care
Bone Marrow Concentrate for the Treatment Discogenic
Low Back Pain October 2013 Online
Kenneth Pettine MD
Type Prospective Non randomized 26 patients (13 one level 13 two levels)
Product BMAC (Bone Marrow Aspirate Concnetrate)
Device Celling Bio Science ART 21
Source Autologous
bull Construct Evaluation CFU
bull Endpoint 2-3cc BMAC no pressure manometry
bull No information as to the degenerative staging of the disc
bull Evaluation Tools VAS ODI
bull Results 1 year Average VAS reduction at 58 ODI reduction 56
bull 1st study to correlate CFU and outcome
bull Regardless of CFU all patients under 40 did well
bull Over 40 with CFU less than 2000 CFU-F ml less reduction in VAS ODI
bull No lumbar MRI follow up
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
26
Kenneth Pettine MD
Kenneth Pettine MD
Intra-discal BMAC
Percutaneous Lumbar IntradiscalInjection of Autologous Bone Marrow Concentrated Cells Significantly Reduces DiscogenicPain through 24 MonthsFernando Techy MD
University of Colorado Health Rocky Mountain Associates Department of Spine Surgery Fort Collins CO US Proceedings NASS 30th Annual MeetingThe Spine Journal 15 (2015) 126S
Percutaneous Lumbar Intradiscal Injection of Autologous Bone Marrow Concentrated Cells
Significantly Reduces Discogenic Pain through 24 Months
Treatment Intra-discal BMAC ( Average 120 million TNCml and CFU 300) patients (median age 40) Levels 13 One 13 two
Assessment Tool VAS ODI (Oswestry Dissabilty Index) Lumbar MRI
Follow Up Period 24 months (2326)
Results Average reduction in ODIVAS 7778 820 One grade Pffirman improvement 523 failed and underwent instrumented lumbar fusions None of those patient improved ODIVAS after surgery
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
27
Effects of the intradiscal implantationof stromal vascular fraction plus platelet rich
plasma in patients with degenerative disc disease
Comella Kristin1 Silbert Robert2 and Parlo Michelle1 Transl Med (2017) 1512 DOI 101186s12967-016-1109-0
1-3 cc of prpsvf (30-60 mill estimated not tested)
N 15 patients no discography
Average VAS scores improvement 40 some increase in mobility at 6 months 60 improve at 6month 40 showed no improvement at 6 month
ODI and BDI did not show statistically significant changes
Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy comparison with Long-Acting Steroid Injection Bhattacharya Niranjan (2012 December 5)
Human Fetal Tissue Transplantation 2013 pp 251-264
Compared injection of intradiscal and paraspinousMethylpredisolone with fresh aminiotic fluid
Results at 3 months steroid clinically superior
Results at 24 months 221 patients had sustained pain relief while 1224 patients had significant pain relief
Changes noted on VAS ODI SF 36
Ex-vivo MSC Expansion
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
28
In 2010 Yoshikawa et al analyzed the regenerative ability of autologous MSCs in markedly degenerated IVDs of two patients with chronic low back pain radiculopathy and paresthesias [25]
MSCs isolated from bone marrow aspirate were coupled with collagen sponges and grafted percutaneously to the degenerated IVD following partial laminotomy Two years after surgery both patients had significant symptomatic relief as assessed by VAS and T2-weighted MRIs showed high signal within the treated IVDs indicating high NP hydration without progressive degeneration
Disc regeneration therapy using marrow mesenchymal cell transplantation a
report of two case studies Yoshikawa T Ueda Y
Miyazaki K Koizumi M Takakura Y Spine 201035475ndash480
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
bull 129 patients undergoing microdiscecomy Age 18-60 BMI below 28
bull Sequestered cells expanded in culture and transplanted in the contralateral side small bore cannula 12 weeks post procedure
bull Volume pressure measured prior to injection 5 million cells injected per disc
bull Primary analysis at 12 months interim analysis at 24 months and final analysis at 48 months MRI used to assess the respective disc height from the sequestration date until the 2 year follow up VAS ODI SF-36 QBPDI
bull Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
Interim Results at 2 years
Trend to a decrease fluid content over the follow up period in the non treated group Treated group 41 preservation versus 25 control
Adjacent disc one or two levels also had higher water content
Patient who received ACDT had greater pain relief at 2 years
Hohaus C et al Cell transplantation in lumbar spine disc degeneration disease Eur Spine J (2008) 17 (Suppl 4 ) S492-S503
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
29
Euro Disc Randomized TrialAutologous Chondrocyte Disc
Transplantation (ACDT)
28 yo woman undergoing discectomy at L5- S1
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull 10 patient who failed conservative therapy for 6 months Average age 35 Discogenic and Radicular pain
bull Cell expansion Source Bone Marrow(90 ml 800 million total nucleated) Expansion 25 million MSC Viability 83
bull Metrics VAS ODISF-36
bull Response Greatest improvement at 3 months and continue improving to 12 months Significant improvement 71
bull Imaging The ratio of fluid content to the normal disc did not improve until month 6 to 12 Able to stop progression of degeneration
Intervertebral Disc Repair by Autologous Mesenchymal Bone
Marrow Cells A Pilot Study
Orozco L et al2011 Intervertebral Disc Repair by Autologous Mesenchymal Bone Marrow Cells A Pilot Study Transplantation 92 7 822
bull No improvement of disc height In accordance to previous studies
bull Analgesic effect mainly due to the immunoregulatory trophic effects of MSCs
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
30
A Randomized Controlled Trial Evaluating the Safety and Effectiveness of Immunoselected Allogeneic Mesenchymal Precursor Cells for
Treatment of Chronic Low Back Painrdquo24th Annual Scientific Meeting of the Spine Intervention Society (SIS) held
in New Orleans July 27-30 and received the 2016DePalma et al
Overall Treatment Success at both 12 and 24 months was achieved by 385 of the 6 million MPC group 346 of the 18 million MPC group 177 of the hyaluronic acid group and 125 of the saline group
Case 141 yo female with a longstanding history of low back pain no significant radiation or paresthesias in the lower extremities
Failed conservative therapies PT spinal decompression and LESI
Discography concordant at L4
BMI 29 Smokes 1ppd High cholesterol Poor trunk stabilization
P 1 Amniotic Graft
PRE 6 Months POST
L4L4
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
31
Case 2
63 yo female presents with a 8 year history of persistent neck pain Status post Anterior Cervical Fusion at C5-6 6-7 with resolution of left arm pain
Developed non-union and subsequently underwent a C3-7 posterior fusion with instrumentation Persistent neck pain
Did not respond to PRP (x2) Botox Spinal Cord Stimulation
BMACLIPO ASPIRATE
4 Months post procedure 50 improvement6 Months post procedure 90 improvement
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
A 48 yo female patient with intractable low back and left lower extremity radicular symptoms
Duration 6 years not responding to conservative care and interventional pain management therapeutics
Patient obtained prior neurosurgical consultation recommending an inter-body fusion with instrumentation or a total disc arthroplasty at L-5
Garcia C Treatment of Lumbar Degenerative Disc Disease withAdipose-Derived Stromal Vascular FractionPoint of CareAbstract IFATS Oct 2012 Quebec
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
32
Treatment of Lumbar Degenerative Disc Disease with
Adipose-Derived Stromal Vascular FractionPoint of Care
Lumbar MRI consistent with a L-5 central disc herniation (3mm) significant disc desiccation end plate changes and a ldquoblack discrdquo
Garcia C Abstract IFATS Oct 2012 Quebec
Biologic Construct
Adipose Derived SVF
Standard procedures were used for SVF isolation from autologous lipo-aspirate 50cc
Cells processed via a lecithin based emulsification
93 viability
80 CD 34- CD 45- CD 29+ CD90+ CD 105+
Estimated MSC injected 5 x 106
PRP - Platelet Rich Plasma
Cellerate RX Fragmented Collagen
Results
Lumbar MRI at 6 and 12 months post procedure was positive for an increased in the T2 weighted signal at the L5 nucleus consistent with ECM deposition
Preservation of disc height at the treated level (L5) and the adjacent level (L4)
No ectopic bone formation
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
33
Visual Analog Scale
0
1
2
3
4
5
6
7
8
Pre Month 1 Month 3 Month 6 Month 9 Month 12
VAS
PreLumbar MRI
T 2
6 Months PostLumbar MRI
T 2
12 Months PostLumbar MRI
T 2
v
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
34
MRI Results
Lumbar MRI T 2 weighted
Pre 12 Months Post
Conclusions
A biologic construct with autologous AD-SVF at point of care was successful in treating a patient with advanced symptomatic Lumbar DDD
ECM production in the nucleus pulposus at 6 and 12 months post-transplantation was confirmed by increased T2 Lumbar MRI
Prevention of further disc degeneration at the treated L-5 and adjacent L-4 disc was achieved
Case 4
72 yo presents with a complaint of left foot drop status post a Laminectomy decompression at L1-5 followed by a next day re-operation at L4-5 left
Excellent response in terms of back pain but developed a drop foot upon waking up from the 1st surgery
PE Absent left foot dorsiflexion
BMI 27 HTN High Cholesterol Active Farmer
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
35
Caudal Epidural AdhesiolysisAmniotic Tissue Graft
50 Improvement in dorsiflexion left foot 30 days post pro cedure
Laboratory Testing
Cell Counts and Viability
PRP Counts Endotoxin Testing
04272017
36
Thank You
04272017
36
Thank You
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