We provide many innovative approaches for fixing nerve entrapments and neuropathies. In many cases the causes are some variation of mechanical entrapment, impingement, or irritation. This can be due to many causes, from tight nerve tunnels, fascial bands, scar tissue, bony spurs, ligament hypertrophy, or other well-known entrapment sites like in the spine with disc herniations, spinal stenosis, neural foraminal stenosis, and facet arthritis, or as can happen in peripheral nerves, such as with common carpal tunnel, cubital tunnel, and tarsal tunnel syndromes as well as many other entrapment sites. In fact we have treated neuropathies of nearly every major and minor nerve throughout the body with minimally-invasive image-guided interventions, including cervical and lumbar nerve roots, stellate ganglion, median nerve, ulnar nerve, radial nerve, axillary nerve, suprascapular nerve, greater occipital nerve, lesser occipital nerve, third occipital nerve, cervical plexus, brachial plexus, interscalene plexus, intercostal nerve, sciatic nerve, femoral nerve, gluteal nerve, cluneal nerve, tibial nerve, fibular/peroneal nerve, obturator nerve, lateral femoral cutaneous nerve, sural nerve, saphenous nerve, and many other deep, superficial, cutaneous, sensory, motor, and autonomic nerves. We also diagnose and treat other complex syndromes like thoracic outlet syndrome and complex regional pain syndromes (CRPS), and many educational videos showing our nerve release procedures can be seen on our Instagram page, Facebook page, and YouTube videos.
We routinely treat neuropathies in both acute and chronic stages, and we always seek to first address the root cause of the neuropathy before simply masking the pain or providing temporary symptomatic relief. Once the source of the nerve pain is elucidated, then that particular problem can be targeted with a variety of therapies, medications, and minimally-invasive interventions. While we do prescribe neuropathic pain medications, it is important to recognize that these do not actually remyelinate the nerve nor resolve the root cause of the neuropathy, but instead these only provide symptomatic relief and often have unwanted systemic side effects. Therefore we take a more proactive regenerative approach to neuropathies, seeking to provide actual therapeutic interventions to the nerve itself.
Neuropathies can arise due to a variety of injuries and conditions, and we treat everything from simple single nerve entrapments to complex regional pain syndromes (also see our pain page for acute and chronic pain management strategies). Our tools include everything from neuropathic pain medications (oral and topical) to advanced minimally-invasive image-guided nerve release to interventional regenerative therapies and, if necessary, nerve blocks or nerve ablations. The following are just some of the interventional tools and modalities we utilize in providing pain relief and restoring nerve functions, the exact choice of which will depend on the specific location and pathology and whether the nerve is acutely injured or has begun chronic demyelination [Note: many of these can also be combined together in the same injection]:
- Image-Guided Hydrodissection: in some cases, a simple saline solution, PRP, and/or D5 can be used to open up nerve spaces and dissect away scar tissue or fibrotic fascial scar entrapments from around the nerve, thereby relieving pressure, calming the nerve, and allowing the nerve to glide more freely.
- Image-Guided Nerve Releases and Regional Nerve Blocks: blocking the nerve not only can provide significant relief for several hours while the block is in place, but also is enough to calm the nerve down to provide relief even after the block wears off. Using image-guidance, we can target nerve roots via transforaminal or interlaminar approaches, medial branch blocks, peripheral nerves along the brachial plexus or lumbosacral plexus (e.g., axillary, median, ulnar, radial, interscalene, stellate ganglion, sphenopalatine pterygopalatin ganglion, trigeminal ganglion, occipital, suprascapular, dorsal scapular, femoral, obturator, sciatic, tibial, peroneal, sural, saphenous, plantar, and many other nerves).
- Image-Guided Corticosteroid Injections: this class of steroids includes powerful agents that can calm inflammation in the nerve, suppress scar tissue formation, release fascial entrapment, and open up nerve spaces for improved nerve gliding. These steroid injections can be given in the epidural space around spinal nerve roots or at targeted sites along peripheral nerves. Research has shown that chronically compressed nerves become more inflammed, sensitive, and reactive due to impedance in axoplasmic flow and demyelination; however, glucocorticoid injections help to suppress and reverse this reaction at the injury site and along the nerve sheath.
- Image-Guided Platelet-Rich Fibrin (PRF) Injections: PRF provides numerous growth factors, biochemical activators, biologic glue, and scaffolding matrix that have been shown to enhance healing and regeneration of nerve. We concentrate and maximize natural healing factors from your own plasma and platelets directly at the nerve injury site for maximal benefit. With each type of injury, it is also essential to understand when to use leukocyte-rich versus leukocyte-poor preparations, when to use platelet-rich fibrin versus plasma, and how to inject at the optimal site of an injury using image-guidance to avoid hitting the nerve itself but bathing the nerve sheath with the healing nutrients. Fibrin has also been used by many neurosurgeons to repair peripheral nerves, and platelet-rich fibrin (PRF) has been shown to promote schwann cell proliferation and remyelination of peripheral nerves [1-7], which may be useful in many cases of nerve injury and peripheral neuropathy. The benefits of plasma-derived PRF are dramatically enhanced when in is injected at targeted nerve sites under ultrasound-guidance. PRF and its signaling factors have also been shown to activate recruitment and differentiation of Mesenchymal Stem Cells (MSCs) as well as enhance expression of several essential tissue remodeling genes [8-11]. PRF can also be used as a medium for numerous types of stem cells which enhances stem cell survival, proliferation, migration, and differentiation [12-19]. For tissue and joint regeneration, PRF has the advantage of causing platelets to bind to fibrin, which initiates biochemical activation of certain cells, platelets, and growth factors and also provides an organized scaffolding matrix and natural fibrin glue to help heal structural tissue damage. Ongoing studies of plasma-derived orthobiologic agents have also shown significant effectiveness in low back pain and spinal disorders like facet joint arthritis, discogenic pain, and other spine pathologies [19-28]. Alpine Athletic Medicine was one of the first clinics to perform PRF repair and to use direct ultrasound-guided visualization to maximize repair at the exact injury site while minimizing any needle damage in healthy tissue. Dr. McMurtrey originally developed image-guided PRF repair techniques for his own injuries after completing his research thesis in tissue engineering and stem cell signaling at the University of Oxford as well as other early work around the globe in PRF isolation, activation, and injection for injury repair.
- Image-Guided Injections of Orthobiologic Agents: Orthobiologics can include peptides, biologic agents, PRF, plasma-derived agents, and/or autologous cells, which all activate specific cell receptors and signaling pathways to drive unique cellular functions such as anti-inflammatory effects, remyelination, wound healing, and tissue repair [29-35]. These again are injected with the use of targeted neuromusculoskeletal ultrasound imaging.
- Image-Guided Injections or Infusions of Vitamins & Nutrients for Nerve Repair: Several vitamins, nutrients, and other medications can also be injected at the nerve injury site, including Vitamin B12 (Methylcobalamin), Alpha-Lipoic Acid (ALA), Glutathione (GSH), Levocarnitine (L-carnitine), Folate, D5, Methylene Blue, and other agents that have shown evidence of acting on various cell signaling mechanisms to help calm and repair nerves [36-44].
Nutrition for Neuropathy, Neuritis, & Myelin Repair - the myelin that supports proper nerve signal transmission is made primarily of lipids (70%), including phospholipids (50%), cholesterol (27%), and glycosphingolipids (17%), and the rate-limiting step in myelin synthesis appears to be cholesterol production. About 30% of myelin is protein embedded in the fatty layers. Some evidence suggests supplementation with phospholipids can help repair myelination defects , so those with neuropathic conditions may want to consider supplementing with various components of myelin. The study referenced above used 55% phosphatidylcholine + 20% phosphatidylethanolamine as 3% of the diet, with most of the fats being lineoleic components (60%) as well as smaller amounts of oleic, linolenic, palmitic, and stearic fats. It may also be useful to add protein and cholesterol such as that found in eggs, as well as omega-3 fatty acids and lecithin (which makes up ~11% of myelin) and alpha-lipoic acid, which we can provide as an IV infusion [46-47]. Eggs have the added benefit that they have small amounts of FGF that promotes tissue repair and mesodermally-directed stem cell differentiation, plus they are composed of a very similar amino acid composition to muscle, meaning that when they repair muscle there is not a lot of extra amino acids left over for conversion into fat. Because L-carnitine helps transports fats into the mitochondria and metabolic byproducts back out, it may also play an important role in remyelination. Palmitoylethanolamide from nuts and egg yolks may also act as an anti-inflammatory agent and analgesic in addition to membrane repair. Several other agents such as α-lipoic acid, benfotiamine, CDP-choline, curcumin, quercetin, vitamin B12, vitamin D, and EGCG (from green tea extract) have also shown some evidence of benefit in nerve repair. Vitamin B12 in particular can provide significant therapeutic benefit for some peripheral neuropathies, and we are one of the few clinics in the world that can perform image-guided injections of B12, Folate, Glutathione, PRF, Peptides, ALA, D5, Corticosteroids, and other agents directly around injured nerves to optimize myelin repair at the injury site [47-50]. The peptides page, PRF page, and infusion page further discuss more potential re-myelination therapies with good scientific support.
(1) Effects of Leukocyte-Platelet Rich Fibrin (L-PRF) on Suppression of the Expressions of the Pro-Inflammatory Cytokines, and Proliferation of Schwann Cell, and Neurotrophic Factors
(2) Comparison of the Regenerative Effects of Platelet-Rich Fibrin and Plasma Rich in Growth Factors on Injured Peripheral Nerve: An Experimental Study
(3) Effect of Platelet Rich Fibrin on Sciatic Nerve Regeneration in a Rat Model
(4) Platelet-Rich P Combined with Low-Dose Ultrashort Wave Therapy Accelerates Peripheral Nerve Regeneration
(5) Platelet-Rich P: a Promising Product for Treatment of Peripheral Nerve Regeneration after Nerve Injury
(6) Effect of Platelet-Rich P on Peripheral Nerve Regeneration
(7) Experimental Study on Autologous Injectable Platelet Rich Fibrin Combined with Bone Mesenchymal Stem Cells in Treating Sciatic Nerve Injury in Rats
(8) Proliferation-promoting effect of plasma on human adipose-derived stem cells and human dermal fibroblasts
(9) Plasma enhances mesenchymal stem cell proliferation and chondrogenic differentiation
(10) Human plasma stimulates migration and chondrogenic differentiation of human subchondral progenitor cells
(11) Adult and umbilical cord blood-derived plasma for mesenchymal stem cell proliferation, chemotaxis, and cryo-preservation
(12) Injectable-platelet rich fibrin using the low speed centrifugation concept improves cartilage regeneration when compared to platelet-rich plasma
(13) Role of Platelet-Rich Fibrin (PRF) and Platelet-Rich Plasma (PRP) in Oro-Facial Tissue Regeneration: A Narrative Review
(14) Fibrin and Activated Platelets Cooperatively Guide Stem Cells to a Vascular Injury and Promote Differentiation
(15) Effect of scaffold dilution on migration of mesenchymal stem cells from fibrin hydrogels
(16) Shedding light in the controversial terminology for platelet-rich products: platelet-rich plasma (PRP), platelet-rich fibrin (PRF), platelet-leukocyte gel (PLG), preparation rich in growth factors (PRGF) classification
(17) Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing
(18) Platelet-rich fibrin: evolution of a second-generation platelet concentrate
(19) Human fibrin is a physiologic delivery system for bone morphogenetic protein (20) Platelet-Rich Fibrin and Its Emerging Therapeutic Benefits for Musculoskeletal Injury Treatment
(21) Platelet-Rich Fibrin Scaffolds for Cartilage and Tendon Regenerative Medicine: From Bench to Bedside
(22) Advanced Platelet-Rich Fibrin: Biological Achievements and Clinical Advances in Modern Surgery
(23) Leucocyte and Platelet‐rich Fibrin: a carrier of autologous multipotent cells for regenerative medicine
(24) Cytokine and Growth Factor Delivery from Implanted Platelet-Rich Fibrin Enhances Rabbit Achilles Tendon Healing
(25) Do the fibrin architecture and leukocyte content influence the growth factor release of platelet concentrates?
(26) The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane
(27) Blood products in the management of chronic low back pain: a critical review
(28) Use of Blood Products in Treating Low Back Pain: A Review of the Current Literature
(29) Growth Hormone Improves Nerve Regeneration, Muscle Re-innervation, and Functional Outcomes After Chronic Denervation Injury
(30) Growth hormone treatment enhances the functional recovery of sciatic nerves after transection and repair
(31) Effects of human growth hormone on peripheral nerve regeneration
(32) Treatment of neurological injury with thymosin β4
(33) Neuroprotective and neurorestorative effects of thymosin β4 treatment initiated 6 hours after traumatic brain injury in rats
(34) Thymosin β4 Promotes the Recovery of Peripheral Neuropathy
(35) Thymosin beta4 activates integrin-linked kinase and promotes cardiac cell migration, survival and cardiac repair
(36) Effects of methylene blue on postoperative low-back pain and functional outcomes after lumbar open discectomy
(37) Methylene Blue Reduces Neuronal Apoptosis and Improves Blood-Brain Barrier Integrity After Traumatic Brain Injury
(38) Methylene Blue Application to Lessen Pain: Its Analgesic Effect and Mechanism
(39) A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain
(40) Effect of Intradiscal Methylene Blue Injection for the Chronic Discogenic Low Back Pain
(41) Cognitive Improvement with Glutathione Supplement in Alzheimer's Disease: A Way Forward
(42) Cognitive impairment and vitamin B12: a review
(43) Effects of Folic Acid and Vitamin B12, Alone and in Combination on Cognitive Function and Inflammatory Factors in the Elderly with Mild Cognitive Impairment
(44) Targeting myelin lipid metabolism as a potential therapeutic strategy in a model of CMT1A neuropathy
(45) Characteristic Composition of Myelin
(46) Effects of consumption of choline and lecithin on neurological and cardiovascular systems
(47) Ultrasound-guided Perineural Vitamin B12 Injection for Peripheral Neuropathy
(48) B12 as a Treatment for Peripheral Neuropathic Pain: A Systematic Review
(49) The Impact of Supplements on Recovery After Peripheral Nerve Injury: A Review of the Literature
(50) Vitamin B12 Enhances Nerve Repair and Improves Functional Recovery After Traumatic Brain Injury by Inhibiting ER Stress-Induced Neuron Injury.
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*Disclaimer: The information presented here is for informational use and cites the ongoing cutting-edge research and medical advancements on these relevant topics. There are many treatments, interventions, and protocols routinely practiced in medicine and surgery which the FDA has not studied nor formally approved yet which have demonstrated overwhelming evidence of efficacy and clinical benefit. The FDA does not regulate the practice of medicine but rather regulates medical marketing of devices and drugs. The FDA does not conduct clinical trials or attempt to discover new treatments, but rather requires companies or other entities to fund marketing approvals. Breakthrough technologies typically require years to decades of research work to optimize the technology and collect enough data to prove efficacy and superiority, which in some cases can optionally be submitted to the FDA if there is sufficient financial backing to market a specific product or drug. Thus the FDA has not yet studied, evaluated, or formally approved many regenerative therapies currently practiced by many of the top physicians and surgeons in the United States and around the world. Some therapies, products, or interventions may still be considered investigational or "off-label" even with substantial evidence of efficacy, and many different applications of regenerative therapies continue to be researched by our institute and other top institutions around the world. We seek to always provide the highest-quality evidence-based care to our patients, which may include FDA-approved therapies as well as additional investigational or alternative therapies. We always discuss potential risks and benefits of all these options. The rapid evolution and advancement of medicine demands that physicians continually update their knowledge and practice techniques to adapt to future improvements and advancing technologies. These statements have not been evaluated by the FDA, and the treatments and products presented here are for informational purposes and not intended or guaranteed to diagnose, treat, cure, or prevent any specific disease or condition. All injuries and conditions should be formally evaluated by a knowledgeable medical professional whereby standard treatments and/or additional therapeutic interventions may be considered with the diagnosis and treatment plan.