- Degnerative disc disease and discogenic pain
- Herniated, ruptured, bulging, prolapsed, and degenerative discs
- Cervical, thoracic, & lumbar spine injuries and pathologies
- Atlanto-Axial-Occipital joint disorders, craniocervical instability, & whiplash injuries
- Spinal canal stenosis and neuroforaminal stenosis
- Facet arthritis, arthropathy, & arthrosis
- Sacroiliac joint pathologies
- Facet cysts, bone spurs, disc-osteophyte complexes, and other joint disease
- Spinal fractures, instability, and deformations
- Spondylosis, spondylolysis, pars defect fractures, and spondylolisthesis
- Idiopathic and degenerative scoliosis
- Radiculopathy, neuropathy, pinched nerves, and nerve pain
- Spinal cord injury and sequelae
- Neuromuscular blocks and trigger point injections
- Ligament sprains, muscle strains, and muscle spasms
- Differential diagnosis of many other potential pathologies in surrounding tissues and organs.
- Spinal epidural corticosteroid injections (translaminar or transforaminal)
- Zygapophyseal facet injections, medial branch nerve blocks, or nerve ablations
- Nerve root injections and regional nerve treatments (erector spinae, paravertebral, costovertebral, occipital, etc.)
- Minimally-invasive regenerative interventions
- Stem cell patches and anchoring with PRF
- PRF injections and fibrin sealant disc patches
- Peptide therapies
- Osteoarthritis treatments
- Bone marrow stem cell harvesting and injections
- Ultrasound imaging of nerves, joints, ligaments, and other sites of injury or degeneration
- Trigger point injections
- Myofascial release and medicated analgesic creams
- Shockwave therapy
- Spinal rehabilitation & physical therapy
- Transcutaneous electrical nerve stimulation (TENS) therapy
- Other minimally-invasive image-guided interventional spinal procedures
Spinal pain in the neck and back can be extraordinarily complex because the pain can arise from so many different mechanisms, whether neurogenic, discogenic, vertebrogenic, facetogenic, arthritic, radicular, musculoskeletal, ligamentous, mechanical, inflammatory, degenerative, or many other cellular and immune-related signaling pathways. Because of this, it is entirely possible that the level of pain does not match visible pathologies. These problems tend to result both from cellular-level biochemical signaling cascades, nerve injury with aberrant neural firing patterns, and macroscale biomechanical problems. Thus despite its high prevalence, back pain is often a misunderstood problem with a wide variety of pathological mechanisms and manifestations. Rather than perform highly-invasive surgeries with traditional complications without addressing underlying causes of pain and injury, we prefer to take a minimally-invasive regenerative approach that addresses root causes of the painful condition to maximize healing and repair.
We are the premiere clinic using stem cell therapies for numerous spine and neurologic injuries and conditions, including the use of stem cell patches that are anchored with PRF at the site of injury using minimally-invasive image-guidance to enhance survival and integration of the stem cells. These stem cell patches can be used to repair degenerative disc defects, annular tears, nerve injuries, facet arthritis, atlanto-axial-occipital joint/ligament whiplash injuries, and have even been used to repair spina bifida defects around the spinal cord in infants (1) (2). One of the mechanisms of stem cell healing for herniated spinal discs and nerve compressions may be not only direct repair of the injured tissues but also suppression of the painful inflammatory immune signaling around the injury site (3). Bone marrow stem cells have also been used to successfully treat traumatic brain injuries, which can preserve critical neural tissue architecture and suppress post-traumatic inflammatory signaling (4).
As an example of the complexity of back pain, a herniated disc can cause classic symptoms of discogenic pain, which by itself can cause much suffering, plus this can further induce painful muscle spasms and painful nerve irritations which may manifest in a variety of ways either in adjacent tissues or far away from the source. This causes long term changes to muscle tone as well as changes in neural adaptations and sensitivities that tend to have amplifying runaway feedback. To complicate matters further, all sorts of subtleties can result in dramatically different symptoms in different patients, such as the positioning of herniated disc material and what particular cell signaling pathways get hyperactivated in different patients. Some evidence indicates that herniated disc material can trigger immune reactions that are designed to digest away the disc over time but which may actually also digest other connective tissues and cause further inflammatory cascades that stimulate new vessel and nerve growth into the torn fibrocartilage of the disc. (5) (6) (7) (8)
Furthermore, the joint inflammation and instability around the herniated disc can lead to effusions and degenerative arthritis of the facet joints over time, causing further spinal degeneration. Even many physicians do not realize that the facet joint in the spine is very similar to the knee joint (it is a weight-bearing true synovial joint with fluid, capsule, cartilage, and often even has a meniscus!). As such, novel osteoarthritis treatments can be used for degenerative spinal conditions, including certain glycosaminoglycans and PRF, both of which are some of the only therapies that have evidence of regenerating cartilage degradation and protecting against arthritic changes (9) (10) (11) (12) (13). The facet joint capsule stabilizes the facet joint but can also degenerate over time or become injured in accidents with whiplash injuries or other head and neck trauma, and image-guided PRF, peptide, and/or prolotherapy injections can help address capsular ligament laxity or strain that may result in disabling neck pain (14) (15) (16) (17), especially in patients who have had whiplash injuries or connective tissue disorders (e.g., Ehlers-Danlos syndrome). Furthermore, PRF can also provide many additional significant benefits in back pain and spinal pathologies (18) (19) (20) (21) (22) (23) (24). PRF can also be concentrated with alpha-2-macroglobulin ("A2M") which acts as a master inhibitor of many cartilage-destroying enzymes and inflammatory processes, thus making it a new and unique therapeutic agent for degenerative disc disease and arthritis in the spine, and this can also be combined with another unique agent called pentosan (see the arthritis page for more information). Furthermore, PRF has also been shown to release growth factors and promote remyelination of nerves that are damaged (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35).
As we age, the discs between the vertebral spine bones can degenerate, dehydrate, tear, herniate, or rupture. While you cannot feel the actual herniated disc itself (there are no nerves in the nucleus pulposus, often making it difficult to pin down what the primary source of pain is), you can certainly have dozens of different symptoms throughout the body screaming that something is wrong. In practice, these sorts of complex problems tend to arise in progressive ways, which is why even minor symptoms warrant careful investigation. Sometimes these symptoms can be resolved with well-known interventions, or they may also be precursors and warnings of more serious damage or chronic inflammatory degenerative processes that requires more advanced treatments and regenerative interventions.
In some cases, major surgery may be necessary, but the vast majority of the time the injury can be treated with more advanced and minimally-invasive treatments that have fewer risks and faster recovery. Interestingly, surgery is typically not a good remedy for back pain unless significant compression of the nerve root is involved, as removal of degenerative and herniated discs does not necessarily provide relief and may even worsen the back pain (e.g., failed back surgery syndrome, which has dozens of potential reasons, including misdiagnosis of pain generator or missed pathology, poor fusion or failed union, poor operative techniques, durotomy/fistula, myofascial pain, poor rehabilitation, implant irritation, inflammatory responses around the disc annulus, infection, arthropathy, mechanical changes in joint movement, instability and improper neural feedback) (36) (37) (38). In addition, once a patient goes down the road of back surgery, it is not uncommon that further surgeries will be necessary, such as when fused vertebrae force increased movement and mechanical stress on adjacent levels of the spine that then also tend to herniate (adjacent segment disease) or become arthropathic (39).
Thus many therapeutic options should be explored before undergoing major surgery, including minimally-invasive interventions targeting the specific pathology such as regenerative interventions, steroid injections, facet injections, nerve blocks, trigger point injections, PRF injections, stem cell injections, arthritis medication injections, methylene blue injections, and shockwave therapy to remodel degenerative disc and bone, modulate and suppress painful nerve firing, strengthen structural connective tissues and joints, and release myofascial pain (40) (41) (42) (43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) . In fact, in studies of degenerative disc and facet joint therapies, simple extracorporeal shockwave therapy has shown superior long-term outcomes compared to more traditional therapies of steroid injections, likely because rather than weaken osseoligamentous structures, shockwave can simultaneously strengthen interspinal/iliolumbar ligaments, relax strained paraspinal musculature, and modulate neural pain feedback. (55) (56) (57) (58) (59). Shockwave has also proven useful in sacroiliac (SI) joint and hip diseases, which can sometimes mimic lumbosacral pathologies and should be carefully differentiated (60) (61), plus we can also do several types of image-guided SI joint injections to calm down inflammation and promote healing of this unique joint.
We also provide numerous therapies to treat sequelae of traumatic brain injuries, concussions, headaches, spinal cord injuries, stroke, nerve compressions and entrapments, neuropathic pain, spasms and contractures, post-traumatic and post-surgical complications, and many other neurological conditions.
Dr. McMurtrey knows firsthand how devastating back pain can be, having suffered herniated discs himself that took him out of the activities he loved for over a year and led him on a research exploration of nearly every therapy available. Despite having operated on several complex spine cases himself in his neurosurgical training and having performed several interventional pain procedures in his anesthesia training, he came to realize that he still had much to learn about how to treat the full complexity of back pain. He discovered that the signs and symptoms of back pain do not always follow classical textbook teachings and that the severity of symptoms do not always correlate with the imaging pathology for multiple scientific reasons-- for example, nerve roots and branches can be tethered or pinched between herniated discs, osteophytes, and foraminal ligaments in ways that may not be apparent on MRI, and a good neurological exam is necessary to elucidate whether transiting or exiting nerve roots are affected at the level of the herniated disc or facet hypertrophy. It is also important to remember that MRI is done lying down without weight-bearing, so some findings like degenerative changes, instability, spondylolisthesis, antero/postero/lateral-listhesis, neuroforaminal stenosis, spinal stenosis, and other findings may not actually be apparent or accurately captured on MRI. Because back pain can involve many different pathologies and deleterious signaling pathways in different people, there is not one treatment that will always work for all people, so it is like a complex puzzle that must be solved by a clinician experienced in these complexities, and the potential advantages and disadvantages of each treatment must be taken into consideration. Thus back pain cannot simply be approached from a one-dimensional perspective, and that is why the Alpine Athletic Medicine clinic has numerous resources available to provide an array of interventional therapeutic options that are targeted to your specific pathology and symptoms.
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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.