Back Pain Treatments on the Horizon

New and Upcoming Non-Invasive Therapies Offer Hope

Physical therapy treatment
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People who struggle with herniated disc often complain about the lack of non-invasive treatment options. Available therapies include physical therapy, injections and pain medication, and the scariest option of all: back surgery.

There are spine therapies that may soon be on the horizon for patients stuck between failed conservative care and risky spine procedures. Some are already offered on the market, while others still have a long way to go. Either way, educating yourself may lead to better decisions in the near or distant future.

Recovery from disc herniation is generally successful possibly because the disc tends to resolve itself in the span of about a year by resorbing back into the body. Even so, and even when you’ve had a battery of conservative treatments to help manage symptoms, it is possible to develop chronic pain related to the herniation.

Promising Back Pain Treatments

Chemonucleolysis with Chymopapain: Chemonucleolysis is a process by which an enzyme is used to dissolve extruded disc material. In this way, the treatment may help alleviate pressure on the spinal nerve root, along with related inflammation and pain. The first agent to be used for chemonucleolysis was chymopapain.

Chymopapain was proven successful in the 1960s and 1970s by reducing the size of disc herniations in patients.

But starting in the 80s, spine surgeons and others against adopting chemonucleolysis into routine clinical practice began pushing back against the increasing use of this treatment. In 2003, chymopapain was taken off the market.

Four years later, a Cochrane review published in Spine named chymopapain as the only minimally invasive technique to have shown evidence of reducing symptoms.

No one is completely sure why chymopapain was removed. Some cite safety concerns because approximately three percent of North Americans are allergic to the papaya enzyme. There are other potential complications, as well, including discitis, subarachnoid hemorrhage, paraplegia, and possibly acute transverse myelitis, but those in favor of using chymopapain say these can be avoided by screening patients ahead of time and only selecting for the treatment patients who are not at risk for the stated complications.

It is believed by some that the removal of chymopapain was financially and politically motivated. In other words, surgeons generally make more money on discectomies than outpatient procedures such as this one.

As chymopapain fell out of favor, the interest in and awareness of chemonucleolysis as a spine treatment was suspended, until recently.

New enzymes are now being tested for safety, as well as their effectiveness at dissolving the disc material. These enzymes are collagenase, MMP-7 and ethanol gel.

Collagenase: The enzyme collagenase is good at splitting collagen molecules, especially the type that is found in the nucleus pulposus of the disc. The nucleus pulposus is the soft, jelly-like center of the disc that allows the disc to withstand compression and torsion (twisting). This ability allows the disc to absorb shock that occurs during movement.

As mentioned above, one of the few sticking points with chymopapain was the potential for an allergic reaction. Collagenase has less risk for allergy than chymopapain, plus a good track record for decreasing symptoms in patients with lumbar disc disease.

But collagenase is not without its own risks for complications. It’s possible that taking this drug, which is often given by injection, may lead to hemorrhage, paraplegia and/or erosion of the endplate of neighboring vertebrae.

MMP-7: MMP-7 is another enzyme that breaks down proteins. It works similarly to chymopapain but perhaps offers more safety. Lab experiments on animals have been done on MMP-7, but as of June 2018, studies on humans have yet to be conducted.

Ethanol Gel: Ethanol gel is applied by fluoroscopy to a herniated disc to help to hurry tissue death of the extruded nucleus pulposus material. Originally, the drug contained only ethanol. While this first version did yield some good results for patients, it was thin and runny, leading to leaking in nearby areas, which caused pain. Ethylcellulose, a thickening agent, was added to try to mitigate this unwanted side effect. A radiopaque substance was also added to enable surgeons to see the disc while operating, as well as to detect any leaks from occurring during the procedure.

How well does ethanol gel work? Authors of a 2017 review published in the ​Journal of Pain Research reported the results of several studies involving patients with lumbar and cervical disc herniations who underwent treatment with ethanol gel. They cite, for example, a study demonstrating 44–62 percent reduction in pain after ethanol gel injection.

The researchers also mention that studies are underway, as of May 2017, that look at how ethanol gel might help tough cases of sciatica, and how ethanol gel might work in combination with pulsed radiofrequency to relieve symptoms.

Nerve Regrowth with Artemin: Regrowing nerves of the peripheral nervous system, in other words, those located outside the brain and spinal cord, is another strategy for managing symptoms related to disc herniation due to degenerative spinal changes. Examples of such symptoms include sciatica and nerve injury.

Some scientists are interested in doing exactly this for spine patients. Unfortunately, progress is slow.

In the past, scientists used growth factors to help regenerate injured peripheral nerves. In the process, though, they found that these substances also caused pain, pins, and needles and/or bowel urgencies.

Enter a new type of growth factor that works specifically on sensory neurons, which are those nerves that relay information to your brain about the things you feel—temperature, joint position, muscle tension, tickling, and pain.

The drug is called Artemin. Artemin is considered a neural regrowth, or nerve regeneration drug. Researchers envision that Artemin will be given to patients by systemic infusion, yet it will have only the targeted effect of modulating pain due to injured peripheral nerves. Researchers also anticipate that the side effects mentioned above will not be an issue for patients.

Artemin has shown promise in animal studies as well as a few done on humans. Just the same, more studies need to be completed before the drug can go mainstream. Unfortunately, as of June 2018, no studies are in the works.

Modulating Nervous System Activity with Tanezumab: Tanezumab, manufactured by Pfizer and Eli Lilly, is another drug that seeks to relieve back pain by addressing nerves. But unlike Artemin, Tanezumab affects the way in which nerve activity is modulated. In other words, Tanezumab does not regrow nerves. Instead, it helps block pain signals so you don’t feel them. This, in turn, may also help you function better in your daily life.

Both long and short-term studies comparing Tanezumab to naproxen, which is an anti-inflammatory pain medication, found that Tanezumab can hold its own against naproxen for up to twelve weeks at the higher doses. That said, Tanezumab may have more risk for complications. In general, most study authors recommend more research be done on the safety profile of this medication.

If your doctor suggests Tanezumab, you may want to ask the hard questions about side effects and complications before assuming it will be helpful as a part of your back pain management plan.

As of June 2018, research on Tanezumab continues with a 13-month study that is looking at the relief of people with chronic low back pain may experience following injections that are given every eight weeks.

Disc Cell Regeneration Therapies: Another way to heal your disc-related pain in the future may be by regenerating the cells of this structure.

Two therapies, platelet-rich plasma, and stem cell treatment may hold promise for people with disc-related back pain. But as of yet, not enough research has been done for doctors and experts to be able to recommend these for back patients.

Speed Healing with Platelet Rich Plasma, or PRP: Platelet-rich plasma, or PRP, is an injection of your own blood into an injured area. The blood is first treated by centrifuge in order to increase the concentration of platelets.

Platelets are one of several solid components that comprise blood, although the majority of blood is actually the plasma, which is liquid. Platelets may be helpful to injury healing because they contain a specific type of protein called growth factors.

Prior to the injection, you’ll first need to have your blood drawn, so that it can be taken through the centrifugation process. Once drawn, but before being centrifuged, the platelets are separated from the other components in your blood. Then, centrifuging the platelets is done to increase their concentration, possibly up to ten times the non-centrifuged amount. Next, the centrifuged platelets are reunited with the rest of your blood sample and injected into the troubled area of your body.

PRP has been on the radar of research scientists since 2011 and since then a handful of studies have cropped up. But there’s not enough evidence for experts to recommend PRP for disc-related pain.

While platelet-rich plasma is considered a very safe therapy, using it for disc disease specifically has its challenges. Some of these include the age of the patient, the potential cost of the treatment and few blood vessels in the disc, which makes it difficult for PRP to do its job of bringing cells closer together, necessary for the healing process.

Other than that, the American Academy of Orthopedic Surgeons says PRP risks are about on par with those associated with cortisone injections. These include infection, tissue damage, and nerve injuries.

Stem Cell Treatment for Spine: You may have heard of stem cell research, where cells are removed from embryos in hopes that they will be developed into life-saving medical treatments. Stem cell research has been done for many different types of treatments. But for the most part, stem cells used in disc treatment research are attained from adult donors.

Scientists developing treatments for back pain use adult stem cells because of their potential for developing into many different cell types. Stem cells also have internal repair power, where they can divide as necessary in an effort to replenish other cells.

According to the National Institutes of Health, an adult stem cell is an undifferentiated cell that is found in tissue or an organ that can be induced to differentiate into a specific (differentiated) cell type.

Scientists have been studying adult stem cells found in the bone marrow since the 1950s. And they’ve found two types: Those that form blood and mesenchymal cells. It’s these mesenchymal cells that could possibly be useful in disc-related procedures. This is because they have the potential to generate bone, cartilage, and fat cells that support the formation of blood and fibrous connective tissue.

Part of the job of research is to figure out what makes stem cells divide. For example, in bone marrow, stem cells regularly divide to help repair this tissue, but in the heart and pancreas, certain things must be in place first before such division, and repair, can take place.

But stem cell treatments for disc and other spine-related disorders are not well studied. And most, if not all, studies on this subject have been done on animals rather than humans.

Critics of stem cell treatment for back pain say that keeping the cells sterile, lack of research on stem cells for disc disorders and potential use of filler material all raise flags as to the safety and/or effectiveness of this treatment.

A Word From Verywell

While many novel therapies are still in the testing and study phase, a few, such as ethanol gel, PRP, Tanezumab and certain aspects of chemonucleolysis are developing robustly. However, most have not been tested enough to justify their use in spine medicine. A good example of this is PRP, or platelet-rich plasma treatment, which is used extensively for knee arthritis and chronic elbow tendon injuries, but not for back pain.

Scientists are also testing a combination of treatments that include some of these new additions. For example, a 2015 study published in the International Journal of Clinical and Experimental Medicine found that chemonucleolysis in combination with radiofrequency was both safe and effective for treating lumbar disc herniation.

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