Abstract
Introduction: There are many problems in case of treatment of the patients reporting with degenerated disc with or without disc prolapse, desiccation, bulge, or compression of the adjacent nerves and its implications. Most of the patients with chronic discogenic back pain, without specific history of trauma, are on geriatric age group. In this age group, low back pain is associated with varying degree of age-induced degenerative osteoporosis, spondylosis, spondyloarthrosis, intervertebral disc prolapse, or even compression collapse apart from other problems like diabetic background, hypertension, ischemic heart disease, chronic obstructive pulmonary disorder, dyslipidemia, and hypothyroidism. MRI presentation of a typical geriatric presentation of low back pain is shown (Figs. 19.1, 19.2, and 19.3).
Materials and methods: 42 patients participated and randomized in two equal groups. Group A (N = 21, male 10 and female 11, mean age 56.4 ± 8.9 year) was treated with 80 mg methylprednisolone in 10 mL water for injection under C-arm guidance in the operation theater (OT) after 1 % infiltration with Xylocaine at the site of maximum tenderness in the back. Similarly, Group B (N = 21, male 12 and female 9, mean age 59.4 ± 6.4 year) was also treated in the OT with similar protocol with 10 mL of freshly collected amniotic fluid from mothers undergoing hysterotomy and ligation. All the procedures passed through the donor and recipient’s informed consent protocol and vetted by the institute-based ethical committee.
Result and analysis: Studying and comparing the clinically manifested effect of treatment, it can be easily seen that both steroid (Group A) and cell therapy (Group B) patients showed improvement of pain and distress from the pretreatment value; however, Group B scoring is much better (p, 0.01), as seen and assessed from the value of the VAS (visual analog pain scale), WD (walking distance in meters), and HAQ (Health Assessment Questionnaire). If we see further the clinical assessment of pain relief and patient’s satisfaction as seen from Table 19.3 and Graph 19.1 in case of Group A (long-acting steroid group), it was 20/21 cases in 1st month which became 12/21 in 3rd month, 6/21 in 6th month, 4/21 in 12th month, and 2/21 after 24-month follow-up. Similarly in Group B (cell therapy patients), the identical values after the 1st month were 18/21, which became 21/21 in 3rd month, 21/21 in 6th month, 14/21 in 12th month, and 12/24 after 24-month follow-up. Another globally practiced guideline for pain assessment or scoring for comparison is Oswestry low back pain disability questionnaire. Here in Table 19.4 and Graph 19.2, we have again compared the effect of treatment of Group A (steroid) and Group B (cell therapy with fresh amniotic fluid) and followed up the results of Group A and Group B treatment as per scoring by Oswestry low back pain disability questionnaire up to 24 months. Here, postinjection with long-acting steroid (Group A) suggested a mean scoring of 9 ± 1.2 % SD after 3 months, which became mean 1.9 ± 1.2 % SD after 6 months, mean 39 ± 9.2 % SD after 9 months, mean 39 ± 8.2 % SD after 12 months, mean 41 ± 7.2 % SD after 18 months, and then ultimately mean 48 ± 12.2 % SD after 24 months.
Similarly in case of cell therapy group (Group B), the mean scoring was 11.7 ± 1.6 % SD after 3rd month follow-up, which became mean 9.4 ± 0.6 % SD after 6th month, mean 9.1 ± 0.96 % SD after 9th month, mean 7.1 ± 0.6 % SD after 12th month, mean 6.7 ± 0.4 % SD after 18th month, and ultimately mean 4.1 ± 0.96 % SD after 24th month follow-up.
Discussion and conclusion: If we analyze the results, we can see long-acting steroid, due to its anti-inflammatory and other activities, causes some improvement of the patients; however, it is ill sustained as noted from the follow-up. But freshly collected simple amniotic fluid cell therapy has a much more sustained effect apart from the remarkable improvement, but the question remains why in long-term follow-up there is reappearance of pain in some of the victims』 Is it psychosomatic aspects or a recurrent cell therapy or increasing the cell dosage that can have a more sustained effect』 These are some of the questions for the future investigators in this frontline area of cellular therapy.
But from an overall point of view, regeneration can only treat the root cause of degeneration of the whole lumbosacral region. Cell therapy is the only curative approach for such a generalized multisystemic deterioration of the region, and the palliative approach of pain relief with anti-inflammatory drug including steroid is short lived and has longtime use and may lead to drug-induced problems in addition of the recurrence of the symptoms.
Keywords
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Hyodo H, Sato T, Sasaki H, Tanaka Y. Discogenic pain in acute nonspecific low-back pain. Eur Spine J. 2005;14(6):573–7.
Peng B, Hao J, Hou S, Wu W, Jiang D, Fu X, Yang Y. Possible pathogenesis of painful intervertebral disc degeneration. Spine (Phila Pa 1976). 2006;31(5):560–6.
Adams MA, Stefanakis M, Dolan P. Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain. Clin Biomech (Bristol, Avon). 2010;25(10):961–71.
Le Maitre CL, Pockert A, Buttle DJ, Freemont AJ, Hoyland JA. Matrix synthesis and degradation in human intervertebral disc degeneration. Biochem Soc Trans. 2007;35(Pt 4):652–5.
Zhao CQ, Zhang YH, Jiang SD, Li H, Jiang LS, Dai LY. ADAMTS-5 and intervertebral disc degeneration: the results of tissue immunohistochemistry and in vitro cell culture. J Orthop Res. 2011;29(5):718–25. doi:10.1002/jor.21285.
Fairbank JCT, Davies JB. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66:271–3.
Tsai YL, Chang YJ, Chou CY, Cheong ML, Tsai MS. Expression of a Hoechst 33342 efflux phenomenon and common characteristics of pluripotent stem cells in a side population of amniotic fluid cells. Taiwan J Obstet Gynecol. 2010;49(2):139–44.
Siegel N, Rosner M, Hanneder M, Freilinger A, Hengstschläger M. Human amniotic fluid stem cells: a new perspective. Amino Acids. 2008;35(2):291–3.
Cananzi M, Atala A, De Coppi P. Stem cells derived from amniotic fluid: new potentials in regenerative medicine. Reprod Biomed Online. 2009;18 Suppl 1:17–27.
Bollini S, Cheung KK, Riegler J, Dong X, Smart N, Ghionzoli M, Loukogeorgakis SP, Maghsoudlou P, Dubé KN, Riley PR, Lythgoe MF, De Coppi P. Amniotic fluid stem cells are cardioprotective following acute myocardial infarction. Stem Cells Dev. 2011;20(11):1985–94.
Peister A, Woodruff MA, Prince JJ, Gray DP, Hutmacher DW, Guldberg RE. Cell sourcing for bone tissue engineering: amniotic fluid stem cells have a delayed, robust differentiation compared to mesenchymal stem cells. Stem Cell Res. 2011;7(1):17–27.
Hyodo H, Sato T, Sasaki H, Tanaka Y. Discogenic pain in acute nonspecific low-back pain. Eur Spine J. 2006;15(1):8–15.
Weiler C, Nerlich AG, Bachmeier BE, Boos N. Expression and distribution of tumor necrosis factor alpha in human lumbar intervertebral discs: a study in surgical specimen and autopsy controls. Spine (Phila Pa 1976). 2005;30(1):44–53.
Podichetty VK. The aging spine: the role of inflammatory mediators in intervertebral disc degeneration. Cell Mol Biol (Noisy-le-Grand). 2007;53(5):4–18.
Bendtsen M, Bünger CE, Zou X, Foldager C, Jørgensen HS. Autologous stem cell therapy maintains vertebral blood flow and contrast diffusion through the endplate in experimental intervertebral disc degeneration. Spine (Phila Pa 1976). 2011;36(6):E373–9.
McCanless JD, Cole JA, Slack SM, Bumgardner JD, Zamora PO, Haggard WO. Modeling nucleus pulposus regeneration in vitro: mesenchymal stem cells, alginate beads, hypoxia, BMP-2, and synthetic peptide B2A. Spine (Phila Pa 1976). 2011;36(26):2275–85.
Wang IC, Ueng SW, Lin SS, Niu CC, Yuan LJ, Su CI, Chen CH, Chen WJ. Effect of hyperbaric oxygenation on intervertebral disc degeneration – an in vitro study with human lumbar nucleus pulposus. Spine (Phila Pa 1976). 2011;36(23):1925–31.
Feng G, Zhao X, Liu H, Zhang H, Chen X, Shi R, Liu X, Zhao X, Zhang W, Wang B. Transplantation of mesenchymal stem cells and nucleus pulposus cells in a degenerative disc model in rabbits: a comparison of 2 cell types as potential candidates for disc regeneration. J Neurosurg Spine. 2011;14(3):322–9.
Bendtsen M, Bünger CE, Zou X, Foldager C, Jøregensen HS. Autologous stem cell therapy maintains vertebral blood flow and contrast diffusion through the endplate in experimental IDD. Spine (Phila Pa 1976). 2010;36(6):E373–9.
Wang YT, Wu XT, Wang F. Regeneration potential and mechanism of bone marrow mesenchymal stem cell transplantation for treating intervertebral disc degeneration. J Orthop Sci. 2010;15(6):707–19.
Blanco JF, Graciani IF, Sanchez-Guijo FM, Muntión S, Hernandez-Campo P, Santamaria C, Carrancio S, Barbado MV, Cruz G, Gutierrez-Cosío S, Herrero C, San Miguel JF, Briñon JG, del Cañizo MC. Isolation and characterization of mesenchymal stromal cells from human degenerated nucleus pulposus: comparison with bone marrow mesenchymal stromal cells from the same subjects. Spine (Phila Pa 1976). 2010;35(26):2259–65.
Jeong JH, Lee JH, Jin ES, Min JK, Jeon SR, Choi KH. Regeneration of intervertebral discs in a rat disc degeneration model by implanted adipose-tissue-derived stromal cells. Acta Neurochir (Wien). 2010;152(10):1771–7.
Ehlicke F, Freimark D, Heil B, Dorresteijn A, Czermak P. Intervertebral disc regeneration: influence of growth factors on differentiation of human mesenchymal stem cells (hMSC). Int J Artif Organs. 2010;33(4):244–52.
Bhattacharya N. Clinical use of amniotic fluid in osteoarthritis: a source of cell therapy. In: Bhattacharya N, Stubblefield P, editors. Regenerative medicine using pregnancy-specific biological substances. London: Springer; 2011. p. 395. doi:10.1007/978-1-84882-718-9_38.
Sjögren P, Halling A. Quality of reporting randomised clinical trials in dental and medical research. Br Dental J. 2002;192:100–3.
Jadad AR. Randomised controlled trials. London: BMJ Books; 1998. p. 28–36.
O’Donoghue K, Choolani M, Chan J, et al. Identification of fetal mesenchymal stem cells in maternal blood: implications for non-invasive prenatal diagnosis. Mol Hum Reprod. 2003;9:497–502.
O’Donoghue K, Chan J, de La Fuente J, et al. Microchimerism in female bone marrow and bone decades after fetal mesenchymal stem-cell trafficking in pregnancy. Lancet. 2004;364:179–82.
Anker PS, Scherjon SA, Kleijburg-van der Keur C, et al. Amniotic fluid as a novel source of mesenchymal stem cells for therapeutic transplantation 3. Blood. 2003;102(4):1548–9.
Tsai MS, Lee JL, Chang YJ, Hwang SM. Isolation of human multipotent mesenchymal stem cells from second-trimester amniotic fluid using a novel two-stage culture protocol 2. Hum Reprod. 2004;19(6):1450–6.
Perin L, Giuliani S, Jin D, et al. Renal differentiation of amniotic fluid stem cells. Cell Prolif. 2007;40(6):936–48.
Acknowledgments
The Department of Science and Technology, Government of West Bengal supported the investigator with a research grant during his tenure at Bijoygarh State Hospital from 1999 to 2006. The work started in Bijoygarh Government Hospital (1999–2006) and was followed up at Vidyasagore Government Hospital subsequently. The author gratefully acknowledges the support of the patients who volunteered for this research work. Guidance of Prof. K. L. Mukherjee of biochemistry and Prof. M. K. Chhetri, former director of health services, and Prof. B. K. Dutta of orthopedics are also acknowledged.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2013 Springer-Verlag London
About this chapter
Cite this chapter
Bhattacharya, N. (2013). Amniotic Fluid Cell Therapy to Relieve Disc-Related Low Back Pain and Its Efficacy Comparison with Long-Acting Steroid Injection. In: Bhattacharya, N., Stubblefield, P. (eds) Human Fetal Tissue Transplantation. Springer, London. https://doi.org/10.1007/978-1-4471-4171-6_19
Download citation
DOI: https://doi.org/10.1007/978-1-4471-4171-6_19
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-4471-4170-9
Online ISBN: 978-1-4471-4171-6
eBook Packages: MedicineMedicine (R0)