Axial Lumbar Back Pain: Surveying the Treatment Landscape

Podcast Transcript

Neuro Pathways Podcast Series

Release Date: August 1, 2024

Expiration Date: August 1, 2025

Estimated Time of Completion: 33 minutes

Axial Lumbar Back Pain: Surveying the Treatment Landscape

Alison Stout, DO

Description

Each podcast in the Neurological Institute series provides a brief, review of management strategies related to the topic.

Learning Objectives

• Review up to date and clinically pertinent topics related to neurological disease
• Discuss advances in the field of neurological diseases
• Describe options for the treatment and care of various neurological disease

Target Audience

Physicians and Advanced Practice providers in Family Practice, Internal Medicine & Subspecialties, Neurology, Nursing, Pediatrics, Psychology/Psychiatry, Radiology as well as Professors, Researchers, and Students.

ACCREDITATION

In support of improving patient care, Cleveland Clinic Center for Continuing Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

CREDIT DESIGNATION

• American Medical Association (AMA)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  
  Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit.

• American Nurses Credentialing Center (ANCC)
  Cleveland Clinic Center for Continuing Education designates this enduring material for a maximum of 0.50 ANCC contact hours.

• Certificate of Participation
  A certificate of participation will be provided to other health care professionals for requesting credits in accordance with their professional boards and/or associations.

• American Board of Surgery (ABS)
  Successful completion of this CME activity enables the learner to earn credit toward the CME requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Credit will be reported within 30 days of claiming credit.

Podcast Series Director

Imad Najm, MD
Epilepsy Center

Additional Planner/Reviewer

Cindy Willis, DNP

Faculty

Alison Stout, DO
Spine Center

Host

Glen Stevens, DO, PhD
Cleveland Clinic Brain Tumor and Neuro-Oncology Center

Agenda

Axial Lumbar Back Pain: Surveying the Treatment Landscape

Alison Stout, DO

Disclosures

In accordance with the Standards for Integrity and Independence issued by the Accreditation Council for Continuing Medical Education (ACCME), The Cleveland Clinic Center for Continuing Education mitigates all relevant conflicts of interest to ensure CME activities are free of commercial bias.

The following faculty have indicated that they may have a relationship, which in the context of their presentation(s), could be perceived as a potential conflict of interest:

The following faculty have indicated they have no relationship which, in the context of their presentation(s), could be perceived as a potential conflict of interest: Cindy Willis, DNP, Alison Stout, DO.

CME Disclaimer

The information in this educational activity is provided for general medical education purposes only and is not meant to substitute for the independent medical judgment of a physician relative to diagnostic and treatment options of a specific patient's medical condition. The viewpoints expressed in this CME activity are those of the authors/faculty. They do not represent an endorsement by The Cleveland Clinic Foundation. In no event will The Cleveland Clinic Foundation be liable for any decision made or action taken in reliance upon the information provided through this CME activity.

HOW TO OBTAIN AMA PRA Category 1 Credits™, ANCC Contact Hours, OR CERTIFICATE OF PARTICIPATION:

Go to: Neuro Pathways Podcast August 1, 2024 to log into myCME and begin the activity evaluation and print your certificate If you need assistance, contact the CME office at myCME@ccf.org

Copyright © 2024 The Cleveland Clinic Foundation. All Rights Reserved.

Introduction: Neuro Pathways, a Cleveland Clinic podcast exploring the latest research, discoveries, and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: The underlying causes of axial lumbar back pain can be diverse, and getting to the root, no pun intended, of the pain, can be challenging. In today's episode of Neuro Pathways, we're discussing the diagnostic complexity of axial lumbar back pain and surveying today's interventional treatment landscape.

I'm your host, Glen Stevens, DO, PhD, neurologist, neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to be joined by Alison Stout, DO. Dr. Stout is a medical spine interventionist in Cleveland Clinic's Center for Spine Health. Alison, welcome to Neuro Pathways.

Alison Stout, DO: Thank you so much.

Glen Stevens, DO, PhD: So Alison, before we start, why don't you introduce yourself to our audience? Tell us a little bit about your background, how you made your way to the Cleveland clinic and what you do on a daily basis.

Alison Stout, DO: I'm a physical medicine and rehabilitation spine specialist, and I was trained as an osteopathic physician. Did my intern year at Hopkins, then did most of my training in the Seattle area, and a fellowship there in spine, and was there for 20 plus years and then with my involvement in national and international organizations, was recruited to Cleveland Clinic and I've been here for two years at the Center for Spine Health in the Neurological Institute.

Glen Stevens, DO, PhD: Excellent, and your practice is primarily?

Alison Stout, DO: Clinical and then I do clinical research. My clinical research focus is in low back pain, and I'm very excited because we just got an NIH grant to be one of the centers for a multi-centered randomized controlled trial, which is the first randomized controlled trial for lumbar radiofrequency ablation for the facet joint pain in the low back.

Glen Stevens, DO, PhD: Why don't we start off by you defining what axial lumbar back pain is? I used to just call it back pain, but I guess we have to be more specific.

Alison Stout, DO: It's better to be more specific. I use the analogy of, just saying low back pain is like saying a cough, it's really a symptom. What is the underlying etiology is much more specific. And the treatment, the evaluation and treatment is much different for back pain that's associated with nerve compression. So today, we're not talking about a lumbar radiculopathy or neurogenic claudication, because that's really a different treatment pathway and actually easier in some respects. Axial low back pain when we're talking about pain that remains mostly in the spine, can be referred into the pelvis, hips, legs, but mostly stays in the spine, is a tougher workup, tougher diagnosis, and it has more limited treatments, actually.

Glen Stevens, DO, PhD: So I'm sure the numbers are all over the place, but what percentage of people will have axial low back pain at some point in their life, everybody?

Alison Stout, DO: It's close to everybody. The statistics are about 80, 85% of people will have it. The other statistic that I think most of us actually see in practice when we see patients with low back pain is, it's about 20% of people with low back pain take about 80% of the care and the cost, right? So it's a subset of people with really debilitating or severe low back pain that end up needing these, more the interventional treatments.

Glen Stevens, DO, PhD: So I come in and see you and I say, "I've got low back pain." What's the workup? What do you do?

Alison Stout, DO: That's a very good question. Now, the workup is a combination of things and the first thing we think about is, what type of low back pain? Acute versus chronic, let's start there. Well, by the time you get to me, it's been more than three months. Inevitably, it's classified as chronic, but that doesn't mean that these treatments are just for chronic pain. It's, our definition of acute versus chronic low back pain leaves us at as kind of a disadvantage of labeling. You say they've had chronic pain. Well, greater than three months is normal for people with axial low back pain that doesn't, it doesn't improve.

The workup then branches from acute versus chronic to, what's the epidemiology? What's your age group? Talking about an adolescent with low back pain who's an athlete is going to be a totally different picture than say, a 25-year-old sedentary computer engineer, as opposed to an active 68-year-old, is going to be a different subset. So we start with looking at the epidemiology of low back pain and how it affects different people in different life stages and their comorbidities. And so that's where the history is really integral, right? So the history in part is, who are you and where are you coming from?

Glen Stevens, DO, PhD: Yeah, I suspect that if you listen to the... They always used to teach you, if you listen to the history and you're not sure what it is, you need more history, that doing an imaging or those types things less likely to help you. So I'm sure it's probably the most critical.

Alison Stout, DO: It is one of the most critical components. For example, in axial low back pain, the disk is considered predominant pain generator. However, as we age and mature, facet joints on the posterior aspect of the spine becomes a bigger and bigger component. So you go from a 25-year-old who has back pain, is most likely going to be from the disk or the disk complex, the anterior column of the spine. And then as we get into our 60s, then facet joint pain becomes more and more common. Arthritis type pain becomes more and more common and you actually have less incidence of disk pain as we mature.

Glen Stevens, DO, PhD: So if I'm doing an exam on somebody and I'm palpating their back and I'm just pushing on the paraspinal muscles and they have tenderness, is that nonspecific? You don't know if it's musculoskeletal, could it be axial back pain, facet joint problem, or it's just too nonspecific? What do you see on exam with these people?

Alison Stout, DO: That's a really good question. Examination can be very helpful and one of the main things it helps with is telling if a patient's pain is very specific and discrete versus widespread, and that's sometimes the most helpful. If their pain is from the bra line to the gluteal fold, that's widespread back pain and it's much more difficult to find a concise diagnosis. Palpating the paraspinals can be very helpful. One, because you can tell if there's precise area of tenderness, right? And that could be muscular, that could be facet joint. And then discerning, is it more on one side or the other or is it truly midline? So for example, in axial low back pain, is it coming from the disk or the anterior column, versus the facet joints, the posterior column? There's really very few physical exam maneuvers that tell us where it's coming from. One of the most useful is if it's midline, predominantly midline, that is not coming from the facet joints. If it's predominantly midline, it could be from midline structures, which disk, disk complex, the anterior column, and occasionally from the ligaments or the interspinous bursa on the spinous processes.

Glen Stevens, DO, PhD: And is it typically multi-level or can you get single level, or it always involves several levels?

Alison Stout, DO: In the lumbar spine, having more than one level being a cause of pain is not uncommon. The L4-5 level is the most common level to have degenerative wear and tear changes. It is the most common to have wear and tear disk herniation at the L4-5 level. The incidence then of L5-S1 is right behind that, and L3-4 right behind L5-S1. The majority of patients have trouble localizing pain to one specific level. So many of our interventions will involve two levels at a time, because of the likelihood that L4-5 and L5-S1 are involved together and it's not, pain in that area, is not well localized.

Glen Stevens, DO, PhD: Okay. So you've listened to my story, you examine me. I don't have a focal neurologic deficit. My strength is good, my reflexes are good. Who needs imaging? And if you get imaging, are you doing a plain film x-ray, a CT scan, an MRI scan? Obviously complicated, but how do you decide?

Alison Stout, DO: So x-rays typically do rule out 80 to 90% of occult processes. They show us the osseous anatomy. Not all that helpful for discerning a pain generator, though it rules out the majority of bad things, really bad things. And those are commonly done in the emergency room, commonly already done if somebody's come to see me. If they have not been done, many payors require them before you move on to say, advanced imaging of MRI. The utility of X-ray is there, one, there's many counting anomalies that can confuse us when doing interventions or surgery with a transitional segment. If somebody's partially lumbarized in their sacrum, defining that at x-ray can be very helpful before you get to an MRI and before you get to a procedure room.

The other thing that x-ray imparts that can't be seen on other imaging is instability or changes in alignment in standing. So from my perspective, I want to know if someone's unstable, if they have a spondylolisthesis, standing x-rays often show that where a supine MRI or a CT scan, it then resolves and you don't see it. Sometimes we add flexion extension to further evaluate for instability, which can't be seen on static advanced imaging.

Mostly for deciding on interventions in surgery, MRI is the gold standard. Some patients can't have an MRI for various reasons. Sometimes we need CT scan in addition to look at the boney anatomy. Typically, the MRI for interventional stage is what we need. A CT scan is added more often than not if there is surgical planning going on.

So MRI before they get to me is great, but if not, I often order it. The important thing for anyone ordering an MRI is pre-loading the patient with some information of what to expect. We are going to see disk wear and tear, disk degeneration is not a disease. We medicalize that so much and patients read the reports and they come in with this catastrophizing of, oh my gosh, I have degenerative disk disease. But it's like, oh, you have gray hair and wrinkles and that's kind of what degenerative disk disease is, right? So, I think if anyone else is ordering it, pre-loading patients with, we are expecting to see disk wear and tear, we're expecting to see arthritis, those are typical things. We are trying to identify if these, the findings match your symptoms.

The incidence of people with disk herniations, disk degeneration, facet arthritis that's profound without pain, is significant. So in the middle-aged population, the number of people that will have disk degeneration is on the order of 60 or 65%, where only 20 or 25% will have any discernible back pain at that moment in time. So, I think when we order that, we have to be cognizant of how it affects our patients when they read those reports with lots of words that sounds scary.

Then my job when I'm seeing that, the imaging, the advanced imaging, is matching the anatomic findings of the MRI with the patient. I think that's where the art comes in because the facet arthritis at L4-5 might be profound, but yet the patient's symptoms really aren't in that location or they don't have any pain parasagittal along the facets, their pain is all midline, and I need to be looking more at the disk and these endplate changes that are there also. And discerning their history, their pain is worse with extension loading, the facet joints. That's pointing me towards looking at those facet joints more. So that history and examination are feeding my decision making when I look at the MRI.

Glen Stevens, DO, PhD: And the role of contrast on MRI?

Alison Stout, DO: That's a very good question. Contrast on MRI is no longer done as a routine basis. Gadolinium has lots of risks to it that we don't understand, as far as accumulation in brain tissue. The standard is, get a MRI without contrast and then if we need contrast, we'll do it again.

Glen Stevens, DO, PhD: So I come in to see you, you listen to my story, you examine me. I've had some imaging, I have the axial lumbar back pain, I probably have some facet joint issues. I've got no extruded disks or that type of thing. What do you do with me then?

Alison Stout, DO: So on the MRI and on the questions, as far as what to do next, facet versus ligaments can be painful and also that you don't have an extruded disk, but do you have endplate changes? So there's this newer concept over the last two or three years of what we call now, vertebrogenic pain. So for years and years and years it was disk, disk, disk, endplate, the disk herniation, the high intensity zone, the annular tears. And then it was actually at Cleveland clinic, Mike Modic, who came up with labeling these endplate changes as Modic changes and saying, hey, these people who have these endplate changes have more back pain, and larger areas of T2 Modic changes. Dr. Modic didn't like them being called Modic changes. These T2 enhancing endplate changes, which is fluid signal, suggests there's inflammation at the endplates, which as it turns out over anatomy studies recently, are really highly innervated and abnormally innervated in people with chronic axial low back pain.

And so in the last two years, a newer interventional treatment is an ablation, a neuro ablative technique called basivertebral nerve ablation, and so we do ablation treatments of the facet joints and we'll talk about those. And then the newer thing is basivertebral nerve ablation, in which we're using radiofrequency inside the vertebral body to ablate the nerve endings that go to the disc endplates.

Glen Stevens, DO, PhD: Do you do a test before you do the radiofrequency ablation to determine if it's going to be effective?

Alison Stout, DO: Yeah, in the pain world, we love our diagnostic tests first, and in radiofrequency ablation of the facet joints, doing the test blocks is standard of care. The North American Spine Society guidelines and most payors, almost all payors require for facet neuro ablative treatments, you have to do two sets of diagnostic blocks first to block the facet joints, prove that you have the right target, and then ablate these medial branch nerves to the facet joints. But those nerves sit on the back of the spine and are easily accessible. Whereas basivertebral nerve ablation has no test because that nerve bundle, it's really not a singular nerve. That nerve bundle sits within the vertebral body and is only accessed by driving an eight gauge cannula through the pedicle, and so you can't test it.

So let's say you come in, you have axial low back pain and I get your MRI and I am not sure if it's, which structure it is. You have facet arthritis, you have these type one or two endplate changes around the disk, let's say all your changes are at L4-5. I would first do what we can do diagnostically, which is facet joint medial branch blocks, that's the diagnostic injection, to see if you're a candidate for the radiofrequency ablation.

Glen Stevens, DO, PhD: Do you always do a bilateral?

Alison Stout, DO: No, no, only the side, only if the symptoms are bilateral. So we go to where the symptoms are. That's a good question. And oftentimes if people have pain that's 75 or 80% one side and they have a little bit of pain on the other side, we will also do just unilateral on the site side of the majority of pain because again in the lumbosacral area, our pain mapping ability is pretty poor. Yeah, so-

Glen Stevens, DO, PhD: Is it done under fluoro?

Alison Stout, DO: Yes. So the fluoroscopy is used for these procedures, CT's guidance could be used but is not considered necessary and is a lot more radiation exposure. So the medial branch blocks and all the radiofrequency ablative techniques are done under fluoroscopic guidance.

Glen Stevens, DO, PhD: And what's considered a response with the block?

Alison Stout, DO: So that's a contentious subject. So in payor, in the North American Spine Society guidelines and a large majority of payors, a positive response is 80% relief from your index pain. So let's say you came in with your pain was a five, your pain has to go down to a one in order to be considered a response, which is a little tricky I think especially for patients because Medicare has come out and said they don't consider... You can't ask the patients specifically percentage, what would you say your pain is relieved? And they go it's 80%, it went from a five to a three. No, they don't count that, it has to numerically decrease by 80% and patients have a hard time with that concept and oh, I didn't meet the criteria. And there are definitely pain physicians, spine physicians who vehemently would disagree with 80%, because 50% relief of really severe low back pain is a significant improvement. So that's, and there's actually multiple societies who've met with Medicare trying to change that 80% to 50%, but we'll see where that goes. Currently, most payors require 80% relief.

Glen Stevens, DO, PhD: And I assume you can't do RF unless you reach that 80% level, correct?

Alison Stout, DO: For most payors, that is correct.

Glen Stevens, DO, PhD: And what is RF? You started to talk about it earlier on, but tell us what RF is, radiofrequency ablation and what it's ablating and-

Alison Stout, DO: Yeah, that's a good question. So radiofrequency is, it's a wave, and then we're oscillating tissue at really crazy oscillations, and basically inducing heat around the needle or the electrode, and melting tissue and in a very discreet area that we know how big it's going to be because there's been studies on how big of an ablative lesion will be created by each size cannula and the 85 degrees Celsius that we use, temperature wise. So we place it on in the proximity of where we know the nerves lie anatomically. And after the area is anesthetized and or the patient is under some amount of anesthesia or sedation, then ablate the tissue. And-

Glen Stevens, DO, PhD: Is it painful?

Alison Stout, DO: It is uncomfortable, it is uncomfortable. So I have had patients who cannot have sedation and have the procedure done without sedation for the facet radiofrequency ablation. For the basivertebral nerve ablation, I have never had a patient do it without sedation because we have to get through the pedicle, yeah. So for the facet procedure, patients who have done it without sedation do describe it as being very uncomfortable. We anesthetize the tissues, however, you can't fully anesthetize the area, there's some heat escape to other tissues and it's uncomfortable.

Glen Stevens, DO, PhD: How long's the procedure?

Alison Stout, DO: The procedure depends on anatomical barriers. The procedure itself, well, and how many levels, how many areas we're treating. The procedure itself, the ablation for the facet joints is 90 to 120 seconds, but getting to the target and all that, so most of these procedures are booked for 30 to 60 minutes for the facet joints. And then for the basivertebral nerve ablation, where we're going into the pedicle, again, it depends on access and anatomical barriers and your x-ray tech's ability to move the C arm back and forth to get there. But that one is typically booked more for, let's say, two hour procedure because it's a little more difficult.

Glen Stevens, DO, PhD: So let's say I have a facet problem, you block me. How long is it good for on average?

Alison Stout, DO: So that's interesting. So the block itself and this, no matter how many times we tell patients, it's always a discussion that comes up again. The block itself is only intended to last for the duration of the anesthetic, which is one to six hours. The block itself is purely diagnostic, like going to the dentist and figuring out which tooth needs the root canal. And we're not going to do the ablation unless we find the right target, and the block unfortunately has to be done twice. For most payors and the North American Spine Society guidelines, the reason we do it a second time is to rule out a placebo response and not ablate things that don't need to be ablated. So and again, this is specific to the facet joints because there is no test injection for the endplates, the basivertebral nerve ablation.

So for the facet joints, the blocks themselves are not intended to be therapeutic. Now, there's about one in 50 people who go, no, it lasted for months, or I actually had a patient today that she had the blocks, the test injection done in March and she still has no back pain, that her back pain hasn't returned. And so that's outlier.

Glen Stevens, DO, PhD: When you normally do the second one?

Alison Stout, DO: The second one is typically a couple weeks, two weeks after the first one.

Glen Stevens, DO, PhD: So I didn't enjoy the first one. So I get to come back and do a second one?

Alison Stout, DO: Well, and if we get the wrong answer then we might have to do a third one.

Glen Stevens, DO, PhD: Thank you.

Alison Stout, DO: Yes, you're welcome. So let's say we decided it was your L4-5 and we blocked L4-5 and you go, hey, that helped, but it was only partial. My pain went from a five to a three and I just still was very uncomfortable. And I had examined you and I had said, okay, well your residual pain was still below where we just injected. Maybe you have both L4-5 and L5-S1, we would have to bring you back again to block both and L4-5, L5-S1, and then have a successful block twice before we did the facet ablation.

Glen Stevens, DO, PhD: Okay. Ablation, take us through that. How does that happen? What does the patient go through?

Alison Stout, DO: So it's having an outpatient procedure under sedation, typically, twilight awake. Patients often ask if they can be asleep and that's no, and the reason for that is it's considered more dangerous to have patients asleep. The risk with an ablation is burning tissue that we don't intend to. Ablating tissue, there is one case report published of a patient who had their L5 nerve root ablated. The patient was under propofol, not responsive. And so we have three or four different safety steps that we all follow to make sure we're not near nerve roots that go to the extremities. However, the last safety step is the patient. And so patients are responsive, must be verbally responsive. The procedure itself can be uncomfortable, but it's manageable. The second and third day after the procedure are painful, but patients have no restrictions, but there's been tissue destruction, so it's sore. That's not unusual at all. And then the healing and the improvement in pain can be delayed up to a month. Yes, so it takes a while for that tissue destruction-

Glen Stevens, DO, PhD: The word I learned today is patience.

Alison Stout, DO: Yeah, yeah, lots of patience. I think the other tough part is then the nerves still regenerate when we're facet ablation. For vertebrogenic pain in the endplates, we have not seen the nerves regenerate. We have not seen patients coming back to have it done again. But for the facet joints, we know that the nerves regenerate and they might need this repeated after six to 24 months they might need it repeated again, but they don't have to go through the test again if it's the same thing, that's the good news.

Glen Stevens, DO, PhD: Let's go into a couple other things. Caudal epidural blocks for axial low back pain. Yes? No? Insurance covers it? Doesn't cover it? Patients like it, don't like it?

Alison Stout, DO: So epidural steroid injections in general for axial low back pain are not proven to work or provide relief in the long term. Caudals especially are considered very generalized, not specific.

So I would say the one place where an epidural steroid injection could be helpful in overall decision making would be a transforaminal epidural steroid injection at the location where we think the patient's pain is coming from, specifically to see if the disk itself is painful. The rationale behind that is with a transforaminal approach, you would block the sinuvertebral nerve, which innervates the posterior annulus, and then you would at least get a diagnostic assessment if their pain was from that segment specifically.

The other thing we can do similar to that is a diskogram, but that's fallen out of favor. There was a lot of back and forth about that. We still do them, but sticking a needle in the disc is painful on purpose and we're trying to reproduce a person's pain, where if we do an epidural block, we're just trying to anesthetize their pain rather than provoke their pain, so a little more tolerable.

Glen Stevens, DO, PhD: I'm sharing a lot of personal stuff today, but I had a hockey induced disk extrusion a number of years ago and I thought I had lumbar canal stenosis because I could walk 50 feet and I had such pain in my leg, I had to stop, sit, then I could go again. I thought, oh my gosh, I got lumbar canal stenosis, and then I got a scan and I had a big extruded disk. And I know it's different than what we're talking about here, but I did one caudal epidural block and have never had a problem since. Now again, it's a different issue than what we're talking about here, but-

Alison Stout, DO: Yeah, but it's still a disk problem, right? And so I think your story proves that what we know, and that's that our bodies do heal. And so an epidural steroid injection might decrease the inflammation, which helps you be able to stand and walk and get through your activities.

Glen Stevens, DO, PhD: Well, I think that's what it did, right?

Alison Stout, DO: And it buys us time for our body to sort it out and heal it, and I think that's a lot of what we do. For example, just even the ablation of the facets or the vertebrogenic pain in the vertebrae, we're buying patients time for their bodies to heal because these procedures aren't intended to last forever. I would say on axial low back pain, on the newer stuff that is supposed to last and prevent things, the whole regenerative medicine.

Glen Stevens, DO, PhD: Yeah, that's where I was going next. So you want to talk about stem cells, mesenchymal cells? Does insurance cover it, doesn't it cover it, and-

Alison Stout, DO: Well, I call it regenerative secret sauce, right? Because there's so many different things out there. And I would say the short answer is no, it's not for prime time. No, insurance doesn't cover it. Is it exciting? Yes, it's sexy, patients are asking about it, but it's not where we need it to be for general use. I would say there's probably 10 different products in queue in the FDA that are very promising. Those are on the realm of bone marrow stem cells. Autologous cells are seemingly better, they have more of a holistic milieu of cytokines and things that are probably more helpful than say, a cell line, is what we're finding. And then there's a lot in creating a structural product to put in the disk and there's a couple different products that are currently out there. And what's exciting is mixing those cell cultures with a structural scaffold, and that's where really our basic science people really think it's going to be, is that with some genetic modification to get the right chemicals produced to balance into anabolic, away from catabolic, destruction of the disk.

Glen Stevens, DO, PhD: Need to hydrate my disks, right? Somehow.

Alison Stout, DO: And I would say the best way to do that now is with our natural healing ability and that is through exercise, not sitting so much like we're doing now. And there's a lot in what we do that's interventional and then regenerative and we forget a little bit about our own regenerative properties.

Glen Stevens, DO, PhD: Are there things we haven't discussed that you think are important in the last minute?

Alison Stout, DO: The last minute I would end with, surgery for axial low back pain is not proven to work. Surgery historically, lumbar fusion for low back pain without nerve involvement has equal odds of making patients better, worse or the same. There are the newer things like total disk replacement, not proven to be better than fusion. So we're in the same boat. There are some motion sparing devices that are out there, and it is something that we do consider at Cleveland Clinic if everything else has been tried, in very select patients. But I would say by and large, if a patient has axial low back pain, a surgical option would be a last resort.

Glen Stevens, DO, PhD: Okay. Well, I think we should have you back in a year because it sounds like a lot going on, going to be coming forward, to sort of see what shakes out and what's available and what's helpful. But I appreciate your joining us today and sharing your information with us and we look forward to it and wish you the best.

Alison Stout, DO: Thank you so much.

Closing: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast, or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website. That's @CleClinicMD, all one word. And thank you for listening.