Regenerative Medicine & Peripheral Nerve Endoscopy

The human desire for everlasting youth and well-being has persisted throughout history. In the modern era, advancements in medicine and the emerging field of longevity have brought this age-old aspiration closer to realization. The remarkable increase in global life expectancy from a mere 30 years in 1870 to an impressive 71 years today, is a monumental healthcare achievement over the past century and a half. This achievement carries profound implications for the economy, necessitating a deeper understanding of the aging process and its influence on economic decision-making. Furthermore, it raises concerns regarding the adjustments required in behavior and lifestyle to adapt to extended lifespans while maintaining a high quality of life. The rise in life expectancy has substantial implications for managing chronic health conditions. Low back pain is nearly ubiquitous, and its global disease burden, particularly in high-socioeconomic standard countries, is high.

The youth and longevity business has carved out a niche from the traditional healthcare industry solely concerned with maintaining a high quality of life while managing the aging process. In this chapter, the authors deliver their perspective on the economic decision-making patterns of an aging population, the demographic changes associated with extended lifespans, and the adaptations in retirement planning and utilization of healthcare systems and social welfare programs. Further, the authors reflect on how aging spine patients adjust their behaviors and lifestyles to align with the demands of prolonged lifespans, prompting considerations of the economic consequences of these adjustments. The pursuit of healthy longevity raises questions about productivity, workforce participation, and the financial implications of supporting extended retire ment periods. Healthy longevity refers to empowering individuals to lead longer lives while maintaining optimal physical, mental, and emotional well-being. Achieving healthy longevity entails making choices that significantly impact long-term health outcomes. The authors describe how the otherwise healthy low back pain patient over 50 should adopt a healthy lifestyle, including regular exercise, balanced nutrition, and stress management, to promote healthy aging while enhancing the quality of life during extended lifespans.

Degenerative disc disease stands as the predominant etiological factor behind low back pain. In recent years, the therapeutic modality of mesenchymal stem cell (MSC) infusion directly into the nucleus pulposus of the deteriorating disc has gained prominence. The intricacies of the intervertebral disc, a biomechanically robust tissue, span its components - the annulus fibrosus, nucleus pulposus, and cartilaginous endplates. Compromising the integrity of these elements can precipitate advanced disc degeneration due to biomechanical disruption. Animal models have demonstrated the therapeutic potential of MSCs. Particularly, adipose-derived stem cells (ASCs), a subset of MSCs originating from adipose tissue, possess attributes akin to their bone marrow-derived counterparts, metamorphosing into mesodermal structures, encompassing bone, cartilage, muscle, and fat. Their abundance in the human system, coupled with minimally invasive extraction methods, makes them appealing for regenerative medicine applications. A comprehensive literature assessment presented in this chapter delineates the therapeutic paradigm of MSCs in addressing degenerative disc disease (DDD) pain. To date, research predominantly centered on the nucleus pulposus, while neglecting the annulus fibrosus and cartilaginous endplates. Notably, clinical manifestations like annular ruptures, Modic alterations, or Schmorl's nodal formations typically hint at pathologies within these overlooked structures. The prospects of successful regenerative interventions within the annulus, endplates, or nucleus pulposus remain controversial, considering the hostile, nutrient-deprived milieu of the deteriorating intervertebral disc often culminating in the swift demise of the introduced MSCs. Singularly targeting the compromised nucleus pulposus via existing MSC-centric regenerative modalities may not achieve disc restoration. Therefore, MSC-based theurapeutic strategies should not just include the nucleus pulposus but also the affected annulus fibrosus and cartilaginous endplates.

Degenerative disc disease, coupled with its consequential low back pain, presents a profound global health challenge, with efficacious clinical interventions still being subject to controversy. Cutting-edge strategies are being developed, targeting both pain mitigation and tissue regeneration. Both concentrated bone marrow aspirate and mesenchymal stem cells (MSCs) have displayed clinical potential in alleviating pain associated with degenerative disc disease. By harnessing molecular and genetic techniques, the utilization of growth factors, cytokines, and the modulation of autophagy and apoptosis processes offers hope in arresting disease progression, fostering tissue recuperation, and tempering inflammatory cascades. This chapter furnishes readers with a contemporary overview of therapeutic and regenerative modalities in clinical use and succinctly delineates the grading of the extant pinnacle clinical evidence.

The functionality of the intervertebral disc can be compromised due to aging and injuries. Synthetic and composite materials are investigated for disc repair to reduce pain. Synthetic materials or composite implants lack interaction with the disc's biological components and have yet to gain widespread usage or achieve desirable outcomes in treating intervertebral disc disorders. This chapter examines bioengineering approaches to disc repair, including cell-enhanced materials or biologically derived acellular materials that allow for cellular interactions and remodeling within the intervertebral disc. While still in its early stages, bioengineering techniques utilizing innovative biomaterials are showing promise as potential alternatives for the clinical treatment of intervertebral disc disorders.

The vertebral endplate is a critical component of the intervertebral disc, and its dysfunction can lead to various spinal disorders and chronic back pain. The structure and function of the vertebral endplate play an important role in disc nutrition, biomechanical support, and waste removal. Endplate-related conditions and their respective pathophysiologies may play a role in painful degeneration, fractures, and Modic changes. This chapter summarizes current concepts of therapeutic strategies with an emphasis on regenerative medicine application. It discusses using mesenchymal stem cells, platelet-rich plasma, growth factors, and tissue engineering approaches for endplate regeneration and repair. Diagnostic strategies for assessing vertebral endplate disorders and palliative as well as regenerative treatment strategies are discussed. The current evidence, ongoing research, and prospects in endplate-based therapies are highlighted.

Spinal cord injury with neurological deficits is devastating to patients and their families. After the immediate treatment that may involve spinal decompression and stabilization surgeries, patients are typically left with long-term disability. Intense research has focused on spinal cord regeneration, tissue repair, and reinnervation to improve function. Stem cell-based therapies are at the center of this effort. This chapter summarizes common spinal cord injury (SCI) patterns, including complete and incomplete SCIs, and their classification-based prognosis and treatments. They review the types of stem cells used in preclinical and clinical trials in the treatment of SCI and the associated ethical concerns and summarize the current state of the art of stem cellbased SCI treatments. 

As surgeons evolve to minimize morbidity and maximize outcomes or return-to-work (RTW) in the treatment of carpal tunnel syndrome (CTS), so have both single portal neuro-endoscopy and ultrasound-guided (US) technical applications procedurally in the safe, effective, and complete release/transection of the transverse carpal ligament (TCL). The chapter is intended as an independent complete go-to content-repository for surgeons desiring to revisit/review a relevant topic or area of thought without needing to reread the entirety of the same prior to a surgical case as a quick refresher. For those surgeons who have either mastered neuro-endoscopy or remain a novice, US techniques may offer patients new possibilities through the simple overlay of novel instruments and instructions over one’s accumulated past experience.

Low back pain from arthritic lumbar facet joints and painful degenerative lumbar discs is widespread and one of the world's most disabling diseases, consuming significant health care resources. In this chapter, the authors report using autologous platelet-rich plasma (PRP) and ozone spinal injections into arthritic lumbar facet joints and painful lumbar degenerative discs to treat inflammatory pain. A prospective observational cohort study from January 2016 to March 2020 was performed at an outpatient clinic of a single academic medical center to assess these injections' safety and therapeutic effectiveness in conjunction with epidural transforaminal epidural steroid injections. Results indicated functional improvements measured by Oswestry Disability Index (ODI) and modified MacNab criteria and pain measured by visual analog scale leg pain (VAS) at rest and during flexion. Although our study was limited in scope, and by the observational nature of our research and the lack of randomized and double-blinding, our work suggests that rapid pain reduction and functional gains may materialize in patients with low back pain due to herniated disc after spinal injections with ozone and activated PRP.

The management of mid-stage degenerative disc disease presenting with pain remains contentious, attributed in part to the scarcity of conclusive clinical trials. Allogeneic mesenchymal stem cells (MSCs), procured from donors, emerge as a viable alternative to autologous stem cell therapy. These MSCs are characterized by their accessibility and the streamlined administration process suitable for procedure-room settings, particularly for addressing discogenic lumbar pain. Within this manuscript, the authors delineate their proprietary protocol involving allogeneic MSC application, detailing the efficacy, safety, and clinical implications post-infusion into symptomatic lumbar intervertebral discs. Their clinical series encompassed 32 subjects, 14 females and 18 males, averaging 47.6 years of age, with a mean follow-up duration of 26.88 months. Two-year post-treatment evaluations revealed notable decrements in both ODI and VAS scores for lumbar pain. Evaluating Macnab outcomes, 11 participants (33.3%) showcased excellent results, 19 (57.6%) reported good outcomes, and a mere 3 (9.1%) indicated fair results. Notably, none necessitated supplementary interventions at the MSC-treated disc level. Despite the study's constraints, such as its observational nature, potential selection and hindsight biases, and modest participant count, the authors' findings substantiate the potential of intradiscal allogeneic MSC injections in managing mid-stage painful degenerative disc afflictions. To fortify these preliminary insights, future research endeavors should encompass a more regimented structure, potentially incorporating a placebo cohort or a natural progression study group.