How to Approach Degenerative Discs with PRP | Conversations in Regen Episode 21

Discover how leading physicians are transforming spine care with orthobiologics, from PRP for spine to Discseel, and why this approach is redefining degenerative disc disease management.
Visit my Website : https://pxllnk.co/AD/BOBsite – Learn More About Advanced Orthobiologics

This content is intended for medical professionals, including spine specialists, pain physicians, and orthopedic surgeons, but patients curious about regenerative spine treatments are welcome to watch.

In this insightful session, Dr. Ariana DeMers, the Queen of Business Orthobiologics, sits down with renowned interventional pain physician Dr. John Knab to explore the forefront of spine care. They discuss the latest evidence and techniques for using PRP for spine, highlight the role of Discseel in repairing annular tears, and provide guidance on managing degenerative disc disease in clinical practice. Beyond treatments, they share strategies for integrating orthopedic innovation into a regenerative practice, addressing both scientific and practical considerations, and offer actionable insights that physicians can apply immediately to enhance patient outcomes and practice success.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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Transcript

SPEAKER_02 0:00

This is crazy, and I'm so thankful that you've said you've got to get the right diagnosis first. And the likelihood is that it's probably E, all of the above.

SPEAKER_01 0:12

So if you're just looking at the report and you just see degenerative disc disease, they don't mention the annular tear, and it's so bright, so white, and it's ipsilateral to their pain, and you're like, well, please, you know, you have to look at the images.

SPEAKER_02 0:25

The next question is what's the most misleading thing that patients are told about their disc problem before they ever reach someone who treats it? Welcome everybody. This is Conversations in Regenerative Medicine, and we are exploring frontiers in PRP, BMC, and MFAT. We are excited to bring controversial topics and cutting-edge insights that are shaping the future for interventional orthobiologics. And so we're gonna get started. I am so, so happy to introduce you all to my friend and colleague, Dr. John Kanab. He is a board-certified fellowship trained interventional pain physician with over two decades of exclusive pain medicine practice. He is a sought-after educator and speaker and planner of events like Toby, IOF, RMLS, and international spine conferences. And he has successfully built a cash-based regenerative practice that is focused entirely on non-surgical solutions for spine and joint pain. And, you know, passionate about advancing intradiscal biologics to help physicians understand what the evidence actually says. And when we first met, my favorite part of him as a human and as a person is that he is, by personal exclamation, an incrementalist. So that is one of my favorite things that you say about yourself is you know, we don't go get too crazy. We're I'm an incrementalist. So that is one of my favorites. For those of you who don't know who I am, I am Dr. Ariana Demers. I am a board-certified fellowship trained sports medicine orthopedic surgeon and regenerative medicine aficionado. I do a lot of educating and training for both orthobiologics and ultrasound. And I have successfully moved my rural Northern California practice away from insurance, and I focus on cash-based orthobiologic procedures, and I am passionate, capital P passionate about helping doctors to successfully and seamlessly integrate orthobiologics into their practices. So I'm so glad that you all are here and joining us today. This is exciting, and this is a little different. This is a little bit more informal, just amongst friends, chatting about the things that we're passionate about. So we are gonna explore the controversial topics in orthobiologics and regenerative medicine, maybe gain some actionable insights that you can implement in your practice immediately. And of course, one of my favorites is participating in that live QA session to get your burning questions answered. So so glad to have you, John. I'm so glad that we this worked out for us, and I think this is gonna be really fun. What a treat for everybody to have you as our human today. That hot seat, if you will.

SPEAKER_01 3:53

No, it feels fine, feels nice and cool.

SPEAKER_02 3:56

Well, hey, happy St. Patrick's Day to you.

SPEAKER_01 3:58

Happy St. Patrick's Day. I'm here at Patty's bar.

SPEAKER_02 4:01

Ah, that's so good.

SPEAKER_01 4:02

Hopefully you can hear me over all the all the noise.

SPEAKER_02 4:04

All the din. Yeah, yeah, yeah. That everyone's you know green beering it up. So thank you so much for taking time out of your St. Patrick's Day to join us. I really appreciate it. So I wanted to share that I believe that orthobiologic treatments will be first line treatment for musculoskeletal care in the next five years. And so if you are not currently offering these treatments, you gotta get on the train. The train is leaving the station. And so hopefully this helps those of you who are maybe at the station but not on the train, getting a little bit further down that path. You know, also having a successful orthobiologics practice is what we're looking for, but sometimes it's hard. And we know orthobiologics is the best treatment for our patients, but how do you be successful at it? And maybe some of you have tried some things, maybe you're not sure about the science, not sure about the techniques, not sure about cash business, marketing, sales. And maybe you've just thought, gosh, I'm just not good at business. But that is not our fault. We did not learn this in school. And so maybe some of you are struggling on how to be successful and capitalize on the four billion dollar worth of biologics market out there. And some of us are thinking, maybe we deserve more, but why is this so hard? So please, please, please type in the chat things that you're struggling with, you know, cash business, finding the patients, who's a candidate, just marketing sales, not trusting those marketers. Put put that in the chat if you can, and we'll we'll maybe talk a little bit about that at the end. So the question is how do we win? And while we are talking about the science today, we also need to consider how we talk about this with our patients. So we all win. And so we need a system, right? We're not gonna go all over this system today. We're gonna talk about the orthobiologic knowledge, but we do want to get you a little bit further along in this journey to be wildly successful. So we are gonna start dropping some orthobiologic knowledge. So we will get started with Dr. Kanab, and we're gonna get down to business. So it turns out, John, we have questions. And so we're gonna just dive straight into our full question and answer for you, basically hot seat, and we're gonna have a little bit of a conversation. So, you know, there's this question about whether discogenic pain is actually a diagnosis, or is it more of this catch-all term when nobody really wants to like commit to a specific pain generator? And maybe even more, should we be committing to a specific pain generator, or is that old news?

SPEAKER_01 7:12

Right. So, first of all, thanks for letting me nerd out on this because I don't often get the chance, or when I do, people start checking their watches and phones for a way to get out of the discussion. But you know, I I was presenting at ASMST this weekend, and you know, one of the slides was on phenotyping chronic low back pain. You know, what where's the back pain coming from? And you know, the slide that I put up had 12 different images on it of all the different places that pain can come from in the spine. And, you know, we all know that it can come from a discarniation, it can come from parse defects, it can come from spondylolysis, it can come from ligaments, muscles, multifitus atrophy, so many different things, vertuber body compression fracture, the hip, the SI joint, everything, right? So, you know, spoiler alert, it it more often than not is everything, you know? And so if we just focus on the disc, and if we say, I'm just gonna specialize in treating the disc, it's like uh my daughter calling me from LA last night. I'm in North Carolina. I thought, oh great, she's calling me to chat. No, she was calling me because she had a flat tire, right? So that gets at why why is the tire flat? You know, and is it because you got loose lug nuts? Is it because there's a nail sticking in it? Is because there's a slow leak, you know, what's going on? You know, so diagnosing the problem is key so she doesn't just keep on, you know, having flat tires. So in my world, I think of discogenic pain as being something that is characterized by different things. You know, axial low back pain, I think of more like vertical up and down as facet joints. Horizontal low back pain kind of going across side to side is is more discogenic in my mind. The other thing that kind of sets off you know an alarm or you know, raises my antennas is poor sitting tolerance. So someone who has poor sitting tolerance, I typically think of the disc as being you know a potential, you know, potential pain generator. And so then we start you know examining the patient, you know, where are they hurting, showing us exactly where in their back they're hurting is key, seeing if their multifidae glutes are firing when when those are are tested, and then looking at looking at imaging, right? A lot of times people come to us with x-rays and a CT scan, which are fine, a good place to start. But what we miss on those studies are the subtle things that are oftentimes very, very important. And those things include loss of water content. So you look at the T2 images and the sagittal and axial scans, and you see that you know you've got dark disc disease at you know 3, 4, 4, 5, 5, 1, and of course the old annular tear, right? So that lights up with a high intensity zone in the annulus, sometimes very easy to see, and also sometimes completely unreported on the report. So if you're just looking at the report and you just see you know degenerative disc disease, they don't mention the annular tear, and it's so bright, so white, and it's ipsilateral to their pain. And you're like, well, please, you know, you have to look at the images. And so we see those. And then what else do we see? We see a lot of times modic change, modic type one, two change. You know, see the vertebral body end plates on either side of the disc are white, you know, and well, why is that? And it comes up starts to become a chicken and the egg discussion. You know, did the did the modic changes start and then cause the disc to degenerate, or did the disc have something go on and cause the end plates to react to the what's going on in the disc? There's this one study, a surgical study, where they were taking out discs for disc surgery anyway. And a fairly good number of patients, I think it was 60, 70s, 80s, something like that, pretty good number, and they sent off just pieces of the disc to the lab, sequenced it, and found that there was a 33, 34% incidence of P acnes in in discs taken off for surgery. And in those patients who had the positive cultures for P acnes, they were five times more likely to have post-surgical ridiculopathy compared to the people who didn't have P acnes in their disc. So the P acnes is getting in there. It's the same stuff, it used to be called C acnes. It's on our skin and it makes its way into the disc. It doesn't cause an infection, but it causes a colonization. So, you know, my belief is that you know there's probably some sort of trigger that causes the the damage to start, but then the the P acnes finds its way in there and kind of propagates and causes a you know a chronic condition, just like bacteria in the gut, you know, SIBO, you know, it's kind of like disc disc dysbiosis.

SPEAKER_02 12:19

Oh my gosh, that's perfect. Discbiosis. Yes, it's a disc dysbiosis, right? And you know, that when I heard about the fact that number one, discs are not sterile, and number two, that there's a microbiome inside the disc. And number three, when we have dys biosis, that is very predictive of the the that degeneration. So the degenerative discs have a disrupted microbiome, whereas normal discs do not, which blew my mind, and I'm thinking, oh my, like, what else don't we know? Right. And then the final piece is those there are relationships between gut microbiome disruption and disc microbiome disruption. We're not gonna go down that rabbit hole today, but I mean, this is crazy, and I'm so thankful that you've said you've gotta get the right diagnosis first, right? And the likelihood is that it's probably E, all of the above. So I think the next question that I we would like to know about is what's the most misleading thing that patients are told about their disc problem before they ever reach someone who treats it, either surgically or biologically? What's like the thing that they all tell you and you're like, oh my gosh, not another one?

SPEAKER_01 13:49

That it's gonna get better and it's gonna resolve on its own in over time.

SPEAKER_02 13:53

Now, where I think we talked about this, but is there some scientific evidence that shows that maybe some do?

SPEAKER_01 14:02

So, yeah, I mean, we first of all, uh, what's the diagnosis? If it's a disc herniation, those are gonna typically, you know, resorb with time or you know, with with treatment, whether it's chiropractic or physical therapy or just the passage of time, you know, it's conservative things, inversion therapy, decompression therapy. Just the it's almost like the bigger the dysfunction is, the more likely it is to resolve. So that's probably true about you know, focal discarniation or even a large protrusion, sometimes even sequestrations, they're gonna get better on their own. But these disdegeneration things, the annular tears, are the ones that kind of fall in between that that classification system. Those are things that don't get better and also recur, you know. So if a patient gets that message, hey, this is going to get better on its own. Well, yeah, these people that the the surgeons are or the primary care are talking about discernations. And what about the person who is having these episodes where they just every, you know, whatever, six months, twelve months, they just do something, they bend over to pick something out of the dishwasher, and their back just locks up and goes out. They go through everything and they may not get you know imaging. So, you know, they may have had imaging three, four years ago, and they're just in this mindset of I just gotta wait for this to go away. I know it's gonna be another three, four weeks. But during that time, they're miserable, they can't do anything, they can't travel, they can't work, they can't sleep. So it's just misery. So although that message may be true, and scientifically it probably is supported, it is not the case for these other, you know, I'm not talking about treating disc carnations, I'm talking about treating these degenerative discs with you know loss of height, loss of water content, and high intensity zones. So these it's kind of a different animal, and I think it defies classification within this, you know, the framework of what we're typically told. So I think I disagree with the fact that these are going to get better. And you know, I had a great example of this, unfortunately, the other day, someone I treated 11 years ago. Okay. I saw her last week and I treated her 11 years ago with a single facet cyst aspiration. Okay, so that's all I did. And the next time I saw her was last week, 11 years later. She had some disc degeneration when I saw her, and I had a she had a bigger problem with the facet cyst causing a ridiculopathy. So drained it and obviously complete success, right? Well, she has developed grade two spondylolithesis, almost complete collapse of that disc at the level where that facette cyst occurred. And so her lack of symptoms did not help her. It helped her to live 11 years, but now she is looking at a situation where I can't help her. There is nothing to help at that L4-5 level. I cannot help her with needles. She's going to need screws and rods. And so that is my concern for anybody who has disc degeneration. And that is kind of my motivation for treating discs in the extreme situation. You know, Greg Lux's book, Heal Your Disc and Your Pain, has a great picture in there of the same exact thing. Someone who, you know, didn't get treatment for her discs and ended up having the same thing. Disc collapse, disc spondolic seasis. So if you have instability at that level, due to, you know, more likely than not due to some disc degeneration, which then weakens and loosens you know the ALL, PLL, and you know, the other supporting structures at that level, you're gonna end up with what she has. Now, can we fix that? Can we stop it from happening? Can we reverse it? That's the question. You know, can we do this with biologics? Maybe, maybe yes, maybe no. But I think it's critical that we think about it.

SPEAKER_02 17:47

Yeah, starting that upstream thought process to say, okay, yeah, if we treat it now, can we avoid fusion in the future? Now, do you look back at that let that woman from 11 years ago and go, dang, I wish I would have done PRP and her, you know, her annulus, and shoot, man, we really missed the boat on that.

SPEAKER_01 18:13

Well, that was uh that was 2015, and I was not thinking about intradiscal injections back then.

SPEAKER_02 18:20

Exactly. That was early.

SPEAKER_01 18:21

I mean, that was that was the year I think before Matt. I was looking the other yeah, Feteen, you know, Matt Murphy and and Fateen, I think that was 2015. So that was probably the earliest I was thinking about treating discs. Very earliest. So I wasn't even that wasn't even on my radar back then.

SPEAKER_02 18:40

Yeah, yeah. If that same facet cyst came in today, would you be more aggressive?

SPEAKER_01 18:47

Well, I would ask why, you know, why do you have a facet cyst? There's there's you know, either clinical or subclinical instability there. You know, that doesn't happen for no reason. And so I would absolutely try to convince that person to treat her, you know, treat her condition with a biologic as opposed to, you know, a a potent, you know, immune suppressor in steroid that's just gonna, you know, obviously fixed her symptoms, but it didn't do anything. I don't think the steroid caused her her spinal column to collapse, but it did nothing to address the biologic insufficiency that she was having at that level.

SPEAKER_02 19:23

Yeah, yeah. So that's such a good thought process. So clearly we have more questions. So buckle up, buttercup. We're we're getting done to this. Let's go.

SPEAKER_00 19:33

Bring it.

SPEAKER_02 19:34

If PRP works in joints and tendons, why are so many physicians still hesitant about intradiscal PRP? So is it the evidence, technical challenge, fear of disguitis? What do you what do you think is like that biggest hang up? I mean, I can share my experience as well, but what do you think that biggest hangup is?

SPEAKER_01 19:52

I think all the above. You know, as having had someone who's you know caused one disguitis in their 30-year career, I can say, and it was with bone marrow concentrate. You know, we were kind of being everyone was kind of echoing the sentiment that bone marrow concentrate is very antibacterial. And you know, it wasn't just wasn't just me, it was me and my partner who had one case of dischitis using both using bone marrow concentrate. And at that time there was you know more more information coming out from Greg Lutz about Luke Sight Rich PRP. So why you know why is that? And I know uh speaking to some people that we mutually know, you know, just seemed you know, the person I'm thinking of seemed comfortable with the like one to two percent instance of disguitis, and it's just you know, for me, that's not in my DNA. I cannot, it really, really upsets me when I cause someone to have you know a condition like disguitis. So fear of that is a big thing, I think. And and the other thing is that you know, we can manage a lot of the symptoms from disks by just treating with the functional spine unit approach. So, you know, I think that's a very effective way of treating and managing symptoms as long as you're also monitoring a radiology along the way, you know. So you can say let's let's let's go mostly on pain and function, and but also agree that we're gonna take a look at your MRI in another year, uh year and a half, to make sure that we're not seeing progressive spondy or something like that. So there are ways of yeah, why not?

SPEAKER_02 21:21

Yeah, yeah, yeah.

SPEAKER_01 21:22

And you know so I think that it's it's probably you know, anyone can do a disc discogram. I think it's it's not that complicated, but you know, post post-disc biologics are a lot more uncomfortable than your your FSU procedure, so that's another reason. I think once people have done it, they realize I gotta kind of hand hold for you know a certain percentage of these patients for a good couple of weeks, and it's you know, maybe something that they're not really too keen on.

SPEAKER_02 21:53

Yeah, yeah. I mean, uh right now I'm not currently doing intradiscal. I think OF share with you. That I am trained as an orthopedic surgeon with an entire year of spine orthopedic surgery training, right? Under my belt. And so then, you know, to learn how to do the injection-based therapies is pretty straightforward and simple. And yet, I'm like, I don't know. And then, you know, the other pieces it's all like degenerative discs, all in theory, are already inoculated, right? So are we really causing disguitis or are those just the ones that kind of get out of control and they're all kind of inoculated with P. acne, and then you know, one percent of them get out of control? I I don't know, you know. I don't have that answer.

SPEAKER_01 22:44

Yeah.

SPEAKER_02 22:44

But that for me, the dischitis um is so the things that is making me nervous.

SPEAKER_01 22:50

So we used to use cefazolin for our antibiotic when we were doing intradiscal procedures, and that's pretty standard for for people even today, even though some really good data from Lutz's clinic showed that gentomycin is is much, much better in terms of killing those bacteria. So that may or may not be the reason we haven't seen, you know, we've seen zero intradiscal any discoites since you know 2018 when those both occurred. And you know, that's through the use of gentomycin, you know, anywhere from 200 to you know 400 marks per cc in our contrast. And then leukocyte-rich PRP, you know, at very kind of strong doses of leukocyte-rich PRP, like 80 cc's of blood being spun down to two cc's of injectable leukocyte-rich PRP. So it's really high dose. Platelets seems to be also very anti-bacterial. So knock on wood. I don't feel hesitant about injecting discs, other than you know, counseling patients about their increased levels of pain afterwards, and then also it's it's more costly. You know, when we inject the disc, it's going to be more expensive.

SPEAKER_02 23:56

Gotcha, gotcha. So, you know, you recently, I was I was calling you on the phone, you're like, hey, I'm at this conference with a disc seal. And so disc seal is based on this idea that the annular tear is the issue, not the the disc height loss. So, what do you think about this? Because we've been talking about getting the right diagnosis, and we've been talking about that probably all of the things are taking effect. So, how do you how do you kind of reconcile that?

SPEAKER_01 24:25

So I think the sensitized nosoceptors in the in the annulus are probably a big source of pain for people, and it gets sensitized because the chemicals from the nucleus pulposis are leaking out into the the rents in the in the annulus, and then you know, in cases where it leaks all the way out, whether you know if it's a full thickness tear, you know, it's gonna leak into the epidural space. So I think you know, sealing those tears is important, and the the knock on PRP and bone marrow concentrate from you know the manufacturers of the disc seal are that it it leaks out, you know, and and it does. It's pretty fluid. And despite you know, us wanting to think that it coagulates inside the disc and forms a clot inside the disc and really you know plugs it up, it really doesn't. I mean it stays pretty liquid. And you know, even if you're being patient and you're just injecting little bits of aliquots at a time, so I wanted to you know check uh tissue disc just to see what it was like what it was like as a as a just a biologic you know preparation uh uh as a glue. And it's definitely it's I don't know if it's a hundred times better as a glue than PRP. It just is, but it's not PRP, it's not you know it's allogenaic, it's coming from you know pooled human serum, and so it's got its pros and cons. Some people like are reviled at the idea of like injecting this into people, your your spine. It just it's the it seems like a terrible idea to them. But I think it's a reasonable tool. I'm glad I have it. And one of the other things that kind of was motivating me to look at it is that it's the only biologic, even though it is all genaic, it's the only biologic that's covered by the VA for their patients who have you know degenerative disc disease. So that's been something that I feel pretty strongly about. We're part of the you know VA community care network. So we we take care of vets with whatever they need, you know, spine joints. But this is something that's unique. And they they did, you know, pauses group put out a pretty large number, you know, 700 plus patients, uh, observational, you know, so it's not level one data, but it's you know, a fairly good number of patients that I look at as having you know a strong safety profile, you know, no serious adverse events and pretty good durability in terms of pain of function going out three three years. So I think it's reasonable because news flash, you know, there is no level one evidence yet, you know, that we have something that is, you know, the bees needs for disc, you know, and that's you know, maybe gonna change with some of these phase three products that are in the pipeline. But you know, right now disc seals definitely not level one. Via disc is the other thing that they're they're doing a phase three B right now, looking at Via Disc compared to a sham procedure because they did via disc versus saline. It turns out the saline is a pretty good drug to inject in your disc, you know, so it really didn't separate out from saline in their initial. So they're they're working on it, but still, you know, I didn't, I've never really thought that was something I wanted to get into too much because it doesn't make sense to me. You know, the nucleus poposis in a disc is is full of noxious chemicals, you know, and injecting that, even though it's from a healthy volunteer, you know, into a damaged disc just has never made sense to me. The fact that it didn't separate out from water in their first trial, the vast trial, was not too thrilling to me either. And it ain't cheap. It's not covered by many insurances, so it's not cheap to if you want to do it.

SPEAKER_02 28:05

So if you were putting a head-to-head trial together and you were you were offered either via disc or PRP, what would you choose?

SPEAKER_01 28:15

Uh I would I would use PRP.

unknown 28:18

Yeah.

SPEAKER_02 28:18

Okay.

SPEAKER_01 28:19

I think it would be an easier sell for most patients. And you know, I think you do have to compare it to something, a sham as opposed to uh, you know, a vehicle like hyaluronic acid. I think the sham is the is the only real way to to judge it it against uh as a placebo.

SPEAKER_02 28:35

Yeah, and maybe in like a with a crossover or something like that. Absolutely. So you know, what's that uncomfortable truth about why disc regeneration, disc injection, disc seal, why is this not mainstream yet? You know, is it the science, is it the economics, the training? To be honest, is it the surgical simple?

SPEAKER_01 28:58

I mean, I presented to Well, it's it's level, you know, it's the level of evidence that we have supporting it. All these studies are super small, and that's all that a surgeon needs to hear in order to just dismiss it, you know, off right off the bat. No offense. I mean, most most spine surgeons. So every single surgeon at this at this event, you know, North Carolina Spine Society had, yeah, they were listening politely, but just said, you know, what's the what's the level of evidence? And when you when you tell them about the numbers of patients in these trials and studies, it's it just doesn't impress them. And the fact that it's not FDA approved, not standard of care, you know, just it it's just self self-fulfilling, you know, prophecy. You're not gonna change minds until you know you have have something with the you know the scientific data behind it, even though you know a lot of the spine surgeries that are done really don't have that either.

SPEAKER_02 29:54

I was just gonna say that, you know, as we we saw recently from John Buford that the for the top five impact journals in orthopedic surgery, the average level of evidence is level three evidence. And so as much as we want to think we're you know practicing with level one evidence, level two evidence, I think we may not be practicing as high a level of as evidence as we probably think or wish we would. So here's the the next question for you. If someone already has a fusion and they develop that adjacent segment disease, are there are the are ortho biologics a real option? Or are we just trying to, you know, delay the next surgery or should they just get oh get it over with and like fuse the whole thing? What what are your thoughts and experience on adjacent segment disease?

SPEAKER_01 30:46

You're just gonna push the lever arm further up or down the spine, you know, the more levels you fuse. So, and I've seen that if you can if you can delay, you know, the quote inevitable, I think you're offering patients, you know, surgical-free time that you can you know realistically provide some meaningful improvements in pain and function. I've I've treated a lot of adjacent segment disease, mostly with PRP, intradiscal. And you know, the the the key also with the PRP approach is that let's just say it's not the disc, let's just say it's the disc and the facets and the you know ligaments on either side of that fusion. We we just by definition are treating everything. I think there's a lot of times facet joint diffusions that we see and that are sometimes missed because they're not really they're not facet cysts, but you know, it's a lot of evidence that looking at us on on MRIs, if we take the time to look for them, and then obviously it makes sense to just not treat the disc, treat the fascia joints in these people and treat the ligaments, treat the SI joints, you know, when it's uh you know L3 to L5 fusion or L4-5 fusion, you know, that bottom disc and SI joint are just getting jacked up. And so we we treat obviously treat the ligaments and and SI joint commonly, and so that would be the you know the thought in adjacent segment disease, it's oftentimes more than just the disc, it's it's it's the other things as well.

SPEAKER_02 32:12

So what do you how do you counsel your patients when they come in and they have pretty significant adjacent segment disease? What do you what do you tell them? What what can they expect?

SPEAKER_01 32:23

Well, in terms of if if we uh treat them with PRP, you mean?

SPEAKER_02 32:29

Yeah, yeah. So like you're like, oh my gosh, you're a candidate, you're gonna do you know, great or pretty good, like what do you tell them? Is this a one and done? Is this something where you're gonna do PRP and then monitor them in the next you know 18 to 24 months? Like how what do you what what should if I was coming to you for treating basic segment disease, what do you tell me?

SPEAKER_01 32:53

So typical plan would be to say, you know, if we're 100% sure and on the same page that we want to inject the disk and we do everything right up, you know, right off the bat, including the disc. If there's any question that, you know, either from a uh financial standpoint, they don't want to, you know, really kind of go all in at once, or they feel like the recovery after an intradiscal procedure might be a little too much for them at that point in time, then we we treat everything except the disc and then wait for a good six to eight weeks. And if they've achieved you know significant your milestones in terms of pain and function, we leave the disc alone and just monitor. And if they've kind of had a so-so response, then I would say that we just go for the you know, round two would be just intradiscal. For the most part, if we have a normal recovery process for the vast majority of my patients, 60, 70, 80 percent are gonna be one and done. Very few people will have you know a boot injection. Some of those that do, maybe more of the high-level athletes who just want to have it done because they feel like they want that extra dose of platelets. But for the vast majority of our patients, you know, 95% of them is gonna be a one and done. And then we just monitor as time goes on. So that you know, patients who get the FSU where you're not going into the disc, it's gonna be maybe a week or so of discomfort, might be use a little journavax, that new sodium channel blocker, non-narcotic, non-addictive. We'll do that for you know a week to 10 days for some people. If we go into the disc, I tell people three days to three weeks of you know pretty elevated levels of pain. Kind of like I want to, I I I'm happy when it's a person who's had these severe, you know, spine blowouts where they can't move, they can't, you know, twist, they can't turn over in bed because I tell them that's what I'm gonna do to you, you know, for the most part over the next you know, three days to three weeks, and and sometimes even longer if we're using the via disc. That can be you know go out a couple months before people start feeling like they're really turning the corner. So a lot of different things come into discussion when we're talking about do we inject the disc or do we not? You know, are you prepared? Are you not getting you know big trips coming up, no weddings, no you know, anniversaries that you're taking a big trip for? So you have to make sure patients are aware of the morbidity that can be associated with these things. The FSU is pretty easy to recover from, but the intradiscal stuff can be a little bit more unpredictable.

SPEAKER_02 35:15

Amazing. Yeah, thank you so much for sharing that. I I know that everyone who's listening can is gonna be able to take that home and have those conversations with their patients about you know, expectations of a functional spinal unit, which is basically treating everything, all pathology with PRP versus you know, that intradiscal experience for the most part. And have you stopped doing bone marrow concentrate intradiscal at this point?

SPEAKER_01 35:41

I have, yeah, I have not done that since that disguitis. That faded that was yeah, I mean, it was bad. I hated it. And we've just had good results, really good results with the PRP. And you know, it wasn't a perfect study, but Anu Novani did a study maybe 23, I think, and she showed that you know intradiscal PRP and Bomero concentrate had similar similar outcomes. And yeah, it was a small study, but you know, uh I I I'll latch on to something like that. If it gives me an excuse to do something that feels uh safer, I'm gonna use that. And uh so I'm glad I I'm glad that was done, and I'm I'm glad that I I have the you know the data to back it up when I'm when I'm kind of explaining risk profiles to different to patients about the different techniques.

SPEAKER_02 36:28

Awesome, awesome. Well, so you know this has been so great. What a what a wealth of knowledge, uh, and I really appreciate this this consideration of like how to deal with these patients and is the disk the end-all be all? And and you know, some of it is, some of it isn't. So thank you so much. So, what is that next step to be successful in our practice? Well, you know, we have a system, our our orthobiological practice launch system, and we know that we've gotten that orthobiologic knowledge from you. Now the next step is to use all this knowledge for the right patients, the ones that need your help. And then finally, you know, obviously creating a cash-based practice as it's not covered by insurance, helping to have those high-converting consultations where you know these people are awesome candidates, but they don't maybe know everything about these or the biologic treatments, and then clearly putting it all together for success. So, you know, if you want the fast track, I have a little quiz for you all. So if you're watching this on a computer, please just scan this QR code, and this will help you evaluate your next steps and evaluate your capital outlay, clinical competence, workflow readiness, and legal freedom. And this will help you understand where you are in building and launching your orthobiologic practice. So please make sure you scan that QR code. And then I did want to invite everybody to this amazing three-day event that we are hosting to be able to engineer your predictable cash pay practice. It is in Scottsdale, Arizona, June 5th through the 7th. And this includes some MMSK Shoulder Primer, AI practice tool implementation blueprint, cash pay revenue infrastructure framework, and private and personalized implementation environment. So I I really would love you all to come. This is that early bird pricing before April 1st and go ahead and scan that QR code. You can check out the full website, and we'd love to have you to be able to fully launch your successful cache database to practice. So, John, I am gonna turn it over to the QA. We've had a bunch of discussions. If y'all have any questions in the we got a ton of questions, so we're just gonna go ahead and start taking them off. This is so great. So, one of yeah, so there's a lot of questions. A lot of people are struggling with marketing. If you are struggling with marketing, please come to our event. We have a full marketing day on what the heck to do and how to do it right. But we have a question for you, John. Do you use PRP with disseal? And you know, when would you use either as a standalone treatment?

SPEAKER_01 39:41

Uh the majority of my disseal patients right now are VA. And so VA will pay for the disseal, but they won't pay for PRP. I could imagine that they might get a little squirrely if I was combining PRP with their disal patients. So I would probably do that sequentially in a in a VA patient if they needed it. If I felt like they had some nerve root irritation or something of that nature on a different day, but I have so far not combined PRP with disseal. Now, there are some people that are doing that with their cash paid disal patients, the epidural PRP and intradiscal platelet disseal, which I think is fine. And, you know, maybe putting, you know, I've thought about putting either a leuk site-rich PRP into the nucleus and then kind of sealing it in there with the disc seal. I think that is interesting to me. I've also thought about injecting platelet lysate. There are some early studies from Makeda back in 2015-2014 just using platelet lysate in the disc. So as long as it's not like that culture media of bone marrow concentrate, and I'm using something like gentomycin, I think you could kind of get pretty creative about ways to add a biologic into the into the disc that's got growth factors and some cytokines in it, you know, because the tissue, I don't think anyone's ever looked at the you know proteomics of that in terms of growth factors or or things like that. It's not what it's designed to do, but yeah, I think it's a good question. I I I think you can combine them safely, reasonable, reasonable thing to do.

SPEAKER_02 41:15

Yeah, so there's a question. What about platelet lysate, especially on you know nerve root irritation or epidural or you know, hot redic kind of pieces? Is that what you're using that for?

SPEAKER_01 41:26

Yeah, well, you know, you know I'm a big fan of platelet lysate. You've seen our setup for that. It's it's a great product because you're kind of cracking open the eggs before you inject them, right? And so you don't have to wait for that aggregation and degranulation that occurs in vivo. You do that ex vivo, and you've got all those you know growth factors and the IRAP and the A2M ready to go. So we use that quite a bit and almost exclusively for transferminal injections, definitely cervical spine. I wouldn't I don't feel great about using straight PRP in the cervical spine in the at the framing, but we use platelet lysate all the time in the framing because it's filtered. You know, we filter it down from 15 microns down down through 0.2 micron filters, and so it's really particulate free, so we don't have to worry about that ridicular embolization that you would potentially be some platelet clumping. So I I love that a lot. I use straight PRP for my interlaminar epidural, so I don't think you really need the lysate in the epidural space because those you know, you're gonna it's gonna stay in the area where you injected pretty well for the time needed for it to, you know, do its thing, degranulate and release the platelets in that way.

SPEAKER_02 42:33

Yeah, that's a great question. You know when we compare or you know, when you are thinking about lysate versus PRP, what's your expected differential in and timed to relief?

SPEAKER_01 42:50

I think uh we original lysate, we were already using plasma concentrate, you know, PC in our epidurals going back that goes back to 2017, that we were using the earliest HPH filters to get at that, you know. They were originally in the selling devices, you know, integrated into the selling devices, you know, Matt Murphy's device there. And so, you know, the I the idea came from that, but then when we kind of moved away from the you know the selling company, we found that we could get those filters directly from Medtronic, I think we were getting them from. And so then you know, we we used we use a different vendor now. I'm not sure if I can say their name, but we use them and they're great. Whatever you want, you can have some Apex filters are so great. It's like smaller, smaller kilodaltons just gets you so much more of the good stuff out of the plasma that we used to throw that away. So we've not been throwing it away for a long, long time. And and I really like the evolution of the Apex filters because it just that to me has I was always surprised at how quickly these like. These people, I just injected like 40 places in your spine, and like I see him back in a week, and I was like, How you doing? They're like, I'm good. You know, like what? I can't believe it. So just for those super hot redicks, platelet lysate. Yeah, I think platelet lysate just has that extra, that extra oomph. It's full of these, you know, really potent IRAP and A2M, Ben Ross. And you saw his study on the those massive disc herniations that he was just using epidural transferaminal platelet lysate. And I felt like he had like, yeah, it was just like study after like case after case of these like very rapid and complete resorptions of these massive disconniations due to just platelet lysate. I was like, Ben, you've you've discovered the like the insulin of you know massive disc carniations. So I like it for that indication quite a bit.

SPEAKER_02 44:49

So our friend here is asking there's a MRI showing C4, C5, C6 disc prolapse, pain-free, but noticing gradual weakness of the left hand, arm, and legs. Thought about PRP intradiscal to reduce that prolapse.

SPEAKER_01 45:08

Well, Ben, I hope it's not you. I know, right?

SPEAKER_02 45:12

Our friend Dear Ben, we hope you're better.

SPEAKER_01 45:16

Friend down under. Well, I I think uh yeah, if you've got weakness going on, depending on you know how how much compression is going on at the DRG or the cord, you know, obviously weakness is very concerning. But I've seen weakness resolve just with epidural, you know, intralaminar and transperamenal. Yeah, you yeah, I've seen it, yeah, I've seen it r resolve with just using PRP, epidurally, not even intradiscal. So if you haven't had you know epidural PRP, I would definitely hit it hard and hit it a number of times, you know, both transferamenal and epidural, maybe before going intradiscal reasoning being that I think if you go intradiscal and you have just a an increase in inflammation, which is very very potential and very likely actually, I would just hate to see that making the the weakness worse. And you know, that might push you more towards a surgical approach sooner rather later. And I would say that it's very unlikely to push it over into like a flare-up situation of you doing epidural. So that would be my suggestion. You know, try to be an incrementalist, right? Do the epidural stuff first. Do the epidural stuff first, yeah, baby. Let's go.

SPEAKER_02 46:31

Yeah.

SPEAKER_01 46:32

So but uh Ben, get over here and I'll treat you myself.

SPEAKER_02 46:36

No kidding. Go go go fly over there, my friend. Okay, so we have a question. How is it working with the ortho biologics, with PRP, with health insurance? It is it extra cost of the patient, or is there any strategy to use it in the hospitals? Uh rarely is it used in the hospitals because they haven't figured out how to actually take cash. There's a lot of there's a lot of uh university settings that are doing it, and there's a lot of university settings that are their regenerative programs are going under because they can't figure out how to take cash. John, what do you what are your thoughts on uh insurance and PRP in the hospital?

SPEAKER_01 47:18

I mean, I always uh I think that you know you've got a lot of people who are at these university programs who are doing it. I don't know how they're I don't know how they're how they're doing it. You know, maybe I don't know, but the in our country, unfortunately, it's it's it's not available for people who are trying to use their insurance. I don't think there's any hope that that's gonna change in the near future. So it is something that is 100% patient responsibility. If they if they want to get it, they have to pay cash, and we have to actually have them in in our country, whether it's commercial insurance or Medicare, we have to have them sign a form that specifically says we are not going to bill your insurance for this. You will be 100% responsible for it, and they either have a payment plan or they pay up front with a credit card. So that's at least in our in our country, in our you know, our state is that's how it is. I don't see that changing with insurance anytime soon.

SPEAKER_02 48:16

This is an interesting question. So would you recommend PRP or disal or lysate if you're pairing an intradiscal injection with a dysquectomy procedure? Like take out the herniated disc and then seal it or and then put maybe lysate or epidural, like man, that'd be pretty great, hey?

SPEAKER_01 48:34

Yeah, I mean, recurrent disc herniations are a big thing. And I I've talked to my surgical buddies about that, and they you know, they say unfortunately it gets you know, they're they're creating a pretty big rent in in the back of the disc sometimes. And I I think disc seal is great, but it's more for like it's kind of like uh slime for a tire. Like if you have a puncture hole, slime, you know, you can put that green goo inside your tire and it'll fix that, but it's not gonna fix uh you know a hole created by someone's using a knife to you know to cut a hole in the side of your tire. It's just not that not that good. So I think if you have a if you've if you're just taking out a kind of a pedunculated, you know, herniation that with a small you know area where it came out of the out of the disc, sure, try to seal it up at the time of surgery. Um but again you're c talking about cost. I mean, it's a pretty expensive drug to use.

SPEAKER_02 49:28

And um this can you just use tissil?

SPEAKER_01 49:32

Yeah, that's it's yeah, you can use that's what it is. It's tissile, but it's it's not cheap.

SPEAKER_02 49:40

Fascinating, because like we use that in orthopedic surgery all the time.

SPEAKER_01 49:45

Yeah, I think if you're buying it from Baxter, it's it's one of these things that's a it's a couple grand. So I think without being able to tell a patient that this is definitely gonna help you, I I don't I don't know if you could if you could get it covered with their surgical procedure or not.

SPEAKER_02 50:04

Yeah, I don't I don't know either. Report back. Uh let's try that out and report back. Yeah. Quick question any success with motor vehicle or personal injury with any ortho biologics. Oh my god, yes, all day on Sunday, right?

unknown 50:20

Yeah.

SPEAKER_00 50:23

We don't see any third party. We did, we don't anymore.

SPEAKER_02 50:27

Yeah, yeah. So, you know, I think third party and a motor vehicle, maybe. I have some friends that do a ton of PI and do a lot of orthobiologics, have a lot of success with that. Just get them to pay up front, you know. So awesome, awesome. So Jonathan Parrison is gonna see he sees the cost benefit analysis, might be there, and hit thanks for the response, and he'll report back if he ends up putting a little to seal after pulling out a little herniated disc. That's that's awesome. So good, so good. Okay, so anything that you want us to know about you, how to get a hold of you, reach out on LinkedIn, look at your your website. Please let everybody know how to get a hold of you.

SPEAKER_01 51:11

Yeah, so I'm on LinkedIn pretty much every day. And if you just uh connect with me, I'll connect back. And if you are interested in seeing kind of my philosophy about regenerative medicine, our YouTube page is Elite Spine and Joint. It's Elite Spine Plus Sign Joint, but I think if you just put that in there, you'll find it. There's a lot of greens and grays and whites on ours, so look for that, and you'll see my face among the videos. Our website is www. And it's me. Just this face right there. That's me. So and then our our website is uh www.elitespine joint.com. So awesome.

SPEAKER_02 51:52

Awesome.

SPEAKER_01 51:53

Yeah, but John reach out and I'm happy to share knowledge.

SPEAKER_02 51:56

Yeah, oh my gosh, so good. We always nerd out about this stuff. I think we just invented a new surgery, so congratulations to all of us. And Dr. Paris has done a report back on uh he's gonna do 20 of them and then we'll have a an amazing you know series that'll that'll look at that. So awesome. This has been so great. Yeah, I think Ben Sibley might might actually give you a ring.

SPEAKER_00 52:20

So I'm waiting for perfect.

SPEAKER_02 52:27

All right, guys, this is the top of the hour. And uh, you know, John, thank you so much for sharing your time. Everyone else, thank you so much for sharing time. We will be back here in two weeks with an amazing set of questions regarding periprocedural nutrition and supplementation and what works, what doesn't, what the science supports and how that supports it with the great and super super smart Dr. Jordana Quinn. So I hope to see you in two weeks for that, all of that periprocedural, very, very nerdy science stuff regarding what supplements we should be helping to stimulate and improve our patients during in this periprocedural orthobiologic timing. So I'll see you guys next time. Thank you so much for everyone sticking around. And uh, we'll we'll catch you on the flip side. Everyone else, thanks so much. You guys uh have been truly great. Happy St. Patty's Day. Go pinch somebody, please.