Financial Disclosures

•I am a share holder and medical director of Regenerative Sciences, LLC

•I am not being directly compensated for this presentation

Intradiscal Stem cells: Are they an Effective Treatment Technique?

Chris Centeno, M.D.

What autologous biologics can be used in discs?

• Blood Products– PRP

– Platelet lysates

– Cultured serum (IRAP)

– Cultured platelet supernatants

• Stem cells– Bone marrow aspirate concentrate

– Cultured stem cells

At one time or another, we’ve used all of these things in discs…

• Blood Products– PRP

– Platelet lysates

– Cultured serum (IRAP)

– Cultured platelet supernatants

• Stem cells– Bone marrow aspirate concentrate

– Cultured stem cells

How do we currently treat a disc bulge with surgery?

Is there a problem with trimming the outer disc?

Less outer disc to hold annulus. Is it surprising that we get recurrent disc herniations?

What if we could rebuild the torn fibers of the outer disc?

Disc Regeneration

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Are bipeds like quadrupeds?

•Sakai. Biomaterials. 2003 Sep;24(20):3531-4.

•Able to regenerate rabbit IVD’s by injecting cultured bone marrow MSC’s

= ?

Our research experience:(pre-post 3.0T MRI with pain functional

ratings)

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•Injected concentrated bone marrow nucleated cells (BMAC) and PRP into NP-Didn’t work.

•The next step?•Isolate and then culture expand MSC’s.

So how do you isolate and grow mesenchymal stem cells ex-vivo?

Expand them by passaginginto new flasks. They should double every 2 days.

Our research experience:(pre-post 3.0T MRI with pain functional

ratings)

12

•Injected culture expanded MSC’s into NP-Didn’t work.

= ?

So what’s unique about human discs?

13

•They have really poor blood supply past adolescence•They have unusually high loads

•There is a stark difference between an animal stab model of DDD and the real McCoy

So what’s unique about human discs?

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•They are hypoxic and acidic•They get their nutrition by primarily imbibition (pump like nutrient diffusion) and secondarily blood supply•In a DDD patient, the cells in the NP are like survivalists dropped in the middle of the Sahara desert

For the last decade, some European researchers have postulated that DDD

and radiculopathy are vascular problems…

15

Disc Blood Supply

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If you place cells here, they have a blood supply and will survive

If you place cells here,they will not survive

These blood vesselsbecome incompetent,so the NP is avascular

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Based on histology studies, there is a “red” area (vascularized) and a white area (poorlyVascularized) in the posterior disc annulus.

The problem is how do you physically get cells to this area via a needle?

Advances inner catheter Advances guide canula

Nitinol inner catheterNitinol guide canula

What else besides placement can improve cell survival?

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•Increase vascular supply with vascular growth factors•Condition cells for low oxygen survival while still in culture

The Results in Real Patients (not Rabbits)

Pre-procedure sagittal slice through

the maximum extent of the

contained L4-L5 disc extrusion.

Image was taken at 12:15 pm.

ET=6, TR=4816.7, TE=48.1. The

L4-L5 disc extrusion is measured at

0.6 cm. Disc heights measured at

the mid-portion of the disc on this

slice were: L4-L5=0.8 cm, L5-

S1=0.7 cm, S1-S2=0.5 cm.

4.5 months post-procedure. This

is matching sagittal STIR slice with

same imaging parameters. ET=6,

TR=4833.3, TE=48.2. Image was

taken at 12:27 pm. The L4-L5 disc

extrusion is measured at 0.3 cm.

Disc heights measured the same

as pre-procedure: L4-L5=0.8 cm,

L5-S1=0.7 cm, S1-S2=0.5 cm.

0.6 cm

0.3 cm

Short Tau Inversion Recovery (STIR)

image taken less than 1 month prior to

procedure. This sagittal slice is chosen

as it represents the maximum extent of

the contained L5-S1 disc extrusion.

ET=6, TR=4816.7, TE=48.1 with an

imaging time of day of 1:01 p.m. This

image demonstrates a 0.7 cm disc

extrusion at L5-S1. L5-S1 disc height

measured at central disc is 0.5 cm with

L4-L5 measuring at 0.7 cm.

5 month post procedure matching

sagittal slice using the same STIR

parameters. ET=6, TR=4816.7,

TE=48.3. Imaging time of day was

10:23 a.m. This image

demonstrates a 0.3 cm disc

extrusion at L5-S1. Note disc

heights 0.5 cm at L5-S1 and 0.7 cm

at L4-L5.

0.7 cm

0.3 cm

KG-39 year old otherwise healthy white female status post a failed laminectomydiscectomyfour years prior to injection of MSC into her L5-S1 disc.

-Pre-op Jan 08 Sag STIR 3.0T MRI with ET=12, TR=5550.0, TE=47.7

Post-op Feb 09Sag STIR on same magnet with ET=12, TR=5550.0, TE=47.4

Before

Before

Before

After

After

After

KG-Axial T2 FRFSE scans on the same 3.0T scanner. Note the increased T2 signal in the L5-S1 disc (brighter inside dashed circle) as well as the resolution of the right>left central disc bulge (red arrow).

Pre-op Jan 08: ET: 19, TR: 3450.0, TE: 96.1Post op Feb 09: ET: 19, TR: 3450.0, TE:96.1

Before After

How about the same patient at 2 years?

How does this work?

Is there a way to manage radiculopathy and avoid the high dose

steroids?

How about using platelets?

• We have been substituting platelet lysate for corticosteroid in epidurals for about 3 years.

• Our opinion is that it’s as good or better than steroids.

• Tracking two large groups (PL vs. steroids) and should have that data by fall.

Regulatory Update

• What’s the latest on whether FDA believes technologies are regulated as drugs?

Exempt-Practice of Medicine

Regulated as 351 Biologic Drug

PRP Adipose SVF

Bone MarrowConcentrate

Cultured Cells

New Update: Adipose SVF is a Drug

• FDA Tissue Reference Group has issued at least two letters showing that SVF is a new drug requiring clinical trials

• The TRG has a special taskforce working on how to enforce this new initiative

Rodriguez FDA TRG Letter

Breaking down the “adipose tissue” alters it’s relevant characteristics=Drug

Enforcement Actions on SVF

• State of Florida Medical Board/Department of Health revoked the license of a cardiologist infusing IV SVF for pulmonary fibrosis after the patient died-Homicide Investigation in progress

• State of Louisiana Medical Board has disallowed adipose SVF under the practice of medicine

On the flip side of the coin…

• State of Texas Medical Board now allows “non-FDA Approved” stem cells to be used under the practice of medicine as long as:

– The patient is consented as to the investigational nature of the care

– The procedure is approved through an IRB

Summary

• PRP and bone marrow concentrate don’t seem to help discs much

• Routinely cultured stem cells placed into the NP don’t work well either

• Specially cultured and administered stem cells do seem to be capable of resolving disc bulges

• PRP and Bone Marrow Concentrates are being left alone by FDA, adipose SVF is the next big FDA enforcement target