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Discogenic lbp

Discussion in 'Pain Medicine' started by paindoc007, Sep 8, 2018.

  1. bedrock

    bedrock Member
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    regular cardiovascular exercise is definitely recommended. Running can go either way. I've seen it dramatically improve or worsen someones discogenic pain.

    I'd certainly make time to swim at least three times per week.
     
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  3. Papa Lou

    Papa Lou ASA Member
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    Yeah I've done the back brace, TENS, and lido/voltaren patches. I'm just going to make a list for myself here to reference over time.
    1) I have not done the caudal and that gives me hope so I'll try that.
    2) I didn't even think about AS. My father has similar issues with facet type back pain from his 20s and occasional SI pain...I am definitely going to get tested for that.
    3) I feel like I have a little professional permission to just try maybe one tramadol a day and see how things go. So we'll see if I do that.
    4) Start swimming. Running would kill me but I have put off swimming too long. I'm going to get back into a gym with a pool and do that already.
    5) Have one more MBB and see if removing that old aching facet pain makes my life a little better, even if 40-50% and maybe consider RF later.
    6) Timeoutofmind I really appreciate the advice. I have limited my role at work a lot, and have taken steps to improve my interpersonal relationships and reduce stress levels. I'm trying meditation and I know I need more things in that direction for general life progression so I'll keep going. So far no effect on the pain unfortunately (yet?).
    7) I'm buying a new mattress. Had a 3 inch firm topper on my side of our expensive tempurpedic for 8 months now it's weird to sleep so "separate" from my wife so I'm finally gonna get a new one. I'm thinking air mattress from what I've heard. Thinking sleep number. They have a 100 day return policy. But if anyone reading this warns me about it I'll keep looking.
    8) No more imaging. I was right in the end that getting to see the MRIs did more harm for me than good. I would get some flex/ext films to r/o instability b/c I'm pretty sure I do have instability because I sometimes just feel unhinged down there (hard to explain but really painful), but I wouldn't get surgery anyway without waiting it out several more years and I don't want to break down my psyche even more.

    I'm scared of SCS on myself...just being one of those patients. It's a bit much to face right now. Hearing confirmation that waiting 5-10 years things might get better helps. And that I'm not blatantly mistreating/misleading myself due to bias and denial b/c it likely is discogenic pain so there isn't much to do.

    I did run across this amazing set of videos on youtube if anybody gets curious. This is a business owner, seems like a loaner type of guy, who was suicidal from the pain. He posts serial MRIs (6 or 7 total) during the course of his treatment with stem cells with the procedure completed in Spain. It's pretty remarkable and unlike anything I think we've seen in our field yet just the combination of imaging and personal experience description. He does emphasize the role physical therapy played but the MRI changes are undeniable. This is one thing that really, really gives me hope and I know it's crazy to most of us here including myself who are very skeptical but if it's my last option someday soon, there isn't much of a choice. I used to be normal and now I don't feel like a normal man anymore. www.youtube.com/watch?v=eAk2H2Hq-Cw&t=0s&index=38&list=LLNq9NMDoewNd61VuEwhxUNg

    Thanks to everyone that has replied with advice.
     
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  4. Dr. Ice

    Dr. Ice Attending
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    I have personally seen changes in the annulus of the disc with annular tears 6 months post prp in some patients with follow up mri. Also seen changes with size of disc herniation after epidural lysate prp..
     
  5. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I see changes in size of disks with no treatment. These are not static conditions.
     
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  6. SommeRiver

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    One of my good buddies did a fellowship with Chris Centeno and the only thing he does is orthobiologics. He swears by intradiscal stem cells. I can't sit here and debate the topic bc I'm in no position to do that and truly I don't care what anyone's opinion of it is but my buddy swears by it for annular tears and painful discogenic disease. There are other applications for what they do but since we're talking about discogenic pain...

    Edit - Lemme add that the PRP and lysate procedures into the interspinous ligaments and facets seems to be pretty effective as well.
     
    #105 SommeRiver, Nov 6, 2018
    Last edited: Nov 6, 2018
  7. Ducttape

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    isn't the natural history for most disc herniations to have gradual reduction in size?

    fwiw, one of my colleagues thinks that 2 level fusion is the best treatment for annular tears. oddly enough, he is a spine surgeon.
    another person i know thinks that deep tissue laser treatment will heal disc herniations.
    almost every chiropractor thinks that spinal decompression or manipulation will cure patient's back pains.
    Dr. Oz thinks devil's claw will cure SI pain.


    just quoting what a friend swears by is at best inconsequential but at worst outright dangerous. have some proof it will work....

    think if this article when you talk to a patient:

    Pseudo-quackery in Chronic Pain Care

     
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  8. SommeRiver

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    I think there is SOME proof it works.
     
  9. bedrock

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    i
    i agree intradiscal stem cells have some promise, but I suspect your friend is extremely biased as this is all he does. I would have more trust in a physician that offers all options, not just the ones that pay him the most.......
     
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  10. clubdeac

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    Wow he bashes about everything PT's do, no?
     
  11. SommeRiver

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    My buddy in question didn't do a Pain fellowship, he did a fellowship with Regenexx and from what I can tell they don't do much other than orthobiologics.

    To say there isn't promise with orthobiologics for certain Dx is ludicrous. The jury is still out on various spine Dx but like everything else...give it time...
     
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  12. Dr. Ice

    Dr. Ice Attending
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    Not sure why you even try to argue with some people on this forum...
     
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  13. lonelobo

    lonelobo PAIN DOC
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    :laugh:
     
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  14. Ducttape

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    Advocate treatment that is evidence based, non biased, and tested against current standard of care, and is statistically better.


    If it isn’t, then you shouldn’t be recommending it to patients.

    Regenexx began in 2005. 13 years isnt enough time to come up with some evidence other than case reports? The dearth of good studies thus far is telling, to those who are inquisitive...

    Your buddy is probably a great regenerative medicine guy, but he’s not a pain doc. You are a pain doc. You are better than him.



    Story: I had a patient tell me that he was diagnosed with herniated disc, back in the 60s. Refused surgery. His mom, a nurse, told him to lie on concrete driveway for 2 hours a day during hottest time of day.

    Pain went away in a couple of weeks.

    I’m not recommending hot concrete therapy, but just saying.......
     
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  15. SommeRiver

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    There is no evidence to support the use of orthobiologics. Despite the fact that many ppl swear by it, and it is widely used all over the world, it is all bogus and merely a sham used to make money.

    The sports guys at Emory who use it are all full of BS. I've never referred a pt to anyone for PRP, stem cells, anything...Why? I can't promise their $3k will be money well spent. I will bet my penile meatus that in 10 yrs it will be a much better option for ppl.
     
    #114 SommeRiver, Nov 7, 2018
    Last edited: Nov 7, 2018
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  16. Dr. Ice

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    Hmm let’s see...”it’s all anecdotal, hearsay, patients are lying, it’s placebo affect because they paid cash for it, no evidence to support it, dumping steroids into spines, burning nerves and electrical stimulation are all way better and the literature is all just so much more substantial to support all of that..”
     
  17. DOctorJay

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    An Active Life Restored, Thanks to Regenerative Medicine
    I'm hoping for more evidence as well. Wenchun is pushing the process.

    November 2, 2018
    An Active Life Restored, Thanks to Regenerative Medicine
    By SharingMayoClinic
    [​IMG]

    For years, Rick Amatuzio lived with severe back pain that kept him from the active life he'd always savored. But advanced diagnostic tests and regenerative medicine therapy at Mayo Clinic ultimately led to a complete recovery. Now Rick once again can play sports and enjoy the outdoors free from pain.
    A typical weekend for Rick Amatuzio involves playing two rounds of golf, riding his motorcycle and mountain biking. But less than two years ago, the active motocross champion couldn't get out of bed or stand up straight. Debilitating back pain kept him from doing many of the activities he'd once enjoyed.

    "I can recall crawling to the bathtub many mornings on my hands and knees in an attempt to loosen my body for the upcoming day," Rick says. "You feel helpless, emptiness, and like there's nowhere to turn for help to improve the situation."

    Rick finally found the help he needed when he sought care at Mayo Clinic in 2017. Wenchun Qu, M.D., Ph.D., a specialist in physical medicine and rehabilitation and pain medicine, offered Rick a treatment that involved injecting stem cells into his spine. It worked. Now Rick's pain is gone.

    "Dr. Qu is one of the best doctors I've ever seen," Rick says. "He didn't make promises, yet he gave me a lot of hope."

    Progressive pain
    Rick can trace his back issues to 10 years ago, when the Duluth, Minnesota, resident had spinal fusion surgery to correct a spine condition known as spondylosis. Two years after that surgery, Rick began noticing a dull ache in his lower back that got progressively worse each year until he had a pain level of 7 out of 10 for most of the day.

    "I was getting epidural steroid shots, which would help for a month or two, and then the problem would return," Rick says. "I was taking six or eight Tylenol a day."

    When the pain kept him from getting more than an hour of sleep at night, Rick's local neurosurgeon, who had performed the spinal fusion, recommended he go to Mayo Clinic to pursue regenerative medicine therapy.

    During his first consult with Dr. Qu in May 2017, Rick was diagnosed with a spine disorder known as adjacent segment disease. The disease had developed as a result of his spinal fusion.

    "I was getting epidural steroid shots, which would help for a month or two, and then the problem would return. I was taking six or eight Tylenol a day."
    Rick Amatuzio
    "Adjacent segment disease is when you have a fusion of two vertebrae, and the next level of vertebrae have to move more to compensate, which causes those discs to wear out," Dr. Qu says. "Imaging studies showed he had quite active disease in the discs below the fused discs."

    The next step was to do a test called a provocative discography. It could determine whether the worn discs were causing Rick's pain. The test involved injecting contrast dye in the discs to put pressure on them and reproduce the pain he'd been feeling. Test results confirmed the pain was coming from Rick's degenerated discs.

    To treat Rick's condition, Dr. Qu recommended an approach that used regenerative medicine. Unlike traditional treatment for adjacent segment disease that destroy the discs by burning or fusing them, Dr. Qu would treat the disc degeneration with therapy to reduce the inflammation that was responsible for Rick's pain.

    "Stem cells have growth factors which activate the dormant cells indigenous to the disc and restore the health of the disc by reducing inflammation," Dr. Qu says. "If you reduce inflammation, you reduce pain."

    Outstanding outcome
    On Sept. 28, 2017, Rick returned to Mayo Clinic's Rochester campus to have a combination of platelet-rich plasma and bone marrow aspirate concentrate injected into his spine. The benefit from the treatment was not immediate. In fact, Rick's pain become worse before he saw significant improvement — an outcome that was not unprecedented, according to Dr. Qu.

    "It takes about two months, or even longer, to see the treatment effect, and I have seen low-level inflammatory responses in between," he says.

    But throughout that period, Rick felt the support of his Mayo Clinic care team. "Dr. Qu and his team stood with me and helped me through the process," he says. "They would call or email frequently to see how I was doing."

    "I am extremely grateful for Dr. Qu and Mayo Clinic. They have given me my life back."
    Rick Amatuzio
    By the time he celebrated his 44th birthday in March, Rick was feeling much better. Since then, he's lost 30 pounds and can now carry his golf bag for 36 holes without pain. He says it's the best he's felt in 12 years.

    "I wake up in the morning, and I can stand up straight easily. The burning pain in my back and the back of my legs is gone. I can sleep through the night. I can go out with my friends without discomfort. I work out every morning. I can go mountain biking," Rick says. "I am extremely grateful for Dr. Qu and Mayo Clinic. They have given me my life back. Every day is a blessing that I can do the activities I enjoy doing."
     
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  18. Dr. Ice

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    “He’s lying, he was desperate and was reaching for something, his psych meds finally kicked it, this doctor at mayo is a money hungry hack who manipulated the patient into believing in snake oil...” etc etc

    Or how bout this one..of course his prior treatment didn’t work..because he had adjacent segment disease so he most certainly would have gotten better by mbb/rfa, or wait maybe venom or cooled rfa of his sij..that would have definitely worked right?
     
    #117 Dr. Ice, Nov 7, 2018
    Last edited: Nov 7, 2018
  19. SommeRiver

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  20. lobelsteve

    lobelsteve SDN Lifetime Donor
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    You clearly forgot 8th grade science. N of 1 is an N of none. No conclusions can be made based on this other than 1 guy got better. Great ad for the stupid sheeples. As a doc, you should be wiser. Should.
     
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  21. SommeRiver

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    Except there's not an n=1, there is an n of many, many more. We all agree that we would like much more data and evidence but to dismiss this outright is foolhardy.

    Edit - Earlier in this thread I said I would bet my penile meatus that the evidence will grow stronger for orthobiologics but i want to go back and recant that statement...I could end up being very wrong here and that seems like an unfair price for me to pay for being duped...
     
  22. lobelsteve

    lobelsteve SDN Lifetime Donor
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    OOps, you misunderstand. Science requires a scientific method. Hypothesis, research design, experimentation, adjust hypothesis, plausible possibility, etc. I can correct it and make it N's of 1. But the many, many more are not more than a repeated experiment with an N of 1.
     
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  23. SommeRiver

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    Just like using a parachute is an n=1.

    Are you saying that orthobiologics do not work at all, or just spine?
     
  24. lobelsteve

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    Im saying they might not work better than placebo and we lack reasonably good data to support their use outside of controlled trials.

    A new shop selling widgets on every corner. North cobb regenerative medicine has full page ads in local paper. Check their website. Find the red flags?
     
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  25. SommeRiver

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    Tons of ppl hawking growth factors and irradiated tissue products as "stem cells." I get that, but no one is talking about the products that nurses inject in a chiropractor's offices or the many quacks out there who will come to your house and give you a vitamin infusion with facial Botox.

    There are a LOT of very legitimate ppl out there getting good results with various products.

    Why would you automatically assume anyone in this conversation is referring to anything that isn't above board?

    Did you ever listen to the podcast that Ken Mautner and Gerry Malanga did about stem cells, PRP, etc? It is pretty good. As a resident at Emory I worked with him and he frequently did all sorts of stuff with PRP, fat grafts (Lipogems), BMAC, etc. I have forgotten anything I ever learned back then but I can tell you by and large his pts did pretty darn good. But I guess I similarly did the same thing his pts did, and that was fall for his slipperiness.

    I hope he realizes he is staking the reputation of his fellowship on this field of quackery and mischief.

    There are absolutely indications for these products and they are frequently used with success...I wish I could say that about epidurals...You choose a perfect candidate and nothing happens.

    These two guys here are less qualified, less intelligent, and sadly MUCH LESS ethical than you.

    Listen to Regenerative Medicine. An interview with Dr. Gerry Malanga and Ken Mautner by cardiffdoc #np on #SoundCloud
     
    #124 SommeRiver, Nov 7, 2018
    Last edited: Nov 7, 2018
  26. lobelsteve

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  27. callmeanesthesia

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    Not sure on the attribution but perhaps the trite phrase you are looking for is “The plural of anecdote is not evidence”?
     
    #126 callmeanesthesia, Nov 7, 2018
    Last edited: Nov 7, 2018
  28. SommeRiver

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    Regen medicine does not work.

    It is all a huge cash grab.

    Seriously...Yall are nuts...
     
    #127 SommeRiver, Nov 7, 2018
    Last edited: Nov 7, 2018
  29. lobelsteve

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    No one is saying it doesn’t work. We are saying it has not been adequately studied. To make it easier for you, think of it as fake news.
     
  30. SommeRiver

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    The irony of you posting that video is not lost on me...
     
  31. nvrsumr

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    Had a local guy -PMR guy trained at emory with some type of "fellowship" -set up shop in a chiro office doing only stem cells. Met him. Super unimpressive doc. Lasted about a year before chiro fired him then pushed him out of town with noncompete and nastygrams from PI attorney co owner of said chiro clinic. All the regen med docs are really in medicine for all the right reasons.
     
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  32. SommeRiver

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    Right. So if I mentioned any one of the dozens and dozens of appropriately trained Pain doctors that have gone to prison I could do exactly what you did, and then say that pain doctors are all in it for the right reasons...

    Also I may know who you are talking about...Is this the guy who did a TED video on stem cells?

    Legitimate doctors in the field of orthobiologics want ppl like him gone as much as you do. Centeno goes after those guys nearly every day.

    Edit - No one is as unethical as Spaulding Rehab...No one...Greed and a wanton disregard for evidence...

    Regenerative Medicine | Spaulding Rehabilitation Network
     
    #131 SommeRiver, Nov 8, 2018 at 9:31 AM
    Last edited: Nov 8, 2018 at 9:39 AM
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  33. nvrsumr

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    Not certain about TED talk. Only know about this doc as I was asked to be an paid expert witness as to what constitutes pain medicine by the chiro/atty when they were enforcing the noncompete. I declined as I do not testify against other docs. Money is not everything and bad karma.

    I do regen med and I think my first PRP case was 2009. Have had successes and failures. Telling everyone regen med is a panacea and not trying less expensive traditional options first is what has set this field back. There is no reason to be a regen med "expert" in the community medicine setting. Too limited of a field.

    I do not have ax to grind with Emory pain fellowship. Training has to be 1000X better than 10 years ago when it was a PMR based "pain fellowship" that was located in a strip mall -pokes for percs- clinic under the supervision of a single doc now in jail for fraud.
     
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  34. Dr. Ice

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    Don’t think anyone has suggested it is a panacea..no one is advocating jumping directly to it without discussing all the alternatives. I gotta be honest, the very small percentage of my practice that is regen, the office visits with these patients prior to consideration are very long and back me up for the whole day. It’s probably more financially rewarding for me to burn through more patients in an office setting than from what I’m getting with what I charge for regen..
     
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  35. Ducttape

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    no one is saying that regenerative medicine does not have its place in the pantheon of chronic pain treatments.

    do you lack the basic scientific ethos to understand what is being stated?


    before we, as a specialty, tout that orthobiologics help, we, as a specialty, need evidence more than the lowest possible form (ie case reports, which are what all of these are) to promote them.

    in fact, I would say that I currently do tout regenerative medicine, per drusso's definition, when it comes to epidural blood patches.

    I may actually suggest that PRP for SI joints might be possible to tout, based on the previous study I posted.

    but please, if you think that it is okay to tout orthobiologics for such things such as spine, post any prospective double blind nonbiased (the hardest criteria to attain) study to let us review, before giving patients false hope.
     
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  36. SommeRiver

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    If this is the guy who is now in practice in NJ, and previously was in Colorado, he never did an Emory fellowship of any kind. I know this for a fact. He was a worthless resident as well.
     
  37. myrandom2003

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  38. SommeRiver

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    Definitely would be a massive breakthrough in pain management.
     
  39. lobelsteve

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  40. Ducttape

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    Way too early to tout. . Not a new study, it’s a phase 1/2 (out of at least 3) clinical trial, with very small group size. 24 patients, and is a press release. A way to get more angel investors, I suppose.

    Hold any judgement and not really tout until phase 3 trials done, pls...

    I find it very interesting that, of all the online reports I found, none separated out the patients treated with CybroCell alone from those who got CybroCell with PRP.

    Maybe it was all due to effects of the PRP and not their fibroblasts!!
     
  41. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    @Ducttape Have you ever attended IOF? These are the conversations we sit around and have...it's a science-based professional society with excellent CME.

    Controversies in Orthobiologics

     
  42. clubdeac

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    Interesting... I may like to attend one of these. Dave why are you wearing your fluoro glasses? ;P
     
  43. Ducttape

    Ducttape SDN Lifetime Donor
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    Dr. Bertram makes a significant statement starting 54 seconds.
     
    sloh likes this.
  44. jesspt

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    Conservatively treated massive prolapsed discs: a 7-year follow-up
     

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