Dr. Edward Tobinick and Enbrel injection for discogenic pain

[herniated C6-7]

There is very suggestive, but as yet not fully confirmed evidence, that Enbrel injection can dramatically alleviate discogenic pain. The principal evidence comes from a randomized controlled trial done at Johns Hopkins and Walter Reed for sciatica. The trial was small but the results dramatic.

Of 24 patients in the trial, 6 received placebo and the other 18 received varying dosages of Enbrel injected via the disc epidural. Only 1 of the 6 receiving placebo showed improvement. Of the 18 receiving Enbrel injection, 13 reported more than 50% pain improvement lasting more than 6 months. Most of the 13 had virtually no pain at all after just two injections.

Enbrel is FDA approved for use in auto-immune conditions. In theory it works for discogenic pain by "down-regulating" "the inflammatory process (I'm not certain what this means).

Off label use of Enbrel injection for discogenic pain was pioneered by a Dr. Edward Tobinick in Los Angeles and is available from him currently. It is also being studied for treatment of sciatica in a phase 2 FDA trial by Bioassets Development Corporation. A major pharmaceutical company, Cephalon, has paid $30 million to Bioassets for an option on the intellectual property, with another $70 million or so to be paid if the trial is successful.

Currently, Dr. Tobinick charges some $4200 per Enbrel injection, which you must pay up front.. But because Enbrel is FDA approved, and because California law mandates insurance coverage of off-label use of FDA approved drugs if such use is supported by two or more published medical journal articles, I got almost full insurance coverage from Anthem Blue Cross of California.

Dr. Tobinick tells me that Enbrel injection will not work if the disc is literally compressing a nerve or the spinal cord. It works if the discogenic pain is from inflammation alone: it is known that a herniated disc, even if it causes no compression, emits proinflammatory chemicals.

Dr. Tobinick does not inject Enbrel into the epidural space but into a cerebro-vertebral venous system. This is a less invasive procedure than epidural injection. According to Dr. Tobinick, this venous sysem was documented in medical journals as long as 70 years ago but mostly forgotten till recently.

I tried the Enbrel injection from Dr. Tobinick because the Hopkins trial convinced me it really works for some. But it did not work for me, probably because I have disc compression of nerve/spinal cord.


Dr. Tobinick reports that in his clinical practice about half the patients respond to Enbrel injection for discogenic pain, generally within 2 minutes. Dr. Tobinick also reports that patients can present with head pain or low back and leg pain, as well as cervical symptoms and still get relief from a single Enbrel injection in a single location. Dr. Tobinick thinks Enbrel as well as pro-inflammatory chemicals, TNF-alpha in particular, can travel via the cerebro-vertebral venous system—the inflammatory response can thereby cause symptoms at locations remote from the local disc injury.

Tobinick’s diagnostic hypothesis lends support for clinical observations by a Dr. Herman Kabat, author of Low Back and Leg Pain, whom I saw back in the 1970s, and about whom, more later. Kabat thought a significant percentage of patients with head pain or low back and leg pain suffered from herniated C6-7, but that the true source was never suspected by doctors applying the usual diagnostic criteria. Kabat attributed diverse symptoms to herniated C 6-7 because a good many patients with diverse symptoms, myself among them, reported dramatic relief in their varied symptoms shortly after beginning a conservative treatment program that Kabat devised.

[herniated C6-7]

There is a risk that the work of Dr. Herman Kabat, now deceased, will soon be entirely lost to spine patients. The loss is serious because Kabat had clinical observations that suggest the current diagnostic understanding of chronic spinal pain may often be seriously deficient.

Kabat was a co-inventor of a form of physical therapy known as proprioceptive neuro-muscular facilitation, still used today for rehabilitation of stroke and MS victims. Kabat’s background in rehabilitative medicine gave him a one-of-a kind touch when it came to manual detection of relative muscle weakness in patients, which he drew upon for diagnosis of discogenic pain.

Kabat’s treatment sprang directly from diagnosis and was simple and intuitive as well as conservative. Kabat uniquely noted that patients with relative weakness in one arm in such muscles as the triceps or wrist flexor would regain normal arm strength immediately after cervical traction. Kabat then asked what was the source of renewed arm weakness and found the source—and the patient’s pain trigger--was any stress, even a slight stress, from the same direction as the original traumatic injury to the neck.

The short term treatment that Kabat prescribed was frequent traction and rigorous avoidance for 24 hours of any stress whatsoever from the direction that causes renewed weakness in one arm. The long-term treatment is for the patient to be very, very careful of even moderate stress to the neck, lest the arm become weak again, in which case the patient must start treatment all over again with a new 24 hour regimen, avoiding whatever direction of stress is the source of the most recent injury.

Kabat’s long term treatment is very difficult to complete. But his short-term treatment has repeatedly and quick alleviated symptoms of mine that have included, in addition to upper back and arm pain, low back and leg pain as well as head pain.

Kabat’s clinical observations were that many spinal patients were like myself: many patients had diverse symptoms, but very often, all symptoms would respond quickly to Kabat’s conservative treatment of C 6-7. Having altered standard manual tests for relative muscle weakness, Kabat further found that signs of herniated C6-7 were extremely common in the population and often went undetected by other doctors, even by MRI. This led Kabat to venture the hypothesis that herniated C6-7 was the single most common source of chronic pain conditions.

Kabat had no explanation for how herniated C6-7 could cause such diverse symptoms. And his work was very hard to replicate, partly because it depended on manual testing of muscles for weakness, for which no one but Kabat himself had so special a touch. With Kabat deceased, I know of only one physician moderately skilled at Kabat’s diagnostics, and this physician is currently not practicing, and is likely to be soon (if not already) retired.

Kabat’s clinical observations draw some support from the work of Dr. Edward Tobinick, who has pioneered the still experimental use of Enbrel injection for discogenic pain. Dr. Tobinick reports that patients can present with head pain or low back and leg pain, as well as cervical symptoms and still get relief from a single Enbrel injection in a single location. Dr. Tobinick thinks Enbrel as well as pro-inflammatory chemicals, TNF-alpha in particular, can travel via the cerebro-spinal venous system—the inflammatory response can thereby cause symptoms at locations remote from the local disc injury. I have posted about Dr. Tobinick and Enbrel injection on another thread.

Mainstream spine physicians rely narrowly for diagnostic inference on the anatomical map of nerve connections. They do not entertain the possibility that spinal pain can depart from the path of neural anatomy. But pain from heart attacks does not go only to the chest, but also to the left arm, apparently because the nervous system simply makes a mistake. I can understand why spine doctors want to be conservative when it comes to surgical decisions. But my own experience suggests that the neuro-anatomical map cannot alone explain the pattern of pain in many patients.

[Harrison]

Wow, this seems to be a very impressive, detailed summary for which we thank you. Sorry to ask, but some may be wondering if you have any affiliation with the doctors mentioned...I presume you are looking into it for yourself but wanted to double-check...Thx again for sharing this interesting information.

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[Hulagu]

Herniated C6-7 describes very accurately the experience every one in my family had with Dr Kabat's diagnosis and treatment of our herniated discs. It is a great relief to read such a detailed, clear description of a process that most (I'd say 99.9%) of the health care professionals I (and my mother, father, sister, cousin, aunt and many friends) have told about the Kabat method - they all react with that look of 'ho hum, another kook, another alternative medicine quack'. Mr Moderator, C6-7 most likely isn't affiliated with the physicians, but is definitely affiliated with the treatment. It works. It is very hard to do, but Dr K always told us it was not difficult. What he meant, I am sure, is that his method is easy compared to surgery which ultimately doesn't fix the problem (as the surgery community has recently admitted).

My injury occurred during recess when I was in second grade sixty years ago. I slipped and hit my forehead very hard on ice. I went into shock (cold, clammy, nauseated - I still remember the event), but the symptoms didn't manifest until my 20s. Dr Kabat had me immobilize one quadrant of my body for 24 hours (very difficult), and gave me a list of things to do and not to do, and a very simple self-traction exercise. It works, and the relief is immediate. However, as C6-7 reported, any stress from the same direction does reignite the problem. Even someone gently killing a mosquito on that part of my forehead. However, if I myself swat the mosquito, the injury does not happen.
Before he died, Dr Kabat taught his method at a hospital in Vallejo, I assume the Kaiser hospital where he had worked in the 40s-50s. Surely there is someone there who learned enough to carry on and disseminate Herman Kabat's brilliant work.