Mesenchymal Stem Cells for Lumbar Degenerative Disc Disease

Bone Marrow Aspiration and Cell Culture Procedure

Utilizing fluoroscopic guidance, a coaxial needle will be advanced to the bone marrow space.
The inner portion will be removed and 10-20mL of marrow aspirated.

MSCs will be isolated and cultured in the Case Western Reserve University National Center for
Regenerative Medicine/Seidman Cancer Center Cellular Therapy Lab using standard operating
procedures established under the ongoing IND - as above.

MSC Delivery/Transplantation Procedure

Utilizing fluoroscopic guidance, a needle will be advanced to the outer annulus of the
affected disc(s). Through the coaxial anchor, a needle will be advanced to the middle 1/3 of
the disc, and confirmed in two planes (AP and lateral).

On the day of infusion, MSCs will be transported from the Cellular Therapy Lab to the IR
suite in a validated dry shipper. MSCs will be thawed in a 37ºC water bath and drawn into 1
ml syringes. Prior to delivery, an aliquot of the infused product will be tested for
viability (trypan blue exclusion). Viability must be >70% for cell transplantation. Treatment
group one will receive an injection of 1-2 ml of a 2 x 106/ml concentration solution of MSCs
and treatment group 2 will 1-2 ml of a 4 x 106/ml concentration solution of MSCs. Both
treatment groups will be injected under intermittent fluoroscopic observation. A manometer
will be used to monitor disc pressures, especially during MSC injection keeping pressure
below 100 psi. Specifically, the volume of injectate will be determined based on three
dynamic factors: real time imaging of contained contrast volume during discography, psi as
measured during the injection (< 100), and patient's symptoms (if patient's pain exceeds
baseline, injection will be stopped) - up to a volume of 2cc of the assigned concentration.

An aliquot of infused product will be submitted to the University Hospitals Cleveland Medical
Center Microbiology Laboratory to test for microbiological contamination. In the event of a
positive microbial test following administration of a cellular product: 1) The Principal
Investigator and his/her designee will be notified and will notify the participant, 2) The
contaminant will identified to a species level and antibiotic sensitivities determined, 3)
The Medical Director of the Cellular Therapy Laboratory and/or the Principal Investigator
will determine the best course of action based on the clinical situation. This may include
blood cultures, administration of prophylactic antibiotics, and repeat cultures on the cell
product. 4) An investigation to determine the source of the contamination will be conducted,
and appropriate corrective measures will be undertaken. Finally, the adverse event will be
reported to the IRB and FDA based on the respective federal and institutional reporting
requirement, as well the approved data safety monitoring board charter.

MRI/Quantitative MRI Procedure

Routine images of the lumbar spine (sagittal and axial T1 and T2 weighted images) will be
obtained for the purposes of: Monitoring for potential alternative effects of the cells
including osteophyte formation, as well as any unexpected local outcome. In addition, a
quantative MRI including fingerprinting. Magnetic resonance Fingerprinting (MRF) allows rapid
and simultaneous quantification of T1and T2 relaxation times. The MRF sequence is based on
varying multiple MR acquisition parameters [ e.g. flip angle (FA) and time of repetition
(TR)] in a pseudorandom manner, such that unique signal evolutions called "fingerprints" are
generated for each combination of tissue properties. These fingerprints are compared with a
dictionary of simulated fingerprints generated for that sequence by a pattern matching
process. Once there is a pattern match, the T1 and T2 values used to generate that dictionary
entry are assigned to that voxel and used to create T1 and T2 maps that are perfectly
anatomically co-registered.

For spine, the proposed MRF sequence is based on a multislice Fast Imaging with Steady
Precession (FISP) acquisition. Scanning will be done both in sagittal and axial planes using
a multislice acquisition. The scan parameters are as follows:

FOV: 400 mm, matrix 400 x 400 mm , TR/TE: 13-15 msec, in-plane resolution 1 x 1 mm, section
thickness 5 mm, flip angle 5-75 degrees, acquisition time ~ 39 seconds per slice, with ~ 4
minutes scan time for a 5 slice sagittal image. In axial plane, the disc would be covered at
each intervertebral level in 4-5 transverse slices and each axial acquisition would take ~ 3
minutes scan time.

The MRF maps would be directly generated as DICOM images using Gadgetron online
reconstruction. Image analysis would be done using a DICOM viewing software to draw Regions
of Interest (ROIs) on nucleus pulposus for direct quantification of relaxation times. There
is the capacity to generate MRF maps from raw data on Matlab which can also be used to draw
ROIs for simultaneous quantification of T1 and T2 relaxation times.

These values will be calculated on the pre and post treatment MRIs.

Inclusion Criteria:

- Symptoms despite conservative (non-surgical) management for > 6 months

- Leg pain, if present, is of nonradicular origin, i.e., not due to stimulation of
nerve roots or dorsal root ganglion of a spinal nerve by compressive forces.

- Leg pain, if present, does not extend below the knee and is no greater than 50%
of low back pain as measured on a visual analog scale. If bilateral leg pain
existed, the worst leg pain is no greater than 50% of low back pain.

- Diagnostic medical branch block or facet joint injection between 18 months and 2 weeks
prior to the study procedure indicates no facet joint involvement.

- Distress and risk assessment method stratification to a) normal or b) at risk
designations

- Modified Pfirrmann MR classification of implicated intervertebral discs of III, IV, or
V

- Absence of infection

- Absence of coagulopathy

- Ability to provide informed written consent

Exclusion Criteria:

- Age > 80y or < 18 y

- Neoplasia

- History of recent or active malignancy(non-melanoma skin cancers, carcinoma in situ,
etc. are allowable)

- Active infection

- Underlying congenital segmentation or other spinal anomalies that result in
differential intervertebral disc pressures

- Significant spinal stenosis

- Interpreted as "severe" on any cross sectional imaging study

- Pregnant or planning to become pregnant

- Contraindication to MRI

- Indwelling medical devices such as pacemakers, aneurysm clips, etc

- Indwelling metal from any other cause (trauma, etc)

- To be excluded with history and radiographs, as necessary

- Immunosuppression

- History or laboratory results indicative of any significant cardiac, endocrine,
hematologic, hepatic, immunologic, infectious, metabolic, urologic, pulmonary,
gastrointestinal, dermatologic, psychiatric, renal, neoplastic, or other disorder that
in the opinion of the Principal Investigator or his/her designee would preclude the
safe performance of BM aspiration, transplantation of autologous MSCs, or performance
of any of the planned study assessments.

- Uncorrectable coagulopathies

- Concurrent participation in another investigational trial involving systemic
administration of agents or within the previous 30 days.

- Extreme obesity, as defined by NIH Clinical Guidelines Body Mass Index (BMI >35).

- Clinically relevant instability on flexion-extension as determined by the investigator
by overlaying films.

- Have undergone a previous surgery at the involved level that may have altered the
target disc (e.g. discectomy, laminectomy, foraminotomy, fusion, intradiscal
electrothermal therapy, intradiscal radiofrequency thermocoagulation etc.).

- Have an acute fracture of the spine at the time of enrollment in the study. Clinically
compromised vertebral bodies at the affected level due to current or past trauma,
e.g., sustained pathological fracture or multiple fractures of vertebrae.

- Have a history of epidural steroid injections within 1 week prior to study treatment.

- Have received chronic (more than 7 consecutive days) treatment with systemic
corticosteroids at a dose equivalent to prednisone ≥ 10 mg/day within 14 days prior to
injection procedure.

- Have received systemic or local nonsteroidal anti-inflammatory drugs (NSAIDS)
injections into the index and/or adjacent vertebral levels within 48 hours prior to
study procedure.

- Have a known history of hypersensitivity or anaphylactic reaction to murine or bovine
products or dimethyl sulfoxide (DMSO).

- Have a known history of hypersensitivity or anaphylactic reaction to products from
birds, such as feathers, eggs or poultry.

- Have a positive screen for human immunodeficiency virus (HIV) by antibodies or nucleic
acid test.

- Have had treatment with any investigational therapy or device within 6 months of study
procedure and/or plans to participate in any other allogeneic stem cell/progenitor
cell therapy trial during the 3-year follow-up period.

- Have been a recipient of prior stem cell/progenitor cell therapy or other biological
intervention to repair the target intervertebral disc.

- Are transient or has been treated in the last 6 months before enrollment for alcohol
and/or drug abuse in an inpatient substance abuse program.

- Habitual use of tobacco throughout the trial and follow-up.

- Have a mental illness that could prevent completion of the study or protocol
questionnaires. If subjects with psychiatric disease are stable, then they should be
allowed to participate in the trial.

- Neurological diseases including unstable diseases or disease which renders subjects
unable to give informed consent which renders unable to give informed consent.
(Subjects with well controlled epilepsy should not be excluded.)