omega 6 results in pro-inflammatory end products. The modern human diet with industrial processing has an omega 6
to omega 3 ratio of about 40: 1. The human body needs both
inflammatories and anti-inflammatories to heal, much the
same way a car needs both a gas pedal and a brake pedal.
Omega 3 supplements primarily come from fish oil but can
also come from krill oil and plant supplements. Plant sources
(ALA) need to be converted in the body to EPA and DHA
which are the active forms and this can be impaired with age.
Marine-based omega 3s have been shown to decrease inflammatory markers such as CRP, IL- 6 and TNF-a. 1, 2 High doses,
upwards of 15,000mg/day, are shown to have a positive impact
on traumatic brain and spinal cord injuries. When combined
with curcumin (the most potent bioactive substance found in
the turmeric root) in mice with spinal cord injuries simulating cervical stenosis, the combination was found to preserve
ambulatory balance and BDNF levels. 3, 4 It is often believed
that fish oil supplementation increases the risk of bleeding.
However, in a recent study in children, it failed to show an
increased risk of procedure-related bleeding even with use
of high dose IV fish oil. 5
Curcumin is found in turmeric root and gives the root its
vibrant orange color. Over 9,000 articles on curcumin are
currently found on PubMed. It has been found to decrease
inflammation by inhibiting the mediators of inflammation,
including cytokines, chemokines, adhesion molecules and
Cox- 2. A randomized double blind placebo controlled study
in patients with mild-moderate knee arthritis showed symptomatic improvement taking 500 mg of curcuminoids per
day. Other studies have shown significant improvement in
pain and stiffness with improved joint function. It may have a
positive impact on rheumatoid arthritis and has been shown
to decrease the likelihood of progression from pre-diabetes to
Type 2 diabetes. Absorption of the curcumin alone is limited
and can be increased with black pepper and other proprietary
formulations. The recommended dose is 1,000-3,000 mg per
day. It should be used cautiously in patients taking warfarin
as it can potentiate the effects. 6-14
Bromelain is derived from the pineapple fruit and stem.
It is approved for both oral and topical use in Europe but is
classified as a supplement in the US and is not FDA approved.
In a PubMed search, nearly 3,000 articles discuss bromelain,
1,550 of which discuss its anti-inflammatory effects in surgical
patients. The mechanism of action is through the kallikrein-kinin pathway lowering plasmakinin (bradykinin) at inflammatory sites and prostaglandin E2. Via the arachadonic acid
pathway, bromelain increases platelet derived cAMP. It has
immunomodulatory effects on T-cells by inhibiting T-cell signal transduction. At a dosage of 90 mg, it significantly reduced
pain and swelling in long bone fractures and accelerated healing compared to treatment with standard NSAIDs.
Alpha lipoid acid is an antioxidant that helps turn glucose
into energy. It is both fat and water soluble unlike other anti-
oxidants. It is also able to pass through the blood brain barrier
and has been used to treat neuropathic pain. A systematic
review of the literature included five randomized controlled
trials and one meta-analysis. Four of the RCTs showed a signif-
icant reduction in total symptom scores with 600 mg per day.
A German study demonstrated its use in improving insulin
sensitivity.17 Therefore, patients on insulin and sulfonylureas
are cautioned to watch for hypoglycemia. Long-term usage
can lower B1 (thiamine) in some patients and supplementa-
tion to overcome this may be necessary.
Neuropathies associated with deficiencies in B1, B6 and
B12 are real and often missed, particularly if a spine provider
is focused on an anatomic cause for a patients symptoms. Supplementation with a B-complex can seem relatively straight
forward, however, depending on the population up to 40% of
individuals will have difficulty processing standard B vitamin
supplements because of a mutation in methylenetetrahydro-folate reductase (MTHFR). This enzyme is the rate-limiting
step in the methylation process. It catalyzes the conversion of
5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate, a
co-substrate for homocysteine. MTHFR variants can be identified in laboratory testing or measuring homocysteine levels
can be a surrogate. Patients with impaired methylation can
have signs of nutritional deficiencies. Eating folate rich green
leafy vegetables is recommended and if supplementation is
used it should be with methyl-folate and methyl-cobalamin.
In the process of caring for spine patients factors beyond
medication, physical therapy, interventional injections and
surgery are involved. They are diet, sleep, stress, psychological
well-being and exercise. In my clinical practice, I recommend
that patients work on these issues in conjunction with more
conventional medical treatments. Supplements can be used
as an adjuvant to assist with restoring health. At the minimum,
a spine provider should be aware of what supplements their
patients are using and how they affect medications and treatments.
1. Robinson LE, Mazurak VC. n- 3 polyunsaturated fatty acids:
relationship to inflammation in health adults and adults
exhibiting features of metabolic syndrome. Lipids. 2013; 48( 4):
2. Li K1, Huang T, Zheng J, Wu K, Li D. Effect of marine-derived n- 3
polyunsaturated fatty acids on C-reactive protein, interleukin
6 and tumor necrosis factor α: a meta-analysis. PLOS ONE.
2014; 9( 2):e88103.
3. Lei E, Vacy K, Boon WC. Fatty acids and their therapeutic potential
in neurological disorders. Neurochem Int. 2016;95:75-84.
4. Holly LT, Blaskeiwicz, Wu A, Feng C, Ying Z, Gomez-Pinilla F.
Dietary therapy to promote neuroprotection in chronic spinal
cord injury. J Neurosurg Spine. 2012;17( 2):134-40.
5. Nandivada P, Anez-Bustillos L, O’Loughlin AA, et al. Risk of post-procedural bleeding in children on intravenous fish oil. Am J Surg.
2016;Dec 1. Epub ahead of print.
6. Goel A, Aggarwal BB. Curcumin, the golden spice from Indian
saffron, is a chemosensitizer and radiosednsitizer for tumors
and chemoprotector and radio prtector for normal organs. Nutr
7. Goel A, et al. Specific inhibition of cyclooxygenase- 2 (COX- 2)