Efficacy of platelet-rich plasma for back pain

Regenerative injection therapies such as dextrose prolotherapy (DP) and platelet rich plasma (PRP) have been evaluated as viable treatment options of pain management. There are established bodies of evidence that show clinical efficacy for the treatment of knee osteoarthritis and lateral epicondylitis(1-3), however the emergence of evidence to support the use of injection therapies for low back pain from discogenic and facet arthropathy are growing.

PRP is a method of injection therapy that uses autologous plasma with high concentrations of platelets, above normal levels, as a proliferant to be injected into intervertebral discs or facet sites. It is a process that involves drawing blood from a patient, taking the sample through a centrifugation process which separates the cellular elements into different molecular weighted solutions. The plasma rich in platelets is collected and used in orthopedic injections, similar to those of cortisone and hyaluronic acid injection techniques(4).

Different types of autologous PRP solutions can be prepared, some including leukocytes (white blood cells elements), varying platelet concentrations, and red blood cells, which some studies have shown varying levels of efficacy for certain orthopedic conditions (4,5).The repairing effect on the body is to promote a healing process in which the body recruits cellular material and growth factors proliferating the regeneration of the injected tissue.

The exact mechanism remains unclear however it is growth factors released by platelets which allows deposition of cellular matrix that fortify injected structures. The elements include vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), transforming growth factor (TGF), platelet-derived growth factor (PDGF), fibroblast growth factor (bfGF), insulin-like growth factor (IGF), and connective tissue growth factor (CTGF). These components significantly enhance the proliferation and growth of tissue.(5,6)

This can be specific to disc degeneration as the proposed mechanism involves regenerating the radial tears that allow a herniation of the annulus fibrosus. The reduction of this herniating process reduces the degeneration of height and resorption of the disc. It is also proposed that the platelets regenerate the cellular discs themselves.

PRP studies for disc degeneration causing low back pain

Clinical studies that look at the effect of PRP on discogenic lumbar and thoracic back pain have been practiced since 2011. In 2014 Bodor et al performed a study with 35 patients who were given a single injection of PRP in various sites in the lumbar and thoracic spine. Over two thirds of patients showed significant positive outcomes ranging from 10 days to 10 months after the treatment.

The authors had also presented case studies that highlighted pain improvements that were not only measured by Oswestry pain scores but by the ability for patients to return to normal physical activity in daily life. Safety outcomes reported in the study were high, with no severe complication and only two patients experiencing vaso-vagal effects with treatment.(5)

In 2016, Hussein et al performed a study on the effect of PRP injections on intervertebral discs in patients suffering from MRI evidenced discogenic back pain. Pain outcomes were measured (7). The difference in this study is that the solution used also included leukocyte platelet rich plasma. An injection was performed once a week for six weeks and pain scales were evaluated by a numeric rated pain scale. Follow up was at 12-18 months and there was a 71% success rate reported by the authors.

In the same year the first double-blind randomized controlled trial of intradiscal PRP was done. Tuakli-Wosornu et al recruited 47 participants with a history of chronic lumbar pain that was due to degenerative disc disease. Symptoms of the patients ranged from localized back pain to radiating neurologic involvement down the lower limbs. A single injection was performed at a single or multiple sites that were determined to be involved, and follow up data was collected at eight weeks post injection.

Pain scales were measured by functional rating index (FRI), numeric rating scales (NRS), short form (SF36), and modified north American spine society satisfaction scores (NASS), and compared to control groups found statistically significant improvements in the treatment group. The effects were found to be sustained after a period of at least one year.(8)

PRP studies for facet arthropathy causing low back pain

Facet arthropathy may be another reason for the occurrence of low back pain. Although there is no gold standard for the diagnosis of degeneration of facet joints, studies show that with appropriate clinical indications, astute objective tests, and clinician knowledge the identification of this disorder can be done with a significant level of confidence.

This particular etiology of back pain is proposed to occur when the articulating surface and ligamentous tissue of facets degenerate. Neurophysiologic studies have shown that facet joints are well innervated, with presence of free and encapsulated nerve endings.(9,10) Subsequent degeneration, inflammation, and injury to these regions may contribute to pain experiences for patients.In 2016 Wu et al, performed a prospective study comparing PRP, local anesthetic, and corticosteroid in intra-articular injections of lumbar facet joint syndromes.

46 patients were recruited and were randomized into group A to receive PRP, and group B to receive a combination of local anesthetic and corticosteroid. Pain scales were assessed with visual analog scales (VAS), Roland-Morriss disability questionnaires (RMQ), and Oswestry Disability Index (ODI). Short term outcomes were similar within a one month follow up between both groups however the PRP treatment group showed an increase in success rates (lowered pain indexes) after 6 months.(11)

Facet arthritis within a joint can also cause dysfunction and low back pain. In 2017 Singla et al, designed a prospective randomized open blinded study of 40 patients diagnosed with sacroiliac joint pathology. The patients were randomized into 2 treatment groups, one to receive 1.5 ml of methylprednisolone and the other receiving 3 ml of leukocyte-free PRP.

Both groups’ subjective pain reports were determined by VAS scores, MODQ, and SF12 surveys at 2, 4, 6 weeks, and 3 months post treatment of a single injection. The results showed a decrease in pain intensity significantly lower with the PRP group than the methylprednisolone group. What was most remarkable was the sustained improvement after a 3 month follow up.(12)

These studies highlight the efficacy and superiority of PRP injections versus other injection therapies. It has been shown that PRP is effective, easy, and safe enough to treat discogenic and facet syndromes for chronic low back pain.

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RESOURCES

1. Meheux, Carlos J. et al. “Efficacy of Intra-Articular Platelet-Rich Plasma Injections in Knee Osteoarthritis: A Systematic Review.” Arthroscopy - Journal of Arthroscopic and Related Surgery 1 Mar. 2016: 495–505. Arthroscopy - Journal of Arthroscopic and Related Surgery. Web.
2. Peerbooms, Joost C et al. “Positive Effect of an Autologous Platelet Concentrate in Lateral Epicondylitis in a Double-Blind Randomized Controlled Trial: Platelet-Rich Plasma versus Corticosteroid Injection with a 1-Year Follow-Up.” The American journal of sports medicine38.2 (2010): 255–62. The American journal of sports medicine. Web.
3. Chang, Ke Vin et al. “Comparative Effectiveness of Platelet-Rich Plasma Injections for Treating Knee Joint Cartilage Degenerative Pathology: A Systematic Review and Meta-Analysis.” Archives of Physical Medicine and Rehabilitation Mar. 2014: 562–575. Archives of Physical Medicine and Rehabilitation. Web.
4. Platelet-rich plasma in mono-segmental posterior lumbar interbody fusion. Sys J, Weyler J, Van Der Zijden T, Parizel P, Michielsen J Eur Spine J. 2011 Oct; 20(10):1650-7.
5. Bodor M, Toy A, Aufiero D. Disc Regeneration with Platelets and Growth Factors. In: Duarte Lana JFS, Andrade Santana MH, Belangero WD, et al. editors. Platelet-rich plasma: regenerative medicine: sports medicine, orthopaedic, and recovery of musculoskeletal injuries. Berlin, Heidelberg: Springer, 2014:265-79.
6. DeChellis DM, Cortazzo MH. Regenerative medicine in the field of pain medicine: Prolotherapy, platelet-rich plasma therapy, and stem cell therapy-Theory and evidence. Tech Reg Anesth Pain Manag 2011;15:74-80. 10.1053/j.trap.2011.05.002
7. Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease.SICOT J 2016;2:12. 10.1051/sicotj/2016002
8. Tuakli-Wosornu YA, Terry A, Boachie-Adjei K, et al. Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study. PM R 2016;8:1-10; quiz 10. 10.1016/j.pmrj.2015.08.010
9. Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Pain Physician. 2013;16:S49–283.
10. Cavanaugh JM, Lu Y, Chen C, Kallakuri S. Pain generation in lumbar and cervical facet joints. J Bone Joint Surg Am. 2006;88 Suppl 2:63–67
11. Wu, Jiuping et al. “A New Technique for the Treatment of Lumbar Facet Joint Syndrome Using Intra-Articular Injection with Autologous Platelet Rich Plasma.” Pain Physician 19 (2016): 617–625. Print.
12. Singla, Varun et al. “Steroid vs. Platelet-Rich Plasma in Ultrasound-Guided Sacroiliac Joint Injection for Chronic Low Back Pain.” Pain Practice 17.6 (2017): 782–791. Pain Practice. Web.