Professional Documents
Culture Documents
doi: 10.1093/pm/pnv053
SPINE SECTION
Original Research Articles
Intradiscal Platelet-Rich Plasma Injection for
Chronic Discogenic Low Back Pain: Preliminary
David Levi, MD,* Scott Horn, DO,* levels, two at 3 levels, and one at 5 levels. Categorical
Sara Tyszko, PA,* Josh Levin, MD,† success rates were as follows: 1 month: 3/22 5 14%
Charles Hecht-Leavitt, MD,‡ and (95% CI 0% to 28%), 2 months: 7/22 5 32% (95% CI
Edward Walko, DO* 12% to 51%), 6 months: 9/19 5 47% (95% CI 25%
to 70%).
*APM Spine and Sports Physicians, Norfolk, Virginia;
†
Stanford School of Medicine, Department of Conclusion. This trial demonstrates encouraging
Orthopaedic Surgery, Redwood City, California; ‡MRI preliminary 6 month findings, using strict categori-
and CT Diagnostics, Virginia Beach, Virginia, USA cal success criteria, for intradiscal PRP as a treat-
ment for presumed discogenic low back pain.
Correspondence to: David Levi, MD, APM Spine and Randomized placebo controlled trials are needed to
Sports Physicians, 5665 Lowery Rd, Norfolk, VA, USA. further evaluate the efficacy of this treatment.
Tel: 757-422- 2966; Fax: 757-422-4563; E-mail:
levid@cox.net. Key Words. Disc; Intradiscal; Platelet-rich Plasma;
PRP; Discogenic
Conflict of interest: No authors have any conflict of
interest.
Introduction
Abstract
Low back pain is a very common cause of pain and dis-
Background. Platelet-rich plasma (PRP) has been ability. Although several structures within the spine have
found to be effective for a variety of musculoskele- been identified as pain generators, the intervertebral disc is
tal conditions. The treatment of discogenic pain felt to account for 40% to 50% of chronic low back pain
with PRP is under investigation. [1,2]. The most common conservative treatment options
for discogenic back pain include activity restriction, medica-
Objective. To assess changes in pain and function tions, physical therapy, chiropractic treatment, and steroid
in patients with discogenic low back pain after an injections. Many patients have an inadequate response to
intradiscal injection of PRP. these conservative measures and progress to surgical
treatment, either lumbar fusion or disc replacement.
Study Design. Prospective trial.
Methods. Patients were diagnosed with discogenic Minor complications are common with lumbar fusion
low back pain by clinical means, imaging, and exclu- surgery. Severe complications are rare but do occur,
sion of other structures. Provocation discography with mortality rates ranging from 0.1% to 0.6% [3–11].
was used in a minority of the patients. Patients Beyond the issue of the complication rate is the ques-
tion of the effectiveness of fusion or disc replacement
underwent a single treatment of intradiscal injection
procedure as a treatment for low back pain. The evi-
of PRP at one or multiple levels.
dence for the superiority of fusion over conservative
Main Outcome Measures. Patients were considered treatment, at this point, remains unclear [12–17]. In
a categorical success if they achieved at least 50% addition, the outcomes for lumbar disc replacement
improvement in the visual analog score and 30% have not demonstrated superiority over fusion [18].
decrease in the Oswestry Disability Index at 1, 2,
and 6 months post-treatment. Prior interventional conservative treatments have been
aimed at annular tear pathology, which is felt to be the
Results. 22 patients underwent intradiscal PRP. Nine anatomic source responsible for discogenic low back
patients underwent a single level injection, ten at 2 pain [19,20]. Attempts to alter the annular tear and
C 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 1010
Preliminary Results from a Prospective Trial
associated neural structures with heat or radiofrequency were seen [41–45], nor were there any mutagenic
energy have been disappointing [21,22]. More recently, changes of the nucleus pulposus cells to indicate an
Peng and colleagues investigated the use of methylene increased risk of neoplasm [41].
blue as a neurolytic agent within discs [23,24]. These
investigators published two quality clinical studies A randomized placebo-controlled trial of intradiscal PRP
in humans is currently under way [46]. The researchers
demonstrating the efficacy of intradiscal methylene
are injecting PRP at the time of provocation discogra-
blue. Unfortunately, further investigations have failed to
produce their superior results [25–28]. phy. Patients demonstrating a painful response to disc
pressurization are injected with a variable volume (1 to
Ultimately, the ideal treatment for pain induced by annular 2 mL) PRP (treatment group) or further contrast injection
1011
Levi et al.
Table 1 Exclusion criteria for a study of one or two discs to be injected) or APC 60 (for more than
intradiscal injection of platelet-rich plasma for two discs to be injected) at point of care in the pre-op
area. For the APC 30 kit, 3 mL anticoagulant citrate dex-
discogenic low back pain trose formula A (ACD-A) were drawn into a 35 mL blood
Non-discogenic source of back pain. draw syringe. For the APC 60 kit, 6 mL of ACD-A were
drawn into a 60 mL blood draw syringe. Venipuncture was
Negative provocation discography.
performed after prepping the region with chlorhexidine
Active moderate to severe lumbar radiculopathy.
and isopropyl alcohol. The syringe was disconnected from
Intradural disc herniation.
the tubing, and a sterile blunt needle with cap was con-
Spinal fracture within past 6 months.
nected. The syringe was labeled with the patient’s name
1012
Preliminary Results from a Prospective Trial
60 minutes prior to the procedure. Alternatively, patients injected, the needle was removed. The antiseptic prep
were offered conscious sedation in the form of 2 to was cleansed from the patients’ back and the drape
6 mg Versed IV with the possible addition of 50 to removed. The patients then either ambulated with assis-
150 mg fentanyl IV. Continuous cardiac, pulse oximetry, tance or were transported via wheelchair to the recovery
and clinical monitoring were performed throughout the room.
procedure.
Patients completed a follow-up visual analog score and
Patients were placed in a prone position in an outpatient Oswestry Disability Index [58] before treatment, and at 1
fluoroscopy suite. Strict sterile technique was observed. month, 2 months, and 6 months after the procedure
The lower back was cleansed with chlorhexadine and [58]. These instruments of assessment were adminis-
Figure 1 Fluoroscopy views of needle placement for an inje ction of platelet-rich plasma into an L5-S1 disc. (a)
Antero-posterior view before injection of contrast medium. (b) Antero-posterior view after injection of contrast medium.
(c) Lateral view.
1013
Levi et al.
Table 3 Diagnostic criteria satisfied by patients selected for treatment with intradiscal platelet-rich plasma
Z-joint: zygapophysial joint. SIJ: sacroiliac joint intra- articular block. (þ): block positive. (-): block negative. IA: intra-articular.
MBB: medial branch blocks. RF: no relief from radiofrequency neurotomy. Modic changes: (1) ¼ type 1, (2) ¼ type 2, mixed ¼ type
1 and 2. HIZ: high-intensity zone.
1014
Preliminary Results from a Prospective Trial
Table 4 Segmental levels of discs in each patient treated with injections of platelet-
rich plasma
Disc treated
Patient
L1/2 L2/3 L3/4 L4/5 L5/S1
1
2
3
A successful outcome was defined as 50% improve- However, 36% achieved a 50% decrease in VAS inde-
ment in VAS accompanied by a 30% improvement in pendent of their ODI score.
ODI.
At 2 months, seven patients (32%; 12% to 51%)
had a successful outcome (Table 7), and 41%
Results achieved a 50% decrease in VAS independent of their
ODI score.
Table 2 records the demographic features of the
patients treated. Table 3 shows the diagnostic features At 6 months, 9 of 19 patients had a successful outcome
satisfied by each patient for inclusion in the study. Table (47%; 25% to 70%) (Table 7). Results were the same
4 shows the segmental levels and the number of discs for a 50% decrease in VAS alone.
treated. All patients received a uniform volume of 1.5 mL
of PRP. There were no instances of discitis or increased Although no patient was lost to follow-up, a single sub-
radicular symptoms and no neurologic or other ject (patient 5) who did not qualify as a categorical suc-
complications. cess at any follow-up time point did undergo a
concurrent treatment. The patient underwent an epi-
No patients were lost to follow-up. All 22 patients com- dural steroid injection (ESI) for a severe exacerbation
pleted the 2-month follow-up, and 19 patients reached after the 2 month data were recorded. One month fol-
6-month follow-up at the time of publication. Individual lowing the ESI (3 months after the PRP injection), he
VAS and ODI scores and percent changes, along with underwent a second PRP injection. His 6 month data,
group median and interquartile range, are provided in provided in Table 6, remained below the ODI success
Tables 5 and 6. threshold of 30% improvement. Therefore, the patient
was considered a categorical failure regardless of the
At 1-month follow-up, only 3 of the 22 patients concurrent treatment. In determination of the group
(14%, with 95% confidence intervals [CIs] of 0% to 28%) median and interquartile range, however, his 6 month
satisfied the criteria for successful outcome (Table 7). data were not used. Rather, the 2 month follow-up
1015
Levi et al.
data were carried forward and used for the 6 month fol- The poor early results in this study may reflect the mecha-
low-up. nism of action of PRP and the time required for the treat-
ment effect to occur. Multiple studies using PRP for other
orthopedic conditions have demonstrated similar lengths of
Discussion time for significant improvement [32,63,64]. The exact proc-
ess by which PRP may facilitate healing has been postu-
Although the early results of this trial are poor, the pre- lated but is not clearly understood [65–69]. Therefore, the
liminary 6 month results are encouraging. At the 6 month time frame for the theoretical beneficial effect to the disc to
follow-up after a single intradiscal injection of PRP, occur is also unknown but may be between 2 and 6
47% of patients reported at least a 50% improvement in months based on the findings of the present trial.
Table 5 Scores for back pain on visual analog scale (VAS) and Oswestry Disability Index (ODI) of
patients treated with intradiscal platelet-rich plasma, at inception, and at 1, 2, and 6 months after
treatment
VAS ODI
Patient number Inception 1M 2M 6M Inception 1M 2M 6M
1 88 79 78 48 30 32 34 28
2 55 62 48 60 33 26 22 30
3 65 67 83 0 24 38 36 10
4 70 28 50 5 12 14 14 6
5 64 26 66 66* 17 14.5 20 20*
6 54 34 61 22 26 20 18 16
7 75 66 62 73 40 36 34 40
8 68 55 35 31 44 42 40 22
9 65 19 70 17 30 20 36 12
10 52 70 7 64 40 54 10 64
11 48 31 20 8 22 16 14 4
12 61 22 26 65 44 42 38 44
13 64 19 0 80 40 18 14 44
14 75 64 57 32 34 28 24 10
15 61 71 41 74 31 40 29 29
16 77 59 38 53 38 34 14 30
17 86 65 72 62 26 30 23 14
18 99 19 2 8 44 27 17 22
19 65 66 32 19 30 9 8 2
20 50 21 22 10 14 26
21 51 30 14 32 24 16
22 58 41 42 34 30 26
Median 64.5 48 41.5 48 31.5 27.5 22.5 22
IQR 55-75 26-66 22-62 17-65 26-40 18-36 34-14 10-30
1016
Preliminary Results from a Prospective Trial
Table 6 Percentage changes in back pain scores on visual analog scale (VAS) and
Oswestry Disability Index (ODI) of patients treated with intradiscal platelet-rich plasma, at
1, 2, and 6 months after treatment
IQR: interquartile range. A positive change indicates improvement; a negative change indicates pain (VAS)
or function (ODI) worsened.
Specifically, the system used in this study produces a rela- ample time for a treatment effect compared to pla-
tively high hematocrit. Studies do indicate that red blood cebo as they used an 8 week crossover protocol [46].
cells may have a deleterious effect not only on platelet The PRP injection in the Lutz et al. study was per-
function by alteration of the pH [67,74] but also on chon- formed at the time of discography immediately follow-
drocyte survival [75]. This is an area for future research ing a positive determination. This protocol did not
consideration. allow a uniform volume of PRP to be injected, which
raises concerns that an inadequate treatment volume
Our findings are similar to the results presented at was delivered. This is in contrast to the current study,
several scientific meetings. Lutz and colleagues have in which a uniform volume of 1.5 mL PRP was deliv-
presented preliminary data on a randomized, pla- ered to each disc. Both the current trial and Lutz
cebo-controlled trial of 42 patients with an 8 week et al. study used a red blood cell–rich and leukocyte-
crossover [46]. The 8 week between-group data rich PRP formulation.
showed modest but categorical results demonstrating
a much higher satisfaction rate for the PRP group Akeda and colleagues injected six patients with a uniform
over control using the North American Spine Society volume of 2 mL leukocyte-poor and red blood cell–poor
patient satisfaction questionnaire. One year, within- PRP releasate (substance isolated from activated PRP) at
group data demonstrated significant, but modest, discogram-positive levels [76]. The benefit seen in their
pain improvement. Based on the apparent improve- small group of patients was exceptional: mean pain scores
ment time frame seen in the current study (between 2 decreased from 7.1 to 1.8 on a numeric rating scale
and 6 months), Lutz et al. may have failed to allow (NRS) by 1 month and were sustained at 6 months [76].
1017
Levi et al.
Table 7 Number and proportions (95% confidence intervals) of patients who reported the combinations
of categorical changes indicated in back pain scores on visual analog scale (VAS) and Oswestry Disability
Index (ODI) after treatment with intradiscal platelet-rich plasma
Outcomes
Back pain (VAS)
ODI
Follow-up 100% >50% <50% Worse
Regions highlighted in bold indicate numbers and proportions of patients who satisfied the combined criteria of 50% improvement
in VAS and 30% improvement in ODI score.
Their protocol differed from that of the present study by accordance with ISIS guidelines requires needle puncture
the PRP formulation but was similar in that the PRP was with potential harm to a previously unaffected disc. As
not injected at the time of discography, allowing for a PRP is a minimally processed autologous substance and
larger volume of PRP injectate. The time frame of improve- very unlikely to have any detrimental effects [29,31,41,42],
ment was also much earlier than in the present trial. the authors felt that the potential adverse effects of intra-
discal PRP were likely no greater than those of discogra-
There are several limitations in this trial. The most signifi- phy. Therefore, subjecting patients to discography
cant issue is the diagnostic criteria for the intradiscal PRP (including injecting a normal control level) in order to deter-
treatment. The patients in this study were presumed to mine which discs are symptomatic adds an additional
have discogenic pain based on clinical and imaging fea- invasive procedure with disc puncture that is not war-
tures and the exclusion of other likely sources of low back ranted if discography is being utilized only for qualification
pain. Most did not undergo provocation discography, a of an intradiscal PRP injection. The authors’ position, in
diagnostic procedure that is often performed pre-opera- summary, was that PRP at the time of discography would
tively prior to lumbar fusion to help determine which discs not provide ample volume for the PRP, and performing a
are the source of the patient’s pain. The decision to forgo separate discography procedure solely for determining the
discography as an inclusion criterion was based on multi- candidacy and level for the PRP injection could not be
ple factors. Although performing an intradiscal PRP injec- justified.
tion at the time of discography seems most practical, the
volume of contrast during this diagnostic test may reach Without discography as a patient selection criterion in
3 mL if performed in accordance with ISIS guidelines [47]. this trial, significant bias does exist. The authors used
This may leave little to no residual volume capacity to findings on history, physical examination, and imaging
accommodate a presumed adequate PRP volume for studies that did have some correlation with positive dis-
treatment. Secondly, in accordance with ISIS guidelines cography but were certainly limited in diagnostic value
[47], discography requires at least one negative control [48–57].
disc. Discography is invasive and has the potential for
negative effects, including those that may have future clini- A further limitation of our patient selection protocol was
cal relevance [59]. Therefore, performing discography in the non-standardization of z-joint and SIJ blocks to rule
1018
Preliminary Results from a Prospective Trial
out these structures as the primary source of pain. The 3 Turner JA, Ersek M, Herron L, et al. Patient out-
authors followed general guidelines of pain location for comes after lumbar spinal fusions. JAMA 1992;268
this determination [48,50]. However, clinical and imaging (7):907–11. Review.
findings felt to be more consistent with a discogenic
source [48–57] were also considered in the determina- 4 Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol
tion to perform z-joint or SIJ blocks. In situations in MA. Morbidity and mortality in association with oper-
which the investigators felt a non-disc source of pain ations on the lumbar spine. The influence of age,
was very unlikely, patient preference was also consid- diagnosis, and procedure. J Bone Joint Surg Am
ered in the decision to perform the blocks. This element 1992;74(4):536–43.
of the protocol clearly introduces bias, as patients with-
1019
Levi et al.
14 Hanley EN, David SM. Lumbar arthodesis for the 27 Gupta G, Radhakrishna M, Chankowsky J, Asenjo
treatment of back pain. J Bone Joint Surg Am JF. Methylene blue in the treatment of discogenic
1999;81:716–30. low back pain. Pain Physician 2012;15(4):333–8.
15 Brox JI, Sorensen R, Friis A, et al. Randomized clini- 28 Kim SH, Ahn SH, Cho YW, Lee DG. Effect of intradis-
cal trial of lumbar instrumented fusion and cognitive cal methylene blue injection for the chronic discogenic
intervention and exercises in patients with chronic low back pain: One year prospective follow-up study.
low back pain and disc degeneration. Spine 2003; Ann Rehabil Med 2012;36(5):657–64.
28(17):1913–21.
29 Nguyen RT, Borg-Stein J, Mcinnis K. Application of
1020
Preliminary Results from a Prospective Trial
39 Chen WH, Lo WC, Lee JJ, et al. Tissue-engineered 51 Aprill C, Bogduk N. High-intensity zone: A diagnos-
intervertebral disc and chondrogenesis using human tic sign of painful lumbar disc on magnetic reso-
nucleus pulposus regulated through TGF-beta1 in nance imaging. Br J Radiol 1992;65:361–9.
platelet-rich plasma. J Cell Physiol 2006;209:744–54.
52 Peng B, Hou S, Wu W, Zhang C, Yang Y. The
40 Kim HJ, Yeom JS, Koh YG, et al. Anti-inflammatory pathogenesis and clinical significance of a high-
effect of platelet-rich plasma on nucleus pulposus intensity zone (HIZ) of lumbar intervertebral disc on
cells with response of TNF-a and IL-1. J Orthop Res MR imaging in the patient with discogenic low back
2014;32(4):551–6. pain. Eur Spine J 2006;15(5):583–7.
46 Tuakli-Wosornu YA, Terry A, Gribbin C, et al. 59 Carragee E, Don A, Hurwitz E, et al. Does discogra-
Lumbar intradiscal platelet rich plasma injections: A phy cause accelerated progression of degeneration
prospective, double-blinded randomized controlled changes in the lumbar disc. Spine 2009;34:2338–45.
study. Presented at International Spine Intervention
Society Annual Meeting. Orlando, FL; 2014. 60 Farrar JT, Young JP, La Moreaux L, Werth JL,
Poole M. Clinical importance of changes in chronic
47 Bogduk N. Practice Guidelines for Spinal Diagnostic pain intensity measured on an 11-point numerical
and Treatment Protocol, 2nd edition. San Francisco: pain rating scale. Pain 2001;94:149–58.
International Spine Intervention Society; 2013;420–58.
61 Ostelo RW, Deyo RA, Stratford P, et al. Interpreting
48 Young S, Aprill CN, Laslett M. Correlation of clinical change scores for pain and functional status in
examination characteristics with three sources of low back pain: Towards international consensus
chronic low back pain. Spine J 2003;3:460–5. regarding minimal important change. Spine 2008;33
(1):90–4.
49 Laslett M, Oberg B, Aprill CN, McDonald B.
Centralization as a predictor of provocation discog- 62 Hägg O, Fritzell P, Nordwall A. Swedish Lumbar Spine
raphy results in chronic low back pain, and the influ- Study Group. The clinical importance of changes in
ence of disability and distress on diagnostic power. outcome scores after treatment for chronic low back
Spine J 2005;5(4):370–80. pain. Eur Spine J 2003;12(1):12–20.
50 DePalma MJ, Ketchum JM, Trussell BS, Saullo TR, 63 Kon E, Mandelbaum B, Buda R, et al. Platelet-rich
Slipman CW. Does the location of low back pain plasma intra-articular injection versus hyaluronic acid
predict its source? PM R 2011;3(1):33–9. viscosupplementation as treatments for cartilage
1021
Levi et al.
pathology: From early degeneration to osteoarthritis. 71 Chee AV, Ren J, Lenart BA, et al. Cytotoxicity of
Arthroscopy 2011;27(11):1490–501. local anesthetics and nonionic contrast agents on
bovine intervertebral disc cells cultured in a three-
64 Spakova T, Rosocha J, Lacko M, Harvanova D, dimensional culture system. Spine J 2014;14
Gharaibeh A. Treatment of knee joint osteoarthritis with (3):491–8.
autologous platelet-rich plasma in comparison with hya-
luronic acid. Am J Phys Med Rehab 2012;91(5):411–7. 72 Hoelscher GL, Gruber HE, Coldham G, Grigsby JH,
Hanley EN Jr. Effects of very high antibiotic concen-
65 Smyth NA, Murawski CD, Fortier LA, Cole BJ, trations on human intervertebral disc cell prolifera-
Kennedy JG. Platelet rich plasma in the pathologic
1022