Can Orthobiologics Solve Chronic Back Pain?



Anybody that has ever suffered from chronic or recurring back pain knows how debilitating the condition can be on your physical and mental well-being. It limits your ability to recreate on weekends, perform basic manual tasks, and even get up out of a chair without excruciating pain.

As a large percentage of our population ages and we become increasingly sedentary, it's no surprise that back pain is one of the most common complaints among patients visiting their primary care physician. In fact, in the United States over 80% of adults will experience one or more episodes of back pain in their lifetime (1). Symptoms of back pain may include localized back or neck pain, radiculopathic (radiating) pain, weakness in leg(s) or arm(s), and numbness in the hands or feet.

The underlying condition of back pain, in nearly 40% of all cases, is Degenerative Disc Disease (DDD) (1). This type of pain is commonly known as "discogenic" and refers to the breakdown of intervertebral disc (or intervertebral fibrocartilage) which lies between adjacent vertebrae in the spine. Each disc forms a fibrocartilaginous joint (a symphysis) which facilitates movement of the vertebrae in addition to acting as a shock absorber for the spine (2).


DDD is not the only source of back pain. Facet joints are located in the back portion (posterior) of the spine and consist of bony surfaces cushioned by cartilage that can become the subject of arthritic pain and inflammation. Facet joint arthritis can be a symptom of DDD, however, it's important to understand what is causing the back pain before deciding on an appropriate course of treatment.





What are the current treatment options for back pain?

As most practitioners are familiar with, conservative treatment options for back pain include activity restriction, NSAIDs, physical therapy, and chiropractic treatment. Unfortunately, most of these fail to produce long-term symptom relief (2). Next up are nerve blocks, nerve ablation, or steroid injections. However, each of these interventions carry risks of complications and with steroid injections, pain-relief is short lived and prolonged use of this treatment option is discouraged.

The last stop for treating back pain is surgery to fuse the joints of the spine or perform a total disc replacement. And while severe complications are rare, the efficacy of these procedures is contested and patients must undergo months of rehabilitation following the operation (3). Fortunately, orthobiologics like platelet-rich plasma (PRP) have emerged as a promising intervention for treating back pain that fails to respond to conservative treatment and can keep you out of the OR.


How PRP therapy can help back pain

PRP is a biological solution derived from a patients blood that is specially processed in a centrifuge to increase the concentration of platelets to supra-physiological levels before being injected back into the patient. Platelets contain numerous growth factors that help stimulate and accelerate tissue healing - especially for degenerative conditions like DDD. It is a relatively low cost treatment option that is well tolerated with minimal side effects, as it is produced entirely from cells within you own body.

For these reasons, PRP has emerged as a very popular treatment option for all sorts of MSK conditions including discogenic back pain and facet joint arthritis. A single injection of highly concentrated PRP can yield positive benefits for patients in as little as 2 weeks, lasting for up to 1 year. Let's showcase some of the literature below:

Discogenic Back Pain

Levi et. al. in 2016 assessed changes in pain and function in patients with discogenic low back pain after an intradiscal injection of Harvest Terumo PRP (2). 22 patients received one or multiple PRP injections depending on the number of affected discs. The authors established a high-bar for success, with criteria including at least a 50% improvement in conjunction with a 30% improvement in their ODI score. Categorical success rates were as follows: 1 month: 3/22 = 14% (95% CI 0% to 28%), 2 months: 7/22 = 32% (95% CI 12% to 51%), 6 months: 9/19 = 47% (95% CI 25% to 70%). For such a high bar, these results were impressive.

In a similar study undertaken by Tuakli-Wosornu et. al., 42 patients were treated with a single injection of PRP (4). Authors concluded that patients who received intradiscal PRP showed significant improvements in FRI, NRS Best Pain, and NASS patient satisfaction scores over 8 weeks compared against a saline control. Additionally, those who received PRP maintained significant improvements in FRI scores through at least 1 year of follow-up.



Tuakli-Wosornu et. al. Change in Functional Rating Index over time from baseline to 8 weeks for control and PRP groups.


Facet Joint

For facet joint arthritis, Wu J et. al. compared the effectiveness and safety between platelet-rich plasma (PRP) and Local Anesthetic (LA)/corticosteroid injected into the facet joints of 47 patients (5). They found that while both a single injection of PRP and LA/corticosteroid for intra-articular injection are effective, PRP was a superior treatment option for longer duration efficacy. This is consistent with the body of evidence comparing PRP vs. corticosteroids in other indications, as I've written about previously.

In another study by Singla et. al., patients were randomized into 2 groups. One group received 1.5 mL of methylprednisolone 40 mg/mL and 1.5 mL of 2% lidocaine with 0.5 mL of saline, whereas, the other group received 3 mL of leukocyte free PRP with 0.5 mL of calcium chloride with ultrasound guided sacroiliac joint injection. The results here were more dramatic. At 3-month follow-up, 90% of the patients reported satisfactory relief with PRP; whereas, satisfactory relief was observed in 25% of the patients receiving steroids. Authors noted a strong association was observed in patients receiving PRP and showing a reduction of VAS of greater than 50% from baseline.

Singla et. al. Trends in visual analog scale (VAS) scores of both groups at baseline and subsequent follow-ups. PRP, platelet-rich plasma.


Best Practices for Physicians

As you can see, there is more than promising data to support using PRP for treating both discogenic and facet joint back pain. But what are some of the best practices physicians can follow to increase the chance of success for their patients? Through the literature and our own experiences working with physicians performing these injections, this is what we know today:

  1. Proper diagnosis and patient selection is key. Understanding the root cause of back pain through clinical assessment, medical imaging and diagnostic tests such as discographies will help ensure that you're treating the right area.

  2. It is not recommended to perform a discography at the time of PRP injection. The reason for this is that the volume of contrast solution required to complete a discography will limit the amount of PRP injectate, thus potentially compromising the therapeutic potential of the treatment.

  3. Due to the unique architecture of the spine and surrounding network of nerves, most practitioners will perform these injections under fluoroscopy or ultrasound guidance. This ensures the precise delivery of PRP and increases the efficacy of injection.

  4. Choose the right PRP. Beyond ensuring that your PRP meets the baseline concentration for regenerative (4x), it is recommend that LP-PRP be used for facet joint injections to prevent further inflammation. For intradiscal injections, the literature is a bit divided as both LR-PRP and LP-PRP have demonstrated success. With that being said, LR-PRP has anti-microbial properties which can be beneficial for these types of injections.

  5. Most studies available have only performed a single injection. However, trends in other MSK indications as well as anecdotal reports suggest that multiple injections spaced out over a period of 2-4 weeks may offer improved benefit (6)


In conclusion, orthobiologics such as PRP can offer a low-cost, safe, and efficacious alternative to conventional treatment options for back pain. If you're interested in exploring this option for your patients, please contact MDBiologix and get started today.


Literature

  1. Hirase T, Jack Ii RA, Sochacki KR, Harris JD, Weiner BK. Systemic Review: Is an Intradisca Injection of Platelet-Rich Plasma for Lumbar Disc Degeneration Effective?. Cureus. 2020;12(6):e8831. Published 2020 Jun 25. doi:10.7759/cureus.8831

  2. David Levi, MD, Scott Horn, DO, Sara Tyszko, PA, Josh Levin, MD, Charles Hecht-Leavitt, MD, Edward Walko, DO, Intradiscal Platelet-Rich Plasma Injection for Chronic Discogenic Low Back Pain: Preliminary Results from a Prospective Trial, Pain Medicine, Volume 17, Issue 6, June 2016, Pages 1010–1022, https://doi.org/10.1093/pm/pnv053

  3. Mechanisms of intervertebral disk degeneration/injury and pain: a review. Ito K, Creemers L Global Spine J. 2013 Jun; 3(3):145-52.

  4. Tuakli-Wosornu YA, Terry A, Boachie-Adjei K, Harrison JR, Gribbin CK, LaSalle EE, Nguyen JT, Solomon JL, Lutz GE. Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study. PM R. 2016 Jan;8(1):1-10; quiz 10. doi: 10.1016/j.pmrj.2015.08.010. Epub 2015 Aug 24. PMID: 26314234.

  5. Wu J, Zhou J, Liu C, Zhang J, Xiong W, Lv Y, Liu R, Wang R, Du Z, Zhang G, Liu Q. A Prospective Study Comparing Platelet-Rich Plasma and Local Anesthetic (LA)/Corticosteroid in Intra-Articular Injection for the Treatment of Lumbar Facet Joint Syndrome. Pain Pract. 2017 Sep;17(7):914-924. doi: 10.1111/papr.12544. Epub 2017 Feb 22. PMID: 27989008.

  6. Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid vs. platelet-rich plasma in ultrasound-guided sacroiliac joint injection for chronic low back pain. Pain Pract 2017; 17:782-791.



This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and any related subjects. The views and opinions expressed in this post are those of the author and may not reflect the views and opinions of MDBiologix. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if any treatment is right for you.