Journal Club January 2017: Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

Article Title: Lumbar Intradiskal Platelet-Rich Plasma (PRP) Injections: A Prospective, Double-Blind, Randomized Controlled Study

Author: Yetsa A. Tuakli-Wosornu, MD, MPH Alon Terry, MD, Kwadwo Boachie-Adjei, BS, CPH, Julian R. Harrison, BS, Caitlin K. Gribbin, BA, Elizabeth E. LaSalle, BS, Joseph T Nguyen, MPH, Jennifer L. Solomon, MD, Gregory E Lutz, MD

Journal: PM R. 2016 Jan;8(1):1-10; quiz 10. doi: 10.1016/j.pmrj.2015.08.010. Epub 2015 Aug 24.

Discussion:

Musculoskeletal complaints are the second most common cause for doctor visits in the United States. The overwhelming odds indicate that these complaints are of low back pain (LBP). In fact, more than 80% of American adults experience at least one episode of LBP during their lifetime. Various structures within the human body can cause LBP and the intervertebral disk (IVD) accounts for more than 40% of cases of chronic LBP. Being the largest avascular structure in the human body, the IVD has poor inherent healing potential. Therefore, it is necessary to develop a recipe for a healing cascade to address the numerous pathologies associated with the IVD. Platelet Rich Plasma (PRP) can provide the essential ingredients for the body to address these pathoanatomic processes and help treat LBP.

PRP is thought to provide the necessary growth factors that are lacking at injurious sites, especially ones with a scarcity of vasculature like the IVD. Placing a high concentration of growth factors (PDGF, VEGF, TGF-Beta, IGF etc.) directly at the site of collagen injury or degeneration can help restore the integrity of the structures via a healing response. In addition, the cytokines in PRP act as humoral mediators to induce the natural healing cascade. In comparison to surgery, PRP is readily available and cost-effective.

In this study, Tuakli-Wosornu et al 2016 investigated whether a single intradiskal injection of PRP delivered to symptomatic degenerative IVD(s), would be clinically beneficial for individuals with chronic diskogenic LBP. This was a prospective, double-blind, randomized controlled trial. A single independent observer randomized 47 participants into two treatment groups (29 in the treatment and 18 in the control). PRP or contrast agent was used under standardized protocol as the injectate for either group. Only disk levels that elicited pain with evidence of incomplete annular disruption were injected. Four internationally validated surveys were used as outcome measures over the 8 weeks of follow-up: the FRI, the NRS, the SF-36, and the modified NASS Outcome Questionnaire.

Participants who received intradiskal PRP injections experienced significantly greater improvements in FRI, NRS-Best Pain, and NASS satisfaction scores compared with those who received contrast agent alone over 8 weeks. Moreover, the improvement in FRI scores lasted for up to 1 year or more for the PRP group. Consequently, this study highlights that intradiskal PRP can be considered a viable option to alleviate pain and restore function for a universally common complaint of low back pain.

Discussion Author: Altamash Raja, OMS-IV, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

Discussion Points:

  1. What are the most common causes of chronic low back pain? Which causes are more prevalent in the various age groups? Young adults (18-35)? Middle aged (35-60)? Elderly (>60)?
  2. What therapeutic objectives should techniques for diskogenic low back pain aim to achieve?
  3. Describe some of the current limitations regarding PRP injections.
  4. How does PRP compare to other interventional treatment options such as facet joint injections, epidural steroid injections etc.? What are the pros? Cons?
  5. What other orthobiologics can be utilized for treatment of musculoskeletal complaints? Where does the future go?
  6. What are some osteopathic techniques for the treatment of low back pain that should be explored further?
  7. When is surgery the preferred treatment option, even in the eyes of a non-operative expert?

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Journal Article Summary and Discussion Questions January 2017

Journal Article January 2017