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The Effectiveness and Safety of Percutaneous Platelet-Rich Plasma and Bone Marrow Aspirate Concentrate for the Treatment of Suspected Discogenic Low Back Pain: a Comprehensive Review

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Abstract

Purpose of Review

Comprehensively review the effectiveness and safety of percutaneous, fluoroscopically guided, intradiscal injection of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) for the treatment of suspected discogenic low back pain.

Recent Findings

Publications in PubMed up to February 2019 were independently assessed. The literature search yielded three intradiscal PRP studies: one randomized controlled trial and two prospective cohort studies. Five intradiscal BMAC studies were identified. Four of the five prospective cohort studies were completed by the same primary author and results pertained to the same treatment group at different follow-up time points. A single case series of treatment with intradiscal BMAC was identified.

Summary

The evidence for use of percutaneous, fluoroscopy-guided, intradiscal PRP or BMAC for the treatment of suspected discogenic low back pain appears safe, potentially positive, but is limited due to low-quality studies, natural history of discogenic pain, and variable reporting characteristics. Further quality research is needed.

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Fig. 1

Change history

  • 20 December 2019

    The original version of this article unfortunately contained a mistake in the authorgroup section. Author Byron Schneider’s family name was incorrectly presented as “Schnieder”.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.

    Murray CJL, Atkinson C, Bhalla K, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591–608. https://doi.org/10.1001/jama.2013.13805.

  2. 2.

    United States Bone and Joint Initiative. By the numbers: musculoskeletal back pain: back and neck disorders, injuries, and disk disorders. www.usbji.org. Accessed March 18, 2019.

  3. 3.

    Schwarzer AC, Wang SC, Bogduk N, McNaught PJ, Laurent R. Prevalence and clinical features of lumbar zygapophysial joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis. 1995;54(2):100–6. https://doi.org/10.1136/ard.54.2.100.

  4. 4.

    Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. BMC Musculoskelet Disord. 2004;5(1):15. https://doi.org/10.1186/1471-2474-5-15.

  5. 5.

    Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine (Phila Pa 1976). 1995. https://doi.org/10.1097/00007632-199509000-00007.

  6. 6.

    Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine. 1996;21:1889–92. https://doi.org/10.1097/00007632-199608150-00012.

  7. 7.

    Schwarzer AC, Aprill CN, Bogduk N. The sacroiliac joint in chronic low back pain. Spine (Phila Pa 1976). 1995. https://doi.org/10.1097/00007632-199501000-00007.

  8. 8.

    Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007;16:1539–50. https://doi.org/10.1007/s00586-007-0391-1.

  9. 9.

    DePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011;12(2):224–33. https://doi.org/10.1111/j.1526-4637.2010.01045.x.

  10. 10.

    Cooke PM, Lutz GE. Internal disc disruption and axial back pain in the athlete. Phys Med Rehabil Clin N Am. 2000;11:837–65.

  11. 11.

    Teraguchi M, Yoshimura N, Hashizume H, Muraki S, Yamada H, Oka H, et al. The association of combination of disc degeneration, end plate signal change, and Schmorl node with low back pain in a large population study: the Wakayama Spine Study. Spine J. 2015;15:622–8. https://doi.org/10.1016/j.spinee.2014.11.012.

  12. 12.

    Haschtmann D, Stoyanov JV, Gédet P, Ferguson SJ. Vertebral endplate trauma induces disc cell apoptosis and promotes organ degeneration in vitro. Eur Spine J. 2008;17:289–99. https://doi.org/10.1007/s00586-007-0509-5.

  13. 13.

    Kim SM, Lee SH, Lee BR, Hwang JW. Analysis of the correlation among age, disc morphology, positive discography and prognosis in patients with chronic low back pain. Ann Rehabil Med. 2015;39:340–6. https://doi.org/10.5535/arm.2015.39.3.340.

  14. 14.

    Bogduk N, Aprill C, Derby R. Lumbar discogenic pain: state-of-the-art review. Pain Med (United States). 2013;14(6):813–36 http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed11&NEWS=N&AN=2013407027.

  15. 15.

    McCormick ZL, Lehman VT, Plastaras CT, Walega DR, Huddleston P 3rd, Moussallem C, Geske JR, Verdoorn JT, Kennedy DJ, Maus TP, Carr CM. Low-pressure Lumbar Provocation Discography According to Spine Intervention Society/International Association for the Study of Pain Standards Does Not Cause Acceleration of Disc Degeneration in Patients with Symptomatic Low Back Pain: A 7 Year Matched Cohort Study. Spine (Phila Pa 1976). 2019 Jun 27. https://doi.org/10.1097/BRS.0000000000003085.

  16. 16.

    Wolfer LR, Derby R, Lee JELS. Systematic review of lumbar provocation discography in asymptomatic subjects with a meta-analysis of false-positive rates. Pain Physician. 2008;11(4):513–39.

  17. 17.

    Carragee EJ. Persistent low back pain. N Engl J Med. 2005;352:1891–8. https://doi.org/10.1056/nejmcp042054.

  18. 18.

    Kuijpers T, Van Middelkoop M, Rubinstein SM, et al. A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011;20:40–50. https://doi.org/10.1007/s00586-010-1541-4.

  19. 19.

    Petersen T, Larsen K, Jacobsen S. One-year follow-up comparison of the effectiveness of McKenzie treatment and strengthening training for patients with chronic low back pain: outcome and prognostic factors. Spine (Phila Pa 1976). 2007. https://doi.org/10.1097/BRS.0b013e31815cda4a.

  20. 20.

    Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine (Phila Pa 1976). 2000. https://doi.org/10.1097/00007632-200005150-00012.

  21. 21.

    Kapural L, Vrooman B, Sarwar S, et al. A randomized, placebo-controlled trial of teransdiscal radiofrequency, biacuplasty for treatment of discogenic lower back pain. Pain Med (United States). 2013. https://doi.org/10.1111/pme.12023.

  22. 22.

    Carragee EJ, Cheng I. Minimum acceptable outcomes after lumbar spinal fusion. Spine J. 2010;10:313–20. https://doi.org/10.1016/j.spinee.2010.02.001.

  23. 23.

    Brox JI, Reikerås O, Nygaard Ø, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122:145–55. https://doi.org/10.1016/j.pain.2006.01.027.

  24. 24.

    Fritzell P, Hägg O, Wessberg P, Nordwall A. 2001 Volvo award winner in clinical studies: lumbar fusion versus nonsurgical treatment for chronic low back pain. A multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine (Phila Pa 1976). 2001. https://doi.org/10.1097/00007632-200112010-00002.

  25. 25.

    Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69:1643–8. https://doi.org/10.1136/ard.2009.108902.

  26. 26.

    Shen L, Yuan T, Chen S, Xie X, Zhang C. The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2017;12:16. https://doi.org/10.1186/s13018-017-0521-3.

  27. 27.

    Chahla J, Dean CS, Moatshe G, Pascual-Garrido C, Serra Cruz R, LaPrade RF. Concentrated bone marrow aspirate for the treatment of chondral injuries and osteoarthritis of the knee: a systematic review of outcomes. Orthop J Sport Med. 2016;4(1):1–8. https://doi.org/10.1177/2325967115625481.

  28. 28.

    Damia E, Chicharro D, Lopez S, Cuervo B, Rubio M, Sopena J, et al. Adipose-derived mesenchymal stem cells: are they a good therapeutic strategy for osteoarthritis? Int J Mol Sci. 2018;19. https://doi.org/10.3390/ijms19071926.

  29. 29.

    Willett NJ, Thote T, Lin ASP, Moran S, Raji Y, Sridaran S, et al. Intra-articular injection of micronized dehydrated human amnion/chorion membrane attenuates osteoarthritis development. Arthritis Res Ther. 2014;16(1):R47. https://doi.org/10.1186/ar4476.

  30. 30.

    Wang Y, Yu D, Liu Z, Zhou F, Dai J, Wu B, et al. Exosomes from embryonic mesenchymal stem cells alleviate osteoarthritis through balancing synthesis and degradation of cartilage extracellular matrix. Stem Cell Res Ther. 2017;8:189. https://doi.org/10.1186/s13287-017-0632-0.

  31. 31.

    Kuroki H, Aoyama T, Iijima H, Takahashi M, Isho T. Effectiveness of mesenchymal stem cells for treating patients with knee osteoarthritis: a meta-analysis toward the establishment of effective regenerative rehabilitation. npj Regen Med. 2018. https://doi.org/10.1038/s41536-018-0041-8.

  32. 32.

    Lai LP, Stitik TP, Foye PM, Georgy JS, Patibanda V, Chen B. Use of platelet-rich plasma in intra-articular knee injections for osteoarthritis: a systematic review. PM R. 2015;7:637–48. https://doi.org/10.1016/j.pmrj.2015.02.003.

  33. 33.

    Freitag J, Bates D, Wickham J, Shah K, Huguenin L, Tenen A, et al. Adipose-derived mesenchymal stem cell therapy in the treatment of knee osteoarthritis: a randomized controlled trial. Regen Med. February 2019;14:213–30. https://doi.org/10.2217/rme-2018-0161.

  34. 34.

    Shin TH, Kim HS, Kang TW, Lee BC, Lee HY, Kim YJ, et al. Human umbilical cord blood-stem cells direct macrophage polarization and block inflammasome activation to alleviate rheumatoid arthritis. Cell Death Dis. 2016;7. https://doi.org/10.1038/cddis.2016.442.

  35. 35.

    • Regulatory considerations for human cells, tissues, and cellular and tissue-based products: minimal manipulation and homologous use. https://www.fda.gov/downloads/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/CellularandGeneTherapy/UCM585403.pdf%2D%2D. Accessed February 16, 2019. The Food and Drug Administration (FDA) established regulations regarding the use of human cells and tissues which dictate that human cells and tissues may be used.

  36. 36.

    Fice MP, Miller JC, Christian R, Hannon CP, Smyth N, Murawski CD, et al. The role of platelet-rich plasma in cartilage pathology: an updated systematic review of the basic science evidence. Arthrosc - J Arthrosc Relat Surg. 2019;35:961–976.e3. https://doi.org/10.1016/j.arthro.2018.10.125.

  37. 37.

    McCarrel T, Fortier L. Temporal growth factor release from platelet-rich plasma, trehalose lyophilized platelets, and bone marrow aspirate and their effect on tendon and ligament gene expression. J Orthop Res. 2009;27:1033–42. https://doi.org/10.1002/jor.20853.

  38. 38.

    Huang AH, Motlekar NA, Stein A, Diamond SL, Shore EM, Mauck RL. High-throughput screening for modulators of mesenchymal stem cell chondrogenesis. Ann Biomed Eng. 2008;36:1909–21. https://doi.org/10.1007/s10439-008-9562-4.

  39. 39.

    Indrawattana N, Chen G, Tadokoro M, Shann LH, Ohgushi H, Tateishi T, et al. Growth factor combination for chondrogenic induction from human mesenchymal stem cell. Biochem Biophys Res Commun. 2004;320:914–9. https://doi.org/10.1016/j.bbrc.2004.06.029.

  40. 40.

    Chen FH, Tuan RS. Mesenchymal stem cells in arthritic diseases. Arthritis Res Ther. 2008;10:223. https://doi.org/10.1186/ar2514.

  41. 41.

    • Chu CR, Rodeo S, Bhutani N, Goodrich LR, Huard J, Irrgang J, LaPrade RF, Lattermann C, Lu Y, Mandelbaum B, Mao J, McIntyre L, Mishra A, Muschler GF, Piuzzi NS, Potter H, Spindler K, Tokish JM, Tuan R, Zaslav KMW. Optimizing clinical use of biologics in orthopaedic surgery: consensus recommendations from the 2018 AAOS/NIH U-13 Conference; 2018. Consensus recommendation from the joint 2018 American Academy of Orthopedic Surgery and National Institutes of Health (AAOS/NIH) conference that provides recommended reporting characteristics to help standardize the autologous biologics research.

  42. 42.

    Higgins JPT, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. https://doi.org/10.1136/bmj.d5928.

  43. 43.

    Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653.

  44. 44.

    McCormick ZL, Vorobeychik Y, Gill JS, et al. Guidelines for composing and assessing a paper on the treatment of pain: a practical application of evidence-based medicine principles to the mint randomized clinical trials. Pain Med. 2018;19(11):2127–37. https://doi.org/10.1093/pm/pny046.

  45. 45.

    Bogduk N, Kennedy DJ, Vorobeychik Y, Engel A. Guidelines for composing and assessing a paper on treatment of pain. Pain Med (United States). 2017. https://doi.org/10.1093/pm/pnx121.

  46. 46.

    Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. 2009;62. https://doi.org/10.1016/j.jclinepi.2009.06.006.

  47. 47.

    • 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):1–10; quiz 10. https://doi.org/10.1016/j.pmrj.2015.08.010. Single-center, double-blind RCT evaluating the effectiveness of PRP for the treatment of suspected discogenic back pain in 47 adults.

  48. 48.

    Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–58. https://doi.org/10.1016/S0304-3959(01)00349-9.

  49. 49.

    Levi D, Horn S, Tyszko S, Levin J, Hecht-Leavitt C, Walko E. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med (United States). 2016;17(6):1010–22. https://doi.org/10.1093/pm/pnv053.

  50. 50.

    Akeda K, Ohishi K, Masuda K, Bae WC, Takegami N, Yamada J, et al. Intradiscal injection of autologous platelet-rich plasma releasate to treat discogenic low back pain: a preliminary clinical trial. Asian Spine J. 2017;11(3):380–9. https://doi.org/10.4184/asj.2017.11.3.380.

  51. 51.

    Hu X, Wang C, Rui Y. An experimental study on effect of autologous platelet-rich plasma on treatment of early intervertebral disc degeneration. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2012;26(8):977–83.

  52. 52.

    • Pettine KA, Murphy MB, Suzuki RK, Sand TT. Percutaneous injection of autologous bone marrow concentrate cells significantly reduces lumbar discogenic pain through 12 months. Stem Cells. 2015;33(1):146–56. https://doi.org/10.1002/stem.1845. Prospective cohort study evaluating the effectiveness of fluoroscopically guided intradiscal injection of BMAC for the treatment of suspected discogenic low back pain in 26 patients. This study had the highest percentage of AAOS reporting characteristics at 67%.

  53. 53.

    Pettine K, Suzuki R, Sand T, Murphy M. Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up. Int Orthop. 2016;40(1):135–40. https://doi.org/10.1007/s00264-015-2886-4.

  54. 54.

    Pettine KA, Suzuki RK, Sand TT, Murphy MB. Autologous bone marrow concentrate intradiscal injection for the treatment of degenerative disc disease with three-year follow-up. Int Orthop. 2017;41(10):2097–103. https://doi.org/10.1007/s00264-017-3560-9.

  55. 55.

    Pettine MDK, Dordevic M, Hasz MDM. Reducing lumbar discogenic back pain and disability with intradiscal injection of bone marrow concentrate: 5-year follow-up. Am J Stem Cell Res. 2018. https://doi.org/10.5923/j.ajscr.20180201.01.

  56. 56.

    Haufe SMW, Mork AR. Intradiscal injection of hematopoietic stem cells in an attempt to rejuvenate the intervertebral discs. Stem Cells Dev. 2006;15(1):136–7. https://doi.org/10.1089/scd.2006.15.136.

  57. 57.

    Orozco L, Soler R, Morera C, Alberca M, Sanchez A, Garcia-Sancho J. Intervertebral disc repair by autologous mesenchymal bone marrow cells: a pilot study. Transplantation. 2011;92(7):822–8. https://doi.org/10.1097/TP.0b013e3182298a15.

  58. 58.

    Mochida J, Sakai D, Nakamura Y, Watanabe T, Yamamoto Y, Kato S. Intervertebral disc repair with activated nucleus pulposus cell transplantation: a three-year, prospective clinical study of its safety. Eur Cell Mater. 2015;29:202–12 discussion 212.

  59. 59.

    Elabd C, Centeno CJ, Schultz JR, Lutz G, Ichim T, Silva FJ. Intra-discal injection of autologous, hypoxic cultured bone marrow-derived mesenchymal stem cells in five patients with chronic lower back pain: a long-term safety and feasibility study. J Transl Med. 2016;14:253. https://doi.org/10.1186/s12967-016-1015-5.

  60. 60.

    Piccirilli M, Delfinis CP, Santoro A, Salvati M. Mesenchymal stem cells in lumbar spine surgery: a single institution experience about red bone marrow and fat tissue derived MSCs. J Neurosurg Sci. 2017;61(2):124–33. https://doi.org/10.23736/S0390-5616.16.03266-X.

  61. 61.

    Lutz GE. Increased nuclear T2 signal intensity and improved function and pain in a patient one year after an intradiscal platelet-rich plasma injection. Pain Med. 2017;18(6):1197–9. https://doi.org/10.1093/pm/pnw299.

  62. 62.

    Kirchner F, Anitua E. Intradiscal and intra-articular facet infiltrations with plasma rich in growth factors reduce pain in patients with chronic low back pain. J Craniovert Jun Spine. 2016;7(4):250–6. https://doi.org/10.4103/0974-8237.193260.

  63. 63.

    Sys J, Weyler J, Van Der Zijden T, Parizel P, Michielsen J. Platelet-rich plasma in mono-segmental posterior lumbar interbody fusion. Eur Spine J. 2011;20(10):1650–7. https://doi.org/10.1007/s00586-011-1897-0.

  64. 64.

    Peul WC, Van Den Hout WB, Brand R, Thomeer RTWM, Koes BW. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ. 2008;336:1355–8. https://doi.org/10.1136/bmj.a143.

  65. 65.

    Bush K, Cowan N, Katz DE, Gishen P. The natural history of sciatica associated with disc pathology: a prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976). 1992. https://doi.org/10.1097/00007632-199210000-00013.

  66. 66.

    Guyer RD, Ohnmeiss DD. Lumbar discography. Spine J. 2003;3(3 Suppl):11S–27S.

  67. 67.

    Carragee EJ, Don AS, Hurwitz EL, Cuellar JM, Carrino J, Herzog R. 2009 ISSLS prize winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study. Spine (Phila Pa 1976). 2009. https://doi.org/10.1097/BRS.0b013e3181ab5432.

  68. 68.

    McCormick Z, Lehman VT, Plasta-ras CT, Walega DR, Huddleston PM III, Kennedy DJ, et al. Low pressure lumbar provocation discography according tointernational association for the study of pain or spine interventionsociety standards does not cause accelerated progression of discdegeneration in symptomatic low back pain patients: a 7-year match. Spine J. 2018;18(8):S103.

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Correspondence to Zachary L. McCormick.

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Conflict of Interest

Zachary McCormick serves on the Board of Directors of the Spine Intervention Society. Taylor Burnham, Aaron Conger, Quinn Tate, Daniel Cushman, Richard Kendall, and Byron Schneider declare no conflicts of interest relevant to this manuscript.

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The original version of this article was revised: This article unfortunately contained a mistake in the authorgroup section. Author Byron Schneider's family name was incorrectly presented as “Schnieder”.

This article is part of the Topical Collection on Musculoskeletal Rehabilitation

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Burnham, T., Conger, A., Tate, Q. et al. The Effectiveness and Safety of Percutaneous Platelet-Rich Plasma and Bone Marrow Aspirate Concentrate for the Treatment of Suspected Discogenic Low Back Pain: a Comprehensive Review. Curr Phys Med Rehabil Rep 7, 372–384 (2019). https://doi.org/10.1007/s40141-019-00243-6

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Keywords

  • PRP
  • BMAC
  • Intradiscal
  • Discogenic low back pain