Should You Recommend Platelet-Rich Plasma for Discogenic Pain?

The potential for PRP to treat various musculoskeletal pathologies is becoming more clear, but is it right for spine conditions? Our expert weighs in.

As a spine specialist, you’re doubtless no stranger to the spectrum of claims about platelet rich plasma (PRP) injections. Those of you who incorporate PRP in your practice likely know what it can and cannot do, what it might and might not do. Those of you who don’t offer PRP shots may still need to answer patients’ questions about them.

PRP shows promise for discogenic pain but it remains unproven for now. PRP shows promise for discogenic pain but it remains unproven for now.

It’s harder than it should be to get the answers exactly right. This is owed in part to the fact that PRP therapy is not standardized. Further, we don’t yet have the full picture of its therapeutic mechanisms – not just because it is an emerging therapy, but also because plasma components vary across patients and techniques. And let’s not underestimate the influence of anecdotes on our own biases for or against this form of regenerative medicine.

We reached out to Anis Mekhail, MD, MS, a clinical assistant professor at the University of Illinois College of Medicine. Dr. Mekhail is an orthopedic spine surgeon who trained as a fellow at the Cleveland Clinic nearly two decades ago. He neither researches PRP nor offers it to his patients at Parkview Orthopaedic Group in the Chicago suburb of Palos Heights – so he has no dog in the fight.

Here, Dr. Mekhail breaks down some findings, challenges, and research opportunities for PRP therapy in spine conditions.

Spine Universe: How would you describe PRP to a fellow health professional?

Anis Mekhail, MD: PRP is blood plasma with concentrated autologous platelets, obtained by a centrifugation process that separates liquid and solid components of anticoagulated blood. PRP also contains several growth factors, including platelet-derived growth factor (PDGF), transforming growth factor (TGF), insulin-like growth factor (IGF), epidermal growth factor (EGF), epithelial cell growth factor (EGR), and hepatocyte growth factor (HGF). These promote the healing of bone and soft tissue.

SU: Platelet concentration varies among techniques and even within techniques. Do patients who receive more platelets show greater improvement?

AM: Final platelet concentration depends on initial volume of whole blood, platelet recovery efficiency of the chosen technique, final volume of plasma used to suspend concentrated platelets, relative concentration of white and/or red blood cells, and other factors. A higher concentration of platelets does not necessarily lead to better results. In fact, a saturation effect has been described in which an inhibitory cascade ensues once a sufficiently high concentration of platelets is reached.

SU: Early research suggests PRP may improve discogenic pain, or low back pain (LBP) caused by disc degeneration. How does that work?

AM: The IVD consists of a [tough] outer annulus fibrosus that provides tensile strength, and a [gel-like] inner nucleus pulposus that retains water to help the disc resist compression from loading. Over time the disc loses some of its water content, which compromises its load-bearing characteristics. This may accelerate disc degeneration, an active process involving changes in tissue and the cellular microenvironment that eventually leads to structural breakdown. Regenerative therapies such as PRP may preserve or repair disc structure, potentially reducing related pain.

SU: Just how experimental is PRP therapy?

AM: PRP has been effectively used to treat a variety of orthopedic concerns, including rotator cuff tears, lateral epicondylitis, hamstring injuries, and Achilles tendinopathy. However, there is limited data showing its effectiveness for the treatment of IVD degeneration and LBP.

SU: With respect to PRP for back pain, what are some blanks that still need to be filled in?

AM: Right now, it is unclear at what stage in the cascade of degeneration PRP or other regenerative therapies should be applied. Discs in late-stage degeneration may lack regenerative potential. Early-stage degeneration may be asymptomatic and go untreated. Future studies should also help determine criteria for the best PRP candidate, what the optimal injectate is, and what relationships exist between patient-reported outcomes and radiological findings.

SU: What’s your personal take on PRP shots for LBP?

AM: There are numerous causes of LBP. Since disc degeneration is widely prevalent and usually asymptomatic or mildly symptomatic, treatment for disc degeneration is only indicated if it is believed to be the culprit for the LBP. In this case, the pain usually responds to conservative treatment in the form of over-the-counter medication and physical therapy. For a small subset of patients whose pain does not respond to conservative treatment, I usually offer disc fusion. There is not enough evidence for me to suggest PRP therapy.

Further large-scale studies, such as multicenter and/or society-led clinical trials using the same isolation and/or activating protocol of PRP, may be required to confirm the clinical evidence of PRP for the treatment of LBP.

 

Updated on: 02/16/21
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