Platelet Rich Plasma Therapy and lower back pain
Ross Hauser, MD
Many people that reach out to our center looking for options for their low back pain have done a lot of research on the various remedies. This research probably came as the result of years of trial and error management of their low back problems. Therefore, by the time many people reach out to us they already have had a long history of treatments for their back pain including self-administered over-the-counter medication, various back braces, and belts that they may have purchased online, online yoga or Pilates classes, or exercise technique. When their back pain worsen and became more chronic and painfully acute, medical attention was sought. Now the medication came in prescription dosage, the exercise became physical therapy (Please see our article Why physical therapy and yoga did not help your low back pain), and eventually, cortisone or epidural steroid injection may be recommended.
Along with these treatments came an MRI which may have been inconclusive or conclusive enough to suggest or not suggest surgery, please see our article: Is your MRI or CT Scan sending you to a back surgery you do not need? Eventually, a diagnosis of Degenerative Disc Disease, bulging or herniated disc(s), lumbar stenosis, lumbar spondylolisthesis, SI Joint dysfunction, and sciatica are made.
The treatment of PRP or Platelet Rich Plasma Therapy is considered a controversial treatment with the controversy surrounding the actual effectiveness of the treatment and how the treatment is applied. In one application the PRP solution is injected directly into the flattened disc. In another application, the treatment is given to the facet joint and the ligament attachments that provide the spine stability. It is well documented that flattened discs do not flatten on their own, the loss of disc height is the cumulative effect of degenerative joint disease from spinal instability caused by a chronic back sprain or ligament weakness, laxity, and damage. Solving the problem of persistent low back pain, in some patients, may be as simple as treating chronic spinal ligament sprain as opposed to spinal surgical intervention.
What is PRP, how is it used in treating back pain patients?
PRP is an injection with the injectable solution being derived from your own blood. To create this solution, a small sample of your blood is drawn, similar to a lab-test blood draw.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in injury healing.
- The procedure and preparation of therapeutic doses of growth factors consist of an autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.)
The PRP can then be injected in two ways.
- Into the facet or spinal joint areas to strengthen the connective tissue to provide spinal stability and eventually alleviate pressure on the disc.
- Into the disc itself. Currently, our office does not inject PRP into the disc. Our near three decades of experience have demonstrated that this may not be the best way for all patients and results may not be consistent.
This idea of injecting directly into the disc is one of the controversial aspects of PRP treatments for lower back pain. It is easy for patients to get excited about the prospect of intradiscal injections for their back pain because the idea is simple. Inject the disc, restore disc height alleviate pressure in the spine.
What are we seeing in this image?
In addition to PRP therapy, we offer Prolotherapy treatments. Prolotherapy injections are composed of simple dextrose as opposed to blood platelet concentration. In our office, we do not offer PRP injections into the back as a stand-alone treatment. It is used in conjunction with Prolotherapy. The point of the illustration below is to demonstrate the areas where we give PRP and Prolotherapy injections. Not into the disc, but into and surrounding the injured facet capsular, sacroiliac, and other ligaments that impact stability in the lumbar region.
Current research on the use of PRP in treating low back pain patients
A study from May 2020 in the Journal of Neurological Surgery. Part A, Central European Neurosurgery (1) conducted an analysis of previously published research to help answer the question and controversial results of treatment. The research team examined three randomized clinical trials involving 131 patients. What they found was PRP injection reduced pain scores significantly in a subgroup of these patients some with more than 50% pain relief at 3 months.
Is injecting directly into the disc better or equal to treating the surrounding disc area?
A February 2021 paper (2) had an international team of doctors explore the various aspects of PRP for low back pain. A discussion of both injections into the facet joint and into the disc itself was covered. Here are some of the paper’s learning points:
Facet joints have been implicated in 40% of cases of spine pain. However, the researchers noted that at the time of their study’s publication, only three studies that investigated the results of PRP injections into the facet joints and the surrounding ligaments had been published.
In one study of five patients: “PRP was injected into the facet joints, capsule, supraspinous, and infraspinous ligaments under ultrasound or fluoroscopic guidance. All five cases reported a significant improvement in their pain. However, given the absence of a control group, it is not possible to conclude whether this treatment is better or worse than the established modalities.”
Another study enrolled 19 patients with lumbar facet joint syndrome and injected autologous PRP into the lumbar facet joints under X-ray fluoroscopic guidance. Significant pain reduction was experienced by nine patients (47.37%) immediately after treatment, 14 (73.68%) at 1 week, and 15 patients (78.95%) at one month, two months, and three months.
In 2017, a prospective comparative study randomized 46 patients into group A (intra-articular PRP injections) and group B (intra-articular local anesthetic and corticosteroid . . . Both groups achieved statistically significant pain relief. In the steroid group, improvement peaked (85%) after 1 month, but it was only 20% after 6 months. However, the PRP group achieved better results over time leading to the conclusion that PRP is a superior treatment option for longer duration effectiveness.
In regard to PRP into the disc, the researchers found PRP to be a feasible treatment to counter disc degeneration associated with low back pain. But: “It is vital to administer PRP early in the course of the treatment to stimulate the growth of the remaining cells in the disc. If the treatment is delayed, the number of active cells in the disc will be at a minimum and the PRP will possibly fail to induce the desired impact. Although intradiscal PRP injections show promising results, there is a need for more studies with larger sample sizes and adequate control groups. Further studies are also needed to define the subset of patients most likely to benefit from this treatment.”
This is basically the same reasoning we suggested above. Generally, if a patient has long-term chronic back pain and degenerative disc disease, the likelihood of a good outcome of intradiscular treatment is diminished. In our opinion treatments into the facet joint and capsular joints could provide enough stability in the spine to allow the disc to restore its height over time naturally. Further, a flattened disc may not be the primary cause of the patient’s low back pain. The ligaments themselves are highly sensitive to pain. It may be the ligaments themselves who are the leading pain culprits.
PRP outcomes in 67 patients with low back pain
A 2019 paper in the journal Cogent Medicine (3) demonstrated PRP outcomes in 67 patients with low back pain. Here are the study’s summary findings:
- 67 patients had a series of one, two, or three PRP injections into the ligaments, muscle, and fascia surrounding the lumbar spine.
- Patients who received two treatments received injections an average of 24 days apart and patients who received three treatments received injections an average of 20.5 days apart.
- Patients who received one PRP injection reported 36.33% overall improvement and experienced significant improvements in active pain relief.
- Patients who received a series of two treatments experienced significant decreases in resting pain and active pain and reported 46.17% total overall improvement respectively.
- Patients who received three treatments experienced significant decreases in resting pain and active pain and reported 54.91% total overall improvement respectively.
- In addition, they were able to perform daily activities with less difficulty than prior to treatment. This study demonstrated that one, two, or three PRP treatments were effective in significantly reducing active pain in the lower back. Additionally, functionality scores were significantly increased showing that patients were able to quickly return to everyday activities.
Mechanical and functional spinal instability
What are we seeing in this image? The caption reads: Almost all chronic pain in the lower back occurs in a six-by-four inch area. Pain in the lower back occurs in the area where the lumbar vertebrae join the sacrum and the iliac crest.
Ninety-five percent of low back pain is located in a six-by-four inch area, the weakest link in the vertebral-pelvis complex.
At the end of the spine, four structures connect in a very small, compacted space, a six-by-four inch area. The fifth lumbar vertebra connects with the base of the sacrum. This is held together by the lumbosacral ligaments. The sacrum is connected on its sides to the ilium and iliac crest. This is held together by the sacroiliac ligaments. The lumbar vertebrae are held to the iliac crest and ilium by the iliolumbar ligaments.
Lumbar instability begins when the stabilizing structures of the spine, especially the ligaments can no longer hold adjacent bones together. When present, this is termed mechanical instability. The term functional instability is used when mechanical instability causes symptoms with a certain function or activity (like those described above). Many people are walking around with mechanical instability but are asymptomatic because the force required to perform current normal activities is not beyond the ligaments and muscles’ ability and strength to perform these functions.
The question of PRP treatments should therefore mostly focus on PRP’s ability to address spinal instability and not disc height as the cause of lower back pain.
PRP, low back pain, and Iliolumbar syndrome
One of the reasons that the disc injection will have limited benefit is because for many patients it is not an “into the disc” fix. What are we seeing in this image? Spinal, hip, and pelvic ligaments.
In this image, we see the front of the pelvis and the many ligament attachments that hold the two halves of the pelvis together and connect the pelvis to the lumbar. When you look at the pelvic/spinal ligaments you can see how the spine and pelvic and spinal instability should not be treated in isolation. In this image, we see how the intertransverse ligament, anterior longitudinal ligament, anterior sacroiliac ligaments, iliolumbar ligaments, and the pubofemoral ligaments all interact to provide a “firm girdle.” Injecting PRP into the lumbar discs and its subsequent failure can be seen as a problem of fixing a flat tire but not repairing the axel that holds the tire to the car. Instability in the axel will cause wear to the same area of the tire that leads to the leak that flattened the disc in the first place.
In a December 2020 study (4), doctors at the VMMC medical college and hospital in New Delhi suggested that low back pain could be treated with PRP if the cause of the back pain could be identified as coming from a correct source. In the case of this paper, that source would be the iliolumbar syndrome and the iliolumbar ligaments. Here we have a treatment suggestion for the use of PRP that has nothing to do with treating discs in helping a patient with low back pain. Here are the summary highlights of this research
- Iliolumbar syndrome is a frequent cause of chronic nonspecific low back pain. The cornerstone of its treatment lies in the specific diagnosis of the iliolumbar syndrome. The ultrasound-guided interventions have the potential for the specific diagnosis and treatment of the iliolumbar syndrome.
- The study comprised fifty-seven patients of nonspecific low back pain with the clinically suspected iliolumbar syndrome.
- Two-staged ultrasound-guided interventions were performed: Primary diagnostic and secondary therapeutic interventions.
The patients in this study were first given a mild temporary numbing agent into the pelvic region to help determine the accuracy of diagnosis of the iliolumbar syndrome. Once determined PRP injections under ultrasound were next introduced.
- Ultra-sound PRP was injected in forty-five confirmed patients of the iliolumbar syndrome.
- Out of forty-five patients, forty-two patients showed significant clinico-radiological improvement.
- There was a statistically significant reduction in low back pain scores after PRP injection.
PRP treatments for lower back pain
As stated earlier in this article, we do not offer PRP as a stand-alone treatment or would consider a single injection into the area of back pain a PRP treatment. A 2019 paper (5) however did find that “PRP therapy is a highly effective method for treatment of patients with isolated facet syndrome caused by degenerative diseases of the facet joints. Clinical efficacy is confirmed by the persistent significant reduction of pain symptoms and restoration of functional status in the early and late postoperative periods with low risks of adverse outcomes.”
In a recent paper, (6) doctors looked at 19 patients with lumbar facet joint syndrome who received lumbar facet joint injections with autologous PRP under x-ray fluoroscopic guidance.
Patients were followed up immediately, at one week, one month, 2 months, and 3 months following treatment, and progress was measured with a series of standardized scoring systems.
- At one week after treatment, low back pain reduced significantly
- The outcomes were assessed as “good” or “excellent” for 9 patients (47.37%) immediately after treatment,
- 14 patients (73.68%) at one week,
- 15 patients (78.95%) at one month,
- 15 patients (78.95%) at 2 months,
- and 15 patients (78.95%) at 3 months.
In the short-term period of 3 months, the new technique of lumbar facet joint injection with autologous PRP is effective and safe for patients with lumbar facet joint syndrome.
Our own observations as we approach three decades of medical care is that PRP would work better in many patients if it were combined with Prolotherapy treatments.
PRP and Prolotherapy treatments
A February 2022 study (7) examined the effect of platelet-rich plasma injections for chronic nonspecific low back pain: Then the researchers examined what happened when you treated patients with PRP and Prolotherapy.
The researchers of this study suggested that some patients suffer from chronic nonspecific low back pain that can be attributed to weakened ligaments. They also suggest that Prolotherapy is the effective treatment but its use remains controversial. These ligaments can also be strengthened by platelet-rich plasma injection. The researchers then hypothesized that the effectiveness of platelet-rich plasma injection and prolotherapy may decrease pain and improve the disability of patients with chronic low back pain.
- Thirty-four patients with chronic nonspecific low back pain (duration of at least 3 months) non-responsive to conventional management were randomized to platelet-rich plasma injection and lidocaine injection. Patients were treated with weekly platelet-rich plasma or lidocaine injections at the lumbopelvic ligaments for 2 weeks and then weekly prolotherapy with 15% glucose for 2 weeks and followed up 6 months.
Results: “In chronic nonspecific low back pain, the platelet-rich plasma injection in combination with prolotherapy is an effective intervention and either lidocaine or platelet-rich plasma injection significantly reduced disability. And injection at the lumbopelvic ligaments using the platelet-rich plasma and prolotherapy is also an effective treatment for pain.”
Prolotherapy strengthens the lumbar vertebral ligaments and prevents the progressive degeneration that occurs with age to the intervertebral discs. A patient with chronic low back pain is typically treated with Prolotherapy injections into the insertions of the lumbosacral, iliolumbar, and sacroiliac ligaments. The initial assessment may reveal that the chronic low back pain and referred leg pain may be caused by a referred pain from other areas such as the pubic symphysis, hip joint, ischial tuberosity, sacrospinous, and sacrotuberous ligaments. Therefore, these areas are also examined.
For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.
Questions about our treatments?
If you have questions about your pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated March 7, 2022