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Is There Solid Research on Using PRP to Treat Spinal Pain?

Published on Jul 18, 2023

Art: Credit Dall-E with the prompt: “A human spine in 3D surrounded by red blood cells in the style of impressionism.”

As you know, I often write about what I experience. This week an interventional spine physician questioned whether PRP would be useful in the treatment of lumbar radiculopathy or painful facet joints in the neck. Let’s review the RCT data that we have on this topic and the spine in general.

What Are We Talking About Here?

Platelet-rich plasma (PRP) is created by concentrating the platelets found in the blood. The idea is that these platelets assist healing by excreting both growth factors and specific exosomes. There are dozens of randomized controlled trials now that show that PRP is better than steroids, saline, and hyaluronic acid in helping problems like knee arthritis, epicondylitis, and carpal tunnel syndrome.

This blog will also discuss platelet lysate, which is created by stripping the platelets of their growth factors. Since platelets slowly degranulate their growth factors over 7-10 days, PL has more immediate growth factors available to the patient’s tissues (1). In addition, our in-vitro data shows that PL is more anti-inflammatory than PRP.

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The Linkedin Comments

A Linkedin poster who is an interventional spine physician stated that he couldn’t figure out how PRP would work to treat lumbar radiculopathy as, in his mind, this is caused by compression. He also reported that, in his limited experience, injecting PRP into painful neck facet joints didn’t work. I responded that I would put together a blog summarizing what we know about using platelet injections to help spinal pain.

Why Would Platelet Products Help Nerves or the Cartilage in Facet Joints?

PRP has been shown to release various growth factors. One of those growth factors is NGF (Nerve Growth Factor), and it’s believed that through this growth factor as well as others like VEGF (which builds new blood vessels), PRP may be able to help nerves repair (2-6).

The cervical and lumbar facet joints have cartilage like a knee joint (10). The other growth factors in PRP, like TGF-b, also likely have a positive impact on cartilage repair (7-9).

The Use of Platelets in the Spine: What Do We Know?

The infographic above summarizes the RCTs described below. Click on the image above to be taken to the PDF. Each square represents a study with a link to PubMed. A yellow square indicates that the study was positive (PRP was better than the comparison treatment). Each square has the author’s name, the number of patients, and the follow-up period. If you find studies I missed, please don’t hesitate to contact me at [email protected] so I can issue another version of the infographic.

Painful Discs

The intervertebral disc can get damaged and produce pain (17). The treatment options outside of physical therapy, chiropractic, and surgical fusion are limited.

Animal models show that PRP can reduce disc degeneration (16). One of the mechanisms behind this effect has been linked to platelets degranulating a specific type of exosome (14,15).

We have a solid randomized controlled trial (RCT) data that used a radiographic contrast-only control group with a very long-term follow-up that PRP can help painful low back discs (11-13). That result is quite different than a 2022 study that showed no results when compared to saline but only followed patients up for eight weeks (29). More importantly, this study used PRP + Protein Concentrate; hence it was ultimately excluded from this infographic.

Lumbar Radiculopathy

When a spinal nerve is irritated, this is called radiculopathy; the nerve can misfire, leading to numbness or tingling down a leg or weakness. There is also the possibility of compression of the nerve.

What clinical data do we have that platelets can help? We published a large case series of epidural platelet lysate for the treatment of radiculopathy, and a much smaller case series was published on epidural PRP (18, 20). One recent RCT compared epidural PRP versus steroid injection in patients with a herniated disc, and PRP beat the traditional treatment (19). Another PRP RCT showed that PRP beat steroids in patients with lumbar radiculopathy when the outcomes at six months were reported (21). This result was mirrored in a second similar study that found that epidural PRP results lasted longer than corticosteroids (23). Finally, this result is consistent with another RCT, which used CT-guided interlaminar epidurals in radiculopathy patients and showed that in the short run (6 weeks), the PRP was equivalent to steroid (22).

SI Joint Pain

The sacroiliac or SI joint can cause pain, with instability being a major cause (24). Steroid injections are often used in patients who fail physical therapy or manipulative care.

One recent study used ultrasound-guided PRP injections and concluded that they worked better in the mid-term (3 months) than steroids (26). A separate study showed that intra-articular PRP helps but is less effective than steroids (25).

Facet Pain

There are joints in your spine at each level. These joints can get injured or damaged like any other joint with cartilage. Facet pain that is resistant to conservative care is often treated with either a steroid injection or radiofrequency ablation.

A recent RCT compared PRP to steroids for reducing lumbar facet pain and the signs of synovitis on lumbar MRI and showed the PRP to be superior (27). Yet another similar study looking only at pain/functional outcomes concluded that the PRP had longer-lasting effects (28).

My Analysis

I have been using PRP and platelet lysate in the spine since 2005, which would make me the first physician to use PRP in that way. We have observed excellent results in helping patients avoid spinal surgery since then and, as of this month, are tracking 12,964 lumbar and 4,655 cervical orthobiologic procedures. Despite knowing the excellent results represented by that registry data, I’m blown away by the proliferation of high-quality data present on the use of platelet products on multiple indications in the spine.

The Right Way to Use Platelets in the Spine Versus Using Them Like Steroids

Another problem we have in using PRP or PL in the spine is the conceptualization by interventional spine physicians that they should utilize orthobiologics in the same way they used to inject steroids. For example, merely switching out the steroid in the syringe for PRP. Or combining traditional interventional approaches to the spine with PRP. On that note, our physician above seems to have performed RFA to destabilize the neck muscles and then injected PRP into the denervated joints. That approach makes no common sense.

The advantage of using orthobiologics in the spine is the ability to treat the entire functional spinal unit. For example, degenerative instability is common in patients with facet pain. While the research above shows that you can get a certain result by injecting only the joint with PRP, you can likely do far better by injecting the lax ligaments causing the instability and beating up the facet joints. That also means that procedures like RFA that destroy the normal stabilization system of the neck would be antithetical to the use of orthobiologics.

The upshot? It’s great to see the explosion of RCTs on PRP use in the spine these past few years. These results, in general, support what I have been observing since 2005. In other words, I have little doubt that PRP will eventually become a mainstay treatment for the spine.

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