The effectiveness of intradiscal biologic treatments for discogenic low back pain: a systematic review |
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| Institution: | 1. Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, TN, USA;2. Department of Anesthesiology & Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA;3. Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA;4. Department of Pain Medicine, Center of Regenerative Medicine, Mayo Clinic Florida, Jacksonville, FL, USA;5. Department of Radiology, Mayo Clinic, Rochester, MN, USA;6. Penn State Health, Milton S. Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine, Department of Neurology, Hershey, PA, USA;7. Departments of Pain Management and Neurosciences, Cleveland Clinic, Cleveland, OH, USA;8. Spine Intervention Society, Hinsdale, IL, USA;9. Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT, USA;1. Washington University School of Medicine, St Louis, MO;2. Children''s Hospital Los Angeles, Los Angeles, CA;3. Shriners Hospitals for Children – Philadelphia, Philadelphia, PA;4. IWK Health Center, Halifax, Nova Scotia;1. Department of Neurological Surgery, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210;2. Department of Pharmacy, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210;3. Department of General Surgery, Cleveland Clinic Akron General, 1 Akron General Ave, Akron, Ohio, USA, 44307;4. Department of Anesthesiology, The Ohio State University Wexner Medical Center, 410 W 10th Ave, Columbus, Ohio, USA, 43210;1. Department of Orthopedic Surgery, Seoul Segyero Hospital, Seoul, Republic of Korea;2. Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, PungNap-2-dong, SongPa-gu, Seoul, Republic of Korea;3. Department of Orthopedic Surgery, Dongguk University Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea;1. Department of Orthopaedic Surgery – Orthopaedic Oncology Service, Massachusetts General Hospital – Harvard Medical School, Yawkey 3A, 55 Fruit St, Boston, MA 02114, USA;2. Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Yawkey 6E, 55 Fruit St, Boston, MA 02114, USA |
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| Abstract: | BACKGROUND CONTEXTThere are limited treatments for discogenic low back pain. Intradiscal injections of biologic agents such as platelet-rich plasma (PRP) or stem cells (SC) are theorized to have regenerative properties and have gained increasing interest as a possible treatment, but the evidence supporting their use in clinical practice is not yet well-defined.PURPOSEDetermine the effectiveness of intradiscal biologics for treating discogenic low back pain.STUDY DESIGNPRISMA-compliant systematic review.PATIENT SAMPLEPatients with discogenic low back pain confirmed by provocation discography or clinical and imaging findings consistent with discogenic pain.OUTCOME MEASURESThe primary outcome was the proportion of individuals with ≥50% pain relief after intradiscal biologic injection at 6 months. Secondary outcomes included ≥2-point pain score reduction on NRS; patient satisfaction; functional improvement; decreased use of other health care, including analgesics and surgery; and structural disc changes on MRI.METHODSComprehensive literature search performed in 2018 and updated in 2020. Interventions included were biologic therapies including mesenchymal stem cells, platelet rich plasma, microfragmented fat, amniotic membrane-based injectates, and autologous conditioned serum. Any other treatment (sham or active) was considered for comparative studies. Studies were independently reviewed.RESULTSThe literature search yielded 3,063 results, 37 studies were identified for full-text review, and 12 met established inclusion criteria for review. The quality of evidence on effectiveness of intradiscal biologics was very low. A single randomized controlled trial evaluating platelet-rich plasma reported positive outcomes but had significant methodological flaws. A single trial that evaluated mesenchymal stem cells was negative. Success rates for platelet-rich plasma injectate in aggregate were 54.8% (95% Confidence Interval: 40%–70%). For mesenchymal stem cells, the aggregate success rate at six months was 53.5% (95% Confidence Interval: 38.6%–68.4%), though using worst-case analysis this decreased to 40.7% (95% Confidence Interval: 28.1%–53.2%). Similarly, ≥30% functional improvement was achieved in 74.3% (95% Confidence Interval: 59.8%–88.7%) at six months but using worst-case analysis, this decreased to 44.1% (95% Confidence Interval: 28.1%–53.2%).CONCLUSIONLimited observational data support the use of intradiscal biologic agents for the treatment of discogenic low back pain. According to the Grades of Recommendation, Assessment, Development and Evaluation System, the evidence supporting use of intradiscal mesenchymal stem cells and platelet-rich plasma is very low quality. |
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