Lumbar Transforaminal Epidural Platelet Rich Plasma Injections: The Novel Modality for the Treatment of Low Back Pain

Abstract

Background: Low back is a common health problem, it causes significant morbidity that limits the economic productivity, the use of platelet rich plasma has been shown to be effective in cosmetic surgical procedures and help accelerate wound healing in trauma and joint injuries. Platelet rich plasma injections use each individual patient’s own healing system to improve musculoskeletal problems. We therefore investigated the use of lumbar transforaminal epidural platelet rich plasma injections for the treatment of low back pain patients.

Methods: We evaluated a pain numerical rating scale for a total of 210 patients with low back pain at the level of L3-4-5, immediately prior to the procedure, the patients completed the pain numerical rating scale score were 0 no pain and 10 the worst pain, a successful categorical outcome were defined as reduction in pain by at least 50%, we also evaluated an assessment of immediate post procedure numerical rating scale at 2 weeks and we measure the successful outcomes at 2 months.

Results: Immediate NRS response was weakly associated with 2-month outcomes, Patients that responded at 2 weeks were more likely to be responders at 2 months than those who were non-responders at 2 weeks.

Conclusion: Immediate post-TFE PRP pain relief does not strongly predict longer term effectiveness in pain relief or functional recovery. Response in pain relief or functional recovery at 2 weeks is more strongly associated with 2-month outcomes.

Keywords: Lumbar transforaminal epidural platelet rich plasma; Low back pain

Introduction

Platelet Rich Plasma (PRP) therapy uses injections of a concentration of a patient’s own platelets to accelerate the healing of injured tissues. The ability to regenerate tissues and decrease pain is through the effect of bio active molecules and growth factors present in alpha granules. the success of this therapy depends on the method of preparation and composition of the PRP. This novel technique seems to be a promising method for the treatment of chronic back pain. Low back pain is one of the major causes of physical disability affecting both older and younger people and can have enormous socioeconomic and health impacts [1]. One of the major causes of low back pain is age-associated intervertebral disc degeneration, which affects the nervous system around the disc. Stimulation of the nociceptors in the annulus fibrosus causes pain, which is termed “discogenic” pain. Interestingly, degeneration, endplate injury and inflammation can stimulate pain receptors inside the disc, leaving the external disc intact. Intervertebral disc degeneration can be described as an active process involving changes in tissue and the cellular microenvironment that eventually lead to structural breakdown and impairment of intervertebral disc function [2]. In this study we elected to investigate the effect of lumbar transforaminal epidural PRP injections for low back pain.

Patients and Methods

The study was approved by the local institutional review board.

The study included a total of 210 patients with low back pain and receiving a lumbar transforaminal epidural platelet rich plasma injections at the level of L3-L4 or L5 spine level and evaluation of the pain Numerical Rating Scale (NRS of 0-10) prior to TEPRP, immediately after TEPRP, at 2 weeks follow up after TEPRP and at 2 months follow up after TEPRP. A successful pain relief was more than 50% NRS reduction and assessment of post procedure NRS response and NRS at 2 weeks and we measure the successful outcome at 2 months

Study Design

This is an observational study at Mount Lebanon Hospital – Balamand University Medical center during the period of time from June 2022 till june 2023 where a total of 210 patients were included in the study with the main chief complaints of acute low back pain, same methods, same dose of PRP and same technique of tranforaminal PRP injections were used.

Technique of Transforaminal PRP Injecton

The patient lied prone, 3 to 5 cm from midline of L3 or L4 or L5 spine level depending on the side with the corresponding symptoms and under C Arm X ray, we insert a 22 gauge spinal needle until it passes the outer edge of the superior joint, we gently withdraw the seringe to check for blood or CSF then we inject 1 ml of omnipaque dye contrast and we check with C-Arm X ray to see if the drug spreads along the path of the nerve roots into the epidural area, then we inject 2.5 ml of PRP (we take 45 ml of the patient blood then we centrifuge it and make it 3 ml of platelet rich plasma) and at the end we withdraw the needle.

Discussion

Platelet-Rich Plasma (PRP) therapy is a natural and non-invasive treatment because it uses platelets from your own blood to create a highly concentrated solution to turbocharge the healing process.

Blood platelets contain human growth factors, which contribute to cell regeneration, healing, and new tissue growth. PRP therapy has become popular in treating orthopedic and sports injuries but has also been used to treat other common conditions like hair loss [3].

From a sample of your blood, the platelets are separated in a centrifuge. 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.” lution is then injected directly into the lower back to accelerate the healing process [4].

The clinical studies that used PRP injections as a therapy for discogenic low back pain reported good results overall. A major and notable advantage of the therapy is the safety of the autologous PRP itself, which does not cause any major complications [5]. Other than a few temporary side effects (soreness at the injection site, numbness in legs), none of the studies reported any serious adverse events or complications resulting from the injections. Because autologous PRP is obtained from the patient’s own blood, PRP therapy carries low risks of disease infection and allergic reaction [6]. In addition, it has been reported that PRP has antimicrobial properties, which in turn could reduce postsurgical infection risk.

Statistical Analysis

The logistic regression models were used to determine if the immediate pos procedure NRS score or complete relief states were predictors of a more than 50% improvement in the NRS at 2 weeks or 2 months, the outcomes, percentage of change in NRS were calculated from the procedure to 2 weeks and from the procedure to 2 months, to further assess the association of immediate and 2 weeks responses with 2 months outcomes (50% reduction in NRS) immediately following the procedure and at 2 weeks post transforaminal epidural Platelet rich plasma were assessed.

The association of the 2 months outcome with the presence or absence of motor blockade was also assessed.

The Table 1 demonstrated the statistical analysis that the immediate pain response following transforaminal platelet rich plasma (82 patients) as numerical pain rating was a poor predictor of patients achieving responder status of >50% pain relief at 2 months (90 patients). While the <50% improvement immediately (10 patients) have a <50% improvement in NRS at 2 months of 28 patients.

  


    


    
Response at 2 months

  

  


    
>50% improvement in NRS

    
<50% improvement in NRS

  

  


    
Response at 2 weeks:

    


    


  

  


    
>50% improvement in NRS

    
70

    
30

  

  


    
<50% improvement in NRS

    
26

    
84

  

  


    


    
Response at 2 months

    


  

  


    
>50% improvement in NRS

    
<50% improvement in NRS

  

  


    
Immediate response :

    


    


  

  


    
>50%improvement in NRS

    
82

    
90

  

  


    
<50% improvement in NRS

    
10

    
28

  

  


    
NRS: Numerical rating scale of pain

  

Table 1: The 2 weeks and immediate pain response association with 2 month pain response (NRS).