PAIN MANAGEMENT
From Midwest Orthopaedic at Rush, Rush University Medical Center, in Chicago, Illinois.
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Intradiscal Injections Is There Evidence to Support It? Intervertebral disc degeneration is one of the most common causes of chronic low back pain in adults. Compared to other sources of chronic low back pain, such as the sacroiliac joint or posterior facets, discogenic pain is more common in younger patients.1 The pathomechanisms underlying discogenic back pain are incompletely understood, but they are thought to involve a complex interplay between inflammation, hypermobility, and nerve ingrowth and upregulation, all of which may be further modulated by psychosocial factors such as depression or the presence of work-related injury.2 In the midst of such complexity, identifying a low-cost, minimally invasive treatment strategy such as intradiscal injection for the treatment of discogenic back pain would be of great clinical utility, but does the evidence support it?
Intradiscal Biologics Among the different types of intradiscal injections, intradiscal biologics are currently perhaps the most popular. A 2022 systematic review examined several intradiscal biologic agents for the treatment of discogenic low back pain, including platelet rich plasma (PRP), autologous bone marrow aspirate concentrate (BMAC), autologous mesenchymal stroma cells (MSCs), and allograft disc chondrocytes.3 Among the 2 randomized controlled trials and 10 observational cohort studies included in the review,4-14 the aggregate rate of success (defined as pain
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reduction of ≥50% from baseline) George W. Fryhofer, for PRP and MSC injections at 6 MD, MSc months were 54.8% and 53.5%, respectively. However, the review ultimately concluded that the body of evidence supporting intradiscal MSCs and PRP was limited only to observational data that was “very low quality” for a variety of reasons, Gregory Lopez, MD ranging from low sample size to insufficient blinding. Additionally, success rates in these studies often had lower end confidence intervals that overlapped with clinically important thresholds, suggesting the absence of clinical significance. Finally, the one randomized controlled trial that was included for PRP injection alone—comparing PRP versus sham 8 weeks after injection13—was also found to be “very low quality,” given the high risk of bias arising from inadequate randomization and missing outcome data in more than 20% of patients in that study. Other reviews have also been performed, including one that focused solely on injection of BMAC and culture-expanded bone marrow MSCs.15 In that review, 16 studies were identified, and it was generally concluded that intradiscal autologous or allogeneic BMAC and culture-expanded bone marrow-derived MSCs did improve pain compared to baseline. However, the quality of evidence among those studies was also found to be “very low” due to heterogeneity and limited generalizability.
Vertebral Columns
Fall 2023
