Treatment of Symptomatic Lumbar Internal Disc Disruption (IDD) With the Biostat® System

A Multicenter, Randomized, Blinded, Saline-Controlled Trial of Resorbable Biologic Disc Augmentation for Treatment of Symptomatic Lumbar Internal Disc Disruption (IDD) With the Biostat® System

The purpose of this investigation is to establish the safety and efficacy of the Biostat System when used for treatment of chronic low back (lumbar) pain due to symptomatic internal disc disruptions (IDD) by comparing safety and efficacy outcome measures between one group receiving BIOSTAT BIOLOGX® Fibrin Sealant through the Biostat® Delivery Device and another group receiving a preservative-free normal saline control delivered with the Biostat Delivery Device.

Study Overview

• Status: Terminated
• Conditions: Back Pain; Degenerative Disc Disease; Chronic Low Back Pain; Internal Disc Disruption
• Intervention / Treatment: Biological: BIOSTAT BIOLOGX; Drug: Saline

Detailed Description

The Biostat System is a combination product combining a resorbable biologic product with a delivery device system used to prepare and insert the biologic material into a lumbar intervertebral disc.

Symptomatic IDD is defined as a painful disruption of the internal architecture of a lumbar intervertebral disc, which appears as fissures, cracks or tears within the internal structures of the disc. Pain arising from a lumbar disc may not only be perceived as pain located in the low back (axial pain) but also as somatic referred pain involving the posterior hips, buttocks, lateral hips, groin, or posterior thighs.

The diagnosis of symptomatic IDD cannot currently be made on the basis of imaging studies, physical examination, or symptoms alone, and is best established with meticulously conducted disc provocation studies (provocation discography) that include pressure manometry and identification of an adjacent normal disc.

This treatment and study are not designed for patients exhibiting other potential sources of chronic low back pain such as more advanced degenerative disc disease with significant loss of disc height (>33%), spinal stenosis, or spondylolisthesis (see Eligibility Criteria).

• Study Type: Interventional
• Enrollment (Actual): 220
• Phase: Phase 3

Contacts and Locations

Study Locations

• United States
  • Alabama
    • Birmingham, Alabama, United States, 35235
      • Alabama Clinical Therapeutics, LLC
  • Arizona
    • Phoenix, Arizona, United States, 85050
      • HOPE Research Institute
  • California
    • Chula Vista, California, United States, 91914
      • Pain Control Associates of San Diego
    • Napa, California, United States, 94559
      • Napa Pain Institute
    • San Francisco, California, United States, 94115
      • California Spine Diagnostics
    • Santa Monica, California, United States, 90403
      • The Spine Institute
  • Florida
    • Merritt Island, Florida, United States, 32953
      • The Pain Institute, Inc
  • Illinois
    • Bloomington, Illinois, United States, 61701
      • Millennium Pain Center
  • Maryland
    • Baltimore, Maryland, United States, 21211
      • The Spine Center
  • Minnesota
    • Edina, Minnesota, United States, 55435
      • Medical Advanced Pain Specialists Applied Research Center
  • Mississippi
    • Flowood, Mississippi, United States, 39232
      • NewSouth NeuroSpine Pain Center
  • North Carolina
    • Charlotte, North Carolina, United States, 28207
      • OrthoCarolina Spine Center
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cleveland Clinic
    • New Albany, Ohio, United States, 43054
      • OrthoNeuro, Inc.
  • Pennsylvania
    • Altoona, Pennsylvania, United States, 16602
      • Allegheny Pain Management
    • York, Pennsylvania, United States, 17402
      • Orthopaedic & Spine Specialists
  • Texas
    • Tyler, Texas, United States, 75701
      • Spine Specialists PA
  • Virginia
    • Richmond, Virginia, United States, 23235
      • Virginia Spine Research Institute
    • Virginia Beach, Virginia, United States, 23454
      • Advanced Pain Management
  • Washington
    • Bellingham, Washington, United States, 98226
      • Bellingham Spine Pain Specialists PS

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Age 18 or older and skeletally mature.
• Voluntarily signs the subject informed consent form and agrees to the release of medical information for purposes of this study (HIPAA authorization).
• Physically and mentally able to comply with the protocol, including ability to read and complete required forms, and willing and able to adhere to the follow-up requirements of the protocol.
• Chronic low back pain for at least 6 months.
• Pretreatment baseline low back pain of at least 40 mm on a 100 mm visual analog scale.
• Pretreatment baseline Roland-Morris Disability Questionnaire score of at least 9 on the 24-point questionnaire.
• Leg pain, if present, is of nonradicular origin, i.e., not due to stimulation of nerve roots or dorsal root ganglion of a spinal nerve by compressive forces.
• Leg pain, if present, does not extend below the knee and is no greater than 50% of low back pain as measured on a visual analog scale. If bilateral leg pain, the worst leg pain is no greater than 50% of low back pain.
• Low back pain unresponsive to at least 3 months of nonoperative care, which may include bed rest, antiinflammatory and analgesic medications, chiropractic manipulations, acupuncture, massage, physical therapy or home-directed lumbar exercise program.
• Diagnostic medial branch block or facet joint injection between 18 months and 2 weeks prior to the study procedure indicates no facet joint involvement.
• Diagnosis of symptomatic lumbar (L1-L2 - L5-S1) internal disc disruption (IDD), which requires confirmation of discogenic pain at one or two contiguous levels through positive provocation discography performed between 18 months and 2 weeks prior to the study procedure using pressure manometry and identification of an adjacent nonpainful disc. The disc provocation studies must precisely demonstrate concordant pain (<50 psi above opening pressure) and must demonstrate a fissure(s) in the outer one-third of the posterior or lateral anulus.

Exclusion Criteria:

• Cauda equina syndrome.
• Active malignancy or tumor as source of symptoms.
• Current infection or prior history of spinal infection (e.g., discitis, septic arthritis, epidural abscess) or an active systemic infection.
• Previous lumbar spine surgery.
• Evidence of prior lumbar vertebral body fracture.
• Disc bulge/protrusion or focal herniation at the symptomatic level(s) > 4 mm.
• Presence of disc extrusion or sequestration.
• Leg pain is greater than 50% of low back pain as measured on a visual analog scale.
• Leg pain that extends below the knee.
• Lumbar intervertebral foramen stenosis at the affected level(s) resulting in significant spinal nerve root compression (effacement of the majority of periganglion fat and loss of CSF signal around the nerve rootlets).
• Symptomatic central vertebral canal stenosis or absolute sagittal vertebral canal diameter < 9mm.
• Loss of disc space height at the symptomatic level(s) greater than one-third of an adjacent normal disc (or of the expected height in the case of an L5-S1 disc).
• Spondylolisthesis (> Grade 1) with or without spondylolysis at the symptomatic level(s).
• Lumbar spondylitis or other undifferentiated spondyloarthropathy.
• Dynamic instability at the symptomatic level(s) on lumbar flexion-extension radiographs indicated by >4.5 mm of translation or angular motion >15° at L1-L2, L2-L3, or L3-L4; >20° at L4-L5; or >25° at L5-S1.
• Diagnostic medial branch block or facet joint injection indicate facet joint involvement.
• Diagnostic sacroiliac injection indicates sacroiliac joint involvement for those patients with pain in the sacral region.
• Sustained relief (>3 months) of low back pain obtained with epidural injection of corticosteroids.
• Symptomatic involvement of more than two lumbar disc levels determined from discography.
• Neurological examination shows findings of radiculopathy or a significant underlying neurological condition (motor strength <4; sensory assessment abnormal; or reflexes absent or hyperactive with clonus).
• Prior thermal intradiscal procedure (e.g., intradiscal electrothermal therapy, intradiscal radiofrequency thermocoagulation).
• Any lumbar intradiscal injection procedure other than discography (e.g., injection of corticosteroids, methylene blue, dextrose, or glucosamine and chondroitin sulfate).
• Significant systemic disease, including unstable angina, autoimmune disease, rheumatoid arthritis, and muscular dystrophy.
• Congenital or acquired coagulopathy or thrombocytopenia; or currently taking anticoagulant, antineoplastic, antiplatelet, or thrombocytopenia-inducing medications; or undergoing radiation therapy.
• History of unexplained, easy, or persistent bruising or bleeding, bleeding from the gums, or bleeding problems experienced in previous surgical procedures.
• Aspirin or aspirin-containing medication taken ≤ 7 days prior to the procedure.
• Known or suspected hypersensitivity or allergy to drugs or components of the fibrin sealant (fibrinogen, thrombin, aprotinin, CaCl2) used in the procedure.
• History of, or current psychiatric or psychological condition, or substance or alcohol abuse that would potentially interfere with the subject's participation in the study.
• Ongoing or previous participation in another drug or device clinical study within the previous 2 months.
• Subject known to be pregnant or nursing at time of enrollment or with plans to become pregnant within the planned length of follow-up.
• Body habitus precludes adequate fluoroscopic visualization for the procedure or the procedure is physically impossible using the device.
• Concomitant conditions requiring daily oral steroid use for more than 30 days in the preceding 90 days.
• Pending litigation against a health care professional, except where required by the insurer as a condition of coverage, personal injury compensation or litigation claims.
• Prisoner or active military personnel who would not be available for follow-up.
• Presence of ferromagnetic implants that would disallow MRI of the symptomatic disc(s).
• Active or pending workers' compensation claims.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: BIOSTAT BIOLOGX; One injection of up to 4 mL of BIOSTAT BIOLOGX Fibrin Sealant into a single lumbar intervertebral disc	Biological: BIOSTAT BIOLOGX; One injection of up to 4 mL of BIOSTAT BIOLOGX Fibrin Sealant into a single lumbar intervertebral disc using the Biostat Delivery Device; Other Names: Fibrin Sealant
Placebo Comparator: Saline; One injection of up to 4 mL of saline solution into a single lumbar intervertebral disc	Drug: Saline; One injection of up to 4 mL of saline using the Biostat Delivery Device; Other Names: 0.9% w/v Sodium Chloride Injection, USP

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Subject Composite Success	Subject success based on a composite of minimum 30% decrease in low back pain, 30% improvement in function, maintenance of neurological status, no secondary interventions, and no serious adverse events.	26 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Visual Analog Scale for Low Back Pain	Percent of subjects achieving a minimum 30% decrease in pain from baseline. The visual analog scale is a horizontal 100 mm line anchored on the left with the words "No Pain" and on the right with the words "Worst Possible Pain". Scores were obtained by measuring the distance in millimeters from the left origin of the line (0) to the point indicated with a slash placed by the subject to indicate the subject's level of low back pain experienced over the last week.	26-weeks
Roland-Morris Disability Questionnaire Score	Percent of subjects achieving a minimum 30% decrease in Roland-Morris Disability Questionnaire score The Roland-Morris Disability Questionnaire is a widely studied and frequently used instrument for the assessment of function and disability related to low back pain. The questionnaire consists of 24 statements related to how a subject's back condition affects various activities of daily living. Subjects marked whether the statement either applied to them or did not apply at the time they responded to the statements. The score is the total number of questions with which the subject agreed. A higher score indicates less function and greater disability.	26-weeks

Collaborators and Investigators

• Sponsor: Spinal Restoration, Inc.
• Investigators: Principal Investigator: Kevin J Pauza, MD, Spine Specialists PA

Publications and helpful links

General Publications

• Yin W, Pauza K, Olan WJ, Doerzbacher JF, Thorne KJ. Intradiscal injection of fibrin sealant for the treatment of symptomatic lumbar internal disc disruption: results of a prospective multicenter pilot study with 24-month follow-up. Pain Med. 2014 Jan;15(1):16-31. doi: 10.1111/pme.12249. Epub 2013 Oct 23.
• Buser Z, Keulling F, Jane L, Liebenberg E, Tang J, Thorne K, Coughlin D, Lotz J. Fibrin injection stimulates early disc healing in the porcine model [NASS Abstract 199]. Spine Journal 9:105S, 2009.
• Buser Z, Kuelling F, Liu J, Liebenberg E, Thorne KJ, Coughlin D, Lotz JC. Biological and biomechanical effects of fibrin injection into porcine intervertebral discs. Spine (Phila Pa 1976). 2011 Aug 15;36(18):E1201-9. doi: 10.1097/BRS.0b013e31820566b2.
• Pauza K, Yin W, Olan W, Doerzbacher JF. BIOSTAT BIOLOGX(R) intradiscal fibrin sealant used for treatment of chronic low back pain caused by lumbar disc disruption: results of a 12 month, prospective multicenter pilot study. Spine Arthroplasty Society Meeting, April 27-30, 2010; New Orleans, LA. Abstract 248.
• Yin W, Pauza K, Olan W, Doerzbacher JF. Long-term outcomes from a prospective, multicenter investigational device exemption (IDE) pilot study of intradiscal fibrin sealant for the treatment of discogenic pain [ISIS Abstract]. Pain Medicine 12:1446-1447, 2011
• Buser Z, Liu J, Thorne KJ, Coughlin D, Lotz JC. Inflammatory response of intervertebral disc cells is reduced by fibrin sealant scaffold in vitro. J Tissue Eng Regen Med. 2014 Jan;8(1):77-84. doi: 10.1002/term.1503. Epub 2012 May 18.

Study record dates

Study Major Dates

• Study Start: March 1, 2010
• Primary Completion (Actual): December 1, 2012
• Study Completion (Actual): May 1, 2013

Study Registration Dates

• First Submitted: November 9, 2009
• First Submitted That Met QC Criteria: November 10, 2009
• First Posted (Estimate): November 11, 2009

Study Record Updates

• Last Update Posted (Estimate): May 16, 2014
• Last Update Submitted That Met QC Criteria: May 5, 2014
• Last Verified: May 1, 2014

More Information

Terms related to this study

• Keywords: intervertebral disk
• Additional Relevant MeSH Terms: Pain; Neurologic Manifestations; Musculoskeletal Diseases; Spinal Diseases; Bone Diseases; Back Pain; Low Back Pain; Intervertebral Disc Degeneration; Hemostatics; Coagulants; Fibrin Tissue Adhesive
• Other Study ID Numbers: SR-BX01-2007