Regenerative Injection Treatments Utilizing Platelet Products and Prolotherapy for Cervical Spine Pain: A Functional Spinal Unit Approach

Christopher Williams, Mairin Jerome, Chaz Fausel, Ehren Dodson, Ian Stemper, Christopher Centeno, Christopher Williams, Mairin Jerome, Chaz Fausel, Ehren Dodson, Ian Stemper, Christopher Centeno

Abstract

Background The increasing burden of musculoskeletal disorders combined with the high utilization of opiates and the relatively limited ability of traditional approaches to satisfactorily address many of these conditions has spurred an increased interest in alternative treatments such as regenerative medicine therapies. Evidence is growing to support the use of regenerative injection treatments, including prolotherapy, platelet-rich plasma (PRP), platelet lysate (PL), and mesenchymal stromal cells. This study aims to offer a proof of concept via a case series of patients with neck pain treated using a functional spinal unit (FSU) model with combination prolotherapy, PRP, and PL injections. Methodology A chart review identified patients with neck pain treated with a combination of cervical injections using concentrated platelets and prolotherapy. Results A total of 14 patients met the inclusion criteria. The average decrease in the Numeric Pain Score was 2.8 (p = 0.002). The mean decrease in the Functional Rating Index was 27.3 (p = 0.004) at 24 months. Two patients had mild adverse reactions. Conclusions This case series demonstrates basic safety and clinically significant improvements in patients treated for neck pain with autologous concentrated platelet products and prolotherapy utilizing an FSU treatment protocol. Additional clinical studies are warranted with a larger patient sample size and longer follow-up periods.

Keywords: chronic pain; interventional pain management; neck pain; opioid epidemic; opioids; orthobiologics; platelet lysate; platelet-rich plasma (prp); prolotherapy; regenerative medicine therapies.

Conflict of interest statement

The authors have declared that no competing interests exist.

Copyright © 2021, Williams et al.

Figures

Figure 1. Companion case example fluoroscopy images.
Figure 1. Companion case example fluoroscopy images.
(A) Cervical facet injection, contralateral oblique view. (B) Cervical facet injection with epidural overflow, anteroposterior view. (C) Cervical interspinous ligament injection, lateral view.
Figure 2. Flowchart of the included patients.
Figure 2. Flowchart of the included patients.
BMC: bone marrow concentrate; NPS: Numeric Pain Score; FRI: Functional Rating Index
Figure 3. FRI outcomes.
Figure 3. FRI outcomes.
(A) Average FRI scores. P-values are representative of Wilcoxon signed-rank test comparisons between the time-point and baseline. N’s: 14, 11, 11, 10, 10, 12, 14. (B) Percentage of patients meeting the FRI MCID. FRI: Functional Rating Index; MCID: minimal clinically important difference
Figure 4. NPS outcomes.
Figure 4. NPS outcomes.
(A) Average NPS scores. P-values are representative of Wilcoxon signed-rank test comparisons between the time-point and baseline. N’s: 14, 11, 11, 10, 10, 12, 14; (B) Percentage of patients meeting the NPS MCID. NPS: Numeric Pain Score; MCID: minimal clinically important difference
Figure 5. Average SANE scores per time-point.
Figure 5. Average SANE scores per time-point.
N’s: 11, 11, 10, 10, 12, 14. SANE: Single Assessment Numeric Evaluation

References

    1. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Global Burden of Disease Study 2013 Collaborators. . Lancet. 2015;386:743–800.
    1. Prevalence and factors associated with neck pain: a population-based study. Genebra CV, Maciel NM, Bento TP, Simeão SF, Vitta A. . Braz J Phys Ther. 2017;21:274–280.
    1. US national prevalence and correlates of low back and neck pain among adults. Strine TW, Hootman JM. . Arthritis Rheum. 2007;57:656–665.
    1. The epidemiology of neck pain. Hoy DG, Protani M, De R, Buchbinder R. . Best Pract Res Clin Rheumatol. 2010;24:783–792.
    1. Mental disorders among persons with chronic back or neck pain: results from the World Mental Health Surveys. Demyttenaere K, Bruffaerts R, Lee S, et al. . Pain. 2007;129:332–342.
    1. Race, care seeking, and utilization for chronic back and neck pain: population perspectives. Carey TS, Freburger JK, Holmes GM, Jackman A, Knauer S, Wallace A, Darter J. . J Pain. 2010;11:343–350.
    1. An approach to neck pain for the family physician. Teichtahl AJ, McColl G. Aust Fam Physician. 2013;42:774–777.
    1. Axial low back pain: one painful area--many perceptions and mechanisms. Förster M, Mahn F, Gockel U, Brosz M, Freynhagen R, Tölle TR, Baron R. PLoS One. 2013;8:0.
    1. An updated assessment of utilization of interventional pain management techniques in the Medicare population: 2000 - 2013. Manchikanti L, Pampati V, Falco FJ, Hirsch JA. Pain Physician. 2015;18:0–27.
    1. Cost utility analysis of cervical therapeutic medial branch blocks in managing chronic neck pain. Manchikanti L, Pampati V, Kaye AD, Hirsch JA. Int J Med Sci. 2017;14:1307–1316.
    1. Cost utility analysis of caudal epidural injections in the treatment of lumbar disc herniation, axial or discogenic low back pain, central spinal stenosis, and post lumbar surgery syndrome. Manchikanti L, Falco FJ, Pampati V, Cash KA, Benyamin RM, Hirsch JA. Pain Physician. 2013;16:0–43.
    1. Management of lumbar zygapophysial (facet) joint pain. Manchikanti L, Hirsch JA, Falco FJ, Boswell MV. World J Orthop. 2016;7:315–337.
    1. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Falco FJ, Manchikanti L, Datta S, et al. Pain Physician. 2012;15:0–68.
    1. The effect of ketorolac tromethamine, methylprednisolone, and platelet-rich plasma on human chondrocyte and tenocyte viability. Beitzel K, McCarthy MB, Cote MP, et al. . Arthroscopy. 2013;29:1164–1174.
    1. The chondrotoxicity of single-dose corticosteroids. Dragoo JL, Danial CM, Braun HJ, Pouliot MA, Kim HJ. . Knee Surg Sports Traumatol Arthrosc. 2012;20:1809–1814.
    1. In vitro toxicity of local anesthetics and corticosteroids on chondrocyte and synoviocyte viability and metabolism. Sherman SL, Khazai RS, James CH, Stoker AM, Flood DL, Cook JL. . Cartilage. 2015;6:233–240.
    1. Surgical anatomy of the nerves and muscles in the posterior cervical spine: a guide for avoiding inadvertent nerve injuries during the posterior approach. Zhang J, Tsuzuki N, Hirabayashi S, Saiki K, Fujita K. Spine (Phila Pa 1976) 2003;28:1379–1384.
    1. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Carragee EJ, Hurwitz EL, Cheng I, et al. Eur Spine J. 2008;17:153–169.
    1. Regenerative injection treatment in the spine: review and case series with platelet rich plasma. Aufiero D, Vincent H, Sampson S, Bodor M. J Stem Cells Res Rev Rep. 2015;2:1019.
    1. Effect of regenerative injection therapy on function and pain in patients with knee osteoarthritis: a randomized crossover study. Dumais R, Benoit C, Dumais A, et al. . Pain Med. 2012;13:990–999.
    1. New and emerging strategies in platelet-rich plasma application in musculoskeletal regenerative procedures: general overview on still open questions and outlook. Salamanna F, Veronesi F, Maglio M, Della Bella E, Sartori M, Fini M. . Biomed Res Int. 2015;2015:846045.
    1. Safety and efficacy of autologous intra-articular platelet lysates in early and intermediate knee osteoarthrosis in humans: a prospective open-label study. Al-Ajlouni J, Awidi A, Samara O, et al. Clin J Sport Med. 2015;25:524–528.
    1. The use of lumbar epidural injection of platelet lysate for treatment of radicular pain. Centeno C, Markle J, Dodson E, Stemper I, Hyzy M, Williams C, Freeman M. . J Exp Orthop. 2017;4:38.
    1. A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries. Taylor DW, Petrera M, Hendry M, Theodoropoulos JS. Clin J Sport Med. 2011;21:344–352.
    1. Regenerative approaches to tendon and ligament conditions. Brown MN, Shiple BJ, Scarpone M. . Phys Med Rehabil Clin N Am. 2016;27:941–984.
    1. Does intra-articular platelet-rich plasma injection provide clinically superior outcomes compared with other therapies in the treatment of knee osteoarthritis? A systematic review of overlapping meta-analyses. Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. . Arthroscopy. 2015;31:2213–2221.
    1. Role of platelet-rich plasma in articular cartilage injury and disease. Mascarenhas R, Saltzman BM, Fortier LA, Cole BJ. J Knee Surg. 2015;28:3–10.
    1. Effect of platelet-rich plasma on chondrogenic differentiation of adipose- and bone marrow-derived mesenchymal stem cells. Liou JJ, Rothrauff BB, Alexander PG, Tuan RS. . Tissue Eng Part A. 2018;24:1432–1443.
    1. Platelet-rich plasma in the pathologic processes of cartilage: review of basic science evidence. Smyth NA, Murawski CD, Fortier LA, Cole BJ, Kennedy JG. . Arthroscopy. 2013;29:1399–1409.
    1. Anatomy and biomechanics of the spinal column and cord. Miele VJ, Panjabi MM, Benzel EC. . Handb Clin Neurol. 2012;109:31–43.
    1. Anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow nucleated cells: a case series. Centeno CJ, Pitts J, Al-Sayegh H, Freeman MD. J Pain Res. 2015;8:437–447.
    1. Measurement of pain. Katz J, Melzack R. . Surg Clin North Am. 1999;79:231–252.
    1. Functional rating index: a new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Feise RJ, Michael Menke J. . Spine (Phila Pa 1976) 2001;26:78–86.
    1. Correlation of a single assessment numeric evaluation (SANE) rating with modified Cincinnati knee rating system and IKDC subjective total scores for patients after ACL reconstruction or knee arthroscopy. Shelbourne KD, Barnes AF, Gray T. . Am J Sports Med. 2012;40:2487–2491.
    1. Psychometric properties of the functional rating index in patients with low back pain. Childs JD, Piva SR. . Eur Spine J. 2005;14:1008–1012.
    1. Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Manchikanti L, Manchikanti KN, Cash KA, Singh V, Giordano J. . Pain Physician. 2008;11:67–75.
    1. Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions. Manchikanti L, Boswell MV, Singh V, Pampati V, Damron KS, Beyer CD. . BMC Musculoskelet Disord. 2004;5:15.
    1. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Falla DL, Jull GA, Hodges PW. Spine (Phila Pa 1976) 2004;29:2108–2114.
    1. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. Murray CJ, Atkinson C, Bhalla K, et al. . JAMA. 2013;310:591–608.
    1. Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions. Davis MA, Onega T, Weeks WB, Lurie JD. Spine (Phila Pa 1976) 2012;37:1693–1701.
    1. Treatment of cervicothoracic pain and cervicogenic headaches with regenerative injection therapy. Linetsky FS, Miguel R, Torres F. . Curr Pain Headache Rep. 2004;8:41–48.
    1. Case series on chronic whiplash related neck pain treated with intraarticular zygapophysial joint regeneration injection therapy. Hooper RA, Frizzell JB, Faris P. . Pain Physician. 2007;10:313–318.
    1. Early inflammatory response of knee ligaments to prolotherapy in a rat model. Jensen KT, Rabago DP, Best TM, Patterson JJ, Vanderby R Jr. . J Orthop Res. 2008;26:816–823.
    1. Fluoroscopically guided cervical prolotherapy for instability with blinded pre and post radiographic reading. Centeno CJ, Elliott J, Elkins WL, Freeman M. . Pain Physician. 2005;8:67–72.
    1. Hackett GS. Springfield, IL: Charles C Thomas; 1958. Ligament and tendon relaxation treated by prolotherapy.
    1. Randomized, prospective, placebo-controlled double-blind study of dextrose prolotherapy for osteoarthritic thumb and finger (DIP, PIP, and trapeziometacarpal) joints: evidence of clinical efficacy. Reeves KD, Hassanein K. . J Altern Complement Med. 2000;6:311–320.
    1. A systematic review of prolotherapy for chronic musculoskeletal pain. Rabago D, Best TM, Beamsley M, Patterson J. Clin J Sport Med. 2005;15:376–380.
    1. Augmenting tendon and ligament repair with platelet-rich plasma (PRP) Yuan T, Zhang CQ, Wang JH. Muscles Ligaments Tendons J. 2013;3:139–149.
    1. PRP and articular cartilage: a clinical update. Marmotti A, Rossi R, Castoldi F, Roveda E, Michielon G, Peretti GM. . Biomed Res Int. 2015;2015:542502.
    1. PRP for degenerative cartilage disease: a systematic review of clinical studies. Laver L, Marom N, Dnyanesh L, Mei-Dan O, Espregueira-Mendes J, Gobbi A. . Cartilage. 2017;8:341–364.
    1. A prospective study comparing platelet-rich plasma and local anesthetic (LA)/corticosteroid in intra-articular injection for the treatment of lumbar facet joint syndrome. Wu J, Zhou J, Liu C, et al. . Pain Pract. 2017;17:914–924.
    1. Socioeconomic disparities in health in the United States: what the patterns tell us. Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Am J Public Health. 2010;100 Suppl 1:0–96.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir