Intradiscal PRP

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Intradiscal PRP anyone? I’ll call out @drusso as he is our resident regen expert but hope this can lead to some open discussions!

www.sciencedirect.com

Effectiveness of intradiscal platelet rich plasma for discogenic low back pain without Modic changes: A randomized controlled trial

To determine if autologous platelet-rich plasma (PRP) injection into a degenerative intervertebral disc, without Modic changes on magnetic resonance i…
www.sciencedirect.com www.sciencedirect.com
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Seems like a pretty well designed study. Not sure why only 1 cc though.

Here's two other recent RCTs.


www.ncbi.nlm.nih.gov

Platelet-Rich Plasma Releasate versus Corticosteroid for the Treatment of Discogenic Low Back Pain: A Double-Blind Randomized Controlled Trial

Clinical application of platelet-rich plasma is gaining popularity in treating low back pain (LBP). This study investigated the efficacy and safety of platelet-rich plasma releasate (PRPr) injection into degenerated discs of patients with discogenic LBP. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

One common theme in all these intradiscal studies, including ViaDisc, is lack of difference between experimental and control, but both groups improve from baseline. Whether that is placebo, natural progression, or active effect in both groups, is unclear.

The other common theme is relatively high risk of discitis.
 
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Been doing it for a few years now. Highly selective. Symptoms of discogenic pain with imaging correlating internal disc disruption. Lengthy conversation usually regarding prior treatments, expectations, “experimental” status of the treatment and of course payment options. Initially I tried to get the discogram component covered and would charge separately for the PRP, but it got quite complicated. Now I bundle the price covering everything.

Have had pretty good success in the appropriate patient. N is not large, but I’m not Greg lutz so how could it be. Have had patients say it’s changed their lives and from that have gotten a bunch of family and friend referrals. Have also had some patients with no relief. The reality is I’m not pitching this like I’m a KOL…I’m having a frank discussion regarding the option and make no promise of efficacy. Have been doing intradiscal and sometimes intra-articular facet prp at the same time. Use 60 pure and usually single level disk, +/- facet. Follow up in a month. Lay out expectations about it not being effective or minimally effective at 2 month mark. No Nsaids for 2 weeks before and at least 2 weeks after. The longer they are off, the better.

That’s all I got right now..if I think of anything else, will post
 
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RoloTomassi said:
Seems like a pretty well designed study. Not sure why only 1 cc though.

Here's two other recent RCTs.


www.ncbi.nlm.nih.gov

Platelet-Rich Plasma Releasate versus Corticosteroid for the Treatment of Discogenic Low Back Pain: A Double-Blind Randomized Controlled Trial

Clinical application of platelet-rich plasma is gaining popularity in treating low back pain (LBP). This study investigated the efficacy and safety of platelet-rich plasma releasate (PRPr) injection into degenerated discs of patients with discogenic LBP. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

One common theme in all these intradiscal studies, including ViaDisc, is lack of difference between experimental and control, but both groups improve from baseline. Whether that is placebo, natural progression, or active effect in both groups, is unclear.

The other common theme is relatively high risk of discitis.
Click to expand...
Technically PRP is bacteriostatic
 
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Dr. Ice said:
Been doing it for a few years now. Highly selective. Symptoms of discogenic pain with imaging correlating internal disc disruption. Lengthy conversation usually regarding prior treatments, expectations, “experimental” status of the treatment and of course payment options. Initially I tried to get the discogram component covered and would charge separately for the PRP, but it got quite complicated. Now I bundle the price covering everything.

Have had pretty good success in the appropriate patient. N is not large, but I’m not Greg lutz so how could it be. Have had patients say it’s changed their lives and from that have gotten a bunch of family and friend referrals. Have also had some patients with no relief. The reality is I’m not pitching this like I’m a KOL…I’m having a frank discussion regarding the option and make no promise of efficacy. Have been doing intradiscal and sometimes intra-articular facet prp at the same time. Use 60 pure and usually single level disk, +/- facet. Follow up in a month. Lay out expectations about it not being effective or minimally effective at 2 month mark. No Nsaids for 2 weeks before and at least 2 weeks after. The longer they are off, the better.

That’s all I got right now..if I think of anything else, will post
Click to expand...

What are your criteria for offering someone intradiscal PRP?
 
Dr. Ice said:
Been doing it for a few years now. Highly selective. Symptoms of discogenic pain with imaging correlating internal disc disruption. Lengthy conversation usually regarding prior treatments, expectations, “experimental” status of the treatment and of course payment options. Initially I tried to get the discogram component covered and would charge separately for the PRP, but it got quite complicated. Now I bundle the price covering everything.

Have had pretty good success in the appropriate patient. N is not large, but I’m not Greg lutz so how could it be. Have had patients say it’s changed their lives and from that have gotten a bunch of family and friend referrals. Have also had some patients with no relief. The reality is I’m not pitching this like I’m a KOL…I’m having a frank discussion regarding the option and make no promise of efficacy. Have been doing intradiscal and sometimes intra-articular facet prp at the same time. Use 60 pure and usually single level disk, +/- facet. Follow up in a month. Lay out expectations about it not being effective or minimally effective at 2 month mark. No Nsaids for 2 weeks before and at least 2 weeks after. The longer they are off, the better.

That’s all I got right now..if I think of anything else, will post
Click to expand...
do you have to/like to see an annular tear on MRI?
 
bedrock said:
What are your criteria for offering someone intradiscal PRP?
Click to expand...
Failure of other treatments or lack of response. Functional impairment. Symptoms consistent with discogenic pain, no opiates, annular tear on mri.

Again, my n is not very high.
 
study looks good.

unfortunately, results are not favorable for PRP.

2 issues that were discussed and not avoided - the proceduralist was not blinded (because of the difference in viscosity of the fluids) and no contrast (could have altered PRP effectiveness).
 
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evidence base, mechanism of action, etc IMO are not favorable for a PRP solution to DDD

PRP is ripe with cytokines to stimulate turnover of tissue. there is an inflammatory component and then the anti-inflammatory component. the cytokines are both and in part respond to the nascent injured tissue. then these recruit other cell types... VEGF recruits endothelial cells that become vasculature, PDGF recruits MSCs etc

the disc is generalized as being avascular. though this will depend on age, degeneration, and location of the IVD. the annulus has some in some places/stages but it primarily receives it's nutrients through diffusion at the endplate.

the NP is naturally anti-angiogenic. sticking stuff into the jelly where it gets stuck, does that make sense? what about targeting the tears in the annulus?

if PRP is meant to stimulate healing it needs some pipeline to recruit cells. there would be the assumption that even if cells were recruited, they would stimulate growth and healing of those annular fibers which are inherently under a lot of stress.

I think to accomplish that in a weight bearing person would be like trying to patch a rubber tire at the molecular level while the car is going down the freeway. Pauza's idea of putting fibrin in there sounds a little better, but fibrin clot is soft and mucinous. IMO it's like patching the hole in the tire with a piece of bubble gum and getting back on the freeway expecting your tire to hold 40 psi

from their methods it sounds like they spun it twice and used the very buffiest of the buffy coat, to have a 1 ml of LR PRP. I don't think we could make any conclusions on whether more of the plasma would have made any difference
 
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oreosandsake said:
evidence base, mechanism of action, etc IMO are not favorable for a PRP solution to DDD

PRP is ripe with cytokines to stimulate turnover of tissue. there is an inflammatory component and then the anti-inflammatory component. the cytokines are both and in part respond to the nascent injured tissue. then these recruit other cell types... VEGF recruits endothelial cells that become vasculature, PDGF recruits MSCs etc

the disc is generalized as being avascular. though this will depend on age, degeneration, and location of the IVD. the annulus has some in some places/stages but it primarily receives it's nutrients through diffusion at the endplate.

the NP is naturally anti-angiogenic. sticking stuff into the jelly where it gets stuck, does that make sense? what about targeting the tears in the annulus?

if PRP is meant to stimulate healing it needs some pipeline to recruit cells. there would be the assumption that even if cells were recruited, they would stimulate growth and healing of those annular fibers which are inherently under a lot of stress.

I think to accomplish that in a weight bearing person would be like trying to patch a rubber tire at the molecular level while the car is going down the freeway. Pauza's idea of putting fibrin in there sounds a little better, but fibrin clot is soft and mucinous. IMO it's like patching the hole in the tire with a piece of bubble gum and getting back on the freeway expecting your tire to hold 40 psi

from their methods it sounds like they spun it twice and used the very buffiest of the buffy coat, to have a 1 ml of LR PRP. I don't think we could make any conclusions on whether more of the plasma would have made any difference
Click to expand...
Well said.

1. Silicone caulking for the annulus, stem cells through the endplates.
2. Disc replacement: similar to TKA, cut the lower third of the vertebral body above / upper third of vertebral body below. Graft in donor vertebral bodies with intact disc.

If only it were this easy.
 
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lobelsteve said:
Well said.

1. Silicone caulking for the annulus, stem cells through the endplates.
2. Disc replacement: similar to TKA, cut the lower third of the vertebral body above / upper third of vertebral body below. Graft in donor vertebral bodies with intact disc.

If only it were this easy.
Click to expand...

why stop at one disc... I want a new spine. adamantium. random, but what ever happened to that company/study where they placed tizanidine pellets around the nerve root? was it medtronic?
 
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oreosandsake said:
evidence base, mechanism of action, etc IMO are not favorable for a PRP solution to DDD

PRP is ripe with cytokines to stimulate turnover of tissue. there is an inflammatory component and then the anti-inflammatory component. the cytokines are both and in part respond to the nascent injured tissue. then these recruit other cell types... VEGF recruits endothelial cells that become vasculature, PDGF recruits MSCs etc

the disc is generalized as being avascular. though this will depend on age, degeneration, and location of the IVD. the annulus has some in some places/stages but it primarily receives it's nutrients through diffusion at the endplate.

the NP is naturally anti-angiogenic. sticking stuff into the jelly where it gets stuck, does that make sense? what about targeting the tears in the annulus?

if PRP is meant to stimulate healing it needs some pipeline to recruit cells. there would be the assumption that even if cells were recruited, they would stimulate growth and healing of those annular fibers which are inherently under a lot of stress.

I think to accomplish that in a weight bearing person would be like trying to patch a rubber tire at the molecular level while the car is going down the freeway. Pauza's idea of putting fibrin in there sounds a little better, but fibrin clot is soft and mucinous. IMO it's like patching the hole in the tire with a piece of bubble gum and getting back on the freeway expecting your tire to hold 40 psi

from their methods it sounds like they spun it twice and used the very buffiest of the buffy coat, to have a 1 ml of LR PRP. I don't think we could make any conclusions on whether more of the plasma would have made any difference
Click to expand...
Agree with this and it is why I don't do intradiscal PRP. From a standpoint of targeting the tears in the annulus, I think that epidural PRP does that better, with less risk than intradiscal PRP. Annular tears communicate with the epidural space so epidural prp can reach them with less risk, and as I've posted before, I've had a number of patients do very well with epidural PRP for annular tears.

On a similar note, do you think that anything has promise for intradiscal therapy? I know you do lots of regen, but I think you've stayed away from intradiscal. I was wondering if there is an intradiscal therapy that tempts you......?
 
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If there is a radicular component, lystate works well. I used to only do ilesi lysate, but low volume tfesi lysate can be effective too
 
As an aside, for anyone who might be interested in this..

Have a patient 48, otherwise healthy with history of osteochondromas effecting primarily his hip and knee. Has been through many conservative treatments. Was told because of his age, and the nature of the oateochondroma, he should really only consider one joint replacement is his lifetime, and that revision surgery would likely not be an option. His X-rays are nasty. I don’t even know how the guy walks around. Basically end stage djd of left hip and right knee. Finally found relief with left hip PRP for 1.5 years at a time. My former partner (now TOBI ceo) was doing PRP for him previously before he left. I saw him recently. Did pure for his left hip and right knee (60 kit, 4 per joint) and 3 months later, he is extremely satisfied. His right knee has responded very well and left hip also quite well (as it has historically). He is the father of two young children and feels as though he can play with his kids without worrying about dealing with pain.
 
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Anyone get the recently released “atlas of interventional orthopedics”
 
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Int Orthop. 2022 Mar 28. doi: 10.1007/s00264-022-05389-y. Online ahead of print.

Clinical outcomes following intradiscal injections of higher-concentration platelet-rich plasma in patients with chronic lumbar discogenic pain

Cole Lutz 1, Jennifer Cheng 2, Meredith Prysak 3, Tyler Zukofsky 3, Rachel Rothman 2, Gregory Lutz 4 5
Affiliations expand
PMID: 35344055 DOI: 10.1007/s00264-022-05389-y

Abstract
Purpose: This study aimed to assess clinical outcomes following intradiscal injections of higher-concentration (> 10 ×) platelet-rich plasma (PRP) in patients with chronic lumbar discogenic pain and to compare outcomes with a historical cohort.

Methods: This retrospective study included 37 patients who received intradiscal injections of higher-concentration (> 10 ×) PRP and had post-procedure outcomes data (visual numerical scale pain score, Functional Rating Index [FRI], and NASS Patient Satisfaction Index). Outcomes were compared to a historical cohort of 29 patients who received intradiscal injections of < 5X PRP.

Results: Pain and FRI scores significantly improved by 3.4 ± 2.5 and 46.4 ± 27.6, respectively, at 18.3 ± 13.3 months following intradiscal injections of > 10 × PRP (p < 0.001). These improvements were greater than those reported by the historical cohort (1.7 ± 1.6 and 33.7 ± 12.3; p = 0.004 and 0.016, respectively). Additionally, the satisfaction rate was higher in patients receiving > 10 × PRP compared to those receiving < 5 × PRP (81% vs. 55%; p = 0.032).

Conclusions: Findings from this study suggest that clinical outcomes can be optimized by using PRP preparations that contain a higher concentration of platelets. Further research is needed to continue to optimize the composition of PRP used to treat patients with lumbar disc disease.

Keywords: Lumbar discogenic pain; Outcomes; Platelet-rich plasma; Platelets, Historical.
 
drusso said:
Int Orthop. 2022 Mar 28. doi: 10.1007/s00264-022-05389-y. Online ahead of print.

Clinical outcomes following intradiscal injections of higher-concentration platelet-rich plasma in patients with chronic lumbar discogenic pain

Cole Lutz 1, Jennifer Cheng 2, Meredith Prysak 3, Tyler Zukofsky 3, Rachel Rothman 2, Gregory Lutz 4 5
Affiliations expand
PMID: 35344055 DOI: 10.1007/s00264-022-05389-y

Abstract
Purpose: This study aimed to assess clinical outcomes following intradiscal injections of higher-concentration (> 10 ×) platelet-rich plasma (PRP) in patients with chronic lumbar discogenic pain and to compare outcomes with a historical cohort.

Methods: This retrospective study included 37 patients who received intradiscal injections of higher-concentration (> 10 ×) PRP and had post-procedure outcomes data (visual numerical scale pain score, Functional Rating Index [FRI], and NASS Patient Satisfaction Index). Outcomes were compared to a historical cohort of 29 patients who received intradiscal injections of < 5X PRP.

Results: Pain and FRI scores significantly improved by 3.4 ± 2.5 and 46.4 ± 27.6, respectively, at 18.3 ± 13.3 months following intradiscal injections of > 10 × PRP (p < 0.001). These improvements were greater than those reported by the historical cohort (1.7 ± 1.6 and 33.7 ± 12.3; p = 0.004 and 0.016, respectively). Additionally, the satisfaction rate was higher in patients receiving > 10 × PRP compared to those receiving < 5 × PRP (81% vs. 55%; p = 0.032).

Conclusions: Findings from this study suggest that clinical outcomes can be optimized by using PRP preparations that contain a higher concentration of platelets. Further research is needed to continue to optimize the composition of PRP used to treat patients with lumbar disc disease.

Keywords: Lumbar discogenic pain; Outcomes; Platelet-rich plasma; Platelets, Historical.
Click to expand...
1 pt got discitis.
 
Dr. Ice said:
Anyone get the recently released “atlas of interventional orthopedics”
Click to expand...
Elsevier Site says it’s not released yet. Pre-order. Anyone on here have access to advanced copies (or a discount)? I’ve been looking for something just like that. It’s pretty reasonably priced anyway but if anyone on here has the connections to not have to wait until June…
 
Dr. Ice said:
www.ncbi.nlm.nih.gov

The use of lumbar epidural injection of platelet lysate for treatment of radicular pain

Epidural steroid injections (ESI) are the most common pain management procedure performed in the US, however evidence of efficacy is limited. In addition, there is early evidence that the high dose of corticosteroids used can have systemic side effects. ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...

"All samples were then placed in a − 80° Celsius freezer for 5–10 min followed by thaw"

-80 degree Celsius freezer? where do you get one of these?
 
PL to PRP is like dex to Depo. Faster onset, shorter duration of release, less embolic risk. Most here seem to prefer Depo ILESI, so why not just do PRP IL instead of going through the trouble of making PL?

Interesting use of cytotoxic 4% lido in a regenerative injection. What is effect of this?

3 PDPH in 470 TF/IL combined is not great.
 
author told me their on back order and slow production. Coming in June most likely. Good book, said it will have rehab protocols in it too
 
Intra-annular if you can reach the teari…..otherwise epidural
 
bedrock said:
Agree with this and it is why I don't do intradiscal PRP. From a standpoint of targeting the tears in the annulus, I think that epidural PRP does that better, with less risk than intradiscal PRP. Annular tears communicate with the epidural space so epidural prp can reach them with less risk, and as I've posted before, I've had a number of patients do very well with epidural PRP for annular tears.

On a similar note, do you think that anything has promise for intradiscal therapy? I know you do lots of regen, but I think you've stayed away from intradiscal. I was wondering if there is an intradiscal therapy that tempts you......?
Click to expand...

I am hopeful that some of the pharmaceutical developments in regen will pan out (really pan out, not just marketing data..) but reality is I think most of the chronic degen spine diseases are going to be tough to treat unless you're early in the disease process.

that said, I have patients with facet disease that I used to do RFA that I have gotten by with dextrose around/into the capsule and they are happy. :unsure:
 
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oreosandsake said:
I am hopeful that some of the pharmaceutical developments in regen will pan out (really pan out, not just marketing data..) but reality is I think most of the chronic degen spine diseases are going to be tough to treat unless you're early in the disease process.

that said, I have patients with facet disease that I used to do RFA that I have gotten by with dextrose around/into the capsule and they are happy. :unsure:
Click to expand...

this is for facet issues... not DDD.
 
oreosandsake said:
I am hopeful that some of the pharmaceutical developments in regen will pan out (really pan out, not just marketing data..) but reality is I think most of the chronic degen spine diseases are going to be tough to treat unless you're early in the disease process.

that said, I have patients with facet disease that I used to do RFA that I have gotten by with dextrose around/into the capsule and they are happy. :unsure:
Click to expand...
In which clinical scenarios do you do this instead of RFA?

What dextrose concentration?
 
devlinmacgregor.com

Provasic

Devlin Macgregor Pharmaceuticals is a leading, world class pharmaceutical and human-biosciences based research, development, and manufacturing organization that specializes in targeted drug…
devlinmacgregor.com devlinmacgregor.com
 
Ducttape said:
devlinmacgregor.com

Provasic

Devlin Macgregor Pharmaceuticals is a leading, world class pharmaceutical and human-biosciences based research, development, and manufacturing organization that specializes in targeted drug…
devlinmacgregor.com devlinmacgregor.com
Click to expand...
that link reads like a movie plot
 
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wow. somebody has a lot of time on their hands....
 
generic drug name: "ru4-dachtakhymbul"

patent number OU-8125150

I'm sure it's full of clever little easter eggs like that
 
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