Steroid Versus Platelet Rich Plasma Injection for Chronic Low Back Pain
Steroid Versus Platelet Rich Plasma Injection for Chronic Low Back Pain
Chronic low back pain, with or without lower extremity pain, which arises from various
 structures of the spine constitutes a majority of pain complaints. The sacroiliac joint (SIJ)
 has been implicated as the primary source of pain in 10% to 27% of patients with mechanical
 low back pain below L5 vertebra. The common causes of SIJ pain include a trauma like direct
 fall on the buttocks, a rear-end or broad-side type motor vehicle accident, and an
 unanticipated step into a hole or from a miscalculated height, fusion surgery, anterior
 dislocation, inflammatory and degenerative sacroiliac joint disease and idiopathic. The
 treatment of SIJ pain remains a therapeutic challenge. Besides physiotherapy and systemic
 therapies including non-steroidal anti-inflammatory drugs (NSAIDs) and biologic agents,
 intra-articular and peri articular injections of SIJ, radiofrequency neurotomy and surgical
 fusion are often performed for pain relief. However, the success of these interventions has
 been determined according to the therapeutic efficacy and correct placement of the drug. The
 image guidance of SIJ injections seems to be important due to the complex anatomy of the
 joint causing a low accuracy when performed according to clinical judgement only. The
 feasibility of ultrasound (USG) guided injection of SIJ has recently been demonstrated
 resulting in very high success rates up to 90%. Various agents being used in SIJ injections
 include local anaesthetics, corticosteroid, botulinum toxin-A, 12.5% dextrose,
 phenol-glycerine-glucose (P2G) and sodium morrhuate (cod liver oil extract). SIJ steroid
 injection is commonly used technique and has been found to be effective to treat SIJ pain.
 However, the main drawback is short term effect. Borowsky et al reported improvement in
 visual analog score (VAS) of 14.1% and reduction of VAS ≥ 50% in only 12.50% patients at 3
 months after intra-articular steroid (2 mL 0.5% bupivacaine plus 40 mg methylprednisolone)
 SIJ injection. Treatment modalities being currently used do not, in general, address the
 disease process itself, there is clearly a need to investigate treatments that are more
 widely applicable for symptom management and which may also directly address the disease
 process itself. Current research efforts aim at modifying the rate of healing of joint by
 using biological healing factors which are various growth factors (transforming growth
 factor, vascular endothelial growth factor, fibroblast growth factor, epidermal growth
 factor, platelet derived growth factor etc.) found abundantly in the human blood especially
 in platelets. The platelet rich plasma (PRP) is an ideal autologous biological blood-derived
 product, which can be exogenously applied to various tissues where it releases high
 concentrations of platelet derived growth factors that enhance the body's natural healing
 response. In addition PRP possesses antimicrobial properties that may contribute to the
 prevention of infections. PRP is now being widely tested in different fields of medicine for
 its possibilities in aiding the regeneration of tissue with low healing potential. Local
 injection of PRP is a new modality which has been effectively used for the treatment of
 Achilles tendon injury in athletes, chronic epicondylar tendinopathy, chronic patellar
 tendinosis, rotator cuff tear, anterior cruciate ligament injury, gonoarthrosis and plantar
 fasciitis. The intra-articular injection of PRP into knee joint has been found to reduce the
 incidence of local inflammatory changes in early knee osteoarthritis. Recently, PRP has been
 used for low back pain caused by SIJ laxity showing significant improvement in pain scores.
 However, there is no study at present comparing the efficacy of intra-articular injection of
 PRP with corticosteroids for the treatment of chronic SIJ pain. Considering the vast
 potential of PRP and its safety, this study aimed at studying the efficacy of ultrasound
 guided intra-articular SIJ injection of leukocyte free PRP for chronic low back pain due to
 SIJ pathology. In the current study, we tested the hypothesis that the SIJ injection of
 leukocyte-free PRP may be more effective for the treatment of sacroiliac joint pain as
 compared with steroid injection.
Inclusion criteria:

 -  Chronic low back pain (predominantly below L5 vertebra) of moderate intensity (visual
 analog scale score more than 3) for greater than 3 months

 -  Patients with 3 or more positive provocative tests out of 6 (Annexure-1)

 -  Positive X-ray, MRI or nuclear scan findings

 -  Failure to achieve adequate improvement with comprehensive non-operative treatments,
 including but not limited to activity alteration, NSAIDS, physiotherapy and/or
 psychological counselling

 Exclusion criteria:

 -  Systemic infection (H/O fever, chills and/or night sweats) or localized infection at
 anticipated introducer entry site

 -  Spinal pathology that may impede recovery such as spondylolisthesis at L5/S1, or
 scoliosis

 -  Symptomatic foraminal or central canal stenosis

 -  H/O potentially confounding intervertebral disc disease or zygapophyseal joint pain

 -  Pregnancy

 -  Active radicular pain

 -  Immunosuppressive conditions (H/O TB, AIDS, cancer, diabetes, surgery <3 months)

 -  Allergy to medications used in the procedure

 -  High narcotic use (>30 mg morphine daily or equivalent)

 -  Contraindications pertaining to the use of platelet concentrate like history of
 thrombocytopenia, use of anticoagulant therapy, active infection, tumor and metastatic
 disease