Marc Darrow, MD, JD.
In May of 2024, the American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders was published in the Journal of Pain Research (1). Among the management options for sacroiliac disorders was a discussion on regenerative medicine.
“When patients with confirmed SIJ pain do not obtain satisfactory pain relief with conservative measures or intra-articular steroid injections, and want to avoid more invasive options, intra-articular regenerative medicine injections may be considered. Specifically, this term refers to platelet-rich plasma (PRP), bone marrow aspirate stem cell concentrate (BMAC), stromal vascular fraction (SVF), or a combination of these injectates. These options aim to reverse the underlying causative pathology by healing the damaged tissues. The two options most commonly utilized and well-studied are PRP and bone marrow aspirate stem cell concentrate (BMAC). . . Unfortunately, there is a scarcity of peer-reviewed published data pertaining to regenerative medicine injections for SIJ-related pain, and there is no evidence to suggest that one regenerative medicine injectate is superior to another.”
PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.
The platelets contain healing agents, or “growth factors.” Let’s look at some of the growth factors and what they do:
- Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
- Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
- Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
- Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
- Epidermal growth factor plays a key role in tissue repair mechanisms.
A study published in Pain practice : the official journal of World Institute of Pain (2) compared the effectiveness of these two injection treatments. These are the paper’s main points:
- “Despite widespread use of steroids to treat sacroiliac joint (SIJ) pain, their duration of pain reduction is short. Platelet-rich plasma (PRP) can potentially enhance tissue healing and may have a longer-lasting effect on pain.
- Forty patients with chronic low back pain diagnosed with SIJ pathology were randomly allocated into 2 groups.
- Group S received methylprednisolone
- Group P received PRP
- After treatment:
- Intensity of pain was significantly lower in the PRP group at 6 weeks and 3 months as compared to the steroid group.
- The efficacy of steroid injection was reduced to only 25% at 3 months while it was 90% in the PRP group.
- A strong association was observed in patients receiving PRP and showing a reduction of pain of more than 50% from baseline. Pain and function scores favored the PRP treatment as well. In the steroid group pain reduction and function improvements were seen up until 4 weeks after treatment and then the effectiveness declined. While the PRP group saw pain and function scores steadily increase at the three month marker.
Conclusion: “The intra-articular PRP injection is an effective treatment modality in low back pain involving SIJ.”
Fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection
Giving another opinion is a November 2021 (3) paper. Here doctors compared outcomes with a fluoroscopically-guided intra-articular injection of steroid or platelet rich plasma injection. Follow-up was at 1-month, 3 months, and 6-months.
Results: “At one, three, and six months, both groups improved, however subjects who received steroid injections reported lower pain scores than subjects who received platelet rich plasma. Using categorical data, we observed significantly more responders (defined as pain scores which improved by 50% or more from baseline) at one and three months in the group that received steroids compared to the group that received platelet rich plasma. Conclusion: While both groups showed improvements in pain and function, the steroid group had significantly greater response and significantly more responders than the PRP group. “
In our office, we do not consider PRP a one shot treatment. Often the treatment requires a peppering of numerous PRP injections into the back and more than one treatment occasion. Our process is described below.
PRP treatment for a patient’s sacroiliac joint pain who has fluoroquinolone-related mitochondrial dysfunction
An April 2022 case history (4) presents the case of using ultrasound-guided platelet-rich-plasma injections for reducing sacroiliac joint pain. In this case a 52-year-old Caucasian male with fluoroquinolone-related mitochondrial dysfunction complained of severe SIJ pain. He was treated with two bilateral PRP ultrasound-guided injections at the sacroiliac level. PRP is a simple, efficient, and minimally invasive approach. After the first PRP injection, there was a considerable reduction of pain. The second PRP infiltration was performed after 2 weeks and in both cases no adverse events. At the 6-month follow-up evaluation, the patient showed good physical recovery, with the absence of pain.
A case history from the US military – PRP treatment for a soldier’s sacroiliac joint pain who was taking high-dose opioids
A case history was given in August 2020 in the journal Military medicine (5) of a soldier with sacroiliac joint pain. Here is a summary of this case:
“Back pain and its associated complications are of increasing importance among military members. The sacroiliac joint is a common source of chronic low back pain and functional disability. Many patients suffering from chronic low back pain utilize opioids to help control their symptoms. Platelet-rich plasma (PRP) has been used extensively to treat pain emanating from many different musculoskeletal origins; however, its use in the sacroiliac joint has been studied only on a limited basis.
The patient in this case report presented with chronic low back pain localized to the sacroiliac joint and subsequent functional disability managed with high-dose opioids. After failure of traditional treatments, she was given an ultrasound-guided PRP injection of the sacroiliac joint which drastically decreased her pain and disability and eventually allowed for complete opioid cessation. Her symptom relief continued one year after the injection. This case demonstrates the potential of ultrasound-guided PRP injections as a long-term treatment for chronic low back pain caused by SIJ dysfunction in military service members, which can also aid in the weaning of chronic opioid use.”
An August 2020 study (6) investigated the efficacy of ultrasound-guided platelet-rich plasma in reducing sacroiliac joint disability and pain. in 50 patients diagnosed with low back pain secondary to sacroiliac joint dysfunction.
“Platelet-rich plasma was injected into the sacroiliac joint under ultrasound guidance. Oswestry Disability Index and Numeric Rating Scale were measured at baseline, 2 weeks, 4 weeks, 3 months, and 6 months after injection.
- Results: The mean reduction in Oswestry Disability Index and Numeric Rating Scale scores were significantly reduced at 6 months after injection compared with baseline values. All timeframes showed significant mean reduction compared with baseline, but overall improvement tapers off after 4 weeks with no statistically significant reduction from 4 weeks to 3 months or three to six months.
- Conclusions: Ultrasound-guided platelet-rich plasma injections in the sacroiliac joint are effective at reducing disability and pain with most improvement seen within 4 weeks after injection and with sustained reduction at 6 months.”
We usually ask the patients to return for more treatment if initial results were good and then being to taper off. In our years of experience and as documented in our medical research, we usually find multiple PRP treatments to be more effective than a single treatment. But, people do vary, some may derive benefit from one treatment.
A 2019 study in the journal Pain Physician (7) posted the following guideline recommendations from the American Society of Interventional Pain Physicians (ASIPP) Guidelines.
“Based on the evidence. . . there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.
Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient’s needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient’s medical history.
Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy.”
A January 2021 paper (8) came to inconclusive results when assessing the effectiveness of PRP for sacroiliac joint (SIJ) dysfunction. The authors wrote: “A review of the literature on PRP interventions on the SIJ or ligaments was performed. Seven studies had improvements in their respective primary end point and demonstrated a strong safety profile without any serious adverse events. Only five articles demonstrated clinical efficacy of more than 50% in their primary outcome measures. There appears to be inconsistent and insufficient evidence for a conclusive recommendation for or against sacroiliac joint PRP”
Low back pain injections
Low back pain injections
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If you have chronic back pain, have had painkillers, physical therapy, and other conservative care options that have not helped, and, now you are being told to have another surgery, we may be able to help reduce pain and increase function non-surgically. Regenerative medicine injections may be an alternative for you. Many people benefit from these treatments, but, they do not work for everyone. Will it work for you? Get a FREE phone consultation.
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References
1 Sayed D, Deer TR, Tieppo Francio V, Lam CM, Sochacki K, Hussain N, Weaver TE, Karri J, Orhurhu V, Strand NH, Weisbein JS. American Society of Pain and Neuroscience Best Practice (ASPN) Guideline for the Treatment of Sacroiliac Disorders. Journal of Pain Research. 2024 Dec 31:1601-38.
2 Singla V, Batra YK, Bharti N, Goni VG, Marwaha N. Steroid vs. platelet‐rich plasma in ultrasound‐guided sacroiliac joint injection for chronic low back pain. Pain Practice. 2017 Jul;17(6):782-91.
3 de Sire A, Lippi L, Mezian K, Calafiore D, Pellegrino R, Mascaro G, Cisari C, Invernizzi M. Ultrasound-guided platelet-rich-plasma injections for reducing sacroiliac joint pain: A paradigmatic case report and literature review. J Back Musculoskelet Rehabil. 2022 Apr 8. doi: 10.3233/BMR-210310. Epub ahead of print. PMID: 35431228.
4 Chen AS, Solberg J, Smith C, Chi M, Lowder R, Christolias G, Singh JR. Intraarticular Platelet Rich Plasma vs Corticosteroid Injections for Sacroiliac Joint Pain—a Double Blinded, Randomized Clinical Trial. Pain Medicine. 2021 Nov 24.
5 Broadhead DY, Douglas HE, Bezjian Wallace LM, Wallace PJ, Tamura S, Morgan KC, Hemler DE. Use of Ultrasound-Guided Platelet-Rich Plasma Injection of the Sacroiliac Joint as a Treatment for Chronic Low Back Pain. Military medicine. 2020 Jul;185(7-8):e1312-7.
6 Wallace P, Wallace LB, Tamura S, Prochnio K, Morgan K, Hemler D. Effectiveness of ultrasound-guided platelet-rich plasma injections in relieving sacroiliac joint dysfunction. American journal of physical medicine & rehabilitation. 2020 Aug 1;99(8):689-93.
7 Navani A, Manchikanti L, Albers SL, Latchaw RE, Sanapati J, Kaye AD, Atluri S, Jordan S, Gupta A, Cedeno D, Vallejo A. Responsible, Safe, and Effective Use of Biologics in the Management of Low Back Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain physician. 2019 Jan 1;22(1):S1-74. 3519
8 Rothenberg JB, Godha K, Civitarese DM, Malanga G, Singh JR, Panero A, Everts P, Dididze M, Jayaram P. Pain and functional outcomes of the sacroiliac joint after platelet-rich plasma injection: a descriptive review. Regenerative Medicine. 2021 Jan;16(01):87-100.