Sanapati J, Manchikanti L, Atluri S, et al. Do Regenerative Medicine Therapies Provide Long-Term Relief in Chronic Low Back Pain: A Systematic Review and Metaanalysis. Pain Physician. 2018 Nov;21(6):515-540. (Systematic review)

BACKGROUND: Several cell-based therapies have been proposed in recent years the management of low back pain, including the injection of medicinal signaling cells or mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). However, there is only emerging clinical evidence to support their use at this time.

OBJECTIVE: To assess the effectiveness of MSCs or PRP injections in the treatment of low back and lower extremity pain.

STUDY DESIGN: A systematic review and metaanalysis of the effectiveness of PRP and MSCs injections in managing low back and lower extremity pain.

DATA SOURCES: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematic reviews, and reference lists. The literature search was performed from 1966 through June 2018.

STUDY SELECTION: Randomized trials, observational studies, and case reports of injections of biologics into the disc, epidural space, facet joints, or sacroiliac joints.

DATA EXTRACTION: Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5.

DATA SYNTHESIS: Twenty-one injection studies met inclusion criteria. There were 12 lumbar disc injections, 5 epidural, 3 lumbar facet joint, and 3 sacroiliac joint studies RESULTS: Evidence synthesis based on a single-arm metaanalysis, randomized controlled trials (RCTs), and observational studies, disc injections of PRP and MSCs showed Level 3 evidence (on a scale of Level I through V). Evidence for epidural injections based on single-arm metaanalysis, a single randomized controlled trial and other available studies demonstrated Level 4 (on a scale of Level I through V) evidence. Similarly, evidence for lumbar facet joint injections and sacroiliac joint injections without metaanalysis demonstrated Level 4 evidence (on a scale of Level I through V).

LIMITATIONS: Lack of high quality RCTs.

CONCLUSION: The findings of this systematic review and single-arm metaanalysis shows that MSCs and PRP may be effective in managing discogenic low back pain, radicular pain, facet joint pain, and sacroiliac joint pain, with variable levels of evidence in favor of these techniques.

KEY WORDS: Chronic low back pain, regenerative therapy, medicinal signaling or mesenchymal stem cells, platelet-rich plasma, disc injection, lumbar facet joint injections, sacroiliac joint injections.

Discipline Area Score
Physician 5 / 7
Comments from MORE raters

Physician rater

There are problems with the analysis - single-arm meta-analyses. The abstract doesn't report results clearly (and most readers won't go beyond the abstract). I'm not confident in the findings. However, the topic is interesting and relevant to large groups of patients.

Physician rater

This is a very interesting paper looking at the evidence supporting the use of platelet rich plasma injections or mesenchymal stem cells in the the management of chronic low back pain. The injections were either intradiscal, epidural facet joint or sacroiliac joints with the primary outcome being reduction in pain and the secondary outcome being functional improvement. Like so many of similar systematic reviews, the weakness is the lack of good quality studies and the considerable heterogeneity in the published studies included in the systematic review. These issues along with limited patient numbers treated resulted in a downgrading in level of evidence supporting these therapies with disc injections of either treatment receiving a level 3 evidence rating (out of 5 with 1 being the highest evidence level) and epidural facet joint and sacroiliac joint injections receiving a level 4 evidence rating. However there is promise here which should encourage more studies of higher quality.
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