Platelet rich plasma application in chronic low back pain – clinical and anatomical rationale and review of the literature


Key words: Platelets, Low Back Pain, Tissue Regeneration

How to Cite

Todorov, P., Mekenjan, L., Popova, S., & Batalov, A. (2019). Platelet rich plasma application in chronic low back pain – clinical and anatomical rationale and review of the literature. Rheumatology (Bulgaria), 27(4), 27-41.


Low back pain (LBP) is an extremely common symptom in populations of all ages with significant economic and social burden worldwide. As such it should be among the priorities for trying to find more efficient methods for prevention and treatment. Currently the exact cause for the complaints can be found in most of the cases following thorough clinical examination, adequate diagnostic tests and modern image diagnosis. Most often the complaints are cause by degenerative processes affecting certain structures in the lumbosacral area – the intervertebral discs, the tendons/entheses along the iliac crest, the sacroiliac and lumbar facet joints. Platelet rich plasma (PRP) is a widely used therapeutic method aimed at recovering (both anatomical and functional) degenerative or traumatic damaged collagen tissues by injecting/applying autologous blood concentrate, rich in growth factors and other biologically active molecules. PRP demonstrates huge potential in stimulating cell proliferation and metabolic activity in vitro. Trials with animals show/prove the full recovery of the structural changes and the matrix integrity of the damaged tissue. In recent years some prospective clinical studies and published case series report that PRP could be a safe and efficient therapy for patients with chronic low back pain that do not yield to traditional/standard treatment options. Data though limited/scarce for the time being includes/covers the most common cause for this complaint, namely pathology of the intervertebral discs, facet and sacroiliac joints, as well as paraspinal soft tissues. The possibility for precise intralesional application of this regeneration autologous product in the damaged tissue gives it a huge advantage over the common algorithms currently used in the clinical practice to treat patients with such complaints. Future bigger studies including image methods to evaluate the structural recovery of the degenerative changed tissue responsible/blamed for the pain and functional deficit would bring light to the place PRP therapy should take in the treatment of low back pain.


  1. Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 2012;64(6):2028-2037.
  2. Swain MS, Henschke N, Kamper SJ, et al. An international survey of pain in adolescents. BMC Public Health. 2014;14(1):447.
  3. DALYs GBD, Collaborators H. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1603-1658.
  4. Theis KA, Roblin DW, Helmick CG, Luo R. Prevalence and causes of work disability among working-age U.S.adults, 2011-2014, NHIS. Disabil Health J. 2018;11:108-15.
  5. Bogduk N. Clinical anatomy of the lumbar spine and sacrum. Elsevier, 2005.
  6. Depalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and does age play a role? Pain Med. 2011;12(2):224-233.
  7. Abraham I, Killackie-Jones B. Lack of evidence based research for idiopathic low back pain. The importance of a specific diagnosis. Arch intern med 2002; 162: 1442-1444.
  8. Anitua E, Andia I, Ardanza B et al. Autologous platelets as a source of proteins for healing and tissue regeneration. Thromb Haemost 2004;91(1):4-15.
  9. Alsousou J, Ali A, Willett K, Harrison P. The role of platelet-rich plasma in tissue regeneration. Platelets. 2013;24(3):173-182.
  10. Nurden AT. Platelets, inflammation and tissue regeneration. Thromb Haemost. 2011;105(Suppl 1):S13-S33.
  11. Wasterlain AS, Braun HJ, Dragoo JL. Contents and formulations of platelet rich plasma. In: Maff ulli N, editor. Platelet Rich Plasma in Musculoskeletal Practice. London: Springer London; 2016:1-29.
  12. Cavallo C, Roffi A, Grigolo B, et al. Platelet-rich plasma: the choice of activation method aff ects the release of bioactive molecules. Biomed Res Int. 2016;2016(1):1-7.
  13. Akeda K, Yamada J, Linn E, et al. Platelet-rich plasma in the management of chronic low back pain: a critical review. Journal of Pain Res. 2019;12 753-767.
  14. Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fi brin (L-PRF). Trends Biotechnol. 2009;27(3):158-167.
  15. Chahla J, Cinque ME, Piuzzi NS, et al. A call for standardization in platelet-rich plasma preparation protocols and composition reporting: a systematic review of the clinical orthopaedic literature. J Bone Joint Surg Am. 2017;99(20):1769-1779.
  16. Khan KM, Cook JL, Kannus P et al. Time to abandon the “tendinitis” myth. BMJ 2002; 324:626-627.
  17. Franchini M, Cruciani M, Mengoli C et al. Effi cacy of platelet-rich plasma as conservative treatment in orthopaedics: a systemic review and meta-analysis. Blood Transfus. 2018;16:502-13.
  18. Di Matteo B, Filardo G, Kon E, Marcacci M. Platelet-rich plasma: evidence for the treatment of Patellar and Achilles tendinopathy - a systematic review. Musculoskelet Surg. 2015;99(1):1-9.
  19. Dai WL, Zhou AG, Zhang H et al. Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: a metaanalysis of randomized controlled trials. Arthroscopy. 2017; 33(3)651:659-670.
  20. Желязкова М. Приложение на тромбоцит богата плазма при лечение на първична остеоартроза на колянна става, Докторска теза, МУ Пловдив 2018.
  21. Akeda K, Imanishi T, Ohishi K, et al. Intradiscal injection of autologous serum isolated from platelet-rich-plasma for the treatment of discogenic low back pain: preliminary prospective clinical trial. In: poster presentation of the ISSLS meeting; June 14-18, 2011; Gothenburg, Sweden. General posters GP141.
  22. Bodor M, Toy A, Aufi ero D. Disc regeneration with platelets and growth factors. In: Platelet-Rich Plasma: Regenerative Medicine: Sports Medicine, Orthopedic, and Recovery of Musculoskeletal Injuries.
  23. Berlin,Heidelberg: Springer Berlin Heidelberg; 2014:265-279.
  24. Levi D, Horn S, Tyszko S, et al. Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial. Pain Med. 2016; 17(6):1010-1022.
  25. Tuakli-Wosornu YA, Terry A, Boachie-Adjei et al. Lumbar intradiscal platelet-rich plasma (PRP) injections: a prospective, double- blind, randomized controlled study. PMR. 2016;8(1):1-10.
  26. Aufi ero D, Vincent H, Sampson S, et al. Regenerative injection treatment in the spine: review and case series with platelet rich plasma. J Stem Cells Res Rev Rep. 2015;2(1):1019.
  27. Kirchner F, Anitua E. Intradiscal and intra-articular facet infiltrations with plasma rich in growth factors reduce pain in patients with chronic low back pain. J Craniovertebr Junction Spine. 2016;7(4):250-256.
  28. Wu J, du Z, Lv Y, et al. A new technique for the treatment of lumbar facet joint syndrome using intra-articular injection with autologous platelet rich plasma. Pain Physician. 2016;19(8):617-625.
  29. Wu J, Zhou J, Liu C, et al. A Prospective study comparing platelet-rich plasma and local anaesthetic (LA)/corticosteroid in intra-articular injection for the treatment of lumbar facet joint syndrome. Pain Pract. 2017;17(7):914-924.
  30. Vleeming A, Mooney V, Stoeckart R. Movement, stability and lumbopelvic pain. Integration of research and therapy. Churchill Livingstone Elsevier, 2007.
  31. Singla V, Batra YK, Bharti N et al. Steroid vs. platelet-rich plasma in ultrasound-guided sacroiliac joint injection for chronic low back pain. Pain Pract 2017:782-791.
  32. Navani A, Gupta D. Role of intra-articular platelet-rich plasma in sacroiliac joint pain. Tech Reg Anesth Pain Manage 2015; 19:54-59.
  33. Borg-Stein J, Wilkins AN. Soft tissues determinants of low back pain. Curr Pain Headache Rep2006; 10:339-44.
  34. Todorov P, Nestorova R, Batalov A. Diagnostic value of the musculoskeletal ultrasound in patients with low back pain – a review of the literature. Medical ultrasonography 1(1), October 2018;1:80-87.
  35. Darrow M, Shaw B, Schmidt N et al. Treatment of unresolved lower back pain with platelet-rich plasma injections. Cogent Medicine 2019; in press.
  36. Hussein M, Hussein T. Effect of autologous platelet leukocyte rich plasma injections on atrophied lumbar multifidus muscle in low back pain patients with monosegmental degenerative disc disease. Sicot J. 2016;2(1):12.
  37. Cameron JA, Thielen KM. Autologous platelet rich plasma for neck and lower back pain secondary to spinal disc herniation: midterm results. Spine Res. 2017;03(02):10.
  38. Sanapaty J, Manchikanti L, Sairam A et al. Do Regenerative Medicine Therapies Provide Long-Term Relief in Chronic Low Back Pain: A Systematic Review and Meta-analysis. Pain Physician 2018; 21:515-540.
  39. Todorov P, Nestorova R, Batalov A. The sonoanatomy of lumbar erector spinae and its iliac attachment  the potential substrate of the iliac crest pain syndrome, an ultrasound study in healthy subjects. J Ultrason 2018; 18:16-21.
  40. Lutz GE. Increased nuclear T2 signal intensity and improved function and pain in a patient one year after an intradiscal platelet-rich plasma injection. Pain Med. 2017;18(6):1197-1199.
Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.