Abstract

STUDY DESIGN Systematic review. OBJECTIVES We performed this systematic overview on overlapping meta-analyses that analyzed the role of platelet-rich plasma(PRP) in enhancing spinal fusion and identify which study provides the current best evidence on the topic and generate recommendations for the same. MATERIALS AND METHODS We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Embase, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects till October-2020 for meta-analyses that analyzed the role of PRP in spinal fusion procedures. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades. We then utilized the Jadad decision algorithm to identify the study with highest quality to represent the current best evidence to generate recommendations. RESULTS 3 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of included studies varied from 5-8(mean:6.3) and all included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The current best evidence showed that utilization of PRP was not associated with significant improvement in patient-reported outcomes such as Visual Analog Score for pain compared to the standard fusion procedure. Moreover, PRP was found to be associated with lower fusion rates. CONCLUSION Based on this systematic overview, the effectiveness of PRP as a biological agent in augmenting spinal fusion is limited. Current evidence does not support the use of PRP as an adjuvant to enhance spinal fusion.

Abstract

BACKGROUND Recurrent intervertebral disc herniation and an exacerbated degenerative process have been identified as the most important factors contributing to persistent pain and disability after surgical discectomy. Defects in the annulus fibrosus remain a surgical challenge, as the preference for minimally invasive surgical approaches for lumbar microdiscectomy, surgical access, and the specifics of anatomy. limit the types of devices that permit annulus fibrosus repair. Furthermore, the intervertebral disc is a relatively avascular structure, and surgical procedures can accelerate the degenerative disc process. This study aimed to evaluate the clinical safety and efficacy of a novel microdiscectomy annular repair technique combined with an autologous conditioned plasma (ACP) intradiscal injection for the treatment of lumbar disc herniation (LDH). METHODS From July 2017 to December 2018 this study recruited 75 patients with LDH (single segment) and randomly divided these patients into the following three groups: group A, full endoscopic discectomy; group B: full endoscopic discectomy and annular repair; group C, full endoscopic discectomy annular repair and ACP intradiscal injection. The pre- and postoperative neurological function and pain status were evaluated by the visual analog scale (VAS) score and the Oswestry disability index (ODI). Patients were followed up once preoperatively, and at 1, 3, and 6 months postoperatively. RESULTS The procedure was successfully performed in all cases. No cases required conversion to an open procedure. The preoperative symptoms were alleviated significantly after surgery. The VAS scores for lower back and lower limb pain and ODI score were significantly difference at 1 month, 3 months, 6 months post operation compared to pre-operation scores (P<0.05). For VAS scores of the lower back, the difference between group A and group C was statistically significant (A>C), as was the difference between group B and group C (B>C). CONCLUSIONS Early results showed that the use of the novel full endoscopic annular repair technique and ACP intradiscal injection serial therapeutic model are beneficial for short term outcomes and demonstrates a reduction in symptomatic disc reherniation with low postoperative complication rates. This new serial therapeutic model may significantly improve the symptoms of postoperative lower back pain.

Abstract

This systematic review compares clinical outcomes between platelet-rich plasma (PRP) and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy. A systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Pubmed, SCOPUS, and Ovid MEDLINE databases. All level I-III evidence comparative studies published in the English language investigating the clinical outcomes between PRP and corticosteroid injections for the treatment of lumbar spondylosis and sacroiliac arthropathy were included. Five studies (242 patients, 114 PRP, 128 corticosteroid) were analyzed. One randomized study was level I evidence, two randomized studies were level II, and two non-randomized studies were level III. Final follow-up ranged from six weeks to six months. Four studies found that both PRP and corticosteroid treatment led to a statistically significant reduction in the visual analog scale (VAS). One found that only the PRP group led to a statistically significant reduction in VAS. Three studies found more significant improvements in one or more clinical outcome scores among PRP patients as compared with corticosteroid patients at the three- to six-month follow-up. Two studies found no difference in outcome score improvements between the two groups at six- to 12-week follow-up. There were no reports of major complications. There were no significant differences in minor complication rates between the two groups. In conclusion, both PRP and corticosteroid injections are safe and effective options for the treatment of lumbar spondylosis and sacroiliac arthropathy. There is some evidence that PRP injection is a more effective option at long-term follow-up compared with corticosteroid injection. Further randomized controlled trials with longer-term follow-up are necessary to compare its long-term efficacy.

Abstract

Background: Platelet-rich plasma (PRP) has been used very successfully in enhancing bone fusion in animal experiments. Also, the efficaciousness of PRP in other specialties of medicine such as dentistry, dermatology ophthalmology, and sports medicine is well documented. But the use of PRP to augment bone fusion after spinal surgery in humans is still controversial. We conducted a meta-analysis to determine the role of PRP in enhancing spinal fusion by fastening the rate of new bone formation and decreasing pain after spinal surgery in humans. Methods: We searched PubMed, EMBASE, and the Cochrane Library studies that compared PRP versus control in enhancing spinal fusion after deformity correction. Results: Five retrospective studies with 253 participants and nine prospective cohort studies with 460 participants were identified. The bone fusion rate was excellent for studies that used a high platelet concentration in PRP relative to control (odds ratio (OR) = 4.35, 95% confidence interval (CI) (2.13, 8.83), and P < 0.05) while bone fusion was poor to studies that used a low concentrate of platelet in PRP relative to control. The rate of new bone formation was high in the PRP group compared to the control group with the mean difference in Hounsfield unit (HU) 144.91 (95% CI (80.63, 209.18), P < 0.05). Time to bone fusion was short in the PRP group during the first six months of surgery relative to the control group with a mean difference of -2.03 (95% CI (-2.35, -1.7); P < 0.05). No difference was found in pain reduction by visual analog score (VAS) between the PRP group and control. Conclusion: PRP facilitates new bone formation and bone fusion with a minimum concentration of the growth factor 5 times that of the peripheral blood. PRP stimulatory effects are not continuous and are very effective within six months of implantation.

Abstract

BACKGROUND Platelet transfusion has been utilized to reverse platelet dysfunction in patients on pre-injury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS Controlled, observational and randomized, prospective and retrospective studies describing tICH, pre-injury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS Twelve articles out of 18609 screened references were applicable to our PICOS questions were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (OR 1.29; 95% CI 0.76-2.18; p=0.346; I=32.5%). There was no significant reduction in hemorrhage progression (OR 0.88; 95% CI 0.34-2.28; p=0.788; I=78.1%). There was no significant reduction in the need for neurosurgical intervention (OR 1.00, 95% CI 0.53-1.90, p=0.996, I=59.1%, p=0.032). CONCLUSIONS Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE level III, Systematic Reviews and Meta-Analyses.

Abstract

OBJECTIVE Platelet-rich plasma (PRP) is a biological agent obtained by centrifuging a sample of blood and retrieving a high concentration of platelets and plasma components. The concentrate is then stimulated for platelet secretion of various growth factors and cytokines. Although it is not widely used in clinical practice, its role in augmenting bony union among patients undergoing spinal fusion has been assessed in several clinical studies. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to determine the efficacy of PRP use in spinal fusion procedures. METHODS A comprehensive literature search was conducted using PubMed, Scopus, and EMBASE for studies from all available dates. From eligible studies, data regarding the fusion rate and method of assessing fusion, estimated blood loss (EBL), and baseline and final visual analog scale (VAS) scores were collected as the primary outcomes of interest. Patients were grouped by those undergoing spinal fusion with PRP and bone graft (PRP group) and those only with bone graft (graft-only group). RESULTS The literature search resulted in 207 articles. Forty-five full-text articles were screened, of which 11 studies were included, resulting in a meta-analysis including 741 patients. Patients without PRP were more likely to have a successful fusion at the last follow-up compared with those with PRP in their bone grafts (OR 0.53, 95% CI 0.34-0.84; p = 0.006). There was no statistically significant difference with regard to change in VAS scores (OR 0.00, 95% CI -2.84 to 2.84; p > 0.99) or change in EBL (OR 3.67, 95% CI -67.13-74.48; p = 0.92) between the groups. CONCLUSIONS This study found that the additional use of PRP was not associated with any significant improvement in patient-reported outcomes and was actually found to be associated with lower fusion rates compared with standard grafting techniques. Thus, PRP may have a limited role in augmenting spinal fusion.

Abstract

BACKGROUND Platelet-rich plasma (PRP) is widely used in many orthopedic surgeries and spinal disease treatments; however, the effect of PRP on spinal fusion remains controversial. QUESTIONS/PURPOSES To assess the fusion rate and clinical results of PRP compared with non-PRP administration in the treatment of spinal fusion with regard to decreasing pain and improving healing and function. PATIENTS AND METHODS Studies comparing PRP to non-PRP treatment with respect to the fusion rate and clinical outcome in patients who underwent spinal fusion surgery were included. RESULT Three randomized controlled trials (RCTs) and 7 prospective cohort studies were identified. The spinal fusion rate was not significantly different between the groups in all RCTs or cohort studies at the final follow-up. In comparison, PRP significantly reduced pain after surgery as evaluated in the RCT analysis and the complication rate did not differ significantly between the two groups. CONCLUSION According to the available studies, PRP does not contribute to the union rate, relieve pain or increase the complication rate in spinal fusion surgery. As clinical heterogeneity exists in these studies, further large, well-designed RCTs that focus on the standard assessment of PRP are needed.

Abstract

BACKGROUND Platelet-rich plasma (PRP) has been frequently used to enhance bone regeneration. A meta-analysis was conducted to systematically assess the fusion rate and pain relief of applying PRP in spinal fusion surgery. METHODS Studies investigating spinal fusion surgery combined with PRP procedure were retrieved from Medline and Web of Science according to inclusion and exclusion criteria. Quality evaluation was conducted using the Cochrane collaboration tool for randomized controlled trials and the Newcastle-Ottawa Scale quality assessment for cohort trials. Statistics were managed using RevMan 5.3. RESULTS A total of 12 studiesincluding 3 randomized controlled trials and 9 cohort studies, with 661 patients were enrolled in this meta-analysis. The mean age was 52.3+/-8.0 years. The over pooled results demonstrated that there was no statistically significant difference in fusion rates between PRP and non-PRP treatment groups. The risk ratio was 1.01 (95% confidence intervals (95%CIs): 0.95-1.06, p=0.83). There was no significant difference in pain relief as measured by the Visual Analog Scale between the two groups. The mean difference was -0.08 (95% CIs:-0.26 - 0.11, p=0.42). CONCLUSION Adding PRP could not increase fusion rates in spinal fusion surgery. Meanwhile, there was no significant difference in pain relief between PRP and non-PRP treatment groups.

Abstract

INTRODUCTION We have conducted a systematic review and meta-analysis that aims to compare outcomes (pain VAS, fusion and adverse event) of PRP and placebo after posterolateral lumbar fusion (PLF) surgery. MATERIALS AND METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies were identified from Medline and Scopus from inception to September 16, 2019 that reported visual analog scale back pain, postoperative complications and fusions of either group. RESULTS In a total of seven studies, two, two, three studies were RCT, prospective and retrospective studies, respectively. Overall, there were 270 patients (150 in the PRP group and 149 in the placebo group). Three, three, four, three, two, seven and four studies were reported for pain VAS back in 3 months, 6 months, 12 months, 24 months, period of fusion, postoperative fusion and adverse events, respectively. The unstandardized mean difference (UMD) VAS back in 3, 6, 6 and 24 months was - 0.41 (95% CI - 0.87, 0.05) score, - 0.97 (95% CI - 1.68, - 0.27) score, - 0.33 (95% CI - 0.61, - 0.59) score, - 0.19 (95% CI - 1.00, 0.62) scores lower than placebo after posterolateral lumbar fusion (PLF) patients. The UMD period of bone union were - 1.62 (95% CI - 1.85, - 1.39) months faster than placebo after PLF patients. A total of seven and four studies were reported fusion and adverse events between PRP and placebo group. No significant differences were noted for fusion and adverse events with the pooled RR of 1.03 (95% CI 0.48, 1.80) and 0.95 (95% CI 0.14, 6.56). CONCLUSIONS PRP with autologous bone graft had lower back pain and faster bone union time than bone graft alone. While, there have no difference in fusion rate and adverse events in both groups. Larger, prospective randomized controlled studies are needed to confirm these findings as the current literature is still insufficient. Further research including cost of operation, postoperative function and satisfaction, quality of life and cost-efficacy analysis is required to determine whether the PRP with autologous bone graft is superior to bone graft alone or not. LEVEL OF EVIDENCE Level II.

Abstract

BACKGROUND CONTEXT Platelet-rich plasma (PRP) accelerates bone union in vivo in a rodent model of spinal fusion surgery. However, PRP's effect on bone union after spinal surgery remains unclear. PURPOSE To evaluate the efficacy of PRP after posterolateral lumbar fusion (PLF) surgery. STUDY DESIGN/SETTING Single-center prospective randomized controlled clinical trial with 2-year follow-up. PATIENT SAMPLE Total 62 patients (31 patients in PRP group or 31 patients in control groups OUTCOME MEASURES Bone fusion rate, area of bone fusion mass, duration for bone fusion, and clinical score using visual analog scale (VAS). METHODS We randomized 62 patients who underwent one- or two-level instrumented PLF for lumbar degenerative spondylosis with instability to either PRP (31 patients) or control (31 patients) groups. PRP-treated patients underwent surgery using an autograft bone chip (local bone) and PRP was prepared from patient blood samples immediately before surgery; patients from the control group underwent PLF without PRP treatment. We assessed platelet counts and growth factor concentrations in PRP prepared immediately before surgery. Duration for bone union, postoperative bone fusion rate, and area of fusion mass were assessed using plain radiography every 3 months after surgery and by computed tomography (CT) at 12 or 24 months. The duration for bone fusion, and clinical scores for low back pain, leg pain, and leg numbness before, and 3, 6, 12, and 24 months after surgery were evaluated using a VAS. RESULTS Data from 50 patients with complete data were included. Bone union rate at final follow-up was significantly higher in the PRP group (94%) than controls (74%) (P = 0.002). Area of fusion mass was significantly higher in the PRP group (572 mm2) than controls (367 mm2) (P = 0.02). The mean period necessary for union was 7.8 months in the PRP group and 9.8 months in controls (P = 0.013). In the PRP, platelet count was 7.7 times higher and growth factor concentrations were 50 times higher than found in plasma (P < 0.05). There was no significant difference in low back pain, leg pain, and leg numbness in either group at any time evaluated (P > 0.05). CONCLUSIONS Patients treated with PRP showed a higher fusion rate, greater fusion mass, and more rapid bone union after spinal fusion surgery than patients not treated with PRP.