Epidurals-Steroids vs. PRP/Exosomes

According to the American Medical Association, back and neck pain are among the highest amounts of total health care spending in the United States. Each year, physicians administer more than 10 million epidural steroid injections for back and neck pain. Steroids are the common medication given in these procedures. However, due to the diverse nature of the pathology causing the pain, not all patients experience pain relief from these injections.

As a result, epidural injection procedures are currently facing increased scrutiny by hospital systems and public and private insurance groups.

Causes of Back Pain

Back pain often develops, and the cause may not be found. Common conditions linked to back pain are:

Muscle or ligamentous injury- repeated heavy lifting or sudden awkward movements can put a strain on back muscles and spinal ligaments. Poor physical conditioning can be an added risk for injury.
Bulging or ruptured discs- the disc is a cushion between vertebral segments. The soft material in the disc can rupture and impinge on the spinal nerves. This is commonly seen on CT scan or MRI.
Arthritis- arthritis can narrow the spinal canal and cause pressure on the spinal nerves.
Osteoporosis- the bones become demineralized and brittle. As these areas collapse, nerves are commonly involved.
Axial spondylarthritis- This is an inflammatory condition causing the bones to fuse and impinge on the nerves.
Referred pain syndromes- back pain may have a source that is non spinal in origin such as referred pain from a visceral source.

Risk Factors

Anyone can develop back pain at any age but is more common in the aged population.

Age- most common starting age 30-40. Not common in children.
Lack of exercise- weak core muscles
Obesity- excess body weight adds stress to the back.
Improper body mechanics while lifting- using back rather than legs to lift loads.
Psychological conditions- Depression and chronic anxiety patients have an increased risk of back pain.
Smoking- smokers have an increased rate of back pain. This is attributed to decreased blood flow to the spine.

Treatment

Medications

Pain relievers- Nonsteroidal anti-inflammatory agents are the most commonly prescribed medication. These drugs have significant side effects including ulcers, kidney problems and even heart failure in some cases. They should not be used long term in any case.
Muscle relaxants are commonly given if there is appreciable spasm and spasticity. They cause dizziness and sleepiness.
Topicals- These deliver pain relief through the skin with similar side effects.
Narcotics- Only for short term use with high addiction potential
Antidepressants- Have been shown to help in some cases. Side effects are dizziness and sleepiness.
Physical Therapy- To help flexibility, muscle strengthening and neuromuscular re-education. Gait and posture training with education.

Surgical and other procedures

Surgery- to remove the impingement on the nerve root. The spinal segments may be fused at this time.
Nerve stimulators- implanted devices to deliver electrical impulses to the nerves to block to pain signals to the brain.
Radiofrequency ablation- a fine needle is placed in the area where the pain originates, and the electrical waves are passed into the area to damage the nerves. Damaging the nerves interferes with the pain signals to the brain.
Cortisone injections- Cortisone plus a local anesthetic are placed into the space around the spinal cord and nerve root. Cortisone, as an anti-inflammatory, may help with pain relief but it is not long lasting.

Recent articles debate how many epidurals with cortisone should be done within a years’ time. The authors all agree on four with the most being six.

Steroids can cause hypothalamic pituitary adrenal axis suppression and worsen osteoporosis. Steroids can weaken and damage tissues and raise blood sugars therefore must be used in caution in diabetics.

In 1998, Fukusaki et al conducted a prospective study comparing the effect of epidural injection of steroids and local anesthetics with that of local anesthetics alone for radicular pain. They concluded that epidural steroids have no added advantage over local anesthetics.

Platelet Rich Plasma has been used for discogenic back pain and radicular pain. It contains multiple growth factors and both inflammatory and anti-inflammatory cytokines. Insulin like growth factor, transforming growth factor, fibroblast growth factor, endothelial growth factor, vascular growth factors and platelet derived growth factors are a few of the bioactive proteins contained in platelet rich plasma.

Autologous PRP has been used in multiple orthopedic applications to treat injuries to tendons, cartilage, ligaments and muscles. Once PRP is activated, the concentrated platelets release the growth factors and cytokines and alter the microenvironment and relieve pain. There is sufficient clinical evidence that shows PRP induces extra cellular matrix regeneration and cell proliferation.

In a pilot study, Chopra et al administered PRP via the epidural route to treat pain associated with herniated discs and received favorable clinical outcomes. In patients with degenerative disc disease and chronic low back pain, Akeda et al, found improvement sustained over 6 months.

In a double blind randomized controlled study, published in February 2024, Gupta et al compared outcomes of steroids with autologous platelet rich plasma administered by lumbar transforaminal injection in patients with lumbar radiculopathy.

The one week outcome for pain was better in the steroid ,as expected. However, the six week and six month outcomes were significantly better with PRP. The conclusion was PRP is a useful alternative to steroids in lumbar radiculopathy with less side effects.

Wang et al revied and explored novel therapies for disc disease. They found PRP to be a widely used therapeutic agent for tissue repair and regeneration. In addition, as a therapeutic strategy, PRP has the merits of being low cost, ease of preparation, ease of application and autologous sources without rejection reaction.

Wang investigated other impactful treatments for disc disease. He stated the application of exosomes in disc treatment is still in an early stage. It is clear that there is growing interest in their use. Reduced extracellular matrix content, cell loss, inflammation and increased oxidative stress are the pathological and physiologic hallmarks of intervertebral disc degeneration. Exosomes restore discs by targeting these four elements of the disease.

No matter the source of MSC-exosomes, there was similar therapeutic effects in restoring ECM homeostasis, promoting cell proliferation, reducing cell death, regulating inflammation and attenuating oxidative stress.

The conclusion was exosomes by the nature of their therapeutic functions may provide a novel cell free treatment for the regeneration and repair of intervertebral disc disease while minimizing the risks associated with other cell therapies.

Author’s note- I personally had two epidurals in my cervical spine with steroids. I can honestly state that I did not get anything from them other than a pain in my neck. I ended up with two surgeries. Platelet Rich Plasma and exosomes were not options offered to me at the time. The moral of the story is to ask questions of your healthcare provider, discuss options and research before a final decision is made in the treatment of your back pain.

Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma kits are FDA cleared and designed for safety, sterility and effectiveness. Our kits are scientifically manufactured to provide a platelet concentrate, devoid of red blood cells with a minimum number of leukocytes, critical to the regenerative process.

Juventix Regenerative Medical offers a LED Activator to activate the platelets and begin the regenerative process. The activation is a critical step in the release of cytokines, growth factors and bioactive proteins from the alpha granules on the platelets and is accomplished with LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin or Collagen. This mode of activation by LED light provides sustained growth factor release versus older methods of activation while adhering to the minimal manipulation guidelines of the FDA.

Juventix Regenerative Medical supplies a Bio-Incubator to transform the Platelet Rich Plasma into Platelet Rich Fibrin. The Platelet Rich Fibrin, commonly called the “second generation of platelet products” has different cytokines and growth factors than the original PRP. These different cytokines provide an anti-inflammatory microenvironment and can be used confidently in inflammatory conditions.

Juventix Regenerative Medical has many products, services and devices for the regenerative medical professional. Through our collaboration with Evolutionary Biologics, tissue based products such as exosomes are available for an addition to other therapies or as a “stand alone” alternative.