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BackTable / MSK / Article
Intradiscal PRP Injections: Formulation Prep & Procedure Technique
Reilly Fogarty • Updated Apr 29, 2025 • 41 hits
Degenerative disc disease affects nearly all adults over age 40 and, for a significant portion of this population, causes loss of mobility and intractable back pain. Historically there have been few techniques to prevent degeneration or effectively address pain, but intradiscal platelet-rich plasma (PRP) therapy has emerged as a viable treatment option for select patients. PRP is an autologous platelet, growth factor, and cytokine rich formulation that’s extracted from the peripheral blood of the patient and injected into the intradiscal space under fluoroscopic guidance. With the right formulation and injection technique, PRP can offer effective and durable pain relief, and potentially mitigate further degeneration.
To help refine your intradiscal PRP approach, interventional pain specialist Dr. Guilherme Santos, Senior Pain Medicine Specialist at the University of Barcelona, shares his PRP formulation algorithm and walks through the details of his procedure technique. This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• PRP preparation must be targeted to the patient. Leukocyte poor (LP) versus leukocyte-rich (LR) formulation, platelet concentration, and antibiotic protocol selection play an enormous role in conferring positive patient outcomes.
• Fluoroscopic guidance is pivotal for precise needle placement in intradiscal PRP. Under fluoroscopy, Dr. Santos advocates for a posterolateral oblique single-needle technique, with a 30-40 degree angle of initial approach, advancing the needle to the level of the superior articular process of the targeted disc level.
• Due to in vitro evidence suggesting that intradiscal antibiotic use may limit early PRP efficacy, intravenous prophylactic antibiotics are typically preferred.
• Small (0.2-0.3cc) volumes of contrast can be used to confirm needle placement and evaluate disc integrity. Fluid escape from the disc as shown with contrast may be a valuable tool for predicting the success of PRP injections.
Table of Contents
(1) Intradiscal PRP Preparation & Formulation
(2) Intradiscal PRP Injection Technique: Anatomic Approach Under Fluoroscopic Guidance
Intradiscal PRP Preparation & Formulation
Effective intradiscal PRP therapy relies on obtaining a platelet-rich plasma concentrate with platelet and leukocyte dosing based on the specific needs of the patient. Peripheral blood from the patient is taken and spun down into its component pieces, then recombined in the concentrations required for the specific patient and approach. With a total treatment volume of just 1-2cc and the difficulty of accessing the intradiscal space, treatment relies on effective solution preparation and formulation. Recent studies have also shown a linear correlation between platelet dose and analgesic effect, making it uniquely important to maximize platelet concentration while managing leukocyte load.
[Dr. Guilherme Santos]:
This is what a typical intradiscal PRP preparation looks like.. PRP stands for platelet-rich plasma. What that means is we collect a blood sample from your peripheral blood and then we put it inside a centrifuge and we spin it really quickly for five to 10 minutes, depending on the system you have.
What that does is it separates your peripheral blood into several layers. The bottom layer, the denser, the heavier layer is where you have your RBCs, your red blood cells. We're not interested in those for this specific kind of treatment. Then immediately above the RBCs, you get what we call the buffy coat. The buffy coat is where a lot of the platelets and the leukocytes, the white blood cells are located.
Then immediately above that, that's where you get your plasma with a lot of platelets, a lot of proteins. We're mostly interested in getting this more superficial kind of layer. We're interested in getting the plasma. Then we can talk about either including or excluding the buffy coat, which would mean the difference would be if you would be working with what we call a leukocyte-poor or a leukocyte-rich or enriched concentrate. The difference being if the average cell count of your leukocytes is below baseline or above baseline.
If it's below baseline, you're working with a LP PRP concentrate, meaning leukocyte-poor platelet-rich concentrate. If you're working with a lot of leukocytes, a lot of white blood cells, and the white blood cell count is above baseline, then you're working with what we typically call an LR PRP concentrate, meaning leukocyte rich or leukocyte-enriched concentrate. We can get to that part a little bit further into the discussion. For the sake of simplicity. We get the peripheral blood from you if you're a patient, we get the RBCs, the red blood cells out, and then we get the more superficial layer, the platelets, and the plasma. That's where you can see on the big 20cc syringe that is here in the middle of my screen. When you're working with platelet-rich plasma, most systems either have what we call a single spin or a double spin system.
A double spin system just means that after you centrifuge once and you get rid of the RBCs, you centrifuge everything again to try to concentrate the most amount of platelets possible in the least amount of volume possible. This is important for intradiscal procedures because obviously, the lumbar disc has a very limited volume of medication that it takes, where most discs take up to 1, 1.5 cc's, maybe 2 cc's if you can get away with it. What that means is you have a very low volume of medication that you can actually put inside the disc.
Obviously, we're trying to squeeze as many platelets possible into as low a volume as possible. That's where you can see on the very small 10cc syringe to the right within the orange highlighting, meaning that that's my end solution. That's my last two cc's of PRP that I'm going to be injecting inside the disc. Then the other cc, the other small 1ml syringe has calcium chloride, which is what we call an external activator. It's also controversial if you need to use an external activator or not, I choose to use one before doing my discs.
For simplicity sake, you basically try to get as many platelets as possible in the least amount of volume possible, and then put those platelets inside the disc. Basically what you're looking for is all of the growth factors, we call them proteins that help our tissues repair after any sort of trauma or injury happens. We're trying to get all of those in a very super- physiological concentration within the disc. Then hopefully, those will help trigger your repair mechanisms within the disc and will help fight the degeneration of that disc.
[Dr. Jacob Fleming]:
Fantastic. Thank you for that overview. As you alluded to, the dose is something that's really important. This is something I've seen a number of orthobiologic experts allude to and really harp on. Don Buford is one who comes to mind who is really all about the dosage and a big critic of these papers that come out and say, "Oh, no benefit of PRP." Often in those papers, they report no dose or they report no dose, but calculating it back, it's quite low. This is something that's really really important in terms of the treatment efficacy. As you said, the disc being a very small volume that we need to get the maximum amount into.
[Dr. Guilherme Santos]:
A curious thing that's been shown in the lumbar disc specifically is that the analgesic effect of your intradiscal PRP actually correlates linearly with the PRP dose, meaning with the absolute number of platelets you can actually get inside the disc. That's been shown in two level-one studies. That means that obviously, you want to try to get, we now believe, up to tenfold of your baseline count inside the disc. If we can do that, we're probably looking at a treatment that's going to help the patient a great deal.
The problem is it's not easy. Not a lot of commercial systems out there are able to concentrate to a degree where you can regularly get up to tenfold concentration of platelets into such a low volume. Not a lot of systems are able to do that and to reproduce that consistently. If you're doing 100, 200, 300 treatments a year of your patients, you might get away with 20 or 30 that are above that level. To consistently get in that range is key to making your clinical results obviously what you want them to be, which is mostly positive, obviously.
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Intradiscal PRP Injection Technique: Anatomic Approach Under Fluoroscopic Guidance
Dr. Santos’ intradiscal PRP injection technique focuses on a posterolateral oblique approach with a single-needle technique advanced to the level of the superior articular process of the targeted disc level. A 25-gauge needle is used to reach the superior articular process, followed by a 22 gauge needle for intradiscal access. Small volumes of PRP solution (1-2cc) are injected, accompanied by intravenous prophylactic antibiotics (typically 2g cefazolin) which are administered 20-30 minutes prior to the procedure. Small volumes (0.2-0.3cc) of contrast are used to confirm needle placement and evaluate disc integrity – providing significant prognostic value. The precise, low-impact technique allows for effective treatment while minimizing risk profiles and recovery time.
[Dr. Jacob Fleming]:
Tell us a little bit about the technicality of the intradiscal treatment. I assume you do this under fluoroscopy and what's your approach?
[Dr. Guilherme Santos]:
I do what most people would, I believe what most people would use for an intradiscal axis, meaning a posterolateral oblique technique at about 30 to 40 degrees. I had two needles on that screen, one of them being a 25 gauge. I use the 25 gauge to the level of the SAP, so to the superior articular process of the level that I'm working at. I do a little bit of lidocaine up to the level of the SAP. Then I use a 22 gauge as my intradiscal axis needle. I use a single-needle technique. That's a controversial topic.
You know you use a single needle or a double needle system where you get an introducer to the level of the SAP, and then you use a second needle within the introducer to hopefully decrease the risk of just getting your more superficial potential microbes from the skin and superficial layers down the needle track inside the disc. I've always used a single-needle technique. I've never never used a double needle. I tried it a couple of times, it just felt trickier to me. I didn't feel as comfortable as I did when using a single needle.
Until I'm able to read or until someone is able to show me a level-one study that convinces me that a double-needle technique is actually much safer than a single-needle technique, I'll be using a single-needle technique. Then, I access my disc, I use prophylactic antibiotics, obviously. I do intravenous prophylaxis about 20 to 30 minutes before the procedure. I do two grams of cefazolin. That's what I believe most people use. That's what's recommended on most international guidelines.
Another controversial topic is, are you doing intradiscal antibiotics together with your injector or not. For discs, when I'm using orthobiologics, I'm not using intradiscal prophylaxis. The reason is there's in vitro studies showing that the use of antibiotics decreases the efficacy of PRP at early time points. There's no way of knowing how much they will affect PRP effects on the medium to long term. Obviously, for technical reasons, it's difficult to be assessed, but because it affects PRP clinical efficacy at early time points, I do not use any intradiscal antibiotics when I'm doing orthobiologic intradiscal injections.
Most people who work in the spine space, I'd say guideline-wise for safety, most people tend to agree that the guidelines from IPCIS, from the International Pain and Spine International Society, are what most people tend to use as their holy grail of how they do things. The most recent IPCIS guidelines, or their, how did we call it, consensus practice lines, I believe, from 2022 on intradiscal antibiotics for intradiscal access, they do not state that you need to use intradiscal antibiotics when doing orthobiologic procedures, is that exactly because of these studies that have shown that it may decrease PRP efficacy at early time points.
They are very black and white on, obviously, you need to use intravenous prophylaxis. That's a non-discussion, I believe. The discussion is, do you use or don't you use intradiscal? Do you use them in your practice or?
[Dr. Jacob Fleming]:
I've never used intradiscal antibiotics routine IV, as you said, and in my year or so of experience so far, I haven't had a single issue, no case of discitis or anything. For the issues that you said, the potential for mucking with your treatment effect, I think that I would definitely abide by that as well. Even when we would commonly do anesthetic disc injections, just because that's something that we can get reimbursed quite easily and works very well too, we wouldn't use intradiscal antibiotics either.
I'd be interested to hear about the approach of some of our other colleagues out there using it. One other thing I'd like to ask about is when you're doing your intradiscal orthobiologic treatment, do you use any contrast in the disc to confirm your location or do you just use your fluoroscopic triangulation to know that you're within the nucleus?
[Dr. Guilherme Santos]:
No, I always use a little bit of contrast. I typically don't go above 0.2, 0.3 maybe, and that's number one. I want to make sure that I'm where I want to be. If I want to be at the nucleus, I want to make sure that the contrast stays within the center of the disc and it also gives me some information in leaky discs where the leak may be coming from. Sometimes you have discs that leak everywhere, meaning they disc posteriorly, they disc anteriorly, they leak laterally, and so if the disc leaks everywhere, whatever you put in there, it's probably not going to work as well as a disc in which you put a little bit of contrast and after 20 seconds you do another shot and everything stays clean in the center of the disc.
I've never read a level one study that would assure me that putting contrast before an orthobiologic would be the way to go versus not utilizing contrast. In my daily practice, what I found is it gives me another visual confirmation of how bad that disc is, how leaky it may be, and how confident I am regarding is my medication, my platelet-rich plasma, going to mostly or most of it going to stay within the disc, or am I expecting my plasma to just leak everywhere?
Now obviously, with plasma, you're not, like in a vertebroplasty where you're actually worried that the cement is going to leak for obvious reasons. When you're doing an intradiscal plasma injection, the leaking of the plasma itself, I'm not expecting any complication because of the leaking of the plasma, but for the clinical efficacy of the procedure, hopefully, I want to get as many platelets within the disc as possible.
If I see that most of my contrast is getting away from the disc, potentially that's a case that's not going to work as well as I anticipated it to work before doing the contrast. It gives me that second layer of information as to what my prognostic expectations are regarding that treatment. This being said, this is mostly derived from my personal practice. I've never read, never found anything in the literature showing that you should versus you don't need to use the contrast.
Podcast Contributors
Dr. Guilherme Ferreira Dos Santos
Dr. Guilherme Ferreira Dos Santos is an Interventional Pain Physician in Barcelona, Spain.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2024, October 29). Ep. 62 – Exploring Intradiscal PRP for Back Pain Relief [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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