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Successful Treatment of Supraspinous and Interspinous Ligament Injury with Ultrasound-Guided Platelet-Rich Plasma Injection

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Successful Treatment of Supraspinous and Interspinous Ligament Injury with Ultrasound-Guided Platelet-Rich Plasma Injection HSSXXX10.1177/1556331621992312HSS Journal®: The Musculoskeletal Journal of Hospital for Special SurgeryCreighton et al 992312case-report2021 Case Report HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery Successful Treatment of Supraspinous 1 –4 © The Author(s) 2021 Article reuse guidelines: and Interspinous Ligament Injury sagepub.com/journals-permissions DOI:https://doi.org/10.1177/1556331621992312 10.1177/1556331621992312 With Ultrasound-Guided Platelet-Rich journals.sagepub.com/home/hss Plasma Injection: Case Series Andrew Creighton, DO1, Roger A. Sanguino, MS1, Jennifer Cheng, PhD1, and James F. Wyss, MD, PT1 Keywords supraspinous ligament, interspinous ligament, platelet-rich plasma, ultrasound, nonoperative treatments, lumbar spine Received October 18, 2020. Accepted October 21, 2020. Introduction running volume. The LBP intensity ranged from 3 to 9/10 and was worse with prolonged standing, sitting, or running. Low back pain (LBP) is a very common complaint and is He reported no improvement with 3 prior courses of PT, now the number one cause of disability across the globe NSAIDs, and use of a seat cushion. Physical examination [5,13]. Both the supraspinous ligament (SSL) and interspi- revealed mild right thoracolumbar curvature. Tenderness nous ligament (ISL) form part of the posterior ligamentous was appreciated over the L5 spinous process and interspi- complex, which is believed to play an integral role in the nous region above and below L5. Strength, sensation, and stability of the thoracolumbar spine [8]. The SSL begins at reflexes were normal. the C7 spinous process and extends to L3 and L4 in 22% Radiographs were unremarkable. Magnetic resonance and 74% of adults, respectively [11]. In contrast, the ISL is imaging (MRI) revealed remodeling of an old left L5 pars formed by a fibrous sheet of dense connective tissue that stress fracture without spondylolisthesis, stenosis, or disk connects the spinous process of adjacent vertebrae and is herniation. Bedside ultrasound confirmed maximal tender- most developed in the lumbar region [8,4]. Historically, ness at the tip of the L5 spinous process. The SSL appeared SSL and ISL injuries have been grouped together with hypoechoic and thickest at L3 and L4 levels. strains and sprains of the lumbar spine [6]. Next, he underwent a diagnostic injection. Using ultra- With the improvement of imaging modalities, we now sound guidance, the SSL at L5 and ISL at L4-L5 were have the ability to more specifically diagnose SSL and ISL injected with 2 to 3 mL of 1% lidocaine total. He reported sprains that lead to acute and chronic lower back pain [8]. 100% relief of symptoms during the anesthetic phase and Through the novel technique of ultrasound-guided leuko- improvement for 1 week, after which symptoms returned. cyte-rich platelet-rich plasma (LR-PRP) injection targeted to Given the positive diagnostic response, he then underwent the SSL and ISL, treatment of SSL and ISL sprains is possi- an injection of LR-PRP to the same site. Under ultrasound ble when other conservative treatments—such as over- guidance, the needle was then guided to the SSL and ISL as the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), previously described. Autologous LR-PRP (3.5 mL) was acetaminophen, rest, and physical therapy (PT)—fail. injected at these sites. At 6 weeks postinjection, he reported This case report highlights the clinical value of ultra- >70% reduction in pain and improved function but had not sound as both a diagnostic and therapeutic tool. Here, we returned to running. At 6 months postinjection, he was run- present 2 cases of SSL and ISL injuries that failed multi- ning and exercising with no limitations (Fig. 1). modal treatment plans and had success with ultrasound- guided LR-PRP injections. 1Department of Physiatry, Hospital for Special Surgery, New York, NY, Case Report USA Case 1 Corresponding Author: James F. Wyss, MD, PT, Department of Physiatry, Hospital for Special A 28-year-old former collegiate runner presented with achy Surgery, New York, NY 10021, USA. LBP for 2 years; his complaints began after increasing his Email: [email protected] 2 HSS Journal ®: The Musculoskeletal Journal of Hospital for Special Surgery 00(0) Fig. 1. Ultrasound of L4–L5 region using a high frequency linear transducer in short axis in Case 1. (a) Ultrasound-guided injection showing needle tip at the interspinous space of the L4–L5 vertebrae targeting the ISL. (b) Ultrasound-guided Fig. 2. Ultrasound of L1–L2 and L2–L3 region using a injection showing needle tip at the supraspinous ligament high frequency linear transducer in long axis in Case 2. superior to the L5 vertebra. (a) Ultrasound-guided injection showing needle tip at the interspinous space of L1–L2 targeting the ISL. (b) Ultrasound- Case 2 guided injection showing needle tip at the interspinous space of L2–L3. A 29-year-old man presented with intermittent LBP for 8 months; his complaints began during an extension maneu- ver. Prior workup led to PT emphasizing core strengthen- Discussion ing, but his LBP persisted. Magnetic resonance imaging The cause of LBP can be challenging to diagnose and treat. was unremarkable. A previous palpation-guided cortisone By using imaging modalities, specifically ultrasound, it is injection offered 75% relief for 1 week before LBP returned evident that the SSL and ISL can be a source of LBP. to baseline. Ultrasound can be used to guide diagnostic and therapeutic At our initial consultation, the LBP was described as injections for SSL and ISL injuries. After identifying an sharp/achy/dull and rated 5/10 at its worst and 3/10 at its injury to the SSL and/or ISL a multimodal approach is often best. Bending forward or backward exacerbated the pain. initiated, including PT, medications, and steroid injections. Physical examination findings revealed approximately 20% To our knowledge, there are no reports of an ultrasound- motion restriction on lumbar flexion. The ISLs were focally guided PRP injection to treat SSL and ISL pathology. tender at L1–L3, and the neurological examination was nor- In these 2 reported cases, the patients did not respond to mal. First, a fluoroscopically guided interspinous steroid traditional multimodal approaches. Injections of LR-PRP injection at L1–L2 and L2–L3 was performed. At 1 month were found to be successful in treating SSL and ISL inju- postinjection, he reported >50% relief of symptoms for 2 to ries. The literature is scarce regarding the diagnosis and 3 weeks after the injection, after which the LBP returned to treatment of pain generated from the SSL and ISL. Heylings baseline. [7] analyzed 28 cadaveric specimens by dissection and his- Next, he underwent an LR-PRP injection. The L1–L2 and tological examination and demonstrated that the SSL and L2–L3 spinous process and ISLs in between them, at areas of ISL are connected and play an important role in spinal sta- maximal tenderness to palpation, were marked and autolo- bility, opposing lumbar flexion. With flexion, loading of gous LR-PRP (1.5 mL) was injected at each site. He reported the spine shifts to the posterior elements, which become some pain, but the procedure was tolerated well. At 1 month denser with greater load bearing [14]. According to postinjection, he reported 10% improvement and was advised Solomonow [12], ligaments are able to monitor relevant to continue his home exercise program to restore range of kinesthetic and proprioceptive information. Ligaments can motion and improve core strength. At 6 weeks postinjection, be acutely inflamed from long-term exposure to static or he reported 75% improvement with near-full range of motion cyclic high loads, long load duration, and high number and and minimal pain. At 9 months postinjection, he reported frequency of load repetitions. MRI is considered the nearly 100% improvement (Fig. 2). modality of choice in assessing ligamentous pathology Creighton et al 3 [14]. However, a study by Zhao et al [15] showed that whether needle tenotomy to the ligaments can be as effec- ultrasound can be a reliable complementary diagnostic tool tive as LR-PRP, and at identifying the optimal postinjection for evaluating the posterior ligamentous complex. In case rehabilitation protocol. 1, ultrasound was used to guide the diagnostic block. In both cases, ultrasound was used to guide the therapeutic Declaration of Conflicting Interests injection that gave the patient significant pain relief. The author(s) declared no potential conflicts of interest with respect Platelet-rich plasma (PRP) includes numerous growth to the research, authorship, and/or publication of this article. factors, such as transforming growth factor-β1, insulin-like growth factors 1 and 2, and vascular endothelial growth Funding factor [15]. Several studies have demonstrated success The author(s) received no financial support for the research, with injecting PRP to treat ligaments. Podesta et al ana- authorship, and/or publication of this article. lyzed 34 athletes who received ultrasound-guided LR-PRP injections for the treatment of grade I and II ulnar collateral Human/Animal Rights ligament sprains [9,10]. By 6 months, 88% of athletes had returned to play without complaints at the same level, had All procedures followed were in accordance with the ethical stan- dards of the responsible committee on human experimentation improvement in outcomes scores, and showed decreases (institutional and national) and with the Helsinki Declaration of in medial elbow joint space gapping from 7 to 2.5 mm. 1975, as revised in 2013. Bagwell et al [1] reported a case of a series of LR-PRP injections, along with early rehabilitation, that showed Informed Consent promise in treating an acute grade III medial collateral liga- ment injury. Given the reported success of PRP in treating Informed consent was waived from the patients included in this ligaments, and the fact that the patients in our cases had case study.
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