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Chapter Summary
• Context: Most conventional treatments for degenerative spine disease manage symptoms or resect structural lesions without directly addressing the underlying cellular mechanisms driving tissue degeneration. Regenerative medicine aims to leverage biological repair mechanisms, modulate pro-inflammatory cascades, and stimulate extracellular matrix regeneration. Discussed strategies include blood-derived products such as platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), adipose-derived stromal vascular fraction, and cultured mesenchymal stem cells. The chapter reviews preclinical and clinical evidence for discogenic low back pain, facet arthropathy, and related spinal pain generators. Simultaneously, it highlights methodological heterogeneity, variable levels of clinical evidence, patient selection criteria, and regulatory frameworks. The 'multitarget' biological strategy is examined as a method to treat the entire functional spinal unit (disc, facets, paraspinal muscles) simultaneously, rather than focusing solely on isolated intradiscal injections.
• Chapter Objective: To understand the biological foundations of regenerative medicine in degenerative spine disease, recognize major classes of orthobiologics and cellular therapies, understand proposed mechanisms of tissue repair and immunomodulation, and critically appraise clinical evidence, limitations, and the role of these therapies as adjuncts to conventional care.
• Interfering directly in biological cascadesTable 50.1 organizes major classes: blood derivatives, bone marrow products, adipose tissue, and cultured stem cells. Orthobiologics utilize minimally manipulated autologous components to promote tissue repair and anti-inflammatory signaling. PRP and BMAC represent the most widely investigated modalities.
• Platelet-rich plasma (PRP)The chapter outlines the transition from in vitro disc research to randomized trials in discogenic pain. Reported outcomes demonstrate pain and functional improvements in selected cohorts. Applications extend beyond the disc to facet joints, paraspinal musculature, and epidural injections. The authors stress that preparation protocols and platelet concentrations vary significantly, complicating cross-study comparisons.
• The multitarget spinal strategyDegenerative disease frequently involves discs, facets, and paraspinal musculature concurrently. The multitarget approach posits that addressing multiple pain generators in a unified biological protocol better reflects the complex pathophysiology of chronic low back pain than isolated intradiscal delivery.
• Bone marrow, adipose derivatives, and stem cellsBMAC, adipose stromal vascular fraction, and culture-expanded mesenchymal stem cells offer regenerative and immunomodulatory potential. However, clinical evidence is heterogeneous, with variable sample sizes and preparation methods preventing these therapies from being considered universal standards of care.
• Patient selection and regulatory boundariesInfection, malignancy, pregnancy, and severe systemic frailty are contraindications. Clear identification of degenerative pain generators and preserved disc height improve biological feasibility. The authors address regulatory requirements governing cellular manipulation.
• Clinical Application: In clinical practice, regenerative medicine must not be used as an empirical trial-and-error treatment. Clinicians must establish a plausible link between symptoms and identifiable degenerative generators (disc, facets, sacroiliac joints). Transparent communication is mandatory: patients must understand that while PRP and BMAC have clinical data, they are not universal cures for spinal degeneration. Multitarget protocols provide a conceptual framework for comprehensive pain management, but must be accompanied by active physical rehabilitation and lifestyle modification (weight control, smoking cessation). Clinicians must navigate regulatory compliance and avoid unproven commercial claims.
