Clinical and radiological resolution of multilevel lumbar disc extrusion and spinal stenosis following combinatorial intradiscal bone marrow aspirate concentrate and epidural platelet lysate: a longitudinal case study

INTRODUCTION

Lumbar disc degeneration and spinal stenosis are among the most prevalent causes of chronic low back pain and radiculopathy, particularly in middle-aged and elderly populations.^1,2 These conditions are characterized by progressive intervertebral disc dehydration, loss of disc height, annular fissuring, and narrowing of the spinal canal, ultimately leading to nerve root compression and neurological deficits.^1-3 Clinically, patients present with axial back pain, radiating leg pain, sensory disturbances, and functional limitations that significantly impair quality of life.² Conventional management including medications, physiotherapy and epidural steroid injections focuses primarily on symptomatic relief rather than reversing the underlying pathology.⁴ In refractory or advanced cases, surgical interventions such as discectomy or spinal fusion are often considered; however, these are associated with complications with requiring prolonged recovery and inconsistent outcomes.^4,5

In recent years, regenerative and orthobiologics therapies have gained increasing attention for their ability to target the underlying disease process.^6,7 BMAC, rich in mesenchymal stem cells, growth factors and anti-inflammatory cytokines, have shown promising results in negate inflammation, promoting tissue repair and improve functional outcomes.^7,8 Emerging evidence supports the safety and efficacy of intradiscal BMAC-based therapies in patients with degenerative disc disease.^7,8

This report presents the clinical outcome of intradiscal BMAC therapy in a 55-year-old male with lumbar disc degeneration and spinal stenosis, demonstrating significant symptomatic and functional recovery over a period of five months follow-up study.

CASE REPORT

Patient information

A 55-year-old male presented with chronic lumbosacral pain radiating to the right lower limb.

Medical history

The patient reported insidious onset of low back pain that progressively evolved into right-sided radiculopathy. Symptoms were refractory to conservative management, including NSAIDs and physiotherapy. There was no history of trauma, corticosteroid use, or alcohol abuse. The patient had a known history of hypertension, controlled with medication.

Family history

No such cases were reported in the family.

Psychosocial history

Persistent lower back pain significantly limited the patient’s mobility and contributed to psychological stress. However, no formal psychiatric consultation was sought.

Genetic information

No relevant genetic testing was performed.

Relevant past interventions

Patient add had reported pain with pain in lower back which was radiating down towards right leg.

Clinical findings

At initial presentation, the patient reported moderate pain with a Numerical pain rating scale (NPRS) score of 6/10. On observation, he exhibited a mesomorphic, muscular build with a mild listing of the spine towards the left. Palpation revealed grade II tenderness over the L3 to S1 spinal and paraspinal regions. Neurological examination demonstrated involvement of the right-sided dermatomes (L3, L4, L5, and S1) with diminished sensation, along with mild motor weakness in the corresponding myotomes (L5 and S1). Nerve tension tests, including the straight leg raise (SLR) and slump test, were positive on the right lower limb, indicating nerve root irritation. The neurological examination was highly suggestive of multilevel nerve root involvement, as detailed in the following baseline metrics (March 2025) (Table 1).

Diagnostic assessment

Lumbar disc degeneration and lumbar stenosis with a NPRS score of 6/10. On observation, he exhibited a mesomorphic, muscular build with a mild listing of the spine towards the left.

Palpation revealed grade II tenderness over the L3 to S1 spinal and paraspinal regions indicating significant mechanical and inflammatory irritation of the traversing and exiting nerve roots. The diminished sensation in the L3-S1 dermatomes suggested a broad field of neural compromise, probably secondary to the multilevel disc pathology confirmed on imaging.

The extrusion at L4-L5 was particularly pathological, as it involved the displacement of nucleus pulposus material beyond the confines of the annulus fibrosus, occupying a significant volume of the central canal and leading to frank spinal canal stenosis. While the primary extrusion was paracentral to the left, the resulting stenosis and diffuse bulge significantly impacted the right-sided lateral recess and neural foramen, correlating with the patient’s right-sided radicular symptoms.

Furthermore, the paracentral fissure at L5-S1 indicated a breach in the annulus, allowing inflammatory nuclear material to approximate the thecal sac and neural elements.

Therapeutic intervention

Following the failure of conservative management, the patient underwent a two-staged regenerative intervention in March 2025. The procedure was designed to address both the internal disc disruption and the secondary neural inflammation through targeted delivery of autologous biologics.

Phase I: epidural platelet lysate administration (24-03-2025)

The initial phase focused on modulating the neuro-inflammatory environment of the lumbar epidural space. Platelet Lysate (PL) was injected into the lumbar epidural space to target the "hot" nerve roots and facilitate an immediate reduction in radicular pain.

Phase II: intradiscal BMAC and disc repair (31-03-2025)

The second phase involved the definitive treatment of the L4-5 and L5-S1 discs. Under fluoroscopic guidance and after confirming the internal disc architecture via discography with dye, the BMAC was injected directly into the nucleus pulposus of the symptomatic segments.^9,10

Follow-up and outcomes

Clinical outcomes were evaluated at baseline (day of treatment) and at six months post-procedure using the NPRS for pain assessment and nerve tension tests, including the Straight Leg Raise (SLR) and Slump test, for functional evaluation. The NPRS score demonstrated a marked reduction in pain from 6/10 at baseline to 1/10 at six months post-procedure represents an 83% improvement, which is significantly higher than the standard 30-50% improvement often cited in orthopaedic literature for successful outcomes.

On observation, the patient initially exhibited a mesomorphic, muscular build with mild left-sided spinal listing, which became negligible at follow-up, indicating improved postural alignment. Palpation findings improved from grade II tenderness over the L3-S1 spinal and paraspinal regions at baseline to grade I tenderness localized to the L5-S1 region at six months. Neurological examination at baseline revealed diminished sensation in the right L3, L4, L5, and S1 dermatomes, along with mild weakness in the L5 and S1 myotomes, and positive SLR and Slump tests on the right side, suggestive of neural involvement. At six months post-procedure, there was substantial neurological recovery, with only minimal residual sensory deficit in the right L5 and S1 dermatomes and normalization of myotomal strength suggesting that the physiological environment around the L5 and S1 nerve roots had stabilized enough to allow for full motor unit recruitment. Furthermore, both SLR and Slump tests were negative, indicates that the mechanical or inflammatory irritation of the nerve roots has been largely abolished. Overall, our findings demonstrate significant symptomatic, functional and neurological improvement over the course of treatment and the patient demonstrated a remarkable clinical recovery, characterized by the rapid resolution of radicular pain and the restoration of neurological function (Table 3). The clinical success was mirrored by a profound transformation in the structural appearance of the lumbar spine on follow-up imaging (Table 4). The most significant radiological change was observed at the L4-5 level. The pre-operative report explicitly identified "spinal canal stenosis" secondary to a disc extrusion. The post-operative report definitively stated there was "No central canal stenosis," representing a complete radiological resolution of the stenotic condition. This transition from a central canal-occupying extrusion to a simple broad-based bulge indicates a massive reduction in the volume of the herniated material. Similarly, at L5-S1, the previously noted "indentation" and "narrowing" resolved to a state of "no significant nerve root compression," explaining the clinical normalization of the S1 myotomes and dermatomes.

DISCUSSION

The present case demonstrates a marked clinical improvement following intra-discal BMAC therapy, as evidenced by significant reduction in pain (NPRS score from 6/10 to 1/10), improvement in neurological function, and restoration of daily activity. The patient initially presented with classical features of lumbar disc degeneration with radiculopathy, including radiating pain, dermatomal sensory deficits, mild motor weakness and positive nerve tension signs (SLR and slump test), which are indicative of nerve root compression secondary to disc pathology and spinal canal narrowing.¹¹ Following BMAC treatment, there was a substantial reduction in pain intensity along with improvement in both sensory and motor deficits. The transition from positive to negative SLR and slump tests further supports the resolution of neural irritation. These findings are consistent with recent evidence demonstrating that intradiscal regenerative therapies significantly improve pain and functional outcomes in chronic low back pain patients.⁴ The therapeutic benefits observed in this case can be attributed to the biological properties of BMAC. Mesenchymal stem cells (MSCs) present in BMAC exert strong paracrine effects by secreting anti-inflammatory cytokines and growth factors that regulate inflammation, promote tissue repair and enhance extracellular matrix remodelling.^12,13 These mechanisms contribute to reduced nerve root irritation, improved disc microenvironment, and potential regeneration of degenerated disc tissue. Recent systematic reviews and meta-analyses have further confirmed that MSC-based intradiscal therapies are safe and effective, with sustained improvements in pain and disability scores.⁷ Emerging clinical evidence, including recent randomized trials, has demonstrated that intradiscal stem cell therapies can improve disc integrity, increase disc height, and provide long-term symptomatic relief in degenerative disc disease.¹⁴ Furthermore, advances in regenerative medicine highlight the potential of orthobiologic therapies to modify disease progression rather than merely alleviating symptoms.⁶ An important clinical implication of this case is the avoidance of major spine surgery, which is often considered in patients with persistent symptoms. The significant improvement achieved with a minimally invasive orthobiologic intervention highlights its potential as an effective alternative or adjunct to conventional therapies. This is particularly relevant for patients seeking to avoid surgical risks or those with comorbidities such as hypertension, as seen in the present case. However, despite the encouraging outcome, this report represents a single case and the findings cannot be generalized. Long-term follow-up and larger controlled studies are required to establish the efficacy, optimal dosing, and safety profile of intra-discal BMAC therapy. Additionally, imaging correlation (e.g., MRI-based disc regeneration assessment) would further strengthen the clinical observations.

CONCLUSION

Intradiscal BMAC therapy Add containg MSCs, Growth factors and anti-inflammatory cytokines demonstrated significant an improvement in the, neurological function and overall clinical outcomes in this patient with lumbar disc degeneration and radiculopathy. By addressing the underlying pathology, this regenerative approach offers a promising alternative to conventional therapies and may delay or prevent the need for surgery. However, large-scale studies are essential to translate these findings and to optimize treatment strategies.

Funding: Regen Ortho Sport Movva Health Care Hospital

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee (EC/NEW/INST/2024/TE/0518)

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