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Ozone/Oxygen-injections in cases of disc hernia -
Die Ozon/Sauerstoff-Injektionbeim Bandscheibenvorfall
Thomas Lehnert, T.J. Vogl
Department of Diagnostic and Interventional RadiologyJohann Wolfgang Goethe University Clinic Frankfurt/Main, Germany
IndicationsCombined intradiscal and periganglionic injection of medical ozone
Combined intradiscal an periganglionic injection ofmedical ozone is reserved for patients failing to
respond to conservative treatment.
IndicationsCombined intradiscal and periganglionic injection of medical ozone
NeurologicalExamination
CT / MRExamination
O2/O3-Injection
Precondition to O2/O3-injectionAftercare of O2/O3-injection
CT / MRExamination
NeurologicalExamination
IndicationsCombined intradiscal and periganglionic injection of medical ozone
256 x 100
256 x 100
512 x 60
512 x 50
512 x 60
512 x 50
Image
matrix
15
17
109
15
109
49
TE(in ms)
19
15
15
15
18
18
Slices(per slab)
600
550
3600
500
4000
4560
TR(in ms)
4
4
4
4
4
4
S-thickness(in mm)
10090° t1_se_sag_reph_fs
10090° t1_se_sag
100160° t2_tirm_sag
100
64
100
FoV phase(in mm)
Siemens Magnetom Symphony / Siemens Magnetom Sonata
90°
180°
180°
Flip angle
t2_tse_tvs
t1_se_tvs_fs
t2_tse_sag
Sequence
IndicationsCombined intradiscal and periganglionic injection of medical ozone
- major neurologic deficits
- referred allergy to proposed drugs
- facet syndrom
- sacroileitis
- bone lesions (infective, inflammatory, neoplastic)
- previous spine surgery
- lumbar disc herniation on CT/MR images
- monoradicular pain
- herniation site congruous with the neurologic
levelIncl
usio
nO
2/O
3-in
ject
ion
Exc
lusi
onO
2/O
3-in
ject
ion
ProcedureCombined intradiscal and periganglionic injection of medical ozone
Medical oxygen
Clinico Biozomat 11T
(Bad Hersfeld, Germany)
Siemens Somatom Plus 4
(Erlangen, Germany)
ProcedureCombined intradiscal and periganglionic injection of medical ozone
120
Tube voltage(in kV)
200
Tube current(in mAs)
4
TF/R (in mm)
1.5 / 0.7
Thickness/Increment(in mm)
4 x 1 non enhanced
Siemens Somatom Plus 4
CollimationPhase
~ 45 BiopsyComb
DLP(mGy.cm)
~ 300 Helical scan
Intervention planningCombined intradiscal and periganglionic injection of medical ozone
Intervention planningCombined intradiscal and periganglionic injection of medical ozone
ProcedureCombined intradiscal and periganglionic injection of medical ozone
1 mL corticosteroid(Celestan® depot)
2 mL anesthetic(Carbostesin® 0.25%)
7 mL O2/O3 (ratio 97:3)
3 mL O2/O3 (ratio 97:3)
ProcedureResults
Biochemical mechanismCombined intradiscal and periganglionic injection of medical ozone
The herniation can impinge on the venous and arterial flow and cause phlebostasis and arteriostenosis. These conditions can lead to a serious hypoxemia and pain. By applying the oxygen to herniation area, both a direct and indirect hyperoxygenation occurs, which reduces the pain.
Reduction of anoxia
Ozone has an effect on the disc inflammation by altering the breakdown of arachidonic acid to inflammatory prostaglandins. Therefore, by reducing the inflammatory components there is a corresponding reduction of pain.
Reduction of
inflammatory components
Ozone has a direct effect on the proteoglycans in the nucleus pulposus. The water binding capacity of proteoglycans is the main force that holds water to the nucleus pulposus. Destruction of the proteoglycans reduces the hold water and therefore diminishing the size of herniation.
Reduction of hold water
in nucleus pulposus
Purpose of studyCombined intradiscal and periganglionic injection of medical ozone
To evaluate the therapeutic benefit andmorphologic changes in herniated lumbar diskafter CT-guided intradiscal and periganglionic
ozone-oxygen injection combined with aperiganglionic administration of steroids and anesthetic.
Patients groupCombined intradiscal and periganglionic injection of medical ozone
n=39 (42.4%)
n=18 (19.5%)n=49 (53.3%)83
n=10 (10.9%)n=43 (46.7%)24
n=2 (2.2%)n=9254.1
n=23 (25.0%)
L5/S1
L4/L5
L3/L4
L2/L3
L1/L2
Localisationherniated disk
male
female
overall
Gender
max.
min.
∅
Agein years
Time scheduleCombined intradiscal and periganglionic injection of medical ozone
+
+
+
+
+
+
EvaluationChanges in radiculopathy
+
+
-
-
-
+
EvaluationChanges in disk volume
-
-
-
-
+
-
CT
+
+
-
-
-
+
MRI
7 days
6 months
3 months
1 month
injection
before
ResultsCombined intradiscal and periganglionic injection of medical ozone
- 0.8
- 1-3
- 0.6
- 1.5
- 1.9
- 1.4
- 0.9
- 1.5
- 1.2
- 4.2
- 0.4
- 1.1
- 0.7
- 1.1
- 1.0
- 0.9
- 0.6
- 0.1
- 0.9
- 2.5
1.41.82.2 Traveling
1.52.43.4 Standing
1.41.72.3 Motility
1.31.62.5 Self supply
1.6
1.2
1.2
1.5
2.1
2.4
Evaluation6 months after therapy
1.8
1.1
1.6
2.0
3.5
4.1
Evaluation1 week after therapy
2.9
1.8
2.7
2.9
3.6
6.6
Evaluationbefore therapy
Sitting
Social life
Sex life
Sleeping
Physical constitution
Pain intensity
Results6 months after O2/O3-injection
DescriptionOutcome
n=2
(2.2%)
n=17
(18.5%)
n=27
(29.3%)
n=46
(50.0%)
Patientsmax.min.mean
+ 1.7%
- 0.8%
- 3.6%
- 6.0%
+ 3.0%
- 6.4%
- 16.2%
- 19.3%
Disk volume reduction
+ 2.4 %
- 4.1 %
- 8.3 %
- 14.0 %
- No improvement
- Worsening of clinical situation
- Insufficient improvement of
symptoms
- Periodic administration of drugs
- Limitation of physical activities
- Occasional episodes of low back
pain or sciatica
- No limitations of occupational
activities
- Disappearance of symptoms
- Complete recovery in working
- Complete recovery in sports
poor
surgery
good
excellent
Modified MacNab method
Results / ComplicationsCombined intradiscal and periganglionic injection of medical ozone
-
-
n=18
(19.6%)
n=58
(63.0%)
1 month
-
-
-
-
injection6 months3 months7 days
-
-
n=21
(22.9%)
n=49
(53.3%)
-
-
n=19
(20.7%)
n=51
(55.4%)
after O2/O3-injection
-
1
n=13
(14.1%)
-
-
-
n=88
(95.7%)
n=82
(89.1%)
before
Severe
complications
Allergic
reactions
Analgetics
Physical
therapy
Treatment success6 months after O2/O3-injection
6 months after O2/O3-injectionbefore O2/O3-injection
Treatment success6 months after O2/O3-injection
6 months after O2/O3-injectionbefore O2/O3-injection
Literature reviewCombined intradiscal and periganglionic injection of medical ozone
n=179.3%n=922006 Lehnert T et al.
n=0
n=0
n=0
n=0
complicationsafter therapy
74.0%
90.0%
80.0%
78.3%
success6 months after therapy
n=82
n=30
n=1750
n=300
patients
2007
2005
2004
2003
year
Buric J et al.
Gallucci M et al.
Muto M et al.
Andreula CF et al.
ComplicationCombined intradiscal and periganglionic injection of medical ozone
Lo Giudice G, Valdi F, Gismondi M, Prosdocimo G, de Belvis V
Acute bilateral vitreo-retinal hemorrhages following oxygen-ozone therapy for lumbar disk
herniation. Am J Ophthalmol. 2004 Jul;138(1):175-7.
„…the real mechanism of action producing intraocular hemorrhages after intradiscal infiltration of O2O3 is unclear.“
„…an abrupt, transient spike in cerebrospinal fluid pressure after disk infiltration was responsible for the retinal hemorrhages. Although an accidental injection delivered directly into epidural space cannot be excluded, we also suggest that an increased intradiscal pressure with an overload and microrupture of the disk after the injection could have caused a quick spread of the mixture into epidural space proportional to the speed and volume of the infiltration. An increase in cerebrospinal fluid pressure after the injection was thus transmitted directly through the optic nerve sheaths to the retinal venous circulation, thus causing distension and rupture of peripapillary and retinal capillaries.“
ComplicationCombined intradiscal and periganglionic injection of medical ozone
Ginanneschi F, Cervelli C, Milani P, Rossi A
Ventral and dorsal root injury after oxygen-ozone therapy for lumbar disk herniation.
Surg Neurol. 2006 Dec;66(6):619-20.
„The real mechanism underlining this double injury is not clear.“
„The hypothesis of a direct toxic effect of ozone is unremarkable.“
„Concerning the pathophysiology of the lesion, it could be hypothesized that an abrupt and transient increase of the CFP causes focal damage by means of mechanical mechanism, in the form of direct root trauma. The possibility of direct damage by needle introduction may be clinically excluded because the subject did not complain of electric shock sensation after needle introduction. In conclusion, we suggest that root injury after O2O3 therapy for lumbar disk herniation should be considered an uncommon but significant complication.“
ComplicationCombined intradiscal and periganglionic injection of medical ozone
Gazzeri R, Galarza M, Neroni M, Esposito S, Alfieri A
Fulminating septicemia secondary to oxygen-ozone therapy for lumbar disc herniation:
case report. Spine. 2007 Feb;32(3):E121-3.
„Autopsy confirmed an acute bilateral lobar pneumonia and paraspinal muscle abscess, with positive results for E. coli. Spinal canal content was relatively intact.“
„…most likely pathophysiological mechanism in our case was direct inoculation of the bacteria during the procedure. Wound or systemic infections in ozone therapy are mostly related to a lack of sterility during the administration of therapy.“
„…secondary pneumonia might have originated from the hematological spread of bacteria from the paraspinal abscess.“
„…prophylactic antibiotic therapy should always be given to the patient.“
ConclusionCombined intradiscal and periganglionic injection of medical ozone
The combined intradiscal and periganglionic injectionof medical ozone and periganglionic administrationof steroids and anesthetic offers a treatment optionfor lumbar disk herniation that has failed to respond
to conservative management, before recourseto surgery or when surgery is not possible.
Its ease of execution permits the successfuloutpatient treatment of lumbar sciatic pain.
ConclusionConservative management
13 months after conservative management
before treatment