Oxygen-ozone therapy for herniated lumbar disc in patients with subacute partial motor weakness due to nerve root compression

Ozone Disc Nucleolysis for Cervical Intervertebral Disc Herniation: A Systematic Review and Meta-Analysis

Cervical intervertebral disc herniation is a common condition and most often presents as neck or upper limb pain causing varying levels of disability and dysfunction. Percutaneous injection of ozone into the intradiscal space is a novel and minimally invasive technique for managing this condition and can be an effective alternative to surgical management. A literature search was done using the keywords ozone disc nucleolysis of cervical intervertebral lesions, and five studies were selected based on the inclusion and exclusion criteria. Meta-analysis was performed to determine safety, effectiveness, and symptomatic relief (determined based on the visual analog scale (VAS)) with the publication bias being removed. Subjects treated with ozone therapy showed significant reduction (p < 0.0001) in VAS score as compared to baseline VAS score with a standardized mean difference of 2.78 (95% CI = 1.48 to 4.07; Z value = 4.20). Ozone nucleolysis is a minimally invasive, relatively safe, and optimally effective treatment option for reducing the pain related to cervical disc. Intradiscal ozone therapy can be considered an alternative treatment modality, and well-designed, randomized clinical trials are required to confirm the long-term superiority of ozone therapy against other treatment modalities available for cervical disc herniation.

Ozone therapy (O2-O3) alleviates the progression of early intervertebral disc degeneration via the inhibition of oxidative stress and the interception of the PI3K/Akt/NF-κB signaling pathway

Intervertebral disc degeneration (IDD) stands for the most frequent cause of low back pain. Finding a cure for this disease is an important challenge as current conservative treatments and surgical interventions fail to bring a solution to this disease. Ozone therapy (O2-O3) has yielded outstanding outcomes in intervertebral disc pathology. The ozone's efficacy in the treatment of IDD remains unconfirmed. This study aimed to assess the effectiveness of intradiscal ozone injection on IDD induced in a rat. Effects of ozone therapy on the viability of nucleus pulposus cells were evaluated by CCK-8 assays. Macrophage immunoreactivity was detected by immunohistochemical, the expression of collagen type II was evaluated by western blot, and measurement of oxidative stress parameters was realized. Molecular docking studies were carried out in order to predict the interaction formed between O3 and the target enzymes, on the one hand, O3 with PI3K and, on the other hand, O3 with COX-2. IRM, X-ray, hematoxylin-eosin, and bleu alcian staining were realized to assess the therapeutic impacts of ozone in the puncture-induced rat model of IDD. In vivo, O3 ameliorated the IDD in the early stage of this disease. It was also displayed in molecular docking that O3 might bind to PI3K to suppress the PI3K/Akt/NF-κB signaling pathway. This study's results show that the O3 should be administered at the low grade of IDD and at an early stage because it cannot restore the advanced inflammatory alteration of the IVD. Our results corroborated also that O3 inhibits the progression of IDD via the PI3K/Akt/NF-κB signaling pathway, which supports O3 as an effective therapeutic option for treating IDD.

Ozone in the adjunct medical treatment. The round personality of a molecule with hormetic properties

Ozone, an allotrope of oxygen, is enjoying an increasing interest in the setting and management of the medical adjunct treatment, which is called, maybe too simplistically, "ozone therapy". Ozone is not a medicine, so the word therapy does not properly fit this gaseous molecule. Like many natural compounds, for example plant flavonoids, even ozone interacts with aryl hydrocarbon receptors (AhRs) and, at low doses, it works according to the paradoxical mechanism of hormesis, involving mitochondria (mitohormesis). Ozone, in the hormetic range, exerts cell protective functions via the Nrf2-mediated activation of the anti-oxidant system, then leading to anti-inflammatory effects, also via the triggering of low doses of 4-HNE. Moreover, its interaction with plasma and lipids forms reactive oxygen species (ROS) and lipoperoxides (LPOs), generally called ozonides, which are enabled to rule the major molecular actions of ozone in the cell. Ozone behaves as a bioregulator, by activating a wide population of reactive intermediates, which usually target mitochondria and their turnover/biogenesis, often leading to a pleiotropic spectrum of actions and behaving as a tuner of the fundamental mechanisms of survival in the cell. In this sense, ozone can be considered a novelty in the medical sciences and in the clinical approach to pharmacology and medical therapy, due to its ability to target complex regulatory systems and not simple receptors.

Ozone disc nucleolysis in the management of herniated lumbar intervertebral disc: A retrospective analysis

Background

Various minimally invasive surgeries were proposed for the management of herniated lumbar intervertebral disc. However, to choose optimal treatment modality to maximize patient benefit is a clinical challenge for the treatment givers.

Objective

The objective was to study the role of ozone disc nucleolysis in the management of herniated lumbar intervertebral disc by retrospective analysis.

Methodology

We conducted a retrospective analysis of patients of lumbar disc herniation treated by ozone disc nucleolysis during May 2007-May 2021. There were total of 2089 patients with 58% of males and 42% of females. The age ranged from 18 to 88 years. Outcome was measured on the Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) along with modified MacNab method.

Results

The mean baseline VAS score was 7.73, which became 3.07 at 1 month, 1.44 at 3 months, 1.42 at 6 months, and 1.36 at 1 year. Similarly, the mean ODI index was 35.92 at baseline, which improved to 9.17 at 1 month, 6.14 at 3 months, 6.10 at 6 months, and 6.09 at 1 year. VAS score and ODI analysis was found to be statistically significant with P < 0.05. Modified MacNab criterion showed successful treatment outcome in 85.6% with excellent recovery in 1161 (55.58%), good recovery in 423 (20.25%), and fair recovery in 204 (9.77%). Mediocre or no recovery was seen in the remaining 301 patients amounting to a 14.40% failure rate.

Conclusion

This retrospective analysis confirms that ozone disc nucleolysis is an optimally effective and least invasive treatment option for herniated lumbar intervertebral disc with a significant reduction in disability.

Local ozone therapy options for lumbosacral dorsopathy

The characteristic resistance of dorsopathies to conventional therapy explains the attention to new technologies that combine several therapeutic links and, in particular, ozone therapy. The study involved 90 patients under the age of 55 in the exacerbation phase of lumbar and sacrum dorsopathy with the leading vascular component. The patients were divided into three groups, in which basic medical and physical treatment was given. At the same time, ozone therapy was used the first two groups: the 1st group received standard ozone therapy, with a predominant selection of algic zones, the 2nd - according to the rules of biopuncture, affecting the complex of segmental, distant and "vascular" points. In the 3rd control group, the correction was limited to a standard therapeutic complex. The verification of the observed changes was carried out through clinical, psychological and electrophysiological analysis. As a result, both ozone therapy schemes (effective in 69% and 73% of observations respectively) were found to have a reliable advantage over the base complex, where 49% of patients demonstrated improvement. Differences within the ozone therapy groups themselves related to the achievement of a stable effect (in the 2nd group 2.6 days earlier) and the degree of reduction of vaso-reflex reactions (observed in 50% and 75% of observations respectively). Thus, by bringing in additional control methods, it has been proven that the implementation of ozone therapy in compliance with the rules of biopuncture ensures faster and more sustainable effects.

Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial

BACKGROUND CONTEXT

Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy.

PURPOSE

To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations.

STUDY DESIGN / SETTING

Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers.

PATIENT SAMPLE

Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population.

OUTCOME MEASURES

Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals.

METHODS

Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate.

RESULTS

In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group.

CONCLUSIONS

Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.

Ozone disc nucleolysis in cervical intervertebral disc herniation: A nonrandomized prospective analysis in 246 patients

Background:

Inherent complications associated with surgery and limited success of percutaneous minimally invasive procedures make researches wanting for an ideal treatment for cervical disc herniation.

Objective:

We prospectively study the role of ozone disc nucleolysis in cervical intervertebral disc herniation.

Patients and Methods:

From January 2008 to December 2020, we prospectively study 246 consecutive patients of cervical disc herniation treated by a single session of intradiscal injection of ozone–oxygen mixture (ozone disc nucleolysis). There were 55% of females and 45% of males. Age ranged from 28 to 68 years with a mean of 47. The outcome was measured on visual analog scale (VAS) scale and neck disability index (NDI) along with Mcnab method.

Results:

The mean baseline VAS score was 7.87 which became 3.09 at 1 month, 1.42 at 3 months, 1.40 at 6 months, and 1.35 at 1 year. The mean NDI was 36.27 at baseline which improved to 9.24 at 1 month, 6.25 at 3 months, 6.20 at 6 months, and 6.22 at 1 year. This was found to be significant with P < 0.05. Modified McNab criterion showed excellent recovery in 138 (56.10%), good recovery in 50 (20.32%), and fair recovery in 22 (8.94%), resulting in a successful rate of 85.36%. Mediocre recovery was seen in the remaining 36 patients amounting to a 14.64% failure rate.

Conclusion:

This study showed that ozone disc nucleolysis significantly reduces the pain related to cervical disc herniation along with a significant reduction in disability.

O2-O3 chemodiscolysis: How much, how long? Retrospective outcome evaluation of different treatment sessions in partially-responder patients

PURPOSE

To retrospectively evaluate the clinical and instrumental outcome of different treatment sessions of oxygen-ozone (O₂-O₃) chemodiscolysis in patients with lumbar disc herniation.

METHODS

We evaluated 73 patients partially responders to a single session of oxygen-ozone (O₂-O₃) chemodiscolysis and submitted to multiple injections sessions. All patients completed a pre- and post-treatment clinical (VAS and modified McNab score) and instrumental MRI follow-up. Imaging evaluation included assessment of intervertebral disc area (IDA). Pre- and post-treatment differences were compared to evaluate differences in variation between groups. Correlation analysis was used to evaluate the relationship between morphological and clinical parameters.

RESULTS

Based on the type and number of treatments performed, patients were divided into three groups: Group A) patients submitted to an additional periradicular anaesthetic/steroid injection; Group B) patients submitted to an additional session of intradiscal O₂-O₃ injection; Group C) patients submitted to two further sessions of intradiscal O₂-O₃ injection.The results showed an improvement of pain scores in all groups, and a smaller disc area change in group B. Comparing the differences between pre- and post-treatment features among the three different groups of patients, we did not find any statistically significant difference. Correlation analysis did not show any statistically significant correlation between the morphological changes of the intervertebral disc and the clinical output scores.

CONCLUSIONS

In our retrospective observation of partially responder patients, multiple intradiscal ozone injections were not associated with a higher disc shrinkage nor superior clinical outcome compared to a single intradiscal O₂-O₃ application with an additional periradicular injection session.

Effect of local ozone treatment on rats with anterior rectal resection and the possible mechanisms

BACKGROUND

Anterior resection syndrome (ARS) is characterized by the diverse and interchangeable evacuatory symptoms that may occur following distal colorectal resection. We aimed to investigate the effect and potential mechanisms of ozone perfusion on rats with anterior rectal resection (ARR).

MATERIAL AND METHODS

After establishment of rat ARR model, 20, 40 and 80 ug/ml ozone was used to treat rats by enema administration. The pathological examination of intestinal tissue was detected using hematoxylin-eosin staining. The rate of loose stools, minimum threshold volume of abdominal withdrawal reflex (AWR) and Bristol grade were used to evaluate the degree of abnormal defecation function. Subsequently, the levels of oxidative stress- and inflammation-related markers, 5-hydroxytryptamine (5-HT), inducible nitric oxide synthase (iNOS) and nitric oxide (NO) in the serum and intestinal tissue were determined with the corresponding kits. Meanwhile, the expression of nuclear factor kappa B (NF-κB) p65, transient receptor potential vanilloid (TRPV)1, TRPV4, iNOS and 5-HT receptor 3A (5-HTR3A) was determined with RT-qPCR and western blotting.

RESULTS

Ozone administration (20 and 40 ug/ml) significantly alleviated the pathological changes of intestinal tissue-induced by ARR, accompanied by the decreased loose stools rate, Bristol score and increased abdominal withdraw reflex. However, 80 ug/ml of ozone intervention played opposite roles in the aforementioned changes with 20 and 40 ug/ml of ozone. Additionally, remarkably elevated reactive oxygen species (ROS), malonaldehyde (MDA), superoxide dismutase (SOD), 5-HT, iNOS and NO levels were observed in the ozone-treated groups (20 and 40 ug/ml), while high dose of ozone drastically improved ROS, MDA, 5-HT, iNOS and NO levels but reduced the activity of SOD. Consistently, the contents of inflammatory factors were decreased after low and middle doses of ozone administration. However, high dose of ozone aggravated the inflammatory injury. Moreover, 20 and 40 ug/ml ozone upregulated TRPV1 and TRPV4 expression but downregulated 5-HTR3A expression, which was restored after 80 ug/ml of ozone intervention. Remarkably, the levels of NF-κB p65 and iNOS were dose-dependently enhanced following ozone treatment.

CONCLUSIONS

Taken together, low concentration of ozone attenuated intestinal injury induced by ARR via balancing oxidative stress and inflammation, but high concentration of ozone exacerbated the intestinal injury, which might be related to the 5-HT and TRPV signaling.

Expert consensus of Chinese Association for the Study of Pain on the application of ozone therapy in pain medicine

This consensus was compiled by first-line clinical experts in the field of pain medicine and was organized by the Chinese Association for the Study of Pain. To reach this consensus, we consulted a wide range of opinions and conducted in-depth discussions on the mechanism, indications, contraindications, operational specifications and adverse reactions of ozone iatrotechnique in the treatment of pain disorders. We also referred to related previous preclinical and clinical studies published in recent years worldwide. The purpose of this consensus is to standardize the rational application of ozone iatrotechnique in pain treatment, to improve its efficacy and safety and to reduce and prevent adverse reactions and complications in this process.

Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome

Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4–5 mL of an O₂-O₃ mixture (24 μg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman’s rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.

The effectiveness of percutaneous injections of ozonotherapy in low back pain

INTRODUCTION

Lumbar pain is one of the main reasons for medical consultation, causing the disruption of daily routines due to its disabling nature, thus resulting in social and personal damage. Among the complementary treatments, ozonotherapy offers analgesia to most patients, with reports of complications. However, great questions about its clinical effectiveness have not been answered yet, and there have been reports of serious complications.

OBJECTIVE

To describe the use of ozonotherapy in the treatment of lumbar pain, focusing on its favorable and unfavorable effects, and its analog profile.

METHODS

A cross-sectional bibliographic research was performed with scientific articles obtained from the Pubmed, LILACS and Scopus database, using the following descriptors: "Ozone", "Therapy", "Lumbar pain", "complication", "Disk herniation", "Guideline", "Protocol", "Standards", "Criteria".

RESULTS

The researched literature corroborates that, in clinical practice, there is safety in the use of oxygen-ozone therapy through percutaneous injections for the treatment of lumbar pain, especially when compared to surgeries and use of medicines, provided that strict criteria are followed.

CONCLUSION

The procedure is effective and has a favorable analgesic profile. However, it is necessary to produce a medical guideline that will help in its strict and systematic control.

Predictive factors of volumetric reduction in lumbar disc herniation treated by O2-O3 chemiodiscolysis

Purpose:

Aim of this study is to assess the effectiveness of O₂-O₃ percutaneous chemiodiscolysis by evaluating volumetric changes in lumbar disc herniation on magnetic resonance imaging, in order to identify possible pre-treatment factors affecting such changes

Methods:

Between January 2014 and December 2017, a total of 87 patients with low back pain and 103 lumbar disc herniations with MRI confirmation were considered for O₂-O₃ chemiodiscolysis. The volume of each herniated disc was determined before and after the treatment.

Results:

Multiple linear regression analysis showed a strong correlation between post-treatment LDH volume percent change and both pre-treatment LDH volume and pre-treatment EQ-VAS (p<0.05), while age showed only a weak positive correlation with post-treatment LDH volume percent change (p<0.1). No association was found for other factors, such as sex and herniation disc level.

Conclusions:

In conclusion, age, baseline LDH volume and self-assessed disease severity score could represent three easy accessible outcome predictive parameters to consider when intradiscal O₂-O₃ chemiodiscolysis is envisaged. Better results after intradiscal O₂-O₃ chemiodiscolysis were obtained in older patients with higher pre-treatment LDH volume and low-moderate pre-treatment EQ-VAS. (www.actabiomedica.it)

The Effect of Paravertebral Ozone Injection in the Treatment of Low Back Pain

AIM

Paravertebral ozone injection is a new treatment method described in the literature for low back pain. The aim of this study was to compare the pre- and post-treatment pain scores of patients undergoing paravertebral ozone/oxygen (O₃ /O₂ ) injections for low back pain.

METHODS

From September 2018 to December 2018, 122 patients who underwent paravertebral ozone injections due to low back pain were examined retrospectively; 62 patients who met the study criteria were included. The patients were injected with 15 µg/mL (50 mL) O₃ /O₂ gas in the paravertebral space. The subjects were treated every 7 days for 6 total session. The VAS and Oswestry Disability Index (ODI) scores were assessed before treatment and after treatment (first and third months). The patients' body mass indexes (BMIs) were measured before the injections.

RESULTS

There were 12 male patients and 50 female patients. The mean age was 51.9 (range 25 to 71) years. The mean duration of pain was 9.1 (3 to 24) months. Significant improvements were observed in the statistical comparison of VAS and ODI scores between the pre-injection and first month controls (P < 0.000). There was no significant difference in the statistical comparison of VAS and ODI scores between the first and third months (P < 0.05). There was no statistically significant difference between BMI and pain scores (P > 0.213).

CONCLUSION

Paravertebral O₃ /O₂ gas is a reliable and effective treatment for the treatment of lumbar disc herniation, radicular pain, and mechanical back pain due to low back pain.

Current concepts for lumbar disc herniation

PURPOSE

To present the pathophysiology, biology, clinical presentation, diagnosis, and current treatment options for lumbar disc herniation.

METHODS

A thorough literature search was undertaken in PubMed and Google Scholar to summarize the current knowledge and future perspectives on lumbar disc herniation.

RESULTS

Several changes in the biology of the intervertebral disc are thought to contribute to disc herniation; nevertheless, the exact inciting event leading to disc herniation is yet to be discovered. Non-operative treatments have stood the test of time as the first-line treatment for most patients with lumbar disc herniation; however, operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function.

CONCLUSIONS

The exact event leading to disc herniation remains unclear. Non-operative treatments should be the first-line treatment for most patients with lumbar disc herniation. Operative treatment remains the current gold standard, with minimally invasive endoscopic microdiscectomy techniques showing best results with respect to postoperative pain and function. Regenerative medicine is promising.

Comparison of percutaneous intradiscal ozone injection with laser disc decompression in discogenic low back pain

Background

Intervertebral disc herniation with the pressure on the surrounding neural structures is one of the most important causes of chronic low back pain, which sometimes leads to open surgery. Reducing the pressure inside the disc with intradiscal intervention such as laser irradiation or ozone injection is a minimally invasive method and an alternative to surgery with satisfactory results. These two methods were compared with each other in this research.

Patients and methods

In this clinical trial, 40 patients with back pain radiating to lower limb due to lumbar intervertebral disc herniation were selected. These patients were randomly divided into two equal groups for percutaneous intradiscal intervention. The Laser Disc Decompression Group (LDG) (n=20) was exposed to 1500 J of laser irradiation into the disc center. In the Ozone Injection Group (OZG) patients (n=20), 6 mL of ozone 30 µg/mL was injected into the center of the disc. Considering the level of neural root involvement, both groups received 20 mg of triamcinolone injection via transforaminal epidural. Patients were followed up for 12 months regarding score on visual analogue scale and life performance improvement based on Oswestry Disability Index (ODI) and satisfaction level.

Results

According to the results, no difference was found between the two groups for ODI variable before intervention, whereas OZG showed better ODI scores in the measured time intervals. In LDG, only a significant difference in terms of ODI score was found between the times of before surgery and the first month.

Conclusion

Intradiscal ozone injection could be an effective and cost-effective method for treatment of patients with discogenic back pain.

Intradiscal O2O3: Rationale, Injection Technique, Short- and Long-term Outcomes for the Treatment of Low Back Pain Due to Disc Herniation

The management of low back pain should always start with a conservative approach; however, when it fails, intervention is required and at that moment the most appropriate choice remains unclear. Before invasive surgery, minimally invasive techniques can be adopted. In European trials and in a trans-Canadian clinical trial 03 ozone has been used successfully. In total over 50,000 patients have been treated safely. Ozone is a gas normally present in the atmosphere with potent oxidizing power; it has been used for percutaneous intradiscal injection combined with oxygen (O₂O₃) at very low concentrations for 15 years in Europe. The main indication is back pain with or without radicular pain but without motor deficits, which is refractory to 4-6 weeks of conservative therapies. Its mechanism of action on the disc is mechanical (volume reduction by subtle dehydration of the nucleus pulposis) and antinflammatory. The intradiscal ozone injection is performed with a thin needle (18-22 gauge) image guided by computed tomography or angiofluoroscopy and is usually complimented by periganglionic injection of corticosteroids and anesthetics. This combination gives immediate pain relief and allows time for the ozone to act. It is a cost-effective procedure that presents a very low complication rate (0.1%). The radicular pain is resolved before the back pain does, as is seen with microdiscectomy. Peer-reviewed publications of large randomized trials, case series, and meta analysis from large samples of patients have demonstrated the procedure to be safe and effective in the short and the long terms, with benefits recognized up to 10 years after treatment. We aim to review the principles of action of O₂O₃ and report the injection techniques, complications, and short- and long-term outcomes.

Clinical and Radiological Improvement Following Ozone Disc Nucleolysis: A Case Report

The results of traditional open surgery for herniated intervertebral disc are often limited by complications and failed back surgery syndrome (FBSS). Over the past few decades, a considerable amount of research has been done in the field of minimally invasive procedures as a treatment option for herniated intervertebral disc disease. Ozone disc nucleolysis is one such procedure which has results equal to or better than traditional surgery with virtually no complications. A 27-year-old post-partum female presented to the clinic with acute onset of severe lower back pain radiating to the left lower limb for one month. The pain started suddenly during labor and gradually increased over a period of few weeks post-partum. A magnetic resonance imaging (MRI) scan showed a large herniated disc bulge at the L4-L5 level causing severe radiculopathy. There was no bladder or bowel involvement. The patient was managed conservatively for three weeks. However, she failed to show any signs of improvement. She opted to undergo ozone disc nucleolysis under local anaesthesia. She showed significant improvement immediately after the procedure and there was further improvement in symptoms over a period of six weeks. Post-procedure follow-up at three months and six months showed significant improvement on the visual analogue scale (VAS), which was used to measure pain intensity and pain affect, along with the Oswestry Disability Index (ODI), which was used to measure the degree of disability due to the lower back pain.

Her VAS score improved from nine to two at three months and finally to one at six months, whereas the ODI score improved significantly from 46 to 10 at three months and eventually to four at six months. Ozone disc nucleolysis is an efficacious, safe, durable, and cost-effective treatment option for mild to moderate cases of herniated intervertebral disc which are resistant to conservative management. However, randomized control trials are required to build a long-term database regarding the efficacy and durability of ozone disc nucleolysis as compared to other minimally invasive procedures and surgery. We strongly believe that the availability of long-term data on ozone disc nucleolysis would make it a more acceptable form of treatment for disc herniation as compared to traditional surgery.

Rational approach, technique and selection criteria treating lumbar disk herniations by oxygen-ozone therapy

Radicular lumbar back pain is an important public health problem not yet benefiting from a unequivocal treatment approach. Medical and physical therapies represent the first solution; however, when these fail, the second therapeutic step is still controversial and mini-invasive treatments may play an important role. In these cases oxygen-ozone therapy has been proved to be a very safe and effective option that is widely used with different modalities. This paper, by reviewing oxygen-ozone therapy literature data, aims to describe the rationale of oxygen-ozone therapy for the treatment of lumbar disk herniations, propose an effective procedural technique and clarify patient selection criteria; furthermore, complications and follow-up management are also considered.

Herniated disks unchanged over time: Size reduced after oxygen-ozone therapy

The spontaneous regression of disk herniation secondary to dehydration is a much-debated topic in medicine. Some physicians wonder whether surgical removal of the extruded nucleus pulposus is really necessary when the spontaneous disappearance of a herniated lumbar disk is a well-known phenomenon. Unfortunately, without spontaneous regression, chronic pain leads to progressive disability for which surgery seems to be the only solution. In recent years, several studies have demonstrated the utility of oxygen-ozone therapy in the treatment of disk herniation, resulting in disk shrinkage. This retrospective study evaluates the outcomes of a series of patients with a history of herniated disks neuroradiologically unchanged in size for over two years, treated with oxygen-ozone therapy at our center over the last 15 years. We treated 96 patients, 84 (87.5%) presenting low back pain complicated or not by chronic sciatica. No drug therapy had yielded significant benefits. A number of specialists had been consulted in two or more years resulting in several neuroradiological scans prior to the decision to undertake oxygen-ozone therapy. Our study documents how ozone therapy for slipped disks "unchanged over time" solved the problem, with disk disruption or a significant reduction in the size of the prolapsed disk material extruded into the spinal canal.