Could Hyperbaric Oxygen Be a Solution in the Treatment of Spinal Infections?

Hyperbaric Oxygen Therapy in Orthopaedics: An Adjunct Therapy with an Emerging Role

Introduction

Hyperbaric oxygen therapy (HBOT) has emerged as an adjunct treatment modality in various orthopedic and rheumatological conditions. Undersea and Hyperbaric Medical Society (UHMS) defined the minimum number of HBOT cycles, dose, and frequency for various diseases. UHMS laid the 14 absolute indications for HBOT. This article deals with the mechanism of actions of HBOT and evidence of various musculoskeletal disorders where HBOT was utilized to accelerate the healing process of the diseases.

Materials and methods

The review literature search was conducted by using PubMed, SCOPUS, and other database of medical journals for identifying, reviewing, and evaluating the published clinical trial data, research study, and review articles for the use of HBOT in musculoskeletal disorders.

Results

Various clinical researchers documented cellular and biochemical advantages of HBOT which possess allodynic effects, anti-inflammatory, and prooxygenatory effects in patients with musculoskeletal conditions. Studies on the usage of HBOT in avascular necrosis and wound healing provide a platform for exploring the plausible uses of HBOT in other musculoskeletal conditions. Literature evidence states the complications associated with HBOT therapy.

Conclusion

The existing HBOT protocols have to be optimized for various musculoskeletal disorders. Large scale blinded RCTs have to be performed for demonstrating the level of evidence in the usage of HBOT in various musculoskeletal clinical scenarios.

Utilization, Utility, and Variability in Usage of Adjunctive Hyperbaric Oxygen Therapy in Spinal Management: A Review of the Literature

The objective of this review was to understand the clinical utilization, utility, and variability in the usage of adjunctive hyperbaric oxygen therapy (HBOT). Surgical site infection is associated with high morbidity and mortality, increased health care expenditure, and decreased quality of life. With the increasing prevalence of adult spinal deformity and spinal fusion surgery, it is imperative to understand the potential benefits of adjunctive treatments. HBOT is a safe and common procedure indicated to treat various medical conditions. We conducted a literature search across 3 databases for English articles published between December 1, 2019 and December 1, 2000. Thirteen studies were included. HBOT may lessen the duration of antimicrobial therapy and mitigate instrument removal and revision surgery. The current usage indications for HBOT are supported by level III evidence for chronic osteomyelitis and level IV evidence for osteoradionecrosis. However, the same level of evidence exists to support the beneficial use of adjunctive HBOT for noncomplicated spinal infections within 2 months after surgery. When cultured, the most common organisms were Staphylococcus aureus and other low-virulence organisms. The most common treatment protocol consists of 90-minute sessions of 100% Fio₂ at 2-3 atmosphere absolute with a mean of 35.3 ± 11.6 sessions for 5.2 ± 1.4 weeks. Adjunctive HBOT should be considered in select high-risk patients. Further improvements in diagnosis and categorization of spinal infections are necessary and will indelibly aid the decision making for the initiation of HBOT.

Hyperbaric oxygen treatment: A complementary treatment modality of Modic changes?

Modic changes (MCs) have attracted great interest in recent years. The complex process of MC development and progression seems to involve interplay between mechanical, infective, inflammatory, and degenerative processes that cannot be clearly differentiated. Based on signal intensity on T1- and T2-weighted MRI scans, MCs can be divided three types: Type 1, Type 2, and Type 3. Predominantly Type 1 MCs are commonly associated with chronic low back pain that is unresponsive to classic treatment options. Infection with low-virulent anaerobic microorganisms, most commonly Propionibacterium acnes, has been implicated in MC development following a disc herniation when a tear enables bacteria to enter the disc. Recent studies in patients with chronic low back pain following a lumbar disc herniation associated with Type 1 MCs have reported promising results following prolonged systemic antibiotic treatment with amoxicillin-clavulanate. Hyperbaric oxygen therapy, as primary or adjuvant treatment in association combination with systemic antibiotics or anti-inflammatory therapy, could offer important advantages in treating patients with suspected low-virulent disc infections due to anaerobic microorganisms associated with Type 1 MCs. We believe that hyperbaric oxygenation could contribute to faster resolution of Type 1 MCs and associated pain through multiple effects-including direct antimicrobial effects through formation of reactive oxygen species (ROS), altering the favorable low oxygen tension milieu such that it becomes unfavorable for bacterial growth and survival, and anti-biofilm effects. Additionally, hyperbaric oxygenation could contribute to faster pain resolution via direct and indirect anti-inflammatory effects. As an adjuvant treatment administered in combination with systemic antibiotics, HBOT could increase the sensitivity of Propionibacterium acnes to antimicrobial drugs under hyperoxic conditions, resulting in faster MC resolution. Overall, the faster infection resolution, diminished bacterial load, and anti-inflammatory effects due to reduced cytokine expression and levels of infectious by-products could lead to faster pain resolution following HBOT, and a significant improvement of quality of life in these patients.