vice-chairperson dept. of anaesthesiology, pain...

OzoneDiscectomy

Prof.PradeepJainVice-Chairperson

Dept.ofAnaesthesiology,Pain&PerioperativeMedicine

SirGangaRamHospital,NewDelhi

SGRH

Ozone

•  Atri-atomicoxygenmolecule•  ChemicallyOzoneisOxygenplusanextraradicalofOxygen

•  Symbol–O3•  Greek‘ozein’meaning‘tosmell’•  Colourless,pungent,unstablegas•  FirstreportoftherapeuticuseofozonewasseeninbloodpuriFicationin1870byCLender

•  TheFirstozonegeneratorwasdevelopedbyWernerVonSiemensinGermanyin1987

OzoneMedicalGenerator

HowisOzoneProduced

•  O3isproducedbythemedicalgeneratorfrompureO2passingthroughahighvoltagetubesgradient(5-13Mv)

usingcoldsparktechnique

•  3O2+68,400CAL----------203

•  AdministeredasaO2-O3gasmixtureatnon-toxic

concentrationvaryingfrom1-40microgm/mlofozone

•  Alwaysfreshlypreparedonsite(half-life=20min)

Indications

•  Discogenicpain

•  Indiscprolapseordiscbulgewithorwithoutrootirritation

•  Osteoarthritis

•  Triggerpointinjection

HistoryOfOzoneTherapyForDiscDiseases

•  CesareVergausedmedicalozoneforherniateddiscin1983

•  MutosuggestedCT-guidedintradiscalinjectionfordischerniationin1998

•  LeonardipopularizedFluoroscopyguidedozoneinjectionintotheintervertebraldisc

JNeuroradiol2004

MechanismofAction

Mechanical

•  Thesingletoxygenorfreeoxygenradicalattacheswith

theProteoglycanbridgesintheNucleusPulposus,

whicharebrokendownandcannolongerholdwater

•  Thedischenceshrinksalongwithdecompressionof

nerverootsandloweringofintradiscalpressure

MechanismofAction•  Improvedmicrocirculationandoxygenation

–  Resolutionofvenousstasis–  Increasein2-3DPGlevelinthebloodcells

•  Bactericidal,FungicidalandVirucidal•  Analgesicandanti-inJlammatoryaction

–  InhibitingsynthesisofproinFlammatoryprostaglandins,bradykininorsynthesisofalgogeniccompounds

–  IncreasedreleaseofantagonistsabletoneutralizeproinFlammatorycytokineslikeinterleukin(IL)-1,IL-2,IL-8,IL-12,interferonandtumornecrosisfactors

MechanismofAction

•  Immunomodulatingaction-promoteshealingLocalproductionofAntioxidantEnzymesandreleaseof

immunosuppressorcytokinesliketransforminggrowthfactorand

IL10

•  ThisresultinreductionininFlammationofthenerverootsincreaseinoxygenationtothediseasedtissueand

fasthealing

CausesOfLowBackPain

•  Facetarthropathy

•  Musclestrains

•  Sacroilitis

•  Bulgingorherniateddisc

•  Degenerativediscdisease

•  PIVDcommonestcausewithadeFinedstructural

abnormality

TreatmentModalitiesofLowBackPain

•  Medical/ConservativeManagement

•  InterventionalMethods/MinimalInvasiveModalities

•  Surgical

Techniques

Minimallyinvasivepercutaneoustechniquesinclinicalpracticeare:

•  CaudalandInterlaminarepiduralsteroidinjection•  Transforaminalinjection•  APLD,PLDDandIDET•  Percutaneouscoblationnucleoplasty•  Dekompressorpercutaneousdiscectomy•  ChemodiscolysiswithO2-O3mixturewithperiradicularandperiganglionicinFiltration

Procedure•  Daycare

•  Informedconsent

•  ↓Localanaesthesia

•  Lightsedation

•  Fluoroscopicguidance

•  Discogram

•  Proneposition

•  Fluoroscopy/CTguidance

•  20or22Gneedleisintroducedintothediseaseddiscusingtunnelvision

•  ThepositionofneedletipmaybeconFirmedbycompleteAP&lateralview

•  Radio-opaquedyeisinjectedfordiscogram

•  3-10ccofozoneisinjectedintothedisc

Procedure/Ozonucleolysis

OzoneTherapy

Conc.Ofozoneis29-30microgram/ml

3-4mlofozoneisinjectedatthecentreofthediscwith/withoutintraforaminalinjection

Contraindications

•  RecurrentdiskwithepiduralFibrosis

•  CalciFiedherniateddisk

•  Spinalcanalstenosis

•  SpinalDeformity

•  CaudaEquinaSyndrome

•  NeurologicaldeFicit

•  Coagulopathy,pregnancyandinfection

Complications

•  Bloodclot,nerverootirritationduetoinsertionofneedle

•  Temporaryincreaseofpreviouspainsymptoms

•  Vagalreaction

•  Ifthedoseofozonemixtureexceedsthecapacityof

antioxidantenzymes,itcausescellmembrane

degradation

Advantages•  Leastinvasive

•  Highandlongtermsuccessrates

•  80%successratewithnomorbidity

•  Fewerchancesofrecurrence

•  Daycareprocedure/shorthospitalstay

•  Costeffective

OtherusesinPainManagement

•  Usedastissueproliferantinaconc.of5-10micgr/ml

•  Osteo-arthritisofknee,RheumatoidArthritis

•  Triggerpointinj

•  Fibromyalgia&MyofascialPain

IntraarticularO3therapyforpaincontrolinosteoarthritisoftheknee

•  Currentlytestedforitseffectivenessin

relievingthepaininpatientssuffering

fromosteoarthritisoftheknee

•  Thecurrentstatusofthestudyisphase

2whichissponsoredbyBen-Gurion

UniversityoftheNegevandthestudy

beingconductedbyNCT00832312.

http://clinicaltrials.gov/ct2/show/NCT00832312?

Reporteda78.3%successrateinpatientstreatedwith

ozonetherapyandperiganglionicsteroidinjection

comparedwitha70.3%rateinthosetreatedwithozone

therapyalone

Complicationsoccurredin2of235patients

Studiedthedifferencesinoutcomebetweenintradiscalozone

chemonucleolysisandmicrodiscectomyinpatientswith

noncontainedlumbardischerniations

Documentedthat27patients(90%)inthechemonucleolysis

groupshowedastatisticallysigniFicantimprovementinpainand

function;thesamewastruein14(93.3%)patientsinthe

microdiscectomygroup

Studied621patientstodetermineassociationsamongthe

morphologyofthediscdisease,patient-speciFicdata,andtreatment

outcomes

PatientsweresubjectedtoCT-guidedozonucleolysisincombination

withperiradicularinFiltrationbysteroidsunderLA

Patientsyoungerthan50yearshadsigniFicantlybettervaluesonthe

VASandinODIscores6monthsaftertreatment

OurExperience

•  OzonetherapyforlowbackpaininPainReliefClinicsinceMarch2015

•  Followupexaminationafter1week,6weeks

and12weeksaftertreatment

•  Clinicaloutcomeassessmentafter3months

usingModiFiedMacNabMethod

Analysis

•  Totalnoofpatients88

•  Herniateddiscwithunilateralradiculopathy

•  20-80yearsofeithersex

•  Painofmorethan6weeksduration

•  Failureofconservativetreatment

•  CorrelationofclinicalFindingswithMRI

TwoGroupsOfPatients

O3+TF:(n=48)

Intradiscalozone(5mloffreshlypreparedoxygen-ozone

mixtureataconc.of30mcg/ml.)+transforaminalblockwith

40mg(1ml)oftriamcinolone+2mlof0.5%bupivacaine

TF:(n=40)

Transforaminalblockwith40mg(1ml)oftriamcinolone+

2mlof0.5%bupivacaine

ClinicalOutcomeAfter3Months•  83.3%patientsreceivingO3hadexcellenttogoodresultsas

comparedto57.5%patientsreceivingTFblockalone•  16.7%patientsreceivingO3hadfailurecomparedto42.5%patients

receivingTFalone•  NosigniFicantside-effectorcomplicationobserved

23

9

1714

6

10

2

7

0

5

10

15

20

25

Excellent Good Poor Surgery

Ozone+TF TF

Conclusion

CombinedOzonenucleolysisandtransforaminal

steroidinjectionhasacumulativeeffectthat

enhancestheoveralloutcomeoftreatment

Conclusion

•  Ozonenucleolysisoffersthepromiseofexcellentpainreliefandtheavoidanceforsurgeryinpatientswithprolapsednucleuspulposus

•  IthasthebeneFitsofbeingasafe,cheapprocedurewhichdoesnotrequirehighlyexpensiveequipment