Ozone/Oxygen-injections in cases of disc hernia - Die Ozon/Sauerstoff-Injektion beim Bandscheibenvorfall Thomas Lehnert, T.J. Vogl Department of Diagnostic

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.


NeurologicalExamination

CT / MRExamination

O2/O3-Injection

Precondition to O2/O3-injectionAftercare of O2/O3-injection

CT / MRExamination

NeurologicalExamination


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


- 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)


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


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.“


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.“


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

Documents

Ozone/Oxygen-injections in cases of disc hernia - Die Ozon/Sauerstoff-Injektion beim Bandscheibenvorfall Thomas Lehnert, T.J. Vogl Department of Diagnostic