1. M.D.(Anaesthesiology) Interventional Pain Physician Director of SPINETICS,A Spine endoscopy & Advanced Interventional Pain Management and Rehab Centre, Surat & Anand www.spinetics.in

2. The loss of youth is melancholy enough: but to entre into old-age through the gate of infirmity, most disheartening.. -HorraceWalpole, 1765 [Backache Macnab (IV edition, pg 263)] It is easy to get a thousand prescriptions but hard to get a single remedy -Anonymous [Backache Macnab (IV edition, pg 163)] www.spinetics.in 3. Spinal Canal Stenosis over view Stenosis is defined as a narrowing or constriction of a passage or canal By a combination of bone and soft tissues, which causes mechanical compression of spinal nerve roots, at central, lateral recess or neuro- foraminal level The additional connotations of irreversible and progressive narrowing of the canal are implied Such irreversible narrowing is in contrast to waxing and waning symptoms of encroachment occurring with a herniation of nucleous pulposus (HNP). The intervertebral discs can develop circumferential or radial annular tears, internal disruption, loss of disc height, and protrusion The zygapophyseal joints can undergo synovitis, synovial cyst formation, cartilage destruction, osteophyte formation, capsular laxity, ligamentum hypertrophy or buckling, and joint instability or subluxation. As a result of injuries, www.spinetics.in 4. IPM..is a "discipline of medicine devoted to the diagnosis and treatment of pain related disorders. ..is minimally invasive, non-surgical and target specific procedure. ..also strives to help patients return to their everyday activities quickly and without heavy reliance on medications ..Newer modality .. is Non-surgical & Day care option for back pain .. is Safe for those patients in whom anesthesia and surgical risk is higher (IHD and cardiomyopathy, COPD and CRF, Old age and obesity.) www.spinetics.in 5. www.spinetics.in 6. www.spinetics.in 7. Treatment ladder step- 1 # rest #physio #care #medicine step-2 injections- diagnostic and therapeutic blocks step-3 PAIN MANAGEMENT BY RADIOFREQUENCY ABLATION/ LASER/OZONE step -4 surgery - endoscopic or open step- 5 spinal cord stimulator/ intrathecal pump/ epidural adhesinolysis, endoscopic procedure www.spinetics.in 8. Ozone property Ozone(O3) is three atomic oxygen radical with molecular weight of 48 Heavier than air Having peculier smell Previously used for industrial fumigatio in early 1900 Due to not much evidences its use has been stopped In early years 2000 it again in lime light due to its antiimflammatory, antiinfective and proliferative property Medically non-harmful agent with such a diversity in nature that it can be used in various field in medicine www.spinetics.in 9. Ozone property We will consider its use in spinal pain management Especially in disc herniation with nerve root compression As every procedure has its own limitation we will consider its use in where it is indicated Mild disc herniation with nerve root compression Minimal protrusion etc It works only on nucleous pulposus Or where there is hydration, even imflammation It lyses the nucleous via breaking the water-bond of proteoglycans Thus reduces intradiscal pressure and nerve root compession www.spinetics.in 10. Its image guided procedure Indication matters Wrongly selected case will give you failure Consider red flags Give adequete lysis time in single sitting Even you can use it in foraminal level wisely Where there is a nucleous part it will work Where there is an imlammation it wil work Thorough your clinical radioimaging knowledge Then definitely you will find indications Not merely reading MRI reports Ozone nucleolysis www.spinetics.in 11. EVIDENCE ozone discectomy American Journal of Neuroradiology (May 2003) Oxygen-Ozone for Lumbar Disc Herniation Journal of Neuroradiology June 2004 INTRADISCAL AND INTRAFORAMINAL (O2-O3) INJECTION Radiology. 2007 Mar; oxygen-ozone versus steroid for Sciatica treatment Spine , 2009 Jun Intramuscular oxygen-ozone in acute back pain (a multicenter, randomized, double-blind, clinical trial) www.spinetics.in 12. Mixter and Barr in their hallmark studies in 1934 first drew the widespread attention in herniated disc or nucleus pulposus as one of the important cause of low back pain and leg pain. (1) Apart from conservative therapy all other forms of treatment aim at decompressing the nerve roots. These can be done by taking the disc out by surgery or by decompressing the foramen and disc by different interventions. www.spinetics.in 13. The various treatment options have confused clinicians due to significant failure rate associated with different kinds of surgeries as well as with different interventions. www.spinetics.in 14. 2)Reasons for this failure are: 1)dural fibrosis, 2)arachnoidal adhesions, 3)muscle & fascial fibrosis 4) mechanical instability resulting from the partial removal of bony and ligamentous structures required for surgical exposure and decompression leading to facet & sacro-iliac joint dysfunctions, 5)recurrent disc herniation. www.spinetics.in 15. Evidence o2o3mixer March 11, 2009 (San Diego, California) o2o3mixer injections into herniated discs are equal in efficacy to surgical discectomy in the areas of pain relief and function outcome, but the complication rate is considerably lower and the recovery time is significantly shorter, according to a new meta-analysis presented at the Society of Interventional Radiology 34th Annual Scientific Meeting. www.spinetics.in 16. The procedure is a minimally invasive treatment that is expected to become a standard option for patients within the next couple of years, according to researchers. Currently, open discectomy and microdiscectomy are the standard in surgical treatments; they both involve removal of disc material through an incision. www.spinetics.in 17. "Undergoing invasive surgical discectomy puts you on a path where you may be left with too little disc, but this procedure will lower the number of patients who require surgery because the oxygen/ozone will result in the patient's body being able to shrink and heal their disc, investigator and presenter Kieran J. Murphy, MD, interventional neuroradiologist and vice chair and chief of medical imaging at the University ofToronto, in Ontario, said during a news conference. www.spinetics.in 18. Dr. Murphy said he learned the process in Naples, Italy, working with Mario Muto, MD, and colleagues at Cardarelli Hospital, where he personally did a few of the herniated disc treatments. He said the oxygen/ozone therapy is de rigueur in Italy. From June 2000 to December 2006, the Muto group performed the oxygen/ozone procedure on 2900 patients with lumbar disc herniation,with 84.5% success ratio. www.spinetics.in 19. Dr. Murphy told Medscape Radiology that the oxygen/ozone mixture injected into the disc works through a redox (or reductionoxidation) reaction.This is a chemical reaction in which atoms have their oxidation state changed. "It is the biochemical properties of the oxygen and ozone that interact with proteoglycan's core protein that is broken into smaller portions, shrinking disc volume, which in turn relieves the pain," www.spinetics.in 20. Brian Stainken, MD, interventional radiologist, RogerWilliams Medical Center, in Providence, Rhode Island, and moderator of the session said "Dr. Murphy may have one of these solutions here." Dr. Stainken told Medscape Radiology that he thought the ozone procedure could be an option for those who suffer from back pain . "Scientifically, it makes sense and now what they need to do is to validate this technique www.spinetics.in 21. Disc disease www.spinetics.in 22. The intervertebral disc www.spinetics.in 23. Disc herniation/hnp/pid Outbulging of N.P through the defect in the annulus Presents as follows : Bulge Protrusion Extrusion Sequestration www.spinetics.in 24. Annular tear Annular tears are of 3 types Concentric delamination of longitudinal annular fibers Radial involves all layers of annulus from center to disc surface Transverse involves the insertion of Sharpeys fiber into ring apophysis www.spinetics.in 25. Bulge Loss of concave posterior margin indentation of the subarachnoid space / cord / nerve roots www.spinetics.in 26. Protrusion Focal outbulging of the nucleus pulposus, outside the margin of the annulus. www.spinetics.in 27. Extrusion Focal outbulging of the nucleus pulposus, through the annulus defect BEYOND DISC LEVEL. www.spinetics.in 28. Sequestration Separation of the disc material from the parent disc with or without superior or inferior migration www.spinetics.in 29. Endplate changes Types I (oedema) hypointenseT1 & hyperintenseT2W II (fatty) hyperintense onT1 & iso to hyper onT2 III (sclerosis) both T1 &T2 darkening www.spinetics.in 30. SCHMORLS NODE focal herniation of nucleus pulposus (transvertebral disc herniation) through the endplate into the vertebral body www.spinetics.in 31. Percutaneous Intradiscal procedures for Disc herniation Ozone nucleolysis= ozone discectomy IDET (Intradiscal electrothermal therapy Intradiscal RF thermocoagulation Nucleoplasty- few small studies Stryker disc decompression Hydrocesion Disc FX www.spinetics.in 32. www.spinetics.in 33. www.spinetics.in 34. www.spinetics.in 35. AP and lateral fluoroscopic images demonstrati ng needle position within the central third of the L4L5 disc prior to contrast injection. www.spinetics.in 36. AP view during initial contrast injection into the disc.At this point, as the earliest amount of injected contrast is visualized, the opening pressure is recorded. www.spinetics.in 37. Unusual case A male 42 years had acute excruciating leg and back pain He was a hard worker laborer Financial issues Govt hospital resistance Subjected to pain management after lots of consents Within 24 hours, Injected transforaminal ozone after confirmation with non ionic contrast Waited for few minutes till any untowards events to occur With comfortable vital parameters, planning to shift him in recovery area, rather he immidiately walk out pain free Even long term followup kept to see any reoccurance www.spinetics.in 38. Unusual case Neurological behaviour differs in same presenting spine conditions Even though we repeated MRI in one month span as there is no reccurance what it suggest There is resolving annular tear with sequestration Many of our patients we routinely found such herniations which might be too painful to the patients In opposite this patient was not having any symptoms regarding reccurance of pain This the follow-up of more than 2and half years www.spinetics.in 39. www.spinetics.in 40. www.spinetics.in 41. www.spinetics.in 42. www.spinetics.in 43. www.spinetics.in 44. www.spinetics.in 45. www.spinetics.in 46. www.spinetics.in 47. www.spinetics.in 48. www.spinetics.in 49. Ozone vs idet Though Overall indication remain near about, when there is contained disc herniation with or without minimal protrusion OZONE prooves better Cost effectiveness three- four time less than idet 3 years of follow-up with ozone nucleolysis 85% are better and non recurrent with proper spine rehab program www.spinetics.in 50. www.spinetics.in 51. www.spinetics.in 52. www.spinetics.in 53. Choice is yours But stick to the subject and indication Unless you reach the target you can have the successful result, though procedurial satisfaction you have If your patient doesnt relived find out the other cause www.spinetics.in 54. M.D.(Anaesthesiology) Interventional Pain Physician Director of SPINETICS,A Spine endoscopy & Advanced Interventional Pain Management and Rehab Centre, Surat & Anand kiranjayswal@gmail.com 09925242142 www.spinetics.in