Ozone Therapy in slipped disc cases (Ozonucleolysis)
Disc prolapse is one of the important cause of low back pain radiating to limbs. 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. The various treatment options have confused clinicians due to significant failure rate associated with different kinds of surgeries as well as with different interventions.
Outcome studies of lumber disc surgeries document a success rate between 49% to 95% and re-operation after lumber disc surgeries ranging from 4% to 15%.
Reasons for this failure are:
- dural fibrosis
- arachnoidal adhesions
- muscle & fascial fibrosis
- mechanical instability resulting from the partial removal of bony and ligamentous structures required for surgical exposure and decompression
- presence of neuropathy.
There has been surge of interest in search of safer alternative method of decompressing the nerve roots maintaining the structural stability.
Alternatives to lumbar disc surgeries
Epidural steroid injection, transforaminal epidural decompressions has a high success rate (up to 85%) but chances of recurrences are there specially if these interventions are done at later stage. Chemonucleolysis using chymopapain has also high success rate (80%) with low recurrences but not popular owing to the chances of anaphylaxis following intradiscal chymopapain injection. Injection of ozone for discogenic radiculopathy (low back pain with radiation to legs) has developed as an alternative to chemonucleolysis and disc surgery owing to its high success rate (85% to 90%), less invasiveness, fewer chances of recurrences and remarkably no side effects.
Muto suggested intradiscal injection of ozone for disc hernia in 1998 under CT guidance. Leonardi popularized fluoroscopy guided ozone injection into the intervertebral disc. After that, successful outcome has been reported from various European centers. It is very important to note from those reports that complications are remarkably few. Not a single serious life-threatening complication was found even after 30,000 cases of Ozonucleolysis, which stresses the safety of these procedures.
How ozone acts?
The action of ozone is due to the active oxygen atom liberated from breaking down of ozone molecule. When ozone is injected into the disc the active oxygen atom called the singlet oxygen or the free radicle attaches with the proteo-glycan bridges in the jelly-like material or nuceus pulposus. They are broken down and they no longer capable of holding water. As a result disc shrinks and mummified and there is decompression of nerve roots. It is almost equivalent to surgical discectomy and so the procedure is called ozone discectomy or ozonucleolysis. Besides, it has an anti-inflammatory action due to inhibitions of formation of inflammation producing substances and tissue oxygenation is increased due to increased 2,3 diphosphoglycerate level in the red blood cells. All this leads to decompression of nerve roots, decreased inflammation of nerve roots, increased oxygenation to the diseased tissue for repair work.
How is ozone administered?
It is done usually under local anaesthesia. The patient is taken to the cardiac cath-lab lying on prone position. A very fine needle is introduced into the diseased disc under fluoroscopic guidance. The position of needle tip is confirmed by injecting a small amount of radio-opaque dye. The ozone is freshly extracted from high-grade ozone generator and introduced in the disc. Some 15 to 30 minutes is required to perform the total procedure.
There are few conditions when this procedure should not be performed. They are - active bleeding from any site, pregnancy, G6PD deficiency and active hyperthyroidism.
Ozone therapy or surgery for slipped disc cases?
Ozonucleolysis or ozone discectomy has a success rate of about 80% to 90%. On the other hand surgical discectomy has much higher side effects compared to remarkably few side effects of ozone discectomy. Ozone discectomy is usually a day care procedure and general anaesthesia is not usually required. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular in European countries. It is also gaining popularity in our country due to its low cost, less hospital stay, no post-operative discomfort and morbidity and practically no side-effects. Only occasionally, patients have developed headache and/or nausea - which is reversible.