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