Role of Ozone nucleolysis in prolapsed intervertebral disc disease

1. Dr Kaustav BasuThakur
MBBS, MD (PM&R)
NEUROREHABILITAION ,RHEUMATOLOGY, PAIN INTERVENTION
SPECIALIST

2.  LBP with or without sciatica affects 85% of global
population once in a lifetime
 Work loss and Lost wages
 Decreased quality of life
 Disc herniation – most important cause of LBP radiating
to limbs
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4.  Conservative management is primary
 Surgical approach in failed cases
 Success rate of disc surgeries 49% to 95%
 Re operation rate 4% to 15%
 Reasons
 dural fibrosis
 arachnoid adhesions
 mechanical instability
 neuropathy
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5.  ESI – high success rate (85%) but recurrences
 Chemonucleolysis – high success rate (80%) with low
recurrences but risk of anaphylaxis
 Percutaneous discectomy
 Radiofrequency ablation
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6.  High success rate
 Minimally invasive
 Fewer recurrences
 Less side effects
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7.  Greek word “ozein” meaning “smelling gas”
 Unstable gas, strong oxidising power
 Good antiseptic, disinfectant and antiviral properties
 Triatomic allotropic form of O2
 Molecular weight is 48 kDa
 Half life 20 mins
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8.  Corona discharge
 Ultraviolet light
 Electrolysis
 Radiochemical methods
 Cold plasma
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9.  Power switch
 Flow meter
 Ozone ratio controller
 Ozone indicator
 Oxygen/air inlet port
 Built in syringe port
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10. Step 1
• O2 source connected to generator through gas feeding tube
Step 2
• O2 flow set at 0.5-1L/min
Step 3
• DesiredO3 concentration set on the controller (30μg)
Step 4
• O3 generation indicated by pungent smell or an indicator
Step 5
• Initial volume discarded and rest filled in ozone resistant
syringe
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11.  Proper ventilation
 Avoid breathing directly
 Not to be exposed to skin and eyes
 Not to allow water to enter the machine
 Use filters
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12.  Anti-inflammatory effect reducing pain
 Hyperoxygenation
 Mummification of disc
 Initiation of repair process
 Increased microcirculation
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13.  IDD with discogenic pain
 Contained, hydrated disc bulge with root irritation
 Non-contained, hydrated disc extrusion or sequestration with
root irritation
 Spinal canal stenosis
 Failed back surgery syndrome
 Facet joint arthropathy
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14.  Absolute
1. Infection
2. Coagulopathy
3. Anticoagulant therapy
4. Lack of consent
5. Active hypothyroidism
6. G6PD deficiency
 Relative
1. Pregnancy
2. Unable to lie prone
3. Non co-operative
4. Cognitive dysfunction
5. Allergy to drugs used
6. H/O surgery
7. Anatomical variation
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15.  Rule out red flags
 Informed and written consent
 Explain procedure to the patient
 Assessment of patient
 Basic investigations (coagulation profile, RBS)
 X ray LS spine (AP & Lat)
 Standard preprocedural fasting
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16.  Start iv 20G cannula
 Prophylactic antibiotic 20 mins before procedure
 Ceftriaxone 1g IV single dose
 Cefazolin 900mg single dose
 Sedation with midazolam or propofol or opiods for
comfort during procedure
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19.  Patient in prone position
 Pillow under abdomen
to correct lordosis
 Adequate head and leg rest
 Standard basic monitoring
 Prepare skin with betadine
 Sterile draping
 Patient to inform any paresthesia along nerve root
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24.  Six hundred patients were treated with a single session of oxygen-ozone
therapy. Three hundred patients (group A) received an intradiscal (4 mL)
and periganglionic (8 mL) injection of an oxygen-ozone mixture at an
ozone concentration of 27 micro g/mL. The other 300 patients (group B)
received, in addition, a periganglionic injection of corticosteroid and
anesthetic.
 Therapeutic outcome was assessed 6 months after treatment by using a
modified MacNab method.
 In group A, treatment was a success (excellent or good outcome) in
70.3% .In group B, treatment was a success in 78.3% .The difference in
outcome between the two groups was statistically significant (P <.05).
Andreula CF et al. Minimally invasive oxygen-ozone
therapy for lumbar disc herniation. AJNR Am J Neuroradiol.
2003;24(5):996-1000.
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25.  A non-randomized, prospective analysis of 68 patients of lumbar
disc herniation was treated with ozone nucleolysis.
 Out of 68 patients 89.7% patients had good outcome,7.35% patients
had moderate outcome, 2.95% had poor outcome.
 Intra-op in 1 patient where ozone spread in Para spinal muscles but
had no postoperative problem.4 patients had mild nausea, 2 had mild
headache & no infection.
Patil VS, Garampalli A, Patil SN. Ozone nucleolysis in lumbar
intervertebral disc herniation: non-randomized prospective analysis.
Journal of Evolution of Medical and Dental Sciences
2015;37(4):6456-64
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26.  A prospective cohort study conducted after obtaining ethical committee
permission, 53 consecutive patients complying with selection criteria
were treated with a single session of oxygenozone therapy.
 Pain intensity significantly reduced (VAS baseline 7.58±0.86, after
three weeks 2.75±1.42 and after two years 2.64±2.14). ODI showed a
remarkable improvement in the functional status of the patients
(p<0.05)
Das G, Ray S, Ishwarari S, Roy M, Ghosh P. Ozone
nucleolysis for management of pain and disability in
prolapsed lumber intervertebral disc:A prospective cohort
study. Interventional Neuroradiology 2009;15:330-4.
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27.  Post procedural muscle spasm
 Burning pain
 Discitis
 Vitreoretinal hemorrhage
 Thunderclap headache
 Stroke
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28.  Success rate of 80%
 Minimally invasive
 Day care procedure
 Low cost
 Less hospital stay
 Few side effects
 Minimal complications
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29.  Safer alternative when conservative management fails
 Effective, low cost & reasonably safe
 Works best when disk is adequately hydrated
 Strict asepsis is mandatory during procedure
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