1. M.D.(Anaesthesiology)
Interventional Pain Physician
Director of SPINETICS,A Spine endoscopy &
Advanced Interventional Pain Management and Rehab Centre,
Surat & Anand
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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)]
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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,…
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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.)
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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
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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
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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
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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
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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)
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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19. Dr. Murphy told Medscape Radiology that the
oxygen/ozone mixture
injected into the disc works through a redox
(or reduction–oxidation) 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,"
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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
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21. Disc disease
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22. The intervertebral disc
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23. Disc herniation/hnp/pid
 Outbulging of N.P through the defect in the
annulus
 Presents as follows :
◦ Bulge
◦ Protrusion
◦ Extrusion
◦ Sequestration
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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 Sharpey’s fiber into ring
apophysis
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25.  Bulge
Loss of concave
posterior margin ±
indentation of the
subarachnoid space /
cord / nerve roots
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26. Protrusion
• Focal outbulging of the nucleus pulposus, outside
the margin of the annulus.
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27. Extrusion
• Focal outbulging of the nucleus pulposus, through the
annulus defect – BEYOND DISC LEVEL.
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28. Sequestration
• Separation of the disc material from the parent disc with
or without superior or inferior migration
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29. Endplate changes
• Types
– I (oedema)
hypointenseT1 &
hyperintenseT2W
– II (fatty)
hyperintense onT1
& iso to hyper onT2
– III (sclerosis) both
T1 &T2 darkening
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30. • SCHMORL’S NODE
focal herniation of
nucleus pulposus
(transvertebral disc
herniation) through the
endplate into the
vertebral body
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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
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35. AP and
lateral
fluoroscopic
images
demonstrati
ng needle
position
within the
central third
of the L4–L5
disc prior to
contrast
injection.
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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.
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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
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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
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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
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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 doesn’t relived find out the
other cause
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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