I. History of ozone.
In 1839, German chemist Schonbein (1799-1868) published “The Odor of the Anode in the Electrolysis of Water” in Basel and named this irritating gas Ozone. 1857, Von Siemens invented the first ozone generator. In 1870, the first report on the use of ozone for blood purification appeared, and in 1915, A. Wolff applied ozone topically to treat severely infected wounds. 1936, French physician P. Aubourg injected ozone into the rectum to treat chronic colitis. 1988, Italian physician In 1998, Muto et al. reported that ozone was injected into the intervertebral disc and paravertebral space for the treatment of lumbar disc herniation, and the effective rate was 78%. 1994-2000, Albertini reported the results of a multicenter study of 6665 cases of lumbar disc herniation, and the excellent rate was 80.9%.
In 2000, He Xiaofeng of Southern Hospital introduced this technology into China and treated more than 450 cases of lumbar disc herniation with an efficiency rate of 75.9% until June 2004.
Besides, ozone is also used to treat joint pain, frozen shoulder, diabetic ulcer, viral hepatitis, etc.
II. Physicochemical properties of ozone and treatment principles.
1.Physical and chemical properties ○3 is a light blue gas with a strong special odor, extremely unstable, easy to decompose into ○2 + ○- in the air and human tissue. Compared with oxygen, ozone has a large specific gravity, taste, color, soluble in water, easy to decompose, etc. The half-life at room temperature is about 20 min. because ○-atoms are very active, so ozone has a strong oxidizing ability, the effect is completed in an instant, there is no permanent residue.
2.Treatment principle
(1) Oxidation of proteoglycans in the nucleus pulposus: one of the main components of the nucleus pulposus has a negative charge and can attract positive charges to the nucleus pulposus matrix, i.e., it has the property of fixed charge density. This property determines the distribution of ions within the matrix of the nucleus pulposus, resulting in a high osmotic pressure in the matrix, which is the main reason why the water content of the nucleus pulposus is as high as 85%.
After the injection of ○3 into the intervertebral disc, the proteoglycans in the nucleus pulposus are rapidly oxidized, the cell membrane and intracellular structure of the nucleus pulposus are destroyed, causing cell degeneration and necrosis, and the function of cell synthesis and secretion of proteoglycans is decreased or lost, so that the osmotic pressure of the nucleus pulposus decreases thus leading to water loss and reduction of the volume of the nucleus pulposus. Therefore, some people call this method of ozone treatment for disc herniation ozone chemonucleolysis.
(2) Anti-inflammatory effect: The herniated nucleus pulposus and fibrous ring compress the dura mater, nerve roots and surrounding veins, causing impaired reflux, exudation and tissue edema. The glycoproteins and β-proteins released after fibrous ring fracture act as antigenic substances, causing the body to produce an immune response and forming sterile inflammation. Ozone stimulates the overexpression of oxidative enzymes, neutralizes the overproduction of reactive oxidative products in the inflammatory response, antagonizes the release of immune factors in the inflammatory response, dilates blood vessels, improves reflux, and reduces edema around nerve roots.
(3) Analgesic effect: The herniated disc tissue can compress the nerve roots and stimulate the release of pain-causing substances (such as substance P, phospholipid plum A2, etc.) from the small intervertebral articular processes, adjacent ligaments and nerve endings present on the surface of the disc.
(4) ○3 can act directly on nerve endings after injection and stimulate inhibitory interneurons to release enkephalins and other substances, thus achieving analgesic effects, which is the basis for the treatment of soft tissue pain by ○3.
III. Animal experimental studies of ozone.
Yu Zhijian et al. injected different concentrations of ozone (50μg/ml, 30μg/ml) into the central part of the lumbar intervertebral disc and intervertebral foramen of adult domestic dogs under X-ray fluoroscopy and observed them for 2 months, and found that the nucleus pulposus slowly atrophied and no adverse reactions occurred.
The safety of intrathecal ozone injection has not been reported and needs to be further studied.
IV. Indications.
1.Intervertebral disc herniation.
2.Failed Back Surgery Syndrome (FBSS).
Soft tissue pain: various soft tissue pains, such as frozen shoulder, myofascial pain syndrome, third lumbar transverse process syndrome, pear-shaped muscle syndrome, etc.
4, arthritis: ozone injection can treat various rheumatic diseases, ischemic necrosis of the femoral head, osteoarthritis of the knee and other complications of the sacroiliac joint, hip and knee joint cavity aseptic inflammation.
5, neuropathic pain: for example, for postherpetic neuralgia of the intercostal nerve (postherpetic neuralgia PHN), local anesthesia, radiofrequency post-injection ozone can be used as an adjuvant treatment method.
V. Contraindications.
1.Ozone allergy.
2, puncture site infection.
3, elevated body temperature.
4.Serious psychological disorders.
5. Menstruating and lactating patients.
6.Cervical disc herniation compressing the spinal cord causing spinal edema degeneration.
7, free type lumbar disc herniation.
8, lumbar disc herniation calcification, combined with bony spinal stenosis or cauda equina syndrome.
Sixth, the operation essentials.
1, cervical intervertebral disc puncture.
(1) puncture access: cervical disc herniation often uses the lesion intervertebral space healthy side anterolateral access.
(2) Ozone concentration: 40 to 50 μg/ml.
(3) Volume: 3 to 5 ml in the cervical disc.
(4) Number of injections and interval: generally 1 to 2 injections with an interval of 3 to 5 days.
2.Lumbar intervertebral disc puncture.
(1) Puncture approach: lumbar disc herniation and FBSS generally use the posterior lateral safety triangle approach (Figure 3, 4); for L5/S1 intervertebral disc puncture, if puncture is difficult due to high iliac crest, the small joint inner edge approach can be taken, which is more likely to be successful.
(2) Ozone concentration: 40 to 50 μg/ml.
(3) Volume: 6～10ml of injection in the lumbar disc; withdraw the needle to the outside of the disc and inject 10ml in the spinal canal.
(4) Number of injections and interval: generally 1 to 2 injections with an interval of 3 to 5 days.
3.Soft tissue pain, arthritis and intercostal nerve PHN: After puncture in place under 0.5% lidocaine local anesthesia and retraction without blood and gas, inject 5～10ml of ozone into each painful point, 5ml of ozone into each intercostal nerve, and 10～20ml of ozone into each joint cavity.
4.Caution.
Ozone injection is a safe, effective and economical treatment for a wide range of chronic pain, but to improve the therapeutic effect and expand its indications, the following two points must be achieved.
(1) Ensure that the incoming needle reaches the diseased tissue – target point injection.
For example, in the treatment of lumbar disc herniation, the needle must be inserted into the herniated intervertebral disc. Intradiscal puncture has a decompression and decongestion effect on the bulging disc, but for lumbar disc herniation in which the annulus fibrosus has ruptured and the nucleus pulposus has herniated and prolapsed, ozone injection within the herniation should be performed, while for prolapsed lumbar disc herniation, ozone injection should start from the distal end of the herniation and be performed in stages to prevent the herniation from dislodging and compressing the nerve caused by direct injection of the herniation and the connection of the disc.
(2) Taking advantage of multiple techniques – comprehensive treatment.
Various treatment techniques have certain indications and contraindications, and have their own advantages and defects. One method cannot treat all kinds of pain disorders, one disease has different characteristics in different cases, and one case may also have multiple lesions or multiple types of one lesion. Therefore, the most appropriate treatment technique and the best combination of techniques should be selected according to the type, type and characteristics of the patient’s disease. Commonly used combinations of treatment techniques are: (1) ozone combined with radiofrequency (RF).
(2) combination of ozone and percutaneous laser disc decompression (PLDD); (3) combination of PLDD + RF + ozone; (4) combination of ozone + nerve block + acupuncture (acupotomy).
VII. Postoperative rehabilitation.
Patients with cervical and lumbar disc herniation and FBSS should be bedridden for 1 day after surgery, and activities should be gradual after getting out of bed, paying attention to the application of cervical collar or lumbar girth protection, bed rest should be the main focus within 1 month, avoiding strenuous movement of cervical or lumbar spine; 2 to 3 months after surgery, gradually exercise the muscles of the neck and lumbar region to increase the mobility of the spine; 3 months later, the best recovery state of ozone therapy is reached, and those with excellent or good results resume daily work and After 3 months, the best recovery state of ozone treatment will be achieved, and those with good and excellent results will resume their daily work and life.
VIII. Adverse reactions and complications.
Possible adverse reactions and complications of ozone treatment for chronic painful diseases include: allergic reaction, nerve damage, infection, bleeding, headache, abdominal distension, dural sac injury, limb weakness and myasthenia gravis. So far, no serious adverse reactions and complications have been reported. Strictly grasping the indications and controlling contraindications, careful operation and strengthening postoperative supervision are the keys to avoid serious complications.
IX. Outlook
Although medical ozone has been used in pain clinical practice for only a decade, it has gradually gained popularity among physicians and patients because of its simplicity, safety, effectiveness, economy, and few adverse effects.
However, since this technology has not been developed for a long time and is still in its initial stage, its long-term efficacy is yet to be further observed, and the safety of intrathecal injection also needs to be further studied. Therefore, it should be emphasized that the indications must be strictly controlled and contraindications must be controlled when applying this technique.