Percutaneous Treatment of LUMBAR disc - PowerPoint Presentation

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Percutaneous Treatment of LUMBAR disc herniations by ozone DISCOLYSIS

Alper

Muradov

M.D.

St.Sofia

Hospital

Sofia,Bulgaria

Slide2

Epidemiology

Low back pain is the commonest condition affecting the lumbar spine, and is the most frequent cause of absence from work. Around 80% of the population in western countries will experience at least one episode of low back pain in their lifetime and 55% suffer from low back pain associated with

radicular

syndromes.

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Epidemiology

In the United States alone around 200.000 patients with

lumbalgia

or sciatica are treated surgically every year. The short-term success rate after surgery for

lumbosacral

disc herniation is around 95-98% with a 2-6%, incidence of true recurrence of

herniation

. This percentage drops to around 80% in the long-term (more than 6 months) due to the onset of symptoms linked to Failed Back Surgery Syndrome (FBSS) characterised by recurrence and/or hypertrophic scarring with severe symptoms in 20% of patients and FBSS proper in 15%.

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Mini Invasive Techniques

These techniques have minimized the invasive nature of open surgery and avoid or decrease the complications associated with surgery.

Reducing

intervertebral

disc size by mechanical aspiration of a part of the disc or partially dissolving the

herniation

by drying, reduces the conic pressure on the torn annulus and creates the space necessary for

retropulsion

whenever the circular fibres of the annulus regain a minimum capacity to contain the disc under tension. The strategy in these techniques is based on the fact, that a small change in volume produces large change in pressure.

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Mini Invasive Techniques

LASER DISCECTOMY

COBLATION

THERMAL COACULATION

ASPIRATION

ENDOCOPY

CHEMONUCLEOLYSIS

Slide6

Mini Invasive Techniques

According to the site

and the mechanism of action the MIS techniques can be divided in 3 groups:

DECOMPRESSIVE:

chemonucleolisys,percutaneous

decompression and

nucleodiscectomy

, LASER and thermal

discectomy

ANTIINFLAMATORY: Anti TNF therapy

COMBINED:Decompressive

and direct

antiinflamatory

like

coblation

nucleoplasty

and oxygen-ozone

dicolysis

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Pathogenesis of Low Back Pain

Still

discutable

,but 2 Main group

s of factors are responsible:

MECHANIC FACTORS

DIRECT:

-Direct pressure of hernia on the spinal ganglion

-Deformation of the ligaments and

anullus

with stimulation of

noccireceptors

of

Luschka’s

nerve

INDIRECT:

-Ischemia due to compression on the arteries

-Venous stasis

INFLAMATORY FACTORS:

The

inflammatory factors are

- cell-mediated response to the disc

protrusion,possibly

related to segregation of the disc to the immune system)

-

biohumoral

factors like

Phospholipase

A2 (indirect inducer of pain mediators), Prostaglandin E2 (inflammatory inducer through

Phospholipase

A2), and Matrix

metaloproteinases

(MMPs)(inflammatory enhancers)

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Pathogenesis

Herniation

of the nucleus

pulposus

is thought to trigger an autoimmune reaction, the

proteoglycan component of its nucleus being segregated from the immune system after birth.

Moreover the nucleus

pulposus

can also give rise to an inflammatory process through a non-immune-mediated mechanism supported by

histiocytes

, fibroblasts of the reactive

perihernial

tissue, and

chondrocytes

in the disc protrusions able to produce cytokines (Interleukin-1 alpha, Interleukin 6 and TNF-alpha). This lead to an increase in

phospholipase

A2 leading to the release of prostaglandin E2,

leucotrenes

and

thromboxanes

found in larger quantities in non-contained disc

herniations

and patients presenting more severe symptoms.

Prostaglandins cause pain. In small amounts, they enhance sensitivity of the nerve roots and other pain-producing substances like

bradykinin

.

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DISCO-RADICULAR CONFLICT

COMPRESSION

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DISCO-RADICULAR CONFLICT

MECHANICAL COMPRESSION

OF

THE NERVE ROOT

DOES

NOT

PROVOKE THE IRRADIATED

PAIN

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DISCO-RADICULAR CONFLICT

PAIN

compression

edema

obstacle to circulation

ischemia+pH

Contracture of

paravertebral

muscles

NEUROLOGICAL

DISFUNCTION

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DISCO-RADICULAR CONFLICT

INFLAMATION

AND

PAIN

Enzymes

Phospholypase

A2,prostaglandine E2

and

Interleukine

6 are elevated in herniated disc

and generate

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DISCO-RADICULAR CONFLICT

COMPARTMENT SYNDROME

I

IN THE NERVE ROOT AND IN THE GANGLION

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DISCO-RADICULAR CONFLICT

THIS LEADS TO EXTRINSIC COMPRESSION ON THE

ROOT

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DISCO-RADICULAR CONFLICT

FIBROSIS

MECHANICAL INJURY

OEDEMA

VENOUS STASIS

FIBRINOLITIC DEFICIT

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Mechanisms of Action of Ozone

Mechanical:

Stimulates disruption of intra/inter – molecular

valencies

and leads to collapse of the 3D structure of

proteoglycans

and collagen of the disc. with features of nucleus

pulposus

matrix

dehydratation

and signs of regression (so called “disk mummification”).

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Mechanisms of Action of Ozone

Biochemical:

Strongly stimulating the local production of antioxidant enzymes

Intra- and trans-tissue oxygenation in the diseased site with reduced hypoxia and venous stasis.

Reduction of the cell-mediated process inhibiting proteinases release and an increase of the

immunosupressor

cytokines

Inhibition of inflammatory inducers (PPL) and pain-producing mediators ( ozone inhibits

sinthesys

of

prostaglandines

, liberation of

bradikinines

and other pain inducing products, secretion of proteinases from

macrofages

and polymorphous

neutrophyles

).

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Mechanisms of Action of Ozone

Some studies on

histologic

disc

specimenns removed during open discectomy

confirmed the direct effect of Ozone on the mucopolysaccharides

making up the nucleus

pulposus

of the ruptured disc of water molecules and shrinkage of the

disc,exerting

compression on the nerve root.

Direct:

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Ozone Injection

THROUH ALL THESE EFFECTS,OUR AIM IS TO OBTAIN

-DISC DEHIDRATATION

- NERVE METABOLISM CORRECTION

- PAIN RELEIF

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O2-O3 Intradiscal Injection

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O2-O3 Intradiscal Injection

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Technique

Lateral position

Posterolateral

extraarticular

approach

Fluoroscopic C-arm system

Paralleling the vertebral plates

on AP and lateral

proections

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Technique

-

Chiba needles 20G

-50 cc syringe

-Sterile drapes

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Ozone Generators

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Procedure

Paralleling The Needle

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Procedure

Puncture of the disc

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Procedure

Intradiscal

infiltration (Ozone discography)

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Procedure

Epidural ozone diffusion

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Procedure

Intraforaminal

injection of Local

Anesthetic(

Chirocaine

, Dexametasone and

Methylprednizolone

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Procedure

Sterile draping

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Indications

-Low back pain and/or nerve root pain resistant to previous medical treatment, physiotherapy and other therapies at least 3 month

-

Paresthesia

or hypoesthesia over the dermatome involved, mild muscle weakness and signs of root-ganglion irritation without motor loss.

-CT and/or MR signs of small and medium-sized herniated discs correlating with the patient’s symptoms with or without degenerative disease complicated by

intervertebral

disc changes –protrusion or

herniation

-FBSS-residue of surgical

discetomy

with

herniation

recurrence and/or hypertrophic fibrous scarring

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Contraindications:

Favism

(G6PD deficiency)

Pregnancy

Disc

herniation

on CT/MRI corresponding to clinically severe motor deficit and/or sphincter disturbance

Free

discal

fragment

Severe spinal

stenosis

Spinal instability

-Severe

spondylosis

with development of big

osteophytes

Slide33

Matherials and methods

For the period 2008 - 2014 , 3049 patients underwent

percutaneous

injection of O2-O3 mixture for treatment of symptomatic disc

herniations.All

patients had CT/MRI,and complained of back pain and leg

pain.The

patients were divided in four groups:

Group 1: L4-L5 or/and L5-S1

herniations

Group 2: Multiple level herniated discs

Group 3: Degenerative Disease complicated by

herniation

Group 4: Failed Back Surgery Syndrome(FBSS)

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Results

The results after procedure were evaluated by

modified Mc Nab

method,VAS

and Oswestry Disability Index.

Group 1

excellent

80,2%

good

13,1%

poor

6,7%

( 93,3)

Group 2

excellent

75,6%

good

15,5%

poor

9,9%

( 91,1)

Group 3

excellent

49,1%

good 22,7 %

poor 28,2% (71,8)

Group 4 excellent 44,5% good

23,7% poor 31,8% (68,2)

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Case 1

Before 4 months later

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Case 2

Before 3 months later

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Case 2

Before 3 months later

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Case 3

Before 6 month later

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Before 6 month later

Case 3

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Case 4

Before 7 months later

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Case 4

Before 7 months later

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Case 5

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Complications

NO Cases Of adverse reactions

NO Cases Of

spondylodiscitis

NO Cases Of root injury

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Complications

Early-immediately after infiltration

Hypotension

Bradicardy

0,4%

Collaps

Late

Fibrotisation

over the site of infiltration

0,1%

Slide47

Conclusion

Oxygen-ozone treatment of herniated disc is an effective and very safe procedure

Pain and functional results are similar to the outcomes for herniated discs treated with classic surgical

discectomy

Complication rate is extremely lower (<0,1 %)

Recovery time is significantly shorter

No need for general

anestesia

Do not modify normal spinal anatomy

Avoids bone demolition

Minimize

peridural

scarring

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Conclusion

The O2-O3

intradiscal

injection is:

SAFE

No lesions of intrevertebral

disc and surrounding tissues

No

peridural

cicatrisation

No skin incision-lowered risk of infection

No muscle damage-no postoperative pain

No bone loss-no spinal instability

Do not except or impede open surgery if it is necessitated.

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THANK YOU