Ozone Therapy for the Treatment of Herniated Intervertebral Discs (HID)
by Gaetano Morello, BSc., N.D.
Introduction:
Low back pain is one of the most common complaints during primary
care office visits. It is estimated that approximately 80% of all
Americans report low back problems at some time in their lives.[1]
Among working age people, as many as 20 percent experience back
symptoms at least every year. In the United States, spinal diseases
are the most common cause of disability in persons under the age of
45.[2] What is even more surprising is that the estimated costs of
direct medical and indirect expenses for low back pain in the U.S.
range from $20 to $100 billion annually. Spine care results in
expenditures two to three time greater than cardiac services for many
health plans.[3]
Some of the main causes of back pain include spinal stenosis,
sciatica, muscle strain, bulging or herniated discs and degenerative
disc disease. Herniated intervertebral discs (HID) are the most
common cause of low back pain associated with a defined structural
abnormality.[4,5]
The most common treatments for HID include surgical discectomy,
epidural steroid injection and the use of non-steroidal anti-
inflammatory drugs (NSAIDs). Other therapies have included
chemonucleolysis, prolotherapy, traction and conservative therapy
(rest). [6, 7-9]
Patients who are not helped by weeks of conservative therapy are
often referred for surgery on the premise that further non-operative
care is unlikely to help. More recent data however, is suggesting
that extended conservative therapy (up to 4 years) leads to favorable
outcomes just as often as surgery. But it is this long period of time
needed with conservative therapy that often makes surgery the
treatment of choice.[10]
In the last 10 years there has been a growing interest in
alternatives to surgery. Chemonucleolysis gained some favor in the
early 80's and more recently prolotherapy has been receiving some
much-deserved attention.
Another alternative therapy that has been receiving exposure in
Europe is the use of medical ozone (02/03 mixture) in the treatment
of HID. Medical ozone has been widely used in Europe for 40 years and
now is seriously being looked at as a possible treatment for
herniated discs and other types of lower back pain. In order to
acquire an understanding about the biochemical action of ozone in
treating HID, a foundation of the structure of the intervertebral
disc and diagnostic criteria of HID is essential.[11,12]
Structure of the intervertebral disc:
The intervertebral discs make up about a quarter of the length of the
vertebral column. They may be regarded as semielastic discs, which
lie between vertebral bodies. Their physical characteristics permit
them to serve as shock absorbers when the load on the vertebral
column is suddenly increased.
Each disc consists of a peripheral part, the annulus fibrosus and a
central part, the nucleus
pulposus.[4] The annulus fibrosus is composed of fibrocartilage in
which the collagen fibers are arranged in concentric lamellae that
surround the nucleus pulposus. The lamellae are thick in the anterior
and lateral portions of the anulus, but posteriorly are thinner and
more densely packed. Water makes up about 60-70% of the weight of the
annulus fibrosus while collagen and proteoglycans make up 50% and 20%
respectively of the dry weight of the annulus.
The nucleus pulposus is gelatinous in structure and is the actual
shock absorber between the vertebrae. Bio-mechanically, the fluid
nature of the nucleus allows it to be deformed under pressure, but as
a fluid, its volume cannot be compressed. When subjected to pressure
from any given direction, the nucleus will attempt to deform and
transmit the applied pressure in all directions. Water makes up about
70-90% of the nucleus pulposus although the exact fraction varies
with age. The next major components are proteoglycans; the water of
the nucleus is contained within the domain of these proteoglycans.
The upper and lower surfaces of the bodies of adjacent vertebrae that
abut onto the disc are covered with thin plate of hyaline cartilage
(known as the vertebral end-plates).[13]
Diagnostic Considerations:
Diagnosis of HID comes from a thorough history, physical exam (PE),
neurological and orthopedic tests, and is confirmed with proper
diagnostic imaging.[4] The symptoms of HID include pain that can
develop gradually or suddenly. It is worst on movement and may be
exacerbated by the Valsalva maneuver. Paresthesias or numbness in the
sensory distribution of the root may occur and tendon reflexes may be
depressed. Straight leg raise may produce back pain because it
stretches the nerve roots. Muscles supplied by the impaired root
eventually become weak, wasted, flaccid and may show fasciculations.
Signs and symptoms of herniated discs are caused by compression of
either nerve roots or the spinal cord. The specific signs and
symptoms are based on which part is compressed and at which level the
neural structures are compressed. The diagnosis of a herniated disc
is usually ascertained from the characteristic clinical symptoms and
diagnostic findings. Because more than 95% of lumbar disc herniations
are at the L4-L5, L5-S1 levels, the physical examination should focus
on abnormalities of the L5 and S1 nerve roots.
Neurological and orthopedic tests should include: Bowstrings sign
(excellent for nerve root compression), straight leg raise (Lasegue
test, for L5 and S1 radiculopathy), femoral stretch test (L4
radiculopathy), Achilles reflex (S1 nerve root) and Patellar reflex
(L4 nerve root). Plain radiography is not useful in diagnosis of a
HID but computed tomography (CT) or magnetic resonance imaging (MRI)
is often diagnostic. MRI is becoming the preferred choice of
diagnostic imaging because of the lack of radiation and the superior
view of the discs.[4,7,13,11]
Ozone Therapy
The use of medical ozone in the treatment of HID was developed by
Cesare Verga (an orthopedic surgeon) in 1983. Dr. Verga has since
treated over 8,000 patients with HID and documented a 95% cure rate
(35% of these cases had at least one prior surgical intervention). In
80% of the clinically healed cases there are also corresponding CT
and MRI images confirming resolution. In 15 years of treatments Dr.
Verga states that relapses occur in less than 2% of cases. The method
he uses which we will term the "Verga Method" (VM), involves the
administration of 40/60 cc of ozone gas (O2-O3
mixture) at a concentration of 20/30 micrograms per cc, repeated 8-14
times. The injection is generally made into the paravertebral
musculature, and in the hernia zone. The injection itself, except for
a slight sense of localized pain of short duration, is generally
painless and well tolerated. There have been a number of European
studies confirming the efficacy of the "Verga Method" and new studies
are currently underway.[11,15-17]
How does Ozone Therapy using the "Verga Method" work?
Although the exact mechanism of action is not completely understood,
there are a number of characteristics of medical ozone that offer
some insights into its mode of action in treating HID. Thus, it has
been hypothesized that the success of the "Verga Method" is based on
four main biochemical actions on the intervertebral disc and its
surrounding tissues. The various proposed mechanisms of action are:
1. Several studies suggest disc inflammation as a mechanism of
sciatica due to disc herniation.[7,18] Ozone has been shown to have
an effect on the inflammatory cascade by altering the breakdown of
arachidonic acid to inflammatory prostaglandins.[11] Therefore, by
reducing the inflammatory components there is a corresponding
reduction in pain.
2. Another hypothesis as to the mechanism of action of the VM is
based on the fact that the circulatory environment around a HID can
be compromised. The herniation can impinge on the venous and arterial
flow and cause phlebostasis and arteriostenosis. The combination of
these two conditions can then lead to a serious hypoxemia. These
factors can contribute to the pain experienced with a HID. In fact,
the sensory roots more so than the motor are particularly sensitive
to anoxia. By applying the ozone to HID area, both a direct and
indirect hyperoxygenation of the zone occurs, which reduces the pain.
The direct effect is the oxygen directly diffusing into the area. The
indirect action is the ozone
causing an increase in 2,3-DPG (diphosphoglycerate) which has a
direct effect in the release of O2 from hemoglobin.[12] The end
result is an increase in the amount of oxygen and a reduction in
anoxia.
3. The third plausible mechanism of action is the direct effect of
the ozone on the herniation. It is well established that the nucleus
pulposus (the actual part of the disc that herniates) is 70-90% water
contained within the domain of proteoglycans.[13] The water binding
capacity of the proteoglycan molecule is partially a property of its
size and physical shape, but the main force that holds water to the
molecule stems from the ionic, carboxyl (COOH) and sulphate (SO4)
radicals of the glycosaminoglycan chains. The ozone can have a direct
effect on these carboxyl and sulphate groups, breaking down some of
these glycosaminoglycan chains which make up the proteoglycans. The
destruction of these cross-linked structures reduces their ability to
hold water therefore diminishing the size of the herniation.
[12,15,16]
4. Another action which may prove to be one of the most important is
the stimulation of fibroblastic activity by ozone. Fibroblasts
initiate the repair process by stimulating the deposition of
collagen. Although yet to be validated, this mode of action could
explain the resolution of HID on CT scans and the small percentage of
patients who have relapses after the completion of treatment plan.
[12,16]
How is the Verga Method performed?
The VM is performed by injecting 60 cc of O2-O3 mixture in 4 divided
doses paravertebrally around the HID zone. Each site injected will
receive approximately 15 cc of the gas. The concentration of ozone
used will be between 20-30 micrograms/cc. A glass syringe or a
silicone coated disposable syringe must be used in order to properly
administer the ozone mixture (needles used are 22-25 gauge, 1.5-2.0
inches in length). The amount of treatments needed varies from
patient to patient; but the average patient has recovery in about 14
sessions.
Advantages of the Verga Method:
1. A great advantage of this method is that it practically has no
contraindications.
2. There are no limits to the number of sessions, adapting to the
necessity of the patient.
3. Patients who have already had back surgery even several times have
benefited from the VM.
4. The mode in which the VM works, does not in anyway alter the
biomechanics of the back.
5. It does not require hospitalization.
Final Comments
The Verga Method has shown to be a promising therapy for patients
with herniated intervertebral discs. Its modes of action seem to
address the underlying pathology without disturbing the biomechanics
of the back.. There is a definite need for more clinical research to
fully understand the promising results this method is providing
physicians. But the clinical results obtained thus far by a large
number of orthopedic surgeons in Europe offer real hope to people
suffering from this debilitating condition.
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