DR. NEERAJ JAIN M.B,B.S., M.D., FIPP (USA)
Interventional Pain Specialist ,Spine & Pain Clinic. RU-23 Pitampura,
& Consultant Incharge, Pain Clinic, Sri Balaji Action Medical Institute, New Delhi.
, 9810033800 (Mobile).

LOW BACK/ NECK PAIN (LBP) is a pandemic disease having 80% of lifetime prevalence, affecting 15-20% population at any point of time, being one of the commonest reason for visit to a doctor & young age morbidity/disability/work absenteeism.
AETIOLOGY OF LBP:
LBP is not just a disease but a symptom, a syndrome with combination of multiple possible abnormalities of anterior & posterior longitudinal ligaments, vertebral body, synovia / chondropathy/ osteoarthritis of articulating facets joints, sacroiliac joint, nerve roots & foramen, paraspinal muscles, related connective tissues eg.- ligamentum flavum , spinal canal, intervetebral disc at annulus ring. It may be due to mechanical, nonmechanical, referred pain, psychological & failed back surgery (FBSS).

PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL
PAIN MANAGEMENT OF LBP:-
It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms)
Better results are obtained if treatment is started early.
. LESI-lumbar epidural steroid injections::
. interlamminar or transforaminal or caudal approach
- BALLOON NEUROPLASTY
SNRB- selective nerve root block
. Epidural adenolysis or percutaneous decompressive neuroplasty
. Trigger point injection
. Botox paraspinal muscle injection
. Facet joint or pericapsular injection
. Spine Prolotherapy & manipulation
. Facet RF thermal neurolysis
. SI joint injection or denervation
. Piriformis muscle block
. Diagnostic provocative discography
. Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis
- Dekompressor disc debulking
- IDET-intradiscal electrothermal therapy
- Coblation nucleoplasty
- Laser percutaneous discectomy
. Vertebroplasty & kyphoplasty
. Intrathecal pump neuraxial implants
. Augmentation or neuromodulation spinal cord stimulation
ONCE THE CONSERVATIVE TREATMENT FAILS:-
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although patient selection is important even then.
Depending upon the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.
Using precision diagnostic & therapeutic blocks in chronic LBP , isolated facet joint pain in 40%, discogenic pain in 25%(95% in L4-5&L5S1) ,segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.
LESI : LUMBAR EPIDURAL STEROID INJECTION
Indicated in - Acute radicular pain due to irritation or inflammation.
- Symptomatic herniated disc with failed conservative therapy
- Acute exerbation of discogenic pain or pain of spinal stenosis
- Neoplastic infiteration of roots
- Epidural fibrosis
- Chronic LBP with acute radicular symptoms
ESI TREATMENT PLAN:
Compared to interlaminar approach better results are found with transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space.Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level .
SNRB- SELECTIVE NERVE ROOT BLOCK.
Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if
. There is minimal or no radiological finding.
. Multilevel imaging abnormalities
. Equivocal neurological examination finding or discrepancy between clinical & radiological signs
. Postop patient with unexplainable or recurrent pain
. Combined canal & lateral recess stenosis.
. To find out the pathological dermatome for more invasive procedures , if needed
EPIDURAL ADENOLYSIS OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROMES (FBSS)
A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach
After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE.
FACET SYNDROME:- FACET JOINT INJECTION OR
RF MEDIAL BRANCH NEUROTOMY
It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in male of younger age group during active careers . CT/ MRI/ Bone scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1ml of LA+ 20 mg triamcinolone) which has therapeutic value also.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two level medial branches of dorsal ramus is a safe, effective & long term treatment.
SACROILIAC JOINT INJECTION & DENERVATION:
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.
INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT
A diagnostic procedure & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines
PERCUTANEOUS DISC DECOMPRESSION (PDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:--
OZONE-DISCOLYSIS: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.
DEKOMPRESSOR: A mechanical percutaneous nucleotome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.

INTRATHECAL (SPINAL) PUMP IMPLANTS:
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.
NEUROMODULATION TECHNIQUES:
SPINAL CORD STIMULATION (SCS) IMPLANTS :
Done for FBSS( failed back surgery syndrome) & CRPS(comlex regional pain syndromes) inUSA. In Europe it is done for chronic intractable angina & pain of peripheral vascular diseases (PVD). The indications are expanding further in chronic pain states. A set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. A trial stimulation is done before permanent SCS lead implant.
PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional techniques in which PMMA bone cement is injected under L.A. via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.

Vertebroplasty/Kyphoplasty: A Novel Approach for Treatment of Spine Fractures
Neeraj Jain
Senior Consultant Spine & Pain Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi, India.
Abstract: As life expectancy is increasing so is the incidence of vertebral body (VB) fractures now being the commonest fracture of the body.
Percutaneous Vertebroplasty/ Kyphoplasty (PVP) is an established interventional technique in which bone cement is injected under local anaesthesia
via a needle into a fractured VB with imaging guidance providing instant pain relief, increased bone strength, stability, decreasing analgesic medicines,
increased mobility with improved quality of life and early return to work in days. In this era of minimally access surgery replacing open surgeries, PVP
is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression
fracture spine. PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral
fractures. Vertebroplasty is a palliative procedure and does not correct the underlying cause of the vertebral fracture. Medical management of
osteoporosis or malignancy must therefore be initiated and continued.

INTRODUCTION
Discovering the fact that fracture /# vertebrae is the commonest # of
body, its incidence >the # hip, it becomes imperative to take it more
seriously. With increasing life span there is more of aged osteoporotic
population, more so due to sedentary indoor lifestyle and post menopausal
osteoporosis. Diabetics, smokers & alcoholics are at higher risk of
developing osteoporosis. I have seen such alcoholic patient developing
six spine fractures in just three months time from a single fracture being
on complete bed rest.
Stable VB # are normally treated conservatively with bed rest, strong
analgesics, removable braces, a programmed progressive ambulation and
physiotherapy. Fractures with > 50% of anterior VB collapse or > 20%
of sagital angulations are potentially unstable and may require posterior
instrumentation and fusion if not cemented in time. For burst # pedicle
instrumentation with extension segmental constructs are required. PVP
is not ideal for # dislocations or # distractions. Spine surgeon has to be
consulted if patient needs operative spine stabilization.
Quick fix of fracture spine makes patient walk back same day instead of
bed rest of months together avoiding morbidity & mortality of prolonged
bed rest, making bedridden patient walk, in a way bringing patient back
to normal life.
VERTEBROPLASTY: AN OVERVIEW
Percutaneous Vertebroplasty (PVP) is an established interventional
technique in which rapidly hardening surgical polymethyl methacrylate
bone cement is injected under local anesthesia via a large bore needle
into a vertebral body (VB) under imaging guidance providing increased
bone strength, stability, pain relief, decreased analgesics, increased
mobility with improved QOL and early return to work. Kyphoplasty has
the added advantage of addressing fracture with spinal deformity and
appears to be associated with fewer instances of bone cement
extravasations.
As per Greek mythology pain was thought to be due to intrusion of particles
into soul, now pain relief is done by intrusion of particles into bone. The
bone of content is to fill bone with content. In this era of MAS replacing
open surgeries, PVP is a novel procedure & should be in the first line of
management in place of painful conservatism or major spinal surgery
with a list of complications in polytrauma settings for painful
uncomplicated VB #; especially when the spine surgery is relatively
complicated or patient refuses due to surgery phobia or cost involved or
there may be comorbid conditions /injuries deterrent for surgery. PVP is
a big help in polytrauma setting when stabilizing spine does lot of good
to the patient’s overall management.
Collapsed 1 year old # Both spine & Implant fractured! # Spine with bowel & bladder
involved
INDICATIONS
Started in 1984 by Galibert PVP is done in host of indications: Senile
osteoporotic compression # remains the commonest Indication (83%).
Both men and women are at risk for spinal fractures, with over 700,000
new fractures occurring every year. In fact, one in four women over 50
will suffer an osteoporosis related spinal fracture. Even more startling,
spinal fractures are twice as likely as hip fractures. And they’re three
times more common than breast cancer. Yet as many as two-thirds of
spinal fractures go untreated.
• Painful new or progressive osteoporotic collapse # refractory to
medical therapy or dosage of analgesia leads to unacceptable side
effects.
• Complicating Co-morbid diseases, on steroids & received transplant.
• To reduce loss of vertebral height and possibility of continued collapse
• Metastatic VB #, Multiple Myeloma VB # (3%). Approximately 30%
of patients with various neoplastic conditions develop symptomatic
spinal metastases during the course of their illness & pain is the
presenting complaint in the majority of cases.
• Aggressive painful VB haemangioma
• Vertebral osteonecrosis
• For strengthening VB before major spinal surgery.
• The benefit has been extended to the traumatic uncomplicated VB
compression # (VCF) (14%) which is commoner in younger age
group with active life profile and prime of their career where strict
bed rest and acute or chronic pain are unacceptable and they are
more demanding for proactive treatment approach so as to be back
to work ASAP.
CONTRAINDICATIONS
• Pre-existing neurological deficit
• Burst fractures (relative C/I)
• Fracture related spinal canal stenosis
• Uncorrectable coagulation disorders
• Allergy against bone cement or contrast media
• Unable to lie prone
LONG-TERM MORBIDITY &
CONSEQUENCES OF VERTEBRAL
COMPRESSION FRACTURES
Whether painful or not, the long-term consequences of VCF can be
devastating and can include:
• Traumatic VB # is painful condition requiring bed rest restricting
daily activities markedly as “spine cripples”.
• Left untreated it can cause DVT, increase osteoporosis, loss of VB
height, respiratory & GI disturbances, emotional & social problems
secondary to unremitting pain, loss of independence with high cost
of rehabilitation.
• High risk of primary or consequential damage to neural, bony or disc
elements.
• Increased wedging, deformity & increase incidence of fall and
adjacent VB #.
• Chronic debilitating pain of kyphosis & altered spine mechanics.
• Uncomfortable braces & sleep disturbance because of pain &
discomfort with its sequels.
• Decreased pulmonary function and increased lung disorders , 9%
reduction in vital capacity per #
• Decreased appetite and potential for malnutrition due to stomach
compression & visceral crowding.
• Five-fold increased risk of future vertebral fractures after the first
and 75-fold increased risk after 2 or more vertebral fractures coupled
with low bone mass
• Increased dependence on family and friends
• 40% Clinical anxiety and/or depression
• Loss of self-esteem and compromised social roles
MORBIDITY & COMPLICATIONS OF SPINAL
SURGERY
• Cost of surgery and hospital treatment
• Cost of implants
• Phobia of surgery
• Prolonged recovery period & Extensive rehabilitation
• Changed spinal mechanics & transition syndrome
• Major surgery & anesthesia with its own complications
• Anaesthesia related • DVT • Mechanical Pulmonary
• Medical morbidity • Infection • Hardware related
Persistent pain
• Implant migration • Spinal cord/nerve injury
Pseudoarthrosis
• Sexual dysfunction • Transition syndrome
PRE-OPERATIVE WORKUP
Detailed history & investigation including coagulation profile.
Neurological battery checkup of motor / sensory / reflexes should be done
pre & post operatively & notified. In neurological deficiency wait for 72
hrs for spinal shock to wean off if there was any and then take decision
accordingly
X-ray spine in A/P & lat view. CT is more informative of bone & #
morphology. MRI is good for soft tissue injuries e.g. spinal cord/ root
damage, hematoma, canal stenosis and ligamentous injury
Ask for pedicle size in all dimensions and construct a 3D image aiming
needle placement and cement filling mentally in scan room itself as
rehearsal of PVP. This reduces operative time & gives better results.
Outcome with risk & complication should be well informed & consented
HOW TO PERFORM PVP STEP BY STEP
Sedate with fentanyl & midazolam. To have a feedback in case of any
eventuality instantly, only sedate the patient. Start oxygen, monitor vitals.
Prone positioning with adequate padding.
Fix fluoroscope view as desired & check for its movements.
Total aseptic precautions of major surgery. Cleaning & fully draping of
the patient and the C-Arm.
Do skin marking & measurements & Give liberal local anaesthesia from
skin up to the bone.
Adjust fluoroscope from P/ A to oblique to see “Scottie dog” with pedicle
in maximum oval view with flattened end plates, hit the superior lateral
quadrant of pedicle oval for transpedicular approach. Alternatively
parapedicular route is used in thoracic region & antero-lateral approach
for cervical vertebra.
• 23-34 % increased age adjusted mortality compared with patients
without VCF
• Women unaware that they have vertebral fractures have a 16%
increased mortality compared to women without fracture
• Nine-fold increased risk of mortality in 4 years, compared with 7-
fold increased risk with hip #
• Women with vertebral fractures are 2-3x more likely to die of
pulmonary causes than those without fractures

Conventionally PVP is done by hammering the vertebroplasty needle
through the bone. Here we used light weight drill to bore through the
vertebra. With drill one can do a graduated drilling starting from smaller
gauze wire, this allows extra scope for maneuvering needle to the desired
most location in VB which is difficult to attain with hammered bone
biopsy needle which by its impact cause unacceptable distraction of #
fragments & intense pain.
It is important to set the needle at exact entry site & side with right
trajectory aiming the # defects
In lateral view needle should go through middle of the pedicle going up
to anterior 1/3 of VB.
In P/A view the needle can be in midline or paramedian depending upon
# & if uni/bipedicular approach is planned
Wash haematoma of VB with saline. Do bone biopsy if there is any doubt
about # lession. Do dye test (vertebral venography). Always wash dye
with saline before injecting cement to have good view of cement flow.
Make cement more radiopaque by adding barium /or tungsten. Then inject
cement with 1 or 2 ml leurlock syringes strictly under fluoroscope in
lateral view & cross checking in P/A view. Stop injecting either there is
adequate filling or at the first sight of ectopic cement leak. Total cement
volume varies as per fracture morphology, osteoporotic cavitation & level
of vertebra. Keep sample cement to see for hardening. Remove needle
with rotational movement before cement hardens.
COMPLICATIONS OF PVP/ KYPHOPLASTY
• PVP is generally safe with low risk.
• Ectopic cement leak is frequent but generally inconsequential..
• Symptomatic cement extravasation incidence depends upon etiology
of fracture.
• Osteoporosis 1-2%
• Neoplasm 5-10%
• Location of ectopic cement leaks
• Epidural
• Foraminal
• Paravertebral
• Disc
OUTCOME
• PVP is a novel procedure with high benefit to risk ratio, which is
highly underutilized in relation to the high prevalence of the vertebral
#.
• Different studies show an immediate pain relief in (85 - 90)% of
patients with low complication rate ranging from (1-5)% depending
upon the type of lesion.
• PVP does augment height of VB but ideal would be kyphoplasty.
• Patient is either off medicine or on reduced doses.
• Patient feels so well that he almost forgets about VB #.
Pain relief is by virtue of different mechanisms postulated :
• Cementing of # fragments
• Thermal neurolysis of VB nerve ending, sinu-vertebral nerve & DRG
due to heat of polymerization
• Washing away of nociceptor chemicals
• Neurolytic action of liquid monomer
• By allowing early ambulation decreasing pains of immobility & bed
rest
NEW DEVELOPMENTS
• Non PMMA cements
• Bioactive glass
• Hydroxyapatite
• Osteoconductive coral granules
• Composite cements
• Ideal cement volumes
• Variations of technique
Kyphoplasty or Balloon Vertebroplasty is cementing the fractured
vertebra after creating cavity, is ideal for collapse osteoporotic # with
Varied Vertebrae Anatomy PVP in lat. view
PVP in A/P view Cross-section of PVP
Vertical collapse All six vertebrae cemented & secured
One & three year old # Cemented with preemptive fill in next Habitual #
osteoporotic patient
# Spine patient ventilated/ Normal after cementing

CONCLUSION
• With rich experience in osteoporotic PVP one can comfortably pass
the benefit to traumatic # where -it is more rewarding & satisfying.
• With PVP you just don’t manage pain rather you treat it. It is also
important to remember to address the underlying condition of
osteoporosis. Improve patients bone health and reduce risk for future
fractures through a combination of medication, diet, exercise and
lifestyle modifications.
• Very few people die of pain, many die in pain and even more live in
pain, some of them are sequel to spine traumatic fractures, a reversible
suffering.
• We have to keep pace with patients needs.
• PVP may be is the future of uncomplicated VCF management.
• kyphoplasty has the added advantage of addressing spinal deformity
and appears to be associated with fewer instances of bone cement
extravasation.
• Pain means punishment, we can avoid the chronic punishment of
VCF with PVP avoiding all D’s of disability, depression, drugs
dependence, deformity, dissociation & dejection.
• In future we are looking for high radiopaque biodegradable or
bioactive bone pastes or cement or glues with more procedural time
relaxation which will strengthen the bone while inducing new bone
growth.
• Vertebroplasty is a viable treatment and possible standard
management of the pain and disability of vertebral fractures needing,
height loss & can be employed in selected traumatic wedge collapse VB
# with height loss.
Balloon kyphoplasty
• Restores vertebral body height
• High pressure ballooning (150-400 psi) followed by cement injection
into cavity created by balloon
• fewer complications resulting from cement extravasation
• reduction in morbidity of kyphosis
Clinical outcome data
• 22 published observational studies
• Retrospective designs
• Short term follow up
• Concurrent treatment modalities
• Three series of >250 patients
• Gangi et al Radiographics 2003(868 patients)
Clinical outcome data balloon kyphoplasty
• Five published case series
• Largest describes 188 procedures in 78 patients with minimum 1
year follow up (Coumans JV et al J Neurosurg2003)
• No comparisons with vertebroplasty or conservative therapy
• Pain relief scores similar to those achieved by vertebroplasty
• Adequate training
• Meticulous technique
• Careful patient selection
• If you don’t take up the job the Robots will take over.
BIBLIOGRAPHY
1. Galibert P, Deramond H, Rosat P, Le Gars D. Preliminary note on the treatment of vertebral
angioma by percutaneous acrylic vertebroplasty [in French]. Neurochirurgie 1987;33:166-168
2. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Cloft HJ, Dion JE. Percutaneous
polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression
fractures: technical aspects. AJNR Am J Neuroradiol 1997;18:1897-1904
3. Mathis JM, Petri M, Naff N. Percutaneous vertebroplasty treatment of steroid-induced osteoporotic
compression fractures. Arthritis Rheum 1998;41:171-175
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techniques and indications [in French]. J Neuroradiol 1997;24:45-59
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polymethylmethacrylate: technique, indications, and results. Radiol Clin North Am 1998;36:533-
546
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and fluoroscopy. AJNR Am J Neuroradiol 1994;15:83-86
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unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression
fractures. Spine 1999;24:1772-1776
8. D. H. Choe, E. M. Marom, K. Ahrar, M. T. Truong, and J. E. Madewell
Pulmonary Embolism of Polymethyl Methacrylate During Percutaneous Vertebroplasty and
Kyphoplasty Am. J. Roentgenol., October 1, 2004; 183(4): 1097 - 1102.
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Contrast AJNR Am. J. Neuroradiol., May 1, 2004; 25(5): 840 - 845.
10. D. F. Kallmes and M. E. Jensen. Percutaneous Vertebroplasty Radiology, October 1, 2003; 229(1):
27 - 36.
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a rare complication of percutaneous vertebroplasty. AJNR Am J Neuroradiol 1999;20:375-377
12. Belkoff SM, Fenton DC, Scribner RM, Reiley MA, Talmadge K, Mathis JM. An in vitro biomechanical
evaluation of an inflatable bone tamp used in the treatment of compression fracture.
Spine 2001;26:151-156
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Percutaneous Vertebroplasty: A Developing Standard of Care for Vertebral Compression Fractures
AJNR Am. J. Neuroradiol., February 1, 2001; 22(2): 373 - 381.
14. K. Kim, M. E. Jensen, J. E. Dion, P. A. Schweickert, T. J. Kaufmann, and D. F. Kallmes
Unilateral Transpedicular Percutaneous Vertebroplasty: Initial ExperienceRadiology, March 1,
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Correspondence: Dr Neeraj Jain, Senior Consultant Spine & Pain
Specialist, Spine & Pain Clinics & Sri Balaji Action Medical Institute,
Max Hospital, Pitampura, New Delhi & Sant Parmanand Hospital, New
Delhi. e-mail: managepain@yahoo.com www.spinenpain.com

DR. NEERAJ JAIN M.D., FIPP (USA)
SENIOR CONSULTANT INTERVENTIONAL PAIN SPECIALIST
SPINE & PAIN CLINIC, RU23 PITAMPURA, NEW DELHI. &
SRI BALAJI ACTION MEDICAL INSTITUTE
(M)09810033800

Ozone Discectomy is the injection of Ozone inside the intervertebral disc in trouble. This is done as an outpatient under local anaesthesia with strict real time radiological control, which ensures the proper placement of Ozone in the center of the disc making it shrink.
LOW BACK PAIN, SCIATICA & PIVD:
Among working age people, as many as 20 percent experience back symptoms at least
every year. spinal diseases are the most common cause of disability in persons under the age of 45. Spine care results in expenditures two to three time greater than cardiac services for many health plans. While there is no specific data related to India, spine surgeons estimate that roughly 5% of the general population is affected by serious disc problems.

Some of the main causes of back pain include facet arthropathy, sciatica, muscle strain, sacroilitis, bulging or herniated discs and degenerative disc disease. Prolapsed intervertebral discs (PIVD) are the most common cause of low back pain associated with a defined structural Abnormality.

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. Ideally, a patient with low back pain that has persisted beyond a four-week period should be referred to a multidisciplinary pain centre.

Different Non Surgical Interventions Employed Successfully:
. Epidural Steroid Inj.
. Epidurogram & Epidurolysis.
. Nerve root sleeve/ transforaminal Inj.
. Intra-discal steroid inj.
. Nucleoplasty- Laser, Thermal & Mechanical
. Ozone Discolysis

Conventional treatment methods for back pain comprise lamminectomy/ discectomy microsurgery, endoscopic disectomy and percutaneous arthoscopic disectomy, among others. These are invasive methods and their goal is to remove or contain the protruding disc. However, these methods have occasionally demonstrated a discrete incidence of failure and/or recurrence. Outcome studies of lumber disc surgeries documents, a success rate between 49% to 95% and re-operation after lumber disc surgeries ranging from 4% to 15%, have been noted. "In case of surgery, the chance of recurrence of pain is nearly 15 per cent as against less than three percent in Ozone treatment.
Reasons for the failures of conventional surgeries are:
1. Dural fibrosis
2. Arachnoidal adhesions
3. Muscels and fascial fibrosis
4. Mechanical instability resulting from the partial removal of boney & ligamentous structures required for surgical exposure & decompression
5. Presence of Neuropathy.
6. Multifactorial etiologies of back & leg pain , some left unaddressed surgically.
THE NEED FOR NEOTECHNOLOGY:
. The various treatment options has confused clinicians and investigators due to high failure rate and complications associated with different kinds of surgeries and interventions. There has been surge of interest in search of safer alternative method of decompressing the nerve roots maintaining the structural stability.
. Another safe least invasive alternative therapy that has been receiving exposure in Europe is the use of medical Ozone (02/03 mixture) in the treatment of PIVD. Epidural steroid injection, transforaminal epidural decompressions has a high success rate (up to 85%), but chances of recurrences are there specially if these interventions are done at later stage. Chemonucleolysis using chymopapain has also high success rate (80%) with low recurrences but not popular owing to the chances of anaphylaxis following intradiscal chymopapain injection. Injection of Ozone for discogenic radiculopathy (low back pain with radiation to legs) has developed as revolutionary alternative to chemonucleolysis and disc surgery .

THE OZONE REVOLUTION IN DISC DISEASES:
Muto suggested intradiscal injection of Ozone for disc hernia in 1998 under CT guidance. Leonardi popularized fluoroscopy guided Ozone injection into the intervertebral disc. After that successful outcome has been reported from various European centers. It is very important to note from those reports that complications are remarkably few. Not a serious single life threatening complication was found even after 120,000 cases of Ozone nucleolysis, which stresses the safety of these procedures.

The most critical portion of performing any of the minimally invasive procedures is accurate and safe positioning of the needle (or terminal device) in the centre of the disc space. The risk in ozonucleolysis is particularly minimised, with the use of a very thin 22/25-gauge needle. It may take anywhere from 5 to 30 minutes to position a needle in the centre of the disc space under radiological guidance. Once the needle is safely placed in position, ozonucleolysis is completed in only another 2 to 3 minutes.

HOW DOES OZONE WORK ?
There are four main biochemical actions on the intervertebral disc and its surrounding tissues. The various proposed mechanisms of action are:


. BY “MUMMIFICATION” OF THE DISC.
. Intra/intermolecular Bonds and collapse of the threedimensional Structure of the disc.
The 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 through annulus) is 70-90% water contained within the domain of proteoglycans. 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 by dehydration of the fibrillary matrix of the nucleus pulposus, revealing collagen fibers and signs of regression (vacuole formation and fragmentation)- a sort of disk “mummification.”

. BY INHIBITING INFLAMMATORY NOCICEPTORS.
. Synthesis of Prostaglandines & Secretion of Proteinases
. Liberation of Bradykinines and Pain Inducing Products
. Several studies suggest disc inflammation as a mechanism of sciatica due to disc herniation. Ozone has been shown to have an effect on the inflammatory cascade by inhibiting synthesis of proinflammatory prostaglandins or release of bradykinin or release of algogenic compounds; increased release of antagonists or soluble receptors able to neutralize proinflammatory cytokines like interleukin (IL)-1, IL-2, IL-8, IL-12, IL-15, interferon, and tumor necrosis factor. Therefore, by reducing the inflammatory components there is a corresponding reduction in pain.

. BY STIMULATING FIBROBLASTS & IMMUNOSUPPRESSOR CYTOKINES
. Local production of Antioxidant Enzymes
. Release of immunosuppressor cytokines like transforming growth factor, and IL-10
. 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 PIVD on CT scans and the small percentage of patients who
have relapses after the completion of treatment plan.
. “Ozone may have a reflex therapy effect called ‘chemical acupuncture’, breaking the chain of chronic pain stimulating anti-nociceptor analgesic mechanism. As pain is multi-factorial, ozone may also have a multi-factorial pharmacological effect alleviating disc compression by shrinkage of the herniated disc.”

. BY IMPROVING MICROCIRCULATION & OXYGENATION.
. 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.. The end result is an increase in the amount of oxygen and a reduction in anoxia.
. Disk shrinkage may also help to reduce venous stasis caused by disk compression of vessels, thereby improving local microcirculation and increasing the supply of oxygen.
This effect has a positive effect on pain as the nerve roots are sensitive to hypoxia.

RESULTS & SAFETY:
In a multi-centre, retrospective 3 year follow-up study of lumber disc herniation treated with European Neurosurgical Institute protocol of ozone therapy in 917 patients showed 78.9% good & excellent results with only one case of disc infection which healed with antibiotic.
In fact, over 120,000 patients have been treated successfully worldwide using injection of medical ozone with a success rate of 80-90% and with a near nil rate of procedure-related complications. “The procedure is a safe and effective alternative to open surgical procedure. Patients get the advantage of going home after a short recovery on the same day. They generally go to work within a week and are spared prolonged absence from work and disability,” The treatment relieves pain substantially and, after two sittings, people "can go back to work under medical guidance".

COMPARISON: SPINAL SURGERY OZONE DISCOLYSIS
1 .More Hospital One day/Day Care.
2 Complications of prolonged surgery& anaesthesia GA is not required
3 “failed back surgery syndrome” No “failed back
surgery syndrome”
4 HighCost Total cost is 1/5th to 1/10th
5 Failure rate 10-51% Comparable 10-21%
6 Safety profile comparatively not so high. Very
high safety prorofile
7 Repeat surgeries are more complicated. May be safely repeated many times
8 Cervical PIVD poses a surgical challenge Ideal procedure in cervical PIVD
9 Highly invasive very demanding surgery Least invasive much easier procedure
10 High postoperative morbidity
Negligible morbidity
11 In-patient major surgery Mostly OPD procedure


CONCLUSION:
Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a day care setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular at European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post operative discomfort or morbidity and low cost.

DR. NEERAJ JAIN
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