Ozone in Chemotherapy-Induced Peripheral Neuropathy—Current State of Art, Possibilities, and Perspectives

Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most detrimental toxicity to a patient’s quality of life. Pathophysiological mechanisms involved in CIPN pathogenesis are complex, multifactorial, and only partially examined. They are suspected to be associated with oxidative stress (OS), mitochondrial dysfunction, ROS-induced apoptosis, myelin sheath and DNA damage, and immunological and inflammatory processes. Unfortunately, medications commonly used for the management of other neuropathic pain syndromes, including gabapentinoids, opioids, and tricyclic antidepressants (such as desipramine and nortriptyline), do not bring satisfactory results in CIPN. The aim of this review is to evaluate the existing literature on the potential use of medical ozone as a treatment for CIPN. This paper would explore the potential therapeutic benefits of medical ozone. The review would evaluate the existing literature on the use of medical ozone in other contexts, as well as its potential application in treating CIPN. The review would also suggest possible research methods, such as randomized controlled trials, to evaluate the efficacy of medical ozone as a treatment for CIPN. Medical ozone has been used to disinfect and treat diseases for over 150 years. The effectiveness of ozone in treating infections, wounds, and a variety of diseases has been well documented. Ozone therapy is also documented to inhibit the growth of human cancer cells and has antioxidative and anti-inflammatory effects. Due to its ability to modulate oxidative stress, inflammation, and ischemia/hypoxia, ozone may have a potentially valuable effect on CIPN.

Oxygen-Ozone Therapy Associated with Alpha Lipoic Acid Plus Palmitoylethanolamide and Myrrh versus Ozone Therapy in the Combined Treatment of Sciatic Pain Due to Herniated Discs: Observational Study on 318 Patients

BACKGROUND

The aim of our observational study is to compare the therapeutic efficacy of combined treatment of oxygen-ozone therapy and oral treatment with alpha-lipoic acid (ALA) + palmitoylethanolamide (PEA) and myrrh in patients with peripheral neuropathic pain (sciatica) on radicular disc conflict from disc herniation and the results obtained with oxygen-ozone treatment alone.

METHODS

We enrolled 318 patients with the neuroradiological diagnosis of disc herniation performed with computed tomography (CT) or magnetic resonance imaging (MRI) and symptoms characterized by low back pain complicated by sciatica, which we divided into two groups. Group A was composed of 165 patients who were treated only with oxygen-ozone therapy with CT-guided intraforaminal technique, while the remaining 153 (Group B) have undergone combined oral treatment with ALA + PEA and myrrh. Follow-up visits for the evaluation of the clinical outcome of the treatment were conducted after 60 ± 8 days using a modified version of McNab's method.

RESULTS

At the clinical check-up, 126/165 patients included in Group A had a complete remission of pain (76.4%), while in Group B, 119/153 (77.8%) had a complete remission of pain.

CONCLUSION

The results highlight how the treatment associated with ozone therapy and oral administration of alpha-lipoic acid + palmitoylethanolamide and myrrh is preferred over the simple treatment with only ozone in such patients in the phase of greatest acuity of the disease, where the pain appears to be better controlled.

Updated Review on Ozone Therapy in Pain Medicine

The use of medical ozone in the treatment of chronic pain is progressively expanding in Spain and today it is used both in public and private medical centers. However, there is a great lack of knowledge about this technology not only in primary care but also in medical specialties. Although its biochemical bases are well determined and there are various systematic reviews and meta-analyses in the literature that justify its use in pain medicine, some professionals still are prejudiced against it. The evidence level of using medical ozone according SIGN (Scotish Intercollegiate Guideline Network) criteria is similar or superior to most of the techniques used in a Pain Unit. In this paper, we have done a review on ozone therapy in pain medicine, compiling the evidence published about it.

Percutaneous ozone nucleolysis for lumbar disc herniation. Neuroradiology. 2018;60:1231-1241. [PMID: 30206674 PMCID: PMC6208962 DOI: 10.1007/s00234-018-2083-4]

Purpose

All percutaneous minimally invasive disc treatments are typically indicated to contained disc herniations. Our study’s aim is to evaluate prospectively the efficacy of ozone nucleolysis in the treatment of either contained or uncontained lumbar disc herniations.

Methods

Fifty-two patients, aged 27–87 years, with symptomatic herniated lumbar discs, without migration, sequestration, or severe degenerative disc changes, who failed conservative treatment, were included in our study. The patients underwent fluoroscopic-guided intradiscal oxygen-ozone mixture injection (5 ml) at a concentration of 27–30 μg/ml and periradicular injection of the same O₂-O₃ mixture (10 ml), steroid (1 ml), and local anesthetic (1 ml). Clinical outcomes were evaluated, based on the Oswestry Disability Index (ODI) and pain intensity (0–5) scale results, obtained initially and at 2- and 6-month controls. Our results were analyzed by ANOVA and chi-squared (χ²) tests.

Results

Our initial results obtained at 2-month control were promising, indicating a significant decrease in pain disability and intensity in 74% (37) and 76% (38) of the patients respectively, and minimally increased to 76% (38) and 78% (39) at 6-month control (P < 0.001 and CI 99.9%). The mean preprocedure ODI and pain intensity scores were 35 ± 14.36 and 2.38 ± 0.90, respectively, which were reduced to 19.36 ± 13.12 and 1.04 ± 0.92 at 6-month control. Our failure had been mostly related to long symptoms duration of more than 1 year. No complications were recorded.

Conclusion

Ozone nucleolysis is a safe cost-effective minimally invasive technique for treatment of contained and uncontained lumbar disc herniations.

Therapeutic relevance of ozone therapy in degenerative diseases: Focus on diabetes and spinal pain

Ozone, one of the most important air pollutants, is a triatomic molecule containing three atoms of oxygen that results in an unstable form due to its mesomeric structure. It has been well-known that ozone has potent ability to oxidize organic compounds and can induce respiratory irritation. Although ozone has deleterious effects, many therapeutic effects have also been suggested. Since last few decades, the therapeutic potential of ozone has gained much attention through its strong capacity to induce controlled and moderated oxidative stress when administered in precise therapeutic doses. A plethora of scientific evidence showed that the activation of hypoxia inducible factor-1α (HIF-1a), nuclear factor of activated T-cells (NFAT), nuclear factor-erythroid 2-related factor 2-antioxidant response element (Nrf2-ARE), and activated protein-1 (AP-1) pathways are the main molecular mechanisms underlying the therapeutic effects of ozone therapy. Activation of these molecular pathways leads to up-regulation of endogenous antioxidant systems, activation of immune functions as well as suppression of inflammatory processes, which is important for correcting oxidative stress in diabetes and spinal pain. The present study intended to review critically the available scientific evidence concerning the beneficial properties of ozone therapy for treatment of diabetic complications and spinal pain. It finds benefit for integrating the therapy with ozone into pharmacological procedures, instead of a substitutive or additional option to therapy.

Herniated disks unchanged over time: Size reduced after oxygen-ozone therapy

The spontaneous regression of disk herniation secondary to dehydration is a much-debated topic in medicine. Some physicians wonder whether surgical removal of the extruded nucleus pulposus is really necessary when the spontaneous disappearance of a herniated lumbar disk is a well-known phenomenon. Unfortunately, without spontaneous regression, chronic pain leads to progressive disability for which surgery seems to be the only solution. In recent years, several studies have demonstrated the utility of oxygen-ozone therapy in the treatment of disk herniation, resulting in disk shrinkage. This retrospective study evaluates the outcomes of a series of patients with a history of herniated disks neuroradiologically unchanged in size for over two years, treated with oxygen-ozone therapy at our center over the last 15 years. We treated 96 patients, 84 (87.5%) presenting low back pain complicated or not by chronic sciatica. No drug therapy had yielded significant benefits. A number of specialists had been consulted in two or more years resulting in several neuroradiological scans prior to the decision to undertake oxygen-ozone therapy. Our study documents how ozone therapy for slipped disks "unchanged over time" solved the problem, with disk disruption or a significant reduction in the size of the prolapsed disk material extruded into the spinal canal.

Oxygen-ozone therapy for herniated lumbar disc in patients with subacute partial motor weakness due to nerve root compression

Intradiscal oxygen-ozone (O2-O3) chemonucleolysis is a well-known effective treatment for pain caused by protruding disc disease and nerve root compression due to bulging or herniated disc. The most widely used therapeutic combination is intradiscal injection of an O2-O3 mixture (chemonucleolysis), followed by periradicular injection of O2-O3, steroid and local anaesthetic to enhance the anti-inflammatory and analgesic effect. The treatment is designed to resolve pain and is administered to patients without motor weakness, whereas patients with acute paralysis caused by nerve root compression undergo surgery 24-48h after the onset of neurological deficit. This paper reports on the efficacy of O2-O3 chemonucleolysis associated with anti-inflammatory foraminal injection in 13 patients with low back pain and cruralgia, low back pain and sciatica and subacute partial motor weakness caused by nerve root compression unresponsive to medical treatment. All patients were managed in conjunction with our colleagues in the Neurosurgery Unit of Bellaria Hospital and the IRCCS Institute of Neurological Sciences, Bologna. The outcomes obtained are promising: 100% patients had a resolution of motor weakness, while 84.6% had complete pain relief. Our results demonstrate that O2-O3 therapy can be considered a valid treatment option for this category of patients.

MR assessment of lumbar disk herniation treated with oxygen-ozone diskolysis: the role of DWI and related ADC versus intervertebral disk volumetric analysis for detecting treatment response

We prospectively assessed the diagnostic criteria of morphologic MRI study (MMS) and the accuracy of DWI and related ADC values (DWI-ADC) versus intervertebral disk volumetric analysis (IDVA) for predicting shrinkage of lumbar disk herniation treated with oxygen-ozone (O2-O3) diskolysis. Sixty-eight patients (36 men and 32 women; mean age 39) with lumbosciatica underwent O2-O3 diskolysis. The six-month MRI follow-up was performed with FSE-T2 and T2-fat, SE-T1 and DWI-weighted images. IDVA was determined using OsiriX(®). Diagnostic criteria and accuracy were evaluated with regards to DWI and related ADC in detecting response to ozone therapy. Fifty-eight of 68 patients had successful outcomes (responders), whereas ten patients showed unsatisfactory outcomes (non-responders). MMS showed that a centrally located herniated disk and grade 1 nerve root compression were more common in the responder group (p < 0.05). DWI-ADC and IDVA showed statistically significant shrinkage in the sixth month of follow-up (p < 0.05) with a mean ADC value reduction of 2.10 × 10(-3) mm(2)/s +/- 0.19 SD in the second month of follow-up (p < 0.05). DWI-ADC had an accuracy of 0.81 in detecting response to therapy around the second month of follow-up. DWI-ADC appear to be useful adjuncts to MMS in the follow-up of patients undergoing O2-O3 diskolysis.

Analysis of disk volume before and after CT-guided intradiscal and periganglionic ozone-oxygen injection for the treatment of lumbar disk herniation

PURPOSE

To quantify the change in volume in herniated lumbar disk after computed tomography (CT)-guided intradiscal and periganglionic ozone-oxygen injection and to assess the effects of patient age, sex, and initial disk volume on disk volume changes.

MATERIALS AND METHODS

A total of 283 patients with lumbar radiculopathy received a single intradiscal (3 mL) and periganglionic (7 mL) injection of an ozone-oxygen mixture (ratio, 3:97; ozone concentration, 30 μg/mL). Under CT guidance, intradiscal and periganglionic injection was performed through an extraspinal lateral approach with a 22-gauge spinal needle. All disk volume changes were evaluated on CT 6 months after the procedure in all patients.

RESULTS

Initial mean disk volume was 17.37 cm(3) ± 4.70 (standard deviation; range, 8.12-29.15 cm(3)). Disk volume reduction (mean, 7.70% ± 5.45; range, 0.29%-22.31%) was seen in 96.1% of treated disks (n = 272) at 6 months after treatment and was found to be statistically significant (P < .0001). In 3.9% of patients (n = 11), disk volume increased (mean, 0.59% ± 0.24; range, 0.11%-0.81%). Patient age correlated negatively with disk volume reduction (r = -0.505; P < .0001) at 6 months after treatment, whereas initial disk volume correlated positively with volume reduction (r = 0.225; P = .00014) after therapy. No correlation was noted between patient sex and disk volume reduction after treatment (P = .09).

CONCLUSIONS

Intradiscal administration of medical ozone is associated with a statistically significant volume reduction of the herniated lumbar disk. The volume-reduction effect of ozone correlates negatively with the patient's age and positively with initial disk volume.

Treatment of symptomatic lumbar spinal degenerative pathologies by means of combined conservative biochemical treatments

Research in spine surgery has proposed new soft and less invasive techniques. These are the results of our experience with oxygen-ozone therapy, which we could experiment within the Italian National Health System over 3 years. A total of 1,920 patients were admitted on the basis of unselected enrolment because of lumbosciatic pain. Patients were divided into three groups: (A) Patients with degenerative disc disease and arthropathy: 509 (26.5%), (B) Patients with failed back surgery syndrome (FBSS): 1,027 (53.489%), and (C) Patients with pure herniated lumbar disc: 384 (20%). The rationale of the treatment for all these different pathologies we have taken into consideration is the biochemical mechanism by which they can engender pain and dysfunction. Treatment for group A: paravertebral injection and phleboclysis (two cycles of 6 sessions, one each 3 days) +endoscopic neurolysis. Treatment for group B: paravertebral injection and phleboclysis (two cycles of 6 sessions, one each 3 days) + endoscopic neurolysis with intradiscal procedure (named percutaneous peridurodiscolysis). Treatment for group C: paravertebral injection (two cycles of 6 sessions, one each 3 days) + percutaneous discolysis.The perceived quality of result for this minimally invasive procedure makes oxygen-ozone therapy an interesting weapon in the hands of doctors. Furthermore, if the technique loses its clinical effectiveness, it can be repeated without harm for the patient, and costs for the health organization are notably very low, above all if compared to surgical procedures.We underline the need that this treatment should be performed in protected structures, in operative rooms, under anesthesiologic control, and in the hands of specialists.

The Clinical Application of Ozonetherapy

The reader may be eager to examine in which diseases ozonetherapy can be proficiently used and she/he will be amazed by the versatility of this complementary approach (Table 9 1). The fact that the medical applications are numerous exposes the ozonetherapist to medical derision because superficial observers or sarcastic sceptics consider ozonetherapy as the modern panacea. This seems so because ozone, like oxygen, is a molecule able to act simultaneously on several blood components with different functions but, as we shall discuss, ozonetherapy is not a panacea. The ozone messengers ROS and LOPs can act either locally or systemically in practically all cells of an organism. In contrast to the dogma that “ozone is always toxic”, three decades of clinical experience, although mostly acquired in private clinics in millions of patients, have shown that ozone can act as a disinfectant, an oxygen donor, an immunomodulator, a paradoxical inducer of antioxidant enzymes, a metabolic enhancer, an inducer of endothelial nitric oxide synthase and possibly an activator of stem cells with consequent neovascularization and tissue reconstruction.

Sciatica: Treatment with Intradiscal and Intraforaminal Injections of Steroid and Oxygen-Ozone versus Steroid Only

PURPOSE

To prospectively compare the clinical effectiveness of intraforaminal and intradiscal injections of a mixture of a steroid, a local anesthetic, and oxygen-ozone (O(2)-O(3)) (chemodiscolysis) versus intraforaminal and intradiscal injections of a steroid and an anesthetic in the management of radicular pain related to acute lumbar disk herniation.

MATERIALS AND METHODS

Medical Ethical Committee approval and informed consent were obtained. One hundred fifty-nine patients (86 men, 73 women; age range, 18-71 years) were included and were randomly assigned to two groups. Seventy-seven patients (group A) underwent intradiscal and intraforaminal injections of a steroid and an anesthetic, and 82 patients (group B) underwent the same treatment with the addition of an O(2)-O(3) mixture. Procedures were performed with computed tomographic guidance. An Oswestry Low Back Pain Disability Questionnaire was administered before treatment and at intervals, the last at 6-month follow-up. Patients and clinicians were blinded as to which treatment was performed. Results were compared with the chi(2) test.

RESULTS

After 6 months, treatment was successful in 36 (47%) patients in group A and in 61 (74%) patients in group B. The difference was significant (P < .01).

CONCLUSION

Intraforaminal and intradiscal injections of a steroid, an anesthetic, and O(2)-O(3) are more effective at 6 months than injections of only a steroid and an anesthetic in the same sites.

Ozone chemonucleolysis in non-contained lumbar disc herniations: a pilot study with 12 months follow-up

STUDY DESIGN

Prospective case series with six and twelve months follow up.

OBJECTIVE

To observe clinical and morphological results of the intradiscal ozone chemionucleolysis in patients affected by non-contained lumbar disc herniations.

METHODS

30 patients were included in the study on the base of precise inclusion and exclusion criteria. The patients were followed on 6 and 12 months period by Visual Analogic Scale (VAS), Roland Morris Disability Questionnaire (RMDQ) and Overall Patient Rating Scale (OPRS). Disc herniation volume morphology was evaluated at 5 months by control MRI scanning.

RESULTS

Twenty-seven patients (90%) showed a statistically significant improvement in pain (P < 0.001, Wilcoxon test) and function (P < 0.001, Wilcoxon test), on VAS and RMDQ evaluation, respectively. The mean satisfaction with the treatment on OPSR was 79.3%, with 24 patients referring satisfaction equal or greater than 80%. There were no major complications related to the procedure.

CONCLUSIONS

The results of this study indicate the ozone chemonucleolysis as a possibly effective modality of treatment in patients affected by signs and symptoms of non-contained lumbar disc herniations that have overpassed conservative measures and have not yet fulfilled the indications for open surgical treatment.