Metanalysis on the effectiveness of low back pain treatment with oxygen-ozone mixture: Comparison between image-guided and non-image-guided injection techniques

European Journal of Radiology Open

Volume 8, 2021, 100389

Abstract

Low back pain (LBP) is a common disorder affecting an increasing number of people worldwide, whose diagnosis is focused on the identification of triggering causes. First line therapy usually starts from conservative approaches, whereas second line treatments include a spectrum of minimally invasive techniques, before resorting to more invasive surgical approaches. Among minimally invasive techniques, percutaneous oxygen-ozone injections represent one of the most common and cost-effective procedures. Aim of this study is to provide a metanalysis on literature evidences on percutaneous oxygen-ozone injections, comparing image-guided to non-image-guided techniques for LBP treatment. Imaging-guided procedures showed better performances compared to non-image-guided techniques based only on anatomical landmarks, with higher therapeutic efficacy and lower age-related variability in clinical results.

1. Introduction

Low back pain (LBP) is a common disorder involving spinal joints, intervertebral disk, vertebral bodies and para-vertebral soft tissues, varying by posture and movement. Sciatica is a specific type of LBP referring to pain radiating down the buttock and leg along the path of sciatic nerve, usually compressed in the setting of spine osteoarthritis. LBP and sciatica affect hundreds millions people worldwide, regardless of age, sex, occupation and lifestyle, with approximately 80% of the population experiencing LBP during their lives [1], [2]. Economic and social impact of LBP is therefore impressive, with higher incidence of depression and isolation commonly described in affected people [3], [4].

LBP frequently recognize variable and multi-factorial aetiology. Treatment should generally begin with conservative methods (i.e. oral medications, physical therapy, exercise, occupational modifications); second-line treatments include a wide spectrum of minimally invasive techniques, before resorting to a more invasive surgical approach (mandatory in case of neurological deficit, progressive foot droop and paralyzing sciatica). Among minimally invasive techniques, percutaneous oxygen-ozone (O₂-O₃) gaseous mixture injections are one of the most common and effective procedures adopted in case of conservative approach failure. Since the 90′s, oxygen-ozone injections have been administered into the paravertebral muscles, intervertebral discs, facet joints and neural foramina in order to achieve pain resolution [5]. Needle tip positioning at target can be performed either with or without image-guidance based on fluoroscopy, computed tomography (CT) or rarely ultrasonography (US); if necessary, the procedure can be performed with anaesthesiologic support. In non-image guided procedures, the injection of O₂-O₃ mixture is targeted in the muscular paravertebral tissues localized at the level of pathologic intersomatic space. Conversely, image-guided procedures are based on periradicular, intraforaminal or intradiscal injection of O₂-O₃ mixture at the level of the metamer of the herniated disc under image-guidance.

At present, no consensus was reached concerning the gold standard procedure in terms of efficacy, effectiveness, complications risk and stability over time [5]. Aim of this metanalysis is to provide a comparison in terms of efficacy and effectiveness of percutaneous image-guided versus non-image-guided oxygen-ozone injections in the treatment of LBP and sciatica.

2. Methods

Metanalysis was based on retrospective bibliometric search of papers on percutaneous image-guided and non-image-guided oxygen-ozone injections in the treatment of LBP and sciatica published between January 1980 and December 2020, based on data publicly available on National Library of Medicine MEDLINE database. Search syntax used to gather bibliographic data is listed in Table 1; study selection for statistical purposes was performed in accordance to PRISMA guidelines (Fig. 1). Case reports, congress posters/abstracts, animal model studies, reviews/meta-analyses, as well as methodological or ex-vivo researches were not included. Other exclusion criteria were: injections not including oxygen-ozone (i.e. steroid, collagenase, etc.); studies that analysed non-percutaneous ozone injections (i.e. spinal endoscopy, etc.); studies analysing oxygen-ozone injections performed in non-lumbar region; non-Anglophone publications. Papers were further evaluated to identify missing data needed to perform the metanalysis; missing data were extracted by using statistical methods when possible, conversely studies were removed. A total number of 45 published original articles were finally included in the metanalysis; the complete list is available as a table in Supplementary Materials.