Primary Study On Pressure-controlled Lumbar Intradiscal Ozone Injection With Flexible Puncture Needle Through Inner Margin Of Small Joint

[Background]Ozone is known as one of the most intense oxidants.In the past ten year, intradiscal ozone injection developed in Eroup counties has shows the advantages of minimum trauma,and no side effects,and effective, and with high success rate as compared with other minimally invasive therapies such as chemonucleolysis and percutaneous disctomy. Muto and Andreula reported the total clinical effectiveness was 78% and 76% with posterior-outer side route, Prof.HE Xiaofeng reported that results in extrusion group showed that therapy responses were related to the procedure route.The best response to the therapy can be seen in the group with small joint inner side plus posterior-outer side route which effectiveness was 84.62%.The gases were generally injected into the invertebral disc and lesion of disc. If too big force in injection may lead to fracture of annulus fibrosus, and the nucleus pulposus extruding into the vertebral canal. There is no report on pressure-controlled lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint were found.[Objective]1.To introduce method of the pressure-controlled lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint intreatment of lumbar herniated disc.2.To evaluate the effect of the pressure-controlled lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint intreatment of lumbar herniated disc.3.To analyze the relationship injection-pressure and distribution of ozone and annular disruption, and discuss those factors how to affect efficacy, and to put forward corresponding measurs to get better effect.4.To investigate the ability of preesure-contronlled gas discography to predict outcomes.[Material and Methods]1,Clinical pictureBetween May 2006 and January 2007,32 cases of patients with lumbar herniated discs,which were proves by CT or/and MRI, were selected to enter the study. Their average age was 44.5 years old(ranging from 23 to 66 years old) and patients include 19 male and 13 female cases.All patients complained of sciatica and/or low back pain which existed 1 weeks to 9 years.In physical examination,all patients showed Leasegue Sign positive reaction.Patients included Buldging, Protrusion and Extrusion.2,Instruments and facilitiesOne set of X-Ray machine with C arm was utilized in study.Medical ozone generator which could produce 03 at a concentration of 50 ug/ml at least was adopted. 21G needle, 0.9×80mm needle and pressure readout were chosen.3,Research method32 cases were devided into two groups depending on the different procedure routes including (1) Group A :small joint inner side plus posterior-outer side route and(2) Group B:pressure-controlled flexible puncture needle through inner margin of small joint route.4,Treatment Procedure15Cases in group A were subjected medical ozone injection with small joint inner side plus posterior-outer side route.Firstly the anchoring point of small joint inner side route was confirmed in the positive side 1.5cm away from middle line.Puncture needle was conducted directly to reach the lesion disc.5ml of ozone with 50ug/ml was injected into the inside of lesion disc with 0.9×80mm needle.Then patient laydown on the negative side with a pillow under their waist.Their negative side leg was kept in stretching position and posituvr side leg in flection.Anchoring point of the posterior-purer side route could be located in the positive side 8 to 9 cm away from middle line at the level ofherinated disc space.Local anesthesia was done by injection of 2%Lidocain.Puncture needle was conducted via the posterior-outer side with 45-degree angle to reach the lesion lumbar disc space. When the position of the needle tip was verified at the center or one-third of posteror area of disc sapce,5-10ml of ozone at the concentration of 50ug/ml was injected into inside of lesion disc with 19G needle. The concentration of ozone was 50ug/ml medical ozone were also injection into intraforaminal space with the amount of 10ml and 5ml of AIPKD as the needle withdraw.17cases in group B were subjected medical ozone injection with the pressure-controlled flexible puncture needle through inner margin of small joint. Firstly shape the puncture needle into a curvifo-rm shape which we have been calculated on CT or MRI image. The anchoring point have been calculated on CT or MRI image, and was confirmed under fluoroscopic guidance , Flexible puncture needle was conducted curvilineally to reach the margin of small joint, 2ml of ozone at the concentration of 50ug/ml was injected into the epidural space and recorded pressure with pressure readout.If pressure below 5-15mmhg, needle tip was verified in the epidural space. Then flexible puncture needle was conducted curvilineally to reach the lesion disc space. When the position of the needle tip was verified at the center or one-third of posterior area of disc sapce,5-10ml of ozone at the concentration of 50ug/ml was injected into inside of lesion disc and gas pressure was limited below 1000mmgh. Then recorded the pressure with pressure readout. The concentration of ozone was 50ug/ml medical ozone were also injection into the inside of the lesion of disc and the epidural space with the amount of 2ml and 5ml of AIPKD as the needle withdraw.Complete asepis was kept during the procedure of percutaneous intradiscal ozone-injection, when injected gas into inside of lesion disc.5,Patient Follow-upPatients were fllowed up by telephone interview and questionnaire.The evaluation of curative effect was performed according to MacNab ctriteria.The relieve extent of patients's symptoms within 1 week after ozone injection was observe.The influence of related factors,including injection-pressure,distribution of ozone in discs and with or without annular disruption on curative effect was analyzed.6,Statistical method: Comparison was conducted for effects between group A and group B by Fisher's Exact Test of data of 4-fold Table, and for means of injection-pressure between three groups which were devided into three groups depending on the different distribution of ozone in discs by One-way ANOVA,Post Hoc MultipleComparisons-by Dunntt'T3.Statistical significance level was set as P=0.05.[Results]1.20 discs(17cases) were punctured successfully once time with the pressure-controlled lumbar intradiscal ozone injection with 25G flexible puncture needle through inner margin of small joint.2. The efficacy of group B(17 cases) with the pressure-controlled lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint route was 82.4%.,the efficacy of group A(15 cases) with small joint inner side plus posterior-outer side route was 80.0%,This study demonstrated that the GroupA and groupB had no significant on curative (P＜0.05).3.20 discs were devied into three tapes by distribution of ozone,Tape A:8 discs ,gas was only distributed in disc, mean injection pressure 821.43±60.62mmHg;Tape B: 10 discs,gas was distributed in disc and the vertebral canal, mean injection pressure 602.15±144.85mmHg;Tape C: 2 discs,gas was distributed in disc and the vertebral canal and the front of vertebral, mean injection pressure 267.62±93.81mmHg.This study demonstrated that three Tape had significant on mean injection pressure (F=8047.02, P=0.000, P＜0.05).4.In 9 cases of chemical discs, 7 cases was cured;and in 7cases of mechnical disc, 6 cases was cured. In 7 cases of chemical discs who were be cured,6cases need 2 months or more to be fully recovered. In 6 cases of chemical discs who were be cured,5cases only need 1 month to be fully recovered.[Conclusion]1.The method of lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint is avaliable and practial. 2. This study demonstrated that the group B with the pressure-controlled lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint were equivalent to the group A with small joint inner side plus posterior-outer side route on curative. It was a avaliable method that we can found relationship between injection pressure and curative.3. The preesure of injection without fracture of annulus fibrosus was higher, and the preesure of injection with fracture of annulus fibrosus was lower.4. Introduce one avaliable method that can predict outcomes.In brief, the method of lumbar intradiscal ozone injection with flexible puncture needle through inner margin of small joint is avaliable and practial, a avaliable method that we can found relationship between injection pressure and curative.