Ozone Therapy For Lumber Disc Herniation:Analysis Clinical Effectiveness And Explore Its New Mechanism

Part OneObjective Discussion the different types of disc disease treated by ozone therapy,assess and compare the therapeutic outcome of ozone therapy for different types of lumbar disc herniation. In order to provided the experience and basis for further clinical therapy.Method476patients were diagnosed lumbar disc herniation and accepted ozone therapy from Jan,2009to Dec,2011in Nanfang Hospital. Male346cases (72.7%), female131cases (27.3%), aged14-85years,and the median pain is (22±13.76) weeks.The Inclusion criteria comprised patients with lower back pain and/or sciatica, Single segment of lumbar disk herniation on CT or MR images.without the cauda equina injury, muscle atrophy of the lower limbs and other serious neurological impairment. VAS weighted value greater than6points, All patients complained of pain for at least10weeks. They had received conservative therapy with no or poor clinical improvement or recurrence in short term. Exclusion criteria comprised infected around the puncture way, disc infection or vertebral tuberculosis, severe coagulopathy,more two degree spondylolisthesis, associated with spinal tumors or vertebral metastatic tumors, previous spine surgery,and patients who’s cardiopulmonary,liver and kidney failure can not tolerate surgery, All cases were agreed to the consent of the patients and their families, and signed consent form, the patient lies on the surgical operation bed lateral position.The treatment level was localized and local anesthesia was applied to the skin8-10cm lateral to the midline. The22-gauge needle was directed toward the center of the disc under fluoroscopic guidance, and the annulus was punctured.After the needle was determined radiographically to be in the appropriate position, inject40ug/ml of5-10ml O2-O3into the disc very slowly, then pull out the needle, inject ozone around the nerve root. We classified the cases by CT and/or MR evidence and ozone imaging under the Digital Subtraction Angiography(DSA). All patients were treated with a single session of oxygen-ozone therapy.Therapeutic outcome was assessed3months,6months and12months after treatment by using a VAS weighted value method. The effects of four types were compared by X2test.Result1. Type:476patients were divided into four types:1.the type of Anular disruption and Nucleus pulposus non-Prominent;2.the type of Anular disruption and Nucleus pulposus Prominent;3.the type of Anular non-disruption and Nucleus pulposus non-Prominent;4.the type of Anular disruption and Nucleus pulposus Prominent.The type of Ⅰ and Ⅱ including358patients (75.1%), Male261cases, female67cases, aged14-81years,The history of pain between10weeks to213weeks and the median pain is (23±14.53) weeks. The type of Ⅲ and IV including118patients (24.9%), Male85cases, female33cases, aged13-75years,The history of pain between10weeks to183weeks and the median pain is (17±11.28) weeks.2. Follow-up:The patients were followed up at three months later,six months later and12months later after treatment.The effective rate of the four types after followed up were:type I:81.18%,78.82%,77.65%;II:66.30%,62.89%,63.74%;Ⅲ:65.75%,64.38%,61.64%;IV:46.67%,44.44%,42.22%.Conclusion1. We found that the ratio of anular disruption accounted for all patients is75.1%.2. We discuss the different types of disc disease treated by ozone therapy for the first time, and The best efficacy of all types is Anular disruption and Nucleus pulposus non-Prominent,and the worst efficacy is Anular disruption and Nucleus pulposus Prominent. Part TwoBackground A large number of studies have confirmed that ozone can stimulate the release of anti-inflammatory cytokines such as IL-10, thereby antagonizing the inflammatory responses induced by inflammatory factors like IL-1, IL-6, TGF-β1produced by the diseased intervertebral disc.Objective Through an investigation into the relationship and significance of TGF-betal on the degenerative disc tissues and an examination of the effect of TGF-β1expression on Bax/Bcl-2ratio in the normal and degenerated intervertebral disc, an exploration into a new mechanism was made for the treatment of diseased intervertebral disc with ozone.Methods70cases with complete data were chosen among126cases in paraffin blocks for lumbar disc herniation from February2009to March2011in the pathology department of PLA371Hospital, who were preoperatively confirmed to be with lumbar disc herniation, and postoperative pathological findings were degenerative lumbar disc tissues in42males and28females. In addition,18cases with normal lumbar disc tissues in29cases suffering vertebral burst fracture were taken as normal group (12males and6females). According to the pathological changes, the degenerative intervertebral disc tissues were divided into four classes, and the normal and degenerative intervertebral disc tissues were researched respectively by using HE staining, immunohistochemistry, TUNEL staining and RT-PCR method.Results The degenerated intervertebral disc tissues were divided into four classes by HE staining. Class I:The nucleus pulposus cells denatured mildly and were enlarged. Some cells were fuzzy and ill-defined, some had vacuolar degeneration with no significant reduction in the number of cells, some were normal and their interstitial collagen fibers had no obvious hyperplasia (mild). Class II:Most nucleus pulposus cells had vacuolar degeneration and became larger, and a small number of cells collapsed and disappeared. Only a handful of normal cells were visible, and mild hyperplasia was found in the interstitial collagen fibers (moderate). Class III:Most nucleus pulposus cells had vacuolar degeneration, collapsed and blurred, and a few cells shrank obviously. There was a dramatic drop in the number of the cells, and no normal cells were seen and the interstitial collagen fibers were in moderate hyperplasia (severe). Class Ⅳ:The number of nucleus pulposus cells was extremely reduced and the residual cells had vacuolar degeneration and atrophy, the cytoplasm blurred and interstitial collagen fibers were in severe hyperplasia or even fibrosis (very severe). Immunohistochemistry and RT-PCR showed that TGF-β1and Bcl-2were expressed in the normal tissue, and Bax only had a trace of expression. TGF-β1had an increased expression with higher histological grade, which was the highest in the class VI. And there was significant difference between the degenerated and the normal lumbar disc tissues in each class (P<0.05). The BCL-2expression was different from that of TGF-β1in the degenerative lumbar disc tissues, which gradually decreased with the amount of expression in the degenerative lumbar disc tissues and had a significant difference compared with the normal group (P<0.05). However, the expression of Bax was positively correlated with that of BCL-2, which was of significant difference compared with that of normal group (P<0.05), and the ratio between Bax and Bcl-2increased gradually in the degenerative lumbar tissues.Conclusion1.An increased TGF-β1expression is related to the pathological grading of degenerative disc tissues.2.The increased TGF-β1expression regulates the Bax/Bcl-2ratio, leading to apoptosis and promoting disc degeneration.