Discussion
Neuropathic Pain, nausea, Pain, herniation, adhesiolysis, lumbar problems, radiculopathy, urinary incontinence, neurological or infectious complications, pain, venous stasis, dehydration, lumbosacral canal stenosis, FBSS, lumbar disc herniation, lumbosacral stenosis, headache
SCAR, INFLAMMATION, HERNIATED DISCS, RADICULOPATHY, URINARY INCONTINENCE, VENOUS STASIS, DEHYDRATION, SECONDARY
According to this study, addition of ozone to triamcinolone does not have an added benefit in the treatment of pain in patients with lumbosacral canal stenosis. But it can be effective in some parts of patients’ performance, especially the walking ability. By comparing the ozone plus triamcinolone group with triamcinolone group and examining primary and secondary outcomes, there was no significant difference between VAS and ODI in the two groups in various time points. The only significant difference was the superiority of ozone plus triamcinolone over triamcinolone in WD outcome one month and six months post injection.A 2004 study by Muto et al. Published fascinating results on ozone injection in 2,200 patients. In this study, intradiscal and intraforaminal/epidural ozone injections were used to assess the response to treatment of patients with lumbar disc herniation. According to this large study, ozone can cause good to excellent results in 75% of patients followed up for 18 months. It was also associated with a reduction in herniation size in 63% of patients. In addition to favorable therapeutic outcomes, no serious neurological or infectious complications have been reported in this study. The beneficial effects of ozone in this study have been linked to (1) improved oxygenation and reduced inflammation, (2) direct effects of ozone on mucopolysaccharides in nucleus pulposus and disc shrinkage, and finally, (3) improved microcirculation by reducing venous stasis [Among the few other studies published on epidural ozone injection is the Ryska trial in 2021. In this study, three types of treatments in lumbosacral radicular pain were carried out: transforaminal epidural steroid injection, transforaminal epidural ozone injection, and pulse radiofrequency of DRG. Assessment of VAS and ODI was done immediately after treatment, 3 months and 6 months later. The best response immediately after treatment was in the transforaminal steroid injection group, but there was no significant difference between the groups at 3 months and 6 months. Two cases of transient mild side effects, including nausea and headache after ozone injection, have been reported [Barbosa et al. performed epiduroscopy with concomitant ozone injections in patients with FBSS. Patients with ozone injection showed pain reduction within 21 days of follow-up in various outcome measures, including VAS, Brief Pain Inventory, Neuropathic Pain Symptom Inventory and Douleur Neuropathique 4. At the same time, there was no evidence of improved functional scales. The hypothesis for reducing pain in these patients is scar tissue adhesiolysis causing pain reduction and dehydration of the herniated discs. In addition, reducing the inflammatory processes through various cytokines is another possible cause of relieving pain [Several studies have scrutinized the influence of adding corticosteroids to ozone in treating radiculopathy with intradiscal and/or transforaminal approaches. The results of ozone and steroid combination in most studies favor the cumulative effects of ozone alongside steroids. The use of a combination of ozone and corticosteroids does not reduce the therapeutic effects and can cause additive effects in treating radiculopathy. The results of our study are in the same direction [In general, the results of using ozone in treating lumbar problems and radiculopathy caused by disc herniation have been reported positively. Ozone, whether intradiscal or epidural or paravertebral, can improve the patient’s symptoms and is a practical step before surgical recommendation [Manchicanti et al. proposed that lidocaine alone or combined with steroids in epidural injections was beneficial in lumbosacral stenosis and radiculopathy. However, steroid itself, in combination with sodium chloride or bupivacaine, was not effective in improving symptoms. Despite numerous trials mentioning the usefulness of steroids, a body of literature question its effects [Ozone injection studies in lumbar disc herniation and radiculopathy are mostly intradiscal or a combination of intradiscal and epidural approaches [We have no idea that the improvement in the walking distance in the ozone group is due to the beneficial effects of ozone including anti-inflammatory properties [In our study, two cases of headache were reported in the corticosteroid plus ozone group, but there was no headache in the steroid group. A case of temporary urinary incontinence happened in the corticosteroid group, which recovered rapidly. Overall, the side effects were small and limited. In most of the studies, the side effects of ozone were small and temporary [The use of ultrasound and color Doppler greatly increases the accuracy of caudal injection, and even in some studies, this accuracy has been reported up to 100% compared to fluoroscopy, in our opinion, the lack of fluoroscopy to confirm the proper injection site is one of the disadvantages of this study [Research limitations include the small number of patients recruited and the short follow-up period, lack of consensus on the dose and volume of injectable ozone, and the number of injections. It is not yet clear whether multiple injections can have higher efficacy. Perhaps it would have been better to use ozone without triamcinolone and bupivacaine in another group to confirm the inherent benefits of ozone injection but this was not morally right because we were depriving the patient of the benefits of more proven treatments. Novel group design is the main advantage of this trial. To date, no study has examined the benefits of ozone in addition to triamcinolone and bupivacaine in caudal epidural injections. Using both subjective and objective outcome measures is the other advantage of this research.