Low back pain (LBP) is a common disorder, globally recognized as an important health and socioeconomic challenge. One third of the LBP’s economic cost stem from indirect costs. LBP covers a spectrum of different types of pain that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain.¹ Regardless the taxonomic aspects, about 80-90% of LBP cases is represented by nonspecific low back pain.

Peak prevalence from 28% to 42% in people between 40 years and 69 years and up to 80% of the population presents mild to severe LBP at some point in life. This condition is usually self-limiting, but often becomes chronic.  Pain is distinct from nociception and includes not just A delta fiber and C fiber activation, but also context-dependent emotional, cognitive, and behavioral elements. This could partly explain the poor correlation with pathology and symptoms, and why interventions that have no effect on degenerative processes, can have profound effects on pain and quality of life, whereas interventions that address pathology, often do not provide benefit.

Medical ozone is an analgesic, antiseptic, anti-inflammatory, immune-modulating inorganic gas, active on pro-inflammatory cytokines, prostaglandins, and bradykinins synthesis. Upregulation of endogenous antioxidant systems and the activation of pathways suppressing inflammatory processes are the main mechanisms of action of Oxygen-Ozone Therapy. A correct ozonation process with low dose concentration either carried out in blood, or intradiscally and intramuscularly, should represent an acute but tolerable oxidative stress giving the hermetic-type response of the interacting biological system.^2,4  The main indication is represented by LBP with or without radicular pain in absence of motor deficits, refractory to 4–6 weeks conservative therapy.³ Oxygen-ozone therapy (OOT) might exert its action in reducing LBP with a coupled mechanical and anti-inflammatory effect.

As minimally invasive technique, percutaneous oxygen-ozone injections, due to its analgesic and anti-inflammatory effect, represent an integrative treatment.  

There is no consensus to consider the superiority of image-guided injection vs non-image guided, but when compared with anatomical landmarks techniques, showed better therapeutic performance with higher impact on pain reduction and lower age-related variability. The anatomical view reduces the risk, improves safety and efficacy. With special regard to Oxygene Ozone Therapy, through a literature review, this work evaluate the possible role of ultrasound in paravertebral approach focusing on procedural and technical aspects⁵.

Ozone represents a safety complementary approach when applied with respect to good clinical practices World Federation of Ozone Therapy. Ozone therapy is a medical act therefore the patient must be well evaluated beyond the symptom to consider the improvement not only in pain perception but also in functional terms.

References:

1. Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet. 2021 Jul 3;398(10294):78-92
2. Bocci V, Borrelli E, Zanardi I, Travagli V. The usefulness of ozone treatment in spinal pain. Drug Des Devel Ther. 2015 May 15; 9:2677-85
3. Rimeika G, Saba L, Arthimulam G, Della Gatta L, Davidovic K, Bonetti M, Franco D, Russo C, Muto M. Metanalysis on the effectiveness of low back pain treatment with oxygen-ozone mixture: Comparison between image-guided and non-image-guided injection techniques. Eur J Radiol Open. 2021 Dec 6; 8:100389. 
4. Viebahn-Haensler R, León Fernández OS. Ozone in Medicine. The Low-Dose Ozone Concept and Its Basic Biochemical Mechanisms of Action in Chronic Inflammatory Diseases. Int J Mol Sci. 2021 Jul 23;22(15):7890
5.  Latini E, Curci ER, Massimiani A, Nusca SM, Santoboni F, Trischitta D, Vetrano M, Vulpiani MC. Ultrasonography for oxygen-ozone therapy in musculoskeletal diseases. Med Gas Res. 2019 Jan-Mar;9(1):18-23