Oxygen-Ozone Therapy of Musculoskeletal Neck Pain: A Review.

Minimally invasive oxygen-ozone (O2-O3) therapy utilizing the biochemical effects of O2-O3 mixture is commonly used in the treatment of musculoskeletal pain. The literature dealing with O2-O3 therapy of spinal pain focuses mainly on the lumbosacral region. The aim of this review is to evaluate the efficacy of O2-O3 therapy in musculoskeletal pain in the neck region. The Medline (PubMed), SCOPUS, Web of Science, and Google Scholar databases were searched for clinical studies, using the free text terms: ozone, neck, cervical, spine, pain, disc, hernia, nucleolysis, paravertebral, treatment, and various combinations of them. In total, seven studies (two randomized controlled trials and five observational studies) were found. These studies dealt with the intradiscal or intramuscular paravertebral application of O2-O3 mixture in patients with myofascial pain syndrome, cervical disc hernias, and chronic neck pain. All these studies proved a significant decrease in neck pain (evaluated by Visual Analog Scale or Numerical Rating Scale), and most of them showed improvement in functional status (measured by Oswestry Disability Index or Neck Disability Index). In addition, other pain assessment scales and function and quality of life measures (DN4 questionnaire, pain pressure threshold, cervical lateral flexion range of motion, Japanese Orthopedic Association scale, 12- and 36-Item Short Form Surveys, modified MacNab criteria, and analgesic drug intake reduction) were used. Changes in these measurements also mostly supported the efficacy of O2-O3 treatment. No significant complications of the treatment were reported. The available evidence is sparse, but despite this, the O2-O3 treatment of musculoskeletal neck pain can be considered potentially beneficial and relatively safe.

Previous Lumbar Spine Surgery Decreases the Therapeutic Efficacy of Dorsal Root Ganglion Pulsed Radiofrequency in Patients with Chronic Lumbosacral Radicular Pain.

Chronic lumbosacral radicular pain (CLRP) as a possible adverse consequence of lumbar spine surgery represents a serious medical challenge. Pulsed radiofrequency of dorsal root ganglion (PRF-DRG) treatment is known to be effective in alleviating CLRP. This retrospective study compares the efficacy of a single CT-guided PRF-DRG procedure in the treatment of unilateral CLRP between patients without (non-PSS) and with (PSS) previous lumbar spine surgery. Non-PSS and PSS groups included 30 and 20 patients, respectively. Outcomes (pain intensity and disability) were evaluated by means of the visual analog scale (VAS) and Oswestry disability index (ODI) immediately after the procedure (VAS), as well as three and six months after the procedure, respectively. Non-PSS group showed a significant (p ˂ 0.001) decrease of VAS (median) at all follow-up intervals (from 6 to 4; 4; 4.5 points, respectively). The PSS group showed a significant yet transient VAS (median) decrease (from 6 to 5 points) immediately after the procedure only (p < 0.001). The decrease of VAS was more pronounced in the non-PSS group after three and six months (p = 0.0054 and 0.011, respectively) in intergroup comparison. A relative decrease of VAS ≥ 50% during follow-up was achieved in 40%; 43.3%; 26.7% (non-PSS), and 25%; 5%; 0% (PSS) of patients. ODI (median) significantly decreased in the non-PSS group (from 21.5 to 18 points) at three and six months (p = 0.014 and 0.021, respectively). In conclusion, previous lumbar spine surgery decreases the therapeutic efficacy of PRF-DRG procedure in CLRP patients.

Efficiency of interlaminar uniportal endoscopic lumbar discectomy.

AIM: Prospective evaluation of the results of endoscopic lumbar discectomy. METHODS: 95 patients were consecutively enrolled in the study between 2017 and 2021. We monitored low back pain and sciatica according to the Visual Analogue Scale (VAS), the limitations in daily activities (Oswestry Disability Index, ODI), overall satisfaction according to a 0-100 % scale, and the rate of surgical complications and reoperations. RESULTS: Postoperatively, the VAS values of low back pain and sciatica decreased significantly from 5 to 1 point and from 6 to 1 point, respectively, and the pain remained in the tolerable range (VAS 1-2) throughout the follow-up period. The ODI score improved significantly from severe disability (46 %), preoperatively, to moderate disability at discharge and one month after surgery (29 % and 22 %, respectively), down to minimal disability at 3 and 12 months after surgery (12 % and 14 %, respectively). Overall patient satisfaction improved significantly at all follow-up time points (46 %, 70 %, 77 %, 80 %, and 78 %, respectively). Reoperation rate was 6.3 %. Cerebrospinal fluid leakage was observed in one case only (1.1 %). Transient postoperative perianogenital sensory impairment occurred in two patients (2.1 %). There was no evidence of surgical site infection or haematoma. CONCLUSION: Endoscopic discectomy provides significant pain relief and improves the patient's ability to perform activities of daily living, contributing to greater satisfaction. It is a safe method with a low risk of surgical and neurological complications (Tab. 3, Fig. 3, Ref. 27).

Speed and quality of interbody fusion in porous bioceramic Al2O3 and polyetheretherketone cages for anterior cervical discectomy and fusion: a comparative study.

BACKGROUND: The objective of this prospective randomized monocentric study is to compare the speed and quality of interbody fusion of implanted porous Al2O3 (aluminium oxide) cages with PEEK (polyetheretherketone) cages in ACDF (anterior cervical discectomy and fusion). MATERIALS AND METHODS: A total of 111 patients were enrolled in the study, which was carried out between 2015 and 2021. The 18-month follow-up (FU) was completed in 68 patients with an Al2O3 cage and 35 patients with a PEEK cage in one-level ACDF. Initially, the first evidence (initialization) of fusion was evaluated on computed tomography. Subsequently, interbody fusion was evaluated according to the fusion quality scale, fusion rate and incidence of subsidence. RESULTS: Signs of incipient fusion at 3 months were detected in 22% of cases with the Al2O3 cage and 37.1% with the PEEK cage. At 12-month FU, the fusion rate was 88.2% for Al2O3 and 97.1% for PEEK cages, and at the final FU at 18 months, 92.6% and 100%, respectively. The incidence of subsidence was observed to be 11.8% and 22.9% of cases with Al2O3 and PEEK cages, respectively. CONCLUSIONS: Porous Al2O3 cages demonstrated a lower speed and quality of fusion in comparison with PEEK cages. However, the fusion rate of Al2O3 cages was within the range of published results for various cages. The incidence of subsidence of Al2O3 cages was lower compared to published results. We consider the porous Al2O3 cage as safe for a stand-alone disc replacement in ACDF.

Synovial sarcoma of the tibial nerve - case report of a rare tumor in a rare location requiring early diagnosis.

BACKGROUND: We present the case of a patient with a rare synovial sarcoma (SS) of the tibial nerve. So far, only 4 cases of patients with SS originating from the tibial nerve have been described in the literature, and our patient is only the second patient whose limb was saved during treatment. Synovial sarcomas are malignant mesenchymal tumors, i.e., tumors arising from connective tissue. Synovial sarcomas account for 5-10% of all soft tissue sarcomas. However, the name synovial sarcoma is misleading, because the tumor does not originate from synovial cells, but rather from primitive mesenchymal cells. The name most likely originated from the localization around the large joints on the limbs, more often on the lower ones, in the area of the knee joints. We point out the aspects of correct and quick diagnosis and subsequent treatment, which has very important effect on the patient's prognosis. Primary less radical excision without prior biopsy verification leads to a higher risk of local recurrence, even if a proper reexcision was performed immediately after biopsy verification of the sarcoma. CASE PRESENTATION: A woman born in 1949 began to suffer at the end of 2020 with escalating pain under the left inner ankle with a projection to the sole and fingers. Her personal, family work and social history were insignificant. After the initial neurological examination, the patient was sent for an ultrasound examination of the ankle, which showed a lobular mass measuring 50 × 22 × 16 mm and according magnetic resonance imaging, the finding appeared to be a suspicious neurinoma of the tibial nerve. The tumor was surgically excised, without prior biopsy verification: a 50 × 20 mm tumor was dissected in the distal part of the tarsal canal, which grew through the structure of the tibial nerve and in some places into the surrounding area and appeared intraoperatively as a neurofibroma. But histologically the tumor was classified as monophasic synovial sarcoma. The patient was indicated for a wide reexcision of the skin with the subcutaneous tissue of size 91 × 20 × 15 mm. Now the patient is being treated with external radiotherapy to the tumor bed and she is able to walk. CONCLUSION: This report draws attention to a rare type of malignant nerve tumor, which both clinically and radiologically can mimic benign peripheral nerve sheath tumors. Synovial sarcoma should be considered in very painful resistances, typically located around the joints of the lower limbs, the growth of which can be slow. Because the size of the tumor is a negative prognostic factor, it is necessary to make a timely diagnosis using MR imaging and a biopsy with histological examination and to start treatment quickly. Surgical treatment should take place only after a biopsy with histological examination of the tumor so that it is sufficiently radical and does not have to undergo an additional reoperation, as happened in the case of our patient.

The Need for Emphasis on Intracranial Hypertension Management in Spontaneous Skull Base Meningoencephaloceles.

OBJECTIVE: To provide an analysis of patients with spontaneous skull base meningoencephaloceles (MECs) to determine whether definitive surgical treatment requires management of elevated intracranial pressure (ICP). METHODS: Data of 10 subjects with spontaneous MECs were collected and retrospectively evaluated. Measurement of ICP, prior interventions, treatment with acetazolamide, and characteristics of long-term elevated ICP, among others, were analyzed. Our own indications for cerebrospinal fluid (CSF) diversion and use of postoperative external lumbar drain were analyzed as well. RESULTS: The sphenoid region was the most common location of MECs. CSF leak was diagnosed in all subjects. The most common graphical signs of elevated ICP were empty sella and arachnoid pits, both of which were present in 90% of cases. Lumbar puncture with opening pressure measurement was performed in 7 patients. Ventriculoperitoneal shunt insertion was indicated in 4 cases before skull base repair and in 2 cases after skull base repair. Two postoperative CSF leaks were managed with external lumbar drain and subsequent shunt installation. CONCLUSIONS: Spontaneous MECs are often associated with CSF leak. ICP assessment should be a standard of care to ensure successful operative repair of MECs. Insertion of a CSF diversion device must be considered where direct or indirect signs of intracranial hypertension are present.

Enhancement of subarachnoid space during magnetic resonance imaging of endolymphatic hydrops: a case report.

Enhancement of the subarachnoid space after intravenous administration of gadolinium contrast agent is not common. Enhancement usually occurs in pathological conditions that increase the permeability of the blood-cerebrospinal fluid barrier, most notably in meningitis. We herein describe possible subarachnoid enhancement in patients with no apparent effect on the meninges. These patients had clinical signs of Meniere's disease and underwent specific magnetic resonance imaging of the inner ear to possibly visualize endolymphatic hydrops. The endolymphatic space can be noninvasively imaged by intravenous administration of contrast agent, usually at a double dose, 4 hours before the scanning process. During this time, the contrast agent penetrates not only the perilymph but also the subarachnoid space, where the highest concentration occurs after 4 hours according to some studies.

Comparison of Pulsed Radiofrequency, Oxygen-Ozone Therapy and Epidural Steroid Injections for the Treatment of Chronic Unilateral Radicular Syndrome.

Background and objectives: For the treatment of chronic unilateral radicular syndrome, there are various methods including three minimally invasive computed tomography (CT)-guided methods, namely, pulsed radiofrequency (PRF), transforaminal oxygen ozone therapy (TFOOT), and transforaminal epidural steroid injection (TFESI). Despite this, it is still unclear which of these methods is the best in terms of pain reduction and disability improvement. Therefore, the purpose of this study was to evaluate the short and long-term effectiveness of these methods by measuring pain relief using the visual analogue scale (VAS) and improvement in disability (per the Oswestry disability index (ODI)) in patients with chronic unilateral radicular syndrome at L5 or S1 that do not respond to conservative treatment. Materials and Methods: After screening 692 patients, we enrolled 178 subjects, each of whom underwent one of the above CT-guided procedures. The PRF settings were as follows: pulse width = 20 ms, f = 2 Hz, U = 45 V, Z ˂ 500 Ω, and interval = 2 × 120 s. For TFOOT, an injection of 4-5 mL of an O2-O3 mixture (24 µg/mL) was administered. For the TFESI, 1 mL of a corticosteroid (betamethasone dipropionate), 3 mL of an anaesthetic (bupivacaine hydrochloride), and a 0.5 mL mixture of a non-ionic contrast agent (Iomeron 300) were administered. Pain intensity was assessed with a questionnaire. Results: The data from 178 patients (PRF, n = 57; TFOOT, n = 69; TFESI, n = 52) who submitted correctly completed questionnaires in the third month of the follow-up period were used for statistical analysis. The median pre-treatment visual analogue scale (VAS) score in all groups was six points. Immediately after treatment, the largest decrease in the median VAS score was observed in the TFESI group, with a score of 3.5 points (a decrease of 41.7%). In the PRF and TFOOT groups, the median VAS score decreased to 4 and 5 points (decreases of 33% and 16.7%, respectively). The difference in the early (immediately after) post-treatment VAS score between the TFESI and TFOOT groups was statistically significant (p = 0.0152). At the third and sixth months after treatment, the median VAS score was five points in all groups, without a statistically significant difference (p > 0.05). Additionally, there were no significant differences in the Oswestry disability index (ODI) values among the groups at any of the follow-up visits. Finally, there were no significant effects of age or body mass index (BMI) on both treatment outcomes (maximum absolute value of Spearman's rank correlation coefficient = 0.193). Conclusions: Although the three methods are equally efficient in reducing pain over the entire follow-up, we observed that TFESI (a corticosteroid with a local anaesthetic) proved to be the most effective method for early post-treatment pain relief.

Is percutaneous computed tomography-guided biopsy sufficient to establish indolent lymphoma transformation?

INTRODUCTION: The aim of the study was to retrospectively evaluate the technical features, efficacy, accuracy, and relevant complications of computed tomography-guided biopsies in various anatomical localizations when diagnosing indolent lymphoma transformations, relapses, duplicate malignant diseases or benign processes. MATERIAL AND METHODS: From December 2007 to December 2017, 81 percutaneous biopsy procedures in 72 patients for tumors, sizes 17-232 mm in diameter (median length: 39 mm), were performed in patients with known indolent lymphomas in their clinical history. The patients were men in 41 cases and women in 31 cases, aged 36 to 86 years. RESULTS: In 79 cases (97.5%; 95% CI: 91.3-99.7) results were true positive or true negative; only 2 interventions (2.5%; 95% CI: 0.3-8.6) were histologically false negative. Transformation was verified in 29 cases (35.8%; 95% CI: 25.4-47.2), relapses in 30 cases (37%; 95% CI: 26.6-48.5), duplicate malignancy in 15 cases (18.5%; 95% CI: 10.8-28.7) and benign processes in 7 cases (8.7%; 95% CI: 3.5-17.0). Eight complications in total were revealed, 7 of which were in consequence of thoracic cavity biopsy. A statistically significant relationship between the complication incidence and anatomical localization in the thoracic cavity was identified (p = 0.0104). CONCLUSIONS: Percutaneous CT guided biopsy performed in patients with a history of indolent lymphoma had high accuracy in establishing the correct diagnosis regarding transformation, relapse, duplicate malignancy or a benign process. Simultaneously, the complication rate was low.

Reduction of effective dose and organ dose to the eye lens in head MDCT using iterative image reconstruction and automatic tube current modulation.

AIMS: To compare the effective and eye lens radiation dose in helical MDCT brain examinations using automatic tube current modulation in conjunction with either standard filtered back projection (FBP) technique or iterative reconstruction in image space (IRIS). METHODS: Of 400 adult brain MDCT examinations, 200 were performed using FBP and 200 using IRIS with the following parameters: tube voltage 120 kV, rotation period 1 second, pitch factor 0.55, automatic tube current modulation in both transverse and longitudinal planes with reference mAs 300 (FBP) and 200 (IRIS). Doses were calculated from CT dose index and dose length product values utilising ImPACT software; the organ dose to the lens was derived from the actual tube current-time product value applied to the lens. Image quality was assessed by two independent readers blinded to the type of image reconstruction technique. RESULTS: The average effective scan dose was 1.47±0.26 mSv (FBP) and 0.98±0.15 mSv (IRIS), respectively (33.3% decrease). The average organ dose to the eye lens decreased from 40.0±3.3 mGy (FBP) to 26.6±2.0 mGy (IRIS, 33.5% decrease). No significant change in diagnostic image quality was noted between IRIS and FBP scans (P=0.17). CONCLUSION: Iterative reconstruction of cerebral MDCT examinations enables reduction of both effective and organ eye lens dose by one third without signficant loss of image quality.