Abril - 2017

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2017; 63(4):355-360

joint facet arthropathy, which may not correlate with

clinical findings, particularly in the elderly.

4,10

As an initial therapeutic measure for LBP, rest is in-

dicated in all cases.

Symptomatic treatment can be

performed with analgesics, non-hormonal anti-inflam-

matory drugs, corticosteroids, muscle relaxants, benzo-

diazepines or tricyclic antidepressants, according to the

underlying disease, as well as physiotherapy and weight

control.

1,4,5

In cases where conservative treatment was

not satisfactory, when there are neurological deficits and/

or compressive syndromes, surgery should be consid-

ered.

12,13

Of the surgical indications associated with LBP,

disc herniation is one of the most frequent. Surgery may

be performed through an open approach (hemilaminec-

tomy plus flavectomy at the level of the involved spinal

root, as well as hernia repair)

or using a minimally in-

vasive procedure.

According to Martin et al.,

the fail-

ure rates of surgery for degenerative diseases of the lum-

bar spine may exceed 40% in the first year. Therefore, there

may be poorly indicated surgeries, which contributes to

the worsening of pain and favors a progression to failed

back surgery syndrome (FBSS).

FBSS is defined as “spinal lower back pain of unknown

origin that persists at the same site of the original pain

despite surgical interventions, or appears after the pro-

cedure.”

Despite the term “unknown origin,” it is believed

that the causes of FBSS include disc infection,

epidural

fibrosis and local arachnoiditis,

and even joint facet

instability due to reduced intervertebral space and con-

sequently altered vertebral angle. FBSS is more frequent

as myofascial pain syndrome (MPS), being diagnosed in

85.7% of these patients.

MPS is a regional musculoskel-

etal pain derived from trigger points with motor dysfunc-

tion and autonomic phenomena, which usually affect

one or more muscle groups. A neuropathic pattern, alone

or associated with MPS, is less frequent.

Among the treatment modalities for cases that prog-

ress to FBSS, conservative behaviors, such as medication

and rehabilitation, often yield unsatisfactory results.

Retrospective studies suggest that surgical revisions tend

to have lower rates of improvement than the initial pro-

cedure.

18-20

Some authors mention that lysis of epidural

adhesions may be a therapeutic option,

2,21

but there is

no consensus.

Treatment with spinal cord stimula-

tion

23,24

and intrathecal drug delivery

25,26

produce good

results, but these are procedures that involve high cost

and limited availability. Nevertheless, compared with

the costs related to hospital stay and reoperation, these

procedures may actually cost less and provide better

long-term results.

In the last two decades, the application of ozone has

emerged as a potential therapeutic option for patients with

FBSS. It is suggested that ozone is useful for treating LBP

due to its analgesic and anti-inflammatory properties.

28,29

Although ozone therapy is not validated to treat FBSS, its

cost is low and it is a minimally invasive procedure, which

opens a new therapeutic horizon for the treatment of FBSS,

a condition known to be debilitating and whose treatment

is often frustrating for both physicians and patients.

ethod

A retrospective analysis was carried out including 19 pa-

tients treated with epiduroscopy for adhesiolysis

and

20 mL of a ozone-oxygen mixture at the concentration of

30 ug/mL from January 2013 to June 2014, following the

protocol published by Magalhães.

The patients came

from the Pain Center of the Department of Neurology of

the Faculty of Medicine of the University of São Paulo

and were selected according to the following criteria:

•

Inclusion criteria: Age between 18 and 70 years inclu-

ding both sexes; being able to inform the requested

data, either in the presence of chronic radiating LBP

or not, resulting from herniated disc for more than

one year; having undergone surgery and progressed

without improvement, presenting symptoms and

diagnosis of FBSS.

•

Exclusion criteria: Diagnosis of blood dyscrasia, he-

mophilia, hemolytic anemia, oncological diseases, acu-

te or chronic infections, pregnancy, psychiatric condi-

tions, diabetic neuropathy; diagnosis of favism and

hyperthyroidism, which are contraindications to ozo-

ne therapy; presence of lumbosacral abnormality that

could make the procedure unfeasible; other abnorma-

lities in the spine such as segmental instability, canal

stenosis, spondylolisthesis or scoliosis > 20º.

Pain and disability assessments were performed based on

specific scales and validated in Portuguese. Visual Ana-

logue Scale (VAS) and Neuropathic Pain Symptom Inven-

tory (NPSI) were used to assess pain. The Oswestry Dis-

ability Index (ODI) and the Roland Morris Disability

Questionnaire were used for disability. The Brief Pain

Inventory (BPI) assesses both pain intensity and disabil-

ity caused by it, and therefore was also included. The

Neuropathic Pain Diagnostic Questionnaire (Douleur

Neuropathique 4 – DN4) was used to diagnose neuro-

pathic pain. The selected patients were interviewed and

examined until a week before and 21 days after epidur-

oscopy with ozone therapy, and the scales were applied

on both occasions.