Medical ozone therapy in facet joint syndrome: an overview of sonoanatomy, ultrasound-guided injection techniques and potential mechanism of action

Abstract

Facet joint osteoarthritis is the most prevalent source of facet joint pain and represents a significant cause of low back pain. Oxygen-ozone therapy has been shown to have positive results in acute and chronic spinal degeneration diseases and it could be a safe and efficacious alternative to traditional facet joint conservative treatments. This review article explains the interventional facet joint management with ultrasound-guided oxygen-ozone therapy, providing an anatomy/sonoanatomy overview of lumbar facet joints and summarizing the potential mechanism of action of oxygen-ozone in the treatment of facet joint osteoarthritis, not yet fully understood.

Keywords: facet joint; facet joint injection; facet joint management; facet joint syndrome; facet joint ultrasound-guided injections; low back pain; oxygen-ozone; ozone; ozone therapy; ultrasound-guided oxygen-ozone therapy.

Figure 1

Imaging results of effect of facet joint injection with oxygen-ozone (O₂–O₃). Note: (A) Paramedian sagittal transverse processes view. The hyperechoic reflections of the transverse processes (TP) with their acoustic shadow produce the “trident sign.” The psoas muscle (PM) with its typical hypoechoic and striated appearance, is visible between the transverse processes. The erector spinae muscle (ESM) lies superficially to the transverse processes. (B) Paramedian sagittal articular process view. The articular processes are visible as a continuous hyperechoic line of “humps” with acoustic shadowing beneath, and the bony contour of the superior articular process (SAP) is usually more superficial than the inferior articular process (IAP). The facet joint space (arrowhead) is situated between the articular lines of the SAP and IAP. The ESM lies superficially to the articular processes. (C) Paramedian sagittal oblique view. The sacrum (arrowhead) is recognizable as a horizontal hyperechoic curvilinear structure, the L3–5 laminae (arrows) have the typical “sawtooth” appearance, and the erector spinae muscles (asterisk) are hypoechoic and lie superficial to the laminae. (D) Transverse interlaminar view. Interspinous ligament (ISL) is visible in the midline. The articular process (AP) and the TP are visible laterally on either side of the midline. (E) Ultrasound-guided facet joint injections in lateral to medial approach. The asterisk indicates the entry zone (hypoechoic space) into the lumbar facet joint between the medial aspect of the IAP and the lateral aspect of the SAP. The arrowheads indicate the needle trajectory. (F, G) Facet joint injection with O₂–O₃ in transverse sonogram. (F) The medial aspect of the IAP and the lateral aspect of the SAP is easily recognizable. (G) The O₂–O₃ mixture (arrowheads) appears as hyperechoic area in the peri-facet joint soft tissue with a well-defined shadow beneath. The O₂–O₃ mixture was produced by means of a Multiossigen Medical 99IR generator (Multiossigen S.p.A., Gorle, Italy). (H) Ultrasound-guided facet joint injections in caudal to cranial approach. The articular processes are visible as a continuous hyperechoic line of “humps” with acoustic shadowing beneath. The needle (arrowheads) is directed to the space (asterisk) between the articular lines of the SAP and IAP. A–D were obtained by means of a Mindray DC-60 Ultrasound (Mindray Medical S.R.L, Milano, Italy). E–H were obtained by means of a ESAOTE MyLab OMEGA Ultrasound (Esaote S.p.A, Genova, Italy).

Figure 2

Potential mechanism of action of oxygen-ozone therapy. Note: Oxidative stress is involved in NF-κB pathways activation. NF-κB signaling induces the release of proinflammatory cytokines (IL-1β, IL-6, TNF-α, COX-2), implicated in the inhibition of extracellular matrix components synthesis and in matrix metalloproteinase activation causing cartilage damage, disturbance of the metabolic balance of the cartilage matrix, until apoptosis. Oxygen-ozone mixture attenuates inflammatory responses by inhibiting the activation of NF-κB pathway, resulting in cell proliferation and survival. ATP: Adenosine triphosphate; COX-2: cyclooxygenase-2; IκB: inhibitor of nuclear factor-κB; IL: interleukin; NF-κB: nuclear factor-κB; TNF-α: tumor necrosis factor-α.