Article by Dr. Blionas, published in Eleftheros Typos

A note on the figures in this article. The percentages below describe the proportion of patients who improve. They are not the same as the additional benefit a treatment provides over and above natural recovery. Because sciatica improves on its own in a large proportion of patients, response rates are always considerably higher than the measured effect of the treatment itself. For the comparison of treatments on a like-for-like basis, see: Treatment Options for Sciatica — A Graded Ranking Based on the Evidence.

We frequently see patients presenting with sciatica or low back pain in whom MRI reveals a herniated disc, spinal stenosis, or instability — causing compression and irritation of nerves and surrounding structures, and producing these distressing symptoms. What happens next?

What treatment options are available?

There are many, with surgery always as the last resort. Before surgery — and even before medication or interventional procedures — come lifestyle measures: avoiding heavy lifting, strengthening the abdominal and back muscles, and simply resain’t with specialist follow-up. Weight loss also plays a role, though it takes longer and, on its own, has moderate efficacy. Together, these simple measures can resolve the problem in up to 70% of patients. In the acute phase, however, many of them are not feasible — strengthening the paraspinal muscles, for instance.

The “other” solutions

Where these simple measures cannot be applied, or prove ineffective, several options remain before surgery.

The first step is usually pharmacological treatment. Medication is a reasonable option, but has the drawback that patients often need to take it long term. Some drugs cannot be safely given for prolonged periods and carry contraindications and side effects that make them unsuitable for certain patients. The efficacy of pharmacotherapy also does not typically exceed 70%.

When a patient does not improve on medication, or cannot take it because of contraindications or side effects, several minimally invasive options may be tried before surgery is considered. These include local injections of analgesic or anti-inflammatory agents at the site of pain, and anti-inflammatory injections into the epidural space — that is, within the spinal canal.

Properly applied, these minimally invasive methods can achieve success rates of up to 70%, allowing the patient to avoid an operation. Should they fail and surgery be decided upon, it is worth bearing in mind that surgical efficacy falls within a similar, or somewhat higher, range (70–90%).

Ozone therapy

Among the minimally invasive methods is the use of medical ozone. The technique has a defined mechanism of action and is used in several countries, including Switzerland, Germany, and Italy, as well as at various university centers in Europe. Published studies report efficacy approaching that of surgical intervention — in some series up to 90% — with very low complication rates and without the absolute contraindications frequently associated with pharmacotherapy.

Ozone acts by normalizing cytokine and prostaglandin levels, producing anti-inflammatory and analgesic effects. Its effect can also be visible on MRI: post-treatment imaging may show reduced inflammation, marked disc dehydration, and a significant increase in the space within the spinal canal through which the nerves travel.

How ozone therapy is performed

The method is based on paravertebral intramuscular injection of a medical oxygen–ozone gas mixture, close to the affected area. After administration, enzymatic activation leads to the inactivation of free radicals, enhancing the body’s natural repair mechanisms and neutralizing the formation of reactive molecules. The result is a reduction in inflammation and in disc volume, and therefore in the pressure exerted on the neural structures — culminating in symptom relief.

As with most methods based on local administration of a substance into the spine, ozone therapy is most effective for localized lumbar pain, that is, low back pain. Because its anti-inflammatory action extends a reasonable distance from the injection site, however, it may also benefit cases of sciatica.

In patients who have already undergone surgery without adequate results, ozone therapy is a reasonable option alongside other minimally invasive techniques, since it carries substantially lower complication rates at comparable levels of efficacy.

It is also acceptable as a first-line option, particularly for patients who prefer to avoid pharmacological treatment, or who have contraindications or side effects to it.