A MetaAnalysis of the
Effectiveness and Safety of
Ozone Treatments for
Herniated Lumbar Discs
Jim Steppan PhD1
Thomas Meaders BS1
Kieran Murphy MD FRCPC2
Mario Muto MD3.
1 ActiveO,
Salt Lake City, Utah
www.activeospine.com
2 University of Toronto
3 A. Cardarelli Hospital, Naples, Italy
1
2
3
Normal
Central
Foraminal
Subarticular
Extraforaminal
4
5
6
7
8
Patient Prepped and Needle Positioned
into Herniated Disc Using CT Guidance
Needle Penetration in L2 L3 Disc of Patient 027
9
Contained Intradiscal
3 cc Oxygen/Ozone Gas
CT Image of L2-L3 Disc of Patient 027
from the ActiveO Clinical Trial prior to
Ozone-Oxygen Gas Injection
CT Image of L2-L3 Disc of Patient 027
from the ActiveO Clinical Trial after
Ozone-Oxygen Gas Injection
10
The AO-1000 Device
11
AO-1000 Design
12
MOA Studies
Relationship between MOA studies, clinical and animal trials, and
previous Italian studies
13
Mechanical Analysis of Disc Decompression
14
MOA Studies
Relationship between MOA studies, clinical and animal trials, and
previous Italian studies
15
Animal Studies
16
Animal Studies
17
Histology
18
Histology
Needle-only control
3 wt% O3
19
Histology
2% O3
2% O3
20
MOA Studies
Relationship between MOA studies, clinical and animal trials, and
previous Italian studies
21
Disc Anatomy and Composition
A). Side View Sketch of Intervertebral Disc
[1]
B). Sketch of Nucleus Pulposus[1]
PP Raj, Intervertebral Disc: Anatomy-Physiology-Pathophysiology-Treatment,” Pain Practice, 8(1), 18-44, (2008).
22
Disc Anatomy and Composition
• Aggrecan, the major proteoglycan of the disc, is responsible for maintaining
tissue hydration through the osmotic pressure provided by its constituent
chondroitin and keratan sulfate chains
• Aggregan consists of a large (over 2000 amino acids) core protein with
multiple carbohydrate side chains (glycosaminoglycans (GAGs))
• GAG chains of chondroitin sulfate and keratan sulfate covalently bonded to a
polypeptide core
Schematic of Aggrecan2 (PG)
IGD: Interglobular domain between G1
and G2
KS: keratan sulfate region
cp: core protein
GAG: glycosaminoglycan chains
CS: chondroitin sulfate brush region
N: amine-terminal
C: carboxyl-terminal
G1, G2, G3: globular domains
AFM Image of Fetal Episeal Aggrecan Monome
[2] L. Ng., etal., “Individual cartilage aggrecan macromolecules and their constituent glycosaminoglycans visualized via atomic force microscopy,” J. Structural
23
Biology, 1453, 242-257, (2003).
AO-1000 Mechanism of Action (MOA)
•
The AO-1000™ creates ozone which subsequently cleaves (directly or
indirectly) the proteoglycans (PG) in the nucleus pulposus (NP)
It is well known [1],[2] that ozone can react with organic compounds (like PG) in
aqueous media both directly via Reaction 1 and indirectly via Reactions 2, 3,
and 4.
•
reaction
( Rxn 1) O3  PG direct
 ozone


 PG oxidation products
decomposition
( Rxn 2) O3 
  O2  O
( Rxn 3) O  H 2 O 
 2 HO 
( Rxn 4) HO   PG  PG oxidation products
impact dissociation
( Rxn 5) H 2 O  e  electron

   H   HO 
[1]
[2]
“Alternative Disinfectants and Oxidants,” EPA Guidance Manual, Chapter 3: Ozone, (1999).
B Langlais, et al., “Fundamental Aspects,” Ozone in Water Treatment Application and Engineering, 11-132, (1991).
24
Ozone Reaction with GAGs
•
•
AO-1
800
0 min-1
800
MW = 23,800
700
700
MW = 6600
600
600
500
500
CPM
•
ActiveO and Dr. Balagurunathan (U of Utah) characterized the reaction of ozone with GAGs
A Chinese hamster ovary (CHO) cell line (CHO was also used in Dewey’s benchmark work
on thermal necrosis) was used to obtain GAGs that were similar in composition to those
found in human NP.
GAG samples were treated with 2 wt% ozone in oxygen from the AO-1000™ device and the
samples were then analyzed by high performance liquid chromatography (HPLC) with
radioisotope detection.
Ozone fragments the GAGs as indicated by the appearance of an elution peak at 13.5
minutes and a decrease in the amount of GAGs eluting at retention time over 40 minutes
Exposure of GAGs to an oxygen-only control did not cause any fragmentation.
CPM
•
•
400
400
300
300
200
200
100
100
0
0
20
40
60
Time (min)
a. GAGs with no ozone exposure
80
0
0
20
40
60
80
Time (min)
b. GAGs after exposure to ozone
25
MOA Studies
Relationship between MOA studies, clinical and animal trials, and
previous Italian studies
26
MOA Studies: Cytokine Testing
Left: Image showing puncture and
harvest sites
Below: Harvested discs –
transverse aspect
• Discs frozen in LN2 @ Lychron
• Discs shipped to U of U for
homogenation
• Homogenates shipped to
Pierce Bio in Mass. for ELISA
27
MOA Study: Why Cytokines?
IL-1β
IL-8
IL-6
TNF
IL-1b, IL-6, and TNF- are believed to
be associated with disc degeneration
(IL-1 is neurotoxic)
• IL-8 linked to enhanced disc healing
(IL-8 is neuroprotective)
• Studied 4 unique cytokines
• Each cytokine measured in triplicate
• Samples measured “neat”, e.g. no dilution
28
MOA Study: Cytokine Analysis Results
IL-1Beta
1.60
• IL-1B shows increasing trend (w/ 2 wt% being optimal)
1.40
Disc Cytokine Concentration (pg/mL)
1.20
1.00
0.80
0.60
0.40
0.20
0.00
0
20
40
60
80
100
120
140
160
180
200
-0.20
Ozone Exposure (ug O3/g NP)
29
MOA Study: Cytokine Analysis Results
IL-6
60.00
Disc Cytokine Concentration (pg/mL)
50.00
40.00
30.00
• IL-6 shows similar increasing trend (w/ 2 wt% being optimal)
• Observed very elevated levels of IL-6 compared to other cytokines
20.00
10.00
0.00
0
20
40
60
80
100
120
140
160
180
200
Ozone Exposure (ug O3/g NP)
30
MOA Study: Cytokine Analysis Results
IL-8
• IL-8 shows similar increasing trend (w/ 2 wt% being optimal)
4.50
4.00
Disc Cytokine Concentration (pg/mL)
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
0
20
40
60
80
100
120
Ozone exposure (ug O3/g NP)
140
160
180
200
31
MOA Study: Cytokine Analysis Results
• 2 wt% ozone induces highest response for all cytokines
• IL-1b and TNF- (pro-inflammatory) cytokine levels found
to increase in response to treatment/needle injection
• IL-8 (anti-inflammatory) found to increase in response to
treatment
• Increase in IL-1b and TNF- 2-days after treatment
believed to be due to recent stab incision and needle
injection into disc
• IL-8 produced in response to increased levels of
proinflammatory cytokines (IL-1b and TNF-)
32
Ozone’s Mechanism of Action
– Primary mechanism of action of the oxygenozone mixture injected into the herniated disc is
volume reduction (disc decompression)
– Ozone reacts with the GAGs in the NP which
ultimately results in subtle dehydration (volume
reduction) of the disc
– Secondary mechanism of action is related to
analgesic/antiinflammatory factors
33
Essentially
• Our model shows that volume removal of
0.28 cc (height reduction of 0.010 inch
(0.0254 cm) results in a pressure
reduction of 10 psi or dV of 30ul = 1 psi
• Our model confirms that significant
reductions in intradiscal pressure can
result from small volume (height) reduction
that may be undetectable by CT or MR
34
Purpose
– The purpose of this literature review and
analysis was to determine representative
outcomes of oxygen/ozone treatment for
herniated discs with respect to pain relief,
reduction of disability, and risk of
complications
35
Oxygen/Ozone Treatment
Contained Intradiscal
3 cc Oxygen/Ozone Gas
CT Image of L2-L3 Disc of Patient 027
from the ActiveO Clinical Trial prior to
Ozone-Oxygen Gas Injection
CT Image of L2-L3 Disc of Patient 027
from the ActiveO Clinical Trial after
Ozone-Oxygen Gas Injection
36
Methods
– A random-effects meta-analysis (DerSimonian
and Laird Weighted Least Squares) was used
to estimate treatment outcomes for
oxygen/ozone treatment of herniated discs.
– A literature search was performed, using
search terms associated with ozone treatment
of herniated discs, to obtain the relevant
studies for the meta-analysis.
37
Methods
– Due to the wide range of study quality, each
study was weighted in the meta-analysis by a
study-quality score that was based on
• Type of study – randomized, prospective, or
retrospective
• Whether a control arm was used
• Whether a statistical analysis was performed
• Whether the study was multi-center or single
center
38
Methods
– Separate meta-analyses were performed for each of
the pain and function scales most frequently used in
the studies:
• Visual Analog Scale (VAS) – Pain assessment (analyzed
mean VAS reduction)
• Oswestry Disability Index (ODI) – Pain and function
assessment (analyzed mean ODI reduction).
• Modified MacNab Scale – Pain and function assessment
(analyzed percentage of patients improving 1 category or
more).
– A meta-analysis for the overall complication rate,
based on the reported study complications, was also
performed.
39
Literature Search Results
– Twelve (12) articles met the inclusion criteria
from our literature search and were included
in the meta-analysis.
– The included articles summarized data from
the ozone treatment of over 8000 patients
from multiple centers in multiple locations.
40
Meta-analyses Results
– The overall estimated mean improvement:
• VAS = 3.9 (3.2 – 4.5, 95% CI)
• ODI = 25.7 (18.8 – 32.6, 95% CI)
– The estimated chance of improvement:
• Modified MacNab = 79.7% (74.2% – 84.2%, 95%CI)
– The means for the VAS and ODI outcomes are well
above both the minimum clinically important
difference and the minimum (statistically-significant)
detectable change.
– The estimated chance of complication:
• = 0.003% (0.000% – 0.024%, 95% CI)
• There were no serious complications reported.
41
Improvement in VAS Scores after Oxygen/Ozone Treatment of Herniated Discs
95% CI Weight
NA
3.9
3.21-4.54 NA
NA
Random Effects Model
(All Ozone Studies)
NA
3.5
2.83-4.18 NA
9
ActiveO Clinical Trial
NP
3.7
3.02-4.38 0.870
28
Buric: Ozone Arm
2005
4.0
3.03-4.97 1.000
20
Muto: All Arms
2008
4.7
4.65-4.75 0.838
22
Oder: Bulging Disc
2008
3.5
3.21-3.79 0.819
22
Oder: Herniated Disc
2008
3.5
3.19-3.81 0.817
23
Buric
2003
3.8
3.36-4.18 0.534
22
Oder: Non-Discal
2008
2.7
2.31-3.09 0.805
22
Oder: Post Operative
2008
3.0
2.48-3.52 0.782
22
Oder: Osteochondrosis
2008
2.5
1.91-3.09 0.766
26
CMS: SpineWand Meta-Analysis 2008
3.6
2.29-4.91 0.000
2
Butterman: Discectomy Arm
2004
5.9
5.56-6.24 0.000
28
Buric: Microdiscectomy Arm
2005
4.1
2.40-5.80 0.000
0.0
1.0
Minimum Clinically Important Difference
Year Mean Imp
VAS Minimum Detectable Change
Ref Lead Author: Study Arm
Random Effects Model
NA
(Comparable Studies)
2.0
3.0
4.0
5.0
6.0
7.0
Mean Improvement (Before - After) in VAS Score
Comparable Studies
Studies Not Meeting AO-1000 (Ref 9) Inclusion/Exclusion Criteria
Non-Ozone (Control Arm) Treatments
Random Effect Model (All Ozone Studies)
Random Effects Model (Comparable Studies)
Improvement in ODI Scores after Oxygen/Ozone Treatment of Herniated Discs
NA
Lead Author: Study Arm
Random Effects Model
(Comparable Studies)
Random Effects Model
(All Ozone Studies)
Year Mean Imp
95% CI
Weight
NA
25.7
18.82-32.61
NA
NA
21.0
14.14-27.94
NA
9
ActiveO Clinical Trial
NP
28.4
22.97-33.83 0.675
21
Gallucci: Ozone+Steroid
2007
45.8
42.35-49.17
1.000
28
Buric: Ozone Arm
2005
16.2
4.29-28.18
0.706
20
Muto: All Arms
2008
30.0
29.55-30.45
0.615
22
Oder: Bulging Disc
2008
16.5
14.34-18.66
0.609
22
Oder: Herniated Disc
2008
24.5
22.23-26.77
0.608
32
Leonardi: Long Term
2006
10.8
6.54-15.12
0.394
32
Leonardi: Short Term
2006
9.8
4.67-14.83
0.388
22
Oder: Non-discal
2008
12.0
9.11-14.89
0.604
22
Oder: Post operative
2008
5.0
1.2-8.8
0.596
22
Oder: Osteochondrosis
2008
8.0
3.67-12.33
0.591
27
Mirzai: SpineWand
2007
30.7
27.86-33.54
0.000
2
Butterman: Discectomy Arm 2004
36.5
32.88-40.12
0.000
28
Buric: Microdiscectomy Arm 2005
24.2
7.64-40.83
0.000
21
Gallucci: Steroid Only
36.6
33.06-40.1
0.000
2007
0
ODI Minimum Detectable Change
NA
Minimum Clinically Important Difference
Ref
10
20
30
40
50
Mean Improvement (Before - After) in ODI Score
Comparable Studies
Random Effect Model (All Ozone Studies)
Studies Not Meeting AO-1000 (Ref 9) Inclusion/Exclusion Criteria
Random Effects Model (Comparable Studies)
Non-Ozone (Control Arm) Treatments
Study Weight
Improvement in Modified MacNab Scores after Oxygen/Ozone Treatment of Herniated Discs
Percent Chance of Improvement in MacNab Score
50%
Ref
Lead Author: Study Arm
Year
Imp (%)
NA
95% CI
Random Effects Model
(Comparable Studies)
NA
79.68
74.22 - 84.24
NA
NA
Random Effects Model
(All Ozone Studies)
NA
78.17
72.54 - 82.92
NA
9
ActiveO Clinical Trial
NP
79.00
65.57 - 88.14 0.463
36
Andreula: Ozone
2003
70.30
64.88 - 75.20 1.000
36
Andreula: Ozone+Steroid
2003
78.30
73.28 - 82.60 0.982
20
Muto: Soft disc herniation
2008
75.00
73.32 - 76.61 0.644
35
Muto: All
2004
75.00
73.15 - 76.77 0.642
20
Muto: Multiple herniations
2008
77.00
72.30 - 81.11 0.600
37
He
2003
77.00
71.47 - 81.73 0.389
34
Ying
2005
93.00
89.65 - 95.32 0.347
33
Qing
2005
97.00
95.29 - 98.10 0.333
20
Muto: FBSS
2008
60.00
53.06 - 66.56 0.586
60%
70%
80%
90%
95%
97.5%
Weight
1.00
10.00
100.00
Odds of Improvement in MacNab Score
Comparable Studies
99%
Studies Not Meeting AO-1000 (Ref 9) Inclusion/Exclusion Criteria
Random Effect Model (All Ozone Studies)
Random Effects Model (Comparable Studies)
Complication Rate during and/or after Oxygen/Ozone Treatment of Herniated Discs
0%
Ref
Lead Author: Study Arm
Random Effects Model
(All Studies)
Year Complications (%)
NA
0.003
9
ActiveO Clinical Trial
NP
0.000
0.000 - 0.000 0.016
20
Muto: All
2008
0.000
0.000 - 0.000 1.000
35
Muto: All
2004
0.000
0.000 - 0.000 0.987
36
Andreula: Ozone+Steroid
2003
0.000
0.000 - 0.000 0.370
37
He
2003
0.000
0.000 - 0.000 0.303
23
Buric
2003
0.000
0.000 - 0.000 0.065
21
Gallucci: Ozone+Steroid
2007
0.000
0.000 - 0.000 0.042
32
Leonardi: Long Term
2006
0.000
0.000 - 0.000 0.017
32
Leonardi: Short Term
2006
0.000
0.000 - 0.000 0.009
28
Buric: Ozone Arm
2005
0.000
0.000 - 0.000 0.006
33
Qing
2005
0.499
0.000 - 1.062 0.004
36
Andreula: Ozone Only
2003
0.668
0.000 - 1.590 0.001
34
Ying
2005
2.478
0.783 - 4.174 0.000
22
Oder: All
2008
6.120
4.235 - 8.005 0.000
NA
95% CI
1%
2%
Percent Chance of Complication
3%
4%
5%
6%
7%
Weight
0.000 - 0.024 NA
0
0.01
0.02
0.03
0.04
0.05
0.06
Proportion of Patients with Complication
0.07
0.08
Summary of Reported
Complications
– Qing 2005
• A few patients demonstrated Hypogastric, lumbar, and lowerextremities pain and distention and difficulty urinating
• Symptoms resolved without intervention in 24 hours
– Andreula 2003
• Two patients had impaired sensitivity in the lower limb due to
periganglionic injection of anesthetic
• Symptoms resolved without intervention in 2 hours
– Ying 2005
• A few patients had mild pain in the lumbar spine or leg after ozone
injection – resolved without intervention in several minutes
• Eight patients had mild respiratory impairment, dyspnea and cornea
stimulates due to breathing ozone – resolved upon leaving the
ozone environment and breathing oxygen
– Oder 2007
• 6% of the patients complained of transient aggravation of the
symptoms
46
Check for Bias
– Bias - possibility of published articles underestimating or over-estimating the treatment effect
– To assess for bias we used a quantitative linear
regression test.
– An unbiased meta-analysis should have good linearity
between studies when the precision of each study is
plotted against the standardized effect.
– If the neutral (unbiased) linear regression line (forced
through zero on the y-axis) is within the 90% CI of the
“biased” linear regression line, then there is no
statistical evidence of bias.
– Deviation of the “biased” linear regression line from
the neutral (unbiased) line shows the amount of bias
between studies.
47
VAS Linear Regression Bias Test
VAS Standaridized Effect (Study Treatment Effect / StDev of Study)
200
Bias Linear Regression Line (with 90% CI)
y = 4.852x - 6.574
R2 = 0.997
Probability that Regression Line Intersects Y-axis at Zero
(p<0.1 Indicates Bias at 90% CI)
p = 0.001
150
20 Muto: All Arms
100
Non-Bias Linear Regression Line
y = 4.5574x
R2 = 0.9872
50
9 ActiveO Clinical Trial
23 Buric
22 Oder: Bulging Disc
22 Oder: Herniated Disc
22 Oder: Non-Discal
22 Oder: Post Operative
0
22 Oder: Osteochondrosis
28 Buric: Ozone Arm
-50
0
5
10
15
20
25
30
Precision (1 / Standard Deviation (StDev) of Study)
35
40
45
ODI Linear Regression Bias Test
160
ODI Standaridized Effect (Study Treatment Effect / StDev of Study)
20 Muto: All Arms
140
Bias Linear Regression Line (with 90% CI)
y = 31.31x - 6.83
R2 = 0.97
120
Probability that Regression Line Intersects Y-axis at Zero
(p<0.1 Indicates Bias at 90% CI)
p = 0.03
100
80
Non-Bias Linear Regression Line
y = 28.358x
R2 = 0.9467
60
22 Oder: Herniated Disc
40
21 Gallucci: Ozone+Steroid
9 ActiveO Clinical Trial
20
22 Oder: Non-discal
32 Leonardi: Long Term
22 Oder: Osteochondrosis
0
-20
22 Oder: Bulging Disc
32 Leonardi: Short Term 22 Oder: Post operative
28 Buric: Ozone Arm
0
0.5
1
1.5
2
2.5
3
3.5
Precision (1 / Standard Deviation (StDev) of Study)
4
4.5
5
Discussion of Results
– Pain and function outcomes are similar to the
outcomes for lumbar discs treated with
surgical discectomy, but the complication rate
is much less (<0.1%)
– In addition, the recovery time is significantly
shorter for the oxygen/ozone injection than for
the discectomy
50
Thank You
Kieran.Murphy@uhn.on.ca
www.activeospine.com
51