Ozone nucleolysis is a minimally invasive method for treating pain resulting from disc herniation and nerve root compression. Successfully used in Europe for over 25 years, it is an effective alternative to surgery for patients with sciatica, cervicobrachial neuralgia and discogenic spinal pain.

What is Medical Ozone and How Does it Act on the Disc?

Medical ozone (O₃) is a triatomic, unstable allotropic form of oxygen with potent oxidising properties. In nucleolysis, we use an oxygen-ozone mixture (O₂-O₃) produced in real time by a specialised medical ozone generator, at a precisely controlled concentration of 27–40 µg/ml (the critical concentration – higher concentrations destroy disc structure, lower ones have no therapeutic effect).

The mechanism of ozone’s action on the intervertebral disc is bidirectional:

  • MECHANICAL (chemonucleolysis): Ozone oxidises the proteoglycans of the nucleus pulposus, causing water molecule release. The disc subtly shrinks and dehydrates – its volume decreases, thereby reducing pressure on the nerve root. This is ‘chemical microdiscectomy’.
  • BIOCHEMICAL (anti-inflammatory): Ozone reduces the concentration of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6) in the disc and around the nerve root. It extinguishes neuropathic nerve sensitisation and reverses inflammatory sensitisation of nociceptors.
  • Additionally: improvement of microcirculation around the nerve root, accelerating removal of inflammatory mediators.

In clinical practice: relief of radicular pain (radiating pain) appears quickly (biochemical effect), while disc shrinkage develops gradually over 2–3 months (mechanical effect), providing a durable result.

Indications

  • Sciatica in the course of L4–L5 or L5–S1 disc herniation (without sequestration or migration)
  • Cervicobrachial neuralgia in the course of C4–C7 disc herniation
  • Discogenic lumbar spine pain with MRI-documented disc herniation
  • Patients who have failed 4–6 weeks of conservative treatment (NSAIDs, physiotherapy, steroid blocks)
  • Contraindications to surgery for medical or personal patient choice reasons

Contraindications

  • Nucleus pulposus sequestration or migration (requires surgery)
  • Severe disc degeneration (height loss phase – ozone ineffective)
  • Acute motor deficit/paralysis requiring urgent surgical decompression (24–48 h)
  • Cauda equina syndrome – surgical emergency
  • Severe hyperthyroidism
  • Active infection
  • Pregnancy
  • Uncontrolled coagulopathy

Step-by-Step Procedure

  • Qualifying consultation with MRI review – we determine the level(s) to be treated (1, 2 or 3 discs).
  • The patient lies on their side (or prone) on the table with the C-arm X-ray. Local skin anaesthesia is administered; optionally brief intravenous sedation.
  • Under fluoroscopic X-ray guidance, in sterile conditions, a special 22G needle (15–20 cm) is introduced via the safe posterolateral route through the so-called Kambin’s Triangle. The needle must reach the very centre of the intervertebral disc (nucleus pulposus).
  • After confirming correct needle position in 2 projections, 4–7 ml of the O₂-O₃ mixture at a concentration of 27–40 µg/ml is injected. The gas diffuses through the disc and through the herniation.
  • The needle is then withdrawn to the intervertebral foramen and an additional 10 ml of the mixture is injected periradicularly, for a direct effect on the irritated nerve root.
  • Optionally: at the end, administration of 1 ml steroid (e.g. depo-medrol/triamcinolone) + 1 ml bupivacaine periradicularly for additional anti-inflammatory effect and immediate pain relief.
  • The patient lies for 30 minutes, followed by 2 hours of observation in the recumbent position. Same-day discharge. The procedure for 1 level takes approximately 15–20 minutes.

Preparation

  • Current spinal MRI (no older than 6 months)
  • Discontinuation of anticoagulants per protocol (NOACs – 48–72h, warfarin – INR <1.5)
  • Fasting for 6 hours before the procedure (water – 2h)
  • Relative rest on the first day, light activity for the following 2 days
  • Return to desk work after 7 days, to heavier exertion after 2–3 weeks
  • Return transport

Effects

  • First radicular pain (radiating pain) relief: often in the 1st week (biochemical + steroid effect)
  • Discogenic spinal pain relief: 2–6 weeks (mechanical shrinkage effect)
  • Full effect: 2–3 months
  • Efficacy: in large studies 74–84% of patients achieve significant pain reduction and improvement in ODI at 2-year follow-up
  • Long-term effect: 5- and 10-year studies confirm sustained relief in the vast majority of patients
  • In patients who did not respond to the first session, a repeat session is possible

Possible Side Effects

  • Transient pain at the puncture site (1–7 days)
  • Increased spinal pain for the first 2–3 days (resolves spontaneously)
  • Subcutaneous haematoma
  • Very rarely (<0.1%): discitis, vasovagal reaction, transient thunderclap headache, allergic reactions
  • Occasionally – absence of satisfactory effect (especially in patients with advanced changes)

FAQ

Will ozone nucleolysis replace disc herniation surgery?

In well-selected patients (herniation without sequestration, recent disc herniation) yes – it can avoid surgery in 70–80% of patients. In patients with advanced degenerative changes, sequestration or paralysis, surgery may still be necessary.

Is the procedure painful?

No – we administer local anaesthesia, and the moment of ozone injection may cause a brief sensation of pressure/fullness in the disc area. The procedure is short.

How many levels can be treated simultaneously?

Safely up to 3 levels in one session. Most commonly we treat 1–2 levels corresponding to clinical symptoms and the MRI findings.