Case report
Paravertebral and intra-abdominal abscess due to oxygen-ozone therapy for lower back pain
Absceso paravertebral e intraabdominal secundario a ozonoterapia por lumbalgia
P. Menéndez
, A. García, R. Peláez
Corresponding author
Servicio de Cirugía General, Hospital Gutiérrez Ortega, Valdepeñas, Ciudad Real, Spain
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Menéndez, A. García, R. Peláez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Menéndez" "email" => array:2 [ 0 => "pablomensan@hotmail.com" 1 => "pablo.menendez.sanchez@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "García" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Peláez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía General, Hospital Gutiérrez Ortega, Valdepeñas, Ciudad Real, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Absceso paravertebral e intraabdominal secundario a ozonoterapia por lumbalgia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 489 "Ancho" => 1302 "Tamanyo" => 89873 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) CT scan showing the paravertebral abscesses (arrows). (B) CT scan showing the abscess at the level of the left iliopsoas muscle.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Back pain is one of the most common problems worldwide. Nearly 70% of adults suffer from back pain at some point during their lives and most cases do not have any recognizable cause in imaging studies. Instead, it is usually attributed to muscle or ligamentous lesions.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Percutaneous injections and surgery are the optional treatments once pharmacological treatments and rehabilitation have failed.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Few complications have been reported after percutaneous treatment with ozone. We present a new complication following percutaneous oxygen-ozone therapy, as well as the clinical outcome following treatment with antibiotics and percutaneous drainage.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 54-year-old woman who had no medical history of interest. Due to acute, right, lower back (or lumbar) pain, which was unrelated to physical exertion and trauma, she began treatment with corticosteroids and paravertebral percutaneous oxygen-ozone therapy. After 6 cycles of lumbar paravertebral injections of oxygen-ozone therapy, the patient reported a significant clinical improvement. Two months later, the patient returned to the emergency department of the hospital due to right lumbar pain radiating to the left lower limb, with a duration of 5 days. Physical examination found an antalgic posture with flexion of the right lower limb, pain upon pressure on the right paravertebral muscles from L2 to the sacrum, and negative bilateral Lasègue. Laboratory tests revealed leukocytosis (18.800<span class="elsevierStyleHsp" style=""></span>μl) and elevated C-reactive protein (18.81<span class="elsevierStyleHsp" style=""></span>mg/dl).</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">An ultrasound scan found the presence of a right lumbar, hypoechoic lesion along the paravertebral musculature, with dimensions of 2.8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>cm at the sacral level. A computed tomography (CT) scan showed a lesion with peripheral contrast uptake that extended along the left iliopsoas muscle and a right paravertebral mass with similar characteristics, consistent with an abscess or hematoma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). After placing 2 ultrasound-guided percutaneous drainages under local anesthesia, the material obtained through puncture was referred for culture and antibiogram, and empiric antibiotic treatment with metronidazole and gentamicin was initiated. Cultures of the infected focus showed Gram-positive cocci, with presence of methicillin-sensitive <span class="elsevierStyleItalic">Staphylococcus aureus</span>, so we continued treatment with 1<span class="elsevierStyleHsp" style=""></span>g of intravenous cloxacillin every 6<span class="elsevierStyleHsp" style=""></span>h.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Ten days after starting treatment, a new CT scan showed the disappearance of the right, posterior, paravertebral collection, as well as a significant reduction of the abscess in the left iliopsoas muscle (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). After another 15 days, a new CT scan confirmed the resolution of the abscess in the iliopsoas muscle. Three months later, the patient is asymptomatic.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Oxygen-ozone therapy has become an alternative or additional treatment option for patients with low back pain,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> although there is a low level of evidence to support its use because there are very few high-level studies which have demonstrated its superiority in subacute and chronic back pain.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> There are several mechanisms of action which explain the effectiveness of ozone, such as analgesic, anti-inflammatory and antioxidant action on proteoglycans.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,5</span></a> The therapeutic effects of intradiscal ozone administration include reducing the volume of disk hernia and an analgesic and anti-inflammatory effect.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Ozone is administered as an oxygen-ozone gas mixture in nontoxic concentrations ranging from 1 to 40<span class="elsevierStyleHsp" style=""></span>μg of ozone per milliliter of oxygen. Several methods of percutaneous injection can be used.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Evidence of oxygen-ozone therapy regarding back pain is derived from randomized controlled trials and observational studies, which have estimated that it is an effective and safe procedure.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Secondary complications derived from oxygen-ozone therapy are rare. The 2 most severe complications described so far are acute septicemia, following treatment of a herniated lumbar disk,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and an unexpected death, caused by gas embolism during oxygen-ozone therapy by autohemotransfusion for psoriasis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There have also been other complications, such as vitreous-retinal hemorrhages with bilateral visual loss,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> headaches related to pneumocephalus, paresthesias and hypoesthesias in the ipsilateral lower limb, suggesting a lesion of the spinal nerve, vertebrobasilar stroke, altered sensation in the lower limb, subcutaneous hematoma at the site of the puncture,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> worsening of symptoms, abdominal bloating, abdominal pain, low back pain and dyspnea.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Despite the complications described, the risk associated with oxygen-ozone therapy for disk hernia is 0.1%, with low adverse effects at therapeutic concentrations of 10–40<span class="elsevierStyleHsp" style=""></span>μg/ml.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There have only been 2 reports of infectious complications after ozone therapy. Gazzeri et al. reported a volume increase of the left iliopsoas muscle and a paravertebral abscess at the L2 level, which were associated with acute pneumonia. The patient died due to sepsis secondary to disseminated infection by <span class="elsevierStyleItalic">Escherichia coli</span>.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our case, <span class="elsevierStyleItalic">Staphylococcus aureus</span> (<span class="elsevierStyleItalic">S. aureus</span>) was isolated. Bo et al. reported the presence of an anterior epidural collection secondary to <span class="elsevierStyleItalic">S. aureus</span> and located at the C1–C4 level.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Infectious complications following oxygen-ozone therapy are infrequent but potentially severe; therefore, a high index of suspicion is necessary for their diagnosis. Infection is a common risk for any invasive procedure, so sterility must be a priority for any process involving punctures. According to the present clinical case, other, less invasive options must be explored before deciding on any aggressive surgery.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Level of evidence</span><p id="par0045" class="elsevierStylePara elsevierViewall">Level of evidence iv.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical responsibilities</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of people and animals</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of patient data and that all patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare having obtained written informed consent from patients and/or subjects referred to in the work. This document is held by the corresponding author.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres322607" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec304965" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres322608" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec304964" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-25" "fechaAceptado" => "2013-06-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec304965" "palabras" => array:4 [ 0 => "Oxygen-ozone" 1 => "Lower back pain" 2 => "Infectious complications" 3 => "Percutaneous drainage" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec304964" "palabras" => array:4 [ 0 => "Ozonoterapia" 1 => "Lumbalgia" 2 => "Infección" 3 => "Drenaje percutáneo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Complications secondary to oxygen-ozone therapy are rare, but they have been described in medical literature. There are only two cases of infectious complications after oxygen-ozone therapy. Our aim is to describe a rare case of purulent complication that was secondary to oxygen-ozone therapy for the treatment of lower back pain. We report the clinical improvement with conservative treatment for a local complication after percutaneous oxygen-ozone treatment. According to the clinical improvement of our patient, conservative treatment should be considered before any aggressive surgery.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En la literatura médica se han descrito un número escaso de complicaciones secundarias al tratamiento con ozonoterapia, habiéndose descrito únicamente 2 casos de índole infeccioso tras la terapia percutánea con ozonoterapia. Presentamos el caso de una complicación infecciosa secundaria a ozonoterapia para el tratamiento de una lumbalgia crónica, así como la posterior evolución clínica con tratamiento antibiótico y drenaje de los abscesos. Según la mejoría clínica de la paciente, se deben agotar las posibilidades menos invasivas antes de cualquier cirugía agresiva.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Menéndez P, García A, Peláez R. Absceso paravertebral e intraabdominal secundario a ozonoterapia por lumbalgia. Rev Esp Cir Ortop Traumatol. 2014;58:125–127.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 489 "Ancho" => 1302 "Tamanyo" => 89873 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) CT scan showing the paravertebral abscesses (arrows). (B) CT scan showing the abscess at the level of the left iliopsoas muscle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 517 "Ancho" => 1301 "Tamanyo" => 103246 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) CT scan showing the resolution of the paravertebral abscess. (B) CT scan showing the abscess at the level of the left iliopsoas muscle (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intramuscular oxygen-ozone therapy in the treatment of acute back pain with lumbar disc herniation: a multicenter, randomized, double-blind, clinical trial of active and simulated lumbar paravertebral injection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Paoloni" 1 => "L. di Sante" 2 => "A. Cacchio" 3 => "D. Apuzzo" 4 => "S. Marotta" 5 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 0 | 9 |
| 2024 October | 34 | 3 | 37 |
| 2024 September | 58 | 4 | 62 |
| 2024 August | 41 | 4 | 45 |
| 2024 July | 37 | 3 | 40 |
| 2024 June | 38 | 19 | 57 |
| 2024 May | 19 | 3 | 22 |
| 2024 April | 41 | 3 | 44 |
| 2024 March | 30 | 3 | 33 |
| 2024 February | 42 | 6 | 48 |
| 2024 January | 34 | 8 | 42 |
| 2023 December | 48 | 7 | 55 |
| 2023 November | 25 | 7 | 32 |
| 2023 October | 41 | 13 | 54 |
| 2023 September | 42 | 4 | 46 |
| 2023 August | 41 | 9 | 50 |
| 2023 July | 38 | 2 | 40 |
| 2023 June | 35 | 4 | 39 |
| 2023 May | 59 | 3 | 62 |
| 2023 April | 61 | 6 | 67 |
| 2023 March | 36 | 10 | 46 |
| 2023 February | 40 | 12 | 52 |
| 2023 January | 38 | 10 | 48 |
| 2022 December | 40 | 7 | 47 |
| 2022 November | 33 | 14 | 47 |
| 2022 October | 17 | 16 | 33 |
| 2022 September | 34 | 19 | 53 |
| 2022 August | 32 | 11 | 43 |
| 2022 July | 25 | 8 | 33 |
| 2022 June | 17 | 12 | 29 |
| 2022 May | 24 | 8 | 32 |
| 2022 April | 45 | 6 | 51 |
| 2022 March | 45 | 13 | 58 |
| 2022 February | 38 | 5 | 43 |
| 2022 January | 25 | 8 | 33 |
| 2021 December | 26 | 11 | 37 |
| 2021 November | 21 | 5 | 26 |
| 2021 October | 40 | 10 | 50 |
| 2021 September | 24 | 14 | 38 |
| 2021 August | 30 | 9 | 39 |
| 2021 July | 28 | 9 | 37 |
| 2021 June | 25 | 11 | 36 |
| 2021 May | 30 | 7 | 37 |
| 2021 April | 44 | 7 | 51 |
| 2021 March | 14 | 18 | 32 |
| 2021 February | 11 | 16 | 27 |
| 2021 January | 9 | 4 | 13 |
| 2018 February | 10 | 1 | 11 |
| 2018 January | 19 | 2 | 21 |
| 2017 December | 17 | 5 | 22 |
| 2017 November | 16 | 6 | 22 |
| 2017 October | 14 | 4 | 18 |
| 2017 September | 19 | 6 | 25 |
| 2017 August | 22 | 3 | 25 |
| 2017 July | 18 | 5 | 23 |
| 2017 June | 29 | 8 | 37 |
| 2017 May | 33 | 4 | 37 |
| 2017 April | 21 | 8 | 29 |
| 2017 March | 18 | 8 | 26 |
| 2017 February | 13 | 10 | 23 |
| 2017 January | 15 | 3 | 18 |
| 2016 December | 19 | 7 | 26 |
| 2016 November | 15 | 5 | 20 |
| 2016 October | 26 | 5 | 31 |
| 2016 September | 21 | 2 | 23 |
| 2016 August | 14 | 5 | 19 |
| 2016 July | 17 | 2 | 19 |
| 2016 June | 22 | 7 | 29 |
| 2016 May | 16 | 13 | 29 |
| 2016 April | 22 | 9 | 31 |
| 2016 March | 23 | 23 | 46 |
| 2016 February | 0 | 10 | 10 |
| 2016 January | 0 | 9 | 9 |
| 2015 December | 0 | 5 | 5 |
| 2015 November | 0 | 11 | 11 |
| 2015 October | 0 | 3 | 3 |
| 2015 September | 0 | 2 | 2 |
| 2015 August | 0 | 2 | 2 |
| 2015 July | 0 | 1 | 1 |
| 2015 May | 0 | 1 | 1 |
| 2014 April | 1 | 4 | 5 |
| 2014 March | 1 | 0 | 1 |
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