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Year : 2022  |  Volume : 28  |  Issue : 3  |  Page : 210-215

Effectiveness of ozone-oxygen mixture by ultrasonography-guided facet medial branch block in the treatment of cervicogenic dizziness

1 Department of Anesthesiology and Reanimation, Pain Medicine, Faculty of Medicine, Istinye University, Istanbul, Turkey
2 Department of Otorhinolaryngology, Sakarya University Faculty of Medicine, Sakarya, Turkey
3 Department of Anesthesiology, Sakarya University Training and Research Hospital, Sakarya, Turkey
4 Department of Otorhinolaryngology, Sakarya University Training and Research Hospital, Sakarya, Turkey

Date of Submission26-Dec-2021
Date of Decision28-Jan-2022
Date of Acceptance11-Aug-2022
Date of Web Publication21-Nov-2022

Correspondence Address:
Dr. Oğuz Kadir Eğilmez
Department of Otorhinolaryngology, Sakarya University Training and Research Hospital, 3 Floor, 54100 Adapazari, Sakarya
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.indianjotol_179_21

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Purpose: Among many central and peripheral causes of vertigo, one of the factors whose pathophysiology is not yet understood is cervicogenic dizziness (CD). There are studies reporting that CD may benefit from facet joint medial bundle branch block (MBB). The purpose of our study was to share our experiences of MBB application using ultrasonography (USG) in patients diagnosed with CD. Materials and Methods: After physical examination and necessary cervical imaging, C1, C2 and C3 cervical facet joint MBB and ozone injection were performed using USG for patients who had vertigo and accompanying cervical pathology and neck pain. In order to evaluate the effectiveness of the treatment, pain levels with the Visual Analog Scale (VAS) and the effect of vertigo on the quality of life with the “Dizziness Handicap Inventory (DHI)” Turkish validation questionnaire were documented. Results: Thirty-five patients who met the criteria were included in the study. The mean age of the patients was 50.8 ± 10.7. Of the 35 patients, 10 (28.6%) were male and 25 (71.4%) were female. There was a significant difference between the preoperative period and the postoperative 1st, 2nd, and 6th week VAS scores. A significant difference was found between the preoperative and the postoperative 2nd and 6th week DHI questionnaire survey results as well. Conclusions: In the follow-up after the procedures, it was observed that vertigo complaints of the patients decreased significantly.

Keywords: Dizziness, facet medial bundle branch block, ozone, ultrasonography-guided, vertigo

How to cite this article:
Beyaz SG, Yilmaz MS, Demir G, Kocayiğit H, Eğilmez OK. Effectiveness of ozone-oxygen mixture by ultrasonography-guided facet medial branch block in the treatment of cervicogenic dizziness. Indian J Otol 2022;28:210-5

How to cite this URL:
Beyaz SG, Yilmaz MS, Demir G, Kocayiğit H, Eğilmez OK. Effectiveness of ozone-oxygen mixture by ultrasonography-guided facet medial branch block in the treatment of cervicogenic dizziness. Indian J Otol [serial online] 2022 [cited 2023 Feb 5];28:210-5. Available from: https://www.indianjotol.org/text.asp?2022/28/3/210/361637

  Introduction Top

Vertigo is defined by the Barany society as the false sense of self-motion without any motion or feeling of distorted self-motion with normal movement. They also define dizziness as a sense of disturbed or impaired spatial orientation without a false or distorted sense of motion.[1] Balance disorders and neck pain are the common complaints in the community. If these two complaints are seen together, a relationship may be suspected. When dizziness is closely associated with the neck pain, injury, or neck pathology, it can be called cervicogenic dizziness (CD) after excluding other potential causes of dizziness. It is defined as a nonspecific sensation or altered orientation in space, and disequilibrium originating from abnormal afferent activity from the neck.[2] The pathophysiology of CD is not yet understood. Along with pain and vertigo, neck movement limitation, imbalance, imperfection in movement perception, and ataxia can also be seen in CD.[3],[4] The symptoms often increase with head movement. Although its pathophysiology is still controversial, CD may occur due to insufficient blood supply, cervical spondylosis, migraine, or as a result of whiplash injury.[5],[6] There is no specific test to diagnose CD. Physical and manual therapy are recommended in the first stage for its treatment. There have been studies reporting that surgical interventions were performed for CD treatment.[3],[7],[8] However, it is often not easy to determine the origin of CD and there are studies reporting that it may benefit from facet joint medial bundle branch block (MBB) due to the frequent occurrence of CV with neck pain.[9]

There are free nerve endings originating from the medial branch of the dorsal rami on the facet joint. Recurrent stress, inflammation, and tension in the joint capsule can cause a headache that spreads to the neck, head, and shoulders.[10] The gold standard method in the diagnosis of facet joint pain is MBB with local anesthetic. Radiofrequency ablation provides a longer-lasting effect to a patient whose pain is relieved by local anesthetic injection.[10],[11]

In this study, we aimed to investigate the effectiveness of ozone-oxygen mixture in ultrasonography (USG)-guided facet joint MBB treatment in patients with CD.

  Materials and Methods Top

Our study was initiated after permission from the Sakarya University Faculty of Medicine Ethics Committee (No: 10.20.2020/539). All the procedures were done in accordance with the ethical standards of the Sakarya University Ethics Committee on human experimentation and with the Helsinki Declaration. Patients with CD who were treated and followed by the Algology Clinic of Sakarya University Training and Research Hospital between August 1, 2018 and March 16, 2020 were included in this study. The charts and data of the patients were evaluated prospectively, after obtaining consent from the patients to allow their information to be used. Patients first applied to the outpatient clinic of the Ear-Nose-Throat (ENT) department of the Sakarya University Training and Research Hospital due to balance disorders. A detailed clinical history was obtained from all patients who then underwent otorhinolaryngological and neurological examination by the same physician. In addition to audiometry, videonystagmography and video head impulse test were used for differential diagnosis. After excluding other possible vestibular and central causes of dizziness and vertigo by history, examination and laboratory tests, patients with a history of neck pain, injury or neck pathology were defined as CD and referred to the algology department for the evaluation of suitability of treatment. None of the patients had a history of oncological, psychiatric, infective, or neurological disease.

Patients with complaints of dizziness and accompanying cervical pathology and neck pain were recommended for cervical facet joint MBB blockage and ozone injection by USG after physical examination and necessary cervical imaging.

Patients who accepted the recommended treatment were admitted to the daily service for all procedures after signing informed consent forms before the procedure. The patient was placed in the lateral decubitus position with the side with intense neck pain on the top and the lower part of the neck was supported with a pillow.

The skin area where the procedure was applied was disinfected with 10% povidone iodine solution. A linear USG probe (Esaote, MyLab30, Florence, Italy) was preferred for the procedures and a sterile sheath was attached to the probe. The mastoid process was detected by palpation on the side to be treated. Then, the USG probe was placed at the base of the mastoid process in the longitudinal position and an image of the inferior border of the mastoid process was obtained [Figure 1] and [Figure 2]. The probe was then moved slowly posteriorly until the C1 ( Atlas More Details) vertebral arch and C2 (Axis) vertebra articular pillar were displayed [Figure 3]. The probe was then moved caudally until the C2-C3 facet joint was displayed and “peaks” representing the facet joint formations were seen [Figure 4]. When the cervical medial branch was detected, a 22G block needle was advanced with the out-of-plane technique, away from the vertebral artery and neuraxial structures, from anterior to posterior until it reached the cervical medial branch. Following negative blood and cerebrospinal fluid aspiration, 2 ml of 20 gamma (mcg/ml) ozone was injected for each level. After the procedure, medical dressing was applied to the intervention area. The patients were followed up in the service for 1 hour and discharged after it was observed that no complications developed. The patients were called for control on the 1st day, 2nd week, and 6th week after the procedure.
Figure 1: Positioning of the USG probe on the patient during the procedure. USG: Ultrasonography

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Figure 2: The image of the inferior border of the mastoid process

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Figure 3: C1 (Atlas) vertebral arch and C2 (Axis) vertebra articular pillar

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Figure 4: C2-C3 facet joint and 'peak' representing the facet joint formation

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In order to evaluate the effectiveness of the treatment, pain levels in the preoperative period and postoperative 1st, 2nd, and 6th week were documented with a Visual Analog Scale (VAS) and the effect of vertigo on the quality of life was documented with the “Dizziness Handicap Inventory Turkish Validation” (DHI) questionnaire in the preoperative period and postoperative 2nd and 6th week.

The DHI is a 25-item self-report questionnaire that quantifies the impact of dizziness on daily life by measuring self-perceived handicap. Item scores are summed. There is a maximum score of 100 (28 points for physical, 36 points for emotional, and 36 points for functional) and a minimum score of 0. The higher the score, the greater the disability due to dizziness.[12]

In the data analysis, SPSS for Mac version 23.0 (IBM Corp., Armonk, NY, USA) was used. Values are given as mean ± standard deviation in the statistical analysis. The normality of distribution of the initial data was assessed using the Kolmogorov − Smirnov test. Demographic variables were compared using t-test or Chi-squared test for the continuous and categorical variables, respectively. The difference between repeated measurements in the group was assessed using repeated measures-analysis of variance. P < 0.05 was accepted for statistical significance.

  Results Top

Thirty-five patients who met the study criteria among the patients who underwent MBB block with a diagnosis of CD between August 1 2018 and March 16 2020 were included in the study. The mean age of the patients was 50.8 ± 10.7 years. Of the 35 patients, 10 patients (28.6%) were male and 25 (71.4%) were female. Twenty-three of the patients (65.7%) were found to have neck and shoulder pain due to cervical pathology such as disc herniation or cervical spondylosis in addition to CD complaints. Twenty-two of the patients were treated on the right side and 13 on the left side [Table 1].
Table 1: Demographic data of the patients

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All 35 patients who met the study criteria were examined at the end of the 1st week, 2nd week, and 6th week after the intervention. VAS and DHI questionnaire was applied to the patients during the examination. A significant difference was found between the preoperative VAS scores of the patients and the postoperative VAS scores evaluated on the 1st week, 2nd week, and 6th week (preoperative: 6 [5–7], first week: 2 [1–3], second week: 2 [0–3], sixth week: 1 [0–3], P < 0.01) [Figure 5] and [Table 2].
Figure 5: VAS scores before and after MBB. VAS: Visual Analog Scale, MBB: Medial bundle branch block

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Table 2: Comparison of Visual Analog Scale and Dizziness Handicap Inventory scores of the patients

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In the DHI questionnaire evaluating the effect of vertigo on the quality of life of patients, a significant difference was found between preoperative DHI scores and postoperative 2nd week and 6th week scores (preoperative: 52.22 ± 14.97, second week: 32.48 ± 17.50, sixth week: 27.91 ± 16.26, P < 0.01) [Figure 6] and [Table 2].
Figure 6: DHI scores before and after MBB. MBB: Medial bundle branch block, DHI: Dizziness handicap inventory

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  Discussion Top

CD is characterized by the presence of balance disorders such as unsteadiness, dizziness, and disorientation as well as neck pain and limited cervical range of motion.[5] It also may be accompanied by headache. The causes of the dizziness are not fully understood. Sympathetic vertebral plexus irritation, vertebral artery compression, and abnormal sensory input from neck proprioceptors originating from the superior cervical spine are thought to be possible causes.[13] Various tests can be performed for the diagnosis of CD, but there is still no test widely accepted to diagnose CD. Therefore, this diagnosis is still a debate and exclusion clinical diagnosis seems to be best. Imaging methods such as magnetic resonance imaging (MRI) for degenerative spine disorders and Doppler USG for vascular etiology are used. Some tests have been defined as physical examination tests and the effect of the “vertebral artery test” on CD diagnosis was investigated by Cote et al. According to the vertebral artery test, vertebral artery flow is tested when neck extension and rotation triggers dizziness. However, as a result, it was found that the test was not predictive between vertebral blood flow and neurological symptoms.[14] Although it has been stated by some researchers that the “smooth pursuit neck torsion test”, which is applied using eye movements, can be used for the diagnosis of CD, the patient's cognitive status may affect the test result.[15] MBB is a minimally invasive method and regression of patient complaints after the procedure may also be a marker for diagnosis and contribute to the treatment period.

Previous studies have reported that vertigo sensation is affected by cervical joint movements and by blocking afferent fibers with MBB, dizziness complaints are reduced.[3],[8],[9] In this study, MBB was applied to patients with dizziness who did not benefit from medical treatment previously given by ENT physicians. It was observed that dizziness complaints of patients decreased significantly in the follow-up after the procedure. It was observed that approximately 65% of these patients had cervical pathologies and neck pain accompanying the balance disorders. Neck pain complaints of the patients were evaluated with VAS score and significant decreases were found in the postprocedure VAS score.

While facet MBB was first performed by fluoroscopy for the treatment of low back and neck pain, applications by USG have been used in recent years.[16] A meta-analysis suggested that no significant differences in pain and functional improvement were noted between the USG and computed tomography-/fluoroscopy-guided techniques in facet joint syndrome.[17] The risk of serious complications is high in invasive procedures performed using only anatomical reference points in the neck region without imaging guidance.[18] Galiano et al. stated in their research that USG is a useful guide for facet joint injection in the cervical spine.[19] In this respect, we preferred to perform MBB application using USG in our study. Thus, we aimed to protect employees and patients from radiation exposure.

When the literature was examined for CD, there is only one research study for cervical facet MBB, which was performed by Hahn et al.[9] In this study, they claimed that they applied local anesthetic and steroid injections at C4-5-6 levels with fluoroscopy to 178 patients and it was beneficial in 111 patients with Macnab outcome criteria. In that study, DHI as a detailed, specific and validated scoring for vertigo was used. However, the Macnab outcome criteria, though a simpler test, may not provide detailed information on vertigo. In addition, while Hahn et al. performed these procedures under fluoroscopy guidance in the operating room, USG provided the opportunity to perform this bedside. Another difference is that they performed cervical facet MBB using local anesthetic and steroid. On the other hand, we performed with a mixture of ozone-oxygen.

In the clinical practice, the injection level in patients who undergo cervical facet joint injection due to neck pain is determined according to the spread of the pain in physical examination and anamnesis. Degenerative disorders are most common in the cervical spine in the middle and lower cervical regions (C4-C5, C5-C6, and C6-C7).[20] For this reason, when the literature is reviewed, injection levels frequently appear as middle and lower cervical spine in studies conducted on these subjects. Hahn et al. also decided on the injection level according to the area where neck pain spread in their study.[9] We performed injections to C1-C2-C3 levels to perform the treatment for cervicogenic vertigo, since the complaints of vertigo are at the forefront and neck pain is in the background. As a result of the explanations given above, a more effective discussion could not be made since there is no similar study in the literature and the protocols of this study were different.

It is known that an ozone-oxygen mixture is used in many treatments, but there are limited studies on its effectiveness in CV treatment and neck pain. Yuxia et al. performed percutaneous laser disc decompression and oxygen-ozone therapy with their patients for CV and found this treatment effective.[21] Ucar et al. stated in their study that cervical paravertebral ozone-oxygen mixture injection provided a significant reduction in neck pain complaints.[22] Beyaz and Sayhan found that the 6-month results of intradiscal application of ozone-oxygen mixture in patients with cervical disc disease were quite effective.[23]

In the literature, the DHI questionnaire was used to evaluate the severity of the disease and its impact on daily life in the evaluation of dizziness caused by Meniere's disease, migraine or benign paroxysmal vertigo, regardless of the etiology.[24],[25],[26] In our study, the Turkish-validated DHI questionnaire was used in the evaluation of vertigo complaints. According to the DHI questionnaire, which evaluates the patients physically, emotionally, and functionally, it was found that after MBB, patients experienced an increase in physical functions and had emotional and physical recovery.

The limitation of this study was that it did not include a large number of patients, but it showed the utility of this method in the diagnosis and treatment of CD with MBB testing. MBBs are a special diagnostic tool and afferents from the facet joint and muscle structures in the region are blocked. In the study conducted by Hahn et al., while neck pain was prominent, CD was in the second place.[9] However, the patients included in this study are primarily patients diagnosed with cervicogenic vertigo. Pain is not in the foreground. In this study, clinical examinations and applications for the diagnosis were planned accordingly. Another limitation of this study was that the follow-up period of the patients was as short as 6 weeks. How long CD can be treated with an ozone-oxygen mixture, how long it will be without symptoms and how much additional injections will be needed are questions that need to be investigated.

  Conclusions Top

Our study shows that cervical facet MBB application with an ozone-oxygen mixture in the upper levels of cervical spine under bedside USG-guidance improved cervicogenic vertigo complaints and reduced neck pain for 6 weeks. Our injection method and ozone-oxygen mixture usage improve outcomes for patients.

We believe that randomized controlled studies with different ozone-oxygen mixture injection dose and level together with the long-term follow-up are needed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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