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Back Ozone Injection Protocol
Lumbar landmarks, injection sites and volumes for paravertebral ozone back injections, with the Prolozone mixture and ozone-oxygen approaches side by side.
Quick answer: Paravertebral ozone back injection uses 3–5 mL of gas per site, one finger width from the spine (Wright). Madrid lists 10 mL at 2 cm for the lumbar spine at 10–20 µg/mL.
Warning
Requires hands-on training from an experienced physician
Back ozone injection should only be performed by a practitioner trained in it by an experienced physician.
Practitioner-only procedure. Injecting ozone, with or without a nutrient mixture, is done by trained, licensed clinicians. This sheet is a reference for them. It is not a self-treatment guide and not medical advice. Strict sterile technique is required every time.
What are the basics of ozone back injection?
- Madrid lists back pain, herniated and protruding discs, spinal osteoarthritis, residual pain after herniated disc surgery and spinal canal stenosis as indications for paravertebral intramuscular infiltration. Intradiscal, epidural and intraforaminal techniques are separate and not covered here.
- Prolozone, as Dr. Jeff Wright teaches it, adds nutrients and ozone to damaged tissue. His explanation: swollen tissue receives less blood, which leaves the area short of oxygen, and ozone supplies bioavailable oxygen.
- Wright's expected course from his own practice: a second injection 10 to 14 days after the first, with results after as few as 3 injections or as many as 6 to 8. Chronically ill patients can need more. He describes his success as 90 to 95 percent. That is his clinical impression, not a trial result.
- Wright's tutorials do not state ingredient amounts. The solution he used is a compounded pre-mix of methylcobalamin (vitamin B12), pyridoxine (vitamin B6), dextrose and procaine. The amounts are in the table below, taken from the compounded formula sheet. He also describes drawing up individual nutrients in a hood.
- The Madrid Declaration describes ozone-oxygen infiltration only: no nutrient mixture. Both are shown side by side below and labeled.
Sources: Dr. Jeff Wright's tutorial videos for MediSkill; Madrid Declaration on Ozone Therapy, 4th edition (ISCO3, 2025), sections 1.12 and 4. Paraphrased.
What dose and technique are used for ozone back injection?
Two approaches are shown side by side. They are different procedures: the Prolozone mixture is Wright's, and ozone-oxygen alone is what Madrid describes.
| Prolozone mixture (per Wright) | Ozone-oxygen only (per Madrid) | |
|---|---|---|
| What goes in | Dr. Wright's pre-mixed solution (formula below), then ozone gas, at each level. | Ozone-oxygen mixture. Optional 1 mL of procaine or lidocaine in the muscle, placed above the ozone so it does not oxidize. |
| Gas volume | 3 to 5 mL per injection. The lower segments took about half as much gas as the upper segments. | Lumbar: 10 mL per site (section 4.2). Facet or hernia lumbar: 7 to 10 mL (section 4.3). |
| Concentration | Not stated in the tutorial. | 10 to 20 µg/mL. |
| Entry point | One finger width lateral to the spinous process, at the same level as the spinous process, straight down. Done on both sides and at several levels. | Lumbar: 2.0 cm from the spinous process, bilateral, at a depth of 2 to 4 cm. Or 2 cm above and 2 cm below the hernia. |
| Needle | Not stated. | 27G, 0.40 by 40 mm, or 30G by 1.5 inch. Facet technique: spinal needle 90 mm. |
| Schedule | Second injection 10 to 14 days after the first. Results in as few as 3 and as many as 6 to 8 injections. | Twice a week, 72 hours apart, for 2 weeks. After improvement, weekly for 4 to 6 weeks. Then every 15 days until 15 to 20 sessions. |
Dr. Wright's pre-mixed solution: how it is made (per 8 mL of mixture)
This is the compounded mixture Dr. Wright used in his protocols. The amounts below are the recipe for making the mixture, taken from the compounded formula sheet, not from the tutorial videos. They are not the amount injected at one site.
| Ingredient | Strength | Amount per 8 mL of mixture |
|---|---|---|
| Methylcobalamin (methyl-B12) | 1 mg/mL | 2 mL |
| Pyridoxine (vitamin B6) | 100 mg/mL | 1 mL |
| Dextrose | 50% | 1 mL |
| Procaine | 2% | 4 mL |
| Total | 8 mL |
- Draw up the solution into a sterile syringe using antiseptic technique (the formula sheet uses a 10 mL syringe).
- Inject the solution at the selected site, using this sheet's own technique and volume.
- Leave the needle in place, remove the syringe, and inject the ozone through the same needle.
How much is injected is not stated in Dr. Wright's back tutorial, so this sheet gives no solution volume.
This is a compounded pre-mix with a beyond-use date of 90 days refrigerated. The solution is compounded by a pharmacy and requires a prescriber.
Madrid advises placing any local anesthetic so that the ozone does not break it down. Dr. Wright gives his solution first and then the ozone through the same needle. These are two different practices.
Madrid notes a randomized trial found benefit after five sessions per week for three weeks. Slow injection and distraction reduce the pain of the injection.
What are the best tips when using ozone back injection?
- Listen to the body. Wright stops when the tissue feels full. When the back is very inflamed, pressure rises sooner, so a smaller volume can already feel like a lot. That is the point to stop.
- Lower segments tolerated about half the gas of the upper segments in the demonstration.
- If the sacroiliac joint is very tender, Wright injects there as well. Ask about tenderness along the top of the iliac crest.
- Tell the patient what to expect. Pressure and fullness while the gas goes in are normal, and the patient should say when it is too much. Wright says an electrical zing is not normal: stop and reposition.
What are the precautions for ozone back injection, and who should avoid it?
- Sterile technique every time. Madrid says most serious side effects trace back to malpractice, including technique, asepsis and antisepsis. Its reported serious events include septic arthritis of the knee after intra-articular infiltration, abscess after paravertebral injection, and one death from sepsis after a paravertebral infiltration done without proper asepsis (Madrid Declaration on Ozone Therapy, 4th edition (ISCO3, 2025), section 2.5).
- Clean the injection site with alcohol and let it dry before the needle goes through (as Dr. Wright does). Use sterile, single-use syringes and needles, and do not touch the vial adapter once it is out of its package (Wright).
- Draw up nutrient solutions in a hood with needleless vial adapters, as Dr. Wright demonstrates in his overview video. Check that every solution you inject is allowed by your licensing board, as he advises.
- Never inject ozone gas into a vein or an artery. Madrid strongly discourages both because of the risk of air embolism, and lists embolic events after paravertebral and intradiscal injections among its serious adverse events.
- Madrid's reported serious events after paravertebral injection include multifocal stroke from air emboli, posterior reversible encephalopathy syndrome, massive emphysema with pneumomediastinum, abscess, and one death from septicemia after a paravertebral infiltration done without proper asepsis. Never inject gas into a vessel.
- Milder events Madrid lists after ozone injection: brief local warmth, pain during the injection, hematoma at the site, and low back and leg pain that settled by itself.
Contraindications
The Madrid Declaration lists these contraindications for systemic ozone (IV and blood). It gives no separate list for paravertebral injection, but many practitioners use the same screening before treating:
- Direct inhalation of ozone gas. The fluid lining the lungs has no antioxidants to buffer it, so inhaled ozone is toxic.
- Glucose-6-phosphate dehydrogenase (G6PD) deficiency (favism, acute hemolytic anemia). Madrid lists it as a contraindication for systemic ozone, but whether it is absolute is debated. MediSkill protocols start low and go slow; see the contraindications article.
- Toxic hyperthyroidism (severe Graves' disease)
- Thrombocytopenia (platelets under 50,000) and severe coagulation disorders
- Severe cardiovascular instability
- Acute alcohol intoxication
- Recent acute myocardial infarction
- Acute massive hemorrhage
- Convulsive states
- Hemochromatosis
- Patients receiving intravenous copper or iron therapy
Pregnancy. Madrid advises avoiding ozone therapy in the first trimester (weeks 0 to 13) and reserves its use in pregnancy for specialists in gynecology and obstetrics.
More detail
Landmarks and steps, as demonstrated by Dr. Wright
- Find the iliac crest. It is roughly the level of L4, with L5 below it and the sacral base below that.
- Mark injection points one finger width lateral to the spinous processes at the same level as each spinous process.
- Clean the sites with alcohol and let them dry.
- Insert straight down. Inject the fluid, then the gas, at 3 to 5 mL per site. Ask the patient to say when the tissue feels full.
- Repeat on the opposite side at the same level, then at the other levels. Use about half the gas on the lower segments.
- Add the sacroiliac area if it is sensitive.
Equipment
- Needle: not stated by Wright; Madrid gives 27G, 0.40 by 40 mm or 30G by 1.5 inch for paravertebral injection
- Sterile syringes
- Dr. Wright's compounded pre-mixed solution (requires a prescriber), or individual nutrients drawn up in a hood with needleless vial adapters
- Ozone-oxygen gas in a syringe
- Alcohol prep; imaging guidance where precision matters
What the studies used
Study doses are listed as printed in each paper and are not Madrid or Wright dosing.
- In a double-blind trial against simulated injection in 60 people with acute low back pain from disc herniation, lumbar paravertebral ozone left 61% pain-free at 6 months vs 33% (p<0.05), with less disability and fewer days of NSAIDs. Only the abstract is on file, so concentration, volume and schedule are not known (Paoloni 2009).
- In 546 people with complicated chronic low back pain (retrospective, controlled), ozone (20 µg/mL, 15 mL each side, 12 sessions plus 10 maintenance) with postural re-education beat re-education alone (p=0.005). Ozone alone was not significantly better (Apuzzo 2014).
- In 168 people with chronic low back pain after spinal fusion (observational), CT-guided paravertebral ozone (20 µg/mL, 3 to 4 mL at 2 sites) plus physiotherapy gave lower pain at 6 months than drugs (VAS 4.6 vs 6.2, p<0.001) (Bonetti 2026).
- In a 76-person series, lumbar paravertebral ozone (15 µg/mL, 10 mL, 2 cm from the spinous processes, twice weekly for 12 sessions) took low back pain from 6.4 to 3.2 at 6 months. There was no control group (Latini 2024).
Paravertebral ozone has the strongest back evidence, but the main randomized trial is on file only as an abstract. No human study of the classic Prolozone mixture (procaine, vitamins and ozone) is in the study summary we drew on. Trials that add something to ozone used dextrose, somatropin or hypertonic saline, and the evidence for Wright's mixture itself rests on his clinical experience.
Video
Overview of the technique and the reasoning behind it: Prolozone Overview - Ozone Joint Injections | Dr. Jeff Wright.
Learn more
Background, benefits and research on injections: Ozone injections, full article.
Related protocols: Trigger Point Ozone Injection Protocol, Acupuncture Point Ozone Injection Protocol, Subcutaneous Ozone Injection Protocol.
Other injection protocols
For licensed practitioners. Educational reference only, not medical advice. Follow your scope of practice and local regulations.
