Quimionucleólise cervical associada à espondilectomia ventral em cães: aspectos clínico-cirúrgicos, radiográficos e histológicos / Cervical chemonucleolysis associated to ventral slot in dogs: clinical-surgical, radiological, and histological aspects

Foram avaliados aspectos clínico-cirúrgicos, radiográficos e histológicos de discos intervertebrais cervicais caninos após quimionucleólise com quimiopapaína associada à espondilectomia ventral em 24 cães. Em todos foi realizada a espondilectomia ventral na região do disco intervertebral C2-C3 e quimionucleólises nos demais discos cervicais. Os cães foram sacrificados às 24 horas, e aos 8, 30, 60, 90 e 120 dias após aplicação da enzima para a obtenção de cortes sagitais dos discos intervertebrais tratados e das estruturas cartilaginosas e ósseas adjacentes. Nos mesmos períodos, foram realizadas radiografias para monitoração da espessura dos espaços intervertebrais. Todos toleraram bem o procedimento cirúrgico e não apresentaram alterações clínicas significativas. Na avaliação radiográfica, observou-se marcada redução dos espaços intervertebrais 24 horas após o tratamento. Do oitavo ao 90º dia após aplicação da enzima, foi verificada ausência total de espaço intervertebral na região dos discos tratados. Aos 120 dias, as espessuras dos espaços intervertebrais corresponderam, em média, a 59,1 por cento da espessura anterior ao procedimento. Na avaliação histológica, foram observadas digestão nuclear e redução da intensidade de coloração pela safranina-O 24 horas após a quimionucleólise. A partir do 60º dia, havia material amorfo no espaço nuclear, que, aos 120 dias, tinha aparência fibrocartilaginosa. A quimionucleólise associada à espondilectomia ventral determinou a lise dos discos intervertebrais e lesões nas estruturas cartilaginosas e ósseas adjacentes, com tendência à reparação por tecido fibrocartilaginoso ao longo do tempo.

The clinical-surgical, radiological, and histological aspects of chemonucleolysis with chymopapain in canine cervical intervertebral disks associated to ventral slot in 24 dogs were evaluated. The ventral slot was accomplished in the area of the intervertebral disks C2-C3 and chemonucleolysis in the other cervical disks. The dogs were clinically and radiographically monitored for up to 120 days. Each group of four animals was submitted to euthanasia with an anesthetic overdose at 24 hours, and at 8, 30, 60, 90, and 120 days after the enzyme injection for the acquisition of sagittal sections of the treated disks, as well as adjacent cartilaginous endplates and bony structures. In this study, all dogs tolerated the surgical procedure, without detectable postoperative pain or neurological deficit. In the radiographic evaluation, it was observed consistent disk space narrowing 24 hours after the procedure and total absence of space from the 8th to the 90th day of postoperative in the area of all treated disks. However, 120 days after treatment, there was an increase in disk height, corresponding on average to 59.1 percent of the preinjection value. In the histological evaluation, it was observed nuclear digestion and decrease of safranin-O staining intensity 24 hours after disk injection. At eight days, the nuclear content was still vacuolated, but more fibrillar. An irregularly defined mass was observed in the nuclear space on days 60th and 90th, but it seemed fibrocartilaginous tissue on day 120th. Chemonucleolysis with chymopapain associated to the ventral slot in the cervical column of dogs determined lysis of intervertebral disks, cervical instability, and lesions of cartilaginous and bone adjacent structures that tend to repair with fibrocartilaginous tissue along the time.

Clinical Results of Chemonucleolysis for the Far Lateral Lumbar Disc Herniation

The far lateral lumbar disc herniation occurs ten times less often than the classic posterolateral disc herniations. Its clinical presentation, the anatomy involved, and difficulty of surgical treatment are not well understood. The surgical approach and results also have not been clearly defined. Although there are limited number of reports and series in the literature, there is still no general consensus on the approach to surgical treatment. However, chymopapain, even with a history of controversy and troubling complications, has endured the test of time to show 30 years of clinical success in the treatment of herniated nucleus pulposus. Strict attention to indications, contraindications, and technique ensures safety and efficacy of treatment. Between 1984 and 1997, we treated with chymopapain injection in 69 patients with severe lumbar radiculopathy secondary to far lateral disc herniation. Average patient age was 38.5 years in the 47 male and 22 female patients involved. The L4-5 disc was the most commonly herniated level(44.9%) followed by L3-4(37.8%), L5-S1(13.0%), and L2-3(4.3%). They were assessed using standardized forms as well as the Mcnab classification and questioner. They were reviewed at an average of 5 years 8 months postoperatively. Relief of symptoms was obtained in 63 patients(91.3%) after injection. No one subsequently relapsed requiring operation. All 69 patients available for long-term follow-up had considerable and sustained relief from their symptoms. For ADL(activity of daily living), 50 patients(81.3%) answered that they had no limitation, and regarding the office or house work, 49 patients(71.0%) returned previous work without any difficulties. Based on these findings we recommend the chymopapain injection as the primary treatment for patients with severe radiculopathy secondary to far lateral herniation of a lumbar disc.

A Clinical Study of Cervical Chemonucleolysis

For many years chemonucleolysis has been proven effective in the curative treatment of lumbar disc herniation. However, this technique is seldom popular in the herniated cervical disc. For several years microsurgery of the cervical disc has been effective in the treatment of refractory cervicobrachial neuralgia. To compete with this method which has been familiar to neurosurgeons, cervical nucleolysis using chymopapain for 1 year. Twenty two pateints(75%) had excellent outcomes, 5 pateints(15%) considered good while 3 sustained their symptom, but showed decreased intensity. The decision to intervene is made when the radiculagia is recurrent or resistant to medical treatment of several weeks duration, without myelopathy or bony abnormalities such as spondylosis or canal stenosis. The principal advantages of this method are : short stay in the hospital(3 days to 5 days on average), absence of general anesthesia, prompt resumption of previous activities, and long-term preservation of an intervertebral space. As a result, cervical nucleolysis has been shown to be an effective alternative to surgery for cervical soft disc herniations with refractory radicualgia.

Discographic Findings in the Lumbar Disc Herniations

The authors analysed the findings of discograms in the 1355 levels of 900 herniated lumbar disc cases during May 1984 to January 1987. Prior to intradiscal injection of Chymopapain in the treatment of lumbar disc herniation, Conray contrast medium was injected. The discographic patterns were devided in five types:I) contained, II) degenerative, III) annular bulging, IV) subligamentous leak, and V) epidural leak type. Among the 5 types, annular bulging type was most common(38.7%). Discography was useful in the determination of a needle placement, intradiscal pathology, and Chymopapain injection or not.

The Discolytic Effects of Disken(R)(Chymopapain, made in Korea): Experimental Study

The purpose of this study is to evaluate the effect of Disken(R)(chymopapain) on the intervertebral discs of Mongolian Dogs. Three healthy Mongolian dogs at same age(9 months) were underwent laparotomy, and the intradiscal injections of Disken(R) were made from the anterior. After sequential roentgenographic examination, the dogs were sacrificed at 1 month, and the gross and histological examination were performed. The results were as follows: 1) The discolytic effects of Disken(R) were evidently observed through the roentgenographic and histological examination. 2) The maximal changes of intervertebral disc space narrowing developed within 1 week after injection. 3) The reduction percentage of disc spaces was ranged between 45% to 50%, compared to the pre-injections stage. 4) The nucleus pulposus was evidently affected, but the annulus fibrosus and epiphyseal cartilage were not affected. 5) The adverse reactions were not observed in this study.

Effects of Vasoactive Drugs on Blood Flow in Rabbits: Photoplethysmographic Assessment / 대한정형외과학회잡지

The dynamic blood flow is regulated by the numerous complex mechanisms. Since blood flow varies directly with the radius of the vessel, blood flow is markedly affected by small changes in the caliber of the vessels. Using the hotoplethysmography, we assessed the relative changes of blood flow after topical application of the vasoactive drugs to the femoral arteries of the rabbits. It is the purpose of this study to evaluate the immediate and delayed effects of the vasoactive drugs such as epinephrine, methylergonovine, chymopapain, and lidocaine in course of time when the drugs applied topically to the vessel. 60 rabbits were divided into 6 experimental groups. In group I, the femoral artery was surgically exposed only. In Group g-A, epinephrine was applied to the femoral artery after surgical exposure. In Group Il-B, after spplication of epinephrine, the effect of epiniphrine was reversed with lidocaine. Another drugs were applied as follows methylergonovine in Group Hl-A, methylergonovine and lidocaine in Group Ill-B as in group Il-B, Chymopapain in Group lV. The relstive changes of blood flow were measured by the photoplethymograph for 3 weeks. The results are as follows ; 1. The amplitude of the photoplethysmographic wave decreased immediately after the topical application of epinephrine, methylergonovine and chymopapain. Such an effect could be observed until the 3rd week after the topical application of the drugs, 2. The delayed dffect of reducing the amplitude could be seen during the 1st week in the epinephrine and methylergonovine treated groups. However, it was seen after 1st week in the chymopapain treated group. 3. The delayed effect of epinephrine and methylergonovine could be reversed with lidocaine. 4. It seems that lidocaine can be used clinically to preyent the delayed effect of epinephrine and methylergonovine.

Therapeutic Results of Chemonucleolysis in Patients with Herniated Lumbar Discs

We had experienced 60 cases of chemonucleolysis with Discase(R)(chymopapain for injection) under careful patient selection of herniated lumbar discs and had followed up thereafter at least 3 months since July, 1984. Therapeutic results were generally favorable, with 90% of patients achieving either excellent or good(satisfactory) results. Three patients only had poor or failure results. There was no major anaphylatic reaction and no serious neurologic complications. Back spasm and stiffness/soreness were the most frequently encountered complications.

A Clinical Study of Chemonucleolysis for Herniated Lumbar Discs

The authors analysed 522 patients treated with chymopapain for herniated lumbar discs from May 1984 to December 1985 at the Dept. Neurosurgery, Yongdong Severance Hospital, Yonsei University College of Medicine. The data were obtained from a questionnaire and clinical records. The favorable indications for chemonucleolysis were under the following conditions ; 1) The patient's major complaint was leg pain than low back pain. 2) Marked limitation on straight leg raising test. 3) Spine CT scans showing soft bulging diec herniation without calcification or degenerative changes. The results were more favorable in the younger groups and the more limited straight leg raising group. The favorable results were obtained in 89.8%. In conclusion, our findings suggest that before surgical intervention, chemonucleolysis is a safe and effective nonsurgical method for treatment of herniated lumbar discs.

CT Scan and Discographic Findings in Ruptured Lumbar Discs

The herniated lumbar intervertebral disc, a common affliction in man, had been diagnosed with myelogram and treated with laminectomy. Recently, the application of CT scan and chemonucleolysis markedly changed the mode of management in lumbar disc diseases. High resolution CT scan of lumbar spine became the most popular diagnostic tool to detect herniations of lumbar discs and discolysis with chymopapain an alternative to surgery in a large number of patients. We performed CT scan and discography in 131 discs of 100 patients prior to chemonucleolysis and there were too many ruptured discs not found on CT scan but discography. Of the 5 patients who failed in chemonucleolysis severe dye leakage was seen in 4 cases. Extradural leakage of contrast medium was not a contraindication to the injection of chymopapain. However, when this occured the precaution was taken of injecting more quantity of chymopapain slowly. This report presents our experience with lumbar discography and comparative analysis of CT scan and discography. We think discography is very important diagnostic tool to detect rupture of discs prior to chemonucleolysis and may aid our gradually increasing understanding of the pathophysiology of the disc diseases.