Tratamiento percutáneo de hernias discales y dolor discogénico de columna cervical y lumbar con etanol gelificado radiopaco / Percutaneous treatment of cervical and lumbar disc herniation and discogenic pain with radiopaque gelified ethanol

This study documents the efficacy of chemonucleolysis with radiopaque gelified ethanol in the treatment of cervical and lumbar disc herniation and discogenic pain. Ten patients underwent this procedure between April 1 and June 30, 2010. Satisfactory results were obtained in 100 percent of patients. There were no adverse events reported during or post-procedure and a significant reduction in pain and analgesic intake after intradiscal injection was registered. This technique, simple and safe to perform, yielded satisfactory results; thus, it appears to be a good alternative in the treatment of herniated discs and discogenic pain.

Este estudio reporta el resultado de quimionucleolisis usando etanol gelificado radiopaco en el tratamiento de hernias discales o dolor discogénico en columna cervical y lumbar. La muestra de pacientes fue relativamente pequeña y corresponde al periodo del 1º de abril al 30 de junio de 2011. Los resultados fueron satisfactorios en el 100 por ciento de los pacientes. No hubo eventos adversos durante y luego del procedimiento. Se observó significativa reducción de analgésicos y dolor después del procedimiento. Esta técnica fue relativamente simple de realizar y segura en su aplicación mostrando buenos resultados. Promete ser una buena alternativa en el tratamiento de hernias discales o dolor discogénico.

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.

Effect of cognitive therapy and relaxation training on operation anxiety of patients undergoing chemonudeolysis with collagenase / 中国实用护理杂志

ObjectiveTo explore the effect of cognitive therapy and progressive relaxation training (CTPRT) on the operation anxiety of patients undergoing chemonucleolysis with collagenase.Methods120 patients undergoing chemonucleolysis with collagenase were randomly assigned to the experimental group and the control group.The experimental group received routine care and CTPRT,while the control group only received routine care.The perioperative anxiety status,back and leg pain,heart rate,blood pressure,status of sleeping and urination of the two groups were evaluated respectively.ResultsAnxiety and pain degree in the experimental group was significantly lower than that of the control group (P<0.01).About 30 min pre operation and postoperation,the heart rate and blood pressure of the experimental group were much lower than that of the control group (P<0.01).The experimental group also showed better sleep and urination status.ConclusionsThe cognitive therapy and progressive relaxation training can reduce degree of operation anxiety,release the pain and help promote sleep for patients undergoing chemonucleolysis with collagenase.

Clinical and laboratory study of early nerve foot lesion after collagenase chemonacleolysis / 中国矫形外科杂志

[Objective]To investigate the etioloty of the early nerve root lesion(RNRL) after collagenase chemonucleolyoio(CC) and its prevention and treatment.[Method]Twelve-hundred and eighty case of lumbar disc herniation undergoint cc were reviewed and analyzed.From January,2000 to December,2004 with follow-up time of 4~30 months,in which 12 cases(0.94%)had obvious ENRL after CC.Eighteen rabbits were randomly divided into three groups of six each:Group A,posterior longitudinal ligament intepated+intradisca injection;group B,parterior longitudinal ligamen+booteen+intradiscal injection,and group C,extradiscae injection.The disc and the nerve roots at the inject side were removed,fixed and examined by microscope,and the changes of the discs end nerve roots were analyzed in different inject side and different time after CC.[Result]As the collagenase dose was large in groups of intradiscal+intradiscal injections case of ENRL in this group were more than that in other groups.In the 12 ENRL cases,ten cases of ENRL appeared in about 7 days after CC,8 cases without nerve root compression and all cases were improved in different degree,but no one reeovered completely at follow-up with excellent and good rate of efficiency in the cases operated in 3 days than that in cases operated after 8 days.In the experiment rabbits,there lowed obvious lyeis of nucleus.Pulpus in group A and group B,with severe damage of nerve roots in group B,while in group C,there was no obvious lipis of nucleuss pulpus and damage of nerve roots[Conclusion](1)As the larger collagenas dose in the cases with intradiscal and extradiscal injections can raise.The incidence of ENRL,it is suggested that CC used in cases with broken posterior longitudenal ligament of and brous anmulus and,with nucleus pulpuses herniated into spinal canal,CC should be prudent to apply.(2)The prognoseo of the ENRL after CC is poor and is related to operation time.(3)The incidence of ENRL after CC can be lowered with absolute bed rest and changing body position after CC.

Radio-frequency Disc Nucleoplasty and Chemonucleolysis with Collagenase for Lumbar Disc Herniation / 中国微创外科杂志

Objective To investigate the efficacy of radio-frequency disc nucleoplasty and chemonucleolysis with collagenase for the treatment of lumbar disc herniation.Methods Eighty patients with lumbar disc herniation were treated by nucleoplasty combined with chemonucleolysis using collagenase(1200 U) in our hospital from January 2002 to January 2007.Results The patients were re-examined in 2 weeks,4 weeks and 6 months after the operation.According to the modified MacNab criteria,62 patients achieved excellent outcomes,10 were good,6 were fair,and 2 were poor.The rate of excellent and good outcomes were 90%(72/80).No serious complications occurred in this series.Conclusion Radio-frequency disc nucleoplasty and chemonucleolysis with collagenase are minimally invasive and effective for lumbar disc hernia.

Surgical Treatments for Lumbar Disc Disease in Adolescent Patients; Chemonucleolysis / Microsurgical Discectomy/ PLIF with Cages

The herniated lumbar disc (HLD) in adolescent patients is characterized by typical discogenic pain that originates from a soft herniated disc. It is frequently related to back trauma, and sometimes it is also combined with a degenerative process and a bony spur such as posterior Schmorl's node. Chemonucleolysis is an excellent minimally invasive treatment having these criteria: leg pain rather than back pain, severe limitation on the straight leg raising test (SLRT), and soft disc protrusion on computed tomography (CT). Microsurgical discectomy is useful in the cases of extruded or sequestered HLD and lateral recess stenosis due to bony spur because the nerve root is not decompressed with chymopapain. Spinal fusion, like as PLIF, should be considered in the cases of severe disc degeneration, instability, and stenosis due to posterior central bony spur. In our study, 185 adolescent patients, whose follow-up period was more than 1 year (the range was 1 - 4 years), underwent spinal surgery due to HLD from March, 1998 to December, 2002 at our institute. Among these cases, we performed chemonucleolysis in 65 cases, microsurgical discectomy in 94 cases, and posterior lumbar interbody fusion (PLIF) with cages in 33 cases including 7 reoperation cases. The clinical success rate was 91% for chemonucleolysis, 95% for microsurgical disectomy, and 89% for PLIF with cages, and there were no non- union cases for the PLIF patients with cages. In adolescent HLD, chemonucleolysis was the 1st choice of treatment because the soft adolescent HLD was effectively treated with chemonucleolysis, especially when the patient satisfied the chemonucleolysis indications.

Study of related factors of the therapeutic efficacy of chemonucleolysis under X-ray monitoring for treatment of lumbar disc herniation / 中华物理医学与康复杂志

Objective To study the related factors of intradiscal injection of collagenase. Methods One hundred and sixty eight patients with lumbar disc herniation were injected with collagenase(600U) under X ray monitoring. Assessment of efficacy of the treatment was made in 1 week, 3 months and 1 year follow up. The parameters such as the size, the type and the number of herniated disc were studied. The effect of stenosis was also analyzed. Results The overall success rate after 1 week, 3 months and 1 year following the therapy was 22.62%, 89.29% and 92.26% , respectively. Seven patients were treated with surgical operation during the follow up, 1 developed cauda equina syndromes at the third day after the injection. It was found that the size of herniation did not affect the efficacy of the treatment. The protruded disc got better result than bulge disc after 1 week following the chemonucleolysis ( P

Ozone Chemonucleolysis on the Lumbar Intervertebral Disc of the Rabbit

OBJECTIVE: This study is aimed to evaluate the chemonucleolytic effect of medical ozone by investigating the change of the signal intensity on magnetic resonance imaging (MRI) scan after injection of medical ozone into the lumbar intervertebral disc of the rabbit. METHODS: A series of 21 intradiscal injections of 1ml of medical ozone(30microgram of ozone per ml of oxygen) was performed in 7 young adult rabbits. Two control series, which 20 intradiscal injections of 0.1ml of iodine contrast medium in 7 young adult rabbits and 21 intradiscal injections of 0.05ml of chymopapain in 7 young adult rabbits, were performed. T2 weighted MRI scan was performed pre-operatively and at 4 weeks after injection. RESULTS: T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series (n=21) of intradiscal injections of medical ozone at 4 weeks after injection, as compared with the control series of intradiscal injections of 0.1ml of iodine contrast medium. T2-weighted MRI scan of intervertebral disc spaces demonstrated significantly decreased signal intensities in the series(n=21) of intradiscal injections of chymopapain at 4 weeks after injection. Any neurologic deficit or complication was not found in all groups. CONCLUSION: Intradiscal injections of medical ozone into the lumbar intervertebral disc of the rabbits are proven to have chemonucleolytic effects.

Therapeutic Effect of Collagenase and Oxygen-Ozone in Patients with Lumbar Disc Herniation / 实用放射学杂志

Objective To evaluate the clinical effect of chemonucleolysis with collagenase and oxygen-ozone in lumbar disc herniation.Methods 90 cases with lumbar disc herniation confirmed by clinic,CT or MRI were randomly divided into the control group (collagease was injected outside the lumbar disc) and treatment group (based on the treatment of control group,oxygen-ozone was injected into lumbar disc).Results 90 cases were followed-up after the operation for 3 months. The excellent rate was 37.8% in the control group, 68.9% in the treatment group. The excellent or good rate was 93.3% in the control group, 95.6% in the treatment group. The excellent rate was significantly higher in the treatment group than that in the control group (P

Clinical Application of Collagenase Chemonucleolysis in Treatment of Cervical Disc Herniation / 实用放射学杂志

Objective To introduce the method and to evaluate the therapeutic effect of collagenase chemonucleolysis for treatment of cervical disc herniation.Methods 92 patients with cervical herniated discs were selected from January 2002 to December 2004.The procedure was guided by DSA and the puncture was defined from C_(6~7) or C_7-T_1 extradural cavity.Collagenase(1200~2400 u) was injcted in the herniated extradural cavity through the micrcatheter.Results The procedure of 88 cases was successful.80 cases were followed up from 6 to 12 months.The effect showed that 70 cases(87.5%) were excellent or good.No serious complication occurred.Conclusion The method of collagenase chemonucleolysis for treating cervical disc herniation is safe and effective,it can be used in clinic.

Chondroitinase ABC Chemonucleolysis on Normal Rabbit's Lumbar Discs

OBJECTIVE: This study is aimed to evaluate the effect of chondroitinase ABC on normal rabbit lumbar discs. MATERIALS AND METHODS: A series of intradiscal injections of chondroitinase ABC was performed in 9 young adult rabbits. A control series of intradiscal injections of iodine contrast medium was performed in 6 young adult rabbits. Roentgenograms were taken preoperatively and were repeated at one, three, five, seven days after injection of chondroitinase ABC. Roentgenograms also were taken preoperatiely and at seven days after injection of contrast dye. Magnetic resonance imagings(MRI) scan was performed pre-operatively and at seven days after injection. Light microscopic examination of both groups was done at 7 days postinjection. RESULTS: Roentgenographic evidence of disc space narrowing showed significant correlation with time course in the series of intradiscal injections of chondroitinase ABC compared with the control series. T2 weighted MRI of disc space demonstrated significantly decreased signal intensity in the series of intradiscal injections of chondroitinase ABC at seven days after injection, as compared with the control series. Histologic evaluation revealed the stainability of nucleus pulposus and annulus to toluidine blue which was quite decreased. The cytoplasm of notochordal cells of nucleus pulposus appeared to be shrunken, and the large cytoplasmic vacuoles in hematoxylin-eosin stain were decreased in the series of intradiscal injections of chondroitinase ABC, which were not evident in the control series. CONCLUSION: Intradiscal injections of chondroitinase ABC on normal rabbit lumbar disc proven to have chemonucleolytic effects.

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.

Retrospective Outcome Evaluation of Cervical Chemonucleolysis with Digital Infrared Thermographic Imaging

The diagnostic efficacy and comparability of digital infrared thermographic imaging(DITI), computerized tomographic(CT) scan and magnetic resonance imaging(MRI) in the assessment of outcome of chemonucleolysis for herniated soft cervical disc patients with ce rvicobrachial neuralgia were evaluated. Forty seven patients of herniated cervical discs who were treated with nucleolysis using chymopapain for last 2 years were assessed by each studying modality and clinical examinations. All the cases received DITI, CT scan and/ or MRI, and the thermal difference of each patient between symptomatic and asymptomatic limb was analyzed pre- and post-operatively. The diagnostic efficacy of each technology was similar, and inter-rater comparability did not differ significantly. DITI showed significantly good correlation with clinical outcome although there existed a considerable inaccuracy in assessing individual subjects. Digital infrared thermographic imaging was shown to be very useful method in the outcome evaluation of cervical chemonucleolysis.

Comparison of Automated Percutaneous Lumbar Discetomy (APLD ) and Chemonucleolysis in the Treatment of Herniated Lumbar intervertebral Discs / 대한정형외과학회잡지

Automated percutaneous lumbar discectomy (APLD) and chemonucleolysis represent two major modalities of recently popularized minimally invasive surgical procedures for the treatment of herniated lumbar discs. However, the controversies concerning the safety and efficacy of the procedures are yet to be settled. The purpose of retrospective study was to determine the efficacy of these percutanous procedures and hence to establish a rational guideline for the treatment of lumbar disc herniations. Clinical review of 615 patients treated by percutaneous procedures revealed 81% success rate following chemonucleolysis and 83% following APLD, with a mean follow-up of 38 months (range 24- 60 months) and 30 months (range 24-38 months) respectively. APLD required less time for resolution of back pain, and resulted in less disc space narrowing than chemonulceolysis. Clinical failures of the procedures were associated with extruded or calcified discs, combined spinal stenosis and discitis. Reduction of herniation size in postoperative CT had no significant correlation to the clinical results. In conclusion, both procedures were effective in contained disc without calcification or associated spinal stenosis. This study suggests some advantages of APLD over chemonucleolysis in the aspect of rapidity of symptom relief, disc space narrowing and possible complications. Reduction in herniation size was not imperative for clinical success. Both procedures appear to be good alternatives to open discectomy in well selected patients, and may be good bridges for the wide gap between conservative treatment and open surgery.

A Clinical Study and Analysis of Chemonuecleolysis Versus Automated Percutaneous Lumbar Discectomy in Herniated Nucleus Pulposus of the Lumbar Spine

The authors reviewed the radiographs and medical records of 134 consecutive patients who underwent chemonucleolysis and automated percutaneous lumbar discectomy(APLD) between March 1990 and December 1994 at our institute. Among the 34 consecutive patients, 90 patients underwent chemonucleolysis and the other remaining patients underwent APLD using a nucleotome. The results are summarized as follows: 1) In both groups, predominent patients were of young age and males. 2) The most common lesion was in L4-5 interspace in both groups 3) The posteior lateral type showed high incidence in APLD group. 4) The results were better in the younger age group and when spinal CT demonstrated posterior lateral type in both groups. 5) The results showed relatively good success rate of 84.4% in chemonucleolysis group and 88.6% in APLD group. 6) Better results can be anticipated when patients are carefully selected and operated on with a higher skillful technique.

Minimaly Invasive Spinal Surgery: Cinical analysis of Chemonucleolysis & Percutaneous Automated Lumbar Discectomy

The authors retrospectively analized the radiographs and medical records of 135 consecutive patients who underwent minimaly invasive spinal surgery from January, 1990 to December, 1994 at our institution. Among these, 72 patients have had chemonucleolysis and others percutaneous automated lumbar discectomy(PALD). The success rate was similar in both groups, ie, 75% in chemonucleolysis and 74.6% in PALD by Macnab's criteria. The higher success rate could be obtained in 1) younger age below 30, 2) predominant sciatica than lower back pain, 3) eccentric bulged disc with minimal degeneration, 4) abscent or minimal neurologic deficits. In conclusion, provided patients are carefully screened, minimal invasive spinal surgery is more preferable over conventional surgery, providing a safe and effective therapeutic alternative to many patients suffering from herniated lumbar disc.

Chemonucleolysis in Cervical Disc Herniations

The authors performed chemonucleolysis in 5 patients with cervical disc herniations who were treated at our institution between 1983 to 193. The age of the patients(4 were men and 1 women) ranged from 31 to 53, with the mean age of 44 years. All 5 patients presented with a less than 5-month history of progressive cervicobrachial pain. During a postoperative follow-up period, all patients had marked improvement from the cervico-brachial pain and there was no intraoperative or postoperative complications.

Clinical Significance of CT/Discography in the Determining the Prognosis of Patients for Chemonucleolysis

We analysed the results of 34 herniated lumbar disc patients who were treated with chemonucleolysis and took CT/discography from Jan. 1991 to Jun. 1992 at the Department of Neurosurgery, Presbytrian Medical Center, Chonju, Korea. The overall success rate of chemonucleolysis was 82.4%. The CT/discographic findings were divided according to whether fluorescing or not, and degeneration or not. The success rates in fluorescing and non-fluorescing group were 95.2% & 61.5%, respectively, and those in degeneration and non-degeneration group were 66.7% & 100%, respectively. So, the results showed that the outcome of chemonucleolysis was better when the herniated disc fragment demonstrated a large uptake of contrast material visible, or there was no annular appearance to describe degeneration on CT/discography.

The Clinical Study of the Collagenase Injection for the Treatment of Lumbar Disc Herniation / 介入放射学杂志

We injected collagenase into the lumbor disc(20 cases)or outside the lumbar disc(230 cases)for treating the patients with lumbar disc herniation from December 1994 to August 1996.200 cases had been followed up.The results were excellent or good in 91%.The authers in- troduced the operative method and its indications in detail,and suggested that chemonucleolysis is sate,good and easy to be operated with littlecomp lieation.Herniation more than 10mm in with cal- cification,lateral recess stenosis or recumance after the laminectomy are not the absolute contraindi- cations.

The clinical study of twice chemonucleolysis with collagenase for the treatment of lumbar disc herniation / 介入放射学杂志

Objective To study the feasibility and indication of twice chemonucleolysis with collagenase for the treatment of lumbar disc herniation.Methods Eighty two patients of lumber disc herniation were treated with twice collagenase chemonucleolysis.All patients were followed up for 3 to 12 months and then the clinical results were assessed according to the Macnab criteria retrospectively.Results Eighty two cases were followed up from 3 to 12 months postoperatively.Fifty one cases were excellent,13 cases good,8 as fair and 10 were poor.The rate of excellent plus good reached 78%,the effective rate was 88%.Conclusion Twice chemonucleolysis with strict indications together with prevention of allergic reaction before,during and after the operation;is safe and effective for treating lumbar disc herniation.(J Intervent Radiol,2007,16:258-259)