Clinical Results of Chemonucleolysis for the Far Lateral Lumbar Disc Herniation

ABSTRACT

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.