Javid M J
Department of Neurological Surgery, University of Wisconsin Clinical Science Center, Madison.
J Neurosurg. 1992 Feb;76(2):184-90. doi: 10.3171/jns.1992.76.2.0184.
To help clarify the comparative effects of chemonucleolysis and discectomy, the author studied 178 consecutive patients with sciatica who did not respond to conservative treatment. None had previously undergone laminectomy or chemonucleolysis or had spinal stenosis. All received postmyelography computerized tomography (CT) and, if the radiological interpretation was that of an extruded migrated disc, a laminectomy was performed; otherwise, the patient was given a choice of the two procedures. Of the 178 patients, 106 underwent chemonucleolysis and 72 laminectomy. Workers' compensation was being paid to 21.6% of the chemonucleolysis patients and 20.8% of the laminectomy patients. Postoperatively, substantial improvement was noted in 82.7% of the chemonucleolysis patients and 92.5% of the laminectomy patients at 6 weeks and in 92.8% of the chemonucleolysis patients and 89.7% of the laminectomy patients at 6 months. The majority of patients in both groups had improved neurological signs. Follow-up questionnaires at 1 to 4 years postoperatively revealed an overall success rate of 86.5% for chemonucleolysis patients and 83.8% for laminectomy patients. In patients not receiving workers' compensation, 90.1% of the chemonucleolysis patients and 88.6% of the laminectomy patients had a successful outcome; in those receiving workers' compensation, 69.6% of the chemonucleolysis patients and 60.0% of the laminectomy patients had a successful outcome. No statistically significant differences in improvement rate in neurological symptoms or signs were identified between the two procedures. Overall, 85.1% of the chemonucleolysis patients and 78.5% of the laminectomy patients were employed at follow-up review. To achieve optimum results and eliminate noncandidates for chemonucleolysis, routine use of postmyelography CT is recommended. When properly used, chymopapain chemonucleolysis is an acceptable alternative to surgical discectomy.
为了明确化学髓核溶解术与椎间盘切除术的对比效果，作者对178例经保守治疗无效的坐骨神经痛患者进行了研究。这些患者此前均未接受过椎板切除术、化学髓核溶解术，也没有椎管狭窄。所有患者均接受了脊髓造影后计算机断层扫描（CT），如果影像学检查显示为椎间盘突出移位，则进行椎板切除术；否则，患者可在这两种手术中选择。178例患者中，106例行化学髓核溶解术，72例行椎板切除术。接受工伤赔偿的化学髓核溶解术患者占21.6%，椎板切除术患者占20.8%。术后，6周时化学髓核溶解术患者中有82.7%、椎板切除术患者中有92.5%有显著改善；6个月时化学髓核溶解术患者中有92.8%、椎板切除术患者中有89.7%有显著改善。两组中的大多数患者神经体征均有改善。术后1至4年的随访问卷显示，化学髓核溶解术患者的总体成功率为86.5%，椎板切除术患者为83.8%。在未接受工伤赔偿的患者中，化学髓核溶解术患者的成功率为90.1%，椎板切除术患者为88.6%；在接受工伤赔偿的患者中，化学髓核溶解术患者的成功率为69.6%，椎板切除术患者为60.0%。两种手术在神经症状或体征改善率方面未发现统计学上的显著差异。总体而言，随访复查时化学髓核溶解术患者中有85.1%、椎板切除术患者中有78.5%已就业。为了获得最佳效果并排除化学髓核溶解术的非适宜患者，建议常规使用脊髓造影后CT。当正确使用时，木瓜凝乳蛋白酶化学髓核溶解术是手术椎间盘切除术的一种可接受的替代方法。
