Chemonucleolysis in the treatment of lumbar disc disease.

In a follow-up study of a large group of patients who had been treated by chemonucleolysis, of those patients who had definite neurologic change in the form of reflex, sensory, or motor disturbance, 74 per cent had reverted to normalcy by the time of evaluation one year after injection. The most significant complication (anaphylaxis) was found in 1 per cent of our first 500 patients, but after we started using preoperative steroids along with other safeguards, we were able to control this complication. It is still something to be constantly on guard against. A mildly extruded nucleus pulposus is not a contraindication in chemonucleolysis. A sequestered one is. (table; see text) Patients who have had previous low back surgery have a lower percentage of satisfactory results than those who have not had previous surgery. Chemonucleolysis does not prejudice the chances of a good clinical result if a subsequent open surgical procedure is necessary. Preoperative psychological testing is a very effective predictor of end results in relation to pain relief from chemonucleolysis. Studies in our laboratory again confirm beyond a doubt that, in the dog, injection of very large amount of chymopapain in the epidural space of the lumbar spine has no effect on the subarachnoid contents, the dura, or the spinal nerves as they lie outside the dura and exit through the intervertebral foramina. The rare patient in whom there is a direct communication between the disc space and the subarachnoid space can be detected as the contrast medium is injected. If, by chance, chymopapain were inadvertently injected intrathecally, the maximum dose of that would be injected at any one level, 8 mg, would be well within the tolerable range in the human being.