Chymopapain / Chemonucleolysis

[mmglobal]

A client of mine who doesn't post on the forums asked me to comment on chymopapain... here is what I sent him.

I've been seeing presentations on chymo and discussing it with the surgeons since I started attending surgeons conferences back in 2003. The first time I saw it used in the OR was in 1994.

My father had Chymo scheduled back in the 70's, but his surgeon cancelled because he went on a world tour, teaching chymo. By the time my dad's procedure was rescheduled... he was already better, so he never had it done. Now, more than 30 years later, my dad still hasn't had back surgery. I'm sure he would have counted Chymo as a success as he got better anyway. (However, my dad has suffered with back pain his entire adult life... a few times a year with severe episodes. In any case, for him, the level of problems never rose to a level that justified surgery.)

I have many clients with Chymo in their history. Most were done back in the 1980's. Some are wonderful successes who had leg pain resolved and didn't need further treatment for a decade or more. Some were involved in disasters that we've heard of where the chymo actually caused substantial nerve damage.

Chymopapain is an enzyme that breaks down tissue. It's like a meat tenderizer. Inject a small amount of chymo into a bulging disc immediately behind a CONTAINED disc bulge (one that is still contained inside the PLL) and hopefully, it will dissolve enough disc tissue, allowing the disc to shrink and bulge to retract. We do much the same thing with PLLD or other procedures that may vaporize a small amount of disc material. (Be careful with this... I know horror stories here too.) Other discectomy techniques, with and without thermal annuloplasty do the same thing... remove some nucleus from behind the bulge... hope it shrinks... hope the disc doesn't break down further... hope it doesn't destabilize more

Problems ensue when the chymo comes in contact with sensitive tissues that are damaged by the enzyme. Spinal cord, cauda equina, exiting or transiting nerve roots... should not come in contact with the injectant. In the 80's too many people suffered permanent and serious nerve damage from misused Chymopapain treatments. Another minor problem was death from allergic reaction to the chymo. After some patients died, it was removed from the market. Abuses by the doctors using it were pretty amazing. If 2000 units is good, 4000 units is better? Applying way too much chymo in patients with disc protrusions that are effacing the spinal cord is a potential disaster!

Chymonucleolysis has been making a resurgence for several years now. More is understood about the treatment and the problems experienced in the past. IMHO, stopping all chymo treatments was throwing the baby out with the bath water. It's an example of a good technology that was abandoned because it was misapplied. It's an example of why we need to go to doctors who have great experience and know what they are doing. Even doctors with great experience have learning curves associated with new technology.

Today, before you have chymo, you should be tested for allergy. You'll get an injection that is a fraction of what was used in the disaster cases (hundreds of units instead of many thousands.) You'll not get chymo if you have a uncontained herniation or annular tears that will allow the injectant to flow into the canal area.

I'm not recommending this... I'm just relating what I've learned over the years. Most of the people I see in my business are too far down the degenerative cascade to be a candidate for chymo. Occasionally, I see someone with good indications and they typically wind up with a variety of discectomy procedures... maybe some could entertain chymo. However, because of the history in this country and litigiousness of our society, it may be tough to find.

I'll try to dig out some of the studies I've seen presented and post later.

Mark

[robprodisc]

Comment on chymopapain

I had this done to my back in 1986. Coming out of the operating room my eye began to swell. Some sort of reaction. They quickly injected something and the swelling went away.
Days after the procedure I had no pain in my leg, I spent a summer of picking bails and the back did well for 15 years in the combat arms, I fell from the 2nd floor in house to house fighting in the dark, hit a trench with my wheeled vehicle which smacked my back so hard i had a 5 minute nap. Slowly l5 s1 started to cause problems and the L4-L5 also herniated.
In my opinion it worked very well.
It was 100 percent success in my view. I am not to sure about my prodisc yet. It will be a year in Aug since my prodisc surgery and I am waitin for the nerve pain in the hips and calve to go away. Wishfull thinking maybe.

[mmglobal]

Thanks Rob... I know a few doctors who used Chymo with great results and lament the fact that they can't use it any more.

However... we still need to be careful as this is a technology that when misapplied... can be very dangerious. (That's true for most things SPINE!)

Mark