SPINE Volume 31, Number 24, pp E890 –E897

©2006, Lippincott Williams & Wilkins, Inc.

Transforaminal Posterolateral Endoscopic Discectomy

With or Without the Combination of a Low-Dose
Chymopapain: A Prospective Randomized Study in 280
Consecutive Cases

Thomas Hoogland, MD, PhD, Michael Schubert, MD, Boris Miklitz, BSc, and Agnes Ramirez, ASS

Study Design. A prospective randomized study involv- when an intradiscal injection of 1000 U of chymopapain
ing 280 consecutive cases of lumbar disc herniation man- was added. There was a low recurrence rate with no
aged either by an endoscopic discectomy alone or an major complications. The method can be applied in any
endoscopic discectomy combined with an intradiscal in- type of lumbar disc herniation, including the L5⫺S1 level.
jection of a low dose (1000 U) of chymopapain. Key words: endoscopic discectomy, chymopapain, Chy-
Objective. To compare outcome, complications, and modiactin, chemonucleolysis, HNP, disc herniation, percu-
reherniations of both techniques. taneous nucleotomy. Spine 2006;31:E890 –E897
Summary of Background Data. Despite a low compli-
cation rate, posterolateral endoscopic nucleotomy has
made a lengthy evolution because of an assumed limited It can be assumed that worldwide, dorsal mini-open and
indication. Chemonucleolysis, however, proven to be safe
and effective, has not continued to be accepted by the
microdiscectomy is the most widespread procedure for
majority in the spinal community as microdiscectomy is the decompression of a radicular syndrome caused by
considered to be more reliable. disc herniation. A breakthrough of less invasive decom-
Method. A total of 280 consecutive patients with a pressive procedures was made by the introduction of
primary herniated, including sequestrated, lumbar disc chymopapain by Smith.1,2 After the Food and Drug Ad-
with predominant leg pain, was randomized. A clinical
follow-up was performed at 3 months, and at 1 and 2
ministration approval of chymopapain in 1982, the in-
years after the index operation with an extensive ques- tradiscal injection of chymopapain received worldwide
tionnaire, including the visual analog scale for pain and popularity, but after several years, the enthusiasm re-
the MacNab criteria. The cohort integrity at 3 months was gressed because of a few serious complications, like
100%, at 1 year 96%, and at 2 years 92%. transfers myelitis (most likely due to false intrathecal
Results. At the 3-month evaluation, only minor com-
plications were registered. At 1-year postoperatively,
injections) and anaphylactic reactions. In addition, tran-
group 1 (endoscopy alone) had a recurrence rate of 6.9% sient postoperative back spasms in up to 35% of the
compared to group 2 (the combination therapy), with a cases occurred, and a failure rate of about 20% oc-
recurrence rate of 1.6%, which was a statistically signifi- curred3,4 requiring subsequent surgery. This has faded
cant difference in favor of the combination therapy (P ⫽ the enthusiasm cipher of the enzyme in favor of micro-
0045). At the 2-year follow-up, group 1 reported that
85.4% had an excellent or good result, 6.9% a fair result,
discectomy. As more recently published,5 the application
and 7.7% were not satisfied. At the 2-year follow-up, of chymopapain should still be considered an effective
group 2 reported that 93.3% had an excellent or good and safe treatment for the herniated discs. A number of
result, 2.5% a fair result, and 4.2% were not satisfied. This other transforaminal percutaneous treatments emerged6,7
outcome was statistically significant in favor of the group as transforaminal decompression appeared to cause less
including chymopapain. There were no infections or pa-
tients with any form of permanent iatrogenic nerve dam-
instability compared to posterior decompression.8 In
age, and no patients had a major complication. 1975, Hijikata et al9 published their first experiences
Conclusions. A high percentage of patient satisfaction with the closed percutaneous nucleotomy with a 2.6-mm
could be obtained with a posterior lateral endoscopic cannula, where as Kambin et al10 –19 used a 4-mm
discectomy for lumbar disc herniation, and a statistically Craig20 cannula. Onik et al21 introduced a suction probe
significant improvement of the results was obtained
having an outer diameter of 2.5 mm for removal of nu-
clear tissue. This procedure was extensively studied and
reported with limited results.22–24 Choy25 introduced
percutaneous laser nucleolysis of the lumbar disc herni-
From the Department of Spine Surgery, Alpha Klinik Munich, Munich, ation, and many authors26,27 reported the results. Addi-
Germany.
Acknowledgment date: January 12, 2006. First revision date: June 7, tional percutaneous techniques were developed.28,29
2006. Acceptance date: July 10, 2006. Comparative studies, however, did demonstrate that
The device(s)/drug(s) is/are FDA-approved or approved by correspond- chemonucleolysis appeared to be more effective than per-
ing national agency for this indication.
No funds were received in support of this work. No benefits in any cutaneous nucleotomy or percutaneous laser decompres-
form have been or will be received from a commercial party related sion.30 Disappointment with the outcome of central nu-
directly or indirectly to the subject of this manuscript. clear evacuation evolved the technology that permitted
Address correspondence and reprint requests to Thomas Hoogland,
MD, PhD, Department of Spine Surgery, Alpha Klinik Effnerstr. 38 transforaminal access to the herniation site and the com-
81925 Munich, Germany; E-mail: hoogland@alphaklinik.de pressive elements, resulting in cannulas of a 6.5 and

E890
 Transforaminal Posterolateral Endoscopic Discectomy • Hoogland et al E891

8.5-mm outer diameter.10 –19 In addition, arthroscopes31 dation. The procedure was performed with the patient lying on
and endoscopes32,33 were introduced to visualize the in- his opposite site on a radiolucent table in the operating suite.
traforaminal nerve root, thereby avoiding postoperative The back of the patient was disinfected, and a sterile screen
radiculitis. With the until recently available instruments, drape was applied. A biplane fluoroscopy was used for radio-
the main disadvantages of the percutaneous transforami- graph imaging. Then the entrance point was determined with a
metal rod that was projected with imaging guiding toward the
nal procedures have been: (1) its limited indication for
isthmus of the upper lamina of the involved level. Depending
patients with a contained and small-sized subligamen-
on the size of the patient, gender, and level, the entrance point
tous lumbar disc herniation34 –36 and (2) a 10% reopera- was located at the L5⫺S1 level at 12⫺16 cm from the midline,
tion rate.37 Access to the L5⫺S1 level can be difficult, at the L4⫺L5 level at 11⫺14 cm from the midline, at the
particularly in males because of interference of the iliac L3⫺L4 level 8⫺10 cm from the midline, and at L2⫺L3 level
crest. In 1994, new instrumentation was introduced in 7⫺9 cm from the midline. Then the skin was infiltrated with
our institution,38 – 41 enabling the enlargement of the fo- local anesthesia, and an 18-gauge needle was aimed at the isth-
ramen with special reamers so that the anterior spinal mus of the upper lamina for the L4⫺L5 and L5⫺S1 levels, and
canal could be made accessible for endoscope and instru- it was aimed at the facet joints of the affected levels in hernia-
ments also for the L5⫺S1 level, and avoiding injury to tions at the L3⫺L4 level or above. Once the isthmus was
the exiting nerve root, a problem that has been reported reached, a second, longer 22 curved needle was introduced and
after the regular transforaminal approach. At that point, guided into the extruding or sequestrated fragment. Then the
all types of disc herniations became accessible with the first needle was advanced over the second needle up to disc
height. The second needle was then withdrawn and again in-
lateral percutaneous approach.42 A total of 137 patients
troduced with the curve pointed laterally entering the disc
with a 1-year follow-up was reported with this technique space. With the second needle, the disc space was usually en-
in 1998, with a 88.3% success rate.43 In September tered into the center of the disc. Subsequently, up to 3 cc of
1995, the indication was extended to all types of disc iohexol (240 mg/mL) contrast was injected, and pain reaction,
herniations, and the present study was initiated to eval- dye leakage, and resistance were recorded. In patients in group
uate the effect of an additional injection of a low-dose 2, it was determined whether a low-resistant massive dye leak-
chymopapain. As in 1 study44 in open lumbar discec- age was present. In group 2, out of the 138 patients, 8 did
tomy, the adjunct did reduce the recurrence rate. Both demonstrate a massive leakage of low dose, meaning that a
the endoscopic discectomy and the treatment with chy- intradiscal injection of chymopapain was fruitless and possibly
mopapain are established treatments in Germany for dangerous, and these patients were excluded from the study
herniated discs, and, besides specific informed consent and only had an endoscopic decompression and fragment re-
moval without chymopapain injection. If no massive low-
regarding the potential complications, including an ana-
pressure leakage was present, in group 2, all patients first re-
phylactic reaction with chymopapain, no specific ap- ceived an intradiscal injection of 1000 U of chymopapain. At
proval of the ethical committee was required. that point, the second needle was withdrawn and replaced by a
Materials guidewire. Over the guidewire, a stab incision of about 8 mm
was made, and stepwise guiding and dilatation rods were in-
From January 9, 1996, until January 7, 1998, 280 patients troduced. The first guiding rod was a straight rod that was
were randomized in 2 groups. Inclusion criteria were: (1) pri- introduced up to the isthmus of the lamina. Subsequently di-
marily radicular pain; (2) magnetic resonance imaging (MRI) lating cannulas of 3.5, 5, and 6 mm were advanced up to the
or computed tomography proven disc herniation correspond- facet joint, then the faced joint capsule was infiltrated with 5 cc
ing to the neurologic findings; (3) a clear nerve-root tension of lidocaine 2% with adrenaline. Following this, the rod and
sign with a straight leg raising sign of less than 45, or a positive cannulas were removed except for the guiding wire, and, under
neurologic finding in terms of an absent knee or ankle reflex, imaging, a curved guiding rod of 2 mm then was advanced into
corresponding dermatomal numbness or weakness of quadri- the extruding or sequestrated fragment. Subsequently, a
ceps, foot-toe-dorsiflexors or triceps-weakness; and (4) in all 3.5-mm tube was pushed over the curved rod up to the facet
patients, conservative treatment had failed. Exclusion criteria joint area (Figures 1–3).
were: (1) obesity (patients that had an excess weight of 30 kg At that point, the first cannula was docked at the facet cap-
over: body weight minus body length minus 100 cm ⫻ 1 kg); sule or bone. Over this rod, a 4.5-mm hand reamer was then
(2) previous disc surgery; (3) symptomatic herniations at more introduced over the cannula and the resisting capsule, and bone
than 1 level; (4) patients younger than 18 years; and (5) patients was reamed away until resistance faded, meaning that the spi-
older than 60 years. A total of 280 consecutive patients that nal canal was about to be entered. This was checked with an
met the inclusion criteria were randomized into 2 groups ac- anteroposterior image view. At this point, except the guiding
cording to their birthday. Patients with an even birthday (group wire, all instruments were removed, and a second, thicker,
1: 142 patients) underwent the endoscopic discectomy alone, guiding rod was reintroduced over the guiding wire. At the level
and patients with an uneven birthday (group 2: 138 patients) of the isthmus, the guiding wire was then removed, and the
had the combination with 1000 U of intradiscal chymopapain. guiding rod was introduced deeper and advanced with the aid
of a mallet advancing the tip of the guiding rod into the direc-
Methods
tion of the herniated fragment. The position of the tip of the
All patients were treated as a day case or with one overnight guiding rod was inspected in 2 directions with the image inten-
stay and the first outpatient follow-up on the next day. The sifier, and it was ensured that the guiding rod came in the
procedure was performed with local anesthesia, intravenous vicinity of the extruding or protruding fragment. In case this
sedation with opioid anesthesia, and 2⫺10 mL midazolam se- could not be achieved, the first step of the operation was re-
E892 Spine • Volume 31 • Number 24 • 2006

Figure 1. Endoscopic approach.

peated. After that, guiding rod No. 2 was again introduced and
advanced toward the aimed fragment of the disc herniation. At
that point, a corresponding 4.5-mm cannula was introduced
over the guiding rod. This again was blocked at the facet level,
and a larger 5.5-mm reamer was then used to, subsequently,
open and enlarge the foramen. After the second reaming, all
instruments were again removed except for the guiding wire, Figure 3. Radiographic view.
and a third guiding rod 5.5 mm in diameter was introduced
again up until the isthmus. The guiding rod was then advanced
with a mallet under imaging in 2 directions toward the frag- identical, except for the enzyme injection. At this point, a spe-
ment to be removed. Subsequently, a 6.5-mm cannula and cial spine scope was introduced and the reached area inspected.
7.5-mm reamer were introduced, yielding in a foraminal open- As a rule, an extruding or sequestrated disc fragment could be
ing of 7.5 mm. In difficult cases with difficult access to the observed. Occasionally, a small part of the affected nerve root
fragment, particularly in the presence of foraminal stenosis, a was visible. In cases where the nerve root was also visible, a
fourth step was performed with a reamer of an outer diameter working forceps was introduced through the endoscope that
of 8.5 mm. As a rule, after the third reaming step, a working has a lumen of 2.8 mm, and under endoscopic view, the frag-
cannula of 7.5 mm was then advanced. Image intensifying con- ments underneath the nerve root were removed. The cannula
trolled all steps, and the working cannula with a 1-sided open- was then rotated so that the closed part of the cannula was
ing was directed exactly up to the area of the extruding or protecting the nerve root. Subsequently, the endoscope is re-
sequestrated fragment. As a rule, it takes 10 –15 minutes be- moved, and the large forceps is introduced, grabbing the re-
tween the intradiscal chymopapain injection and the final maining disc fragments and sequester. When at the introduc-
placement of the working cannula. In group 1, all steps were tion of the endoscope, no nerve root could be seen, at that
point, the endoscope was removed, and a large grasping for-
ceps was introduced, and the position of the instrument was
controlled and checked with the image intensifier in 2 direc-
tions. If the isthmus was exactly at the site of the extruding
fragment, according to the MRI or computed tomography
scan, then a firm bite was taken, usually resulting in the extrac-
tion of the most important compressing disc fragment. Once a
considerable disc fragment could be extracted, the endoscope
again was introduced, and the nerve root was inspected. Re-
maining fragments were then removed under endoscopic vi-
sion. When the localization of the instruments was uncertain,
the position of the instruments was checked with the image
intensifier in 2 directions. At all times at the end of the proce-
dure, the freed nerve root could be identified, and it always
could be visualized that the nerve root was mobile with the
heart rate (not with the breathing rate) (Figures 4 and 5).
After the extruded or sequestrated fragment had been re-
moved, the working cannula was then directed at disc level
with the opening away from the spinal canal, and with small
forceps, the hole in the disc was entered. All attainable loose
disc material in the posterolateral segment of the ruptured disc
was then removed. During this maneuver, usually the center of
the disc was not bothered. An intradiscal irrigation was per-
formed with a mixture of saline and nebacetin. Steroids were
Figure 2. Radiographic view. not used. Then the cannula was removed, and the skin was
 Transforaminal Posterolateral Endoscopic Discectomy • Hoogland et al E893

evaluation included a straight leg raising test and check of the

strength of the quadriceps, foot and toe extensors, as well as
triceps strength in order to detect possible persistent or re-
herniation. The 1-year follow-up questionnaire first of all in-
cluded a subjective rating about the result of the operation,
being excellent, good, fair (somewhat improved), or not satis-
fied. On a 10-point visual analog scale (VAS), the amount of
preoperative and postoperative back pain was plotted, the
same as for leg pain. Numbness was rated as: (1) vanished, (2)
improved, (3) unaltered, or (4) worse. Weakness was rated as:
(1) vanished, (2) improved, (3) unaltered, or (4) worse. An
identical questionnaire was completed 2 years postoperatively
with additional questions pertaining to the MacNab45 score.
Patients indicated the amount and frequency of pain medica-
tion, their work ability, and activities of daily life. Furthermore,
at 2 years, a sport activity evaluation was performed, including
intensity and type of sport before the symptomatic herniation,
the interval to sport resumption, intensity of sport activities at
Figure 4. Removal of disc material in endoscopic view. 2 years, and comparison to pre-herniation level. All patients
were asked to whether they would undergo the same procedure
again for the same problem. All patient data were implemented
closed with one stitch. Patients were then observed for 2 hours into Microsoft Access (Microsoft, Corp., Redmond, WA) and
in the recovery room and discharged with a flexible back brace. evaluated with SPSS software (version 8.0; SPSS, Inc., Chicago,
A postoperative checkup was performed the next day, and at IL). Monthly, a computer check was performed as to whether
that point, the patient did receive extensive instructions about the patients had returned their 1 and 2-year questionnaires in a
postoperative restrictions and rehabilitation according to a timely manner. If not, a reminder was sent out. If no response
standardized program. occurred in 4 weeks, the patient was called, and the question-
naire was completed by telephone. Since 1995, all German and
Follow-up. The day after surgery, all patients received a fol- Dutch-speaking patients operated on at the spine department
low-up booklet, including 3-month, 1-year, 2-year, and 5-year of the Alpha Klinik are included in follow-up systems, as de-
questionnaires and preaddressed envelopes. Three months af- scribed above. The statistical evaluation of the results and of
ter surgery, all patients returned for a clinical follow-up, except the recurrence rates was performed with SPSS (version 8.0;
for 2 patients with an early recurrence and treatment else- evaluating the ⫼2 test).
where. At the 3-month follow-up, the patients returned a ques-
tionnaire to evaluate possible complications, including infec- Complications. At 3 months, all patients returned for the
tion, wound healing, thrombosis, recurrent or persistent clinical follow-up, and the perioperative and postoperative
radicular pain, numbness, or weakness. Also, a checkup MRI complications were evaluated.
was made to exclude re-prolapse or re-herniation. The clinical
Group 1 (endoscopic discectomy alone). In group 1, there
were 2 patients with a superficial skin infection, both healed in
3⫺4 weeks with prolonged dressing care. One patient had a
2-month nerve root irritation that cleared with diclofenac and
codeine medication. There were 5 early recurrences after 3, 4,
6, 8, and 9 weeks. All 5 were reoperated on with microdiscec-
tomy. One patient had a postoperative allergic reaction to
cephalosporin antibiotic, with a skin reaction that cleared with
antihistamines.
Group 2 (endoscopic discectomy ⴙ enzyme). Two patients
reported significant postoperative nerve root pain without
nerve root tension signs and no evidence of recurrence. Both
patients were treated with tramadol and diclofenac for 4 and 5
weeks. The radicular pain subsided after 6 and 10 weeks, and
both patients were pain free at the 3-month follow-up. One
patient had a superficial wound infection that cleared with
prolonged dressing care in 3 weeks. There was 1 patient who
had an early recurrent herniation 3 weeks postoperatively,
which was successfully treated with microdiscectomy. One pa-
tient had a recurrence at 11 weeks and was successfully reop-
erated one with a second endoscopic discectomy.
Neither patients in group1 nor in group 2 had signs of deep
vein thrombosis, discitis, increased weakness of quadriceps,
Figure 5. Endoscopic view of the freed nerve. foot/toe extensors, or triceps strength.
E894 Spine • Volume 31 • Number 24 • 2006

Results Table 1. Subjective Satisfaction of the Patients in Group

1 Two Years Postoperative
Demographics
Group 1–Endoscopy Group (n ⴝ 142). Of the 280 patients
that entered the study, 142 were randomized into group1
(even birthday). Of these 142 patients, 130 (92%) re-
turned their 1-year questionnaire, and 119 patients
(83.8%) returned their 2-year questionnaire. The aver-
age age of these patients was 41 years, and 35% were
female, and 65% were male. Of patients, 62% were op-
erated on at level L5⫺S1, 31% at level L4⫺L5, 4% at
level L5–L6, 2% at level L3⫺L4, and 1% at level
L2⫺L3.

Group 2–Endoscopy in Combination With Chymopapain Group One year after the operation, the average improve-
(n ⴝ 138). A total of 138 patients were randomized in ment of leg pain according to the 10-point VAS
group 2 (uneven birthday). Of these 138 patients, 8 pa- amounted to 6.4 points in group 2. There were no pa-
tients appeared to have massive dye leakage during dis- tients that had a worsening of leg pain. Two years post-
kography and were, therefore, excluded from the study. operatively, the average improvement of leg pain in
Of the remaining 130 patients, all returned for the group 2 amounted to 6.37 points (preoperative 8.22
3-month follow-up, and 125 (96.2%) returned the points, postoperative 1.85 points).
1-year and 116 (89.2%) returned the 2-year question- Back Pain (VAS)
naires. In group 2, 32% were female and 68% were The average improvement of back pain according to the
male, with an average age of 40.3 years. Of patients in 10-point VAS amounted to 5.7 points. Four patients in
this group, 60% were operated on at level L5⫺S1, 36% group1 complained about a slight increase of 2⫺3
at level L4⫺L5, and 4% at level L3⫺L4. points. Two years postoperatively, patients in group1
A questionnaire was used to evaluate all patients at 1 noticed an improvement in back pain, averaging 5.6
year for the following criteria: (1) subjective patient sat- points (preoperative 8.2 and postoperative 2.6 points).
isfaction, classified as excellent, good, fair, or not satis- In group 2, the average improvement of back pain
fied; (2) leg pain level according to the 10-point VAS; (3) according to the 10-point VAS amounted to 5.7 points
back pain according to the 10-point VAS; and (4) sub- 1-year postoperatively. One patient complained about a
jective grading of sensibility disturbances. slight increase of back pain of 2 points, 1 patient com-
On the 2-year follow-up questionnaire, the same cri- plained about an increase of 4 points, and 1 of 7 points.
teria were inquired with additional questions regarding Two years postoperatively, group 2 reported an im-
MacNab criteria and sporting activities. provement in back pain, averaging 5.35 points (preoper-
ative 8.19 points; postoperative 2.84 points) according
Subjective Satisfaction of the Patients to the 10-point VAS.
In group 1, 63.1% of the patients rated the operation
result as excellent after 1 year, 23.1% as good (top 2 ⫽ Subjective Grading of Sensibility Disturbances
86.2%), 6.1% as fair, and 7.7% as not satisfied. Ques- Of the 130 patients in group 1, 94 had complained about
tioned after 2 years, 59.2% of the patients in group1 a preoperative sensibility disturbance. One year after the
rated the result of the operation as excellent, 26.2% as treatment, 68% quoted having no sensibility disorder,
good, 6.9% as fair, and 7.7% were not satisfied. 28% felt that the disorder improved, 3% felt that the
Questioned after 1 year, 68% of the patients in group sensibility disorder was unaltered, and 1% felt that it had
2 rated the operation result as excellent, 25.6% as good worsened.
(top 2 ⫽ 93.6%), 1.6% as fair, and 4.8% as not satisfied.
Questioned after 2 years, 70.6% of the patients in group
2 rated the result of the operation as excellent, 22.7% as Table 2. Subjective Satisfaction of the Patients in Group
good, 2.5% as fair, and 4.2% as poor (Tables 1, 2). 2 Two Years Post Operative

Leg Pain (VAS)

The average 10-point VAS improvement of back pain 1
year postoperatively in group1 amounted to 6.3 points.
Three patients in group1 complained about a slight in-
crease of 1–3 points. Two years postoperatively, patients
in group 1 noticed an improvement in leg pain, averaging
6.03 points according to the VAS (preoperative 8.05 and
postoperative 2.02 points).
 Transforaminal Posterolateral Endoscopic Discectomy • Hoogland et al E895

A total of 112 patients in group 2 had complained Recurrence Rate in the First Year
about a preoperative sensibility disturbance. Of these In the first postoperative year, a clear re-herniation (re-
patients, 70% were quoted as having no sensibility dis- current significant leg pain and an MRI proven re-
order 1 year after the percutaneous endoscopic discec- herniation) occurred in 9 patients (6,9%) in group 1, 8 of
tomy, 21% felt that the disorder improved, 7% felt that them requiring reoperation. Two patients (1.6%) in
the sensibility disorder was unaltered, and 2% felt that it group 2 developed a re-herniation, both of them requir-
was somewhat worse. ing reoperation. Statistical evaluation (SPSS 8.0/␹2)
shows a significant (P ⫽ 0.045) reduction of recurrences
MacNab Score at 2 Years in the group receiving additional enzyme.
● Excellent: No pain, no restriction of activity. Comparison Results of Endoscopy With Enzyme Versus
● Good: Occasional back or leg pain of sufficient se- Endoscopy Alone (Table 3)
verity to interfere with the patient’s ability to do nor-
mal work or capacity to enjoy him/herself in leisure Recurrence Rate in the Second Year. In the second post-
hours. operative year, there were 2 recurrences (1.5%) in group
● Fair: Improved functional capacity but handi- 1 and 3 recurrences in group 2 (2.4%). The comparison
capped by intermittent pain of sufficient severity to did not show statistical significance.
curtail or modify work or leisure activities. Subjective Satisfaction of the Patients at 2 Years
● Poor: No improvement or insufficient improvement When comparing the subjective satisfaction of patients in
to enable increase in activities; further operative inter- groups 1 and 2, a statistically significant result (P ⫽
vention required.36 0.025% according to ␹2) in favor of the enzyme group
According to this classification, 50.8% of patients in could be reported. Of the patients in group 2, 93.3% had
group 1 had an excellent result, 33.8% a good result, a top 2 result, rating the outcome of their operation as
14.4% had a fair result, and 0.9% (1 patient) had a poor excellent or good. Only 85.4% of the patients in group 1
result. According to this classification 62.7% of group 2 (no enzyme) had a top 2 result, a discrepancy of 7.9%.
had an excellent result, 27.2% a good result, 9.2% had a MacNab Criteria at 2 Years
fair result, and 0.9% (1 patient) had a poor result. A comparison of the 2-year outcome of both groups ac-
Sporting Activities cording to MacNab did not show statistical significance.
Of patients in group 1, 73 engaged in sporting activities Discussion
before their slipped disc. At the 2-year follow-up, 7 of
these patients no longer engaged in sporting activities In 2002, Yeung and Tsou32 reported the outcome and
after the endoscopic discectomy. complications in 307 cases of posterolateral endoscopic
Of patients in group 1, 85 engaged in sporting activ- discectomies with a minimal follow-up of 1 year (average
ities after surgery, of whom 18 (21.2%) had not engaged follow-up was 19 months). They reported an 83.6% ex-
in sporting activities before their slipped disc. This in- cellent or good result and a 9.3% rate of poor results.
crease means that after the postoperative rehabilitation Their reoperation rate was 5%, with an average fol-
endeavors, additional patients could be motivated for low-up of 19 months. These results are comparable to
sporting activities; 71.2% were able to perform at the the results in our group of endoscopic discectomy alone.
same or higher level, 20.2% at a lower level, and 8.3% The additional intradiscal injection of 1000 U of chymo-
did quit sport activities. The activities began after an papain in the second group of our study yielded a signif-
average of 10.6 weeks. icant improvement of patient satisfaction and decreased
A total of 69 patients in group 2 engaged in sporting recurrence rate. Although there were no complications
activities before their slipped disc. At the 2-year follow- related to the use of 1000 U chymopapain, there is a
up, 3 of these patients no longer engaged in sporting basic complication risk with the use of intradiscal chy-
activities after the endoscopic discectomy, and 84 pa- mopapain, primarily in the form of potential anaphylac-
tients were engaged in sporting activities (an increase of tic reaction. The standard dose of intradiscal chymopa-
18 patients ⫽ 12.9%). A total of 71.2% of patients were
able to perform at the same or higher level, 24.5% at a
lower level, and 4.3% did quit their sporting activities. Table 3. Comparison Results of Endoscopy With Enzyme
The activities began after an average of 11.9 weeks. Versus Endoscopy Alone

Statistical Significance
A statistical evaluation with the Microsoft Access and
the SPSS 8.0 system was performed comparing the re-
sults of both groups pertaining to: (1) recurrence rate in
the first year, (2) recurrence rate in the second year, (3)
subjective satisfaction of the patient at 2 years, and (4)
MacNab criteria at 2 years.
E896 Spine • Volume 31 • Number 24 • 2006

pain as a single treatment for herniated disc is 4000 U. A study36 in 1993 reported the superiority of percutane-
Incidents of anaphylaxis with this dose have been docu- ous, endoscopic discectomy over microsurgical discectomy
mented to be 0.4%.5 In our institution, we have injected in a small group of patients and limited indication. An
a low dose (1000 U) of chymopapain in 3645 cases,46 equally good efficacy of open versus arthroscopic transfo-
and we have seen 2 cases of anaphylactic relations that raminal discectomy was reported in 1999.61
were appropriately treated, including intubation. Both The applied technique is an extended version of tech-
female patients could be extubated the next morning and niques described by Kambin et al,17 and Yeung and
discharged in a stabile condition, with no sequela. We Tsou,32 being a uniportal outside-in technique, whereas
believe that when a careful, slow intradiscal injection of Kambin et al, and Yeung Tsou use the inside-out unipor-
chymopapain is preceded by a 2-direction image intensi- tal or biportal technique. Modern instrumentation, as
fier documentation of central intradiscal needle place- developed by the senior author, allows a stepwise en-
ment, diskography with 2 cc of contrast dye to exclude largement of the intervertebral lateral foramen, allowing
intravenous, or intravascular dye leakage or massive epi- a working cannula to be introduced up to the spinal
dural dye leakage, will avoid the additional (rarely re- canal and creating access to the anterior epidural space in
ported) complications of transverse myelitis and subdural order to remove sequestrated fragments.
hemorrhage. The overall safety of the use of chymopapain, This study has demonstrated the efficacy of this proce-
when properly applied, has been documented in many stud- dure, and showed that the addition of a low-dose chymo-
ies.5,47– 49 The majority in the spine surgeon community papain yields a statistical improvement of outcome and a
does consider microdiscectomy to be the gold standard statistically significant reduction of the early recurrence
operative treatment for lumbar disc herniation that is not rate.
adequately responding to conservative treatment.50 –52
The main objections against percutaneous procedures Conclusions
include the inferior efficacy, higher recurrence rate, and Transforaminal endoscopic discectomy performed by an
limited indication of percutaneous procedures.53 This experienced spine surgeon can be as effective as dorsal
study as well as the previously reported series32 do, how- microdiscectomy with less potential complications. Sig-
ever, demonstrate that posterolateral endoscopic discec- nificant improvement of the outcome and recurrence rate
tomy has an equal efficacy as microdiscectomy, and in can be obtained with the addition of an intradiscal injec-
combination with chymopapain, it might even exceed tion of a low-dose of chymopapain enzyme.
the results of microdiscectomy. In terms of efficacy, a
multicenter randomized study can only prove the supe-
riority of one procedure over the other. From a practical Key Points
standpoint, however, such a comparative study does not
● A prospective randomized study involving 280
appear to be feasible, as proven by the effort trial by
consecutive cases of lumbar disc herniation com-
Haines et al.54 The advantages of a transforaminal en-
pared the outcome managed either by an endo-
doscopic discectomy over a microdiscectomy are, how-
scopic discectomy alone or an endoscopic discec-
ever, obvious: (1) no need for general anesthesia; (2)
tomy combined with an intradiscal injection of a
less/no cases of iatrogenic neurologic damage; (3) signif-
low dose (1000 U) of chymopapain.
icantly less infections; (4) a direct approach to the ex-
● A high percentage of patient satisfaction could
truded disc fragment; (5) no sacrifice of ligamentum fla-
be obtained with a posterior lateral endoscopic
vum or intracanal capsule structures, therefore less scar
discectomy for lumbar disc herniation, and a sta-
formation; and (6) no disturbing scar tissue in case of
tistically significant improvement of the results was
re-intervention. As a matter of fact, in case of recurrence
obtained when an intradiscal injection of 1000 U of
after a dorsal procedure, the posterolateral endoscopic
chymopapain was added.
operation is preferred over a repeated dorsal approach.
● There was a low recurrence rate with no major
Since the introduction of the arthroscopic microdiscec-
complications. The method can be applied in any
tomy in 1992,10 –19 many authors have reported the results
type of lumbar disc herniation, including the
of the transforaminal endoscopic discectomy. There is ex-
L5⫺S1 level.
tensive literature regarding the results of microdiscectomy
● This study has demonstrated the efficacy of this
after its introduction.54 –59 In terms of complications, there
procedure, and showed that the addition of a low-
is a large variety in the incidence of dural tears, infection,
dose chymopapain yields a statistical improvement
reoperation rate, vascular injury, neural injury, and the
of outcome and a statistically significant reduction
complication rate may well be surgeon dependent.60 Nev-
of the early recurrence rate.
ertheless, the complication rate of percutaneous procedures
is, in all aspects, significantly smaller than any type of disc-
ectomy through the dorsal approach. It is obvious that a References
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