Lumbar Disc Herniation

Using data obtained by questionnaire in a retrospective review of pat sciatic pain (eighty-five treated i ents with low-back by injection of chy and ‘rnopapain and seventy-one, by open discectomy), the results at one and ten years after treatment were analyzed. For this analysis we used six measures of pain relief, six measures of the patients’ course during the ten-year period since primary treatment, and four measures of the patients’ history of employment or work since initial treatment. Valid ity studies demonstrated that the painoutcome measures reflected the patients’ condition adequately and that all six measures were significantly related to each other (Pearson’s r, p < 0.003). The chymopapain and discectomy guishable on the basis of the groups pain-ou were not distintcome measures. However, body mass was directly related to the presence of pain ten years of chymopapain. after discectomy but not after injection patients tended to have had a higher rate of reoperation Analysis of the progress measures (indicators of the course of the patients’ pain during the ten-year period) showed at both one and ten years after initial treatment. These that the rates of reoperation measures did not show unequivocal superiority of one in the two treatment groups did not differ significantly, but the discectomy treatment compared with the other. Using the work measures (assessments of the pa* No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. + Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. ** Department of Orthopaedics, Rush Presbyterian-X Luke’s Medical Center, Chicago, Illinois 60611. and tients’ history of employment since initial treatment), it was found that in both treatment groups the patients who returned to work six to twelve weeks after treatment despite persistent symptoms had significantly more pain at ten years (p < 0.04). Also, the patients who returned to work less than six weeks after treatment, while still symptomatic, showed a similar trend. On the other hand, among the patients who were still symptomatic at twelve weeks, it made no difference in the final results whether they returned to work at twelve weeks or thereafter. These findings support the notion that after either discectomy or chemonucleolysis, patients should return to work only after complete symptomatic recovery or a minimum convalescence of twelve weeks. initially. Then, if recovery is delayed after such treatment, surgical intervention in the form of open discectomy or of Indications for each of these techniques vary according to personal opinion. The potential advantages and disadpercutaneous injection of chymopapain may be considered. vantages of each procedure have been discussed12, but the indications for chymopapain as opposed to open surgery in the treatment of disc prolapse remain unsettled. Although some authors have reported comparable results with the two methods”, others have reported less favorable results with chymopapain4.1 1.2] . In addition, when they compared the VOL. 68-A, NO. 1, JANUARY 1986 44 J. WEINSTEIN, K. F. SPRATT, T. LEHMANN, T. McNEILL, AND W. HEJNA outcomes of operative and conservative therapy in selected patients five, ten, and twenty years after treatment, Hakelius, Weber, and Nashold and Hrubec did not find any significant differences between the final results of surgical and non-surgical treatment. Although there have been numerous reports on the results of treatment of patients with sciatic and low-back 3,4,6-8,10.12,14-16.20.22 pain no studies have compared the longterm effects of chymopapain with those of laminectomy and discectomy in the treatment of a herniated disc. Some authors have reported more favorable results in patients who were treated by laminectomy, but doubt remains about whether surgical treatment has any advantage over chymopapain or conservative treatment in the long run6,12,15,22. The purpose of our study was to compare the results of treatment of lumbar and lumbosacral disc herniations by chymopapain injection and by discectomy after ten years. The patients so treated were compared with respect to their general well-being (outcome measures) after ten years and with respect to their course (progress measures) during the ten-year period. The outcome measures included indices of pain and disability at ten years, while the progress measures included speed of relief of symptoms, duration of relief, rate of reoperation after a successful initial procedure, and satisfaction with treatment. It was hypothesized that after ten years no major differences between the chymopapain and discectomy groups would be found based on the outcome measures. However, it was expected that chymopapain patients and discectomy patients would differ in terms of some of the progress measures. Thus, it was anticipated that chymopapain patients would report more rapid relief of symptoms, longer relief from symptoms, and lower rates of reoperation than would the discectomy patients. A second area of interest was the relationship between type of treatment and capacity to work. This relationship was explored using work measures, but no specific hypotheses were proposed.