• Principles Of Neurosurgery Setti Rengachary Pdf Reader Online
• Principles Of Neurosurgery Setti Rengachary Pdf Reader Software

1042-3680/96 $0.00 +.20PERCUTANEOUS SPINE TECHNIQUESLUMBAR CHYMOPAPAIN NUCLEOLYSIS Manucher J. Javid, MD, and Eugene J. Nordby, MDIn 1934, Mixter and Barr29 introduced laminectomy for the removal of herniated disc. By 1961, Barr1 stated that 'some of the people here think that open surgery for disk lesions will probably be primarily a thing of the past.

This seems incredible but I suspect that it may be true. We ought to be able to absorb some of this collagen tissue which is there, biochemically. I will be surprised if some of us here don't see the day when disk surgery is abolished or nearly so. Disks are 90% water.

Why should we have to bail them out with surgical instruments?' ' In 1941, Jansen and Balls13 isolated the enzyme chymopapain from crude papain derived from papaya latex. In 1956, Thomas44 demonstrated the enzyme's selective affinity for chondromucoprotein. He injected adolescent rabbits intravenously and noticed that the rabbit's ears hung down like a spaniel's. Thomas' paper prompted Lyman Smith to begin his own experimental and clinical work with chymopapain. In 1963, he reported on the results of the injection of chymopapain into the intervertebral disc of rabbits, which showed dissolution of the nucleus pulposus without apparent effect on the surrounding tissues.

He injected 22 dogs who had hind leg paralysis owing to herniation of intervertebral disc and found improvement in 14 of the dogs. 42 Subsequently, he started clinical trials and reported on his experience with the injection of chymo-papain in the intravertebral discs of human subjects in 1964.41 Smith coined the term chemonucleolysis (CNL) to describe the dissolution of nucleus pulposus using an injected solution of chymopapain, a proteolytic enzyme derived from papaya latex that catalyzes the rapid hydrolysis of the chondromucoprotein portion of the nucleus pulposus. By August 1975, 75 surgeons in the United States had treated about 17,000 patients experimentally with chymopapain (Disease). Overall, 72% of patients showed improvement. 19 In 1975, a double-blind study of 98 patients at Walter Reed Army Hospital was performed by four neurosurgical residents and at three Veterans Hospitals by three neurosurgeons and three orthopedic surgeons.

With the exception of one orthopedic surgeon, none of the investigators had previous experience with CNL. The results indicated that a placebo was as effective as chymopapain.40 Based on this study, Travenol Laboratories, which manufactured Disease, withdrew its new drug application from the US Food and Drug Administration (FDA) and patented the 'placebo.' CNL effectively ceased to be performed in the United States. There were, however, a number of questions raised regarding the flaws of the double-blind study. 18 In 1980, seven centers from throughout the United States conducted a double-blind study of 108 patients. Nine of eleven neurologic andFrom the Department of Neurological Surgery, University of Wisconsin Medical School and Clinical Science Center, Madison, WisconsinNEUROSURGERY CLINICS OF NORTH AMERICA VOLUME 7 鈥xA2NUMBER 1 鈥xA2JANUARY 19961718JAVID & NORDBYorthopedic surgeons who participated in the study were experienced in the use of CNL.

Based on the statistically significant success of chymopapain versus placebo21 in this second study, after years of controversy in 1982 the FDA approved the intradiscal injection of chymopapain for managing herniated nucleus pulposus with sciatica. A double-blind study by Fraser9 in Australia showed the same successful results. Subsequently, another doubleblind study published in 1988 demonstrated similar successful results. 6 In 1983, 6214 orthopedic and neurologic surgeons participated in 1-day training sessions consisting of lectures and the use of radiograph-controlled mannequins to demonstrate proper needle placement by a lateral approach. Although trainers emphasized repeatedly that chymopapain should be injected by lateral approach (introduced by Brown) and under no circumstances should be injected by posterior approach (introduced by Lindblom) or posterolateral approach (introduced by Erlacher) (Fig.

1), many inexperienced surgeons ignored this warning and major complications resulted. In retrospect, it became clear that 1 day of training was insufficient to achieve competence. A complication of concern was acute transverse myelitis reported by Smith Labora-LindblomErlachertories to the FDA. Subsequent review showed that only one patient demonstrated definite evidence of acute transverse myelitis,8, 34 in retrospect an incidental finding. In a double-blind study, Gogan and Fraser10 reported that a patient developed acute transverse myelitis after saline injection. Because of these problems, potential patients and surgeons not experienced with CNL became frightened and apprehensive and the number of CNL procedures performed in the United States dropped dramatically. During the same period and up to the present, the u se of chymopapain has increased in Europe and elsewhere.

At the American Association of Neurological Surgeons (AANS) in 1986, Professor Mario Brock of Hannover, Germany, said that the major problem in the United States was the inadequacy of 1-day training. In Europe, he said, such training is not allowed. Training is much more comprehensive and every effort is made to ensure that surgeons understand the technique of CNL thoroughly and practice it under supervision before they are allowed to perform it on their own. The prospective validity of the 1-day training session was based on the fact that a less sophisticated training session of that duration was used for 37 investigators in the 'Illinois Study' following the chymopapain double-blind study.Figure 1. Needle placement for lumbar discography.

Lateral approach of Joseph Brown is the only acceptable method for performing chemonucleolysis. (From Nordby EJ: Chemonucleolysis. In Frymore JW (ed): The Adult Spine, Principles and Practice, vol 2. New York, Raven Press, 1991, p 1741; with permission.)LUMBAR CHYMOPAPAIN NUCLEOLYSISOnly 12 of that group had any previous experience with intradiscal therapy and yet no significant complications resulted from about 1500 injections of chymopapain.

There can be no doubt, however, that a hands-on, preceptorial-type training is superior to the 1-day session. An inappropriate mixture of science and 'civil rights' led to the perceived need for the massive educational effort to avoid complaints of anticompetitive advantage. Even so, participants were advised of the advantage of supplementing the course with preceptorial training. Later, a network of experienced investigators was organized to provide such help as requested.30 Failed back syndrome and other complications can occur after laminectomy. There are an estimated 2000 pain clinics in the United States with the majority of their patients suffering from failed back operations.

Although major complications owing to the improper performance of CNL occurred prior to 1987, comparable data on complications owing to laminectomy do not exist because laminectomy is not under FDA scrutiny. Anaphylaxis is no longer a problem with CNL because of the routine use of immunoassay tests and possibly because of the administration of H 1 and H 2 blockers. Of all percutaneous intradiscal procedures, only chymopapain has been approved as an acceptable procedure by the Guideline Panel for the Agency for Health Care Policy and Research. They state that 'the Panel found evidence that percutaneous discectomy is significantly less efficacious than chymopapain in treating patients with lumbar disc herniation, and recommend that this and other new methods of lumbar disc surgery not be used until proven efficacious in controlled trials.'

45PATIENT SELECTIONA careful selection of patients for CNL is the key to successful results. No patient should be considered for this procedure who also is not a candidate for discectomy. Our experience shows that about 70% of laminectomy candidates for herniated lumbar disc syndrome are candidates for chemonucleolysis.

The only indication for CNL is unremitting sciatica that has not responded to conservative measures. Patients with back pain without sciatica should not be injected. Neurologic findings should in-19elude at least two of the following: forward bending and straight leg raising limitations, knee jerk or ankle jerk diminution or absence, and motor or sensory disturbances. At present, MR imaging is the gold standard for diagnosis. Occasionally, postmyelogram CT scan may be necessary. It is essential that involvement of the nerve root is demonstrated clearly before considering CNL or laminectomy. Unlike percutaneous discectomy, which is limited to discs contained by the annulus, CNL is indicated in noncontained discs and is effective in extruded discs in contiguity with the intervertebral space (Figs.

2, 3) and in patients where discography shows leakage of the contrast media (Fig. Immunoassay should be undertaken before considering chemonucleolysis. CONTRAINDICATIONSContraindications to CNL include the following: allergy to papaya or papain; cauda equina syndrome; pregnancy; central stenosis or lateral recess stenosis (Fig.

5); migrated disc (Fig. 6); severe spondylolisthesis; history of discitis; peripheral neuropathy; and previous discectomy at the same level with failed back syndrome (the result of CNL for recurrent herniated disc is good in patients who have had a successful result from previous discectomy). 16 Although repeat injection of chymopapain has proved to be effective/路 43 it is not approved by the FDA at present. TECHNIQUEMeticulous performance of CNL absolutely is mandatory. Biochemical calculations i h segel wiley 1976 pdf to word. Proper placement of the needle into nucleus pulposus must be verified. We routinely obtain radiographs in anteroposterior lateral and oblique views.

Because anaphylactic reaction may occur in 0.3% of patients, premedication with H 1 and H 2 receptor blockers for 24 hours prior to performance of CNL may decrease the severity of anaphylactic reaction should it occur. Diphenhydramine (50 mg four times a day) and cimetidine (300 mg four times a day) is used. Medications that promote the release of histamine should not be used.

PROCEDURE It is preferable to perform the procedure under local anesthesia supplemented by intrave-20JAVID & NORDBYFigure 2. Sagittal proton density-weighted (A) and axial T1-weighted spin-echo (B ) MR images demonstrate a very large L5-S1 subligamentously extruded disc herniation. Extensive disruption of the inferior aspect of the outer annular fibers (arrow) confirms disc extrusion.

There is marked displacement and compression of the right S1 nerve root (curved arrow). The patient had good improvement following chemonucleolysis, despite the definite extruded nature of this large herniation.nous sedation. Some surgeons prefer general anesthesia. It is important not to use the halogens, which may sensitize the heart to epinephrine and cause arrhythmia. The advantages of local anesthesia are: (1) the patient can respond throughout the procedure, especially if the needle touches the nerve root; (2) in case of anaphylaxis, prodromal symptoms are noted earlier; (3) complications from general anesthesia are avoided; and (4) substantial cost savings can be realized because the procedure may be performed in the radiology suite instead of in the operating room.The procedure is performed in the lateral decubitus position.

Some surgeons prefer the prone position. The position of the patient on the table is of the utmost importance. The patient must not be rotated.

The patient is flexed, usually with the left side down, with a roll or cushion under the left hip and knees and hips flexed. Adhesive tapes are used above and below the field to stabilize the position. Under fluoroscopic control, L4-L5 interspace is marked on the skin for disc herniations that occur at this level. With a herniated disc at a higher level, the corresponding level isFigure 3. Sagittal T2-weighted gradient echo (A) and axial T1-weighted spin-echo (B ) MR images demonstrate a huge extruded L5-S1 disc herniation (arrowhead) with marked displacement and compression of the right S1 nerve root (curved arrow).

The extruded disc material is contiguous with the intervertebral disc by way of a rather broad neck; this makes the patient an acceptable candidate for chemonucleolysis. The patient had marked improvement following chemonucleolysis, despite the definite extruded nature of this large herniation.LUMBAR CHYMOPAPAIN NUCLEOLYSIS21Figure 4. Lateral (A) and posterior-anterior (B) films from an L4-L5 discogram confirm correct intranuclear placement of the chemonucleolysis needle. There is discographic evidence of considerable nuclear degeneration and fissuring as well as a posterior-inferior tear of the outer annulus fibrosus. Marked leakage of water-soluble contrast media has occurred through the annular tear into the epidural space (arrows). Although contrast media is seen to extend a considerable distance away from the annular tear, the patient had an uneventful postoperative course and marked improvement following chemonucleolysis.marked. After the usual preparation of the skin under local anesthesia, an 18-gauge needle 6 inches long (longer needle for obese patients) is placed in the direction of the disc for a few centimeters.

In L4-L5 disc usually it is at a 45 degree angle 8 to 11 cm from the middle. At this point, under fluoroscopic control the di-rection of the needle should be checked in lateral, oblique, and anteroposterior views and readjusted as necessary. The needle is advanced slowly and checked frequently and its position is changed if indicated until it is inserted through the annulus. It is similar in feeling to inserting the needle through an unrip-Figure 5. Sagittal proton density-weighted (A) and axial T1-weighted (B) spin echo MR images demonstrate a small L4L5 disc herniation (arrowhead). Moderate left lateral recess stenosis (arrow) is present, however, making the patient a suboptimal candidate for chemonucleolysis.22JAVID & NORDBYFigure 6.

Sagittal T2-weighted gradient echo (A) and axial T1-weighted spin echo (8) MR images demonstrate a large extruded L4-L5 disc herniation. There is 1.5 cm of subligamentous caudal migration of extruded disc material.

Although the extruded disc is still slightly contiguous with the intervertebral disc, it is connected by a very small neck (curved arrow) making the patient a poor candidate for chemonucleolysis.ened pear. The needle is introduced further and the position of the tip of the needle is checked (Fig. At times, in lateral view the needle may seem to be in good p osition but in the oblique and AP view it is found to be outside of the nucleus. The oblique position is very helpful to determine if the needle is too anterior or too posterior. If the needle is too posterior, the thecal sac may be violated with back flow of cerebrospinal fluid. For LS-Sl disc the needle is inserted about 1 cm distal to L4-L5 needle placement level and about 30 degrees caudally.

At times, especially in men, the crest of the ileum is too high and several adjustments are necessary. In some cases it is difficult to insert the tip of the needle into the center of the disc. Saline or sterile water acceptance test routinely is used by injecting about 1 mL of the solution to determine if the needle is in the nucleus. This may reproduce the patient's sciatic pain. Occasionally discography is necessary to visualize the entire disc in all three views. One mL of iohexol (Omnipaque) is used. When the proper placement of the needle is confirmed the chymopapain is reconstituted.

Two mL of sterile water are injected into the vial containing 4000 units of chymopapain. It is important to allow the alcohol used on the vial stopper to evaporate before inserting the needle to mix the enzyme in order to avoid contamination of the enzyme by alcohol, which neutralizes the enzyme. One mL of thesolution containing 2000 units is injected over a 4-minute period. The needle is kept in place for 5 minutes before it is withdrawn. Following the procedure, the patient is observed for about 1 hour in the recovery room and then sent to an ambulatory surgery unit and kept under observation for about 6 hours and then discharged. We advise patients who come from long distances to remain overnight in the hospital or in a local motel.

The majority of patients have relief of sciatica after the procedure but may have back stiffness or spasm. Oxycodone number 1 to 2 every 4 to 6 hours and 5 mg of diazepam three times a day are prescribed for relief of symptom s and an ice pack or heat may be used. The patient is advised to avoid anything that may aggravate his or her pain.

Walking is started almost immediately, and the patient is encouraged to return to work as soon as possible. For sedentary work, within a week or in a few weeks; for heavy work, we do not advise a return to work until evaluation at 6 weeks post-CNL.

COMPLICATIONSChymopapain, a protein, may cause an allergic reaction in less than 1% of patients. With routine IgE serum sensitivity testing the incidence is albout 0.3%. IgE testing isLUMBAR CHYMO P APAIN NUCLEOLYSIS23Figure 7. Needle placement for chemonucleolysis L5-S1 lateral (A), oblique (8 ), and anteroposterior (C) views.99% accurate.

Neurologic complications previously reported were owing to the improper injection of the enzyme intrathecally, causing capillary bleeding. Acute transverse myelitis identified in one patient who had CNL about 3 weeks earlier8 could not be proved to be related to the enzyme, but may have been only an unfortunate coincidence. In five other patients, acute transverse myelitis was suspected but on subsequent investigation none were owing to chymopapain. 34 In our experience with CNL, the incidence of bacterial discitis is about 1 in 200 patients. The incidence of causalgia from nerve root trauma, owing to needle placement when we performed CNL under general anesthesia, was 1 in 400 patients.

Since 1982, local anesthesia supplemented by intravenous sedation has been used in a series of 590 patients by one of the authors (Manucher J. Causalgia occurred in one patient in 1982 that gradually resolved by 3 months.Stiffness and spasm (mild to severe) is an undesirable side effect of CNL that may occur in about 40% of patients. In some of these patients the stiffness may be severe.

Because of the use of lower doses of chymopapain (2000 units), the incidence of severe stiffness has decreased, with some surgeons reporting success with a much lower dose (500 units). MORBIDITY AND MORTALITYThe morbidity and mortality owing to CNL are well documented.

Comparable data on laminectomies for herniated discs are not available in the United States except for the study by Ramirez and Thisted37 reporting on complications and death owing to laminectomies in the United States in 1980 on 28,395 patients. The morbidity rate was 1.57% and the mortality rate was 0.059% for surgical discectomy. The data for CNL indicate a morbid-24JAVID & NORDBYity rate of 0.399% and a mortality rate of 0.02%. 30the careful selection of patients the incidence between the two procedures is similar. 14, 20CNL VERSUS LAMINECTOMYPOST-CNL LAMINECTOMY VERSUS REPEAT LAMINECTOMYIn 1985, Nordby31 reported comparisons of CNL and laminectomy in eight published studies. In six of these, the composite result showed success in 77.5% of CNL patients versus 77% of laminectomy patients. In two small randomized studies a high percentage of failures after CNL raised a question of the potency of the enzyme chymopapain, which was obtained from the same source in Europe.

In a recent report by Wilson and Mulholland, 50 Mulholland, one of the authors of one of the two randomized studies, reviewed the radiculograms of their patients and found a number of large disc protrusions. He concluded that this may be a more important reason for failure of CNL and today with the availability of MR imaging probably would have excluded several patients. In another randomized study, 46 laminectomy was found to be superior to CNL. In this study, however, strict criteria for selecting patients were not carried out. 14 (1) Chymopapain was used in sequestrated discs (a definite contraindication to CNL) (2) Failure to puncture the disc was given as a cause of unsatisfactory outcome. (3) The failure rate of laminectomy was 20.8% versus 27.3% for CNL. Only 3% of patients from the open surgery group, however, underwent reoperation, whereas 25% of the CNL group were subjected to surgery.

The incidence of reoperation was used as the criterion for failure. This w as based primarily on the surgeon's opinion and not the patient's input. 22 Although surgeons are much less inclined to reoperate on patients who have undergone laminectomy than those who have had CNL, this discrepancy in the ratio of discectomy performed after failed CNL is not in conformity with the experience of most surgeons. Even when comparing patients tested before the advent of CT scan and MR imaging, in 11 series published between 1961 and 1984 and encompassing 3485 patients who underwent CNL, there is a reported 12% frequency of laminectomy after unsuccessful CNL, compared with 7% after laminectomy in 16 published studies encompassing 10,502 patients during the same period.

36 With the advent of postmyelogram CT scan and MR imaging andIn a prospective 1- to 13-year follow up of 53 consecutive post-CNL laminectomy patients versus 50 consecutive repeat discectomy patients, better long-term results were obtained in post-CNL laminectomy patients compared with those who had repeat laminectomy.16COST EFFECTIVENESS If patients are selected carefully and the procedure is performed properly, CNL is considerably less expensive than laminectomy. This has been the universal experience in the United States,1s, 20, 27, 37, 39 Europe/ 24, 2s, 28, 48, 49 and Australia.11 If unnecessary CNL is performed, unnecessary laminectomy ensues, increasing overall cost. This was demonstrated well by Norton35 w ho compared the cost of 61 patients who had workers' compensation treated with chymopapain with 44 patients who had worker's compensation treated with laminectomy. In 61% of CNL patients and 54% of laminectomy patients the selection criteria by the AANS and the American Academy of Orthopedic Surgeons (AAOS) were not followed.

Most of the patients had no neurologic deficit. The experience of the 29 surgeons involved in the CN L procedures was limited to a per-surgeon average of three injections. The choice of CNL was made in 58% of the reported 105 cases because the surgeon recently had completed an AAOSAANS sponsored training course in the injection technique. Two months after CNL, 39% of patients underwent laminectomy and of the laminectomy patients, 11% underwent a repeat laminectomy!

Even though it is well known that the success rate of CNL and laminectomy in patients who have workers' compensation is not as good as in noncompensation patients, 17 the results of the above study are outrageous. This shows clearly how cavalier medical practices can increase the cost of medical care in the United States. The cost saving at the University of Wisconsin Hospital comparing 100 consecutive pa-LUMBAR CHYMOPAPAIN NUCLEOLYSIStients who underwent CNL with 100 consecutive patients who underwent laminectomy showed a net saving of $5365 per patient when CNL was performed instead of laminectomy. 15 If all patients who are candidates for CNL were to have the injection instead of laminectomy, the long-term cost savings would be enormous especially because chymopapain, unlike laminectomy, does not contribute to adhesive arachnoiditis or perineural fibrosis.

This 'failed back surgery' syndrome is a major contributor to the ever-increasing cost of healthcare in the United States. 5LONG-TERM RESULTSLong-term follow up of 3120 patients (7 to 20 years) who underwent CNL shows successful results of 71% to 93% among 13 authors, with an average of 77%. 32 Combined long-term successful results in 1736 patients from the United Kingdom, France, and Germany had an overall average of 75.3%. 2 A Norwegian article4 reported a 92% successful result after CNL. Nordby and Wright33 reported an average successful result of 76.2% in 45 published studies appearing between 1985-1993.

Wilson and Mulholland50 concluded that 'the recurrence rate after CNL has proved to be at least as low as that of surgical discectomy, and the durability of a successful outcome following CNL is significantly better than following surgery.' Gogan's10 10-year follow up of Fraser's impeccable 10-year double-blind study comparing CNL with placebo showed successful results in 80% of CNL patients versus 35% for the saline group.REPEAT CNLSutton43 was the first surgeon to report successful results after repeat CNL performed in Canada.

Principles Of Neurosurgery Setti Rengachary Pdf Reader Online

Since then similar successful results have been reported by Deutman et aF in the Netherlands. Although the use of repeat injections of chymopapain is not approved by the FDA at present, with the availability of IgE chymopapain test and pre-CNL preparation of patients with H 1 and H 2 receptor blocks, there is no reason to withhold this valuable procedure from patients who have had good longterm results since their initial laminectomy and either have a recurrent herniated disc or25a herniated disc on the opposite side at the same level or at another level. It is important to apply to the FDA for repeat injections of chymopapain in carefully selected patients.ALTERNATIVE ENZYMESAmong alternative enzymes being investigated is collagenase, which demonstrates a wide range of safety in all tissues except through intrathecal injection. Although no allergenicity was found in guinea pig studies, no animal experiments have demonstrated an allergic response with chymopapain either.

An initial series of 52 patients had a 78% success rate with no systemic or local toxic effects, but the phase III investigation was stopped in 1984 when operative findings in Germany revealed involvement of endplates, bone, ligaments, and epidural fat. It was determined that the collagenase used in the German studies was of greater potency than that used in the United States where similar findings were not found. Pain relief with collagenase is slow, usually taking 3 to 6 weeks, because only protease contamination affects the mucoprotein. The major effect of collagenase is on collagen, whereas chymopapain has no effect on collagen. Chondroitinase ABC is a disaccharidal enzyme from the bacterium Proteus vulgaris, which has a lytic action on the nucleus pulposus comparable with that of chymopapain. Investigation on this enzyme is underway in Japan and in at least one center in the United States.

Naturally occurring proteolytic enzymes produced by the human body, the cathepsins, also have been investigated in experimental models. Cathepsin G obtained from human neutrophil leukocytes, chymotrypsin purified from human pancreatic juices, and Cathepsin B purified from human liver have been injected into rabbit discs and all are effective in removing the nucleus pulposus. Cathepsin G and chymotrypsin are in the range of potency of chymopapain, whereas Cathepsin B is about half as effective. Chymotrypsin has been used for some years in cataract surgery to digest the zonules of the lens in one type of removal.

No antigenic response has been noted in humans during these procedures. 2026JA YID & NORDBYCONCLUSIONCNL is a safe and effective procedure in well-selected patients providing it is performed properly. It is substantially less expensive than laminectomy in short- and long-term results. The most important advantage of CNL over laminectomy is the lack of scar tissue with CNL, a serious complication that may occur after laminectomy. CNL may be performed in the radiology suite under supplemented local anesthesia, thereby decreasing the occasional risk of complication owing to general anesthesia as well as the tremendous operating room cost. CNL is performed as an outpatient procedure; laminectomy patients are hospitalized for about 1 to 4 days. The advantage of CNL over percutaneous discectomy is that chymopapain may be injected into noncontained extruded discs as long as the fragment is in contiguity with the interspace.

In the authors' opinion, unless and until a more effective procedure is found, the choice of CNL as an alternative procedure to laminectomy should be presented to every patient who meets the criteria and is a candidate for surgery.References 1. Barr JS: Lumbar disc lesions in retrospect and prospect. Clin Orthop 129:4-8, 1977 2. Benoist M: Curent issues in chemonucleolysis.

Long term effectiveness of chymopapain chemonucleolysis. Presented at the International Intradiscal Therapy Society Panel Discussion, Nice, France, April 8-12, 1992 3. Bochu M, Demiaus C, Vignon E: The cost of chemonucleolysis. A preliminary study.

In Bonneville JM (ed): Focus on Chemonucleolysis. Berlin, SpringerVerlag, 1986 pp 123- 125 4. Brautaset NJ, Hemminghytt S, Henriksen OA, Sand T: Lumbale skiveprolapser behandlet med kymopapain. Tidsskr Nor Laegeforen 112:2335-2339, 1992 5.

Burton CV: The failed back. In Wilkins RH, Rengachary SS (eds): Neurosurgery. New York, McGrawHill, 1985, pp 2290-2292 6. Dabezies DJ, Langford K, Morris J, et al: Safety and efficacy of chymopapain (Disease) in the treatment of sciatica due to a herniated nucleus pulposus. Results of randomized double-blind study.

Spine 13:561 565, 1988 7. Deutman RD, Bolscher JDH, Barendsen GW: Repeat chemonucleolysis. Presented at the Eighth Annual Meeting International Intradiscal Society Meeting, La Jolla, CA, March 15-19, 1995 8. Eguro H: Transverse myelitis following chemonucleolysis. Report of a case.

J Bone Joint Surg Am 65: 328-330, 19839. Fraser RD: Chymopapain for the treatment of intervertebral disc herniation.

The final report of a doubleblind study. Spine 8:815-818, 1984 10. Gogan WJ, Fraser RD: Chymopapain.

A 10-year double-blind study. Spine 7:388-394, 1992 11. Goldstein G, Gross PF: The treatment of herniated disc in Australia. Cost and benefits for intradiscal injection of chymopapain and surgery. Aust Fam Physician 14:1179- 1190, 1985 12. Gomez-Castresana F, Vazques Herrero C, Baltes Horche JL: Cervical chemonucleolysis. Orthopedics 18:237-242, 1995 13.

Jansen EF, Balls AK: Chymopapain: A new crystalline proteinase from papaya latex. J Biol Chem 137: 459-460, 1941 14. Javid MJ: A 1- to 4-year follow-up review of treatment of sciatica using chemonucleolysis or laminectomey. J Neurosurg 76:184-190, 1992 15. Javid MJ: Chemonucleolysis versus laminectomy: A cohort comparison of effectiveness and cost. Spine 20:18, 1995 16. Javid MJ, Strayer A: Long-term follow up of postchymopapain laminectomy patients versus repeat laminectomy patients.

Presented at the International Intradiscal Therapy Society Meeting, La Jolla, CA, March 14-18, 1995 17. Javid MJ: Signs and symptoms after chemonucleolysis. A detailed evaluation of 214 worker's compensation and non-compensation patients. Spine 13:1428-1437, 1988 18.

Principles Of Neurosurgery Setti Rengachary Pdf Reader Software

Javid MJ: A tale of two drugs: Urea and chymopapain. The 1982 Percival Bailey Oration. Neurosurgery 13:211-213, 1983 19. Javid MJ: Treatment of herniated lumbar disc syndrome with chymopapain. JAMA 234:2043-2047, 1980 20.

Javid MJ, Nordby E: Current status of chymopapain in herniated nucleus pulposus. Neurosurgery Quarterly 62:662-666, 1985 21. Javid MJ, Nordby EJ, Ford LT, et al: Safety and efficacy of chymopapain (chymodiactin) in herniating nucleus pulposus with sciatica. Results of a randomized double-blind study. JAMA 249:2489-2494, 1983 22. Keet JG: Chemonucleolyse of herniotomie; resultaten van een vergelijkend onderzoek bij patienten met een hernia nuclei pulposi lumbalis.

Tijdschrift vour Geneeskunde 132:1129-1130, 1988 23. Kos W: Cervical chemonucleolysis-How long can you go? Presented at the Sixth Annual Meeting of the International Intradiscal Therapy Society, Phoenix, March 10- 14, 1993 24. Lanois R, Reboul-Marty J, Henry B, et al: Analysis of the cost-effectiveness of seven years treatment of herniated lumbar disc.

J Econ Med 10:307- 325, 1992 25. Lavignolle B, Vital JM, Bauln GF, et al: Etudes comparees de la chimionucleolyse dans le tratemenet de la sciatique par hernie discal. Acta Orthop Belg 53:244249, 1987 26. Lazorthes Y, Verdie JC, Richaud J, et al: Chemonucleolysis of cervical discs. In Sutton JC: Current Concepts in Chemonucleolysis. London, Royal Society of Medicine, 1985, pp 217-223 27. McCulloch J: Costs: Surgery versus chemonucleolysis.

Alt Spinal Surgery 2:3- 4, 1985 28. McGrady HM: An economic evaluation of the interventions available for prolapsed intervertebral discs. Presented at the International Intradiscal Therapy Society Meeting, Aberdeen, Scotland, May 17-22, 1994LUMBAR CHYMOPAPAIN NUCLEOLYSIS29. Mixter WJ, Barr JS: Rupture of the intervertebral d isc with involvement of the spinal canal. N Engl J Med 211:210- 215, 1934 30. Nordby EJ: Chemonucleolysis.

In Frymoyer JW (ed): The Adult Spine, Principles and Practice, vol 2. N ew York, Raven Press, 1991, pp 1733-1750 31.

Nordby EJ: A comparison of discectomy and chemonucleolysis. Clin Orthop 200:279-283, 1985 32. Nordby EJ: Editorial comment: Long-term results in chemonucleolysis. Clin Orthop 206:2-3, 1986 33.

Nordby EJ, Wright PH: Efficacy of chymopapain in chemonucleolysis: A review. Spine 19:3578-3583, 1994 34. Nordby EJ, Wright PH, Schofield SR: Safety of chemonucleolysis. Adverse effects reported in the USA 19821991. Clin Orthop 293:123-134, 1993 35. Norton WL: Chemonucleolysis versus surgical discectomy: Comparison of costs and results in worker's compensation claimant.

Spine 11:440-443, 1986 36. Ramirez LF, Javid MJ: Cost-effectiveness of chemonucleolysis versus laminectomy in the treatment of herniated nucleus pulposus.

Spine 10:363-367, 1985 37. Ramirez LF, Thisted R: Complications and d em ographic characteristics of patients undergoing lumbar discectomy in community hospitals. Neurosurgery 25:226-231, 1989 38. Richaud J, Lazorthes Y, Verdie JC, et al: Chemonucleolysis for herniated cervical disc. Acta Neurochir (Wien) 91:116-119, 1988 39. Schwartz D, Ulstrom C, Chowins J, et al: Lumbar disc herniation: How does the choice of treatment affect the cost of care? Minn Med:489- 491, 1988 40.

Schwetschenau PR, Ramirez A, Johnston J, et al: Double-blind evaluation of intradiscal chymopapain for herniated lumbar discs: Early results. Neurosurgery 45:622-627, 19762741. Smith L: Enzyme dissolution of the nucleu s polposus in humans. JAMA 187:137-140, 1964 42.

Smith L, Garvin PJ, Jennings RB, et al: Enzym e dissolution of the nu cleus pulposus. Nature 198:1311-1312, 1963 43. Sutton JC Jr: Repeat chemonucleolysis. Clin Orthop 206:45-49, 1985 44.

Thomas L: Reversible collapse of rabbit ears after intravenous papain and prevention of recovery by cortisone. J Exp Med 104:245- 252, 1956 45. US Department of Health and Human Services: Acute low back problems in adults. The Guideline Panel for the Agency for Health Care Policy and Research in the United States, 1994.

HCPR Publication No. 95-0642, December 1964, p 82 46.

Van Alphen HAM, Braakman R, Bezemer PD, et al: Chemonucleolysis versus discectomy: A randomized multicenter trial. J Neurosurg 70:869- 875, 1989 47. Vertile ST, Styablim N, Pogozheva T: Treatment of cervical disc pathology using chemonucleolysis in complex direction. Presented at the 5th Annual Meeting of the International Intradiscal Therapy Society, Nice, France, April 8-12, 1992, p 39 48. Wardlaw D: Current issues in chemonucleolysis. Presented at the 5th Annual Meeting of the Expert Panel Discussion at the International Intradiscal Therapy Society, Nice, France, April 8-12, 1992 49. Wardlaw D: Disorders of the lumbar spine.

Diagnosis and treatment options. In Proceedings of One Day Conference, Nottingham, UK, September 20, 1991 50. Wilson LF, Mulholland RC: The long-term results of chemonucleolysis. In Bensist M (ed): Chemonucleolysis and Related Intradiscal Therapies.

New York, Thieme Medical Publishers, 1995, pp 69-75Address reprint requests to Manucher J. Javid, MD Department of Neurological Surgery University of Wisconsin Clinical Science Center H4/ 346 800 Highland A venue Madison, WI 53792.

This multi-authored Neurosurgical operative atlas, published under the chairmanship of Professor J.T. Goodrich, covers most of the technical information about how to deal practically with malformations of the CNS and its covering. Twenty out of 46 chapters are devoted to cranio-facial procedures, thus reflecting the influence and personal interest of the chief editor for this topic. Other topics of interest are the approaches for cervico-cranial base malformations, encephaloceles, Dandy-Walker malformation, open and closed spinal dysraphism, hydrocephalus, including shunting and endoscopy, trauma, revascularization procedure for moya-moya disease and surgery of focal brain stem gliomas.A significant number of chapters (19 out of 46) were already published in the AANS series entitled the Neurosurgical operative atlas (issued from 1991 to 2000, edited by Setti S. Rengachary and Robert H. These have been updated and new contributions represent 27 out of 46 chapters.Each.