Chemonucleolysis in Lumbar Disc Herniation: A Meta-Analysis

Abstract

Couto JMC, Castilho EA de, Menezes PR. Chemonucleolysis in lumbar disc herniation: a meta-analysis. Clinics. 2007;62(2):175-80. PURPOSE:To carry out a systematic review and meta-analysis of the efficacy of chemonucleolysis in the treatment of lumbar disc herniation. METHODS: Clinical trials were selected from 3 electronic databases (The Cochrane Controlled Trials Register, MEDLINE, and EMBASE). Data were analyzed with the software STATA, using the meta command. RESULTS: Twenty-two clinical trials were eligible. For chemonucleolysis versus placebo, the summary risk ratio estimate for pain relief as outcome was 1.51 (95% CI: 1.27-1.80). The summary estimate was 1.07 (95% CI: 0.95-1.20) for the comparison between chymopapain and collagenase. Regarding chemonucleolysis with chymopapain versus surgery, the fixed-effect summary estimate of effect for pain relief was 0.93 (95% CI: 0.88-0.98) with surgery as the reference group. In this case, heterogeneity was statistically significant. CONCLUSIONS: Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase in the treatment of lumbar disc prolapse. Results for studies comparing chemonucleolysis with surgery were heterogeneous, making it difficult to interpret the summary measure of effect. KEYWORDS:Chemonucleolysis. Chymopapain. Systematic review. Meta-analysis. Lumbar disc herniation. INTRODUCTIONSurgery to treat lumbar disc prolapse was introduced in 1934, 1 and ever since it has been considered as the main treatment modality when conservative treatment has failed. However, the therapeutic efficacy of surgical intervention has been a concern, considering that 20% of the patients are still in pain after surgery, 3 and that 7% to 15% of the patients undergoing discectomy develop the syndrome of failure of the lumbar surgery. 4 Alternative techniques have been developed and tested, and chemonucleolysis, which refers to the use of chymopapain for enzymatic lysis of the nucleus disc, has been among the most relevant. This technique was first described by Smith in 1964 5 and is the least invasive technique for lumbar disc herniation, presenting lower rates of complications in comparison with discectomy. 6 According to some authors, fewer days in the hospital was found for patients treated with chemonucleolysis, when compared to traditional surgery, 7,8 which augmented the considerable cost savings. [9][10][11][12] In a prospective study with a follow-up of at least 5 years, among 112 patients treated by chemonucleolysis, 83% had excellent/good results, 10% were unchanged, and 8% were worse after chemonucleolysis. 13 Nevertheless, an increased global cost was observed if a conventional surgery was needed following failure to improve after an initial chemonucleolysis.14 Some studies have shown superior efficacy of chemonucleolysis with chymopapain, as compared with placebo, 15-17 but there are conflicting results. 18 In a systematic review of surgical procedures for lumbar disc prolapse that included studies published until 1999, discecto...

Design and level of evidence of studies published in two Brazilian medical journals recently indexed in the ISI Web of Science database

“…Crosssectional studies and case reports were the most frequent design type in both journals, representing over 50% of all the clinical articles published during that year. Out of the 289 articles published in 2007, four were randomized (or quasi-randomized) trials [9][10][11][12] and four were systematic reviews, [13][14][15][16] thus representing less than 2% of the total number of published papers in both of these journals. After exclusion of six clinical guidelines [17][18][19][20][21][22] and 80 non-evidence articles (technical notes, clinical measurement validation studies, continuing medical education, quizzes and others) the distribution of the remaining 203 articles is presented in Table 2.…”

“…According to the Oxford criteria, 25.6% of the articles were classified as level 4 or 5 evidence, while 2.8% were level 1. Table 3 presents the AMSTAR scores of the four systematic reviews [13][14][15][16] published during 2007 in the two journals. The overall scores ranged from 1 to 6, with a mean score of 4.0 (standard deviation: 2.2).…”

Chemonukleolyse und intradiskale Elektrotherapie: was ist die gegenwärtige Evidenz?

“…Während die Ergebnisse der beiden Reviews für die Chemonukleolyse [13,14] zeigen, dass die O 2 O 3 -Nukleolyse ebenso wirksam oder wirksamer als die Kontrollintervention zu sein scheint. Zur Bewertung der Ergebnisse aus kontrollierten Studien für die IDET wurden Daten aus 3 Publikationen extrahiert (• ▶ Tab.…”

Revisão de artigos de ortopedia e medicina esportiva publicados em periódicos brasileiros

“…Proliferating cell nuclear antigen labeling index and p53 may be useful predictors of recurrence. Couto et al 27 evaluated the efficacy of chemonucleolysis in the treatment of lumbar disc herniation by means of a meta-analysis of 22 clinical trials. Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase.…”