Percutaneous Intradiscal Drug Injection Techniques Chymopapain Chemonucleolysis

Chymopapain is no longer available for chemonucleolysis since Abbott laboratories decided to stop its commercialization in 2001, probably because this drug was not providing enough profit. Previously, CC was mainly used in Europe.

Chymopapain is a proteolytic enzyme extracted from latex papaya, which breaks down peptide links between aminoacids of the proteoglycans of the NP (4). Depolymerization of proteoglycans causes reduction in the osmotic pressure and progressive dehydration of the NP

FIGURE 1 Large disc herniation on magnetic resonance imaging (A, after discography (C, D).

B) treated by chymopapain chemonucleolysis

FIGURE 1 Large disc herniation on magnetic resonance imaging (A, after discography (C, D).

B) treated by chymopapain chemonucleolysis

(5) while the annulus is preserved (6). CC is the reference percutaneous treatment of nerve root pain due to lumbar herniated discs, because its efficiency has been controlled in randomized trials where CC provided a success rate almost twice as great as that with placebo (1,2) and similar or slightly different from that of surgical discectomy (3).

CC has been accused of causing serious complications including neurological deficits and anaphylactic shocks. However, neurological complications are the consequence of a wrong technique with subarachnoid injection. An anaphylactic shock occurs in approximately 0.5% of cases and even less with the use of cutaneous tests (prick test), which allow the detection of the most highly sensitive patients (7).

CC provided good results even in cases of large disc herniations (Fig. 1) and foraminal disc herniations, and in the elderly. Local contraindications included a clearly sequestered disc fragment, mostly calcified disc herniations, and stenosis of the central or lateral spinal canal not predominantly due to disc herniation.

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