Chemonucleolysis as treatment for herniated lumbar disc.

Herniated disc, while not the most common cause of low back pain, is the most common reason for surgery to relieve back pain. An alternative to surgery when sciatic pain is the result of disc herniation is chemonucleolysis with chymopapain. Since this enzyme is effective only in very specific circumstances, proper patient selection is crucial. Five criteria for selection are presented, emphasizing that since chemonucleolysis is not conservative treatment, it should be reserved for patients whose pain is unrelieved by conservative methods. There are several important contraindications to chemonucleolysis: allergy to chymopapain, risk of injury to the cauda equina, disc lesions at cord levels, pregnancy, patient's age (not recommended for adolescents) and sequestrated disc. Technique is exacting and should be limited to surgeons with the opportunity for concentrated experience.