Chymopapain chemonucleolysis: CT changes after treatment

Chymopapain chemonucleolysis is now used extensively in this country to treat lumbar disk herniation. Despite increasing experience in patient selection, there continue to be patients who do not respond to treatment and require diagnostic reevaluation. Interpretation of postchemonucleolysis computed tomographic (CT) scans in these patients requires a knowledge of the CT changes that normally occur after treatment with chemonucleolysis. To define these temporal changes, a prospective CT evaluation was performed of 29 treated interspaces in 26 patients who returned for routine postchemonucleolysis follow-up. Despite a successful clinical response in 17 of 21 patients, changes in the size, location, shape, homogeneity, and density of the disk herniation were uncommon at the 6 week follow-up. In 24 treated interspaces, the most common changes at 6 week CT follow-up were the development of vacuum phenomenon in three (12.5%) and a slight decrease in the size of two (8.3%) disk herniations. A successful response was noted in 17 of 21 patients scanned at 6 month follow-up, with five (22.7%) of 22 injected interspaces exhibiting vacuum phenomenon and 13 (59.1%) interspaces showing an observable decrease in the size of the disk herniation. Early improvement of sciatica after chemonucleolysis often occurs without a change in the size of the disk herniation and may be mediated by chymopapain-induced disk-space narrowing. Continued improvement may be accompanied by both a decrease in the disk height and a reduction in the size of the disk protrusion.