Chemonucleolysis with Chondroitin Sulfate ABC Endolyase for Treating Lumbar Disc Herniation: Exploration of Prognostic Factors for Good or Poor Clinical Outcomes

Efficacy of Chemonucleolysis with Condoliase in Patients Aged under 20 Years

Introduction

Chemonucleolysis with condoliase is a minimally invasive treatment option for lumbar disk herniation (LDH). However, studies reporting the efficacy of condoliase in patients aged <20 years are scarce. Therefore, the present study aimed to evaluate the efficacy of condoliase therapy for LDH in the aforementioned population.

Methods

Condoliase administration was determined based on adequate informed consent. The study enrolled 138 patients (mean age, 41.3±15.4 years) with LDH who received condoliase injections with a follow-up period of 1 year. The patients were divided into Group Y (age, <20 years) and Group A (age, 20-70 years). The clinical outcomes were visual analog scale (VAS) scores for leg and back pain and Oswestry Disability Index (ODI) values. Changes in disk height and degeneration were evaluated. These data were obtained at baseline and at the 3-month and 1-year follow-ups. Condoliase therapy was considered to be effective if it improved the VAS score for leg pain by ≥50% at 1 year from baseline and prevented surgery.

Results

Groups Y and A consisted of 15 and 123 patients, respectively. Condoliase therapy was effective in 9 patients (60.0%) in Group Y and 96 patients (78.0%) in Group A. The rates of Pfirrmann grade deterioration and recovery were substantially higher in Group Y than in Group A (83.3% vs. 45.8% and 50.0% vs. 16.3%, respectively). While the disk height reduction in Group Y was greater at 3 months, it recovered to the same level as that in Group A at 1 year. In Group Y, patients who did not respond to the treatment exhibited a considerably higher preoperative ODI (P<0.05).

Conclusions

Chemonucleolysis with condoliase is considered to have limited efficacy in patients aged <20 years. Caution should be taken when managing cases showing lumbar instability or existing disability. While chemonucleolysis with condoliase is a less invasive treatment option for LDH, the administration should be decided upon with sufficient consent considering the potential limited efficacy and disk degeneration.

Utilization of condoliase therapy versus surgery for lumbar disc herniation and comparison of post-treatment motor improvement

STUDY DESIGN

Double-center retrospective study.

PURPOSE

Utilization trends in interventional treatment for lumbar disc herniation (LDH) have not yet been examined. Furthermore, limited information is currently available on motor recovery with condoliase therapy. Therefore, the present study investigated utilization trends in treatment for LDH and the effects of condoliase therapy on muscle weakness.

METHODS

This retrospective, double-center study involved patients with leg pain caused by LDH who received interventional treatment between September 2017 and August 2022. LDH patients were divided into two groups: an operative treatment group and condoliase therapy group. The period between September 2017 and August 2022 was divided into 5 equal parts and changes in the percentage of intervention treatment were examined. Motor recovery was also assessed in the two groups. Patients receiving condoliase therapy were divided into two groups: an effective group and non-effective group. Sex, age, the body mass index, duration of symptoms, herniation level, neurological and radiographic findings, a visual analog scale for leg pain, and the Oswestry disability index were examined in the two groups.

RESULTS

Subjects included 226 males and 115 females with a mean age of 49.2 years, mean BMI of 22.8, and mean duration of symptoms of 5.0 months. The utilization of condoliase therapy for LDH surpassed surgery in the third year after its introduction. In the fourth year, condoliase therapy became the main treatment for LDH. Lower limb muscle strength improved in 76 % of cases receiving condoliase therapy.

CONCLUSIONS

Condoliase therapy has become an intermediate treatment before surgery in our institutions. Motor recovery in patients receiving condoliase therapy was not inferior to that after surgery; however, in cases with severe muscle weakness with manual muscle test ≤3, the improvement rate was approximately 60 %. These results will be useful for clinicians when providing informed consent and selecting condoliase therapy.

Indication and Limitation of Intradiscal Condoliase Injection for Patients with Lumbar Disc Herniation: Literature Review and Meta-Analysis

Background

Intradiscal condoliase injection for lumbar disc herniation (LDH) was developed in Japan in 2018. The treatment is intermediate between conservative therapy and surgery, and its frequency is increasing. Condoliase is limited to a single application over a lifetime, rendering it important to understand the indications and predictors of its effectiveness. This review aimed to summarize published studies and provide appropriate indications and limitations for appropriate patient selection based on existing findings.

Methods

While adhering to PRISMA guidelines, we searched the PubMed, Web of Science, and EMBASE databases to identify articles reporting the clinical outcomes of intradiscal condoliase injection for LDH. Data extraction focused on the effective rate, prognostic factors, and posttreatment imaging changes and was used in the meta-analysis.

Results

Nineteen studies met the inclusion criteria. Our meta-analysis revealed 78% total response, 11% posttreatment surgery, and 42% posttreatment Pfirrmann-classification-grade progression rates. Posttreatment intervertebral disc degeneration was potentially associated with an improved response rate and disc regeneration one year posttreatment, especially in young patients. The Regimen for patients aged <20 and >70 years should be carefully selected, including those with a disease duration of >1 year, recurrent LDH, small-sized LDH, vertebral instability, and inadequate duration (<3 months) of conservative therapy.

Conclusions

Although long-term outcomes and imaging changes must be evaluated owing to the heterogeneity of previous studies, intradiscal condoliase injection is a minimally invasive and cost-effective treatment option for patients with LDH. Treatment indications should be determined after carefully evaluating evidence from previous conservative and surgical treatments.

Immediate Effects, Detailed Clinical Outcomes, and Prognostic Factors of Chemonucleolysis Using Condoliase for Lumbar Disc Herniation

Chemonucleolysis utilizing condoliase is a minimally invasive treatment for lumbar disc herniation (LDH) aimed at reducing intervertebral disc pressure and enhancing symptoms. In this study, lower limb pain was measured using the numeric rating scale (NRS) the day after treatment and 1 and 3 months after treatment. Prognostic factors were assessed, categorizing participants into an improvement group (I-group) for NRS lower limb pain scores of ≥3.5 and a non-improvement group (N-group) for scores of <3.5. This study included a total of 225 patients treated between April 2020 and March 2023. The mean age was 46.5 ± 16.5 years, with 151 males. The mean duration of illness was 6.2 ± 8.52 months. As of the day after treatment, 60 cases were classified into the I-group, 118 cases at 1 month after surgery, and 152 cases at 3 months after surgery. The disease duration before treatment was significantly shorter in the I-group at 1 (8.19 ± 8.74 [I-group] vs. 5.17 ± 8.04 [N-group] months) and 3 months (8.51 [I-group] ± 7.35 vs. 5.69 ± 8.87[N-group] months) after treatment. The comparison of baseline leg pain NRS shows a difference in leg pain NRS in the I-group when compared on the day after treatment (6.02 ± 2.64 [I-group] vs. 7.50 ± 1.79 [N-group]), 1 (5.13 ± 2.69 [I-group] vs. 7.58 ± 1.66 [N-group]), and 3 months (4.42 ± 2.70 [I-group] vs. 7.34 ± 1.77 [N-group]). Chemonucleolysis using condoliase for LDH can improve symptoms the day after treatment and can be a minimally invasive treatment to avoid surgery.

Enzymatic chemonucleolysis for lumbar disc herniation-an assessment of historical and contemporary efficacy and safety: a systematic review and meta-analysis

Lumbar disc herniation (LDH) is often managed surgically. Enzymatic chemonucleolysis emerged as a non-surgical alternative. This systematic review and meta-analysis aims to assess the efficacy and safety of chemonucleolytic enzymes for LDH. The primary objective is to evaluate efficacy through "treatment success" (i.e., pain reduction) and severe adverse events (SAEs) rates. Additionally, differences in efficacy and safety trends among chemonucleolytic enzymes are explored. Following our PROSPERO registered protocol (CRD42023451546) and PRISMA guidelines, a systematic search of PubMed and Web of Science databases was conducted up to July 18, 2023. Inclusion criteria involved human LDH treatment with enzymatic chemonucleolysis reagents, assessing pain alleviation, imaging changes, and reporting on SAEs, with focus on allergic reactions. Quality assessment employed the Cochrane Source of Bias and MINORS tools. Meta-analysis utilized odds ratios (OR) with 95% confidence intervals (CI). Among 62 included studies (12,368 patients), chemonucleolysis demonstrated an 79% treatment success rate and significantly outperformed placebo controls (OR 3.35, 95% CI 2.41-4.65) and scored similar to surgical interventions (OR 0.65, 95% CI 0.20-2.10). SAEs occurred in 1.4% of cases, with slightly higher rates in chymopapain cohorts. No significant differences in "proceeding to surgery" rates were observed between chemonucleolysis and control cohorts. Limitations include dated and heterogeneous studies, emphasizing the need for higher-quality trials. Further optimization through careful patient selection and advances in therapy implementation may further enhance outcomes. The observed benefits call for wider clinical exploration and adoption. No funding was received for this review.

Histological analysis of nucleus pulposus tissue from patients with lumbar disc herniation after condoliase administration

Background

Condoliase is an enzyme used as a treatment for lumbar disc herniation (LDH). This enzyme degrades chondroitin sulfate (CS) in the nucleus pulposus of the intervertebral disc (IVD). However, there are cases in which symptoms do not improve, despite condoliase administration. This study reports histological analysis of lumbar disc tissue of LDH patients who underwent surgery because condoliase had no therapeutic effect.

Methods

Between March 2019 and August 2019, 12 LDH patients who underwent full endoscopic spine surgery (FESS) discectomy at the Dezawa Akira PED Clinic were the subjects of the study. There are two study groups: six cases underwent FESS after condoliase administration, while six underwent FESS without condoliase administration. The average duration from drug administration to surgery was 152 days. Herniated disc removed at surgery was evaluated by histological staining including immunohistochemistry by anti-CS antibodies.

Results

Multiple large clusters (40-120 μm in diameter) were observed in the nucleus pulposus of those who received condoliase, but no clusters were observed in those who did not. The lumbar disc tissues, including the nucleus pulposus of recipients, were stained with anti-CS antibodies that recognize the CS unsaturated disaccharide, but non-administration tissue was not stained. These findings suggest that the enzyme acted on the nucleus pulposus, even in cases where symptoms were not improved by condoliase administration. Furthermore, there was no histological difference between stained images of the extracellular matrix in those who did or did not receive condoliase, suggesting that condoliase acted specifically on CS in the nucleus pulposus.

Conclusions

We demonstrated that CS in the nucleus pulposus was degraded in patients in whom condoliase did not have a therapeutic effect. Moreover, condoliase acts in human IVD without causing necrosis of chondrocytes and surrounding tissues.

Psychological Factors Can Affect the Clinical Outcome of Chemonucleolysis with Condoliase in Patients with Lumbar Disk Herniation

Introduction

Condoliase-based chemonucleolysis is a minimally invasive intermediate treatment option between conservative approaches and surgical interventions for lumbar disk herniation (LDH). In this study, the effects of psychological factors on the clinical outcomes of condoliase therapy for LDH were assessed.

Methods

This study involved patients with LDH who received condoliase injections over a 1-year follow-up period. Data from the visual analog scale (VAS) scores for leg and back pain, Oswestry Disability Index, and Hospital Anxiety and Depression Scale (HADS), which was utilized for the psychological assessment, were collected. Using magnetic resonance imaging, changes in disk height and degeneration were evaluated. Data were assessed at baseline and 1-month, 3-month, and 1-year follow-ups. Condoliase therapy was considered effective in patients whose VAS score for leg pain improved by ≥50% at 1 year from baseline and who did not require surgery. The patients were divided into two groups: those who reported effective treatment (Group E) and those who did not (Group I). Between these two groups, comparative analyses were carried out.

Results

In this study, a total of 102 patients (70 men; mean age, 43.8±18.2 years) were included. Condoliase therapy was effective in 76 patients (74.5%). Thirty-five patients (34.3%) showed psychological factors (HADS-Anxiety [HADS-A]≥8 or HADS-Depression [HADS-D]≥8) preoperatively and had a significantly lower rate of effectiveness than did those without psychological factors. Group I demonstrated significantly higher baseline back pain VAS, HADS, and HADS-D scores when compared with Group E. Logistic regression analysis identified females and the baseline HADS-D score as independent factors that were related to the effectiveness of condoliase therapy.

Conclusions

The patients with psychological factors tended to experience residual pain resulting in adverse effects on the clinical outcomes of chemonucleolysis with condoliase.

MRI characteristics of disc degeneration after condoliase injection in young patients: A consecutive case series

BACKGROUND

Lumbar disc herniation (LDH) results in low back pain due to nerve root compression caused by nucleus pulposus degeneration. Chemonucleolysis of the nucleus pulposus by injection of condoliase is less invasive than surgery, but may cause disc degeneration. The purpose of the study was to examine outcomes of condoliase injection in patients in their teens and twenties using Pfirrmann criteria on MRI.

METHODS

A single-center retrospective study was performed in 26 consecutive patients (19 men, 7 women) who underwent condoliase injection (1 mL, 1.25 U/mL) for LDH and had MRI scans at 3 and 6 months. Cases with and without an increase in Pfirrmann grade at 3 months post-injection were included in groups D (disc degeneration, n = 16) and N (no degeneration, n = 10). Pain was measured on a visual analogue scale (VAS). MRI findings were evaluated using the % change in disc height index (ΔDHI).

RESULTS

The mean age of the patients was 21.1 ± 4.1 years and 12 were <20 years old. At baseline, 4, 21 and 1 were in Pfirrmann grades II, III and IV. In group D, no case had a further increase in Pfirrmann grade from 3 to 6 months. Pain significantly decreased in both groups. There were no adverse events. MRI showed a significant decrease in ΔDHI from 100% pre-injection to 89.4 ± 9.7% at 3 months in all cases (p < 0.05). There was a significant recovery in ΔDHI in group D from 3 to 6 months (85.4 ± 9.3% vs. 86.7 ± 9.1%, p < 0.05).

CONCLUSIONS

These results suggest that chemonucleolysis with condoliase is effective and safe for LDH in young patients. Progression of Pfirrmann criteria at 3 months post-injection occurred in 61.5% of cases, but disc degeneration showed recovery in these patients. A longer-term study of the clinical symptoms related to these changes is required.

Interventional Therapy and Surgical Management of Lumbar Disc Herniation in Spine Surgery: A Narrative Review

Significant advancements in lumbar disc herniation (LDH) management have been made in interventional pain therapy, operative therapy, peri-operative management, and cost analysis of various procedures. The present review aims to provide a concise narrative of all these topics, current trends, and possible future directions in the management of LDH. Interventional pain management using intradiscal injections often serves as a minimally invasive non-surgical approach. Surgical modalities vary, including traditional open laminectomy, microdiscectomy, endoscopic discectomy, tubular discectomy, percutaneous laser disc decompression, and transforaminal foraminotomy. Prevention of infections during surgery is paramount and is often done via a single-dose preoperative antibiotic prophylaxis. Recurrence of LDH post-surgery is commonly observed and thus mitigative strategies for prevention have been proposed including the use of annular closure devices. Finally, all treatments are well-associated with clear as well as hidden costs to the health system and society as described by billing codes and loss of patients' quality-adjusted life-years. Our summary of recent literature regarding LDH may allow physicians to employ up-to-date evidence-based practice in clinical settings and can help drive future advancements in LDH management. Future longitudinal and comprehensive studies elucidating how each type of treatments fare against different types of herniations are warranted.

Factors associated with disc degeneration based on Pfirrmann criteria after condoliase treatment for lumbar disc herniation

BACKGROUND

Lumbar disc herniation (LDH) is a common cause of low back pain and is associated with degeneration of the nucleus pulposus causing nerve root compression. Chemonucleolysis of the nucleus pulposus with condoliase is a low-invasive treatment for LDH. The purpose of this study was to investigate changes in Pfirrmann criteria, which are used to evaluate disc degeneration, after injection of condoliase into a herniated intervertebral disc, and to identify factors associated with disc degeneration at 3 months post-injection.

METHODS

Medical records and radiographic findings were reviewed retrospectively for 127 patients with LDH (88 male, 39 female, mean age: 46.6 ± 17.1 years, mean follow-up: 9.8 ± 7.8 months) who underwent chemonucleolysis with intradiscal condoliase injection at our center since September 2018. Condoliase (1.25 U/mL; 1 mL volume) was injected toward the middle of the affected intervertebral nucleus pulposus using a 21-gauge disc-puncture needle.

RESULTS

Cases in which the Pfirrmann grade did and did not progress in the 3 months after the injection were included in groups P (progression, n = 49) and NP (non-progression, n = 78), respectively. Logistic regression analysis of progression of Pfirrmann grade post-injection showed significant associations with age <40 years (p = 0.013, odds ratio (OR): 3.69, 95% confidence interval (CI): 1.32-10.31), Pfirrmann Grade II or III at baseline (p = 0.021, OR: 3.51, 95% CI: 1.24-9.64), and a high-intensity MRI signal in the herniation (p = 0.047, OR: 2.97, 95% CI: 1.03-8.87). Patients in group P had significantly higher rates of disc height decrease ≥20%, reduced herniated disc size, and improved VAS for pain, but both groups had significant decreases in pain. No cases had anaphylactic shock or neurologic sequelae.

CONCLUSIONS

These results show the safety and efficacy of chemonucleolysis with condoliase for treatment of painful LDH. Progression of Pfirrmann criteria on MRI at 3 months after injection was significantly associated with an improved clinical outcome.

The efficacy and safety of condoliase for lumbar disc herniation: a systematic review and meta-analysis

Background: Chemonucleolysis is a minimally invasive treatment of lumbar disc herniation (LDH). However, the low specificity of the enzyme and the existence of serious adverse events limit the application of chemonucleolysis. Clinical studies in recent years have shown that Chondroitin sulfate ABC endolyase (condoliase) is a potential therapeutic enzyme for LDH. Aim. A meta-analysis was conducted to determine the efficacy and safety of condoliase in LDH treatment. Methods: We searched Web of Science, Embase, PubMed, and Cochrane Library databases. Two reviewers independently screened articles, extracted data, and assessed the risk of bias. The outcomes were the total effective rate, Oswestry Disability Index (ODI) score change, the proportion of lumbar surgery after condoliase treatment, herniated mass volume change, Pfirrmann grade change, and adverse events. Review Manager 5.3 and Stata 12.0 were used for meta-, sensitivity, and bias analysis. Results: Ten studies were included. A single-arm meta-analysis showed that the total effective rate was 78% [95% confidence interval (CI) 75%-81%], the proportion of surgery was 9% (95% CI 7%-12%), the proportion of Pfirrmann grade change was 43% (95%CI 38%-47%), and the adverse events were 4% (95% CI 2%-6%) after condoliase treatment. The two-arm meta-analysis showed that the ODI score change [standardized mean difference (SMD) -2.46, 95% CI -3.30 to -1.63] and the herniated mass volume change (SMD -16.97, 95% CI -23.92 to -10.03) of the condoliase treatment group were greater than those of the placebo control group, and there was no difference in adverse events between the two groups (OR 1.52, 95% CI 0.60-3.85). The results of sensitivity and publication bias analyses showed that the results were robust. Conclusion: Condoliase intradiscal injection has excellent eutherapeutic and safety for LDH, thus, has considerable potential as a treatment option besides conservative treatment and surgical intervention for LDH. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022375492, PROSPERO (CRD42022375492).

Development process and clinical application of collagenase chemonucleolysis in the treatment of lumbar disc herniation: a narrative review in China

Lumbar disc herniation (LDH) is one of the most common causes of lumbocrural pain. In the past 20 years, the incidence of LDH has increased dramatically. There are many treatments for LDH, including conservative treatment (such as acupuncture and physiotherapy), minimally invasive interventional treatment (such as collagenase chemonucleolysis and radiofrequency ablation) and surgical treatment. The main purpose of this paper is to review the development process and application status of collagenase chemonucleolysis in the treatment of LDH at home and abroad and provide a reference for clinical treatment.

Intradiscal injection for the management of low back pain

Low back pain (LBP) is a common clinical problem and a major cause of physical disability, imposing a prominent socioeconomic burden. Intervertebral disc degeneration (IDD) has been considered the main cause of LBP. The current treatments have limited efficacy because they cannot address the underlying degeneration. With an increased understanding of the complex pathological mechanism of IDD, various medications and biological reagents have been used for intradiscal injection for the treatment of LBP. There is increasing clinical evidence showing the benefits of these therapies on symptomatic relief and their potential for disc repair and regeneration by targeting the disrupted pathways underlying the cause of the disease. A brief overview of the potential and limitations for these therapies are provided in this review, based on the recent and available data from clinical trials and systematic reviews. Finally, future perspectives are discussed.

A Case of Postoperative Recurrent Lumbar Disc Herniation Conservatively Treated with Novel Intradiscal Condoliase Injection

Although postoperative recurrent lumbar disc herniation (rec-LDH) is uncommon, it is a challenging situation that requires revision surgery when conservative treatment fails. Recently, an agent inducing chemical dissolution of the nucleus pulposus using condoliase has been approved as a novel intradiscal treatment for LDH. To date, no evidence has been reported regarding its effectiveness in the treatment of postoperative rec-LDH. A 25-year-old man with a history of LDH in L4/5, who underwent transforaminal full endoscopic lumbar discectomy when he was 17 years old, complained of severe pain radiating to his left leg since 1 month. The straight leg-raising test was limited to 25° on the left side. Lumbar T2-weighted magnetic resonance imaging (MRI) showed intracanal, left-sided transligamentous disc herniation at L4/5 with high-signal intensity. Because the conservative treatment with oral analgesics and selective left L5 nerve root block failed, the patient requested intradiscal condoliase injection instead of revision surgery. There were no adverse events reported after the condoliase treatment, and the pain radiating to the left leg improved within 2 weeks. A lumbar MRI performed 2 months after treatment revealed that the disc herniation had significantly decreased in size. The straight leg-raising test examined 3 months after treatment was negative. In this case, the disc herniation was of the transligamentous type and showed a high-signal intensity on T2-weighted MRI which could be suitably treated by condoliase injection therapy. This case report is the first to suggest that intradiscal condoliase injection could be a useful and novel conservative treatment option to treat postoperative rec-LDH.

Comparative Study between Full-Endoscopic Discectomy and Microendoscopic Discectomy for the Treatment of Lumbar Disc Herniation

Background and objectives: Lumbar disc herniation (LDH) is a common disease in the meridian of life. Although surgical discectomy is commonly used to treat LDH, there are several different strategies. We compared the outcomes of uniportal full-endoscopic discectomy (FED) with those of microendoscopic discectomy (MED) in treating LDH. Materials and Methods: FED was performed using a 4.1-mm working channel endoscope, and MED was performed using a 16-mm diameter tubular retractor and endoscope. Data of patients with LDH treated with FED (n = 39) or MED (n = 27) by the single surgeon were retrospectively reviewed. Patient background information and operative data were collected. Pre- and postoperative low back and leg pain were evaluated using the numerical rating scale (NRS) score. Pre- and postoperative disc height index (DHI) values were calculated from plain radiographs, and the disc height loss was evaluated using the ratio (DHI ratio); Results: The median (interquartile range (IQR) Q25–75) operation times for FED and MED were 42 (33–61) and 43 (33–50) minutes, respectively. The median (IQR Q25–75) pre- and postoperative NRS scores for low back pain were 5 (2–7) and 1 (0–4), respectively, for FED and 6 (3–8) and 1 (0–2), respectively, for MED. The median (IQR Q25–75) pre- and postoperative NRS scores for leg pain were 7 (5–8) and 0 (0–2), respectively, for FED and 6 (5–8) and 0 (0–2), respectively, for MED. These data were not different between the FED and MED groups. The median (IQR Q25–75) DHI ratios of FED and MED were 0.94 (0.89–1.03) and 0.90 (0.79–0.95), respectively. The DHI ratio was significantly higher (p < 0.05) in the FED group than in the MED group, and there was less blood loss; Conclusions: The pain-relieving effect of FED in treating LDH was almost identical to that of MED. However, FED was superior to MED in preventing disc height loss, which is one of the indicators of postoperative disc degeneration.