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Clark Watts, Robert Knighton, and George Roulhac

Part 1 Description of Chymopapain C hymopapain is a proteolytic enzyme first isolated in 1941. 17 It has recently attracted interest because of its use in “chemonucleolysis,” a proposed nonsurgical method of treating primary lumbar intervertebral disc disease. It is one of several enzymes prepared from crude papain, which is extracted from the fruit ard other juices of a palm-like tree, the Carica papaya . The noncrystalline form of chymopapain is used in chemonucleolysis and is essentially free of papain as demonstrated by electrophoresis on cellulose

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Dana M. Grzybicki, Edward J. Callaghan, and Stephen S. Raab

T he present standard of care for pathological examination of intervertebral disc material requires that both gross and microscopic pathological examinations be performed on all specimens, including discs removed for benign, noninfectious indications such as disc herniation. Two recent studies have challenged this practice, reporting in retrospective reviews the lack of a single, unsuspected, clinically significant pathological finding that affected patient care among the specimens analyzed. 1, 2 There are several reasons why both gross and microscopic

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W. Eugene Stern and Walter F. Coulson

, 1959 Davidson EA, Woodhall B: Biochemical alterations in herniated intervertebral discs. J Biol Chem 234: 2951–2954, 1959 3. Garvin PJ Jr : Toxicity of collagenase: the relation to enzyme therapy of disk herniation. Clin Orthop 101 : 286 – 291 , 1974 Garvin PJ Jr: Toxicity of collagenase: the relation to enzyme therapy of disk herniation. Clin Orthop 101: 286–291, 1974 4. Garvin PJ , Jennings RB : Long-term effects of chymopapain on intervertebral disks of dogs. Clin Orthop

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Borys Flak and David Li

) and level of 25 HU for soft tissue and a window width of 1500 HU and level of 250 HU for bone. During this period of time we encountered five cases of huge intervertebral discs masquerading as nearly normal dural sacs. There was surgical confirmation in all cases. Results In all five cases the initial impression was that of a relatively normal-appearing dural sac. The diagnosis was usually suspected because the “dural sac” appeared of slightly greater density than would be expected. The presence of a large herniated disc was confirmed by a variety of means

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Mehmet Arslan, Ayhan Cömert, Halil İbrahim Açar, Mevci Özdemir, Alaittin Elhan, İbrahim Tekdemir, R. Shane Tubbs, Ayhan Attar, and Hasan Çağlar Uğur

L aminectomy for decompression of lumbar disc herniation is one of the most common neurosurgical procedures performed. Injury to nerve roots and perforation into the anterior annulus fibrosis and anterior longitudinal ligament with major vascular injury are rare. However, complications may occur due to the proximity of the intervertebral disc to adjacent neurovascular structures. These major vessels include the abdominal aorta, the inferior vena cava, and the common iliac arteries and veins, situated directly anterior to the lumbar spine. 2 , 3 , 9 , 13

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Richard A. Smith, M. Darius Vohman, Joseph H. Dimon III, James E. Averett Jr., and James H. Milsap Jr.

T he syndrome of calcified cervical intervertebral discs in children was first reported in the English literature by Weens 22 in 1945. Subsequent articles have confirmed Weens' classic observations in this rare condition which, however, has received only scant attention in the neurosurgical literature. We wish to report three new cases. Two of these illustrate the typical syndrome. The third case is to our knowledge only the second such patient to undergo anterior cervical discectomy for herniation of the calcified disc with consequent radiculopathy. Case

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Injection of chymopapain into intervertebral discs

Preliminary report on 72 patients with symptoms of disc disease

Burton M. Onofrio

intervertebral disc occurring in the low lumbar spine and causing pressure on the cauda equina. J Bone Joint Surg 19: 323–342, 1937 2. Barr JS , Hampton AO , Mixter WJ : Pain low in the back and “sciatica” due to lesions of the intervertebral disks. JAMA 109 : 1265 – 1270 , 1937 Barr JS, Hampton AO, Mixter WJ: Pain low in the back and “sciatica” due to lesions of the intervertebral disks. JAMA 109: 1265–1270, 1937 3. Barr JS , Mixter WJ : Posterior protrusion of the lumbar

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Peter Grunert, Harry H. Gebhard, Robby D. Bowles, Andrew R. James, Hollis G. Potter, Michael Macielak, Katherine D. Hudson, Marjan Alimi, Douglas J. Ballon, Eric Aronowitz, Apostolos John Tsiouris, Lawrence J. Bonassar, and Roger Härtl

SM , Curtis AS , Roberts S : Topographical guidance of intervertebral disc cell growth in vitro: towards the development of tissue repair strategies for the anulus fibrosus . Eur Spine J 15 : Suppl 3 S389 – S396 , 2006 21 Kepler CK , Hilibrand AS : Management of adjacent segment disease after cervical spinal fusion . Orthop Clin North Am 43 : 53 – 62 , viii , 2012 22 Kraemer J : Intervertebral Disk Diseases: Causes, Diagnosis, Treatment, and Prophylaxis ed 3 Stuttgart , Thieme , 2009 23 Luk KD , Ruan DK : Intervertebral disc

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Hamed Reihani Kermani, Hamid Hoboubati, Saeed Esmaeili-Mahani, and Majid Asadi-Shekaari

without previous LBP. 2 Patients with acute stress usually have high levels of catecholamines. 5 Stress increases proinflammatory cytokine levels (that is, tumor necrosis factor and interleukin-1α and -1β) in the periphery and brain. 22 Elevated levels of inflammatory mediators have been described in pathological intervertebral disc (IVD) tissue, and these levels increase with the severity of the degeneration. 39 Therefore, emotional stress may also influence IVD. Because the effects of chronic stress on disc degeneration have not yet been clarified, the present

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Bernard C. Zook and Arthur I. Kobrine

24. Stern IJ , Smith L : Dissolution by chymopapain in vitro of tissue from normal or prolapsed intervertebral disks. Clin Orthop 50 : 269 – 277 , 1967 Stern IJ, Smith L: Dissolution by chymopapain in vitro of tissue from normal or prolapsed intervertebral disks. Clin Orthop 50: 269–277, 1967 25. Stern WE , Coulson WF : Effects of collagenase upon the intervertebral disc in monkeys. J Neurosurg 44 : 32 – 44 , 1976 Stern WE, Coulson WF: Effects of collagenase upon the intervertebral