Couto JMC, Castilho EA de, Menezes PR. Chemonucleolysis in lumbar disc herniation: a meta-analysis. Clinics. 2007;62(2):175-80. PURPOSE:To carry out a systematic review and meta-analysis of the efficacy of chemonucleolysis in the treatment of lumbar disc herniation. METHODS: Clinical trials were selected from 3 electronic databases (The Cochrane Controlled Trials Register, MEDLINE, and EMBASE). Data were analyzed with the software STATA, using the meta command. RESULTS: Twenty-two clinical trials were eligible. For chemonucleolysis versus placebo, the summary risk ratio estimate for pain relief as outcome was 1.51 (95% CI: 1.27-1.80). The summary estimate was 1.07 (95% CI: 0.95-1.20) for the comparison between chymopapain and collagenase. Regarding chemonucleolysis with chymopapain versus surgery, the fixed-effect summary estimate of effect for pain relief was 0.93 (95% CI: 0.88-0.98) with surgery as the reference group. In this case, heterogeneity was statistically significant. CONCLUSIONS: Chemonucleolysis with chymopapain was superior to placebo and was as effective as collagenase in the treatment of lumbar disc prolapse. Results for studies comparing chemonucleolysis with surgery were heterogeneous, making it difficult to interpret the summary measure of effect. KEYWORDS:Chemonucleolysis. Chymopapain. Systematic review. Meta-analysis. Lumbar disc herniation. INTRODUCTIONSurgery to treat lumbar disc prolapse was introduced in 1934, 1 and ever since it has been considered as the main treatment modality when conservative treatment has failed. However, the therapeutic efficacy of surgical intervention has been a concern, considering that 20% of the patients are still in pain after surgery, 3 and that 7% to 15% of the patients undergoing discectomy develop the syndrome of failure of the lumbar surgery. 4 Alternative techniques have been developed and tested, and chemonucleolysis, which refers to the use of chymopapain for enzymatic lysis of the nucleus disc, has been among the most relevant. This technique was first described by Smith in 1964 5 and is the least invasive technique for lumbar disc herniation, presenting lower rates of complications in comparison with discectomy. 6 According to some authors, fewer days in the hospital was found for patients treated with chemonucleolysis, when compared to traditional surgery, 7,8 which augmented the considerable cost savings. [9][10][11][12] In a prospective study with a follow-up of at least 5 years, among 112 patients treated by chemonucleolysis, 83% had excellent/good results, 10% were unchanged, and 8% were worse after chemonucleolysis. 13 Nevertheless, an increased global cost was observed if a conventional surgery was needed following failure to improve after an initial chemonucleolysis.14 Some studies have shown superior efficacy of chemonucleolysis with chymopapain, as compared with placebo, 15-17 but there are conflicting results. 18 In a systematic review of surgical procedures for lumbar disc prolapse that included studies published until 1999, discecto...

Intramedullary tumors are rare. The authors reviewed 24 cases operated between 1996 and 2006. The study assessed the clinical characteristics and surgical results based upon the neurological function. Method: Medical records of patients with intramedullary astrocytoma and ependymoma were reviewed. The minimal follow up time was 6 months and, at the end of this period, a comparative analysis of the neurological function was performed based using the McCormick scale score. results: Most patients had astrocytoma (75%). Male gender was more prevalent (58.3%). The most common type of tumor was graded as I or II, and in three cases these were malignant. The total resection of the tumor was achieved in 20.8% of the cases. The statistical analysis did not show a statistically significant difference between preoperative and postoperative grades at McCormick scale. conclusion: The authors concluded that microsurgery to intramedullary tumors did not significantly alter the neurological function after six months. Key words: astrocytoma, ependymoma, microsurgery, spinal cord.tumores intramedulares em crianças: análise de 24 casos operados resuMo Os tumores intramedulares são doenças raras. Os autores analisaram 24 casos operados entre 1996 e 2006. O estudo analisou as características clínicas e o resultado da cirurgia quanto à função neurológica. Método: Foram analisados pacientes com astrocitomas e ependimomas intramedulares. O tempo mínimo de acompanhamento foi de 6 meses e ao final deste período foi realizada a avaliação comparativa da variação do estado neurológico baseado na escala de McCormick. resultados: A maioria dos pacientes era de astrocitoma (75%). O gênero masculino foi mais prevalente (58,3%). A maioria dos tumores era de grau I ou II, 3 casos eram malignos. A ressecção total do tumor ocorreu em 20,8% dos casos. A avaliação estatística demonstrou que não houve diferença significativa entre o estado neurológico na escala de McCormick pré-operatória e pós-operatória. conclusões: Os autores concluem que a microcirurgia para ressecção dos tumores intramedulares não ocasionou variação funcional significativa nos pacientes após seis meses da cirurgia. Palavras-chave: astrocitoma, ependimoma, microcirurgia, medula espinhal.

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Spinal cord tumors are a rare neoplasm of the central nervous system (CNS). The occurrence of metastases is related to poor prognosis. The authors analyzed one series of metastasis cases and their associated mortality. METHODS: Clinical characteristics were studied in six patients with intramedullary tumors with metastases in a series of 71 surgical cases. RESULTS: Five patients had ependymomas of which two were WHO grade III. The patient with astrocytoma had a grade II histopathological classification. Two patients required shunts for hydrocephalus. The survival curve showed a higher mortality than the general group of patients with no metastases in the CNS (p<0.0001). CONCLUSION: Mortality is elevated in patients with metastasis and greater than in patients with only primary lesions. The ependymomas, regardless of their degree of anaplasia, are more likely to cause metastasis than spinal cord astrocytomas.