Intervertebral disks

Chymopapain [9001 -90-6] derived from the latex of the papaya tree, produces improvement in lower back pain and sciatica in the majority (75%) of recipients (185—189) when injected into the lumbar intervertebral disks of patients suffering from herniated disk (the nucleus pulposus). This treatment degrades the proteoglycans of the diseased nucleus pulposus, resulting in shrinkage of the disk and reduction of pressure on the nerve roots (190). 

Horner, H.A. and Urban, J.RG. (2001) Effect of nutrient supply on the viability of cells from the nucleus pulposus of the intervertebral disk. Spine 26(23), 2543-2549... 

One important problem in determining efficacy of treatment seems to be the choice of the type of control. While in most cases the same volume of saline is injected into the intervertebral disk as a control 96], little or no rf ia are available that compare the effect of chymopapain treatment with the natural history of the disease [97]. This problem was discussed in an editorial in the Lancet in 1986 [98]. However, a number of studies have been published that compare chemonucleolysis with traditional surgical disc removal [99-1021. These studies indicate that surgical disc removal has an equal or slightly better overall success rate than chemonucleolysis. It has been argued that if chymopapain treatment fails, subsequent surgery may be less successful, especially if the operation Is delayed [103], but recent results indicate that this is not the case [104],... 

L. Smith and J, E. Brown. Treatment of lumber intervertebral disk lesions by direct infection of chymopapain./. Bone Joint Sunr. 4 502(1967t... 

As well as chondroitin sulfate, other glycosaminoglycans, such as keratan sulfate, with shorter chains (Mr = 2,500-5,000) are found in cartilage (Fig. 5-22). N-linked oligosaccharides similar to those found in glycoproteins are also present. Note that keratan sulfate in other tissues, e.g., intervertebral disk or cornea, has a longer chain (Mr= 10,000-25,000) and may have a different oligosaccharide link to the core protein. 

The other sites where cartilage occurs are not meant to mineralize. Articular cartilage is the shiny slippery textured material found at the ends of many bones, a tissue that facilitates the motion between two bones at the joints. The deposition of mineral in articular cartilage and joints is pathological, and briefly discussed in Skinner (2000). Cartilagenous tissues that occur in the ear, epiglottis, and intervertebral disks are normally not mineralized, and the organic components at these sites are distinct chemically and... 

Skeleton Renal phosphate diabetes associated with hypercalciuria may lead to osteomalacia or osteoporosis. Likewise, inflammatory or degenerative arthrosis is thought to be a late manifestation of Wilson s disease. (354) Often, these developments are combined with intra-articular calcium deposits and chondromalacia, in particular patellar chondromalacia. Bone fractures are frequently observed even with minor traumas. Calcification may occur in articular cartilage, capsule and tendinous insertions, and deposits of calcium pyrophosphate dihydrate can appear in the intervertebral disks. 

Keratan sulfate (4,000 to 19,000) D-Glucosamine None (but contains D-Galactose) 6-0-sulfate on both carbohydrate residues Cartilage, cornea, intervertebral disks... 

Degenerative changes involving the spine may occur in the intervertebral disks, vertebral bodies, or posterior apophyseal articulations. Aside from pain and limitation of motion, nerve root compression is a potential complication of arthritis (see Table 90-3). 

The use of chymopapain for the treatment of sciatic has been extensively reviewed by Nachemson and Rydevik [71] and by Buttle [72], Chemonucleolysis is the name used for the treatment of sciatica pain by injection of chymopapain into a protruded or herniated lumbar intervertebral disk. 

Chymopapain is a proteolytic enzyme with chemonncle-olytic properties (2000 to 4000 pKat nnits per disk injected intradiskaUy). The maximum dose in a patient with mnltiple disk herniation is 8000 pKat nnits. The drug is indicated in the treatment of herniated Inmbar intervertebral disk. 

Figure 1 The intervertebral disk. A normal young adult human disk is shown with an outer lamellar annulus fibrosus and an inner gelatinous nucleus pulposus.

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