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The nucleolytic action of chondroitinase ABC was studied by the use of rabbit lumbar intervertebral discs. The injection of one unit of enzyme results in necrosis of the nucleus pulposus. Radiologic, histologic, and biochemical changes were evident in discs studied 2 days after injection, and consistent nucleolysis was seen in those studied after 6 days. These results show that chondroitinase ABC deserves further evaluation as a possible chemonucleolytic enzyme.

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Nucleolysis using chondroitinase ABC was studied using the rabbit's intervertebral lumbar disc. The purpose was to find a possible alternative to chymopapain which is commonly used in the management of sciatica due to disc herniation. The injection of 1 U of the enzyme into the nucleus pulposus gave significant histological and biochemical changes in all twelve discs studied.

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Two hundred and seventy four patients had a lumbar spine fusion between 1949/1971. Seventy-five of them were available for review more than 10 years after the procedure. There were twenty spondylolisthesis, forty-eight degenerative discopathies, six cases of Pott's disease and one benign tumour. All the patients had been treated conservatively before the surgical procedure for an average of 7 years and were still complaining of chronic low back pain. All the cases reviewed had fused. The functional results were not related to the surgical technique, which varied during this period: eight posterior mid-line grafts, seventeen interbody fusions and fifty combined anterior and posterior approaches sometimes used because of a primary failure of fusion and no postero-lateral fusions. The average follow-up was 13 years with a range from 10 to 26 years. The clinical results were satisfactory in 74 p. 100 of the cases. There were thirteen failures. Seven of these patients had been operated on before the era of systematic preoperative discography and psychological evaluation and the failure was primary. Other failures were observed at about the tenth post-operative year. The results were better in spondylolisthesis with isthmic lesions, rather than in degenerative spondylolisthesis. They were better in pure low back pain than when the pain associated with sciatica. They were better when fusion was limited to one or two levels. Radiographs ten years after the procedure frequently showed evidence of degenerative lesions of the disc above the level of the fusion and, at the same time, some slipping of the upper vertebra. Fortunately, there was no correlation between the radiological appearances and the clinical results.

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The authors have studied overgrowth or diminished growth seen in 54 femora lengthened surgically by a one-stage procedure between 1963 and 1979. Thirty six cases were of poliomyelitis. An overgrowth was regularly seen of the order of 2.5 p. 100- that is 11 mm on average. This stimulation of growth by lengthening was not related to age. It was more marked where there was severe involvement. In contrast, in 13 cases of congenital femoral abnormalities and 5 cases of miscellaneous diseases (Ollier's disease, neurofibromatosis, sequelae of septic arthritis) overgrowth or diminished growth have been observed. This phenomenon was not constant and could not be predicted.

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The authors report a retrospective study of 163 cases of degenerative or constitutional stenosis of the lumbar canal. In this series, the most frequent cause was osteoarthrosis and constitutional stenoses were relatively rare. The authors note that this is often a difficult aetiological distinction to make, especially in elderly patients and the anatomical deformities caused by osteoarthrosis lead to stenosis of the canal similar to that seen in constitutional malformations. Sensori-motor claudication is inconstant and was only found in one third of the cases in this series. More often, the lumbar stenosis presents as nerve root pain. It can be distinguished from root disease of disc origin by the frequent absence of Lasegue's sign and of spinal stiffness. When a herniated disc is associated with a stenosis, the clinical picture is altered and can then resemble that of disc sciatica. The diagnosis of stenosis depends on the radiological examination. This series confirms the diagnostic value of the abnormalities seen on standard X-rays, but the severity and the extent of the stenosis can only be assessed by performing tomography, water-soluble contrast myelography and C.T. scan. The authors discuss the limitations and degree of reliability of each of these investigations. The extent of the surgical decompression depends on the severity of the symptoms and on the results of this radiological survey.

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163 patients were operated for degenerative lumbar stenosis (only 10 did not have osteoarthrosis), following the failure of medical treatment. The surgical decompression varied according to the anatomical type of the stenosis: central, lateral or mixed. In 13 p. cent of cases, it was followed by an arthrodesis. There were no deaths. The most frequent complications were: haematoma (6 p. cent), infection (5 p. cent), aggravation of the neurological disturbance (3 cases), breeches in the dura, practically inevitable in very tight stenosis (13 p. cent) and epidural fibrosis (4 re-operations). When there is no sliding prior to the operation, the risk of aggravation or appearance of sliding in cases of spondylolisthesis is somewhat higher (6 cases out of 64). The different symptoms are unequally improved by the decompression: root pain is the best relieved (69 p. cent cure, 20 p. cent improvement) together with intermittent claudication (75 p. cent cure, 14 p. cent improvement) and, to a lesser degree, back pain (48 p. cent cure, 32 p. cent improvement). There is a possibility of recovery even in the severe forms of motor disturbance.

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Ninety of 120 patients with herniated lumbar discs who received an intradiscal injection of chymopapain achieved successful recovery. Sixteen of the 21 patients who underwent subsequent surgery had a good result. Study of the unsuccessful cases showed that disc sequestration and lateral stenosis were the major organic causes of failure. Certain radiologic criteria suggestive of sequestration and of important segmental stenosis are described. They appear to be a contraindication to chemonucleolysis. Psychogenic pain components and the failure of the enzyme to hydrolyse the nuclear proteoglycans in a few cases were the other two causes of poor results. A survey of postchemonucleolysis computed tomographic scans suggested that, although capable of digesting nuclear material in most cases, chymopapain may also work through an "anti-inflammatory" mechanism.

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A proteolytic enzyme was used to dissolve the nucleus pulposus in 140 cases of sciatica from herniated lumbar disc. The results were satisfactory in 75% of 120 patients followed up for more than 6 months. This percentage of success, similar to that obtained with surgical excision of the disc, can only be achieved with a rigourous technique and, more importantly, with strict selection of the patients. Chemonucleolysis is indicated only for patients with unquestionable clinical and radiological evidence of herniated disc, in which case it can be considered as the ultimate medical treatment of sciatica associated with this lesion. No serious complications were observed in our series, but the risk of allergic reaction must be borne in mind.

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One hundred and twenty patients suffering some sciatica due to disc herniation have been treated by chemonucleolysis. All the patients had received conservative treatment for at least four months. The minimum followup after nucleolysis was six months. In 114 patients, radiculography was positive and in 6, radiculography was negative but phlebography was positive. Patients with symptoms of spinal stenosis, or with signs of sequestrated disc or who had been previously operated on by laminectomy were excluded from the study. By a lateral extradural approach, 4000 units of chymopapain were injected into the disc under general anaesthesia after discography. All patients except 3 had only disc injected. Results were good in 92 patients. 21 of the 28 failures were operated on. In 18 cases, a mechanical cause was found at operation with 16 good results. Complications were rare and benign. No neurological complication was noted. It is concluded that chemonucleolysis should be the last step in the conservative management of sciatica.

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The authors report 56 cases of sciatica treated by chemonucleolysis with follow-up ranging from six months to two years. All patients presented with manifest clinical symptomes of intervertebral disc herniation, and the diagnostic was verified by myelography. In all cases myelographic findings corresponded to clinical topography when the topography was precisely defined. This group of patients, therefore, was highly selected, and the authors attempted to eliminate excluded herniations when the myelographic anomaly appeared at a distance from the intervertebral space. Cases of sciatica caused by stenosis, paralytic sciatica, and pure lumbar pain were not treated in this study. At the end of the second month, 70 percent of patients obtained good results; the authors, believe, therefore, that failure of treatment can be ascertained by the eighth week. Thirteen of the fifteen treatment failures in this study were operated. Results of this surgery performed after chemonucleolysis were similar to results obtained from surgery performed as initial treatment. No serious complications were observed. Chemonucleolysis, therefore, appears to be an effective means of treatment for sciatica caused by intervertebral disc herniation. Based on their own experience and reports in the literature, the authors believe that chemonucleolysis is the ultimate stage of conservative treatment when classical measures have failed. In addition, the authors' experience and careful review of the literature has shown that serious iatrogenic accidents are exceptionally rare and can be avoided by the use of rigorous technique.

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This work deals with the results obtained by four French orthopaedic departments using the electromagnetic field stimulation for non union treatment. This is the method established by A. Bassett. 37 cases are studied, the results are known for 35 of them with 6 failures and 29 successes. The failures can be explained for four of them by a bad application of the device. Concerning the 29 successful cases, the role of the stimulation is discussed. Discarding those who have been treated a short time after a surgical procedure, those who have been immobilized more than 6 months and those where the non union could have been a delayed union, it remains 14 successful cases apparently undisputable. For them the role of the electromagnetic field stimulation seems real.

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Sixty eight patients with degenerative lumbar stenosis have been operated on: 42 presented a degenerative spondylolisthesis (S.D) with predominantly central stenosis; while in 36 with arthrosic sciatica (S.A.), stenosis was rather lateral. In most cases clinical symptoms are different from those of disc herniation. Myelography with "amipaque" appears necessary to allow a really planified operation, with liberation of all the roots involved by bony compression. In these conditions, a high percentage of good results is obtained. Consequently, after failure of conservative treatment, open release of the compression is advisable, even in elderly patients. In some cases postero-lateral fusion should be performed in addition.

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Thirty-eight patients with the diagnosis of postoperative epiduro-arachnoiditis are reported upon. All had had previous surgery for disc herniation, and the diagnosis of epiduro-arachnoiditis was confirmed at repeat surgery. Massive epidural scarring with no coexistent pathologic condition was found in every patient, and adhesive arachnoiditis was noted in three. The common clinical presentation consisted of low-back pain and sciatica, and radicular pain was usually a continuation or a recurrence of the preoperative sciatic pain. Neurologic deficits were mild, and no patients with the classic picture of adhesive arachnoiditis were found. Myelographic patterns did not disclose any correlation with the clinical symptoms. Five myelograms were normal, while six others simulated a recurrent disc herniation. The results of scar excision were good in 13 patients, fair in eight, and a failure in 17.

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This report details the expierience with adult lumbar scoliosis among patients at a scoliosis center. Some curves are shown to progress in the adult, while others appear de novo. Pain arising in adult scoliosis may reflect root compression or segmental degeneration. Once pain arises in an adult lumbar curve, it is likely to be progressive and often requires surgical treatment.

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Lumbar epiduro-arachnoiditis is a well-known complication of surgery of the intervertebral disc. The epidural fibrous scar is the normal outcome of inflammatory activity secondary to the mechanical tissue disturbance resulting from surgery. In certain individuals, perhaps genetically predisposed as excessive quantity of fibrous tissue is deposited in the epi and/or nitradural space. This abnormal situation, comparable to cheloid cutaneous scars, is perhaps at the origin of the clinical symptoms. The authors report the clinical and radiological signs observed in 38 patients having had at least one operation for discal hernia, and who underwent further operations in the aim of freeing the roots and the dural sack from fibrous compression. Results of excision of the epidural "cheloid" were good in 13 cases, and average in 8 others. There was a complete failure in 17 other patients. Three explanations were offered to explain the frequency of the failures: 1) formation of a new cheloid, 2) difficulty of neurolysis of the arachnoiditis, 3) possibility of intrinsic lesions of the nerve associated with the epiduro-arachnoiditis.

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