Verification of selection trends in interventional treatment for patients with lumbar disc herniation and effects of condoliase therapy.

Verification of selection trends in interventional treatment for patients with lumbar disc herniation and effects of condoliase therapy. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Verification of selection trends in interventional treatment for patients with lumbar disc herniation and effects of condoliase therapy. Kazuhiro Fujimoto, Hidenori Suzuki, Norihiro Nishida, Masahiro Funaba, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3970032/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study aims to investigate selection trends in treatment for lumbar disc herniation (LDH) and the effects of condoliase therapy on muscle weakness. Patients with leg pain caused by LDH who received interventional treatment between September 2017 and August 2022 were included in this study. 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. Sex, age, the body mass index (BMI), duration of symptoms, herniation level, and neurological findings were examined in the two groups. Motor recovery was also assessed in the two groups. 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 ratio between operative treatment and condoliase therapy reversed in the third year after the introduction of condoliase therapy. In the fourth year, condoliase therapy became the main treatment for LDH. Lower limb muscle strength improved in 76% of cases receiving condoliase therapy. 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 testing ≤3, the improvement rate was approximately 60%. These results will be useful for clinicians when providing informed consent and selecting condoliase therapy. Figures Figure 1 Figure 2 Figure 3 Introduction Lumbar disc herniation (LDH) is a disorder that primarily causes lower limb pain and often occurs in early adolescence and at the L4-5 and L5-S1 disc levels. It is more common in males than in females, and smoking has been identified as a risk factor. [ 1 ] [ 2 ] Treatment for LDH is broadly divided into conservative and operative treatments. Conservative treatment includes rest, medication, and nerve root blocks. Operative treatment includes open surgery and various endoscopic surgeries. [ 3 , 4 ] Since LDH often occurs in individuals of working age, the goals of treatment are early pain relief, improvements in motor function, and social reintegration. Operative treatment is effective for early pain relief, but is associated with the risks of operative invasion and complications. [ 5 ] Chemonucleolysis decomposition is an intermediate treatment between conservative and operative treatments that induces the chemical lysis of the nucleus pulposus of the intervertebral disc. Percutaneous nucleotomy has been reported as a similar intermediate treatment; however, its efficacy is less than that of chemonucleolysis decomposition. [ 6 ] The usefulness of chemonucleolysis decomposition with chymopapain has been widely reported [ 7 ] in Europe and North America, while adverse events include anaphylaxis. Chondroitin sulfate ABC endolyase (condoliase), unlike chymopapain, lacks protease activity and, thus, induces chemical nuclear degradation without affecting nerve and ligament tissues. [ 8 ] The findings of clinical phase III trials contributed to the selection of appropriate therapeutic doses [ 9 ] and demonstrated the efficacy and safety of chemical nuclear degradation with condoliase for patients with LDH. [ 10 ] Condoliase became available in Japan as an intradiscal treatment for LDH in August 2018. Clinical phase III trials are also underway in the United States. Five years have passed since the introduction of condoliase therapy in Japan, and its utility has been reported. However, selection trends in interventional treatment for LDH remain unknown. Furthermore, although pain relief with condoliase therapy has been extensively examined [ 11 – 13 ], limited information is currently available on its effects on motor recovery. Therefore, we herein investigated selection trends in interventional treatment for LDH patients before and after the introduction of condoliase therapy. In addition to pain relief, we focused on the recovery of muscle weakness as an effect of condoliase therapy. Materials and Methods Patient recruitment The study design was approved by the Institutional Review Board of our hospital (Control Number of H2023-069), and experiments were conducted according to the ethical standards of the Declaration of Helsinki. This retrospective, double-center study involved patients with unilateral or bilateral leg pain caused by LDH who received interventional treatment between September 2017 and August 2022. Our LDH treatment strategy is shown in Fig. 1 . We limited indications for condoliase therapy to the subligamentous extrusion and protrusion types of herniation. We excluded patients with compressive cervical or thoracic myelopathy and lumbar spinal canal stenosis detected by magnetic resonance imaging (MRI), spinal deformity, transitional vertebrae, a history of surgery at the same level as the hernia, or brain or peripheral nerve disorders. Informed consent was obtained from all patients. Intradiscal injection technique All intradiscal injections were administered by a qualified spine surgeon. The patient was placed in a prone position and a conventional disc-puncture needle was inserted from the affected side under fluoroscopic guidance. Condoliase was dissolved in 1.2 mL of saline to prepare a 1.25 U/mL solution and was then injected into the intervertebral disc. All patients were carefully observed for at least 2 hours after the injection and then allowed to return home. Clinical assessment The following demographic and clinical data were extracted from medical charts: sex, age, the body mass index (BMI), duration of symptoms, herniation level, and adverse events. To assess pain intensity and health-related quality of life, we collected data using a visual analog scale (VAS) for leg pain and assessed the Oswestry disability index (ODI) at the baseline and in a 3-month follow-up. Radiographic assessment Lumbar X-rays were obtained before and after the injection. Intervertebral disc height was calculated at the midpoint of the end plate on lateral images. We also investigated the intervertebral range of motion (ROM) of the herniated level during maximal flexion extension. Additionally, MRI was examined before the injection. The signal intensity of herniation (a high intensity signal) and the herniated intervertebral disc size on T2-weighted images were evaluated on axial images (Fig. 2 ). A radiographic assessment was performed by three qualified spine surgeons and decided by majority consensus. Statistical analysis LDH patients were divided into two groups: the operative treatment group (Group O) and condoliase therapy group (Group C). The period between September 2017 and August 2022 was divided into 5 equal parts and changes in the percentage of intervention treatment were examined. Furthermore, sex, age, BMI, the duration of symptoms, herniation level, the presence, degree, and recovery of muscle weakness, and adverse events were evaluated in the two groups. Patients in Group C who were able to be followed up for 3 months after the injection or underwent operative treatment within 3 months were targeted. They were divided into two groups: the effective group (Group E) in which VAS for leg pain improved by 50% or more 3 months after the injection, and the non-effective group (Group N) in which VAS for leg pain improved by less than 50% or surgery was performed. Sex, age, BMI, the duration of symptoms, herniation level, the presence of positive straight leg rise, sensory disturbance, and muscle weakness, VAS for leg pain, and ODI were evaluated in the two groups. Furthermore, as an image evaluation, intervertebral disc height and intervertebral ROM were assessed on X-rays. The high signal intensity of herniation and the herniated intervertebral disc size were evaluated on MRI. Relationships between groups were compared by the chi-square and Mann-Whitney U tests in a univariate analysis. P values < 0.05 were considered to indicate a significant difference. StatFlex (version 7.0, Artech Co., Ltd.; http://www.statflex.net/ ) was used for statistical analyses. 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. Herniation levels were the L1-2 (in 1 patient), L2-3 (in 15), L3-4 (in 27), L4-5 (in 169), and L5-S1 (in 129) intervertebral disc levels. Forty-two patients had muscle weakness. Patient demographics and clinical assessments in Groups O and C are shown in Table 1 . Females were more likely to select condoliase therapy. Details on muscle weakness are shown in Table 2 . Adverse events included dural puncture in 2 cases and infection in 1 case in Group O and fever in 4 cases, drug eruption in 1 case, and vertebral body fracture adjacent to the treated intervertebral disc in 1 case in Group C. No serious complications, such as anaphylaxis, were observed. Table 1 Summary of demographics and clinical assessments of LDH patients with interventional treatment All patients (n = 341) Group O (n = 169) Group C (n = 172) P value Sex (male/female) 226/115 122/47 104/68 0.02 Age (years) 49.2 ± 16.3 48.6 ± 15.7 49.8 ± 16.8 0.50 BMI 22.8 ± 3.4 22.8 ± 3.2 22.7 ± 3.5 0.96 Duration of symptoms (months) 5.0 ± 5.5 4.2 ± 3.4 5.8 ± 6.8 0.01 Herniation level L1-2 1 1 0 0.43 L2-3 15 9 6 L3-4 27 15 12 L4-5 169 78 91 L5-S1 129 66 63 Presence of muscle weakness 42 25 17 0.17 LDH, lumbar disc herniation; BMI, body mass index; Table 2 Details of muscle weakness in 42 patients with interventional treatment. Group O Group C Case Pre-MMT Post-MMT Case Pre-MMT Post-MMT 1 4 5 26 4 5 2 4 5 27 4 5 3 4 5 28 4 5 4 4 5 29 4 5 5 4 5 30 4 5 6 4 5 31 4 5 7 3 5 32 4 5 8 3 5 33 4 5 9 3 5 34 4 4 10 3 5 35 3 5 11 3 5 36 3 5 12 3 5 37 3 4 13 3 5 38 3 3 14 2 5 39 3 3 15 2 5 40 2 5 16 2 5 41 1 3 17 2 4 42 0 0 18 1 5 19 1 5 20 1 1 21 0 5 22 0 0 23 0 0 24 2 (anuria+) 4 25 1 (anuria+) 4 MMT, manual muscle test Figure 3 shows selection trends in interventional treatment by year. In 2017, all cases underwent surgery; however, in 2018, 30% received condoliase therapy. The use of condoliase therapy continued to increase from 2018, reaching 56% in 2020 and 76% in 2021. There were 147 patients in Group C who were able to be followed up for 3 months after the injection or underwent operative treatment within 3 months, while there were 16 in Group N, among whom 15 underwent surgery after condoliase therapy. Patient demographics and clinical assessments in Groups E and N are shown in Table 3 . The mean duration of symptoms was significantly shorter in Group E (5.2 months) than in Group N (9.3 months) (p = 0.03). In imaging evaluations, a significant difference was observed in the high signal intensity of herniation in Group E (p < 0.01). Table 3 Summary of patient demographics and clinical assessments in effective and non-effective groups All patients (n = 147) Group E (n = 131) Group N (n = 16) P value Sex (male/female) 86/61 78/53 8/8 0.46 Age (years) 50.3 ± 16.1 50.5 ± 16.1 48.5 ± 16.5 0.64 BMI 22.9 ± 3.6 22.8 ± 3.6 23.7 ± 3.6 0.34 Duration of symptoms (months) 5.7 ± 7.1 5.2 ± 6.4 9.3 ± 10.8 0.03 Herniation level L2-3 5 5 0 0.77 L3-4 8 7 1 L4-5 77 68 9 L5-S1 57 51 6 Presence of positive SLR 115 100(76%) 15(94%) 0.20 Presence of sensory disturbance 75 68(52%) 7(44%) 0.54 Presence of motor weakness 17 17(13%) 0(0%) 0.22 VAS for leg pain 89.3 ± 12.9 89.5 ± 13.0 87.9 ± 12.0 0.65 ODI 61.8 ± 19.0 62.6 ± 19.4 55.1 ± 14.5 0.17 X-ray Intervertebral disc height (mm) 8.6 ± 2.4 8.7 ± 2.2 8.1 ± 3.6 0.34 Intervertebral ROM (°) 7.6 ± 4.7 7.9 ± 4.7 5.4 ± 4.6 0.06 MRI high signal intensity of herniation 79 78 1 < 0.01 herniated intervertebral disc size (mm 2 ) 85.3 ± 24.7 85.8 ± 25.6 81.3 ± 15.4 0.50 BMI, Body mass index; SLR, Straight leg rise; VAS, Visual analog scale; ODI, Oswestry disability index; ROM, Range of motion; MRI, Magnetic resonance imaging; Discussion In the present study, the ratio between operative treatment and condoliase therapy reversed in the third year after the introduction of condoliase therapy. In the fourth year, condoliase therapy became the main treatment for LDH, accounting for 76% of cases. Furthermore, lower limb pain improved in 89% of cases receiving condoliase therapy, while lower limb muscle strength improved in 76% of cases. Limited information is available on selection trends in condoliase therapy. One possible cause is bias in treatment selection. We assessed the prevalence of condoliase therapy because our two institutions use the same protocol (Fig. 1 ) to decide on a uniform treatment strategy. Condoliase therapy was being used more frequently until 2019; however, the number of operative treatments has been increasing. This indicates that there were patients who would not consider operative treatment, but consented to condoliase therapy. In 2020 and 2021, the number of operative treatments decreased, while the use of condoliase therapy increased further. This result demonstrates that the number of patients receiving condoliase therapy before operative treatment increased. Condoliase therapy is now used as an intermediate treatment before operative treatment in our institutions. Previous studies indicated that condoliase therapy was effective against lower limb pain in between 66 and 85% of cases. [ 11 , 13 , 14 ] This finding is consistent with the results obtained herein. In addition, the high signal intensity of herniation on MRI T2-weighted images and the duration of symptoms were good prognostic factors in the present study. The high signal intensity of herniation was previously identified as a good prognostic factor. [ 11 , 12 , 15 ] Herniation with a high signal intensity on MRI T2-weighted images reflects hydrated disc herniation. [ 16 ] We consider chemonucleolysis by condoliase to induce the dehydration of the nucleus pulposus, which is a more effective treatment for herniation with a high signal intensity on MRI T2-weighted images. A shorter duration of symptoms was also identified as a good prognostic factor in a previous study. [ 17 , 18 ] In comparisons with the duration of symptoms in that study, Group E was characterized by a similar duration (mean 5.2 months), whereas Group N was characterized by a shorter duration (mean 9.3 months). Previous studies [ 11 , 12 , 17 , 18 ] reported that the duration of symptoms ranged between 12.0 to 28.8 months in Group N. LDH commonly occurs in working-age individuals and it is unrealistic to live with pain for more than 12 months. The mean durations of symptoms of 5.2 months in Group E and 9.3 months in Group N are considered to be more in line with actual clinical practice. The present results indicate that the effects of condoliase therapy become apparent within approximately six months from the onset of symptoms. Although the cause is still unknown, scar formation inside the hernia may occur six months after the onset of symptoms. Pathological specimens from cases that required surgery after condoliase therapy may serve as a reference to clarify this issue. The rate of neurological function recovery with condoliase therapy in the present study, particularly muscle strength recovery, was 76%, which was similar to the rate of muscle strength recovery after operative treatment (80%). However, bladder-rectal disorders and severe progressive paraplegia are contraindications for condoliase therapy. In the present study, approximately 50% of cases of muscle weakness in Group C had MMT of 4, and many achieved improvement. However, when limited to cases of severe muscle weakness with MMT ≤ 3, the rate of improvement was approximately 60%. Since the muscle strength recovery rate after operative treatment was 80% even though these cases often had muscle weakness with MMT < 3, operative treatment and condoliase therapy did not achieve the same rate of muscle strength recovery. The present results only indicate the potential of condoliase therapy to recover muscle strength in patients with MMT of 4. Nevertheless, this information is useful for clinicians when providing informed consent and selecting condoliase therapy. The limitations of the present study include the short follow-up period (3 months) and the selection of intervention treatment based on a patient’s request rather than on the findings of a randomized controlled trial. Moreover, 25 patients (15%) receiving condoliase therapy were lost to the follow-up. Regarding adolescent LDH patients who aim to return to society as soon as possible, condoliase therapy, which is an out-patients procedure, is highly effective at relieving pain within 3 months and may restore reductions in lower limb muscle strength. Therefore, condoliase therapy may be more frequently used in the future as an intermediate treatment between conservative and operative treatments. Conclusion Condoliase therapy for LDH reversed surgery in the third year after its introduction and was used to treat 76% of cases in the fourth year. With condoliase therapy, lower limb pain improved in 89% of cases, while lower limb muscle strength improved in 76% of cases. Therefore, the use of condoliase therapy as an intermediate treatment between conservative and operative treatments will increase in the future. Declarations Conflict of Interest The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethical Approval The study design was approved by the Institutional Review Board of our hospital (Control Number of H2023-069), and all of the patients consented to participate in this study and to publish. Funding All authors have no Funding. Author Contribution KF: Original draft, Data curation, Review, and Editing. HS: Data curation, Review, and Editing.NN: Data curation, Review, and Editing.MF: Data curation, Review, and Editing.Yusuke I: Image processing, Review, and Editing.HI: Image processing, Review, and EditingYasuaki I: Data curation, Review, and Editing.MY: Conceptualization, Review, and Editing.TS: Supervision, Review, and Editing. Acknowledgment All authors critically revised the manuscript and reviewed the submitted version. We would like to thank Medical English Service ( www.med-english.com ) for English language editing. Availability of data and materials Not applicable. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3970032","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274007575,"identity":"d21207cf-08b2-4642-ba09-2f1d02038610","order_by":0,"name":"Kazuhiro Fujimoto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYBACCQbGBwwSBjYw/gEeKIMNjxZmA6CWNFK1MDAchmsh7DDJ9sNsEhYF5xP7px1+/Jqn5o4Mg0QC44cfDHx5uLRI8ySzSUgY3E6ccTvNzJrn2DMeoBZmyR4GtmJcWuQY8o+BtTTcTjAz5m04zGN/I4FBGuiXxAZcWvgfg2w5lzj/dvo3sBaQLb/xaZGWADvsQOKG2znGj6Fa2PDaIjnjMbOFhEGy8cbbOWWMc44BtfA8bLPsMcDtF4nzyYy3Jf7Yyc67nb75w5uaw/YM7MmHb/yoOIYzxECAWYKBwRHoDDYJCJ8RyDY4loBPC+MHBgZ7kNYPSII1eLWMglEwCkbBiAIA+3RRpxXS6kIAAAAASUVORK5CYII=","orcid":"","institution":"Yamaguchi University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kazuhiro","middleName":"","lastName":"Fujimoto","suffix":""},{"id":274007576,"identity":"8e81b694-a4d5-4ace-a3f2-89959efd2450","order_by":1,"name":"Hidenori Suzuki","email":"","orcid":"","institution":"Yamaguchi University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hidenori","middleName":"","lastName":"Suzuki","suffix":""},{"id":274007577,"identity":"e442ccfe-4e9d-4aa8-8a2f-a2ba20e44c2a","order_by":2,"name":"Norihiro Nishida","email":"","orcid":"","institution":"Yamaguchi University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Norihiro","middleName":"","lastName":"Nishida","suffix":""},{"id":274007578,"identity":"6c0490e3-6d4d-4854-9d02-d9b67827fc1e","order_by":3,"name":"Masahiro Funaba","email":"","orcid":"","institution":"Yamaguchi University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Funaba","suffix":""},{"id":274007579,"identity":"3971b59e-e9af-4e5b-aea7-6ff896560eb5","order_by":4,"name":"Yusuke Ichihara","email":"","orcid":"","institution":"Yamaguchi University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Ichihara","suffix":""},{"id":274007580,"identity":"276554b2-d938-4346-9670-019413b56ae3","order_by":5,"name":"Hiroaki Ikeda","email":"","orcid":"","institution":"tokuyama central hospital","correspondingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Ikeda","suffix":""},{"id":274007581,"identity":"8ff20a67-9849-4ff5-a67c-93f8e6a74614","order_by":6,"name":"Yasuaki Imajo","email":"","orcid":"","institution":"tokuyama central hospital","correspondingAuthor":false,"prefix":"","firstName":"Yasuaki","middleName":"","lastName":"Imajo","suffix":""},{"id":274007582,"identity":"99ff75f2-7942-452c-bb97-97b2aafeda0a","order_by":7,"name":"Manabu Yamamoto","email":"","orcid":"","institution":"tokuyama central hospital","correspondingAuthor":false,"prefix":"","firstName":"Manabu","middleName":"","lastName":"Yamamoto","suffix":""},{"id":274007583,"identity":"c1ac4d67-ce95-46f4-83d8-30f56582428e","order_by":8,"name":"Takashi Sakai","email":"","orcid":"","institution":"Yamaguchi University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Sakai","suffix":""}],"badges":[],"createdAt":"2024-02-19 13:04:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3970032/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3970032/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51512502,"identity":"cc0d81b0-e3f5-4b59-86e0-4e5cdf682d98","added_by":"auto","created_at":"2024-02-22 21:17:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":825203,"visible":true,"origin":"","legend":"\u003cp\u003eOur lumbar disc herniation (LDH) treatment strategy. Treatment selection depended on the patient’s request.\u003c/p\u003e","description":"","filename":"Onlinefig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-3970032/v1/7228e67dc7bab51eebba0183.png"},{"id":51511613,"identity":"d5645318-083e-438c-8df2-9934a5b12fab","added_by":"auto","created_at":"2024-02-22 21:09:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":3599451,"visible":true,"origin":"","legend":"\u003cp\u003eMagnetic resonance image findings ((i) high signal within the hernia and (ii) cross-sectional area (CSA) of the hernia)\u003c/p\u003e","description":"","filename":"Onlinefig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-3970032/v1/a9c9d046bff7c78eb4f3c868.png"},{"id":51511612,"identity":"7bc4484d-ceac-4977-81d1-35cfb097676b","added_by":"auto","created_at":"2024-02-22 21:09:44","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":563565,"visible":true,"origin":"","legend":"\u003cp\u003eSelection trends in intervention treatment by year. The rates of intervention treatment are shown on the left (i) and number of cases on the right (ii).\u003c/p\u003e","description":"","filename":"Onlinefig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-3970032/v1/742359adc45d1df529221e43.png"},{"id":55435966,"identity":"e0722090-a078-417f-a689-68774b46bcda","added_by":"auto","created_at":"2024-04-27 15:38:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1544121,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3970032/v1/c4cf5d54-eb65-439e-bd80-508c87625212.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Verification of selection trends in interventional treatment for patients with lumbar disc herniation and effects of condoliase therapy.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbar disc herniation (LDH) is a disorder that primarily causes lower limb pain and often occurs in early adolescence and at the L4-5 and L5-S1 disc levels. It is more common in males than in females, and smoking has been identified as a risk factor. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Treatment for LDH is broadly divided into conservative and operative treatments. Conservative treatment includes rest, medication, and nerve root blocks. Operative treatment includes open surgery and various endoscopic surgeries. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Since LDH often occurs in individuals of working age, the goals of treatment are early pain relief, improvements in motor function, and social reintegration. Operative treatment is effective for early pain relief, but is associated with the risks of operative invasion and complications. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eChemonucleolysis decomposition is an intermediate treatment between conservative and operative treatments that induces the chemical lysis of the nucleus pulposus of the intervertebral disc. Percutaneous nucleotomy has been reported as a similar intermediate treatment; however, its efficacy is less than that of chemonucleolysis decomposition. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] The usefulness of chemonucleolysis decomposition with chymopapain has been widely reported [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] in Europe and North America, while adverse events include anaphylaxis. Chondroitin sulfate ABC endolyase (condoliase), unlike chymopapain, lacks protease activity and, thus, induces chemical nuclear degradation without affecting nerve and ligament tissues. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] The findings of clinical phase III trials contributed to the selection of appropriate therapeutic doses [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and demonstrated the efficacy and safety of chemical nuclear degradation with condoliase for patients with LDH. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Condoliase became available in Japan as an intradiscal treatment for LDH in August 2018. Clinical phase III trials are also underway in the United States.\u003c/p\u003e \u003cp\u003eFive years have passed since the introduction of condoliase therapy in Japan, and its utility has been reported. However, selection trends in interventional treatment for LDH remain unknown. Furthermore, although pain relief with condoliase therapy has been extensively examined [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], limited information is currently available on its effects on motor recovery. Therefore, we herein investigated selection trends in interventional treatment for LDH patients before and after the introduction of condoliase therapy. In addition to pain relief, we focused on the recovery of muscle weakness as an effect of condoliase therapy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003ePatient recruitment\u003c/p\u003e \u003cp\u003e The study design was approved by the Institutional Review Board of our hospital (Control Number of H2023-069), and experiments were conducted according to the ethical standards of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003eThis retrospective, double-center study involved patients with unilateral or bilateral leg pain caused by LDH who received interventional treatment between September 2017 and August 2022. Our LDH treatment strategy is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. We limited indications for condoliase therapy to the subligamentous extrusion and protrusion types of herniation. We excluded patients with compressive cervical or thoracic myelopathy and lumbar spinal canal stenosis detected by magnetic resonance imaging (MRI), spinal deformity, transitional vertebrae, a history of surgery at the same level as the hernia, or brain or peripheral nerve disorders. Informed consent was obtained from all patients.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIntradiscal injection technique\u003c/p\u003e \u003cp\u003eAll intradiscal injections were administered by a qualified spine surgeon. The patient was placed in a prone position and a conventional disc-puncture needle was inserted from the affected side under fluoroscopic guidance. Condoliase was dissolved in 1.2 mL of saline to prepare a 1.25 U/mL solution and was then injected into the intervertebral disc. All patients were carefully observed for at least 2 hours after the injection and then allowed to return home.\u003c/p\u003e \u003cp\u003eClinical assessment\u003c/p\u003e \u003cp\u003eThe following demographic and clinical data were extracted from medical charts: sex, age, the body mass index (BMI), duration of symptoms, herniation level, and adverse events. To assess pain intensity and health-related quality of life, we collected data using a visual analog scale (VAS) for leg pain and assessed the Oswestry disability index (ODI) at the baseline and in a 3-month follow-up.\u003c/p\u003e \u003cp\u003eRadiographic assessment\u003c/p\u003e \u003cp\u003eLumbar X-rays were obtained before and after the injection. Intervertebral disc height was calculated at the midpoint of the end plate on lateral images. We also investigated the intervertebral range of motion (ROM) of the herniated level during maximal flexion extension. Additionally, MRI was examined before the injection. The signal intensity of herniation (a high intensity signal) and the herniated intervertebral disc size on T2-weighted images were evaluated on axial images (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A radiographic assessment was performed by three qualified spine surgeons and decided by majority consensus.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eLDH patients were divided into two groups: the operative treatment group (Group O) and condoliase therapy group (Group C). The period between September 2017 and August 2022 was divided into 5 equal parts and changes in the percentage of intervention treatment were examined. Furthermore, sex, age, BMI, the duration of symptoms, herniation level, the presence, degree, and recovery of muscle weakness, and adverse events were evaluated in the two groups.\u003c/p\u003e \u003cp\u003ePatients in Group C who were able to be followed up for 3 months after the injection or underwent operative treatment within 3 months were targeted. They were divided into two groups: the effective group (Group E) in which VAS for leg pain improved by 50% or more 3 months after the injection, and the non-effective group (Group N) in which VAS for leg pain improved by less than 50% or surgery was performed. Sex, age, BMI, the duration of symptoms, herniation level, the presence of positive straight leg rise, sensory disturbance, and muscle weakness, VAS for leg pain, and ODI were evaluated in the two groups. Furthermore, as an image evaluation, intervertebral disc height and intervertebral ROM were assessed on X-rays. The high signal intensity of herniation and the herniated intervertebral disc size were evaluated on MRI.\u003c/p\u003e \u003cp\u003eRelationships between groups were compared by the chi-square and Mann-Whitney U tests in a univariate analysis. P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered to indicate a significant difference. StatFlex (version 7.0, Artech Co., Ltd.; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.statflex.net/\u003c/span\u003e\u003cspan address=\"http://www.statflex.net/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) was used for statistical analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSubjects 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. Herniation levels were the L1-2 (in 1 patient), L2-3 (in 15), L3-4 (in 27), L4-5 (in 169), and L5-S1 (in 129) intervertebral disc levels. Forty-two patients had muscle weakness. Patient demographics and clinical assessments in Groups O and C are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Females were more likely to select condoliase therapy. Details on muscle weakness are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Adverse events included dural puncture in 2 cases and infection in 1 case in Group O and fever in 4 cases, drug eruption in 1 case, and vertebral body fracture adjacent to the treated intervertebral disc in 1 case in Group C. No serious complications, such as anaphylaxis, were observed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of demographics and clinical assessments of LDH patients with interventional treatment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAll patients (n\u0026thinsp;=\u0026thinsp;341)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup O\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;169)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;172)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e226/115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e122/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104/68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDuration of symptoms (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHerniation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL1-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL2-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL3-4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL4-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePresence of muscle weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eLDH, lumbar disc herniation;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI, body mass index;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDetails of muscle weakness in 42 patients with interventional treatment.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eGroup O\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eGroup C\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-MMT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-MMT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePre-MMT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePost-MMT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (anuria+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (anuria+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eMMT, manual muscle test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows selection trends in interventional treatment by year. In 2017, all cases underwent surgery; however, in 2018, 30% received condoliase therapy. The use of condoliase therapy continued to increase from 2018, reaching 56% in 2020 and 76% in 2021.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThere were 147 patients in Group C who were able to be followed up for 3 months after the injection or underwent operative treatment within 3 months, while there were 16 in Group N, among whom 15 underwent surgery after condoliase therapy. Patient demographics and clinical assessments in Groups E and N are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean duration of symptoms was significantly shorter in Group E (5.2 months) than in Group N (9.3 months) (p\u0026thinsp;=\u0026thinsp;0.03). In imaging evaluations, a significant difference was observed in the high signal intensity of herniation in Group E (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of patient demographics and clinical assessments in effective and non-effective groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAll patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;147)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGroup E\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;131)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGroup N\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86/61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78/53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.3\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.5\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eDuration of symptoms (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHerniation level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL2-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL3-4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL4-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL5-S1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePresence of positive SLR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100(76%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15(94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePresence of sensory disturbance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68(52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7(44%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePresence of motor weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17(13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eVAS for leg pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87.9\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eODI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.8\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e62.6\u0026thinsp;\u0026plusmn;\u0026thinsp;19.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX-ray\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIntervertebral disc\u003c/p\u003e \u003cp\u003eheight (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIntervertebral ROM (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ehigh signal intensity\u003c/p\u003e \u003cp\u003eof herniation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eherniated intervertebral\u003c/p\u003e \u003cp\u003edisc size (mm\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.3\u0026thinsp;\u0026plusmn;\u0026thinsp;24.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.8\u0026thinsp;\u0026plusmn;\u0026thinsp;25.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e81.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMI, Body mass index;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eSLR, Straight leg rise;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eVAS, Visual analog scale;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eODI, Oswestry disability index;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eROM, Range of motion;\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eMRI, Magnetic resonance imaging;\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, the ratio between operative treatment and condoliase therapy reversed in the third year after the introduction of condoliase therapy. In the fourth year, condoliase therapy became the main treatment for LDH, accounting for 76% of cases. Furthermore, lower limb pain improved in 89% of cases receiving condoliase therapy, while lower limb muscle strength improved in 76% of cases.\u003c/p\u003e \u003cp\u003eLimited information is available on selection trends in condoliase therapy. One possible cause is bias in treatment selection. We assessed the prevalence of condoliase therapy because our two institutions use the same protocol (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to decide on a uniform treatment strategy. Condoliase therapy was being used more frequently until 2019; however, the number of operative treatments has been increasing. This indicates that there were patients who would not consider operative treatment, but consented to condoliase therapy. In 2020 and 2021, the number of operative treatments decreased, while the use of condoliase therapy increased further. This result demonstrates that the number of patients receiving condoliase therapy before operative treatment increased. Condoliase therapy is now used as an intermediate treatment before operative treatment in our institutions.\u003c/p\u003e \u003cp\u003ePrevious studies indicated that condoliase therapy was effective against lower limb pain in between 66 and 85% of cases. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] This finding is consistent with the results obtained herein. In addition, the high signal intensity of herniation on MRI T2-weighted images and the duration of symptoms were good prognostic factors in the present study. The high signal intensity of herniation was previously identified as a good prognostic factor. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Herniation with a high signal intensity on MRI T2-weighted images reflects hydrated disc herniation. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] We consider chemonucleolysis by condoliase to induce the dehydration of the nucleus pulposus, which is a more effective treatment for herniation with a high signal intensity on MRI T2-weighted images. A shorter duration of symptoms was also identified as a good prognostic factor in a previous study. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] In comparisons with the duration of symptoms in that study, Group E was characterized by a similar duration (mean 5.2 months), whereas Group N was characterized by a shorter duration (mean 9.3 months). Previous studies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported that the duration of symptoms ranged between 12.0 to 28.8 months in Group N. LDH commonly occurs in working-age individuals and it is unrealistic to live with pain for more than 12 months. The mean durations of symptoms of 5.2 months in Group E and 9.3 months in Group N are considered to be more in line with actual clinical practice. The present results indicate that the effects of condoliase therapy become apparent within approximately six months from the onset of symptoms. Although the cause is still unknown, scar formation inside the hernia may occur six months after the onset of symptoms. Pathological specimens from cases that required surgery after condoliase therapy may serve as a reference to clarify this issue.\u003c/p\u003e \u003cp\u003eThe rate of neurological function recovery with condoliase therapy in the present study, particularly muscle strength recovery, was 76%, which was similar to the rate of muscle strength recovery after operative treatment (80%). However, bladder-rectal disorders and severe progressive paraplegia are contraindications for condoliase therapy. In the present study, approximately 50% of cases of muscle weakness in Group C had MMT of 4, and many achieved improvement. However, when limited to cases of severe muscle weakness with MMT\u0026thinsp;\u0026le;\u0026thinsp;3, the rate of improvement was approximately 60%. Since the muscle strength recovery rate after operative treatment was 80% even though these cases often had muscle weakness with MMT\u0026thinsp;\u0026lt;\u0026thinsp;3, operative treatment and condoliase therapy did not achieve the same rate of muscle strength recovery. The present results only indicate the potential of condoliase therapy to recover muscle strength in patients with MMT of 4. Nevertheless, this information is useful for clinicians when providing informed consent and selecting condoliase therapy.\u003c/p\u003e \u003cp\u003eThe limitations of the present study include the short follow-up period (3 months) and the selection of intervention treatment based on a patient\u0026rsquo;s request rather than on the findings of a randomized controlled trial. Moreover, 25 patients (15%) receiving condoliase therapy were lost to the follow-up. Regarding adolescent LDH patients who aim to return to society as soon as possible, condoliase therapy, which is an out-patients procedure, is highly effective at relieving pain within 3 months and may restore reductions in lower limb muscle strength. Therefore, condoliase therapy may be more frequently used in the future as an intermediate treatment between conservative and operative treatments.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCondoliase therapy for LDH reversed surgery in the third year after its introduction and was used to treat 76% of cases in the fourth year. With condoliase therapy, lower limb pain improved in 89% of cases, while lower limb muscle strength improved in 76% of cases. Therefore, the use of condoliase therapy as an intermediate treatment between conservative and operative treatments will increase in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e \u003ch2\u003e Ethical Approval\u003c/strong\u003e \u003cp\u003e The study design was approved by the Institutional Review Board of our hospital (Control Number of H2023-069), and all of the patients consented to participate in this study and to publish.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eAll authors have no Funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKF: Original draft, Data curation, Review, and Editing. HS: Data curation, Review, and Editing.NN: Data curation, Review, and Editing.MF: Data curation, Review, and Editing.Yusuke I: Image processing, Review, and Editing.HI: Image processing, Review, and EditingYasuaki I: Data curation, Review, and Editing.MY: Conceptualization, Review, and Editing.TS: Supervision, Review, and Editing.\u003c/p\u003e\u003ch2\u003eAcknowledgment\u003c/h2\u003e \u003cp\u003eAll authors critically revised the manuscript and reviewed the submitted version. We would like to thank Medical English Service (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.med-english.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.med-english.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) for English language editing.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBruske-Hohlfeld I, Merritt JL, Onofrio BM et al (1990) Incidence of lumbar disc surgery. A population-based study in Olmsted County, Minnesota, 1950\u0026ndash;1979. 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J Orthop Sci. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jos.2021.05.005\u003c/span\u003e\u003cspan address=\"10.1016/j.jos.2021.05.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakajima H, Kubota A, Maezawa Y, Watanabe S, Honjoh K, Ohmori H, Matsumine A (2021) Short-Term Outcome and Predictors of Therapeutic Effects of Intradiscal Condoliase Injection for Patients with Lumbar Disc Herniation. Spine Surg Relat Res 5:264\u0026ndash;271. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22603/ssrr.2020-0126\u003c/span\u003e\u003cspan address=\"10.22603/ssrr.2020-0126\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3970032/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3970032/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"This study aims to investigate selection trends in treatment for lumbar disc herniation (LDH) and the effects of condoliase therapy on muscle weakness. Patients with leg pain caused by LDH who received interventional treatment between September 2017 and August 2022 were included in this study. 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. Sex, age, the body mass index (BMI), duration of symptoms, herniation level, and neurological findings were examined in the two groups. Motor recovery was also assessed in the two groups. 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 ratio between operative treatment and condoliase therapy reversed in the third year after the introduction of condoliase therapy. In the fourth year, condoliase therapy became the main treatment for LDH. Lower limb muscle strength improved in 76% of cases receiving condoliase therapy. 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 testing ≤3, the improvement rate was approximately 60%. These results will be useful for clinicians when providing informed consent and selecting condoliase therapy.","manuscriptTitle":"Verification of selection trends in interventional treatment for patients with lumbar disc herniation and effects of condoliase therapy.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-22 21:09:39","doi":"10.21203/rs.3.rs-3970032/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dccfba31-fe05-4967-bbfa-2be971fa78b7","owner":[],"postedDate":"February 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-27T15:29:59+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-22 21:09:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3970032","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3970032","identity":"rs-3970032","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}