What is the role of Chymoral forte (chymotrypsin) in managing Intervertebral Disc Protrusion (IVDP) pain?

Chymoral Forte for Intervertebral Disc Protrusion Pain

Chymoral Forte (chymotrypsin) is not recommended for IVDP pain management, as there is no high-quality evidence supporting its efficacy, and it is not mentioned in any current pain management guidelines.

Evidence-Based Treatment Approach for IVDP Pain

The American Society of Anesthesiologists emphasizes that chronic pain management should follow a multimodal approach prioritizing pain reduction while improving function and rehabilitation 1.

First-Line Pharmacological Management

NSAIDs and acetaminophen should be considered as initial pharmacological therapy for IVDP-related pain 1. These medications provide effective pain relief for musculoskeletal conditions when used appropriately 1.

Anticonvulsants (pregabalin or gabapentin) are strongly recommended if neuropathic radicular pain is present, with Category A1 evidence showing effective pain relief for neuropathic pain over 5-12 weeks 1. Common side effects include dizziness, somnolence, and peripheral edema 1.

Antidepressants (duloxetine or tricyclics like amitriptyline) should be used for neuropathic pain components, with Category A1 evidence supporting their efficacy 1.

Physical and Restorative Therapy

Physical therapy should be implemented as part of the multimodal approach, focusing on:

• Optimal postural alignment during functional activities 2
• Even weight distribution during sitting, standing, and walking 2
• Muscle relaxation techniques to reduce overactivity 2
• Avoiding prolonged end-range joint positioning 2

Critical pitfall: Avoid excessive splinting or immobilization, as this prevents restoration of normal movement and promotes muscle deconditioning 2.

Interventional Options for Refractory Cases

When conservative management fails, consider:

Epidural steroid injections with or without local anesthetics for radicular pain, performed with appropriate image guidance 1. Transforaminal approaches require specific discussion of potential complications and confirmation of correct needle position with contrast before injection 1.

Minimally invasive spinal procedures (percutaneous disc decompression/nucleoplasty) show Category B2 evidence for effective pain relief in back and radicular pain for 2 weeks to 12 months 1.

Nerve blocks may be appropriate for well-localized pain syndromes, including peripheral nerve blocks or epidural neurolysis 1.

Historical Context on Enzymatic Chemonucleolysis

While chymopapain (a related proteolytic enzyme) was historically used for disc herniation treatment in the 1970s-1980s 3, 4, 5, 6, this approach:

• Showed only 60% success rates compared to 89% for surgical discectomy in simple disc disease 5, 6
• Required exacting technique and specific patient selection criteria 3
• Had important contraindications including allergy risk, pregnancy, and sequestrated disc 3
• Is no longer part of contemporary treatment algorithms

Chymoral Forte (oral chymotrypsin) has never been validated in high-quality studies for IVDP pain and lacks any guideline support.

Treatment Algorithm

1. Initial phase: NSAIDs/acetaminophen + physical therapy 1, 2
2. If radicular pain present: Add anticonvulsants (pregabalin) or antidepressants (duloxetine) 1
3. If inadequate response after 4-6 weeks: Consider epidural steroid injections 1
4. If persistent severe pain: Evaluate for minimally invasive procedures or surgical consultation 1

Medications to Avoid

Strong opioids are not recommended for routine IVDP pain management due to lack of demonstrated benefit and significant harm potential 1. Corticosteroids (systemic) lack efficacy evidence for disc-related pain 1.

The goal remains effective pain reduction while improving function, using the least invasive approach that achieves these outcomes 1.