【作者】 全科；

【导师】 李万瑶；

【作者基本信息】 广州中医药大学 ， 中医学， 2012， 博士

【摘要】 背景：腰椎间盘突出症(Lumbar disc herniation简称LDH)的总发病率很高,且大多数是青壮年、肥胖者,并出现年轻化趋势,女性的发病率低于男性,椎间盘突出的部位,L5/Sl节段占大多数,其次是L4/5节段。它是因为腰椎间盘发生退行性改变,并在外力作用下,使纤维环发生破裂,髓核突出刺激或压迫了马尾神经、神经根等,并进一步导致周围组织水肿、炎症、纤维组织增生粘连和微循环障碍,继而出现以腰痛及下肢坐骨神经放射痛等症状为特征的腰腿痛疾患,是一种疼痛剧烈的脊柱疾病,为临床常见病和引起腰腿痛最重要的原因之一,常给患者的生活和工作带来诸多痛苦,甚至造成残废,丧失劳动能力,并消耗大量的医疗资源。本病主要表现为腰腿痛、坐骨神经痛,典型的坐骨神经痛表现为由臀部、大腿后侧、小腿外侧至跟部或足背的放射痛。据临床统计,约95%的腰椎间盘突出症患者有不同程度的腰痛,80%的患者有下肢痛。尤其是腰痛,不仅是腰椎间盘突出症最常见的症状,也是最早出现的症状之一目前国内、外的临床治疗方法虽多种多样,但大致可分为手术疗法和非手术疗法。多数患者可经非手术途径获得缓解或痊愈,但见效缓慢。手术疗法主要用于症状较严重经非手术治疗失败或反复发作者,或有明显神经功能障碍者,但创伤大、并发症较多。针刀疗法将传统的针灸针和现代手术刀有机结合起来,具有操作简单,疗效确切,痛苦少,费用低,安全系数高,患者乐于接受等优点,在临床治疗中取得明显的甚至立竿见影的效果。目的：腰椎间盘突出症(Lumbar disc herniation简称LDH)是临床多发病,针刀疗法是治疗腰椎间盘突出症的一种重要而又行之有效的方法,本研究旨在设计临床试验,通过问卷调查形式评估患者治疗前后在临床症状、临床体征方面的变化以及日常生活工作的变化,分析针刀疗法对腰椎间盘突出症患者的治疗疗效和安全性及接受度,为腰椎间盘突出症的治疗提供有效而安全的治疗方法,减轻患者的临床症状,改善患者的阳性体征,提高患者生活和工作质量。并总结针刀治疗的临床操作经验,分析针刀操作手法等相关因素,同时为临床运用针刀治疗腰椎间盘突出症、完善针刀操作提供一种新的思维。方法：1、病例来源及分组：所有病例来源于2011年3月至2012年2月就诊于广州中医药大学第一附属医院针灸科及广东省银行医院专家诊室的门诊患者,共60例,将60例患者预编号(1-60),用excel选出随机数字并按照随机数字升序用完全随机方法将1-60号进行分组,分为针刺对照组和针刀治疗组,每组30例,进行临床研究。2、治疗：2.1针刀治疗组：2.1.1进针点的选择：根据问诊时病人主诉的疼痛部位,在下列地方反复触摸、按压,寻找激痛点、阿是穴或阳性反应点(压痛、条索、硬结等阳性反应物)。腰骶部：腰椎间盘突出相应节段的上下关节突、棘突(间)、侧隐窝(椎间孔内口)、横突根部(椎间孔外口)以及骶髂关节等。臀部：坐骨大切迹骨缘、骶骨边缘、坐骨棘、坐骨结节、股骨大转子、小转子、梨状肌、臀大、中肌、阔筋膜张肌起止点、肌腹等。小腿后、外侧方：腓骨小头后、外侧方及下方、小腿三头肌、腓骨长肌等。根据阳性反应点的范围和患者的耐受程度按先上后下的顺序,每次选点10个左右。2.1.2操作：采用“纳米寸劲、针刀逐层弹性切刺法”,腰部根据患者的体型选择华夏牌0.6/3号(80mm)或0.6/4号(50mm)针刀,臀部选择华夏牌0.6/3号(80mm)针刀,腿部选择0.6/4号(50mm)针刀,针身与皮肤表面垂直,刀口线和神经血管肌纤维方向一致,首先快速进针,即双手持针,右手捏住针柄,左手捏住针身,露出针尖约0.5-1cm,离进针点皮肤约2-3mm处快速直线进针(突破浅筋膜)的同时左手拇食指卡住针身控刀；然后左手拇、食指放松并稍提退针身,轻缓下探刀下阻力感；当遇到阻力感后,而患者也无异常感觉(疼痛或麻电感),束全身之力,短促速刺,突破触发点紧绷的筋膜,并迅速回抽；如刀下阻力感持续,可继续短促速刺,直至阻力消失,不强求到骨面。每周治疗一次,4个星期为一个疗程。疗程结束后随访1个月。2.2针刺对照组：2.2.1主要取穴：阿是穴、腰部夹脊穴、大肠俞、环跳、委中、昆仑、髀关、血海、三阴交。寒湿型患者可加腰阳关；湿热型患者可加阴陵泉；血瘀型患者可加膈俞；肝肾亏虚型患者可加命门、肾俞、志室等。2.2.2操作：用毫针刺,环跳可直刺2.5寸,余穴均直刺1-1.5寸,得气后行小幅度提插捻转,并用电针机连续波密波加电30min。一周3次,4个星期为一疗程。疗程结束后随访1个月。两组患者分别在治疗前、治疗中期(治疗两个星期后)、治疗后以及随访(疗程结束后1个月随访)时,按照《日本骨科学会(JOA)腰痛疾患疗效评定标准》(见附录),填写《腰椎间盘突出症患者临床治疗观察表》(见附表)。通过参照《日本骨科学会(JOA)腰痛疾患疗效评定标准》,对腰椎间盘突出症患者临床症状、体征及患者日常生活进行评估,根据国家中医药管理局颁布的《中医病症诊断疗效标准》评定(南京大学出版社,1994)、视觉模拟评级法(vas)对腰椎间盘突出症患者的功能活动、疗效、疼痛进行分析。结果：1、针刀疗法对腰椎间盘突出症的临床疗效和安全性研究：本研究将60例患者预编号(1-60),用excel选出随机数字并按照随机数字升序用完全随机方法将1-60号进行分组,分为针刺对照组和针刀治疗组,每组30例,进行临床研究。在两组患者中,治疗前患者的性别、年龄、身高、体重、病程及临床症状、临床体征无差别。根据国家中医药管理局颁布的《中医病症诊断疗效标准》评定(南京大学出版社,1994)调查分析,针刺对照组治疗后的总有效率为76.67%,患者自身治疗前后比较,患者的功能活动、疼痛得到改善,确有临床疗效,差异有统计学意义(P<0.05)。针刀治疗组治疗后的总有效率为93.33%,能有效地减轻患者的腰背痛、腿痛、麻木及步态等临床症状,明显改善患者的临床阳性体征及感觉障碍,提高患者的生活质量及适应能力,治疗前后比较,差异明显,有统计学意义(P<0.05)。在4个星期的治疗时间后,两组腰椎间盘突出症患者的疗效比较,差异明显,有统计学意义(P<0.05)。针刀疗法对腰椎间盘突出症患者的疗效明显优于针刺疗法；针刀疗法的疗效维持作用明显优于针刺疗法；针刀疗法相对针刺疗法对腰椎间盘突出症的疗效维持时间更长,效果更好。针刀治疗对患者腰腿痛程度的减轻、麻木及感觉障碍的改善作用较针刺治疗明显。在治疗时针刀治疗组患者的针感明显强于针刺对照组,针刀治疗组患者的针感遗留时间也明显比针刺对照组长。两组比较差异有统计学意义(p<0.05)。患者接受针灸治疗的程度优于针刀治疗,但针刀对患者的治疗作用能维持更长的时间,从而更能达到良好的疗效,随访时即完成治疗一个月后,仍能保持疗效。在针刀治疗组的30例患者中,患者治疗前后的生命体征比较无显著差别,且均未发现有血管神经损伤或是其他不良事件发生。2、性别、年龄、体重指数、中医证型及突出部位与腰椎间盘突出症的关系研究：在研究的60例腰椎间盘突出症患者中,腰椎间盘突出症的患者男性多于女性；年龄以35—50岁的青壮年患者为主,腰椎间盘突出症的发生与患者的体型有关,体重超重、肥胖及严重肥胖者更易发病。在研究的60例腰椎间盘突出症患者中,中医证型以肝肾亏虚型为主,突出部位以L5/S1椎间盘突出居多。3、与针刀治疗效果相关的因素分析：在本次研究的30例针刀治疗腰椎间盘突出症患者中,针刀的治疗效果与患者的性别、年龄、体重指数、中医证型及突出部位均没有关系。结论：1、针刀疗法对腰椎间盘突出症患者疗效显著,总有效率为93.33%,且疗效明显优于针刺疗法。2、针刀疗法的刺激较大,针感遗留时间较长,疗效维持时间长,效果好。3、针刀治疗不受患者的性别、年龄、体重指数、中医证型、突出部位以及病程长短的影响,能在临床上广泛地开展应用。4、针刀疗法是治疗腰椎间盘突出症的一种有效而安全的方法,值得在临床实践中推广和应用。更多还原

【Abstract】 Background:Lumbar disc herniation (LDH) is a very common disease in the modern world, patients of which are mostly the young and the obese people. Men are more incline to get the disease than women. The age of the group is getting younger and younger. Most of the site of the herniation is at L5/S1segment, next came L4/5segment. It is because of the degenerative changes in lumbar intervertebral disc, and the external force, the annulus fibrosus rupture herniated nucleus irritation or compression of the cauda equina nerve roots, and further lead to the surrounding tissue inflammation, edema, microcirculation, and fibrous tissue proliferation adhesion, followed by low back pain and lower extremity sciatic radiating pain and other symptoms of disorders characterized by low back pain, commonly known as "lumbar syndrome", is a severe pain, spinal disorders, caused by low back pain the most important reason for the clinical common and often bring a lot of pain to the patient’s life and work, and even cause disability, loss of ability to work, and consume large amounts of medical resources. The disease mainly manifested as low back pain, sciatica, typical sciatica performance grounds hips, thigh, lateral leg to the heel or dorsum of the foot, and radiating pain. According to clinical statistics, the disease is more common in young adults; about95%of the lumbar patients have varying degrees of low back pain,80%of patients with lower extremity pain. Especially low back pain, lumbar disc herniation of the most common symptoms, is also one of the earliest symptoms.The treatment methods about Lumbar disc Herniation are various all over the world. They can be divided into two kinds, surgical techniques and non-surgical methods. Most patients can be alleviated or cured by the non-surgical, although slowly but effectively. The surgery is mainly used for the group which has severe symptoms, even significant neurological disorder, that can’t he cured by non-surgical treatment. But it has many complications, and itself is a kind of severe trauma to patients.It is Needle-knife therapy that combines traditional acupuncture needles and scalpel perfectly, to form a simple, effective, safe, less painful, low-cost, and safety treatment, which can be easily accepted by the patients. The effect of this treatment is significant in clinic.Purpose:The study aimed to assess changes of clinical symptoms, clinical signs, patients’daily life and work of through the questionnaire form before and after treatment, analyze the affectivity, safety and acceptance of needle knife therapy for patients with lumbar disc herniation, and summarize the clinical operations experience of needle knife treatment, and analysis of needle knife operating practices and other related factors.Methods:1、case of source and group:All cases are from the acupuncture department of First Affiliated Hospital in Guangzhou University of Traditional Chinese Medicine and the outpatients department of Guangdong Provincial Bank Hospital during March of2011to February of2012. The total amount is60cases.60patients were pre-numbered (1-60elect a random number), excel and completely random way in accordance with the random numbers in ascending order of1-60, and divided into the acupuncture control group and the acupuncture therapy group (n=30cases).2、Treatment:2.1Needle knife therapy group:2.1.1The choice of pin-point:According to the inquiry when the patient complained of pain area, repeated in the following practice of the touch, press, to find our the trigger points, a-shi points, the positive reaction of the hole or positive points (tenderness, cord, induration). Lumbosacral region: the spinous process of the corresponding segments of the lumbar intervertebral disc, the upper and lower articular processes, lateral recess (intervertebral foramen inside the mouth), transverse roots (intervertebral foramen outside the mouth), and sacroiliac joint. Hip:the bone margin of the greater sciatic notch the edge of the sacrum, ischial spine, ischial tuberosity, greater trochanter, lesser trochanter, the piriformis, buttocks, muscles, beginning and ending points of tensor fascia lata muscle belly and so on. Lower leg and lateral side:the fibular head, lateral side and below the calf muscle, peroneus longus muscle. According to the order of the scope of the positive points and the tolerance of patients with the first following each election points5-15.2.1.2Operation:"the strength of nano-inch, needle knife layer elastic cut thorn Law, choose suitable needle knife form China brand0.6/3to0.6/4according to the patient’s body, such as, buttocks China brand0.6/3, the needle knife, leg Ministry to select the0.6/4. keep the knife body and leather pin vertical, and keep the incision line and the blood vessels and nerves of muscle fibers with the same direction. Firstly, rapid pinch into the skin:two hands holding the needle, the right hand and hold the needle handle, left hand hold the needle body, exposing the tip about0.5-lcm, fast straight pinch out2-3mm into the skin pin-point (breakthrough superficial fascia), while the left hand thumb and index finger stuck the needle body control knife; then left thumb and index finger to relax and to mention a little retreat of the needle body, lights low dropping sword resistance flu; case of resistance to influenza, and patients with no abnormal sensation (pain or hemp inductance), the power of the whole body, short speed thorn, breaking the trigger point of tension in the fascia, and quickly retraced; knife resistance flu sustained, may continue to short the speed thorns, until the loss of resistance force to the bone surface, a course of treatment are made of four weeks, and once a week. Follow-up one month after the end of treatment.2.2Acupuncture control group:2.2.1Acupoints:take the A-shi hole, waist Jiaji、Shenshu Dachangshu, ring jump, Venezuela、biguan、xuehai and Kunlun. Clinical disease can be equipped with the acupoint addition and subtraction Yaoyangguan Geshu, Vital Chi room, Yanglingquan Taichong.2.2.2Operation: firstly, use needle pinch the points, such as, ring jump can be perpendicularly2.5inch, and the other points perpendicularly1-1.5inch to get gas underwent small amplitude lifting and thrusting, twisting. Secondly, use electric needle, choosing the Bomi wave to electric for30min. Three times a week, four weeks for treatment. Follow-up one month after the end of treatment. Two groups of patients before treatment, At the time of the treatment of medium-term (two weeks after treatment), treatment and follow-up (1-month follow-up after treatment), in accordance with the assessment standards of the Japanese Orthopaedic Association (JOA) low back pain disorders treatment (see Appendix), fill in the clinical treatment of patients with lumbar disc herniation observed table (see Appendix).By reference to low back pain disorders treatment assessment standards of Japanese Orthopaedic Association (JOA), assessment of lumbar disc herniation in patients with clinical symptoms, signs and daily living in patients, according to the diagnostic efficacy standards promulgated by the State Administration of Traditional Chinese Medicine disease assessment (Nanjing University Press,1994), visual analogue rating method (vas) on lumbar disc herniation in patients with functional activity, efficacy, and pain were analyzed.Results:1、The study of efficacy and safe on needle-knife therapy for lumbar disc herniation clinical:In this study,60patients were randomly divided into acupuncture control group and the acupuncture therapy group,30cases in each group. Before treatment, there is no difference among the patient’s gender, age, height, weight, duration and clinical symptoms, and clinical signs.According to the State Administration of Traditional Chinese Medicine Disease Diagnosis and Efficacy Standards Assessment (Nanjing University Press,1994) to Investigation and Analysis, acupuncture control group after treatment, the total effective rate was76.67%, before and after the patient’s own treatment of patients with functional activities, pain improved, the clinical efficacy, the difference was statistically significant (P<0.05). The total effective rate of needle-knife treatment group was93.33%. Needl knife therapy can effectively reduce the clinical symptoms of patients, such as, low back pain, leg pain, numbness and gait improved significantly in patients with clinically positive signs and sensory disturbances, and improve patient quality of life and ability to adapt, before and after treatment, the differences statistical was significant (P<0.05).After4weeks of treatment, the efficacy of the two groups of patients with lumbar disc herniation, was statistically different (P<0.05). The efficacy of needle-knife therapy in patients with lumbar disc herniation was significantly better than acupuncture; and can maintain long effect than acupuncture group.Needle acupuncture therapy can significantly relief patients’low back pain, numbness, and sensory disturbances, which is better than the acupuncture treatment.At the time of treatment, patients treated with needle knife therapy feel stranger propagated sensation than acupuncture therapy, and the sensation can maintain longer. The difference was statistical significant (p<0.05). Thus, more patients prefer to choose needle knife therapy.Before and after treatment the vital side-effect of the30patients in needle knife group was no significant difference, and no nerve and blood vessel damage or other adverse events occurred.2、research on relationship between sex, age, body mass index, TCM syndrome and protruding parts with lumbar disc herniation:In a study of60cases of lumbar disc herniation, more men suffer form lumbar disc herniation than women.People of35-50years old or overweight, obese have more occurrence of lumbar disc herniation.In the study of60cases of lumbar disc herniation, TCM syndrome is liver and kidney deficiency type, the majority of the prominent parts is the L5/S1disc.3、with small needle-knife treatment-related factorsThe effect of needle knife treatment of lumbar disc herniation in this study of30cases has no relationship with the patient’s gender, age, body mass index, TCM syndrome and protruding parts.Conclusion:1、The efficacy of needle-knife therapy in patients with lumbar disc herniation is significantly, the total effective rate was93.33%, significantly better than acupuncture.2、Needle-knife therapy has a strong stimulation, and can maintain longer time.3、Needle-knife therapy can be used by majority patients suffered from lumbar disc herniation, no matter what gender, age, body mass index, TCM syndrome, or protruding parts. 4、Needle-knife therapy for treating lumbar disc herniation is a safe and effective method, and the recurrence rate is low, it is worth the promotion and application in clinic.更多还原