【作者】 吴靖；

【导师】 庄礼兴；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2010， 博士

【摘要】 1研究目的腰椎间盘突出症又称腰纤维环破裂症,是一种疼痛剧烈的脊椎疾病,由于椎间盘发生退行性变,或外力作用引起腰椎间盘内外力平衡失调,均可使纤维环突然破裂,导致腰椎间盘的髓核突出,压迫或刺激了神经根、硬膜囊、血管及马尾神经等,进一步导致周围组织炎症、水肿、微循环障碍和纤维组织增生粘连,继而出现腰腿痛,甚至出现神经功能障碍的一种疾病。本研究采取简单随机、对照方法设计研究方案,对电针夹脊穴及阿是穴治疗腰椎间盘突出症进行科学的疗效评价,通过观察电针夹脊穴及阿是穴对腰椎间盘突出症疼痛的缓解,探讨一种简单的治疗方法以减轻腰椎间盘突出症对患者带来的痛苦,同时为电针夹脊穴及阿是穴治疗腰椎间盘突出症提供理论依据。2研究方法2.1病例来源及分组所有病例来源于香港大学中医临床教研中心,将诊断为腰椎间盘突出症的患者60例随机分为治疗组(针刺夹脊穴及阿是穴)30例及对照组(常规针刺组)30例,进行临床研究。2.2治疗(1)取穴治疗组取夹脊穴及阿是穴,夹脊穴：病变部位的椎体及下一椎体的夹脊穴；阿是穴：病变部位的椎体水平棘突旁开3寸以内寻找2个深层压痛点；循经配穴及辨证配穴：与对照组相同。对照组：腰痛及坐骨神经痛常规穴位,主穴：肾俞、大肠俞、腰阳关；循经配穴：足太阳经型：环跳、阳陵泉、秩边、承扶、殷门、委中、承山、昆仑；足少阳经型：环跳、阳陵泉、风市、膝阳关、阳辅、悬钟、足临泣。辨证配穴,寒湿型：腰阳关；血瘀型：水沟；肾阳虚型：命门；肾阴虚型：三阴交。(2)操作方法治疗组操作：用75%酒精皮肤常规消毒夹脊穴及阿是穴,用0.25×50mm不锈钢毫针快速进针,直刺40mm；环跳穴、秩边穴及承扶穴用0.25×75mm不锈钢毫针快速进针,直刺70mm；殷门穴用0.25×60mm不锈钢毫针快速进针,直刺50mm；阳陵泉穴、风市穴、委中穴及承山穴用0.25×50mm不锈钢毫针快速进针,直刺40mm；昆仑穴用0.25×40mm不锈钢毫针快速进针,直刺30mm；足临泣穴用0.25×25mm不锈钢毫针快速进针,直刺20mm。腰阳关穴及命门穴用0.25×40mm不锈钢毫针快速进针,斜刺30mm；水沟穴用0.25×25mm不锈钢毫针快速进针,直刺15mm；三阴交穴用0.25×40mm不锈钢毫针快速进针,直刺35mm。以上各穴每穴针刺1针,各穴都以患者局部有酸麻胀为得气感,得气后留针用KWD-808I型治疗仪选用30分钟连续密波加电。对照组针刺操作,用75%酒精皮肤常规清毒,肾俞及腰阳关穴用0.25×40mm不锈钢毫针快速进针,斜刺30mm；大肠俞穴用0.25×50mm不锈钢毫针快速进针,直刺40mm,其余操作同治疗组相同。两组患者均隔日治疗1次,3次为一疗程,疗程之间休息2天,于3个疗程结束后填写量表进行分析。2.3疗效评价体系及观察指标研究中所采用的临床评价体系为：国家中医药管理局1994年颁布的《中医病证诊断疗效标准》、“腰痛疗效分级表”、“简式Mcqill疼痛问卷”及“Oswestry功能障碍指数”。治疗前后密切监测不良反应。3研究结果3.1两组临床疗效比较治疗后两组的临床症状均有改善,治疗组愈好率93.33%,对照组愈好率80%,说明经过治疗两组患者都取得了良好的效果；治疗组治愈17例,好转11例,未愈2例,愈好率93.33%；对照组治愈12例,好转12例,未愈6例,愈好率80%。两组愈好率比较,治疗组优于对照组(P<0.05)。3.2两组腰痛疗效评价比较结果在治疗前两组评分差异无统计学意义(p>0.05)；治疗后两组的腰痛疗效评分均发生了显著的变化,组内治疗前后评分t检验,显示差异具有统计学意义(P<0.05),说明经过治疗两组患者都取得了良好的效果；组间比较治疗组评分优于对照组,且差异具有统计学意义(P<0.05),说明治疗组效果优于对照组。3.3两组对疼痛疗效的比较结果在治疗前两组的疼痛分级指数(PRI)感觉项总分、情感项总分及总分,视觉模拟定级(VAS),现有痛强度(PPI)各项指标经统计学分析,差异无统计学意义,(P＞0.05)；治疗后两组的PRI感觉项总分,PRI情感项总分,PRI总分,VAS,PPI各项指标分别与治疗前比较,差异有显著性意义,(P<0.05,P<0.01,P<0.001),说明两组对腰椎间盘突症均有良好的治疗效果,都能很好地改善腰椎间盘突出症患者的腰痛情况；两组治疗后治疗组PRI感觉项总分,PRI情感项总分,PRI总分,VAS均优于对照组,差异显著,(P<0.05),而PPI差异不明显, (P>0.05),说明治疗组改善腰椎间盘突出症患者的腰痛情况优于对照组。3.4治疗前后两组患者功能障碍测定比较结果在治疗前两组患者Oswestry功能障碍评分无显著差异,经统计学比较,(P>0.05)；经治疗后治疗组和对照组患者评分均发生了显著变化,Oswestry功能障碍评分显著下降,说明两种治疗方法均能改善腰椎间盘突出症患者的腰痛症状及改善患者的生活质量,经统计学比较均有统计学意义,(P<0.01或P<0.05)；而治疗组与对照组比较,差异显著(P<0.05)说明在改善腰痛症状及提高患者生活质量方面,治疗组优于对照组。4研究结论本临床研究显示：电针夹脊穴及阿是穴为主治疗腰椎间盘突出症的临床疗效优于常规穴位针刺治疗。采用电针夹脊穴及阿是穴治疗腰椎间盘突出症为临床上切实可行的治疗方法,值得临床推广及进一步深入研究。更多还原

【Abstract】 1. Research purposesLumbar Intervertebral Disc Herniation also known as Lumbar Anular Disruption, is a spinal disease which causes severe pain. The degeneration of lumbar intervertebral disc or the external force cause the imbalance of the intervertebral disc which in turn leads to the rupture of the annulus fibrosus, resulting in the protrusion of the lumbar intervertebral disc nucleus pulposus. This protrusion causes the compression or stimulation of the nerves, blood vessels and Cauda equine etc, further leads to the inflammation in the surrounding tissue, edema, microcirculation and adhesion of fibrous tissue hyperplasia and in turn causes low back pain or even neurological barriers. This study adopts a simple, randomized, controlled study programs designed for the scientific evaluation of efficacy of EA of Jiaji and Ashi points in the treatment of Lumbar Intervertebral disc herniation. By observing the relief of pain through the treatment of EA of Jiaji and Ashi points, we can investigate a easy way to alleviate the pain that caused by this disease and to provide a theoretical basis in the treatment of Lumbar Intervertebral disc herniation by using EA of Jiaji and Ashi points.2. Research methods2.1 The source of the cases and groupingAll cases from Hong Kong University Chinese Medicine Clinical Research Centre, will be diagnosed with lumbar intervertebral disc herniation.60 patients were randomly divided into treatment group (acupuncture Jiaji and Ashi points 30) and the control group (conventional treatment group=30) in this clinical research.2.2 Therapy(1) Acupoints selection The treatment group taking Jiaji and Ashi points, Jiaji:lesion site of the vertebral body and its lower vertebrae Jiaji; Ashi point:the level of spinous process vertebral lesions adjacent to open 3 inches or less to find 2 point of deep tenderness; acupoints along meridians selection: Bladder Meridian of foot-Tai Yang, BL:Zhibian, Chengfu, Yinmen, Weizhong, Chengshan, Kunlun; Gall bladder Meridian of foot-Shao Yang, GB:Huantiao, Fengshi, Yanglingquan, Xiyangguan, Yangfu, Xuanzhong, Zulinqi. Selection with Syndrome Differentiation, cold dampness:Yaoyangguan; Blood Stasis:Shuigou; Yang deficiency of kidney:Mingmen; Ying deficiency of kidney:Sanyinjiao. Control group:regular acupoints of lowback pain and sciatica, main acupoints: Shenshu, Dachangshu, Yaoyangguan; acupoints along meridians selection and Selection with Syndrome Differentiation:the same as control group.(2) Methods of operation Operation of reatment group:75% ethanol with regular skin disinfection Jiaji and Ashi points 0.25 X 50mm stainless steel needle quickly puncture, puncture perpendicularly 40mm; Huantiao, Zhibian and Chengfu 0.25 x 75mm stainless steel needle quickly puncture, puncture perpendicularly 70mm, Yinmen 0.25x 60mm stainless steel needle quickly puncture, puncture perpendicularly 50mm, Yanglingquan, Fengshi, Weizhong and Chengshan 0.25x 50mm stainless steel needle, quickly puncture, puncture perpendicularly 40mm; Kunlun 0.25x 40mm stainless steel needle, quickly puncture, puncture perpendicularly 30mm; Zulinqi 0.25x 25mm stainless steel needle quickly puncture, puncture perpendicularly 20mm. Yaoyangguan and Mingmen 0.25x 40mm stainless steel needle quickly puncture; puncture obliquely 30mm, Shuigou 0.25x 25mm stainless steel needle quickly puncture, puncture perpendicularly 15mm. Sanyinjiao 0.25x 40mm stainless steel needle quickly puncture, puncture perpendicularly 35mm.Puncture each acupoint above with 1 needle and puncture 2 needles for Ashi points. Patient should feel locally tingling sense of expansion, this is called "De Qi". After "De Qi", remain needles for 30 minutes using KWD-8081 type instrument with continuous electricity current. Operation of control group,75% ethanol with regular skin disinfection Shenshu and Yaoyangguan 0.25x 40mm stainless steel needle quickly puncture, puncture obliquely 30mm; Dachangshu 0.25x50mm stainless steel needle quickly puncture, puncture perpendicularly 40mm, other operation remains the same as treatment group. Two groups of patients were treated every other day,3 times as a course of treatment,2 days rest between each course of treatment; Effects were recorded and analysed at the end of the 3 courses of treatments.2.3 Assessment of therapeutic effect and observed indicators Study used in the clinical evaluation system are:State Administration of Traditional enacted in 1994, "low back pain classification table effect," "simplified Mcqill Pain Questionnaire" and "Oswestry dysfunction index". Close monitoring of adverse reactions before and after treatment.3. Study Results3.1 Comparison of the Clinical curative effects of the two groups There were clinical improvements in both groups after the treatment. The curative rate in Treatment group was 90% while in Control group was 80%, indicating that the therapeutic effects in both groups were good. As for Treatment group,17 cases were cured,10 cases showed improvement, while 3 cases showed no effect, therefore, the curative rate was 90%. As for Control group,12 cases were cured,12 cases showed improvement while 6 cases showed no effect and the curative rate was 80%. The Treatment group had better curative rate than the Control group (P>0.05).3.2 Comparison of the clinical efficacy in low back pain of the two groups Before treatment, the difference between the two groups was not statistical significant as (P>0.05). However, there was a significant change after the treatment as the difference became statistical significant. T-test was undergone before and after the treatment in the groups, the result was (P<0.05), indicating that both groups had achieved good clinical effect after the treatment. The score in the Treatment group was better than that in the Control group and the difference was statistical significant (P<0.05), indicating that the Treatment group was better than the Control group.3.3 Comparison of Pain treatment of the two groups Before treatment, statistical analysis showed that the difference was not statistical significant as (P>0.05), in the indicators such as Pain Rating Index(PRI) in Feel Item Score, Emotion Item Score and Total Score, Visual Analog Rating(VAS) and Present Pain Intensity(PPI). There was a change in the indicators after treatment. The difference became statistically significant in the indicators such as Pain Rating Index(PRI) in Feel Item Score, Emotion Item Score and Total Score, Visual Analog Rating(VAS) and Present Pain Intensity(PPI), they were (P<0.05, P<0.01, P<0.001) respectively. It meant that both groups had good therapeutic effect in improving lumbar intervertebral disc herniation symptoms. They could reduce the low back pain of the patients. Also, the Treatment group had higher score than the Control group in the indicators such as Pain Rating Index(PRI) in Feel Item Score, Emotion Item Score and Total Score, Visual Analog Rating(VAS), which was (P<0.05). The PPI was not significant as (P>0.05). This result showed that the Treatment group is better than the Control group in reducing the low back pain symptoms of the lumbar intervertebral disc herniation patients.3.4 Comparison of Dysfunction effects before and after treatment of the two groupsBefore treatment, the two groups had no significant difference in the Oswestry Dysfunction Index as (P>0.05). There was obvious change after treatment as Oswestry Dysfunction Index was descended. It indicated that these two treatment methods could both improve the low back pain symptoms and the quality of life of the lumbar intervertebral disc herniation patients as (P<0.01 or P<0.05). In comparing the effect in the Treatment group and the Control group, the difference was significant as (P<0.05), indicating that the Treatment group was better than the Control in improving the low back pain symptoms and the quality of life of the lumbar intervertebral disc herniation patients.4 ConclusionsThis clinical study showed that electro acupuncture mainly in Jiaji points and Ashi points were better than other conventional acu points in treating lumbar disc herniation. Using electro acupuncture in Jiaji points and Ashi points were curative in this disease and it was highly recommended in clinical use and further investigations.更多还原