【作者】 邬黎平；

【导师】 钟世镇；

【作者基本信息】 南方医科大学 ， 临床应用解剖学， 2010， 博士

【摘要】 研究背景脊柱推拿治疗颈腰部疾患,因其疗法简单、方便、有效而深受患者的欢迎,在临床上也日益受到重视。但其解剖学、生物力学等现代医学基础研究十分薄弱,中国脊柱推拿的现代基础理论还没构建起来。虽然脊柱推拿疗法在临床上有效,甚至是速效,但其手法的实施和治疗机制缺乏令人信服的理论依据和客观证据,使得人们对其作用机制的解释显得苍白无力,给人一种科学性不强的感觉,成为阻碍其学科发展的致命缺陷。当前治疗颈椎劳损性及退变性疾患的脊柱推拿手法种类繁多,流派各异,操作不一,缺乏标准、规范和统一,在临床上时常造成一些伤害；这些伤害虽然发生率较低,但后果十分严重。同样,脊椎推拿的安全性问题也影响了它在临床中的进一步应用和推广。近年来脊柱推拿对椎间盘髓核内压力的影响成为生物力学研究脊椎推拿治疗机制的热点。有研究认为脊柱推拿手法可使椎间盘局部异常增高的压力减低或恢复正常,甚至可以解除神经根的受压。但也有研究认为旋转复位手法过程,并不能使髓核内压降低,相反会使髓核内压升高,且在手法成功时髓核内压增高。因此,此问题目前存在彼此矛盾的研究结果,没有普遍认可的观点。同时对于在施行脊柱推拿手法时患者的体位摆放问题,特别是颈椎推拿时患者颈椎的体位究竟如何?目前推拿相关文献中就出现中立位、前屈位、后伸位三种观点;而且前屈、后伸程度多大,角度多少均没有统一的标准。许多医者仅凭个人的感觉及经验来选择应用。只凭个人的临床经验体会,没有具体的科学依据,这样应用具有相当大的主观性,治疗效果受医生个人的经验、知识和习惯的影响大,缺乏客观的分析、比较及科学依据。对于在施行颈椎推拿旋转手法的扳动时间多长合适的问题。几秒?十几秒?等等,推拿相关文献中对此描述不一,莫衷一是。而临床上,手法操作的成功率以及治疗效果与手法时患者的体位,施行时间密切相关。手法作用时患者合理的位置、角度和被动运动的幅度,恰当的施行时间,可以降低手法操作阻力,提高手法的安全性和准确性。颈椎各运动节段的不同部位在颈椎推拿时其所受载荷大小,力的作用关系以及进一步导致各种损伤时的载荷大小的研究,对揭示颈椎推拿的治疗机制及安全性的界限都有非常重要的意义。但利用尸体标本进行实验受到试验病理标本来源的限制,而且手法作用时颈椎内部的应力分布和变化是传统的实验方法无法测量的。有限元分析方法的出现及应用,为我们解决此类问题提供了迫切需要的技术。但就目前为止,尚未发现国内外学者对颈椎推拿进行实质性的三维有限元分析研究。目的本研究通过生物力学方法测量颈椎在不同体位,不同旋转扳动时间的情况下模拟颈椎拔伸旋转手法对颈椎髓核内压力的变化;同时利用颈椎三维重建和有限元分析技术多学科交叉研究颈椎旋转手法,即时显示颈椎推拿手法作用时颈椎各结构的内在应力及位移。这样可以1.进一步验证、阐明颈椎推拿作用下颈椎髓核内压力的变化机制,揭示脊柱推拿的疗效机理,提高脊柱推拿的基础理论水平,用于指导临床诊断和治疗。2.选择颈椎推拿合适的推拿体位及恰当的旋转扳动时间,可以澄清临床上的一些迷惑,进而优化颈椎推拿的操作方法,指导临床提高疗效,降低推拿导致的伤害,提高安全性。3.为推拿的规范化、科学化提供理论依据,为推拿科研提供新思路；三维有限元直观的、可视化的研究还可为推拿教学提供方便。方法(1)应用MTS机在新鲜颈椎标本上模拟施行颈椎拔伸旋转手法,采用压力传感器系统,测量并记录颈椎拔伸旋转手法作用过程中颈椎C3/4、C4/5和C5/6节段椎间盘髓核内压力的变化情况。(2)测量并记录颈椎标本在5种不同的体位情况下(前屈20°、前屈10°、中立、后伸10°、后伸20°),3种不同扳动时间情况下(0.06s、0.11s、0.16s)接受颈椎拔伸旋转手法过程中的C3/4、C4/5和C5/6节段椎间盘髓核内压力的变化情况。(3)测量并记录前屈20°、前屈10°、中立、后伸10°、后伸20°5种不同的体位和0.06s、0.11s、0.16s 3种不同扳动时间的组合及交互作用对颈椎标本接受颈椎拔伸旋转手法过程中的各节段椎间盘髓核内压力的变化情况。(4)使用螺旋CT,以1mm的间隔,对1名正常男性青年的颈椎进行断层扫描,结果以Di.com格式将图像输入计算机,应用Mimics、Geomagic、MSC.Patran等软件逐步重建并网格化含有31533个节点,149226个单元的C3/4-C6/7颈椎三维有限元模型。(5)根据颈椎手法原理,将颈椎拔伸旋转手法步骤进行分解,把各项力学参数导入三维有限元模型进行加载,在MSC.Mar软件中进行颈椎旋转手法的有限元分析。即时显示颈椎旋转手法过程中颈椎模型C3-C6运动节段及各髓核部分的应力、位移情况,并对结果进行分析。结果1.模拟拔伸旋转手法过程中髓核内压的总体变化趋势成一个大“V”字型变化。模拟其颈椎标本所受头部的重力(即生理状态时)椎间盘髓核内压较模拟未开始前升高；手法拔伸动作时,椎间盘髓核内压缓慢下降,下降到一定程度后维持压力不变；颈椎手法旋转的阶段髓核内压上升,扳动时刻髓核内压快速下降；扳动结束回位时刻髓核内压又快速上升,形成一个小“V”字型变化；扳动结束回位后椎间盘髓核内压上升到一定程度后维持压力不变,但是比原来生理状态的髓内压高。颈椎手法作用时生理状态、拔伸末期、扳动时刻、手法结束后4个不同手法操作阶段颈椎椎间盘髓核内压有显著差异(F=5498.956,p<0.001)。2.不同颈椎体位条件对手法过程中颈椎椎间盘髓核内压也有显著影响(F=1371.216,p<0.001),颈椎体位从前屈20°、前屈10°、中立位、后伸10°到后伸200时,髓核内整体压力依次减少,以前屈20°体位最高,后伸20°体位最低。不同扳动时间对手法过程中颈椎椎间盘髓核内压也有显著影响(F=419.530,p<0.001),从0.06s、0.11s到0.16s,颈椎髓核内压力依次减少,0.06s时最高,0.16s时最低。不同颈椎节段对手法过程中颈椎椎间盘髓核内压有显著影响(F=84.282,p<0.001),从C3/4、C4/5到C5/6,颈椎髓核内压力依次增加。3.扳动时间*颈椎体位*颈椎节段*手法阶段4因素中,每2个因素的交互作用都对拔伸旋转手法过程中颈椎椎间盘髓核内压都有显著影响(p<0.001或p<0.01)。4.扳动时间*颈椎体位*颈椎节段*手法阶段4个因素的随机3因素的交互作用中,扳动时间*颈椎体位*颈椎节段的交互作用；扳动时间*手法阶段*颈椎节段的交互作用；颈椎体位*手法阶段*颈椎节段的交互作用对颈椎椎间盘髓内压力的有显著影响(p<0.001)；扳动时间*颈椎体位*颈椎节段*手法阶段4因素交互作用对颈椎椎间盘髓内压力的无影响(F=0.843,p=0.759)。5.在模拟上牵过程,有限元模型应力集中的区域及应力大小均出现由大逐渐减少后,再逐渐增大的变化趋势。应力集中主要在C3/4的关节突关节,C4/5及C5/6的关节突关节亦见轻度应力集中。C3/4、C4/5、C5/63个髓核的应力集中主要在C3/4髓核,且C3/4髓核内部各部分应力变化不同。对C4棘突施加推力过程中,整体模型C4棘突的左下部先出现应力集中现象；随着施加力的增加,C4棘突应力集中的范围逐渐扩展到C4棘突的后部、根部、棘突左侧根部与椎弓根结合处。逐渐向右旋转40°过程中,应力集中现象先出现在C3-C6双侧关节突关节,C3-C4棘突根部上下端,侧面观应力集中区域成斜形分布。后随着旋转角度的增大,应力集中的范围轻度增大,包括C4-C6的椎弓、棘突根部、二者结合处及椎体侧方等都出现应力集中现象。在向右旋转到400时,模型应力集中的范围达到最大值,所受的应力也达到最大值,且模型应力最大部位出现在右侧C3/4关节突关节。3个髓核的应力集中变化主要在C3/4,C4/5、C5/6髓核也有小部分变化。随着旋转角度的增加,髓核应力集中部位也随之增加及旋转,且应力数值显著增大。快速返回过程,C3-C6双侧关节突关节等模型出现应力集中的范围及所受的应力均快速减少；在返回中立位后减少到最小值。6.在模拟拉伸开始时有限元模型最大位移位于C3椎体的前端中部,且以此为中心,向四周成递减分布；向上拔伸过程中,模型由压缩变为拉伸,发生位移的区域及程度也出现由大逐渐减少后,再逐渐增大的变化趋势。C3/4、C4/5、C5/63个髓核的位移变化此时也主要集中在C3/4髓核。随着对C4棘突推力的增加,C3/4节段的左侧,C4椎体的右侧、右侧椎弓及棘突先后出现位移增加。同时C3/4髓核的发生位移的区域随着施行的合力的增大而成向右轻度旋转变化。在向右旋转过程中,旋转时模型的位移主要集中在C3/4和C4/5运动节段,但C4椎体的前部除外；3个髓核的位移主要集中在C3/4和C4/5髓核的周边部分,C5/6的上表面也有小部分变化。在向右旋转40°时发生位移的范围和程度达到最大值,最大位移出现在C3椎体上关节突和C3棘突尖部。快速返回过程,模型位移逐渐减少,返回到中立位时最少,但不为0。结论1.在脊柱推拿施行过程中颈椎髓核内压的变化规律为：成一个“V”型变化,但不是简单的升高或降低的变化。在生理状态后,拔伸末期髓核内压力下降最多,扳动时刻髓核内压力上升,但是仍低于生理状态。在手法施行结束后,髓核内压力又升高,并高于手法施行前的生理状态。2.不同的体位,扳动时间及不同颈椎节段(C3/4、C4/5、C5/6)对颈椎手法作用下的颈椎各髓核内压力有明显的影响。颈椎生理范围内前屈位时髓核内压力相对后伸位为高,从0.06s到0.16s,扳动时间越长髓核内压力越小。颈椎手法的施行过程中颈椎体位和扳动时间的交互效应对髓核内压力有显著性影响,其中后伸20°,扳动时间为0.16s时髓核内压力最低,安全性最高,有优化颈椎推拿实施过程的现实意义。3.颈椎手法作用下的颈椎有着其独特的应力及位移变化规律。关节突关节在颈椎活动中承受主要应力,具有重要作用,不可轻易损伤。颈椎手法旋转40°以内不会损伤正常颈椎骨性结构。不同颈椎节段(包括髓核)在手法作用下所发生的位移不同,即使同一髓核内部不同区域的位移也不同。发生位移区域主要集中在C3/4和C4/5运动节段。4.手法作用过程能对颈椎髓核产生的较大位移,并且出现明显的外形改变,为推拿机制中的突出椎间盘和神经根移位的观点提供了支持。主要创新点：1.采用微创压力传感器的测量方法测量并完整记录了颈椎拔伸旋转手法作用下颈椎各节段髓核内压的变化情况。2.首次研究了不同的体位,扳动时间及不同颈椎节段及其三者交互作用对颈椎拔伸旋转手法作用下颈椎各节段髓核内压力的影响。3.实质性利用颈椎三维重建和有限元分析技术研究颈椎旋转手法,即时显示正常状态下颈椎推拿手法作用时颈椎各结构的位移和内在应力的变化。更多还原

【Abstract】 BackgroundSpinal manipulation (SM) is very popular in the patients and it has been more and more attention by clinical doctors. Even it has assured efficacy, however, its basic research of modern medicine is very weak, and lack of modern basic theory. So, SM does not give a strong sense of scientific for people. Now, SM has a range of different types, different operations, and lack of standards, norms and unity. SM also can lead to same damages with low incidence and serious consequences. So, the security problem and lack of modern basic theory hinder the development and popularize of SM.In recent years, the effect of intervertebral disc nucleus pulposus pressures by SM become a hot spots of biomechanical mechanism study of SM. Some researches think SM can reduce the pressure of intervertebral disc nucleus pulposus, even can remove some nerve root compression from protruded nucleus pulposus. However, another studies support opposite conclusions. Furthermore, there is no uniform standard to the position of cervical spine when do spinal manipulation, and neutral position, extension position and flexion position were choose voluntary by doctors. So, the clinical effect can not be promise in this situation.Moreover, there is also no uniform standard to wrench time in the process of SM. A few seconds or teens seconds? Different articles have different opinions. However, it is very important for treatment effect to the position of cervical spine and wrench time in the process of SM. A reasonable approach in patients with appropriate cervical position、rotate angle、passive range of motion and operational time can reduce the operational resistance, and improve the safety and accuracy of SM.It is very significance for mechanism and security of SM to study the suffered payload size, force relations and security load size of cervical motion segment in cervical spine manipulation. And this research cannot carry out by way of human cadavers, the emergence and applications of finite element analysis can provide a technology which can solve such problems for us. As far as we known, this is no material research with three-dimensional finite element analysis about cervical SM (CSM).ObjectiveThis study monitors the change of cervical nucleus pulposus pressures by biomechanical methods simulate CSM which under the different cervical positions and different wrench time. Meantime, it can immediately display the stress and displacement of the structure of cervical spine on the process of CSM by 3-D reconstruction and finite element analysis techniques. So, it cans 1. This study not only can verify and clarify the change of cervical nucleus pulposus pressures under SM, and reveal the efficacy mechanism of SM, but also can enhance the basic theory of SM, and it can be used to guide clinical diagnosis and treatment.2. Selecting the appropriate cervical position and wrench time in SM can clarify some clinical confusion, optimizing the operation method of SM, and improve the clinical efficacy and security.3. It also can provide a theory basis to standardization and scientific of SM, and to explore new ideal of SM research. Intuitive and visual three-dimensional finite element technique could also facilitate the teaching of SM.Methods(1) We simulated the CSM with stretch and rotation by fresh cervical specimens at MTS machine. We also monitored and recorded the change of cervical nucleus pulposus pressures (CNPP) in C3/4、C4/5 and C5/6 under the process of CSM by pressure sensor system.(2) The change of CNPP which under the process of CSM at 5 different cervical spine positions with extension 20°、extension 10°、neutral position、flexion 10°、flexion 20°were monitored and recorded. Further more, The change of CNPP which under the process of CSM at 3 different wrench time with 0.06s、0.11S、0.16s were also monitored and recorded.(3) The change of CNPP which under the process of CSM at the interaction effect between 5 different cervical positions and 3 different wrench times were monitored and recorded.(4) A normal young men’s cervical spine were scanned by spiral CT with 1mm intervals, and the image have been entered into the computer by di.com format. A three-dimensional finite element model of C3/4-C6/7 which containing 31,533 nodes and 149,226 units were gradual reconstructed and grid by Mimics、Geomagic and MSC.Patran software.(5) The CSM was decomposed by principium of manipulation. The parameters of mechanics were analyzed by the finite element system. The change of intra-stress distribution and displacement were displayed in C3/4-C6/7 model simultaneously during simulating manipulation. Results1. The whole tendency of CNPP which under the process of CSM was a bigⅤtype change. The CNPP when simulate cervical suffered the gravity of head (physiological state) was higher than before start. The CNPP decreased slowly firstly, and then, it was maintained low level when simulate pulling manipulation. The CNPP were increased at rotating stage, and reduce quickly at wrenching stage, and rise fast when return the neutral position under the process of CSM, those change of CNPP formed a small V-shaped. The CNPP were keeping the same pressure after finished CSM, but, it was higher than physiological state. There were significantly different CNPP between four stages of CSM (F=5498.956, p<0.001).2. There were also significantly different CNPP between five cervical postions in the CSM (F=1371.216,p<0.001).The C3/4、C4/5、C5/6 CNPP under CSM were reduced in turn at cervical spine position from flexion 20°、flexion 10°、neutral position、extension 10°to extension 20°. More over, There were also significantly different CNPP between three wrench times in the CSM(F=419.530,p<0.001), and it were also reduced in turn at wrench time from 0.06s、0.11s to 0.16s. Further more, three cervical segments also showed in significantly different CNPP (F=84.282, p <0.001), the CNPP were rasied in turn from C3/4、C4/5 and C5/6.3. There were also significantly different CNPP between ench two factors interaction in the four factors including wrench time, cervical postions, cervical segments and CSM stages in the CSM (p<0.001 or p<0.01).4. Except the interaction of wrench time, cervical postions and CSM stages, there were also significantly different CNPP between ench three factors interaction in the four factors in the CSM (p<0.001 or p<0.01). And there was no significantly different CNPP in the interaction of four factors including wrench time, cervical postions, cervical segments and CSM stages in the CSM (F=0.843,p=0.759). 5. The size and the region of stress suffered cervical finite element model were gradual decreased, and then increasing gradually when simulates pulling manipulation. The regions of stress concentration were mainly in C3/4 Zygapophyseak joints and less in C4/5、C5/6 Zygapophyseak joints. Stress concentration was C3/4 nucleus pulposus at C3/4、C4/5、C5/6 nucleus pulposus. With the increased in thrust C4 spinous process, the left bottom of C4 spinous process、the root of C4 spinous process, and the combination area of left root of C4 spinous process and vertebral pedicle appeared stress concentration in turn.In the process of turn right rotate 40°radually, C3-C6 bilateral Zygapophyseak joints、the root of C4-C6 spinous process-、C4-C6 vertebral arch and the lateral side of C4-C6 vertebral body appeared stress concentration in turn; And the stress concentration areas form a sloping-shaped distribution in the view of lateral side; the sizes and the regions of stress in cervical model become the greatest in rotate 40°, and the greatest region occurred in right of C3/4 Zygapophyseak joints; Stress concentration were C3/4 nucleus pulposus and less in C4/5、C5/6 nucleus pulposus at the three nucleus pulposus. Stress concentration areas in nucleus pulposus also rotated follow the process. The size and the region of stress suffered cervical finite element model reduced quickly at the stage of quick return, and the stress drop to least when the model return to neutral position.5. The maximum displacement of cervical finite element model was the middle front of C3 vertebral body at the beginning of the pulling manipulation, and the displacement area were decreased gradually towards surrounding distribution as a center of the middle front of C3 vertebral body. The size and the region of displacement suffered cervical finite element model were gradual decreased, and then increasing gradually when simulates pulling manipulation, and displacement was C3/4 nucleus pulposus at C3/4、C4/5、C5/6 nucleus pulposus in this stage. With the increased in thrust C4 spinous process, the left of C3 vertebral body、the right of C4 vertebral body、C4 vertebral arch and C4 spinous process raised the displacement, and the displacement of C3/4 nucleus pulposus also rotated slightly follow the process. In the process of turn right rotate 40°radually, C3/4 and C4/5 motion segments appeared big displacement, except front of C4 vertebral body. Furthermore, the surrounding part of C3/4、C4/5 nucleus pulposus had the biggest displacement in all three nucleus pulposus model. The sizes and the regions of displacement in cervical model become the greatest in rotate 40°, and the greatest region occurred in superior articular process of C3 and spike of C3 spinous process. The size and the region of displacement suffered cervical finite element model reduced quickly at the stage of quick return, but the displacement not drop to 0 when the model return to neutral position.Conclusion1. The characteristic of changes of CNPP which under the process of CSM was a big V type change, not simply increase or decrease. The CNPP decreased and maintained at low level at simulate pulling manipulation stage. The CNPP were increased at rotating stage, and reduce quickly at wrenching stage, and rise fast when return the neutral position under the process of CSM, The CNPP were keeping the same pressure after finished CSM, However, it was higher than physiological state.2. Different cervical spine position,wrench time and cervical segments at process of CSM had a great effect to the CNPP; and the CNPP of cervical extension position at physiological area is higher than flexion; the longer time, the lower CNPP under the process of CSM from 0.06s、0.11s to 0.16s. The interaction of different cervical spine position and wrench time at process of CSM also have a good effect to the CNPP, and the CNPP was lowest at extension 20°combined 0.16s in the process of CSM, this combination have the most security in our study. 3. Cervical spine model have its unique stress and displacement change rule under the CSM. Zygapophyseak joints suffered the major stress in the cervical spine movement, and It is very important and don’t damage easily. Rotation within 40°nder CSM did not injure the normal structure of cervical spine. The different cervical segments (including nucleus pulposus) have different displacement at process of CSM, and even the different part of the same cervical segment also have different displacement. C3/4 and C4/5 motion segments appeared big displacement.4. Cervical nucleus pulposus can appear large displacement and apparent shape change in the process of CSM; this may support the view that change position between protruded nucleus pulposus and nerve roots is one mechanism of SM.更多还原