【作者】 张仕年；

【导师】 金宏柱；

【作者基本信息】 南京中医药大学 ， 针灸推拿学， 2010， 博士

【摘要】 目的腰椎间盘突出症是临床常见疾病,也是引起下腰痛及坐骨神经痛的最常见的病因。据相关资料统计,腰椎间盘突出症的发病率约为15%-30%,电脑、汽车、空调的日趋普及,影响了人们的工作和生活方式,可能是近年来腰椎间盘突出症发病率增高的重要因素。本课题研究在对临床相关文献加以系统分析归纳的基础上,通过疏经通督法推拿治疗腰椎间盘突出症临床研究和大鼠模型的实验研究,客观评价临床疗效和对神经根微循环影响,阐发疏经通督法推拿治疗对腰椎间盘突出症的作用机制,总结形成一套行之有效、便于推广的临床治疗规范,造福广大病患者。方法1.临床研究符合诊断标准的病例40例,随机分为2组,分别进行疏经通督法推拿及传统推拿治疗,临床观察指标为症状体征量化评分(包括腰背疼痛、臀及下肢痛和／或麻木、压痛和／或按压时放射痛、直腿抬高等)、McGill疼痛问卷评分(包括PPI感觉评分、PPI情绪评分等)以及血浆血栓素B2(TXB2)、6-酮-前列腺素F1α(6-K-PGF1α)含量、TXB2/6-K-PGF1α比值。结果(1)症状体征量化评分：治疗组与对照组比较,腰痛、直腿抬高和症状体征评分总分,治疗10天、20天后治疗组评分明显偏低,臀及下肢疼痛,治疗10天后治疗组评分明显偏低。治疗组在“止痛”效果、改善肢体功能及近期疗效方面优于对照组。(2)McGill疼痛问卷评分：PPI情绪评分、PPI总分,治疗10天后及20天后,治疗组评分明显偏低。治疗组对情绪影响有优势,有较好的“治神”效果。(3)血浆TXB2、6-K-PGF1α含量和TXB2/6-K-PGF1α比值：两组治疗后TXB2含量均明显降低,治疗组6-K-PGF1α含量治疗后较治疗前明显升高,两组log2 (TXB2/6-K-PGF1α)比值治疗后较治疗前明显降低。推拿治疗都能改善神经根微循环。2.实验研究实验研究选择SD大鼠42只,随机分入推拿治疗组、空白对照组、假手术组及模型对照组,造模成功后第10天推拿治疗组进行治疗,比较治疗7天及14天后各组血浆TXB2、6-K-PGF1α含量、TXB2/6-K-PGF1α比值、局部受压神经的超微结构。结果(1)血浆TXB2、6-K-PGF1α含量和TXB2/6-K-PGF1α比值：与7天空白组相比,假手术组、模型组及推拿组TXB2含量明显偏高；与模型组比较,7天、14天推拿组6-K-PGF1α含量明显偏高,log2 (TXB2/6-K-PGF1α)比值明显偏低。推拿治疗能改善神经根微循环。(2)局部受压神经的超微结构：推拿治疗7天及14天组,脊神经病变程度较模型组明显减轻。推拿治疗对脊神经病变有较好的修复作用。结论(1)腰椎间盘突出症其病理机制皆以肾虚血瘀、督脉、足太阳脉气机不利,气血运行不畅为主,疏经通督法推拿治疗腰椎间盘突出症以通督为主,调和经络气血,使气机条达,全身气血阴阳平衡,从而达到补肾通督、舒筋活络、祛瘀除病的目的。(2)腰椎间盘突出症的神经根微循环障碍,是产生神经根痛的作用机制之一,疏经通督法推拿对腰椎间盘突出症神经根微循环有较好的改善作用,具体作用机制与良性调节患者外周血浆TXB2、6-K-PGF1α含量及其log2 (TXB2/6-K-PGF1α)比值有关。(3)疏经通督法推拿治疗腰椎间盘突出症,具有较好的近期临床疗效,疏经通督法推拿治疗有较好“止痛”效应,改善肢体功能,同时还有较好的“治神”效果。(4)疏经通督法推拿对腰椎间盘突出症具有良好的治疗作用,是一套疗效确切、可操作性强的推拿治疗方法,便于推广更多还原

【Abstract】 Objective:Lumbar intervertebral disc protrusion (LIDP) is a common clinical disease, and is the most common etiological factor causing low back pain and sciatica. This study, based on the systematic analysis of clinical literature, aims to evaluate the clinical effect and therapeutic mechanism by Tuina model of Dredge Bladder Meridians and Du Meridian both with clinical research and the experimental study of rat model, so as to format the effective therapeutic model to LIDP which is also easy to promote and be benefit of the patients.Method:1. Clinical researchThe cases were collected during the period March 2009 to march 2010 at Jiangsu provincial TCM Hospital.40 patients suffering from LIDP were randomly divided into two groups: Treatment Group (Tuina model of Dredge Bladder Meridians and Du Meridian) and Control Group (traditional tuina model). Outcomes are evaluated by Sign Symptom Score, McGill pain questionnaire score, plasma TXB2 level, plasma 6-K-PGF1αlevel, TXB2/6-K-PGF1αratio.Results:(1)Sign and Symptom Score:The Treatment Group’s outcome of lumbar pain, straight leg raising and General Score of Symptom and Sign are distinctively lower than those of Control Group after 10 days and 20 days treatment, the Treatment Group’s outcome of buttock and the lower extremity pain are distinctively lower than those of Control Group after 10 days treatment, which indicate that Treatment Group is better than the Control Group on pain relief and short-term therapeutic effect.(2) McGill pain questionnaire score:the score of the Treatment Group is distinctively lower than those of Control Group after 10 days and 20 days treatment. It shows the Treatment Group has an advantage in pain relieving and a better effect on calm patient’s mind.(3) Plasma TXB2 level.6-K-PGF1αlevel and TXB2/6-K-PGF1αratio:the TXB2 level in both groups decreased significantly after respective treatment, the 6-K-PGF1αlevel in Treatment Group increased significantly after treatment, log2(TXB2/6-K-PGF1α) in both groups decreased significantly after respective treatment. It shows that both Tuina model can improve the microcirculation of nerve root.2. Experimental research42 SD rats were divided into Treatment Group. Blank Control Group, sham-operation(sham) group, LIDP Model Group randomly. Rats in LIDP Model received Tuina treatment after 10 days of successful model duplication. The study is evaluated from plasma TXB2,6-K-PGF1αlevel and TXB2/6-K-PGF1αratio, ultra microstructure of local nerve compression after 7 days,14 days treatment.Results:(1)Plasma TXB2 level,6-K-PGF1αlevel and TXB2/6-K-PGF1αratio:compared with blank group, the TXB2 level in Sham group, LIDP Model Group and Treatment Group increased significantly after treatment 7 days, while compared with sham group, the 6-K-PGF1αlevel in Treatment Group increased significantly, and log2 (TXB2/6-K-PGF1α) decreased significant. It shows that Tuina treatment can improve the microcirculation of nerve root.(2)Ultra microstructure of the local nerve compression:compared with the model group, the degree of spinal nerve lesion of the Treatment Group was improved significantly after 7 days and 14 days tuina treatment, which shows that Tuina has satisfactory function on repairing spinal nerve lesion.Conclusions:(1) Kidney deficiency with blood stasis, stagnation of qi and blood in Du and Bladder meridians and urinary bladder meridian are the pathogenesis of LIDP. The Tuina model of Dredge Bladder meridians and Du Meridian, which can promote the flowing of qi and blood in Du meridian, makes free flow of qi movement, balance of qi, blood, yin and yang relationship so as to achieve the goal of replenishing the kidney and dredging Du Meridian, relaxing and activating the tendons, dispelling blood stasis and cure disease.(2) The obstruction of the microcirculation of nerve root is the crucial cause of nerve root pain. Tuina Model of Dredging Bladder Meridians and Du Meridian can improve the nerve root microcirculation of LIDP which is possibly associated with the positive regulation of the plasma TXB2 level,6-K-PGF1αlevel, and log2(TXB2/6-K-PGF1α).(3) Tuina Model of Dredging Bladder Meridians and Du Meridian has comparable good short-term therapeutic effect on treating LIDP on pain relieving besides its calming patient’s mind effect.(4) Tuina Model of Dredging Bladder Meridians and Du Meridian has good therapeutic effect on LIDP, is a Tuina model possesses confirmed effects, operability and easily promotion.更多还原