【作者】 田明波；

【导师】 汪青春；

【作者基本信息】 第一军医大学 ， 中西医结合骨伤， 2007， 硕士

【摘要】 【目的】1．通过对慢性腰痛（CLBP，Chronic low back pain）患者腰椎骨性结构参数的测量和比较，分析参数变化和CLBP的相关关系，探讨不同参数的实际临床参考价值。2．比较不同年龄之间骨性结构的差异以及探讨X线检查在临床诊断CLBP中的实际临床意义。3．低位腰椎间盘突出（LLDH，Lower lumbar intervertebral disc herniation）患者腰椎骨性结构参数的变化及其临床意义。4．腰椎间盘突出（LDH，Lumbar intervertebral disc herniation）术后患者腹肌功能锻炼的意义。【材料和方法】1．病例资料的收集1．1病例来源123例CLBP以及82例腰椎间盘突出患者来源于南方医院中医正骨科和南方医院脊柱骨科。28例非慢性下腰痛者来自于南方医院体检中心。46例腰椎间盘突出术后患者来自于武警河南总队外二科。1．2纳入标准1．符合CLBP纳入标准者。即指从下腰部、臀部到下肢的各种持续或间歇性疼痛，病程在三个月以上。2．LDH患者纳入标准：临床体检有椎间盘突出表现，CT扫描证实髓核突出者。3．LDH术后患者纳入标准：年龄大于20岁，小于65岁，手术方式为后路开窗髓核摘除术，能够配合随访者。1．3排除标准1．腰部骨折、脱位脊柱结核、肿瘤和感染性炎症病变以及其它内科疾病引起的腰背痛者。2．非L_4，5和L₅S₁节段椎间盘突出者。2．参数及其测量方法2．1扫描设备及扫描条件X线检查机型岛津XED150L-20型500 mA X线机，CT扫描机为美国GE8800全身CT。腰椎侧位投照方法：受检者去鞋直立于机器旁，右侧位摄片，目视前方，双上肢平举握前方横杆，双膝、双足并拢，身体放松。拍片时球管中心对准第3腰椎，球管胶片距90 cm。CT按常规扫描条件扫描。图像处理软件使用JW-PACS图像存储与传输系统（JW picture archivingand communication system，JW-PACS）2．2参数测量1)骶骨倾斜角（Ferguson’s法）即S₁上缘切线延长线与水平线的夹角，见附图7；2)腰骶椎间盘角即L₅椎体下缘切线延长线和S₁上缘切线延长线的夹角，见附图8；3)腰椎曲度（Seze’s法）即将T₁₂椎体到S₁椎体后缘弧形连线和T₁₂椎体后下缘和S₁后上缘连线形成一弧，测量该弓顶到弦的距离即为腰椎曲度，见附图9；4)腰椎曲度角（Cobb’s法）即T₁₂椎体下缘切线延长线和S₁上缘切线延长线的夹角，见附图10；5)腰骶前弓角即L₃、L₅和S₁椎体对角线交点连线夹角，见附图11；6)腰骶夹角延L₅椎体前缘和S₁椎体前缘做切线相交之钝角，见附图12；7) L₅椎体指数即L₅椎体后缘高径和前缘高径的比值；8) L₅S₁椎间盘高度即椎体环形阴影前后端内缘（即椎体-皮质的内缘）为定点，上下椎体两定点间的距离；9)腰骶关节角（Gronkopff法）即在腰椎侧位片上L₅椎体上下缘的中央连线和S₁椎体上下缘的中央连线相交所成的角，见附图13；10)腰骶关节突关节角，即测量左右关节突关节角之和的平均数，见附图14。2．3在82例LLDH患者的X线正侧位片及CT片上，测量腰椎曲度、骶骨倾斜角、L₅S₁椎间盘高度、L₅椎体高度和腰骶关节突关节角。对46例LDH术后患者术后疗效评定按照Macnab方法，腰椎前屈功能评定采用距离法，即测量受试者并腿直立位脊柱前屈时中指指尖到地面的距离。2．4误差控制各参数由两人独立测量，取其测量者之平均值。测量前对两名测量者进行测量软件使用和测量标准培训。3．病例分组3．1根据123例患者情况分为一般腰背痛组和椎间盘突出组和正常对照组；根据年龄不同分为30岁以下组、31-40岁组、41-50岁组、51-60岁组和大于60岁组。同时根据性别差异分为男女组。3．2 82例LLDH患者和分为L_4、5突出组，L₅S₁突出组L₅S₁膨出组。3．3 46例LDH术后患者随机分为加强腹肌锻炼组和常规对照组。4．统计方法多组均数之间比较用单方向方差分析（One-way ANOVA）LSD法检验；两组均数之间使用独立样本的t检验。可信区间取95％，即P＜0.05有统计学意义。【结果】1．骶骨倾斜角、腰椎曲度、腰椎曲度角以及L₅S₁椎间盘高度各年龄组之间无显著性差异；51-60岁组腰骶关节角和≤30岁组相比有显著性差异（P=0.029＜0.05）；腰骶夹角除41-50岁组外均有显著性差异，31-40岁组和≤30岁组比较P=0.005＜0.01，51-60岁组和≤30组比P=0.039＜0.05，＞60岁组和≤30岁组比P=0.008＜0.01；腰骶前弓角除51-60岁组外其它各组和≤30岁组比较均有显著性差异，31-40岁组和≤30岁组比P=0.036＜0.05，41-50岁组和≤30岁组比P=0.005＜0.01，＞60组和≤30岁组比P=0.028＜0.05，此外41-50组和51-60岁组间相比差异也具有显著性P=0.018＜0.05；L5椎体指数＞60组和≤30岁组比P=0.016＜0.05，和31-40岁组比P=0.021＜0.05，和51-60岁组比P=0.014＜0.05；腰骶椎间盘角51-60岁组和≤30岁组比也有显著性差异P=0.029＜0.05；从性别来看，男女组仅在腰骶关节角和腰骶夹角上有显著性差异（P=0.007＜0.01，P=0.004＜0.01）。从病因来看，有间盘突出组和无间盘突出组在腰骶椎间盘角和L₅ S₁椎间盘高度上有显著性差异（P=0.049＜0.05，P=0.007＜0.01）。CLBP和非CLBP组之间相比，在腰骶关节角（P=0.000＜0.01），骶骨倾斜角（P=0.000＜0.01），腰骶前弓角（P=0.022＜0.05），腰椎曲度（P=0.000＜0.01），腰椎曲度角（P=0.010＜0.05），L₅椎体指数（P=0.000＜0.01）上都有显著性差异。2．低位腰椎间盘突出结构参数测量结果表明：L_4，5突出组、L₅ S₁突出组、L₅ S₁膨出组和正常对照组相之间腰骶角相比有显著性差异（P＜0.01，P＜0.05）；L₅S₁椎间盘高度方面L_4，5突出组、L₅S₁突出组、L₅S₁膨出组和正常对照组相比也有显著性差异（P＜0.01），L₅S₁突出组、L₅S₁膨出组和L_4，5突出组相比有显著性差异（P＜0.01，P＜0.05），L₅S₁突出组和L_4，5突出组L₅椎体高度相比有显著性差异（P＜0.05）；腰椎曲度方面，L_4，5突出组、L₅S₁突出组、L₅S₁膨出组和正常对照组相之间相比有显著性差异（P＜0.01）；L₅S₁膨出组和L₅S₁突出组之间相比也有显著性差异（P＜0.05）；各组关节突关节角之间无显著性差异；L₅S₁突出组和L_4，5突出组、正常对照组相比盘椎比之间有显著性差异（P＜0.01），L5S1膨出组和L_4，5突出组相比也有显著性差异（P＜0.05）。3．加强腹肌锻炼组和正常对照组在疗效上无显著性差异，但在腰椎屈曲功能上有显著性差异。【结论】1．CLBP患者不同年龄组之间腰椎骨性结构参数以腰骶夹角和腰骶前弓角的变化较为显著，和正常对照组比较除了腰骶夹角、腰骶椎间盘角和L₅S₁椎间盘高度外，其差异均有显著性。2．CLBP患者不同性别腰椎骨性结构参数以腰骶关节角和腰骶夹角变化最为显著，单纯CLBP和LDH之间则以腰椎间盘角和L₅S₁椎间盘高度差异有显著性。3．低位腰椎间盘突出最明显的骨性结构变化是腰骶角、腰椎曲度和椎间隙的变小。L₅S₁突出比L_4，5突出更易出现上述结构的变化。4．腹肌锻炼有利于较早建立腰椎的新平衡，改善腰椎的屈曲功能。更多还原

【Abstract】 Objectives: To measure and compare texture parameters of lumbar vertebra inChronic low back pain（CLBP） and to analyze dependability between changes oftexture parameters of lumbar vertebra and CLBP, to approach practical clinical valuein different parameters of lumbar vertebra. To compare difference of textureparameters of lumbar vertebra in different ages and approach practical clinical valuein diagnosis of CLBP and Lower lumbar intervertebral disc herniation（LLDH） byX-ray. To approach practical clinical value of functional exercise of abdominalmuscle in lumbar intervertebral disc herniation（LDH）.Materials and Methodsdata and case 123 patients of CLBP and 82 patients of LDH come from traditionalChinese medicine orthopedics and vertebra orthopedics of Nanfang hospital. 28Non-CLBP cases come from medical examination center of Nanfang hospital. 46LDH cases come from HeNan hospital of Chinese army police force.Internalize standard To accord with standard of CLBP. Unremitting andintermittent pain from low back, haunch to extremitas inferior, it last more than threemonths. The LDH means there are appearance of intervertebral disk hernia throughclinical medical examination and to confirmed by CT scan. The post-treatment casesof LDH to bring into clinical trial must exceed twenty years old and less than sixtyyears old. In addition the modus operandi should be ex of nucleus gelatinosus fromback windowing and the person should go with us to follow up.Exclusion standard The CLBP from fracture of lumbar vertebra, dearticulation; spinal tuberculosis、tumor、infective inflammation and other internal medicial disease.Lumbar intervertebral disc herniation except L_4.5 and L₅S₁ intervertebral discherniation.Parameters and measures 1. Measuring some parameters of lumbar vertebra onX-ray lateral projection as follow: angle of tilted sacrum（or lumbosaeral angle）;lumbar vertebrae curvature（measured by Seze’s method）; angle of lumbar vertebrae;anterior arch angle of juncturae lumbosacralis; included angle of juncturaelumbosacralis; exponent of L₅ vertebral body; height of L₅S₁’s discusintervertebralis; angle of juncturae lumbosacralis and angle of lumbosacral disc.2. Measuring angle of tilted sacrum（or lumbosacral angle）; lumbar vertebraecurvature（measured by Seze’s method）; angle of lumbar vertebrae curvature; heightof L₅ vertebral body; height of L₅S₁’s discus intervertebralis; angle of lumbarvertebrae articulationes zygapophysiales on X-ray lateral projection and CT film.3. The curative effect evaluation about 46 post-treatment cases of LDH according toMacnab method. Anteflexed functional evaluation of lumbar vertebrae according todistance which from middle finger tip to floor when the case stand up and bend hislumbar vertebrae.Cases and Grouping 1. According to information of 123 CLBP cases, dividatur itinto CLBP group、LDH group and normal control group; According to ages, divid itinto≤30 group、31-40 group、41-50 group、51-60 group and＞60group; Accordingto sex differences,divide it into male group and female group.2. 82 patients of were divided into L4,5 hernia group, L₅S₁ hernia group and L₅S₁bulge group.3. 46 patients of LDH were randomly divided into exercising abdominal musclegroup and normal control group.Statistical methods Compared with multitude means on LSD of One-wayANOVA, and Compared with two means on t test of independent sampler.Confidence interval was 95％, P＜0.05 had significant difference.Results: 1. There was not significant difference in angle of tilted sacrum、lumbar vertebrae curvatur、angle of lumbar vertebrae curvature and height of L₅S₁’s discusintervertebralis on each ages. There was significant difference in included angle ofjuncturae lumbosacralis between 51-60 age group and≤30 age group（P=0.029＜0.05）.There was significant difference in each group except 41-50 age group on includedangle of juncturae lumbosacralis, 31-40 age group compares with≤30 age group:P=0.005＜0.01, 51-60 group compare with≤30 age group: P=0.039＜0.05,＞60 agegroup compares with≤30 age group: P=0.008＜0.01; There was significant differencein≤30 age group comparing with other groups except 51-60 age group on anteriorarch angle of juncturae lumbosacralis. （31-40 age group vs≤30 age group:P=0.036＜0.05; 41-50 age group vs≤30 age group: P=0.005＜0.01;＞60 age group vs30 age group: P=0.028＜0.05）There was significant difference in anterior arch angleof juncturae lumbosacralis between 51-60 age group and 41-50 age group（P=0.018＜0.05）. In exponent of L5 vertebral body,＞60 age group vs≤30 agegroup:P=0.016＜0.05;＞60 age group vs 31-40 age group: P=0.021＜0.05;＞60 agegroup vs 51-60 age group: P=0.014＜0.05; There was significant difference in angle oflumbosacral disc between≤30 age group and 51-60 age group（P=0.029＜0.05）. Thereonly was significant difference in included angle of juncturae lumbosacralis and angleof juncturae lumbosacralis between male group and female group（P=0.007＜0.01,P=0.004＜0.01）. There was significant difference in angle of lumbosacral disc andheight of L₅S₁’s discus intervertebralis between lumbar intervertebral disc herniationgroup and CLBP group.（P=0.049＜0.05, P=0.007＜0.01）. In addition, the significantdifference in angle ofjuncturae lumbosacralis （P=0.000＜0.01）、anterior arch angleof juncturae lumbosacralis （P=0.022＜0.05）、angle of tilted sacrum （P=0.000＜0.01）,lumbar vertebrae curvature （P=0.000＜0.01）、angle of lumbar vertebrae curvature（P=0.010＜0.05） and exponent of L5 vertebral body（P=0.000＜0.01）between CLBPgroup and non-CLBP group.2. The texture parameters of LLDH indicates the significant difference in lumbosacralangle lumbar vertebrae curvature and height of L₅S₁ intervertebral disc comparingcontrol group with L₅S₁ intervertebral disc herniation group、L₅S₁ bulge group、 L_4,5intervertebral disc herniation group. The significant difference in height of L₅S₁intervertebral disc among L₅S₁ intervertebral disc herniation group、L₅S₁ bulgegroup、L_4,5 intervertebral disc herniation group. There was significant in height of L₅vertebral body between L₅S₁ intervertebral disc herniation group and L_4,5intervertebral disc herniation group. There was significant difference in lumbarvertebrae curvature between L₅S₁ intervertebral disc herniation group and L₅S₁ bulgegroup. The same consequence in ratio of disc and vertebra among L₅S₁ intervertebraldisc herniation group、L_4,5 intervertebral disc herniation group and control group.L₅S₁ bulge group compared with L_4,5 intervertebral disc herniation group （P＜0.05）.There was not significant difference in facet joint at L₅S₁ level among four groups3. It also had significant difference in lumbar vertebrae Flexed function betweenabdominal muscle functional exercise grouop and common functional exercise group.Conclusion: 1. Lumbosacral angle and anterior arch angle of lumbosacral differentages of CLBP patients had significant difference, compared with the normalgroup,except the lumbosacral angle, lumbosacral disc angle and height of L₅S₁ disc,the others were significant differences.2. In different sex lumbar vertebra bone structure datas of CLBP patients, lumbosacralarticulation and lumbosacral angle were significant differences.3. Low lumbar intervertebral disk hernia had significant changes in lumbosacral angle,lumbar vertebra curvature and intervertebral space, and L₅S₁ was easier than L_4,5 inthese structure changes.4. Exercising abdominal muscles can not only establish a new banlance of lumbarvertebra,but improve the inflexion function.更多还原