氦氖激光配合针刺治疗犬胸腰椎间盘突出症瘫痪的临床研究

【作者】 陈书琳；

【导师】 李晓泓；

【作者基本信息】 北京中医药大学 ， 针灸推拿学， 2009， 硕士

【摘要】 40多年前,与犬椎间盘相关的疾病仅占临床病例的0-1%。到1970年之后,该比例有了明显升高达到2.3%,并且在以后的10年间每年都在攀升。先天软骨发育不良品种犬的胸腰椎间盘突出症发病率为75%,平均发病年龄为3-6岁。文献报道,国外以腊肠犬的发病率最高,而国内临床上则以北京犬的发病率最高。犬胸腰椎间盘突出症多为先天软骨发育不全,造成椎问盘软骨的病变和髓核发育不全而钙化;外力不当作用下,使得纤维环破裂,突出物压迫脊髓神经根,引发背痛、后肢运动功能障碍等临床症状,为小动物临床常见的疾病之一。犬胸腰椎间盘突出症临床症状可分五级,Ⅰ、Ⅱ级为椎间盘源性背痛和后肢共济失调的运动障碍,Ⅲ-Ⅴ级为较严重的脊髓压迫症状,导致后肢瘫痪,并可能伴有便尿失禁与后肢深度痛觉消失。尤其具有脊髓受压迫严重的神经症状和深度痛觉消失的病例,多数论文支持预后不佳。常规以西医治疗,方法包括外科手术除去椎间盘突出物,与内科保守对症治疗。外科手术和给予西药激素治疗,在临床症状尚不严重初期能得到缓解;但缺点为外科手术侵入性大、费用昂贵、易并发后遗症和感染;内科西药多有副作用发生,须小心使用。中医中药方面没有足够证据支持中药内科疗法对犬胸腰椎间盘突出症有帮助。犬胸腰椎间盘突出症的病位在脊柱和腰,主要归于督脉的病变和肾虚。督脉和肾关系密切,因为在督脉的两侧为足太阳膀胱经,督脉的经脉和经别均通于足太阳膀胱经,而膀胱和肾又互为表里经。病因病机为肝脾肾精血亏虚,和督脉失养有关,加之机体感受风、寒、湿邪或跌仆挫伤,以致脉络闭阻,气血失和,不通则痛。中医针刺疗法治疗椎间盘突出症疗效显着,常用夹脊穴为主穴,同时调理督脉、膀胱经和肾经,达到通调气血,行气止痛。中医针灸治疗犬胸腰椎间盘突出症已有足够的证据表明针刺对椎间盘突出症的疗效,其作用可达到缓解疼痛、肌肉紧张;活化脊髓受损的神经,降低炎症、水肿的发生;改善血管收缩或扩张,促进组织胺和激肽释放,降低疤痕组织产生。氦氖激光穴位照射督脉穴,正是椎间盘突出的病位,可以达到温经通络,行气活血的功效。特点为无痛、不具侵入性,犬只接受治疗意愿度大;使用方便、费用低廉,对宠物主人经济效益高。配合针刺疗法能促进脊髓功能的恢复,可以调节周围神经系统,并促进代谢和血液循环、改善组织营养、消除神经根水肿,椎间盘突出症的临床症状得以缓解。犬胸腰椎间盘突出症是软骨发育不良犬常见疾病,发病率高,病残率也高,严重影响犬的生存质量,并让主人照顾困难。为了探讨提高治愈率的有效方法,以寻求最经济、最人道的治疗方式。本研究应用氦氖激光穴位照射配合针刺,治疗犬胸腰椎间盘突出症瘫痪的病例,经过一周两次、至少三周的疗程,研究方法符合标准的胸腰椎间盘突出症病犬共57例,分为激光加针刺组(29例)和单纯针刺组(28例)。并对临床症状、X光平片观察、后肢趾深度痛觉、排尿障碍、恢复自力行走能力进行了观察比较与FNS分数评估。激光加针刺组共29例,总有效率为82.76%(24/29例),无效17.24%(5/29例),与单独针刺组28例相较,有效率60.71%(17/28例),无效39.29%(11/28例)。总有效率(FNS评分:站立分数=4,行走分数≧2,后肢分数≧3)激光加针刺组疗效与单独针刺组相比,以卡方分析(p=0.064＞0.05)不具有统计意义,提示两组总体疗效没有显着性差异,都具有良好治疗作用。在3+4级轻症时,激光加针刺组有效率为87.5%,与针刺组80.0%相较,两组治疗效果没有统计学差异(P=0.672＞0.05)。但在瘫痪重症(5级)病例(DPP=0)的激光加针刺组有效率为76.92%,明显高于单独针刺组的有效率25.00%(p=0.032＜0.05),提示激光配合针刺治疗犬胸腰椎间盘突出症重症时的疗效较单独针刺好。FNS分数统计结果来看,在第5级激光加针刺组的后期疗效高于单独针刺组(Day14:p=0.003＜0.05;Day last:p=0.002＜0.05)。以上提示,氦氖激光治疗瘫痪重症时的疗效,在远期效果较好。总体FNS分数统计结果,在Day last激光加针刺组结果高于单独针刺组(p=0.026＜0.05),亦提示氦氖激光的效果反映在远期疗效。利用回归分析,结果还发现,排尿障碍、疾病分级和年龄皆为影响有效率的因素(P＜0.05)。更多还原

【Abstract】 The diseases related to the canine intervertebral disc disease(IVDD) was only 0-1%of all canine diseases 40 years’ ago;after 1970’s,the percentage of IVDD was increased to 2.3%,and was rised per year over decades.The incidence rate of thoracolumbar intervertebral disk disease(TLDD) in hypochondroplastic dogs was 75%,and the average of age was from 3～6 years old.According to the records,the breed of the highest IVDD incidence was Dachsund in abroad,and Pekingese dog was the most population of the canine IVDD in China. The underlying disc degeneration of the hypochondroplastic dogs is the precursor to the most cases of disc herniation.The annulus fibrosus fibers break down because of improper movement,and disc materials are herniated or extruded dorsally,bringing about concussion or compression to the spinal cord.TLDD may have clinical signs ranging from only those of mild back pain to nonambulatory paraplegia with loss of pain perception.Clinical signs of canine TLDD were classified to 5 grades,as follows,grade 1=no neurologic signs except pain associated with IVDD,grade 2=conscious proprioceptive deficit and ambulatory paraparesis,grade 3=nonambulatory paraparesisand deep pain perception,grade 4=nonambulatory paraplegia and deep pain perception with or without urinary dysfunction,and grade 5=nonambutatory paraplegia and no deep pain perception with or without urinary dysfunction.The cases who had seriously neurologic deficits because of compression of spinal cord with loss of deep pain perception would be expected in poor prognosis in most documents.Treatment guidelines are made primarily on the basis of the severity and duration of clinical signs.The intervertebral disc fenestration as a prophylactic measure are reserved for use in the back pain only cases,and the decompression surgery for using in dogs with hind limbs’ neurologic deficits.And the medical treatment will also help for releasing the signs in short time.The clinical signs would be released by the surgery or medical treatment only in the begining of the disease or the mild cases.The owners have to take the expensive fee of the surgery,the risks of poor prognosis because of invasive surgery and wound infection,as well as the side effects of the western medicine especially steroid. There were no documents showed the good results of traditional Chinese medicine in treating canine TLDD. The location of canine TLDD in Traditional Chinese medical theory is on the spine and lumber.The risks would be increased by the degeneration of Du channel and the weakness of kidney.The bladder channel is located near by the Du channel and spine,and the bladder and Du channel are connected closely as well as inside to outside of the body.The causes of TLDD in traditional Chinese medicine are from the weakness of liver,spleen,and kidney. Therefore,nutrition would not be enough sent to the Du channel.At the same time,the patient is suffering from windy,coldly,and wetly perverse trend,even or improper movement;the circulation of the blood and Chi near the degenerated disc would become poor,and it leads to cause back pain.The treatment of acupuncture in traditional Chinese medicine reveals great success rate in TLDD.The main points of treatment TLDD are Jiaji points near the herniated discs.Jiaji points could improve blood and Chi circulation and release pain by regulating between Du,bladder,and kidney channel.The treatments of acupuncture in canine TLDD are well documented,and it’s active function has been proved as following:releasing of pain and tension caused by muscle constraction,decreasing the risks of inflammatory and edema of nerves in spinal cord,improving the blood vessels’ constraction and dilation,and increasing histamine and endorphin releasing to decrease scar tissue formation as well.Canine TLDD is the common disease of hypochondroplastic dogs,with high incidence rate and poor outcome.The patients and owners’ life would be influenced a lots.The primary goal is to treat TLDD properly and also economically.The study reported here using the He-Ne laser combined with acupuncture to treat the gradeⅢ～ⅤTLDD dogs,twice a week,at least 3 weeks of the duration of following.We collected 57 cases who corresponded to canine TLDD,and evaluated the population characteristics,historical,clinical,diagnostic findings,hind limbs’ deep pain perception,urine control,and the ability to recover ambulatory,at the same time,also evaluated FNS scores once a week,at least 4 times.As a result,there were 29 cases in He-Ne laser combined acupuncture group and 28 cases in acupuncture group.Overall success rate(Ⅲ-Ⅴgrades),and with grade 3 and 4 dysfunction respectively,for laser combined with acupuncture group(82.76%in all;and 87.5%inⅢ&Ⅳgrade)were not significantly higher than acupuncture group(60.71%in all;and 80.0%inⅢ&Ⅳgrade).Success(able to walk without assistance) rate for dogs with grade 5 dysfunction(without deep pain perception)in laser combined with acupuncture group(10/13 dogs,76.92%) was significantly higher than that of similarly affected dogs in acupuncture group(2/8 dogs,25%),p=0.032＜0.05.The difference of FNS scores in Dogs with two groups was not significant,except only in gradeⅤDay14 & Day last,but in the whole grade(Ⅲ+Ⅳ+Ⅴ) Day last,FNS scores in the He-Ne laser combined with acupuncture group were significantly higher than acupuncture group(P＜0.05).Conclusions and clinical relevance showed that He-Ne laser combined with acupuncture treatment was effective and resulted in longer time to recover ambulation and deep pain perception than did using of acupuncture alone in dogs with signs of thoracolumbar intervertebral disk disease.We also found that urine control ability,the grades of TLDD and the age would influence the results(p＜0.05).更多还原