【作者】 冯宇；

【导师】 冯天有；

【作者基本信息】 中国人民解放军军医进修学院 ， 中西医结合临床， 2012， 博士

【摘要】 [目的]建立COX模型验证并量化冯天有提出的腰椎间盘突出症患者腰型与治愈时间的相关性；利用磁共振脊髓成像术(MRM)为评价脊柱定点旋转复位法巨大腰椎间盘突出症疗效提供影像依据；利用表面肌电图证实矫形鞋平衡腰肌稳定脊柱的作用，前瞻性研究证实矫形鞋可以缩短治愈腰椎间盘突出症治愈时间。[方法]本课题选取了258例腰椎间盘突出症患者，观察并记录发病年龄、性别、工作性质、患病时间、疼痛部位（是否伴有腰痛，是否伴有下肢痛）；疼痛程度，有无间歇性跛行，直腿抬高高度；髓核突出阶段、部位、大小，有无钙化、有无椎管狭窄；体态变化（是否伴有骨盆旋转）以及临床治愈时间。建立脊柱定点旋转复位法治愈腰椎间盘突出症及所需时间的相关因素的COX模型。并进一步对其中39例巨大腰椎间盘突出症的患者手法治疗前后记录直腿抬高角度、视觉疼痛量表（visual analogue，VAL），日本骨科学会腰背痛评分（JOA），MRI突出髓核矢状径指数（SI）、MRM图像上神经根鞘袖和硬膜囊的夹角、神经根鞘袖直径大小、硬膜囊终末段充盈恢复情况。另外，选取骨盆向一侧倾斜的腰椎间盘突出症患者44例，手法治疗前后均进行sEMG测试左右两侧腰段竖脊肌表面肌电图时域平均肌电波幅（average EMG,AEMG）和频谱面积（spectrum area, SPA）,观察穿矫形鞋对左右两侧竖脊肌的影响，根据腰椎间盘突出症治愈标准比较实验组和对照组两组患者的临床治愈时间。[结果]COX模型结果显示：伴有骨盆旋转倾斜的患者治疗时间显著长于无骨盆旋转倾斜的患者。疼痛程度越严重，治愈所需时间越长。巨大突出等有关突出髓核的描述指标对治愈时间无显著影响。而对巨大腰椎间盘突出症的患者进行的手法治疗前后各项临床及影像学指标统计结果提示，部分巨大腰椎间盘突出并没有造成硬膜囊、神经根袖受压。尽管脊柱定点旋转复位法不能使髓核明显改变或还纳，但可以减小突出髓核对硬膜囊的压力。穿矫形鞋可以明显改善腰椎间盘突出症患者站立及患者行走时双侧竖脊肌不对称收缩，证明了矫形鞋可以缩短手法治疗腰椎间盘突出症治愈时间的机制。[结论]综上所述，本课题国内外首次使用COX模型分析影响手法临床治愈腰椎间盘突出症及所需时间的相关因素，MRM观察脊柱定点旋转复位法治疗巨大腰椎间盘突出症前后影像变化。1、脊柱定点旋转复位法疗腰椎间盘突出症可从整体躯干望诊角度观察腰型变化四步规律，依此判断病情病程长短及预后等。符合现代社会腰椎间盘突出症患者对手法治疗不断提高的要求，cox数学模型验证了此临床经验，并为医师及患者选择手法治疗，判断预后及治疗时间提供量化依据。2、脊柱定点旋转复位法配合矫形鞋治疗腰椎间盘突出症取得良好效果，相较其它疗法具有适应征广,痛苦小、费用低，有效率高，治疗时间短的优点。MRM不仅证实了脊柱定点旋转复位法可以减小或消除巨大突出髓核对硬膜囊、神经根鞘袖的压力，患者椎管本身对巨大突出髓核也具有可容性，还使脊柱定点旋转复位法疗效的评判更为直观、客观。更多还原

【Abstract】 [Objective] To establish COX model validation and quantify Feng’s SpinalManipulation prolapse of lumbar intervertebral disc type and cure patients waistthe correlation of time; Using magnetic resonance imaging technique (MRM)spinal cord for fixed point rotation method of evaluation reset spine huge prolapseof lumbar intervertebral disc curative effect provides image basis; Using electricchart table semg confirmed orthopaedic spinal stability shoes balance lumbarmuscle function, prospective studies confirmed orthopaedic shoes can shorten cureprolapse of lumbar intervertebral disc cure time.[Method] In this study258cases of lumbar intervertebral disc herniation patientswere selected to observe and record the age, sex, in the nature of work and sicktime, pain parts (whether waist pain, whether with lower limbs with painful); pain,and presence of intermittent claudication, straight legs raise height; pulp nuclearprominent stage, location, size, and presence of calcification in stenosis, whetheror not; posture change (if accompanied by pelvic rotation) and clinical cure time.Set up the spine fixed point rotation reduction method to cure prolapse of lumbarintervertebral disc and the time required for the related factors of the COX model.And further the39cases huge prolapse of lumbar intervertebral disc of the patientsbefore and after treatment technique record straight legs raise Angle, visual painscale (visual analogue, VAL), Japanese orthopaedic learn to low back pain score(JOA), MRI outstanding nucleus pulposus sagittal diameter index (SI), MRMimage nerve root scabbard sleeve and dural Angle, nerve root scabbard sleeve thediameter size, dural terminal filled with the recovery period. In addition, theselection of pelvic sideways prolapse of lumbar intervertebral disc44cases ofpatients, the tactics were performed before and after treatment sEMG test on a leftand waist segment shaft spinal muscular table electric chart sEMG time domainaverage muscle power amplitude (average EMG, AEMG) and spectrum area(spectrum area, SPA), observation wear shoes left or right side of verticalorthopaedic spinal muscular effects, according to prolapse of lumbar intervertebraldisc cure is the standard and control group in two groups of patients with clinicalcure time.[Result] The COX model results show that: the pelvis rotation with tilt of thepatients had a significantly longer time without the pelvis rotation tilt of thepatients. The more serious pain, the longer the time needed for cure. Greatoutstanding and other relevant highlight the description of the nucleus pulposus index for a cure has no significant effect on time. And for huge prolapse of lumbarintervertebral disc of patients before and after treatment technique of the clinicaland radiographic index statistic suggests, part of the huge lumbar intervertebraldisc and caused no dural, nerve root sleeve under pressure. Although the spinefixed point rotation reduction method can’t make pulp nuclear obvious change orHaiNa, but can reduce the outstanding pulp check dural pressure. Wear shoesorthopaedic obviously improve lumbar intervertebral disc herniation stand andwalk patients with bilateral vertical asymmetric spinal muscular contraction, andprove the orthopaedic shoes can shorten the treatment technique of intervertebraldisc cure time mechanism.[Conclusion]To sum up, the subject for the first time at home and abroad to useCOX model technique analysis on clinical cure prolapse of lumbar intervertebraldisc and the required time related factors, MRM observation fixed point rotationof the spine to treat enormous reduction of intervertebral disc images changesbefore and after.1、Feng’s spinal manipulation of lumbar intervertebral disc herniation can from thewhole trunk inspection perspective waist step four type change rule, in accordancewith the judgment of illness and prognosis length. Meet modern social prolapse oflumbar intervertebral disc patients to improve treatment requirements of technique,cox mathematical models are verified clinical experience, and for physicians andpatients to choose gimmick treatment, prognosis and treatment time providequantitative basis.2、 Feng’s spinal manipulation with orthopaedic shoes treatment lumbarintervertebral disc herniation has achieved good effect, compared with othertreatments to levy wide, the pain is small, low cost, high efficiency, short cure timeadvantages. MRM not only confirmed fixed point rotation method can reset thespine to decrease or eliminate great outstanding pulp check dural, nerve rootscabbard sleeve pressure, patients to great outstanding spinal canal itself also has anucleus pulposus tolerance, still make spine fixed point rotation reset the curativeeffect of evaluation method more intuitive and objective.更多还原