椎间孔镜联合针刀治疗对腰椎间盘突出症患者步行稳定性的影响及部分机制探讨

The effects and partial mechanism of percutaneous transforaminal endoscopic discectomy combined with acupotomy on the walk stability for the patients with lumbar disc herniation

摘要:

目的：探讨椎间孔镜联合针刀治疗对腰椎间盘突出症（Lumbar disc herniation，LDH）患者步行稳定性的影响及相关机制初步研究。方法：纳入2020年9月至2021年9月期间就诊于解放军总医院第六医学中心中医医学部骨伤科、康复医学科、针灸科的104名LDH患者，通过计算机随机分为研究组（n=52）和对照组（n=52）；其中研究组脱落3例，对照组脱落4例。研究组接受腰椎经皮穿刺椎间孔镜（Percutaneous transforaminal endoscopic discectomy, PTED）手术治疗，在突出间盘处理完成后给予针刀治疗，术后48小时开始进行两周的腰椎康复。对照组接受基本相同操作的PTED手术治疗，但不给予针刀治疗，术后48h同样开始进行两周的腰椎康复。在术前基线和术后6个月利用步态分析系统对患者的步行稳定性指标——步行绝对对称指数（Absolute symmetry index, ASI）进行评估，同时收集MRI显影下椎旁MM的脂肪浸润横断面（Cross-Sectional Area, CSA）以及两组患者的JOA评分。结果：术前，两组患者的JOA评分无明显差异，均p＞0.05。术后6个月，两组患者的JOA评分均显著改善，均p＜0.01，同时，研究组JOA总分及其中的主观症状、ADL受限度均显著优于对照组，均p＜0.05。治疗前后，研究组患者的步速、步幅、髋屈曲均值角度、膝屈曲均值角度的ASI均显著降低，均p＜0.01；对照组患者的步幅、髋屈曲均值角度的ASI没有显著变化；在L4/5和L3至S1的总节段，研究组的MM脂肪浸润CSA明显减少，均p＜0.01。结论：PTED联合针刀治疗能够积极影响LDH患者的整体活动能力和步行稳定性，其机制可能是通过改善LDH患者特定节段的椎旁肌结构实现的。

Abstract:

Objective: To focus on the effects of percutaneous transforaminal endoscopic discectomy (PTED) combined with acupotomy on the walk stability for the patients with lumbar disc herniation and the structural changes of multifidus muscle (MM). Method: From September 2020 to September 2021, 104 patients with lumbar disc herniation (LDH) in the department of Orthopedics, Rehabilitation Medicine and Acupuncture of Traditional Chinese Medicine Unit of The Six Medical Center of Chinese PLA General Hospital were included in the study and were randomly divided into 2 groups to receive either PTED combined with acupotomy and exercise rehabilitation (study group, n=52, 3 fell off) or PTED combined with exercise rehabilitation (control group, n=52, 4 fell off). Walk stability indexs (absolute symmetry index, ASI), Japanese Orthopedic Association (JOA) scores and Cross-sectional Area (CSA) of fatty infiltration in MM under MRI imaging and were recorded 6 months after surgery and before surgery. Result: Before surgery, there were no significant difference in JOA between the two groups, p > 0.05. 6 months after surgery, JOA scores in both groups were significantly improved, p < 0.01, and JOA scores in the study group were significantly lower than those in the control group, p < 0.01; Meanwhile, the scores of JOA, subjective symptoms and ADL limit in JOA of the study group were significantly better than those in the control group, p < 0.05. Before and after treatment, the ASI of the step speed, stride length, mean angle of hip flexion and knee flexion in the study group were significantly decreased, p < 0.05, and there were no significant difference in ASI of stride length and mean angle of hip flexion in the control group; At L4-5 and L3-S1, CSA of fat infiltration in MM in the study group was significantly decreased, p < 0.01. Conclusion: For patients with LDH, the walking stability and overall mobility can be improved by PTED combined with acupotomy, which may be achieved by improving the paravertebral muscle structure of specific segments.