坐位旋转手法治疗退行性腰椎滑脱的椎间盘力学分析
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摘要
目的:分析坐位旋转手法作用于退行性腰椎滑脱节段时椎间盘的应力和位移分布,初步探讨手法治疗退行性腰椎滑脱症的作用机制及安全性。方法:采集退行性腰椎滑脱症患者L4-5 CT断层图片,应用Mimics 10.01软件与Abaqus 6.10软件建立退行性腰椎滑脱L4-5节段三维有限元模型。模拟向右侧进行坐位旋转手法,将手法分解后的各项力学参数代入有限元模型,利用Abaqus 6.10软件分析坐位旋转手法作用下退行性腰椎滑脱节段椎间盘的应力和位移分布。结果:椎间盘应力主要集中在纤维环,髓核的应力较小,纤维环左后侧及左后外侧的应力最为集中,前侧、右外侧及右后侧的应力较为集中;椎间盘右后侧的位移最小,位移从此区域向四周呈层状递增,椎间盘右前外侧的位移最大,左后侧的位移较大,主要为向前上方的拉伸位移。结论:坐位旋转手法作用于退行性腰椎滑脱节段时,旋转对侧的后外侧纤维环是应力分布最为集中区域,因此在手法操作中应把握好力度,切忌蛮力,以免造成医源性损伤;手法引起了旋转对侧椎间盘后侧向前上方的拉伸位移,可以改变椎间盘与神经根的位置关系,有利于松解神经根粘连;手法向两侧旋转都是可行的,而旋转向有症状的对侧可能更为合理。
Objective: To analyze the stress and displacement distribution in intervertebral disc of degenerative lumbar spondylolisthesis(DLS) segment under sitting rotation manipulation, and to explore the mechanism and safety of the manipulation in treating DLS. Methods: The L4-5 CT images of DLS patients were collected, Mimics 10.01 and Abaqus 6.10 software were used to establish three-dimensional finite element models of degenerative lumbar spondylolisthesis L4-5 segment. The sitting rotation manipulation was simulated to the right side, and all the mechanical parameters were subdivided into the finite element model, and the stress and displacement distribution of intervertebral disc in the degenerative lumbar spondylolisthesis were analyzed by Abaqus 6.10 software. Results: The stress of intervertebral disc was mainly concentrated in the annulus fibrosus,and the stress of the nucleus pulposus was small. The stress of the left posterior side and the left posterolateral side of the annulus fibrosus was the most concentrated, and the stress on the anterior, the right lateral and the right posterior side was relatively concentrated. The displacement of the right posterior side of the intervertebral disc was the smallest, and the displacement increased from this area to the surrounding layer. The displacement of the right anterior and lateral side of the intervertebral disc was the largest and the displacement of the left posterior side was relatively large, which mainly stretched toward the front upper part. Conclusion: When the sitting rotatory manipulation acted on the degenerative lumbar spondylolisthesis, the contralateral posterior lateral annulus fibrosus of rotation manipulation was the most concentrated area of stress distribution.Therefore, the strength should be grasped and brute force should be avoided to avoid iatrogenic injury in the manipulation.Manipulation induced the stretching displacement of the posterior side of the rotating contralateral intervertebral disc, which could change the location relationship between the intervertebral disc and the nerve root, and was beneficial for loosening the nerve root adhesion. It was feasible to rotate lumbar toward both sides, and it might be more reasonable to rotate lumbar toward the symptomatic opposite side.
Objective: To analyze the stress and displacement distribution in intervertebral disc of degenerative lumbar spondylolisthesis(DLS) segment under sitting rotation manipulation, and to explore the mechanism and safety of the manipulation in treating DLS. Methods: The L4-5 CT images of DLS patients were collected, Mimics 10.01 and Abaqus 6.10 software were used to establish three-dimensional finite element models of degenerative lumbar spondylolisthesis L4-5 segment. The sitting rotation manipulation was simulated to the right side, and all the mechanical parameters were subdivided into the finite element model, and the stress and displacement distribution of intervertebral disc in the degenerative lumbar spondylolisthesis were analyzed by Abaqus 6.10 software. Results: The stress of intervertebral disc was mainly concentrated in the annulus fibrosus,and the stress of the nucleus pulposus was small. The stress of the left posterior side and the left posterolateral side of the annulus fibrosus was the most concentrated, and the stress on the anterior, the right lateral and the right posterior side was relatively concentrated. The displacement of the right posterior side of the intervertebral disc was the smallest, and the displacement increased from this area to the surrounding layer. The displacement of the right anterior and lateral side of the intervertebral disc was the largest and the displacement of the left posterior side was relatively large, which mainly stretched toward the front upper part. Conclusion: When the sitting rotatory manipulation acted on the degenerative lumbar spondylolisthesis, the contralateral posterior lateral annulus fibrosus of rotation manipulation was the most concentrated area of stress distribution.Therefore, the strength should be grasped and brute force should be avoided to avoid iatrogenic injury in the manipulation.Manipulation induced the stretching displacement of the posterior side of the rotating contralateral intervertebral disc, which could change the location relationship between the intervertebral disc and the nerve root, and was beneficial for loosening the nerve root adhesion. It was feasible to rotate lumbar toward both sides, and it might be more reasonable to rotate lumbar toward the symptomatic opposite side.
引文
[1]陈忻,于杰,朱立国,等.坐位腰椎旋转手法治疗退行性腰椎滑脱症的临床观察.北京中医药,2013,32(12):889-892
[2]于杰,朱立国,高景华,等.退行性腰椎滑脱症治疗与康复方案的临床研究.中国中医骨伤科杂志,2016,24(11):11-14
[3]朱立国,于杰,高景华,等.中医正骨推拿手法治疗退行性腰椎滑脱症的临床研究.北京中医药,2006,25(10):579-582
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[6]Polikeit A,Nolte L P,Ferguson S J.The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit:Finite-element analysis.Spine,2003,28(10):991-996
[7]Hua L K,Hua W.Establishment of finite element model of lumbar motion segments and its biomec hanical significance.Chinese Journal of Clinical Rehabilitation,2005,9(14):198-199
[8]Faizan A,Sairyo K,Goel V K,et al.Biomechanical rationale of ossification of the secondary ossification center on apophyseal bony ring fracture:a biomechanical study.Clinical Biomechanics,2007,22(10):1063-1067
[9]Gu W Y,Mao X G,Foster R J,et al.The anisotropic hydraulic permeability of human lumbar anulus fibrosus:Influence of age,degeneration,direction,and water content.Spine,1999,24(23):2449-2455
[10]李义凯,徐海涛,王国林,等.颈椎定点旋转手法所致咔哒声响与最大推扳力的量效关系研究.中国康复医学杂志,2004,19(9):644-646
[11]毕胜,李义凯,赵卫东,等.腰部推拿手法生物力学和有限元比较研究.中华物理医学与康复杂志,2002,24(9):525-528
[12]徐海涛,徐达传,张美超,等.坐位旋转手法时L4-5变形和位移的研究.中国临床解剖学杂志,2008,26(3):321-324
[13]Zauel R,Yeni Y N,Bay B K,et al.Comparison of the linear finite element prediction of deformation and strain of human cancellous bone to 3D digital volume correlation measurements.Journal of Biomechanical Engineering,2006,128(1):1
[14]Fan C Y,Hsu C C,Chao C K,et al.Biomechanical comparisons of different posterior instrumentation constructs after two-level ALIF:A finite element study.Medical Engineering&Physics,2010,32(2):203-211
[15]徐海涛,张美超,李义凯,等.坐位旋转手法对正常腰椎间盘内在应力和位移的实时监测的实验研究.中国康复医学杂志,2005,20(8):563
[16]徐海涛,徐达传,李云贵,等.坐位旋转手法时退变腰椎间盘内在应力和位移的有限元分析.中国康复医学杂志,2007,22(9):769-771
[17]王国林,李义凯,张美超,等.坐位腰椎旋转手法时腰椎单元内在应力和位移的实时监测.中国骨伤,2007,20(3):173-175
[18]陈浩,徐海涛,张美超,等.坐位旋转手法对腰椎内在应力的实时监测.中国临床解剖学杂志,2005,23(4):420-422
[19]徐海涛,张美超,徐达传,等.三种前屈角度下坐位旋转手法对腰椎间盘作用的有限元分析.中国疗养医学,2008,17(2):65-67
[20]王国林,张美超,李义凯,等.三种腰椎前屈状态下坐位腰椎旋转手法比较研究.颈腰痛杂志,2008,29(1):24-26
[21]胡华,熊昌源,韩国武.旋转手法对腰椎骨盆和股骨上端结构有限元模型的分析.中国骨伤,2012,25(7):582-586
[22]郭伟,韩磊,李艺,等.腰段脊柱多体动力学模型模拟脊柱关节手法力学分析研究.中华中医药杂志,2016,31(11):4707-4710
[23]张勇,毕胜,赵卫东,等.腰椎旋转手法对髓核内压力和神经根位移的影响.颈腰痛杂志,2001,22(3):184-186
[2]于杰,朱立国,高景华,等.退行性腰椎滑脱症治疗与康复方案的临床研究.中国中医骨伤科杂志,2016,24(11):11-14
[3]朱立国,于杰,高景华,等.中医正骨推拿手法治疗退行性腰椎滑脱症的临床研究.北京中医药,2006,25(10):579-582
[4]Lee K K,Teo E C.Poroelastic analysis of lumbar spinal stability in combined compression and anterior shear.Clinical Spine Surgery,2004,17(5):429-438
[5]Sylvestre P L,Villemure I,Aubin Cé.Finite element modeling of the growth plate in a detailed spine model.Medical&Biological Engineering&Computing,2007,45(10):977-988
[6]Polikeit A,Nolte L P,Ferguson S J.The effect of cement augmentation on the load transfer in an osteoporotic functional spinal unit:Finite-element analysis.Spine,2003,28(10):991-996
[7]Hua L K,Hua W.Establishment of finite element model of lumbar motion segments and its biomec hanical significance.Chinese Journal of Clinical Rehabilitation,2005,9(14):198-199
[8]Faizan A,Sairyo K,Goel V K,et al.Biomechanical rationale of ossification of the secondary ossification center on apophyseal bony ring fracture:a biomechanical study.Clinical Biomechanics,2007,22(10):1063-1067
[9]Gu W Y,Mao X G,Foster R J,et al.The anisotropic hydraulic permeability of human lumbar anulus fibrosus:Influence of age,degeneration,direction,and water content.Spine,1999,24(23):2449-2455
[10]李义凯,徐海涛,王国林,等.颈椎定点旋转手法所致咔哒声响与最大推扳力的量效关系研究.中国康复医学杂志,2004,19(9):644-646
[11]毕胜,李义凯,赵卫东,等.腰部推拿手法生物力学和有限元比较研究.中华物理医学与康复杂志,2002,24(9):525-528
[12]徐海涛,徐达传,张美超,等.坐位旋转手法时L4-5变形和位移的研究.中国临床解剖学杂志,2008,26(3):321-324
[13]Zauel R,Yeni Y N,Bay B K,et al.Comparison of the linear finite element prediction of deformation and strain of human cancellous bone to 3D digital volume correlation measurements.Journal of Biomechanical Engineering,2006,128(1):1
[14]Fan C Y,Hsu C C,Chao C K,et al.Biomechanical comparisons of different posterior instrumentation constructs after two-level ALIF:A finite element study.Medical Engineering&Physics,2010,32(2):203-211
[15]徐海涛,张美超,李义凯,等.坐位旋转手法对正常腰椎间盘内在应力和位移的实时监测的实验研究.中国康复医学杂志,2005,20(8):563
[16]徐海涛,徐达传,李云贵,等.坐位旋转手法时退变腰椎间盘内在应力和位移的有限元分析.中国康复医学杂志,2007,22(9):769-771
[17]王国林,李义凯,张美超,等.坐位腰椎旋转手法时腰椎单元内在应力和位移的实时监测.中国骨伤,2007,20(3):173-175
[18]陈浩,徐海涛,张美超,等.坐位旋转手法对腰椎内在应力的实时监测.中国临床解剖学杂志,2005,23(4):420-422
[19]徐海涛,张美超,徐达传,等.三种前屈角度下坐位旋转手法对腰椎间盘作用的有限元分析.中国疗养医学,2008,17(2):65-67
[20]王国林,张美超,李义凯,等.三种腰椎前屈状态下坐位腰椎旋转手法比较研究.颈腰痛杂志,2008,29(1):24-26
[21]胡华,熊昌源,韩国武.旋转手法对腰椎骨盆和股骨上端结构有限元模型的分析.中国骨伤,2012,25(7):582-586
[22]郭伟,韩磊,李艺,等.腰段脊柱多体动力学模型模拟脊柱关节手法力学分析研究.中华中医药杂志,2016,31(11):4707-4710
[23]张勇,毕胜,赵卫东,等.腰椎旋转手法对髓核内压力和神经根位移的影响.颈腰痛杂志,2001,22(3):184-186