不同方法射频消融切断脊神经背内侧支后腰椎功能变化的研究
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摘要
目的评价腰椎脊神经背内侧支切断术后腰椎肌力及活动度功能的变化。方法筛选符合小关节源性腰痛诊断标准的患者40例,按照电脑随机数发生器随机分为经皮组(20例)和内镜组(20例)。经皮组行X线辅助下经皮穿刺脊神经背内侧支射频消融术,内镜组行内镜辅助下脊神经背内侧支切断术,记录两组术前及术后6个月时的腰椎前屈、后伸、左右侧屈和左右旋共6个方向的最大等长收缩肌力和活动度,进行组内对照及组间对照对比分析。结果组内对照:两组术后腰椎肌力、前屈活动度与术前相比差异无统计学意义(P>0.05),内镜组术后腰椎后伸活动度为(21.21±0.13)°、左侧屈活动度为(31.95±1.03)°、右侧屈活动度为(34.53±1.12)°、左旋活动度为(45.95±1.19)°、右旋活动度为(45.95±1.19)°均大于术前[活动度依次为(15.05±1.58)°,(24.02±0.92)°,(22.02±1.95)°,(32.72±0.92)°,(34.02±0.31)°],经皮组术后腰椎后伸活动度为(25.25±1.41)°、左侧屈活动度为(32.01±1.01)°、右侧屈活动度为(35.01±2.21)°、左旋活动度为(38.01±1.64)°、右旋活动度(40.01±0.67)°均大于术前[活动度依次为(14.99±2.27)°,(26.38±2.10)°,(23.21±1.30)°,(33.03±1.06)°,(35.31±0.14)°],差异有统计学意义(P<0.05);组间对照:术前腰椎前屈、后伸、左右侧屈、左右旋6个方向肌力及活动度两组间差异无统计学意义(P>0.05),内镜组术后腰椎左右旋活动度[分别为(45.95±1.19)°和(47.37±1.21)°]大于经皮组[分别为(38.01±1.64)°,(40.01±0.67)°]差异有统计学意义(P<0.05),腰椎前屈、后伸、左右侧屈、左右旋6个方向肌力及前屈、后伸、左右侧屈活动度两组间差异无统计学意义(P>0.05)。结论脊神经背内侧支切断并未对腰椎前屈后伸、左右侧旋和左右旋的肌力带来不良影响;脊神经背内侧支切断后,腰椎的腰椎后伸、左右侧屈、左右旋活动度得到了提升;内镜下脊神经背内侧支切断较经皮穿刺射频能获得更为明显的左右旋活动度的提升。
Objective To evaluate the lumbar muscle strength and motive range change after lumbar medial branch neurotomy for facetogenic chronic low back pain. Methods Forty facetogenic chronic low back pain patients were included and randomly assigned to receive percutaneous radiofrequency neurotomy( RN group, 20 cases) or endoscopic neurotomy( EN group, 20 cases) of lumbar medial branch. Endoscopic lumbar medial branch neurotomy was performed for the second group. The following measurements were recorded before operation and at 6 months after operation. The maximum isometric contraction strength and motion range of the lumbar were recorded while the lumbar moved in 6 different directions: anteflexion, rear protraction, left and right lateral flexion, and clock-wise and counter-clock-wise rotation. The results of the 2 groups were compared. Results There were no significant differences of lumbar muscle strength in both groups pre-and post-operatively( P > 0.05). There were no significant differences of anteflexion range in both groups pre-and post-operatively( P > 0.05). Motive ranges in rear protraction( 21.21 ± 0.13) °, left( 31.95 ± 1.03) ° and right lateral flexion( 34.53 ± 1.12) °, and clock-wise( 45.95 ± 1.19) ° and counterclock-wise( 45.95 ± 1.19) ° rotation were significantly greater than those of pre-operation [( 15.05 ± 1.58) °,( 24.02 ± 0.92) °,( 22.02 ± 1.95) °,( 34.02 ± 0.31) °,( 32.72 ± 0.92) ° ] in both groups( P < 0.05). There were no significant differences of lumbar muscle strength between the 2 groups pre-and 6 months after operation( P > 0.05). However, the clock-wise and counter-clock-wise motive rotations of the EN group [( 47.37 ± 1.21) °,( 45.95 ± 1.19) ° ] were significantly larger than those of the RN group [( 40.01 ± 0.67) °,( 38.01 ± 1.64) ° ]( P < 0.05). ConclusionsNeurotomy does not result in negative effects on the motion range and muscle strength of the lumbar. In addition, it is found that the range of motion increases after the neurotomy, and endoscopic neurotomy can achieve better improvement of the left-right rotation range than those of the radiofrequency neurotomy. Therefore, lumbar medial branch neurotomy is an safe and useful surgical procedure in the treatment of facetogenic chronic low back pain.
Objective To evaluate the lumbar muscle strength and motive range change after lumbar medial branch neurotomy for facetogenic chronic low back pain. Methods Forty facetogenic chronic low back pain patients were included and randomly assigned to receive percutaneous radiofrequency neurotomy( RN group, 20 cases) or endoscopic neurotomy( EN group, 20 cases) of lumbar medial branch. Endoscopic lumbar medial branch neurotomy was performed for the second group. The following measurements were recorded before operation and at 6 months after operation. The maximum isometric contraction strength and motion range of the lumbar were recorded while the lumbar moved in 6 different directions: anteflexion, rear protraction, left and right lateral flexion, and clock-wise and counter-clock-wise rotation. The results of the 2 groups were compared. Results There were no significant differences of lumbar muscle strength in both groups pre-and post-operatively( P > 0.05). There were no significant differences of anteflexion range in both groups pre-and post-operatively( P > 0.05). Motive ranges in rear protraction( 21.21 ± 0.13) °, left( 31.95 ± 1.03) ° and right lateral flexion( 34.53 ± 1.12) °, and clock-wise( 45.95 ± 1.19) ° and counterclock-wise( 45.95 ± 1.19) ° rotation were significantly greater than those of pre-operation [( 15.05 ± 1.58) °,( 24.02 ± 0.92) °,( 22.02 ± 1.95) °,( 34.02 ± 0.31) °,( 32.72 ± 0.92) ° ] in both groups( P < 0.05). There were no significant differences of lumbar muscle strength between the 2 groups pre-and 6 months after operation( P > 0.05). However, the clock-wise and counter-clock-wise motive rotations of the EN group [( 47.37 ± 1.21) °,( 45.95 ± 1.19) ° ] were significantly larger than those of the RN group [( 40.01 ± 0.67) °,( 38.01 ± 1.64) ° ]( P < 0.05). ConclusionsNeurotomy does not result in negative effects on the motion range and muscle strength of the lumbar. In addition, it is found that the range of motion increases after the neurotomy, and endoscopic neurotomy can achieve better improvement of the left-right rotation range than those of the radiofrequency neurotomy. Therefore, lumbar medial branch neurotomy is an safe and useful surgical procedure in the treatment of facetogenic chronic low back pain.
引文
[1]Bogduk N.Diagnosing lumbar zygapophysial joint pain[J].Pain Med,2005,6(2):139-142.
[2]Boswell MV,Singh V,Staats PS,et al.Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin[J].Pain Physician,2003,6(4):449-456.
[3]何金鑫,毛军.腰神经后支及其骨纤维管的应用解剖[J].包头医学院学报,2014,30(2):1-4.
[4]陆迪,任宝松,张凡.腰神经后支的解剖结构探讨[J].中国误诊学杂志,2011,11(24):5896.
[5]Bogduk N.Evidence-informed management of chronic low back pain with facet injections and radiofrequency neurotomy[J].Spine J,2008,8(1):56-64.
[6]Shealy CN.Facet denervation in the management of back and sciatic pain[J].Clin Orthop Relat Res,1976,(115):157-164.
[7]Li ZZ,Hou SX,Shang WL,et al.Evaluation of endoscopic dorsal ramus rhizotomy in managing facetogenic chronic low back pain[J].Clin Neurol Neurosurg,2014,126:11-17.
[8]Bogduk N,Long DM.The anatomy of the so-called“articular nerves”and their relationship to facet denervation in the treatment of low-back pain[J].J Neurosurg,1979,51(2):172-177.
[9]Bradl I,Morl F,Scholle HC,et al.Back muscle activation pattern and spectruminde fined loadsituations[J].Pathophysiology,2005,12(4):275-280.
[10]Smuck M,Crisostomo RA,Demirjian R,et al.Morphologic changes in the lumbar spine after lumbar medial branch radiofrequency neurotomy:a quantitative radiological study[J].Spine J,2015,15(6):1415-1421.
[11]Cohen SP,Moon JY,Brummett CM,et al.Medial branch blocks or intra-articular injections as a prognostic tool before lumbar facet radiofrequency denervation:a multicenter,casecontrol study[J].Reg Anesth Pain Med,2015,40(4):376-383.
[12]Stevens VK,Parlevliet TG,Coorevits PL,et al.The effect of increasing resistance on trunk muscle activity during extension and flexion exercises on training devices[J].J Electromyogr Kinesiol,2008,18(3):434-445.
[13]Moseley GL,Hodges PW,Gandevia SC.Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements[J].Spine,2002,27(2):E29-36.
[2]Boswell MV,Singh V,Staats PS,et al.Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin[J].Pain Physician,2003,6(4):449-456.
[3]何金鑫,毛军.腰神经后支及其骨纤维管的应用解剖[J].包头医学院学报,2014,30(2):1-4.
[4]陆迪,任宝松,张凡.腰神经后支的解剖结构探讨[J].中国误诊学杂志,2011,11(24):5896.
[5]Bogduk N.Evidence-informed management of chronic low back pain with facet injections and radiofrequency neurotomy[J].Spine J,2008,8(1):56-64.
[6]Shealy CN.Facet denervation in the management of back and sciatic pain[J].Clin Orthop Relat Res,1976,(115):157-164.
[7]Li ZZ,Hou SX,Shang WL,et al.Evaluation of endoscopic dorsal ramus rhizotomy in managing facetogenic chronic low back pain[J].Clin Neurol Neurosurg,2014,126:11-17.
[8]Bogduk N,Long DM.The anatomy of the so-called“articular nerves”and their relationship to facet denervation in the treatment of low-back pain[J].J Neurosurg,1979,51(2):172-177.
[9]Bradl I,Morl F,Scholle HC,et al.Back muscle activation pattern and spectruminde fined loadsituations[J].Pathophysiology,2005,12(4):275-280.
[10]Smuck M,Crisostomo RA,Demirjian R,et al.Morphologic changes in the lumbar spine after lumbar medial branch radiofrequency neurotomy:a quantitative radiological study[J].Spine J,2015,15(6):1415-1421.
[11]Cohen SP,Moon JY,Brummett CM,et al.Medial branch blocks or intra-articular injections as a prognostic tool before lumbar facet radiofrequency denervation:a multicenter,casecontrol study[J].Reg Anesth Pain Med,2015,40(4):376-383.
[12]Stevens VK,Parlevliet TG,Coorevits PL,et al.The effect of increasing resistance on trunk muscle activity during extension and flexion exercises on training devices[J].J Electromyogr Kinesiol,2008,18(3):434-445.
[13]Moseley GL,Hodges PW,Gandevia SC.Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements[J].Spine,2002,27(2):E29-36.