仰卧前屈拔伸牵引法治疗伴脊髓压迫CSR的机理及临床研究
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摘要
背景：
颈椎病是常见病,牵引作为一种治疗神经根型颈椎病的常用治疗方法,在临床上已经广泛被应用。在临床的工作中,我们经常遇到这样的神经根型颈椎病病人,他们的MR有因退行性改变引起脊髓受压的影像学表现,但临床上仅表现出神经根型颈椎病的特点,没有脊髓损害的临床表现,我们称之为“伴脊髓压迫的神经根型颈椎病”。它包括2个部分,一是症状上的神经根型颈椎病的症状、体征；二是影像学表现的是“无症状颈椎退变性脊髓压迫。”目前对于这种疾病的认识,存在不足,对发病机理认识,只认为是根性压迫,治疗上只针对根性症状,可能伤及脊髓,导致脊髓压迫进一步进展,且目前国内外在保守治疗此类疾病上也无系统阐述。
仰卧前屈拔伸牵引法已被证实在治疗神经根型颈椎病上有显著疗效。在临床的治疗尝试上,我们观察到前屈位下此类病人的症状有明显缓解,并采用了仰卧前屈拔伸牵引法结合其他系统综合疗法治疗伴脊髓压迫的神经根型颈椎病取得了良好的效果。但对于临床应用仰卧前屈拔伸牵引法治疗这种疾病的机理不甚清楚,且对于治疗疾病的有效性缺乏系统的评估。
目的：
针对仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病的自然转归和针对性治疗进行研究,进行相关机理探讨及系统有效性的评估。以求探索仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病的机理,提高疾病的认识和疗效,减缓脊髓损害的发生。
方法：
(一)三维有限元分析
选取符合本课题纳入标准的患者5例,行颈椎C1-C7的CT薄层平扫,扫描厚层为0.75mmm。将CT图片储存并输入Mimics10.01软件,生成三维图像。然后运用Mimics软件中通过不同的灰度值提取颈椎骨骼的轮廓线数据,进而获得颈椎的点云数据,并以STL格式保存,然后将STL格式的数据文件导入Geomagic Studio软件中,根据椎体各部分的曲率变化情况划分成多个区域,然后将各区域的点云数据进行拟合生成颈椎几何模型,最后以IGES格式导入MARC2005进行网格划分,并根据不同结构的建模参数建立有限元建模,最后利用MARC软件进行模拟生物力学实验,分别于中立位、前屈20。位,向颈椎模型纵轴方向施加6Kg牵引力,测量不同角度牵引下颈椎椎体的椎间隙及椎间孔面积的变化,并作生物力学分析。
(二)临床研究
对2007年-2012年3月既往98例仰卧前屈拔伸牵引法治疗的伴脊髓压迫的神经根型颈椎病患者进行电话随访,记录患者的WAS及JOA评分,比较患者治疗前、出院时及随访时的评分,进行回顾性的有效性分析及疾病转归评价；临床选取2012年3月-2013年1月符合本研究纳入标准的患者30例,所有患者行中立及前屈位MR,治疗上首先采用手法进行拔伸牵引,估算最佳的牵引的角度和重量,然后依此用牵引装置牵引,采用前屈位0-40度牵引；开始牵引的重量可由3-5kg逐渐增加至8～l0kg,以牵引处无特别不适感,患者颈后着力感强为宜,每次20分钟,每天2-3次,连续2周,并辅以中药、轻手法及对患者的健康宣教,记录患者入院时、出院时、及随访一个月的VAS、JOA(17分法)、JOA(20分)评分,通过VAS和JOA(20分法)评分评价患者治疗的有效性,通过JOA(17分法)评分评估患者治疗过程中脊髓功能变化；首次牵引时记录患者皮层体感诱发电位,记录电极分别位于头顶C3/C4-Fz、颈7棘突及Erb点,参考电极置于前额,导联组合为Cv7-FPz(记录颈髓、皮层下及外周神经电位)。带通范围20-2000Hz,叠加300-500次,刺激强度5～20mA,以引起拇指轻微抽动为宜,分析时间50ms。信号经滤波和放大,测量N9(锁骨上电位)、N13(颈段脊髓电位)、N20(皮层下及皮层电位)的峰潜伏期(PL)、波幅(Amp)及N20-N13的峰间潜伏期(IPL),重复测量2次,取其平均值。取患者平静状态下正常体位诱发电位波形图为基线,记录患者前屈牵引位波形变化,评估牵引过程的安全性。对中立及前屈位颈椎MR主要从(1)椎间盘突出矢状径指数；(2)颈椎中立、前屈位下椎管矢径及脊髓矢径与椎管矢径比值,两个方面选取MRI上颈椎间盘突出最严重的节段纳入测量,并进行数据统计学分析。
成果：
(一)三维有限元分析
纳入病例5例,均完成相应牵引治疗及影像学检查。前屈20。牵引后椎体位移变化,各节椎均显著,且前屈20。牵引后椎间隙后部高度的变化优于中立位牵引。从统计学分析,牵引前椎间隙高度(除C6/7)及椎间孔面积,无显著差异(P>0.05)。在C3/4节段,前屈20。牵引与中立牵引相比,椎间隙后部的高度显著增加(P<0.05),但椎间隙前部高度和椎间孔面积的变化无明显差异(P>0.05)；在C4/5、C5/6、C6/7节段,前屈20。牵引与中立位牵引相比,椎间孔面积及椎间隙后部高度显著增加(P<0.05)；各节椎牵引前后椎体相对位移变化,前屈20。牵引较中立牵引有显著增加(P<0.05)。前屈20。牵引前后,在C3/4、C4/5节段以椎间隙后部高度相对变化明显,在C5/6、C6/7节段以椎间隙前部高度相对变化明显。前屈20。牵引比中立位牵引相比更能增加颈椎椎体相对位移。生物力分析可见牵引力下牵拉应力主要集中在椎间盘的前部及后部,椎间盘中部所受的牵拉应力较小。在前屈位下椎间盘各部所受牵拉应力较中立位明显增加。
(二)临床研究
既往98例伴脊髓压迫的神经根型颈椎病患者共有72例病人得到随访,平均随访时间3.10年,其中68例患者随访时VAS、JOA评分较入院及出院时改善,有显著差别,4人因症状加重手术治疗。30例伴脊髓压迫的神经根型颈椎病患者的临床观察,VAS及JOA(20分)评分在治疗前、出院时、随访时有显著差异,无症状加重或手术治疗病例。表明仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病疗效确切,且颈椎MRI,前屈位下椎间盘突出矢状径指数较中立位明显减少,椎管矢径较中立位显著增大。30例患者其中18例完成诱发电位的监测,在仰卧前屈位牵引过程中,各波潜伏期及波幅与正常体位无明显差别,提示仰卧前屈牵引过程中无脊髓损伤的发生。
结论：
前屈20。牵引后椎体位移变化,各节椎均显著,且各节椎椎体相对位移的改变优于中立位牵引；前屈20。牵引后与中立位牵引相比,以各节椎椎间隙后部高度的变化显著；在C4/5、C5/6、C6/7节段,前屈20。牵引较中立位牵引能显著增加其椎间孔面积,且前屈牵引后椎间盘的牵拉应力较中立位有明显变化。
通过对伴脊髓压迫的神经根型颈椎病患者的回顾性及前瞻性研究,提示仰卧前屈拔伸牵引法在治疗上的有效性,通过对牵引过程中诱发电位的监测,证明了仰卧前屈牵引的安全性,并通过对颈椎动力位MR的分析,进一步阐明了仰卧前屈拔伸牵引法治疗的部分作用机制及对脊髓的安全性。
综上,通过生物力学模型的建立、相关参数的分析及MR形态学变化,探讨了仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病的作用机理,并通过临床病例的观察证明了仰卧前屈拔伸牵引法的有效性与安全性,便于临床推广应用。
Background
Cervical spondylosis is a common disease, traction as a treatment for cervical spondylosis radiculopathy has been widely applied in clinic. During clinical work, we often meet with some unuaual cervical spondylosis radicul-opathy (CSR) patients, whose MR imaging showed spinal cord compression caused by degenerative changes, but only has the clinical characteristics of CSR. The patient has no clinical manifestations of spinal cord damage, which we called cervical spondylosis radiculopathy with degenerative spinal cord compression. It consists of two parts, one is the symptoms of CSR;the other is asymptomatic spondylotic cervical cord compression which is showed on MR imaging. But sometimes we cannot understand the pathogenesis of this disease sufficient-ly, and the treatment we used is just for the symptoms of the CSR, which may injured the spinal cord, leading to the further progress of spinal cord compression, Also there is no systematically expounded in the conservative treatment of these diseases.
Back-lying and Forward-bending Traction has been showed a significant effect on the treatment of CSR. We also use this method to treat the pat ent which has the CSR with degenerative spinal compression as an attempt, we find during the flexion traction, the patie(?)s' symptoms were obviously alleviated, and there has no symptoms of the spine cord injures showed. However, the mechanism of this method is unclear, and the systematic assessment of the effectiveness of the treatment to the diseases is also lack of.
Objective
To discuss the mechanism and assess the sys effectiveness of the Back-lying and Forward-bending Traction to treat the patient who has the CSR with degenerative spinal cord compression. In order to explore the mechanism of Back-lying and Forward-bending Traction in treatmenting the CSR with degenerative spinal cord compression, and to improve curative effect of disease, and reduce the incidence of spinal cord damage.
Methods
Three-dimensional finite element analysis
Choose5volunteers who are consistent with the CSR with degenerative spinal cord compression diagnosis and meeting the requirements of this subject. Let them take Cervical CT scan, and the scan thick layer is0.75mm. Storing the CT images and input to the Mimisc10.01software to generate three-dimensional images. We can get the Contour datas of cervical vertebras through different thresholds in Mimisc, and save as Binary STL files, which are inputed to the Geomagic Studio.We divide the vertebra into sereval parts according to the curvature of different vertebra, and then we can generate the cervical geometric model by using the point cloud data of each region. Input it to the MARC2005software, and establish the finite element modeling according to the modeling parameters of different structure. Finally we impose6Kg traction to the cervical spine model in neutral and20-degree-flexion position and simulate biomechanical experiment by using the MARC software, in order to get the data of the intervertebral space and foramen intervertebrale from different angles traction, and analysis the biomechanical force of the cervical disc.
Clinical research
Telephoned the98cases who has suffered cervical spondylosis radiculopathy with degenerative spinal cord compression during2007to March2012, comparing their VAS and JOA scores while before treatment, discharge and follow-up visit, to analyse the effectiveness of the Back-lying and Forward-bending Traction. Select30cases of cervical spondylosis radiculopat-hy with degenerative spinal cord compression from March2012to January2013, Each patient take the neutral and flexion MR imaging.First we use our hand to implement traction, in order to find the best traction angle and weight. Then we carry out the Supine front-traction by using the traction device, the traction angle is from0to40degree flexion;traction weight from3to5kg to start, can be gradually increased to810kg. We must make sure there is no special discomfort during the traction. The traction should be taken20minutes each time,2or3times a day, for2consecutive weeks, we also use traditional Chinese medicine, light technique and the patient's health education as supplementary. Record the VAS, JOA (17points), JOA (20points) scores of each patient while before treatment,discharge and one-month-follow-up visit. Then we use the VAS and JOA (20points) scores to evalue effectiveness of the Supine front-traction, using the JOA (17points) score to evaluate the changes of spinal cord function in patients during treatment. The cortical somatosensory evoked potentials were recorded during the first time traction. The recording electrode was respectively placed in the head C3/C4-Fz, the spinous process of C7and the Erb position,while the reference electrode was placed in the forehead to record the evoked potentials of cervical spinal cord, cortical and peripheral nerve. The bandpass range is about20~2000Hz, while the stimulus intensity is5~20mA, in order to cause the thumb slight tic. After signal filtering and amplification, we measured the latent period(PL)and the amplitude of N9(supraclavicular potentials),N13(cervical spinal cord potentials), N20(subcortical and cortical potentials), and the peak latency of N20-N13as also. We use the waveforms while patient in a calm state with normal posture as a baseline, then we observe the waveform changes during the Supine front-traction, and evaluate the safety of traction process. In the MR imagings of he neutral and flexion position, we analyse data statistical at two point, one is the sagittal diameter index of disc herniation;the other is the vertebral canal sagittal diameter and the ratio of vertebral canal sagittal diameter and spinal diameter.
Result
Three-dimensional finite element analysis
All volunteers are required to complete traction, and imaging examination. Changes of vertebral displacement after20-degree-flexion traction is significantly. Changes of intervertebral space after the20-degree-flexion traction, especially in the posterior, is significantly increased compare to the neutral. From the statistical analysis, the intervertebral space (exceptC6/7) and intervertebral foramen has no significant difference before the different angles traction(P>0.05). In the C3/4segment, the posterior intervertebral space has significantly increased(P<0.05), while the intervertebral foramen and the anterior intervertebral space has not (P>0.05)comparing to the different angles traction. In the C4/5,C5/6, C6/7segment, the posterior intervertebral space and intervertebral foramen has significant difference. Also the relative changes of vertebral displacement is significantly increased after the20-degree-flexion traction. So the20-degree-flexion traction can improve the vertebral displacement more obviously than the neutral traction. Biomechanical analysis shows the traction pulling stress is mainly concentrated in the anterior and posterior parts of the disc, while the pulling stress on the nucleus pulposus is less. The pulling stress is significantly increased in the20-degree-flexion traction. Clinical research
72patients get followed-up, the average follow-up time of3.10years. The VAS and JOA scores of68patients is significantly improved comparing to before treatment, discharge and followed-up visit,4patients got operation because of severe symptoms. Clinical observation on30cases of cervical spondylosis radiculopathy with degenerative spinal cord compression showed, the VAS and JOA(20)scores was significantly improved comparing to before treatment, discharge and one-month-followed-up visit. And no symptoms aggravated or operation treatment cases. The front-traction in treating cervical spondylosis radiculopathy with degenerative spinal cord compression is obvious. The MR imaging also showed during the flexion position the sagittal diameter index of disc herniation has significantly decreased while the vertebral canal sagittal diameter has significantly increased than the neutral position.18patients had completed the evoked potential monitoring, during the front-traction process, no significant difference has occurred in the latency and amplitude compare to the normal position.
Conclusions
Changes of vertebral displacement after20-degree-flexion is signify-cantly. Changes of intervertebral space after the20-degree-flexion traction, especially in the posterior, is significantly increased compare to the neutral. The intervertebral foramen and the pulling stress of the disc are all increased after the20-degree-flexion traction compares to the neutral traction.
According to the retrospective and prospective studies associated with cervical spondylosis radiculopathy with degenerative spinal cord compression, we stated the effectiveness of the Back-lying and Forward-bending Traction;By using the cortical somatosensory evoked potentials to monitoring the process during front-traction, we stated the safety of this method. The MR imaging of flexion position also explain some mechanism of using front-traction to treat this disease, and the the security to the as well.
In conclusion,we discussed the mechanism of using the Back-lying and Forward-bending Traction to treat the patient who has cervical spondylosis radiculopathy with degenerative spinal cord compression by using the biomechanical model of the cervical spine. We also proved the effective and secure of the Back-lying and Forward-bending Traction though clinical research. All we did is to facilitate this method to clinical application.
颈椎病是常见病,牵引作为一种治疗神经根型颈椎病的常用治疗方法,在临床上已经广泛被应用。在临床的工作中,我们经常遇到这样的神经根型颈椎病病人,他们的MR有因退行性改变引起脊髓受压的影像学表现,但临床上仅表现出神经根型颈椎病的特点,没有脊髓损害的临床表现,我们称之为“伴脊髓压迫的神经根型颈椎病”。它包括2个部分,一是症状上的神经根型颈椎病的症状、体征；二是影像学表现的是“无症状颈椎退变性脊髓压迫。”目前对于这种疾病的认识,存在不足,对发病机理认识,只认为是根性压迫,治疗上只针对根性症状,可能伤及脊髓,导致脊髓压迫进一步进展,且目前国内外在保守治疗此类疾病上也无系统阐述。
仰卧前屈拔伸牵引法已被证实在治疗神经根型颈椎病上有显著疗效。在临床的治疗尝试上,我们观察到前屈位下此类病人的症状有明显缓解,并采用了仰卧前屈拔伸牵引法结合其他系统综合疗法治疗伴脊髓压迫的神经根型颈椎病取得了良好的效果。但对于临床应用仰卧前屈拔伸牵引法治疗这种疾病的机理不甚清楚,且对于治疗疾病的有效性缺乏系统的评估。
目的：
针对仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病的自然转归和针对性治疗进行研究,进行相关机理探讨及系统有效性的评估。以求探索仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病的机理,提高疾病的认识和疗效,减缓脊髓损害的发生。
方法：
(一)三维有限元分析
选取符合本课题纳入标准的患者5例,行颈椎C1-C7的CT薄层平扫,扫描厚层为0.75mmm。将CT图片储存并输入Mimics10.01软件,生成三维图像。然后运用Mimics软件中通过不同的灰度值提取颈椎骨骼的轮廓线数据,进而获得颈椎的点云数据,并以STL格式保存,然后将STL格式的数据文件导入Geomagic Studio软件中,根据椎体各部分的曲率变化情况划分成多个区域,然后将各区域的点云数据进行拟合生成颈椎几何模型,最后以IGES格式导入MARC2005进行网格划分,并根据不同结构的建模参数建立有限元建模,最后利用MARC软件进行模拟生物力学实验,分别于中立位、前屈20。位,向颈椎模型纵轴方向施加6Kg牵引力,测量不同角度牵引下颈椎椎体的椎间隙及椎间孔面积的变化,并作生物力学分析。
(二)临床研究
对2007年-2012年3月既往98例仰卧前屈拔伸牵引法治疗的伴脊髓压迫的神经根型颈椎病患者进行电话随访,记录患者的WAS及JOA评分,比较患者治疗前、出院时及随访时的评分,进行回顾性的有效性分析及疾病转归评价；临床选取2012年3月-2013年1月符合本研究纳入标准的患者30例,所有患者行中立及前屈位MR,治疗上首先采用手法进行拔伸牵引,估算最佳的牵引的角度和重量,然后依此用牵引装置牵引,采用前屈位0-40度牵引；开始牵引的重量可由3-5kg逐渐增加至8～l0kg,以牵引处无特别不适感,患者颈后着力感强为宜,每次20分钟,每天2-3次,连续2周,并辅以中药、轻手法及对患者的健康宣教,记录患者入院时、出院时、及随访一个月的VAS、JOA(17分法)、JOA(20分)评分,通过VAS和JOA(20分法)评分评价患者治疗的有效性,通过JOA(17分法)评分评估患者治疗过程中脊髓功能变化；首次牵引时记录患者皮层体感诱发电位,记录电极分别位于头顶C3/C4-Fz、颈7棘突及Erb点,参考电极置于前额,导联组合为Cv7-FPz(记录颈髓、皮层下及外周神经电位)。带通范围20-2000Hz,叠加300-500次,刺激强度5～20mA,以引起拇指轻微抽动为宜,分析时间50ms。信号经滤波和放大,测量N9(锁骨上电位)、N13(颈段脊髓电位)、N20(皮层下及皮层电位)的峰潜伏期(PL)、波幅(Amp)及N20-N13的峰间潜伏期(IPL),重复测量2次,取其平均值。取患者平静状态下正常体位诱发电位波形图为基线,记录患者前屈牵引位波形变化,评估牵引过程的安全性。对中立及前屈位颈椎MR主要从(1)椎间盘突出矢状径指数；(2)颈椎中立、前屈位下椎管矢径及脊髓矢径与椎管矢径比值,两个方面选取MRI上颈椎间盘突出最严重的节段纳入测量,并进行数据统计学分析。
成果：
(一)三维有限元分析
纳入病例5例,均完成相应牵引治疗及影像学检查。前屈20。牵引后椎体位移变化,各节椎均显著,且前屈20。牵引后椎间隙后部高度的变化优于中立位牵引。从统计学分析,牵引前椎间隙高度(除C6/7)及椎间孔面积,无显著差异(P>0.05)。在C3/4节段,前屈20。牵引与中立牵引相比,椎间隙后部的高度显著增加(P<0.05),但椎间隙前部高度和椎间孔面积的变化无明显差异(P>0.05)；在C4/5、C5/6、C6/7节段,前屈20。牵引与中立位牵引相比,椎间孔面积及椎间隙后部高度显著增加(P<0.05)；各节椎牵引前后椎体相对位移变化,前屈20。牵引较中立牵引有显著增加(P<0.05)。前屈20。牵引前后,在C3/4、C4/5节段以椎间隙后部高度相对变化明显,在C5/6、C6/7节段以椎间隙前部高度相对变化明显。前屈20。牵引比中立位牵引相比更能增加颈椎椎体相对位移。生物力分析可见牵引力下牵拉应力主要集中在椎间盘的前部及后部,椎间盘中部所受的牵拉应力较小。在前屈位下椎间盘各部所受牵拉应力较中立位明显增加。
(二)临床研究
既往98例伴脊髓压迫的神经根型颈椎病患者共有72例病人得到随访,平均随访时间3.10年,其中68例患者随访时VAS、JOA评分较入院及出院时改善,有显著差别,4人因症状加重手术治疗。30例伴脊髓压迫的神经根型颈椎病患者的临床观察,VAS及JOA(20分)评分在治疗前、出院时、随访时有显著差异,无症状加重或手术治疗病例。表明仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病疗效确切,且颈椎MRI,前屈位下椎间盘突出矢状径指数较中立位明显减少,椎管矢径较中立位显著增大。30例患者其中18例完成诱发电位的监测,在仰卧前屈位牵引过程中,各波潜伏期及波幅与正常体位无明显差别,提示仰卧前屈牵引过程中无脊髓损伤的发生。
结论：
前屈20。牵引后椎体位移变化,各节椎均显著,且各节椎椎体相对位移的改变优于中立位牵引；前屈20。牵引后与中立位牵引相比,以各节椎椎间隙后部高度的变化显著；在C4/5、C5/6、C6/7节段,前屈20。牵引较中立位牵引能显著增加其椎间孔面积,且前屈牵引后椎间盘的牵拉应力较中立位有明显变化。
通过对伴脊髓压迫的神经根型颈椎病患者的回顾性及前瞻性研究,提示仰卧前屈拔伸牵引法在治疗上的有效性,通过对牵引过程中诱发电位的监测,证明了仰卧前屈牵引的安全性,并通过对颈椎动力位MR的分析,进一步阐明了仰卧前屈拔伸牵引法治疗的部分作用机制及对脊髓的安全性。
综上,通过生物力学模型的建立、相关参数的分析及MR形态学变化,探讨了仰卧前屈拔伸牵引法治疗伴脊髓压迫的神经根型颈椎病的作用机理,并通过临床病例的观察证明了仰卧前屈拔伸牵引法的有效性与安全性,便于临床推广应用。
Background
Cervical spondylosis is a common disease, traction as a treatment for cervical spondylosis radiculopathy has been widely applied in clinic. During clinical work, we often meet with some unuaual cervical spondylosis radicul-opathy (CSR) patients, whose MR imaging showed spinal cord compression caused by degenerative changes, but only has the clinical characteristics of CSR. The patient has no clinical manifestations of spinal cord damage, which we called cervical spondylosis radiculopathy with degenerative spinal cord compression. It consists of two parts, one is the symptoms of CSR;the other is asymptomatic spondylotic cervical cord compression which is showed on MR imaging. But sometimes we cannot understand the pathogenesis of this disease sufficient-ly, and the treatment we used is just for the symptoms of the CSR, which may injured the spinal cord, leading to the further progress of spinal cord compression, Also there is no systematically expounded in the conservative treatment of these diseases.
Back-lying and Forward-bending Traction has been showed a significant effect on the treatment of CSR. We also use this method to treat the pat ent which has the CSR with degenerative spinal compression as an attempt, we find during the flexion traction, the patie(?)s' symptoms were obviously alleviated, and there has no symptoms of the spine cord injures showed. However, the mechanism of this method is unclear, and the systematic assessment of the effectiveness of the treatment to the diseases is also lack of.
Objective
To discuss the mechanism and assess the sys effectiveness of the Back-lying and Forward-bending Traction to treat the patient who has the CSR with degenerative spinal cord compression. In order to explore the mechanism of Back-lying and Forward-bending Traction in treatmenting the CSR with degenerative spinal cord compression, and to improve curative effect of disease, and reduce the incidence of spinal cord damage.
Methods
Three-dimensional finite element analysis
Choose5volunteers who are consistent with the CSR with degenerative spinal cord compression diagnosis and meeting the requirements of this subject. Let them take Cervical CT scan, and the scan thick layer is0.75mm. Storing the CT images and input to the Mimisc10.01software to generate three-dimensional images. We can get the Contour datas of cervical vertebras through different thresholds in Mimisc, and save as Binary STL files, which are inputed to the Geomagic Studio.We divide the vertebra into sereval parts according to the curvature of different vertebra, and then we can generate the cervical geometric model by using the point cloud data of each region. Input it to the MARC2005software, and establish the finite element modeling according to the modeling parameters of different structure. Finally we impose6Kg traction to the cervical spine model in neutral and20-degree-flexion position and simulate biomechanical experiment by using the MARC software, in order to get the data of the intervertebral space and foramen intervertebrale from different angles traction, and analysis the biomechanical force of the cervical disc.
Clinical research
Telephoned the98cases who has suffered cervical spondylosis radiculopathy with degenerative spinal cord compression during2007to March2012, comparing their VAS and JOA scores while before treatment, discharge and follow-up visit, to analyse the effectiveness of the Back-lying and Forward-bending Traction. Select30cases of cervical spondylosis radiculopat-hy with degenerative spinal cord compression from March2012to January2013, Each patient take the neutral and flexion MR imaging.First we use our hand to implement traction, in order to find the best traction angle and weight. Then we carry out the Supine front-traction by using the traction device, the traction angle is from0to40degree flexion;traction weight from3to5kg to start, can be gradually increased to810kg. We must make sure there is no special discomfort during the traction. The traction should be taken20minutes each time,2or3times a day, for2consecutive weeks, we also use traditional Chinese medicine, light technique and the patient's health education as supplementary. Record the VAS, JOA (17points), JOA (20points) scores of each patient while before treatment,discharge and one-month-follow-up visit. Then we use the VAS and JOA (20points) scores to evalue effectiveness of the Supine front-traction, using the JOA (17points) score to evaluate the changes of spinal cord function in patients during treatment. The cortical somatosensory evoked potentials were recorded during the first time traction. The recording electrode was respectively placed in the head C3/C4-Fz, the spinous process of C7and the Erb position,while the reference electrode was placed in the forehead to record the evoked potentials of cervical spinal cord, cortical and peripheral nerve. The bandpass range is about20~2000Hz, while the stimulus intensity is5~20mA, in order to cause the thumb slight tic. After signal filtering and amplification, we measured the latent period(PL)and the amplitude of N9(supraclavicular potentials),N13(cervical spinal cord potentials), N20(subcortical and cortical potentials), and the peak latency of N20-N13as also. We use the waveforms while patient in a calm state with normal posture as a baseline, then we observe the waveform changes during the Supine front-traction, and evaluate the safety of traction process. In the MR imagings of he neutral and flexion position, we analyse data statistical at two point, one is the sagittal diameter index of disc herniation;the other is the vertebral canal sagittal diameter and the ratio of vertebral canal sagittal diameter and spinal diameter.
Result
Three-dimensional finite element analysis
All volunteers are required to complete traction, and imaging examination. Changes of vertebral displacement after20-degree-flexion traction is significantly. Changes of intervertebral space after the20-degree-flexion traction, especially in the posterior, is significantly increased compare to the neutral. From the statistical analysis, the intervertebral space (exceptC6/7) and intervertebral foramen has no significant difference before the different angles traction(P>0.05). In the C3/4segment, the posterior intervertebral space has significantly increased(P<0.05), while the intervertebral foramen and the anterior intervertebral space has not (P>0.05)comparing to the different angles traction. In the C4/5,C5/6, C6/7segment, the posterior intervertebral space and intervertebral foramen has significant difference. Also the relative changes of vertebral displacement is significantly increased after the20-degree-flexion traction. So the20-degree-flexion traction can improve the vertebral displacement more obviously than the neutral traction. Biomechanical analysis shows the traction pulling stress is mainly concentrated in the anterior and posterior parts of the disc, while the pulling stress on the nucleus pulposus is less. The pulling stress is significantly increased in the20-degree-flexion traction. Clinical research
72patients get followed-up, the average follow-up time of3.10years. The VAS and JOA scores of68patients is significantly improved comparing to before treatment, discharge and followed-up visit,4patients got operation because of severe symptoms. Clinical observation on30cases of cervical spondylosis radiculopathy with degenerative spinal cord compression showed, the VAS and JOA(20)scores was significantly improved comparing to before treatment, discharge and one-month-followed-up visit. And no symptoms aggravated or operation treatment cases. The front-traction in treating cervical spondylosis radiculopathy with degenerative spinal cord compression is obvious. The MR imaging also showed during the flexion position the sagittal diameter index of disc herniation has significantly decreased while the vertebral canal sagittal diameter has significantly increased than the neutral position.18patients had completed the evoked potential monitoring, during the front-traction process, no significant difference has occurred in the latency and amplitude compare to the normal position.
Conclusions
Changes of vertebral displacement after20-degree-flexion is signify-cantly. Changes of intervertebral space after the20-degree-flexion traction, especially in the posterior, is significantly increased compare to the neutral. The intervertebral foramen and the pulling stress of the disc are all increased after the20-degree-flexion traction compares to the neutral traction.
According to the retrospective and prospective studies associated with cervical spondylosis radiculopathy with degenerative spinal cord compression, we stated the effectiveness of the Back-lying and Forward-bending Traction;By using the cortical somatosensory evoked potentials to monitoring the process during front-traction, we stated the safety of this method. The MR imaging of flexion position also explain some mechanism of using front-traction to treat this disease, and the the security to the as well.
In conclusion,we discussed the mechanism of using the Back-lying and Forward-bending Traction to treat the patient who has cervical spondylosis radiculopathy with degenerative spinal cord compression by using the biomechanical model of the cervical spine. We also proved the effective and secure of the Back-lying and Forward-bending Traction though clinical research. All we did is to facilitate this method to clinical application.
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