腰椎间盘突出症非手术治疗的发展现状

Development of nonoperative therapy for lumbar intervertebral disc herniation

目的:国内外学者认为非手术治疗可使80%～90%的腰椎间盘突出症患者得到临床治愈或缓解,目前非手术治疗仍为该病的基本治疗方法,分析腰椎间盘突出症非手术治疗的发展现状,有助于寻找安全有效防治该病的方法,从而提高疗效。资料来源:应用计算机检索重庆维普中文科技期刊数据库(VIP)1995-01/2004-12和清华同方中文系列等数据库1995-01/2004-12期间的相关文章,并限定文章语言种类为中文和English。检索词“腰椎间盘突出症、非手术治疗机制、卧床休息、推拿手法、牵引、药物、神经根阻滞及封闭、功能锻炼”。资料选择:对资料进行初审,筛除明显不随机临床试验的研究,对剩余的文献开始查找全文,进一步判断是否为随机对照临床试验。纳入标准:随机对照临床试验(RCT),无论是否为单盲、双盲或非盲法。排除标准:重复的同一研究或接受过手术治疗的研究。资料提炼:共收集到66篇与腰椎间盘突出症非手术治疗机制相关的文献,共29篇符合纳入标准。排除的37篇中,22篇系重复的同一研究,15篇为手术后的康复治疗。资料综合:引用29篇文献中,共包括3257例患者,分别对应用卧床休息、推拿手法、牵引、药物、神经根阻滞及封闭、功能锻炼这6种非手术治疗方法予以评价。多数实验报道卧床休息是非手术疗法的基础,且卧硬板床休息时间不少于3周;手法可调节腰椎间盘突出症患者的神经体液系统,提高痛阈及椎旁肌肉的兴奋性,改善微循环,促进致痛物质的排泄及吸收,刺激止痛物质的分泌;初次治疗时牵引力量宜小,以后逐渐增大,以不超过45kg为宜,最多不能超过体质量;中药内服多从祛风止痛、散寒祛湿及活血化瘀辨证施治,西药内服则以解热消炎镇痛、营养神经等对症处理为主;局部封闭、神经根阻滞麻醉及硬膜外封闭等可使药液直达病所而起治疗作用;内源性稳定和外源性稳定因素相互协调才能维持脊柱的稳定,功能锻炼可以增加腰椎的稳定性和活动能力,早期进行功能锻对腰椎间盘突出症患者功能恢复、减轻疼痛与麻木等症状有明显作用。结论:目前认为非手术治疗腰椎间盘突出症主要是通过卧床休息、牵引、手法、药物等手段来改善局部微循环,促使炎性反应物代谢与排泄,纠正腰椎小关节紊乱状态等,从而为患者提供自身修复的有利条件,并利用腰椎间盘突出症的病理转归特点提高疗效。

OBJECTIVE： It is considered by domestic and overseas scholars that nonoperative therapy can cure or relieve the lumbar disc herniation （LDH） in 80% to 90% patients, and nonoperative therapy is still the essential method for LDH at present. Therefore, we aimed to analyze the developing status of nonoperative therapy for LDH assistant to seek for effective approaches to prevent and treat LDH, so as to increase the curative effectiveness. DATA SOURCES： The related articles to nonoperative therapy for LDH published between January 1995 and December 2004 were search for in Chongqing V1P Database and Qinghua Tongfang Chinese Database by using computer with the key words “lumbar disc herniation, mechanism of nonoperative therapy, rest in bed, massage, distraction, drug, nerve root block and blocking, functional exercise”, and the language was limited to Chinese and English. STUDY SELECTION： After primary check-up, the obvious-nonrandomized controlled clinical trials were screened out, and the rest articles were looked up for the full texts to judge whether they were randomized controlled trials （RCT）. Inclusion criteria： RCT, no matter whether they were single blind, double blind or non-blind; Exclusion criteria： repetitive studies or the studies on operative treatment. DATA EXTRACION： A total of 66 articles about the mechanism of nonoperative therapy for LDH were collected, among which 29 were in accordance with the inclusion criteria. In the 37 excluded articles, 22 were repetitive and 15 were about postoperative. DATA SYNTHFSIS： In the 29 studies, 6 nonoperative therapies were used in 3 257 patients and evaluated including rest in bed, massage, distraction, drug, nerve root block and blocking, and functional exercise. It was reported in most experiments that rest in bed was the basis of nonoperative therapy, and rest in hard bed for at least 3 weeks; Massage therapy could regulate neurohumoral system, increase pain threshold and excitability of paravertebral muscle, improve microcirculation, accelerate excretion and absorption of pain-induced substances and stimulate excretion of analgesic substances; Distraction should be performed by little strength for the first time, and then be added gradually till the most suitable mass of 45 kg but not over patients＇body mass for the most part. Oral traditional Chinese medicine mainly focus on syndrome differentiation to expel wind and alleviate pain, dispel cold and remove damp, activate blood circulation to dissipate blood stasis, and oral western medicine on management according to the symptoms to reduce fever, eliminate inflammation, alleviate pain and nourish nerve. Local blocking, nerve root block to anesthesia and epidural blocking played a therapeutic role by facilitating the drug to reach the focal location. Endogenous and exogenous stable factors could maintain the stability of spinal column by a manner of inter-coordination. Functional exercise could enhance the stability and ability to move of lumbar vertebra, and early functional exercise has remarkable function on promoting functional recovery, relieving pain and numbness, and so on in LDH patients. CONCLUSION： It is considered that nonoperative therapies for LDH can improve local microcirculation, promote metabolism and excretion of inflammatory reactants, regulate the disturbance of small joints in lumbar vertebra mainly by means of rest in bed, distraction, maneuver, drugs, etc., which will provide advantageous condition for auto-repair of patients and increase therapeutic effect attributing to characters of pathological outcomes of LDH.