定位腰椎斜扳手法结合超声引导下腰脊神经后内侧支阻滞术治疗腰椎关节突关节综合征的临床研究

A clinical study of lumbar fixed-position oblique-pulling manipulation combined with ultrasound-guided lumbar spinal nerves posteromedial branch blocking for treatment of lumbar facet joint syndrome

目的:探讨定位腰椎斜扳手法结合超声引导下腰脊神经后内侧支阻滞术治疗腰椎关节突关节综合征的临床疗效和安全性。方法:纳入腰椎关节突关节综合征患者74例,按照入组顺序采用随机数字表法随机分为2组,每组37例,分别采用定位腰椎斜扳手法联合超声引导下腰脊神经后内侧支阻滞术(手法联合神经阻滞组)和单纯超声引导下腰脊神经后内侧支阻滞术(神经阻滞组)治疗。2组患者在以上治疗的基础上均口服美洛昔康分散片14 d,并进行臀桥、单侧臀桥、侧卧提臀、卷腹、小燕飞等腰肌康复锻炼2个月。分别于治疗前及神经阻滞术后2周、6个月,采用数字评分法(numeric rating scale,NRS)对患者腰腿疼痛情况进行评分,采用Oswestry功能障碍指数(Oswestry disability index,ODI)量表对腰椎功能进行评分,进行腰部等速肌力测试并记录屈伸肌峰值力矩比值,测量腰部无痛活动角度。记录不良反应发生情况。结果:①腰腿疼痛NRS评分。时间因素和分组因素存在交互效应(F=20.423,P=0.000)。治疗前后不同时间点之间腰腿疼痛NRS评分的差异有统计学意义,即存在时间效应(F=19.278,P=0.000)。2组患者腰腿疼痛NRS评分总体比较,差异无统计学意义,即不存在分组效应(F=10.423,P=0.479)。2组患者腰腿疼痛NRS评分均随时间呈先下降后上升趋势[(7.12±1.56)分,(1.47±0.29)分,(1.61±0.55)分,F=16.556,P=0.000;(7.09±1.43)分,(1.52±0.37)分,(2.13±0.61)分,F=14.234,P=0.000],但2组的变化趋势不完全一致。治疗前及神经阻滞术后2周,2组患者腰腿疼痛NRS评分比较,差异均无统计学意义(t=0.086,P=0.931;t=0.646,P=0.519)。神经阻滞术后6个月,手法联合神经阻滞组腰腿疼痛NRS评分低于神经阻滞组(t=3.851,P=0.000)。②ODI评分。时间因素和分组因素存在交互效应(F=33.423,P=0.000)。治疗前后不同时间点之间患者ODI评分的差异有统计学意义,即存在时间效应(F=24.364,P=0.000)。2组患者ODI评分总体比较,差异无统计学意义,即不存在分组效应(F=7.192,P=0.593)。2组患者ODI评分均随时间呈先下降后上升趋势[(16.84±4.29)分,(4.34±1.09)分,(4.79±1.21)分,F=17.479,P=0.000;(16.14±4.13)分,(4.56±1.09)分,(5.74±1.44)分,F=13.563,P=0.000],但2组的变化趋势不完全一致。治疗前及神经阻滞术后2周,2组患者ODI评分比较,差异均无统计学意义(t=0.715,P=0.476;t=0.868,P=0.388)。神经阻滞术后6个月,手法联合神经阻滞组ODI评分低于神经阻滞组(t=3.072,P=0.003)。③腰部屈伸肌峰值力矩比值。时间因素和分组因素存在交互效应(F=14.005,P=0.001)。治疗前后不同时间点之间患者腰部屈伸肌峰值力矩比值的差异有统计学意义,即存在时间效应(F=12.621,P=0.000)。2组患者腰部屈伸肌峰值力矩比值总体比较,差异无统计学意义,即不存在分组效应(F=9.043,P=0.341)。2组患者腰部屈伸肌峰值力矩比值均随时间呈先下降后上升趋势[(92.47±10.49)%,(72.34±8.05)%,(75.47±9.41)%,F=5.783,P=0.000;(91.47±13.41)%,(72.52±9.04)%,(81.59±11.14)%,F=4.025,P=0.000],但2组的变化趋势不完全一致。治疗前及神经阻滞术后2周,2组患者腰部屈伸肌峰值力矩比值比较,差异均无统计学意义(t=0.357,P=0.721;t=0.091,P=0.928)。神经阻滞术后6个月,手法联合神经阻滞组腰部屈伸肌峰值力矩比值低于神经阻滞组(t=2.552,P=0.012)。④腰部无痛前屈角度。时间因素和分组因素存在交互效应(F=29.473,P=0.000)。治疗前后不同时间点之间患者腰部无痛前屈角度的差异有统计学意义,即存在时间效应(F=21.413,P=0.000)。2组患者腰部无痛前屈角度总体比较,差异无统计学意义,即不存在分组效应(F=12.347,P=0.573)。2组患者腰部无痛前屈角度均随时间呈先下降后上升趋势(76.54°±12.11°,38.72°±5.44°,40.44°±8.97°,F=9.249,P=0.000;75.29°±13.05°,37.37°±7.52°,53.21°±11.44°,F=14.178,P=0.000),但2组的变化趋势不完全一致。治疗前及神经阻滞术后2周,2组患者腰部无痛前屈角度比较,差异均无统计学意义(t=0.427,P=0.671;t=0.884,P=0.379)。神经阻滞术后6个月,手法联合神经阻滞组腰部无痛前屈角度小于神经阻滞组(t=5.343,P=0.000)。⑤腰部无痛后伸角度。时间因素和分组因素存在交互效应(F=19.545,P=0.001)。治疗前后不同时间点之间患者腰部无痛后伸角度的差异有统计学意义,即存在时间效应(F=14.213,P=0.000)。2组患者腰部无痛后伸角度总体比较,差异无统计学意义,即不存在分组效应(F=11.247,P=0.612)。2组患者腰部无痛后伸角度均随时间呈先下降后上升趋势(79.33°±7.09°,63.24°±6.51°,65.97°±8.04°,F=4.874,P=0.000;80.41°±8.21°,64.97°±7.54°,74.97°±9.17°,F=6.037,P=0.000),但2组的变化趋势不完全一致。治疗前及神经阻滞术后2周,2组患者腰部无痛后伸角度比较,差异无统计学意义(t=1.291,P=0.103;t=1.455,P=0.721)。神经阻滞术后6个月,手法联合神经阻滞组腰部无痛后伸角度小于神经阻滞组(t=6.433,P=0.000)。⑥安全性。手法联合神经阻滞组无不良反应发生;神经阻滞组发生恶心、呕吐等消化道症状1例,停药后好转;2组患者不良反应发生率比较,差异无统计学意义(P=1.000)。结论:采用定位腰椎斜扳手法联合超声引导下腰脊神经后内侧支阻滞术治疗腰椎关节突关节综合征,与单纯采用超声引导下腰脊神经后内侧支阻滞术比较,二者在缓解患者腰腿疼痛、增加腰椎活动度、改善腰部肌力平衡、恢复腰椎功能方面近期疗效相当、安全性相当,但前者的中期疗效优于后者。

Objective:To explore the clinical curative effects and safety of lumbar fixed-position oblique-pulling manipulation combined with ultrasound-guided lumbar spinal nerves posteromedial branch blocking for treatment of lumbar facet joint syndrome(LFJS).Methods:Seventy-four LFJS patients were enrolled in the study and were randomly divided into 2 groups by using random digits table according to their enrolled sequence,37 cases in each group.The patients were treated with lumbar fixed-position oblique-pulling manipulation combined with ultrasound-guided lumbar spinal nerves posteromedial branch blocking(combination therapy group)and ultrasound-guided lumbar spinal nerves posteromedial branch blocking alone(monotherapy group)respectively,followed by oral application of meloxicam dispersible tablets for 14 days and psoas muscles rehabilitation exercises for 2 months in all patients.The lumbago-leg pain and lumbar function were scored by using numeric rating scale(NRS)and Oswestry disability index(ODI)respectively,moreover,the waist isokinetic muscle strength test was performed and the ratio of flexor muscle peak torque(PT)to extensor muscle PT was recorded,and the waist painless activity angle was measured before the treatment,at 2 weeks and 6 months after the nerve blocking surgery respectively,and the adverse reactions were observed and recorded.Results:①There was interaction between time factor and group factor in lumbago-leg pain NRS scores(F=20.423,P=0.000).There was statistical difference in lumbago-leg pain NRS scores between different timepoints before and after the treatment,in other words,there was time effect(F=19.278,P=0.000).There was no statistical difference in lumbago-leg pain NRS scores between the 2 groups in general,in other words,there was no group effect(F=10.423,P=0.479).The lumbago-leg pain NRS scores presented a time-dependent trend of decreasing firstly and increasing subsequently in the 2 groups(7.12±1.56,1.47±0.29,1.61±0.55 points,F=16.556,P=0.000;7.09±1.43,1.52±0.37,2.13±0.61 points,F=14.234,P=0.000),while the 2 groups were inconsistent with each other in the variation tendency.There was no statistical difference in lumbago-leg pain NRS scores between the 2 groups before the treatment and at 2 weeks after the nerve blocking surgery(t=0.086,P=0.931;t=0.646,P=0.519).The lumbago-leg pain NRS scores were lower in combination therapy group compared to monotherapy group at 6 months after the nerve blocking surgery(t=3.851,P=0.000).②There was interaction between time factor and group factor in ODI scores(F=33.423,P=0.000).There was statistical difference in ODI scores between different timepoints before and after the treatment,in other words,there was time effect(F=24.364,P=0.000).There was no statistical difference in ODI scores between the 2 groups in general,in other words,there was no group effect(F=7.192,P=0.593).The ODI scores presented a time-dependent trend of decreasing firstly and increasing subsequently in the 2 groups(16.84±4.29,4.34±1.09,4.79±1.21 points,F=17.479,P=0.000;16.14±4.13,4.56±1.09,5.74±1.44 points,F=13.563,P=0.000),while the 2 groups were inconsistent with each other in the variation tendency.There was no statistical difference in ODI scores between the 2 groups before the treatment and at 2 weeks after the nerve blocking surgery(t=0.715,P=0.476;t=0.868,P=0.388).The ODI scores were lower in combination therapy group compared to monotherapy group at 6 months after the nerve blocking surgery(t=3.072,P=0.003).③There was interaction between time factor and group factor in the ratio of flexor muscle PT to extensor muscle PT(F=14.005,P=0.001).There was statistical difference in the ratio of flexor muscle PT to extensor muscle PT between different timepoints before and after the treatment,in other words,there was time effect(F=12.621,P=0.000).There was no statistical difference in the ratio of flexor muscle PT to extensor muscle PT between the 2 groups in general,in other words,there was no group effect(F=9.043,P=0.341).The ratio of flexor muscle PT to extensor muscle PT presented a time-dependent trend of decreasing firstly and increasing subsequently in the 2 groups(92.47±10.49,72.34±8.05,75.47±9.41%,F=5.783,P=0.000;91.47±13.41,72.52±9.04,81.59±11.14%,F=4.025,P=0.000),while the 2 groups were inconsistent with each other in the variation tendency.There was no statistical difference in the ratio of flexor muscle PT to extensor muscle PT between the 2 groups before the treatment and at 2 weeks after the nerve blocking surgery(t=0.357,P=0.721;t=0.091,P=0.928).The ratio of flexor muscle PT to extensor muscle PT was lower in combination therapy group compared to monotherapy group at 6 months after the nerve blocking surgery(t=2.552,P=0.012).④There was interaction between time factor and group factor in waist painless anteflexion angle(F=29.473,P=0.000).There was statistical difference in waist painless anteflexion angle between different timepoints before and after the treatment,in other words,there was time effect(F=21.413,P=0.000).There was no statistical difference in waist painless anteflexion angle between the 2 groups in general,in other words,there was no group effect(F=12.347,P=0.573).The waist painless anteflexion angle presented a time-dependent trend of decreasing firstly and increasing subsequently in the 2 groups(76.54±12.11,38.72±5.44,40.44±8.97 degrees,F=9.249,P=0.000;75.29±13.05,37.37±7.52,53.21±11.44 degrees,F=14.178,P=0.000),while the 2 groups were inconsistent with each other in the variation tendency.There was no statistical difference in waist painless anteflexion angle between the 2 groups before the treatment and at 2 weeks after the nerve blocking surgery(t=0.427,P=0.671;t=0.884,P=0.379).The waist painless anteflexion angle was smaller in combination therapy group compared to monotherapy group at 6 months after the nerve blocking surgery(t=5.343,P=0.000).⑤There was interaction between time factor and group factor in waist painless backward-extension angle(F=19.545,P=0.001).There was statistical difference in waist painless backward-extension angle between different timepoints before and after the treatment,in other words,there was time effect(F=14.213,P=0.000).There was no statistical difference in waist painless backward-extension angle between the 2 groups in general,in other words,there was no group effect(F=11.247,P=0.612).The waist painless backward-extension angle presented a time-dependent trend of decreasing firstly and increasing subsequently in the 2 groups(79.33±7.09,63.24±6.51,65.97±8.04 degrees,F=4.874,P=0.000;80.41±8.21,64.97±7.54,74.97±9.17 degrees,F=6.037,P=0.000),while the 2 groups were inconsistent with each other in the variation tendency.There was no statistical difference in waist painless backward-extension angle between the 2 groups before the treatment and at 2 weeks after the nerve blocking surgery(t=1.291,P=0.103;t=1.455,P=0.721).The waist painless backward-extension angle was smaller in combination therapy group compared to monotherapy group at 6 months after the nerve blocking surgery(t=6.433,P=0.000).⑥No adverse reactions were found in combination therapy group;while the gastrointestinal reaction(1 case),manifesting as nausea and vomiting,was found in monotherapy group,and the symptoms were improved after stopping the medicine.There was no statistical difference in the incidence rate of adverse reactions between the 2 groups(P=1.000).Conclusion:The combination therapy of lumbar fixed-position oblique-pulling manipulation and ultrasound-guided lumbar spinal nerves posteromedial branch blocking is similar to monotherapy of ultrasound-guided lumbar spinal nerves posteromedial branch blocking in short-term curative effects and safety in relieving lumbago-leg pain,enhancing lumbar range of motion,improving waist muscle balance and restoring lumbar function in treatment of LFJS,however,the former is better than the latter in mid-term curative effects.