| BackgroundCervical radiculopathy(cervical radiculopathy,CR)is the most common type of cervical spondylosis,accounting for about 60%.TCM manual therapy can be aimed at the key pathogenesis of cervical spondylosis,‘tendon off-position and joint subluxation’,adjust and change the target segment of ‘tendon off-position and joint subluxation’ and the pathological conditions of the contact surface pressure between the internal tissues of the cervical spine and the abnormal stress distribution of the ligaments.And then,the cervical spine can restore the harmony of musculoskeletal system to achieve the purpose of treatment.Although the manipulation has a definite effect on most cervical spondylosis,when the nerve root canal stenosis such as huge herniated cervical intervertebral disc,hypertrophy and even ossification of the ligamentum flavum and posterior longitudinal ligament,which causes compression of the spinal cord,the treatment with TCM manual therapy has little effect.And may even induce iatrogenic damage.Percutaneous endoscopic cervical diskectomy(PECD)has a positive effect on resolving nerve root canal stenosis,but some patients have not resolved the ‘tendon off-position and joint subluxation’ after surgery or have recurred related symptoms due to various reasons.At that time,the indications for surgery of the patients are not clear.Can the combined intervention of the positioning and directional rotation technique(PDRT),a typical technique of TCM manual therapy,be used to reduce symptoms or reduce the recurrence rate? What is the safety and mechanism of this manipulaiton? Both are worthy of our further study.ObjectiveThis thesis intends to conduct two-way demonstration and research from two dimensions of finite element analysis(FEA)and clinical observation and evaluation:(1)Through analysis the biomechanical influence of PDRT on the cervical spine internal structure after PECD with finite element models(FEM);(2)Analyze the safety and effectiveness of the combined intervention of PECD and PDRT through clinical observation,including the improvement of participants’ clinical symptoms and their radiographic imaging evaluation.Methods(1)Based on the FEM of the normal human cervical spine that was verified and reliable in the previous study,combined with a real CR volunteer,who with typical pathological characteristics was screened,and the PECD postoperative FEM was created.The kinematic data and mechanical parameters of the PDRT will be collected and extracted with the 3D motion capture system and membrane mechanical sensors,and the obtained parameter will be loaded on the normal and post-PECD FEMs.The stress concentration areas and distribution patterns of the cervical vertebral body surface,the von Mises stress of the cervical discs,facet joint surfaces,joint capsule ligaments and main cervical ligaments under the PDRT,as well as the spatial displacement changes between vertebral bodies will be observed;(2)By recruiting patients who meet the requirements of the research protocol,23 CR received the combination management.Visual analogue scale(VAS)and Neck Disability Index(NDI)were recorded pre and postoperatively and 3 months’ and 6 months’ followup to evaluate the safety and clinical outcome.Cervical spine curvature and intervertebral space height of the target segment were measured by the cervical lateral X-ray.Horizontal displacement and angular displacement of the vertebral body were measured by cervical dynamic X Rays.Results(1)It shows that under physiological activities,the stress concentration and distribution characteristics of cervical spine FEM after PECD are not significantly different from those of normal one.It can be seen that PECD has little effect on the stability of cervical spine under physiological activities.During the operation of the PDRT,there is no significant difference in the following aspects,including the stress concentration area generated on the surfaces of each segment of the vertebral body of the model before and after the operation,the displacement value of each segment of the vertebral body,the cervical discs,the joint capsule ligaments and other internal structures.On the whole,the difference in stress change is small between the FEMs,and the stress change trend and distribution law are basically the same.(2)All patients’ PECD operations were successful,and they received manipulation 4～8times.No spinal cord injury,nerve root,or vascular injuries were found.Operation time was from 60 to 120 min with a median of 90 min;intraoperative bleeding was from 35 to80 ml with a median of 50 ml.All patients were followed up for pre-PECD,post-PECD,and post-operation for 3 months,6 months.VAS scores of the patients’ neck and arm,and NDI score after PECD were improved(P<0.05).However,even though the cervical spine curvature and intervertebral disc height after PECD were improved,but there was no significant statistical difference(P>0.05).And the subjects’ cervical stability with horizontal displacement,the angular displacement of the vertebral body was no apparent change before and after the operation(P>0.05).After received the manual therapy,NDI score of the patients were significantly decrease(P<0.05),while VAS scores of neck and arm,cervical spine curvature,and intervertebral disc height were better,but there was no significant statistical difference(P>0.05).And the subjects’ cervical stability was no obvious change(P>0.05).Conclusions(1)The optimized FEM established and validated in this thesis can ideally reflect the non-linear movement characteristics of the cervical spine,and can be used to further interpret the relationship between the PECD postoperative and the cervical spine ‘tendon off-position and joint subluxation’;(2)The PDTR has little effect on the stability of the cervical spine after PECD;(3)The results show that PDTR combined with PECD treatment for cervical radiculopathy can not only quickly improve the radiculopathy symptoms,but also safely and effectively relieve the residual symptoms after PECD,and there is no evidence demonstrate that will accelerate the adjacent segments of the cervical spine instability in the short term. |
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