Study On The Treatment Of Cervical Spondylosis Of Vertebral Artery Type Manipulation Experience Of Professor Sun Shuchun

Sun Shuchun, Chief Physician, is the successor of China’s first batch of National Intangible Cultural Heritage "Chinese Bonesetting". His academic origins are mainly from the Palace School Zhuobanchu in the horse Institute. The Palace bonesetting at Shangsi Courtyard originated from the late Ming and early Qing dynasties when Zhuoerji was the most well-known Mongolian doctor. He imparted his special medical skills to numerous soldiers and trained a large number of orthopedic doctors in the Manchu and Mongolian "Eight Banners", which was called "Zhuoban" in the Manchu language."Golden Mirror of Medicine· The Gist of Bone Setting " was considered as the golden rules by the Zhuoban doctors in Shangsi Courtyard. The academic thoughts it explained, unified these Zhuoban doctors in the medical theory, and also marked the birth of "Bonesetting Heart School" of Zhuoban doctors in Shangsi Courtyard. The academic thoughts experienced infancy (Zhuoerji, the representative, whose academic thoughts mainly showed the characteristics of Mongolian orthopedists’combined osteosynthesis and injuries therapy, relying on secret recipes with the treatment methods supplemented with knives, hammers and special effect Mongolian medicine, techniques and medicine equally matched), formation (Yisang’a. the representative, who was adept at osteosynthesis of the "Orthopedic Eight Skills" and laid more emphasis on the healing effect of these skills, after inheriting the academic thoughts of Zhuoerji), pre-maturity (De Shoutian. the representative, stressing the "dexterity"), maturity (Xia Xiwu, the representative, proposing the treatment thoughts of "li、zheng、jie、shi" in the fracture and "li、pan、 xuan、bei、he、tui、yao、bai、ti" in the tendon wounds, so as to enrich and develop the skills in the "Golden Mirror of Medicine and Traumatology Heart Gist"), and late maturity to present (Sun Shuchun, the representative, putting forward academic perspectives of "Tendon injury treatment, QI and blood significant","association of activity and inertia, medical skill play a major role", and pointing out that great attention should be paid on capitalizing on the trend, treating lightly and softly, and using skills and medicine simultaneously)Cervical spondylotic vertebral arteriopathy. CSA, is a common clinical disease and first proposed by Barre and Lieou in1926. who believed the fact that the sympathetic nervous system, stimulated by the cervical lesions involving the vertebral artery, caused dizziness, blurred vision, ringing in the ears, nausea, vomiting, even cataplexy and other symptoms, was because of the vertebral-basilar artery insufficiency (VBI), clinically known as cervical spondylotic vertebral arteriopathy, vertebral artery ischemia syndrome or cervical vertigo. Over the past70years, many scholars have conducted in-depth researches in CSA from the aspects of anatomy, pathology, neurology and clinical application, and the understanding of its pathogenesis has been increasingly unified; but with the developments of radiographic inspection techniques and clinical applications of new technologies, we also have a new understanding of the diagnosis of CSA; analyzing pathological basis from the perspective of pathology etiology and therefore distinguishing and treating CSA, have attracted much attention, and its treatment skills have become more abundant.Vertebral artery begins with the subclavian artery and is divided into four sections. The first section is from the subclavian artery to the cervical transverse foramen, at the back of which are transverse process of C7, anterior branches of C7and C8spinal nerves, the sympathetic trunk and cervical sympathetic ganglion; the second section is from C6transverse foramen to the hole under the C2transverse foramen, the inside of which is adjacent to the uncovertebral joints while the posterolateral parts are the zygapophysial joints, with sympathetic nerves surrounded; the third section is from the hole under the C2transverse foramen to the foramen magnum, with many bends and pacin bodies on the arterial wall which could reflectively regulate blood vessel diameters through vertebral artery blood pressure changes and ensure the normal operation of neck blood flow; the fourth section is the intracranial segment, both sides of the vertebral artery merging into the basilar artery, with pons branch dominating vestibular nucleus and internal auditory artery dominating labyrinth. Since the anatomical relations of the vertebral artery are complex, the pathogenesis of CSA is also complex and diverse.About the pathogenesis of cervical spondylotic vertebral arteriopathy, there are mechanical compression theory, sympathetic stimulation theory, neck soft tissue lesions theory, humoral factors and microcirculation theory, upper cervical spine theory, and vascular factors theory. These theories explore the pathogenesis of CSA from different perspectives. Currently the pathogenesis relatively recognized is that the uncovertebral joints are squeezed by intervertebral disc degeneration and stenosis so that the proliferation compresses or stimulates the vertebral artery and causes a spasm or distort, which would lead to cerebral ischemia, resulting in dizziness, headache and other symptoms. Other pathogeneses include:instable uncovertebral joints compressing or simulating nerve plexus around the vertebral artery, stenosis or congenital slenderness of vertebral artery transverse foramen, osteophytes from uncovertebral joint hyperplasia compressing the vertebral artery or stimulating nerve plexus around it, neurotransmitter mediating diseases which lead to vertebral artery hemodynamic disorder and vertebral-basilar artery insufficiency. Owing to the diversity of pathogenesis, it is difficult to unify these various theories, bringing difficulties to the CSA diagnosis.The diagnostic criteria of CSA was repeatedly proposed at cervical spondylosis meetings in recent years, but it was quite controversial. An authoritative diagnostic criteria was drawn up at the Second National Symposium on Cervical Spondylosis in1993:(1) cervical vertigo and possible cataplexy history;(2) Neck rotation test proved positive;(3) X-ray abnormal findings;(4) most associated with sympathetic symptoms;(5) excepting eye-derived or ear-derived vertigo;(6) excepting insufficiency of the vertebral artery Section Ⅰ and Section Ⅲ, psychoneurosis and intracranial tumors;(7) a vertebral artery angiography or digital subtraction angiography vertebral artery angiography (DSA) required before making a definite diagnosis while rheograph and encephlogram just as references. The establishment of diagnosis should have the following three principles:(1) clinical manifestations of cervical spondylosis;(2) degenerative changes of intervertebral disc or intervertebral joints demonstrated in the imaging examination;(3) imaging findings corresponding to clinical manifestations which means the imaging findings could explain clinical manifestations. Zeng Shengming stressed that a significant change in X-ray findings without clinical symptoms should not be made a diagnosis of "cervical spondylosis"Currently, there is no unified standard in imaging diagnostics for CSA, as a result of the complexity and diversity of CSA etiology and pathology, causing vertebral-basilar artery insufficiency and a series of symptoms. To sum up, CSA have different radiographic manifestations in various imaging diagnostics, together with their own characteristics and different emphases. Some of them could find the reason of stimulation or compression to the vertebral artery, some could detect whether there is a spasm, stenosis or bending in the vertebral artery, and some could achieve both. Therefore, X-rays, vertebral artery angiography, CT, MRI, TCD and CDFI could directly or indirectly reflect the vertebral artery involvements from different aspects, providing valuable information for clinical diagnosis of CSA.The treatments related to CSA, reviews domestic research documents about relevant manipulation treatments in recent5years and compiles the various therapies of manipulation treatments of this disease, including common massage techniques, rotatory manipulation, pulling manipulation, micro-regulating manipulation, as well as comprehensive manipulation, etc. Among the comprehensive manipulations, there is a combination of traditional Chinese medical techniques, such as manipulation techniques and traditional Chinese medicine, and a combination of manipulation techniques and the Western medical treatments. The comprehensive manipulation could take effect more fast and effectively, compared with a single manipulation. The researches on the manipulation treatments of CSA are mostly based on clinical observations, lacking preciseness in the design of scientific researches, and therefore the diagnostic criteria do not match with the efficacy criteria. Besides, the lack of laboratory diagnosis and a majority of non-controlled trials without setting up corresponding control groups, result in inaccurate judges on its efficacy, seriously affecting the quality of the documents.Professor Sun has his own unique experience in the treatment of CSA, summarized as follows:1. He emphasizes the applications of modern means of diagnosis, treatment and medical examination of CSA. Mr. Sun believes that where are diseases, there are symptoms. Only with the recognition of symptoms, diseases could be distinguished. The two are inseparable. At the time of clinical diagnosis, it is necessary to distinguish diseases, but also symptoms; only when diseases and symptoms match with each other, we could choose the appropriate medicine and manipulation. The identification of diseases contains two aspects:one is the traditional Chinese medicine diseases diagnosis under the theories of traditional Chinese medicine and the other is the Western diseases diagnosis under modern medical theories. The identification of symptoms is to identify the various symptoms at different stages during the developments of diseases, guided by the basic theories of traditional Chinese medicine. The combination of Western medical disease identification and traditional Chinese symptom identification is just a model in the clinical diagnosis. We should rationally utilize modern medical theories and means of detection while basing on the traditional Chinese symptom identification, broadening our diagnosis views. We should analyze and observe intrinsic etiology, pathogenesis and evolution rules of diseases, under the guidance of traditional Chinese medicine. The methods of traditional Chinese medicine diagnosis are mainly looking, smelling, asking and feeling the pulse, the four movements. However, some deeper pathological changes, our sense organs alone are impossible to understand, especially in orthopaedics and traumatology. The help of modern scientific and technological means of checking is required. In the treatment process of cervical diseases, Mr. Sun stressed the X-ray imaging played an important role in assisting the treatment.2. Finding clustered tendons is an important step to treat CSA, as clustered tendons are usually found in the paravertebral soft tissue at the levels of C3-4in this disease."Only with the accurate identification of clustered tendons", we could cure the disease." This concept inflects Mr. Sun’s treatment through identifying clustered tendons. The manifestations of "tendon" in the tendon injury diseases, as recorded in documents, include strong tendon, crooked tendon, broken tendon, moving tendon, thick tendon, turning tendon, relaxing tendon, flaccidity of tendon and muscle, left tendon, transferring tendon and contracting tendon, etc. These manifestations in clinical palpation are described as cord-like clustered tendons, grain-like particles and bean-like hard objects and so on. The modern medicine believes that partial bleeding, blood seeping, edema and inflammatory cell invasion would lead to traumatic inflammatory swelling of tissues and the fibrous tissue proliferation forms the so-called "clustered tendons" after a tendon injury with the tissue recovery. Different tissue injuries could result in different clustered tendons. In the fascia or sarcolemma injuries, clustered tendons are gritty; in the ligament injuries, clustered tendons are about the size of mung beans; in the muscle injuries, clustered tendons are cystic or banding with different thicknesses.3. Rotatory manipulation is a common practice to treat CSA.4. Manipulation treatment of CSA has a clinical curative effect.In order to verify the clinical efficacy and safety of Mr. Sun’s manipulation treatment of CSA, we randomly studied177cases of CSA, which were divided randomly into the group of screwing and raising manipulation,87cases and the group of cervical traction,90cases. Among these cases, male43cases and female134cases; aged35to55with an average of47.2; duration of disease the longest5years and the shortest14days. The group of screwing and raising manipulation was treated every other day, a total of7times, and the group of cervical traction was treated once a day, a total of14times. By observing dizziness, cervical activity, headaches, and other indicators of changes before and after treatments, we compared the efficacy of the two methods through statistical analysis for efficacy evaluation. Results:after2weeks of treatments, the total effective rate of the group of screwing and raising manipulation was98.8%while the total effective rate of cervical traction was83.03%, which showed the group of screwing and raising manipulation was better. The group of screwing and raising manipulation was superior to the group of cervical traction in improving the symptoms of vertigo, cervical activity and headache. Conclusion: screwing and raising manipulation is a worthy choice for treating CSA.