| BackgroundNot only the incidence of low back pain rise year by year but also gradu ally younger. Low back pain can result from a number of causes include the s train of lumbar ligament, muscle or other soft tissue, tumor, lumbar disc et. T he current international is generally accepted that lumbar degeneration is the le ading cause of the disease occurred. Patients with a variety of incentives, such as acute sprain, chronic strain, nucleus pulposus from rupture overflow, stimul ate or oppressed nerve root, horsetail nerve which appear on one side or doub le side waist radioactive pain.In recently,there was unable to reach a consensus in the pathogenesis, dia gnosis and treatment of cervical spondylosis radiculopathy at home and abroa d. Although the study of intervertebal disc degeneration has been to molecular gene level,but the degeneration of the initating and key factors is not clear. In recent years, the amount of neural biochemical and immunological research re sults suggest that aseptic inflammation is closely related with lumbar disc hern iation. Nucleus pulposus overflow from the broken fiber ring, and then spreadi ng between the intervertebral disc and nerve root. Glycoprotein and beta prote in of the nucleus pulposus can lead to inflammation of the nerve root because of their strong chemical excitant to the nerve root and release a large number of histamine at the same time. Inflammation makes local muscle tension, vas oconstriction and then causing ischemia and electrolyte disorder. It is the main casue of the lumbocrural pain.The treatment of lumbar disc herniation mainly non-surgical treatment incl ude traction, physical therapy, acupuncture, moxibustion, massage, oral medicati ons, sacral canal et al. The main purpose of the traction therapy is reducing t he pressure of intervertebral disc, relieving muscle spasms, promoting inflamma tion disappeared et al. So as to realize the purpose of back pay outstanding n ucleus pulposus, but this method has a higher recurrence rate. The various mas sage therapy means must be continued, and the treatment effect is poor. The d rug is given priority to diminish inflammation and pain but it’s adverse event is greater, so a large part of the patients can’t accept it. And sacral canal bio ck therapy is a method to make the drug injected to or spread to the lesion si te in order to reduce inflammation and edema of the nerve root. With the deve lopment of minimally invasive treatment technology, sacral canal blocking has become an important means of lumbocrural pain caused by lumbar disc herniat ion.There are many problems to be solved, although sacral canal blocking can obtain good therapeutic effect. Its treatment effect is depending on whether th e needle arrived in the epidural space and the drugs was injected or spreaded around the nerve root lesion or not. But due to the lack of basis of sacral ca nal anatomy, it can not give solid support and guidance to its clinical applicati on, so it trigger a series of complications and sequelae. The main problem of the sacral canal injection is how to carry out a safe, effective, economic and a pplicable for sacral canal injection. Foreign scholars Park and his colleagues co nducted a study on the treatment effect of sacral canal injection guided by ultr asound or X-ray on 120 patients with unilateral lumbocrural pain to compared the diffrence of the short-term efficac, improving function and patients’satisfa ction of the two methods. Treatment effect and function situation in the 2 wee ks and 12 weeks, verbal number pain scale, oswestry disability index, function assessment and puncture accuracy were assessmented of the two groups. The results of the study is that there is no difference of the two groups in he 2 w eeks and 12 weeks, verbal number pain scale, oswestry disability index, functi on assessment and puncture accuracy. The results suggest that there was no sta tistical differences in the accuracy of the puncture accuracy of sacral canal on the two methods. And ultrasound can distinguish muscles, blood vessels, bony structure, to provide real-time image, and reduce the complications such as va scular puncture.The mainly treatment method of the sacral canal blocking is blind in chin a, but this method has a higher failure rate because of the anatomical variatio ns of sacral canal and osseous fusion structure. While the mainly treatment me thod of the sacral canal blocking in foreign is conduted by X ray or CT. On the one hand, it can improve the puncture accuracy rate, and improve the cura tive effect, On the other hand it can reduce the damage of the surrounding tis sue and the occurrence of adverse reactions. But it also has certain problem, fi rst of all, patients with X-ray and CT guidance is expensive, aggravating the e conomic burden so it is hard to accept of patients. The second, medical staff and patients have a certain degree of the risk of radiation, so they are differen t to promote. The third, they are different to move and complicate to operatio n. Ultrasonic was noticed by people with a lot of advantages such as easy to carry, no radiation, provide real-time image, low price. It can clearly identify t he muscles, nerves, blood vessels, bony structure, ligaments and joints, et al a nd can get real-time image, no radiation to patients and medical staff compar ed with X ray or CT. So it is a good choice to pregnant woman or other peo pie which have a contraindications of radiation. And it is more cheaper than X ray or CT to patients, so it has a wider application. And it is more easy to master to a beginner. Nikooseresht think that the ultrasound images of the sa cral canal anatomical structure is relatively simple, it is just need to identify th e ligament and bony structure, so the operators can easily master the technique of ultrasonic even though he is a beginner. Ultrasound can provide real-time i mages, observe the liquid diffusion process and the vessels, so it can guide th e needle to avoid adverse reactions such as intravascular puncture.Ultrasonic security has been confirmed in the nerve block and articular ca vity injection treatment, et al. We all believe that there will be more study of pain treatment of ultrasonic technology along with development of ultrasonic and the diagnosis and treatment of pain. This will make the pain treatment ha s more pertinence and effectiveness of the application of ultrasound in pain tre atment and it will have a more broad prospects.The traditional method of locating the sacral hiatus is locating the surface sign sacral canal by doctors. But the failure rate of experience physician oper ation achieved 14%-16% because of obesity, malformation, trauma, variation of sacral hiatus and these factors make 12% of the patients have fuzzy sacral horns. So it is difficult to the beginner to master the skill and it often takes longer learning curve to better master the technology. As a visual imaging tec hnology, ultrasound can identify the muscles, blood vessels, ligament, joint and the bony structure and it can clearly show the sacral hiatus, sacral horns, sac ral tail ligament and sacral lumen. So it can position the puncture point accura tly, and guide the needle into the right direction. Thus it can improve the ac curacy and safety of operation, the success rate of puncture, and reduce freque ncy of puncture. So it is a useful tool for the beginner who want to learn the skill of sacral canal punctures. So we proposed to use it in the teaching of t he sacral canal puncture, in order to investigate the effectiveness and repeatabil ity, efforts to improve the learning efficiency.ObjectiveThe purpose of this study is to discusse the following two aspects of the problem.1.The one is to observe the effective of sacral canal blocking guided by ultrasound in patients with lumber disc herniation.2.Another is the discussion of the learning curve of sacral canal blocking guided by ultrasound in order to analysis it’s learning rule and improve the 1 earning efficiency.Method1. A total of 150 patients with lumber disc herniation confirmed by icono graphy were randomly divided into 2 groups:the ultrasound group(group U, n =75) and the non-ultrasound group(group N,n=75). The cases of VAS<4 wer e recorded pre-treatment>.15 min 1w,2w and 4 w after the treatment. Th e number of one-time successful puncture, the average puncture time and cases with second treatment were also recorded. Efficacy evaluation at 1w、2 w an d 4 w and VAS after the treatment and the number of lasegue sign≥75℃ at dif ferent time points as well as the satisfaction of the treatment and the incidenc e of adverse reactions between the 2 groups were also recorded.2. Totally 11 interns trained by experienced anesthesiologists were enrolled in this study. They performed caudal block on 8 patients by the traditional blind and ultrasound-guided (each method for 4 patients) under the supervisio n of experienced anesthesiologists respectively. The choice of the method of ca udal block was determined by computer-generated random number list. Punctur e success rate of the two groups, success rate of one time puncture, the avera ge puncture rate, the average puncture time and the incidence of adverse reacti ons were record. If the puncture time was 3 or more of patient or blood appe ar in every time of puncture were considered failure. The rest were performed by attending physician.Statistical methodsSPSS 18.0 software was used to analyze the statistical data.. Measurem ent data of the experimental data are expressed by Mean ± standard deviation (x±s). The data of normally distributed were compared using T test. Within t he group to compare using repeated measures design analysis of variance. Cou nt data were compared using chi-square test. Compare with rank and inspectio n level data. Wilcoxon test level data to P<0.05 was considered statistically s ignificant.Resultl.Two groups of patients were successfully treated, no exit in this study. There were no significant differences between the two groups in age, sex, bod y mass index, course of the disease, highlight the section and VAS before the treatment. The cases with VAS<4 were increased at each time points after tr eatment in 2 groups. Compared with group N, there were significantly more c ases with VAS<4 in group U at 15 min and 1 w after the treatment (P< 0. 05),while there were no significant difference at the rest time points. Compare d with group N, there were more cases of one-time successful puncture and le ss cases with second treatment in group U (P< 0.05), the average puncture ti me were similar in the 2 group. There were no significant difference of the ef ficacy evaluation and VAS at 2w and 4w after the treatment while the excelle nt and good rate and VAS of group U was significant higher than group N at 1 w after the treatment. The number of lasegue sign≥75°t 15min and 1w aft er treatment and the satisfaction of the treatment of group U was significant h igher than group N and the incidence of adverse reactions was lower compare d with group N, and there was no significant difference at the time point of 2 w and 4w between the two group in the number of lasegue sign>75°.2.A total of 85 patients were enrolled in this study, so 3 of the 11 intern were just completed 7 cases. There were no significant differences between th e two groups in age, sex, body mass index (P>0.05). The success rate of thepuncture and the one-time puncture in the group of ultrasound-guided cauda 1 block (85.7%,50.0%) were significantly higher than the group of traditional b lind caudal block (60.5%,18.6%).The group U was significantly lower than gro up N in average time (11.5±2.1 vs.18.9±2.9), number of times (1.5±0.7 v s.2.3±0.8), and incidence of adverse reactions of puncture (2.7% vs.11.5%) (P <0.05).Conclusion1. Not only the ultrasound-guided caudal epidural block has high accurac y、less treatment times and the lower incidence of adverse reactions but also h as a higher satisfaction of the treatment, which is a safe and reliable visualize d therapeutic method.2. With the advantages of a faster learning curve, higher success rate of p uncture, shorter puncture time and lower incidence of adverse reaction, ultrasou nd-guided caudal block is easier to master for novice personnel. |
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