Discussion On The Correlation Between Lumbar Disc Herniation With Different Syndrome Types And Neuropathic Pain Based On "Tendon Softening And Bone Strengthening"

Background: Lumbar disc herniation(LDH)patients may have varying degrees of dysfunction due to low back pain,lower limb root neuralgia,increased low back muscle tone,and compensatory scoliosis.When LDH causes lumbosacral nerve root compression,it can cause nerve root edema and lower limb root neuralgia.Percutaneous endoscopic lumbar discectomy(PELD)is consistent with "tendon softening and bone strengthening" in traditional Chinese medicine,which can gradually alleviate patients’ root pain and low back muscle tension and compensatory scoliosis by relieving root compression.Objective:1: To construct the evaluation system of the outcome and prognosis of neuropathic pain in LDH based on the Delphi method and provide a scientific evaluation tool for the choice of surgery and conservative treatment in patients with LDH.2: To study whether there is a correlation between the two syndrome types of LDH and the primary data of patients,low back muscle tension and root neuralgia.3: Based on the theory of "tendon softening and bone strengthening," diffusion tensor imaging(DTI)was used to evaluate the compressed nerve root of LDH,which provided a reliable theoretical basis for the application of PELD.Methods:1: The first round of expert letter questionnaires was designed based on literature review and expert interviews,combined with the case data of more than 3000 LDH patients to establish alternative indicators,according to the first round of item selection,combined with the feedback of experts to develop the second round of items.After consulting with experts,we screened the secondary indicators included.The new tertiary indicators were determined for the second round of expert consultation questionnaires to assess the outcome and prognosis evaluation system of LDH neuropathic pain.Finally,the correlation between each score and the total score in the evaluation system was verified by a pre-test.The score range was preliminarily drawn up as conservative/surgical treatment node selection.2: All the patients in this study were from the first ward of Orthopaedics and Traumatology Department of the First Teaching Hospital of Tianjin University of Traditional Chinese Medicine from January 2021 to November 2021 and planned to undergo PELD during hospitalization.70 Patients with LDH who met the diagnostic criteria and included criteria of qi stagnation and blood stasis type and liver and kidney deficiency type were selected.The observation indicators included(1)baseline data: age,sex,body mass index(BMI),course of pain,segment of intervertebral disc herniation,etc.(2)evaluation measures: LDH neuropathic pain outcome and prognosis scale constructed in Experiment 1;Force displacement distance(FDD)changes of low back muscle tension displacement in LDH patients;Clinical evaluation scales,including visual analogue scale(VAS)and Roland-Morris Disability questionnaire(RDQ).To analyze the degree of lower limb root neuralgia and the clinical situation of each observation index in patients with two syndrome types of LDH.3: A LDH patient with lower limb root neuralgia who was hospitalized in the first ward of Orthopaedics and Traumatology Department of our hospital in October 2021 was selected.Based on the concept of "tendon softening and bone strengthening",the involved nerve roots were quantitatively analyzed and visually reconstructed by DTI,and the changes of nerve roots before and after PELD operation were analyzed.The curative effect after PELD was evaluated by posture evaluation,DTI,and infrared thermal imaging of both lower extremities.Results:1: Through two rounds of expert questionnaires,an evaluation system for the outcome and prognosis of LDH neuropathic pain was established,including five first-level indexes,15second-level indexes,and 32 third-level indexes.Through preliminary clinical verification,"walking ability"(r=0.866),"radiation pain of lower extremities"(r=0.854),"self-care ability of daily activities"(r=0.769),"muscle strength of extensor pollicis longus"(r=0.710),"numbness"(r=0.701),"intervertebral disc CT,magnetic resonance imaging"(r=0.686),"degree of lumbar pain"(r=0.625),and had a high correlation.There was no significant difference in the correlation between "body weight","ankle plantar flexor strength" and the total score(P>0.05),and in the general data of patients(sex,age,occupation,etc.)(P>0.05).According to the established score range,the total score of the scale is 63,conservative treatment is recommended when the total score is 20 or less,surgical treatment is recommended when the score is higher than 35,and when the score is between(20-35],it is suggested to give advice according to the doctor’s clinical judgment.2: 35 patients with qi stagnation and blood stasis and 35 patients with liver and kidney deficiency were included.There was no significant difference in sex,lesion segment,lower limb affected side,lower limb root neuralgia course,and BMI between the two groups(P>0.05).In terms of age,the average age of the qi stagnation and blood stasis group was(37.40 ±7.74)years,and that of the liver and kidney deficiency group was(61.94 ±5.75)years,there was a significant difference between the two groups(P<0.05).In the study on the correlation of low back muscle tension,it was found that in the same syndrome type,the muscle tension of the affected side in the qi stagnation and blood stasis group was higher than that in the healthy side(P<0.05),but there was no difference between the liver and kidney deficiency group(P>0.05).The contralateral muscle tension in the liver and kidney deficiency group was higher than that in the qi stagnation and blood stasis group(P<0.05).There was no significant difference between the two syndrome types in the correlation analysis of low back VAS and RDQ scores(P>0.05).In the analysis of the correlation between the degree of lower limb root neuralgia and the observed indexes,in the group of qi stagnation and blood stasis,the degree of lower limb root neuralgia was correlated with the course of pain(r=-0.379),Experiment 1 score(r=0.569),RDQ score(r=0.548)and FDD value of the affected side(r=-0.434),there was a significant difference between the two groups(P<0.05).In the liver and kidney deficiency group,the degree of lower limb root neuralgia was correlated with Experiment 1 score(r=0.560)and RDQ score(r=0.683)(P<0.05).The results of Logistic regression analysis showed that the muscle tension of the affected side(P<0.05)and the degree of low back pain(P<0.05)might be the risk factors of lower limb root neuralgia.3: After PELD,the patient’s posture,imaging findings of lumbar vertebra,clinical evaluation scale,FDD value of low back muscle tension,fractional anisotropy(FA)and apparent diffusion coefficient(ADC)of DTI,and temperature difference of both lower limbs were improved,and the clinical effect was significant.Conclusion:1.When evaluating the condition of patients with LDH,we should pay more attention to their "walking ability","radiation pain of lower limbs","self-care ability of daily activities","muscle strength of extensor pollicis longus","numbness","intervertebral disc CT,magnetic resonance imaging","degree of low back pain".2.Age may be the factor for the classification of LDH qi stagnation and blood stasis type,and liver and kidney deficiency type.The muscle tension of the affected side of the lumbar back of the patients with qi stagnation and blood stasis was often higher than that of the healthy side.In comparison,the muscle tension of the healthy side of the patients with liver and kidney deficiency was higher than that of the patients with qi stagnation and blood stasis.The degree of lower limb root neuralgia in patients with qi stagnation and blood stasis was related to the course of pain,Experiment 1 score,RDQ score,and FDD value on the affected side.In comparison,the degree of lower limb root neuralgia in liver and kidney deficiency patients was related to Experiment 1 and RDQ scores.The muscle tension of the affected side and the degree of low back pain may be the risk factors of lower limb root neuralgia.We can make the individualized treatment plan according to the characteristics of different syndrome types in clinical treatment.3.Based on the theory of "tendon softening and bone strengthening" in traditional Chinese medicine,PELD can effectively remove the protruding intervertebral disc,relieve root compression symptoms,and improve root pain,increased low back muscle tension and compensatory scoliosis of the spine.In addition,DTI can effectively evaluate lumbosacral root neuralgia.