| Background:With the popularization of MRI technology,lumbar MRI examination has become the most important imaging basis for the diagnosis of lumbar disc herniation.There are clinical reports at home and abroad that the herniated intervertebral disc can shrink without surgical intervention,and even the phenomenon of the herniated intervertebral disc completely disappears.This special phenomenon is called the phenomenon of resorption.In our clinical studies,we found that the larger the disc herniation is,the higher the probability of resorption is.However,the existing clinical guidelines for routine surgical treatment in this type of patients have not been studied in terms of conservative treatment.As an empirical prescription of Suzhou Hospital of Traditional Chinese Medicine,Xiaomuhuahe Decoction has been proved by clinical and experimental studies to promote the resorption phenomenon after lumbar disc herniation.However,the occurrence of this special phenomenon cannot be effectively predicted at present,and the mechanism of promoting the resorption by traditional Chinese medicine is still unclear.In this regard,we designed a clinical study,screening the factors affecting disc resorption through classified imaging observation,and using enhanced MRI technology to predict clinical outcomes.In addition,basic experiments were conducted to explore the role of autophagy and apoptosis in the process of intervertebral disc resorption,aiming to provide a scientific basis for the tr eatment of giant lumbar disc herniation with traditional Chinese medicine.Objective:(1)Through follow-up study,the feasibility and risk of conservative treatment of giant lumbar disc herniation were analyzed,and imaging factors affecting resorption of giant lumbar disc herniation were screened to avoid clinical treatment risk.(2)A prospective study was conducted to analyze the predictive significance of enhanced MRI of the lumbar bovine eye sign in the conservative treatment of giant lumbar disc herniation.(3)In order to explore the possible mechanism of the successful treatment of giant lumbar disc herniation,the pathological differences of the nucleus pulposus specimens in the positive group and the negative group of the bull's eye sign were observed by in vitro experimental study on the herniated nucleus pulposus specimens taken out by the operation.(4)Through animal experiments,the effects of Xiaominhuahe Decoction on histoporphology,autophagy and apoptosis in rat model of intervertebral disc herniation were observed,and the possible mechanism of its promotion of resorption after intervertebral disc herniation was explored.Methods:(1)Retrospective study:From January 2008 to December 2019,409 patients with giant lumbar disc herniation who were first selected for traditional Chinese medicine treatment in Suzhou Hospital of Traditional Chinese Medicine were followed up for 1-12 years.Group studies were conducted according to the image grades.The surgical rate,absorption rate of herniation and the rate of good and good clinical efficacy in each group were statistically analyzed:(2)Prospective study:collect lumbar enhanced MRI showed huge type 80 cases of patients with lumbar disc prolapse,according to the bull's eye sign points are divided into ?,?,?,after treatment gives review of magnetic resonance imaging(MRI),statistics and analysis of the operation rate,highlight the rate before and after the treatment,the maximum level protrusions area and the spinal canal area percentage,absorption rate and JOA score changes.(3)In vitro experiment:22 cases of enhanced MRI showed huge surgery patients with lumbar disc prolapse grouping,remove the operation of the bull's eye sign all the 11 cases highlight the positive and negative groups nucleus pulposus pathology study,observation and analysis between the two groups of histomorphology,T cell markers(CD3,CD4,CD8),B cell markers(CD20),vascular endothelial cell markers(CD31),macrophage marker(CD68)the difference between the positive expression rate of.(4)In vivo experimental study:Through the establishment of rat ruptured disc herniation model,96 SD rats were divided into ruptured group and non-ruptured group(48 rats in each group).The two groups were treated with xiaominghuahe decoction and normal saline respectively,which were set as the traditional Chinese medicine group and the control group.To observe the effects of intervertebral disc rupture and elimination of myeloid nucleus decoction on the levels of immunohistochemistry,autophagy and apoptosis of protrusion nucleus pulposus.Results:(1)409 patients were followed up for 1 to 12 years,with an average follow-up time of 3.56±2.81 years.MRI examinations were performed 1-11 times,with an average of 2.94±3.98 times.Among 130 cases(31.78%)of the first diagnosis,87 cases(21.27%)were positive for bovine eye sign and 43 cases(10.51%)were negative for bovine eye sign.Among 89 patients(21.76%)who received surgical treatment,11 patients(2.69%)developed symptoms of cauda equina nerve injury,which disappeared after surgical treatment.After conservative treatment of 320 patients(78.24%),the protrusion rate,the maximum surface area of the protrusion and the percentage of the vertebral canal area in the patients decreased significantly compared with before treatment,and the JOA score increased significantly(P<0.05).The rate of good and good efficacy was 84.06%.Among the patients treated conservatively with taditional Chinese medicine,189 cases(59.06%)had resorption,and 85 cases(26.56%)had obvious absorption.Patients with positive cow's eye sign,MSU3 type and disease course less than 1 year had higher probability of resorption(P<0.05).(2)Among the 80 patients with giant disc herniation revealed by enhanced MRI,12 patients received surgical treatment(15.00%),and 68 patients received traditional Chinese medicine conservative treatment(85.00%).No symptons of cauda equina nerve injury occurred in all the patients during the treatment.The absorption rate of the patients treated with traditional Chinese medicine was(51.37±34.31)%,the protrusion rate,the maximum layer area of the protrusion and the percentage of the vertebral canal area were significantly reduced compared with before treatment,and the JOA score was significantly increased(P<0.05).Among them,the absorption type ? patients(72.68+24.32)%,? type(48.31+29.51)%,as ? type(8.06+14.75)%,the degree of absorption type ?>>? type ? type(P<0.05);1 year after treatment,JOA score ? type>? type>? type(P<0.05).(3)Immunohistochemical staining of nucleus pulposus of 22 cases showed that the positive expression rates of T cell markers(CD3,CD4)and vascular endothelial cell markers(CD31)in positive group were higher than those in negative group(P<0.05),and the positive expression rates of macrophage markers(CD68)were significantly higher than those in negative group(P<0.01).(4)Immunohistochemical staining and transmission electron microscope observation showed that the degree of intervertebral disc degeneration and the number of autophagosomes in the TCM group were better than those in the control group at 8w,and the degree of intervertebral disc degeneration and the number of autophagosomes in the ruptured group at 4w and 8w were better than those in the unpunctured group at 4w and 8w(P<0.05).TUNEL assay showed that the ratio of apoptotic cells in the TCM group was higher than that in the control group at 4W and 8W(P<0.05),and the ratio of apoptotic cells in the ruptured group at 4W and 8W was higker than that in the unpunctured group(P<0.05).Conclusion:(1)After the treatment of giant lumbar disc herniation with traditional Chinese medicine,if the symptoms are gradually reduced in the treatment process and no symptoms of cauda equina nerve injury occur,the probability of resorption of the herniation is large,and the risk of clinical treatment is small.Huge lumbar disc herniation can have a benign outcome under the intervention of traditional Chinese medicine.The shorter the course of disease and the larger the herniation,the greater the success rate of traditional Chinese medicine treatment.(2)Enhancement MRI can be used as an important basis for predicting resorption in giant lumbar disc herniation.The bull's eye sign around the herniated disc is an important indicator indicating that it is easy to be resorption.The bull's eye sign positive is more likely to occur resorption in lumbar disc herniation.(3)Enhanced MRI showed that the bull's eye sign positive patients were prone to resorption.The mechanism may be that the neovascularization around the protrusion into the protruded nucleus pulposus caused the immune phagocytosis reaction,thus promoting the resorption of the herniated disc.(4)The decoction can accelerate the degeneration of herniated intervertebral disc tissue,induce autophagy and apoptosis of herniated intervertebral disc cells and promote the re-absorption of herniated disc. |
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