| BackgroundCervical spondylosis is a common disease, traction as a treatment for cervical spondylosis radiculopathy has been widely applied in clinic. During clinical work, we often meet with some unuaual cervical spondylosis radicul-opathy (CSR) patients, whose MR imaging showed spinal cord compression caused by degenerative changes, but only has the clinical characteristics of CSR. The patient has no clinical manifestations of spinal cord damage, which we called cervical spondylosis radiculopathy with degenerative spinal cord compression. It consists of two parts, one is the symptoms of CSR;the other is asymptomatic spondylotic cervical cord compression which is showed on MR imaging. But sometimes we cannot understand the pathogenesis of this disease sufficient-ly, and the treatment we used is just for the symptoms of the CSR, which may injured the spinal cord, leading to the further progress of spinal cord compression, Also there is no systematically expounded in the conservative treatment of these diseases.Back-lying and Forward-bending Traction has been showed a significant effect on the treatment of CSR. We also use this method to treat the pat ent which has the CSR with degenerative spinal compression as an attempt, we find during the flexion traction, the patie(?)s’ symptoms were obviously alleviated, and there has no symptoms of the spine cord injures showed. However, the mechanism of this method is unclear, and the systematic assessment of the effectiveness of the treatment to the diseases is also lack of.Objective To discuss the mechanism and assess the sys effectiveness of the Back-lying and Forward-bending Traction to treat the patient who has the CSR with degenerative spinal cord compression. In order to explore the mechanism of Back-lying and Forward-bending Traction in treatmenting the CSR with degenerative spinal cord compression, and to improve curative effect of disease, and reduce the incidence of spinal cord damage.MethodsThree-dimensional finite element analysisChoose5volunteers who are consistent with the CSR with degenerative spinal cord compression diagnosis and meeting the requirements of this subject. Let them take Cervical CT scan, and the scan thick layer is0.75mm. Storing the CT images and input to the Mimisc10.01software to generate three-dimensional images. We can get the Contour datas of cervical vertebras through different thresholds in Mimisc, and save as Binary STL files, which are inputed to the Geomagic Studio.We divide the vertebra into sereval parts according to the curvature of different vertebra, and then we can generate the cervical geometric model by using the point cloud data of each region. Input it to the MARC2005software, and establish the finite element modeling according to the modeling parameters of different structure. Finally we impose6Kg traction to the cervical spine model in neutral and20-degree-flexion position and simulate biomechanical experiment by using the MARC software, in order to get the data of the intervertebral space and foramen intervertebrale from different angles traction, and analysis the biomechanical force of the cervical disc.Clinical researchTelephoned the98cases who has suffered cervical spondylosis radiculopathy with degenerative spinal cord compression during2007to March2012, comparing their VAS and JOA scores while before treatment, discharge and follow-up visit, to analyse the effectiveness of the Back-lying and Forward-bending Traction. Select30cases of cervical spondylosis radiculopat-hy with degenerative spinal cord compression from March2012to January2013, Each patient take the neutral and flexion MR imaging.First we use our hand to implement traction, in order to find the best traction angle and weight. Then we carry out the Supine front-traction by using the traction device, the traction angle is from0to40degree flexion;traction weight from3to5kg to start, can be gradually increased to810kg. We must make sure there is no special discomfort during the traction. The traction should be taken20minutes each time,2or3times a day, for2consecutive weeks, we also use traditional Chinese medicine, light technique and the patient’s health education as supplementary. Record the VAS, JOA (17points), JOA (20points) scores of each patient while before treatment,discharge and one-month-follow-up visit. Then we use the VAS and JOA (20points) scores to evalue effectiveness of the Supine front-traction, using the JOA (17points) score to evaluate the changes of spinal cord function in patients during treatment. The cortical somatosensory evoked potentials were recorded during the first time traction. The recording electrode was respectively placed in the head C3/C4-Fz, the spinous process of C7and the Erb position,while the reference electrode was placed in the forehead to record the evoked potentials of cervical spinal cord, cortical and peripheral nerve. The bandpass range is about20~2000Hz, while the stimulus intensity is5~20mA, in order to cause the thumb slight tic. After signal filtering and amplification, we measured the latent period(PL)and the amplitude of N9(supraclavicular potentials),N13(cervical spinal cord potentials), N20(subcortical and cortical potentials), and the peak latency of N20-N13as also. We use the waveforms while patient in a calm state with normal posture as a baseline, then we observe the waveform changes during the Supine front-traction, and evaluate the safety of traction process. In the MR imagings of he neutral and flexion position, we analyse data statistical at two point, one is the sagittal diameter index of disc herniation;the other is the vertebral canal sagittal diameter and the ratio of vertebral canal sagittal diameter and spinal diameter.ResultThree-dimensional finite element analysisAll volunteers are required to complete traction, and imaging examination. Changes of vertebral displacement after20-degree-flexion traction is significantly. Changes of intervertebral space after the20-degree-flexion traction, especially in the posterior, is significantly increased compare to the neutral. From the statistical analysis, the intervertebral space (exceptC6/7) and intervertebral foramen has no significant difference before the different angles traction(P>0.05). In the C3/4segment, the posterior intervertebral space has significantly increased(P<0.05), while the intervertebral foramen and the anterior intervertebral space has not (P>0.05)comparing to the different angles traction. In the C4/5,C5/6, C6/7segment, the posterior intervertebral space and intervertebral foramen has significant difference. Also the relative changes of vertebral displacement is significantly increased after the20-degree-flexion traction. So the20-degree-flexion traction can improve the vertebral displacement more obviously than the neutral traction. Biomechanical analysis shows the traction pulling stress is mainly concentrated in the anterior and posterior parts of the disc, while the pulling stress on the nucleus pulposus is less. The pulling stress is significantly increased in the20-degree-flexion traction. Clinical research72patients get followed-up, the average follow-up time of3.10years. The VAS and JOA scores of68patients is significantly improved comparing to before treatment, discharge and followed-up visit,4patients got operation because of severe symptoms. Clinical observation on30cases of cervical spondylosis radiculopathy with degenerative spinal cord compression showed, the VAS and JOA(20)scores was significantly improved comparing to before treatment, discharge and one-month-followed-up visit. And no symptoms aggravated or operation treatment cases. The front-traction in treating cervical spondylosis radiculopathy with degenerative spinal cord compression is obvious. The MR imaging also showed during the flexion position the sagittal diameter index of disc herniation has significantly decreased while the vertebral canal sagittal diameter has significantly increased than the neutral position.18patients had completed the evoked potential monitoring, during the front-traction process, no significant difference has occurred in the latency and amplitude compare to the normal position.ConclusionsChanges of vertebral displacement after20-degree-flexion is signify-cantly. Changes of intervertebral space after the20-degree-flexion traction, especially in the posterior, is significantly increased compare to the neutral. The intervertebral foramen and the pulling stress of the disc are all increased after the20-degree-flexion traction compares to the neutral traction.According to the retrospective and prospective studies associated with cervical spondylosis radiculopathy with degenerative spinal cord compression, we stated the effectiveness of the Back-lying and Forward-bending Traction;By using the cortical somatosensory evoked potentials to monitoring the process during front-traction, we stated the safety of this method. The MR imaging of flexion position also explain some mechanism of using front-traction to treat this disease, and the the security to the as well.In conclusion,we discussed the mechanism of using the Back-lying and Forward-bending Traction to treat the patient who has cervical spondylosis radiculopathy with degenerative spinal cord compression by using the biomechanical model of the cervical spine. We also proved the effective and secure of the Back-lying and Forward-bending Traction though clinical research. All we did is to facilitate this method to clinical application. |
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