| BackgroundDegenerative lumbar stenosis and degenerative lumbar scoliosis were clinically common lumbar degenerative disease, which were significant causes of symptoms such as low back pain, lower limb radiation pain, claudication, and lower extremity weakness. Lumbar degenerative diseases were focus and difficulty in research of spinal diseases. And image studying of those diseases were very important for diagnosis, identification, and treatment. Many studying revealed that imaging presentations of those diseases were contradictory to severity of symptoms.X-rays was the basic imaging of inspection method for lumbar degenerative diseases, which could exclude the fracture of vertebrae, scoliosis, spondylolisthesis, vertebra abnormality and tumors of spine, when magnetic resonance imaging(MRI) was the common choice of further inspection for favorable comparison of soft tissue. There was no widely accepted grading system to response to severity of degenerative lumbar stenosis in magnetic resonance imaging. The treatment and efficacy could be different according to different severity of disease. Comparison of clinical efficacy were deficient in comparability for lack of grading system. And relationship of severity of stenosis of degenerative lumbar stenosis and clinical symptoms was wanting for studying.Degenerative lumbar scoliosis usually consider secondary to intervertebral disc asymmetrical lesions, and signs of patients of asymmetry of lumbar muscle were observed but often ignored. Is asymmetry of lumbar muscle caused by atrophy or spasm? Is it a secondary role or initial factor? And how is the asymmetry? The relationship of asymmetry of lumbar muscle and scoliosis, and relationship of this two and lumbar function are still unclear. It is high clinical value of application for improve the clinical curative effect and guide the rehabilitation exercise to distinguish relationship of asymmetry of lumbar muscle and scoliosis and pain and disability of lumbar.Most patients with degenerative lumbar stenosis and degenerative lumbar scoliosis might choose conservative treatment for risk of surgical operation, complication, financial burden and others. Acupuncture and manipulation of traditional Chinese medicine play a important role in treatment for low back pain. One basic principle for safe and effective treatment was to choose the appropriate adaptation disease. How are the efficacy of acupuncture and manipulation of traditional Chinese medicine in treatment of degenerative lumbar scoliosis? And how is the relationship of efficacy and severity of scoliosis?Part I A new MRI grading system for degenerative lumbar central canal stenosis and its clinical relevanceObjectiveTo devise an magnetic resonance imaging grading system for lumbar central canal stenosis and to study its clinical relevance on patients with lumbar central canal stenosis and chronic nospecial low back pain, and to evaluate this grading system through analyzing the relationship of imaging and clinical symptoms.Methods and materialsTo devise a MRI 5-grading system for lumbar central canal stenosis on the basis of compression of dural sac and cauda equine and to study clinical relevance. Grade 0=dural sac is surrounded by fat and not compressed by disc or ligamentum flavum. Grade 1=dural sac is slightly compressed by disc or ligamentum flavum but without deformation. Grade 2=dural sac is compressed with deformation and cauda equina is compressed but without displacement. Grade 3=dural sac is severely compressed with deformation and cauda equina is compressed with displacement but is still individualized with obliteration of most cerebrospinal fluid. Grade 4=dural sac is severely compressed with deformation and cauda equina is severely compressed and unrecognizable with obliteration of almost all cerebrospinal fluid.Data were collected for the basic condition and X-rays and MRI slices based on the electronic medical records. Patients with lumbar central canal stenosis or chronic nonspecific low back pain were extracted from inpatients of Department of Orthopaedic of Hainan Provincial Hospital of Traditional Chinese Medicine during January 2013 and June 2014. Data were collected for the basic condition and X-rays and MRI slices were based on the electronic medical records. Also the clinical data included identity document, gender, age, height, weight, occupation, time of low back pain, traveled distance, Oswestry disability index, visual analogue scale and others.Inclusion criteria for patients with lumbar central canal stenosis were age older than 40 years and a clinical diagnosis of lumbar central canal stenosis by orthopedists. Diagnosis was based on the review of patient history, physical examination, and confirmation of anatomical stenosis on MRI. Inclusion criteria for patients with chronic nonspecific low back pain were age older than 40 years and a clinical diagnosis of chronic nonspecific low back pain by orthopedists. Diagnosis was based on the review of patient history, physical examination, and confirmation of anatomical stenosis on MRI.MRI was analyzed in Picture Archiving and Communication Systems (Winning soft, THIS 4.0, company website address http://www.winning.com.cn/). Anteroposterior diameter of spinal cana, dural sac cross-sectional area, the MRI 5-grading was collected from MRI on T2-weighted axial images in the five levels of L1/2, L2/3, L3/4, L4/5, L5/S1. The most stenosis level was adopted for the MRI 5-grading. And the level of L4/5 was adopted for that all levels were Grade 0 for that most patients with stenosis were in the L4/5.All images were analyzed by 3 junior orthopeadists (orthopeadists A, B and C) working in originating institution of this study. Orthopedic department trainees received tuition on the classification, supported by images they encountered in clinical practice. All images were resubmitted 3 weeks later for repeat grading following random rearrangement.Intra-reader agreement was assessed using Kappa value. A Kappa value was categorized as slight (0-0.20), fair (0.21-0.40), moderate (0.41-0.60), substantial (0.61-0.80), and almost perfect (0.81-1.00). One-way ANOVA (Scheffe method) was used to investigate whether anteroposterior diameter of spinal cana, dural sac cross-sectional area, traveled distance, Oswestry disability index, visual analogue scale differed according to the MRI 5-grading. Ap value of less than 0.05 was considered a significant difference. Statistical analysis for calculations was performed using SPSS for Windows version 13.0 (SPSS Inc, Chicago, IL, USA).Results1.General condition of patients It included a total of 112 patients with an average age of 62.964±10.904 (40-85) years, body mass index 24.710±2.875 (16.71-30.86), time for pain last 49.900±61.792 (5-372) months, traveled distance 805.803±681.802 (50-3000)m, visual analogue scale 6.125±1.560 (2-10), Oswestry disability index 26.661±6.358 (10-39), anteroposterior diameter of spinal cana 11.373±2.965 (5.320-20.710), dural sac cross-sectional area 75.301±42.528 (17.160-217.490) (66 with lumbar central canal stenosis and 46 with chronic nonspecific low back pain,49 men and 63 women).2. Stenosis distribution of Grade None Grade 3 and Grade 4 stenosis were observed in chronic nonspecific low back pain group. None Grade 0 and Grade 1 stenosis were observed in lumbar central canal stenosis group. Grade 3 was the commonest in the lumbar central canal stenosis group, whereas Grade 1 was the commonest in the chronic nonspecific low back pain group. In total, levels of the most severe stenosis were three L1/2, five L2/3,25 L3/4,63 L4/5, and 16 L5/S1.3.Intraobserver and Interobserver Reliability Inter- and intraorthopeadist Kappas were 0.681-0.818 respectively between three orthopeadists. It indicated substantial or almost perfect reliabilities.4.Relationship between the MRI 5-grading system and other clinical data Difference in_visual analogue scale was not significant between groups according to the MRI 5-grading system(F=1.348,p=0.257). Time of low back pain, traveled distance, Oswestry disability index, anteroposterior diameter of spinal cana, dural sac cross-sectional area were significantly different between groups according to the MRI 5-grading system(F=6.915,14.586,3.886,34.202,84.449 respectively, all p≤0.005)ConclusionWe conclude that this new MRI 5-grading system based on compression of dural sac and cauda equina on MRI was reliable and easy to perform. Studies of patients with lumbar spinal stenosis had shown that there was no statistically significant correlation between the intensity of pain and the degree of stenosis. Though we found that the MRI 5-grading system did not correlate with visual analogue scale, the MRI 5-grading system correlated with Oswestry disability index perfectly. It was concise, efficacious, excellently repeated and might be a useful tool for clinicians and radiologists to use in daily practice and in communication with each other.Part II Relationship of severity of scoliosis and asymmetry of lumbar muscle of degenerative lumbar scoliosis and function of lumbarObjectiveTo evaluate the relationship between cross sectional area of paraspinal muscles, severity of scoliosis and Oswestry disability index in patients with degenerative lumbar scoliosis, to provide the clinical guidance and advisory opinion for treatment and rehabilitation exercise.Methods and materialsPatients with degenerative lumbar scoliosis was constructed from in-patient of department of orthopaedic of Hainan provincial hospital of traditional Chinese medicine during the period from January 2013 to January 2015. Data were collected for the basic condition and X-rays and MRI slices based on the electronic medical records. Lumbar function was evaluated by Oswestry disability index.Data were collected from the X-rays and Magnetic Resonance Imaging slices in picture arehiving and communication system, including the location and direction of the apex of curve, coronal Cobb’s angle, and cross sectional area of bilateral psoas and paraspinal muscles at L3/4、 L4/5、 L5/S1 level. Cobb’ angle of lumbar was diagnosed when there was a relatively short curvature confined to the level between the T12 and S1 vertebra and with Cobb’s angle larger than 10° in a standing simple radiograph in patients. The Cobb’s angle of lumbar was measured according to Nash and Moe’s method. The cross sectional area of the bilateral psoas and paraspinal muscles (including multifidus, iliocostalis and longissimus muscles) was measured from the digitalized Magnetic Resonance Imaging in picture arehiving and communication system according to Craig A Ranson’s method. Images with T2 sequence were chosen to refer to the results of previous studies. The images were obtained at the level of L3/4、L4/5、L5/S1 level in the middle of disc. Results from X-rays and MRI sclices were analysed by 2 physicians who are experience in imaging assessment. The readers were blinded to each other’s measurements and all clinical measures.Data were analysed using SPSS 13.0 statistical software. The mean and standard deviation were calculated for description of variables. Parametric t-tests and x2 analysis were used to determine the differences between groups. In the case of three groups, one-way analysis of variance (ANOVA) was used. Pearson correlation was used to inspect the relationships between Cobb’ angle and cross sectional area of psoas and paraspinal muscles. All tests were two-tailed, and P< 0.05 was considered statistically significant.Results1.It included a total of 106 patients (68 women and 26 men) with an average age of 58.67±10.19 (40-79) years, a mean of the coronal Cobb’s angle of 22.90±9.43° (10.86-48.52°).80 patients had the apex of the curve on the left side, and 26 patients on the right side.2. Comparison of Cobb’s angle according to different apex level The most common apex levels were L3 of 53 cases (50.00% of all), next 24 cases at L2/3 level, 12 cases at L4 level,9 cases at L2 level, and 8 cases at L3/4 level. Mean Cobb’s angle was biggest at L3/4 level(F=4.28, P<0.01), and trend to become small in upper and down levels.3. Comparison of Oswestry disability index according to different apex level The biggest Oswestry disability index was in group of L3 apex level, and trend to become small in upper and down levels though difference was insiginicant(F=2.00, P=0.10).4.Comparsions for cross sectional area of psoas and paraspinal muscles according to the side of muscle (left side or right side, concave side or convex side) cross sectional area of psoas and paraspinal muscles were statistically larger on the right side than that on the left side (t=4.70,7.53, both P<0.01). However, cross sectional area of psoas and paraspinal muscles were statistically bigger on the concave side than that on the convex side (t=4.51,14.56, both P<0.01).5. Relationship of Cobb’ angle, Oswestry disability index and asymmetry of cross sectional area of posas and paraspinal muscles Relationship of Cobb’ angle and asymmetry of cross sectional area of posas and paraspinal muscles are significant (R=0.25,0.37, both P<0.01). Relationship of Oswestry disability index and asymmetry of cross sectional area of posas and paraspinal muscles are insignificant (R=-0.04,-0.02; P=0.53,0.78). Oswestry disability index is insignificant with Cobb’ angle (R=-0.12, P=0.21).ConculsionCross sectional area of psoas and paraspinal muscles were statistically bigger on the concave side than that on the convex side based on this study, that may be for that spasm of psoas muscle occurred on the concave side resulting in bigger cross sectional area of psoas muscle on the spasm side. So treatment should centre on the concave side of spasmodic muscle, especially the psoas muscle. Vicious circle of spasm and scoliosis leading to aggravation repeatedly should be interdicted through resolving tetany and relieving pain to achieve the balance of spine. The most common apex levels were L3 and mean Cobb’s angle was biggest at L3/4 level, and trend to become small in upper and down levels. That might because that L3/4 level is the middle bowstring of lumbar spine. Relationship of Cobb’ angle and asymmetry of cross sectional area of posas and paraspinal muscles are significant Physicians should think a lot at the function exercise of lumbar muscle to remedy the asymmetry of lumbar muscle. Treatment should be centred on spasm side of muscle for recovery of myodynamia and dynamic equilibrium of spine. Relationship of Oswestry disability index and asymmetry of cross sectional area of posas and paraspinal muscles are insignificant. Oswestry disability index is insignificant with Cobb’ angle. These indicate that symptoms might be influenced by many factors, and severity of imaging do not contact with lumbar disability.Part Ⅲ Relationship of efficacy of acupuncture and Cobb’ angle in middle and old age patients with degenerative lumbar scoliosisObjectiveTo investigate efficacy prospectively treated with accupuncture on middle-aged and elderly with degenerative lumbar scoliosis and relationships between severity of Cobb’angle and the clinical efficacy, to provide the clinical guidance and advisory opinion.Methods and materialsPatients with degenerative lumbar scoliosis was constructed from out-patient of department of orthopaedic of Hainan provincial hospital of traditional Chinese medicine during the period from January 2014 to July 2015. Data were collected for the basic condition and X-rays and MRI slices based on the electronic medical records. Cobb’ angle of Group A of 30 cases was 10°～20°, correspondingly Group B>20° of 30 cases. Also the clinical data included identity document, gender, age, time of low back pain, traveled distance, Oswestry disability index, visual analogue scale and others. Results from X-rays and MRI sclices were analysed by 2 physicians who are experience in imaging assessment. The readers were blinded to each other’s measurements and all clinical measures.All patients were treated with acupuncture by the same acupuncturist. And acupuncture points, which were consistent in all patients, were Ashi points of lumbar,Jiaji(EX-B2),Shenshu(BL2/3),Dachangshu(BL25),Huantiao(GB30),Weizhon g(BL40),Yanglingquan(GB34),Sanyinjiao(SP6). Operational approach of acupuncture:after acupuncture needling, mild reinforcing and attenuating through twirling manipulation, last for 30 minutes, and manipulating every 10 minutes, one time a day, period for 2 weeks. Oswestry disability index, visual analogue scale of all patients were evaluated before and after treatment, and also Cobb’ angle of X-rays before and after treatment were compared.Data were analysed using SPSS 13.0 statistical software. The mean and standard deviation were calculated for description of variables. Parametric t-tests and x2 analysis were used to determine the differences between groups. Pearson correlation was used to inspect the relationships between Cobb’ angle and Oswestry disability index, visual analogue scale. All tests were two-tailed, and P<0.05 was considered statistically significant.Results1.It included a total of 60 patients (36 women and 24 men) with an average age of 62.40±9.51 (40-79) years, duration of low back pain 35.22±25.82(8-120),39 patients had the apex of the curve on the left side, and 21 patients on the right side. The apex levels of L1,L2, L2/3, L3, L3/4, L4 were 1,6,17,28,6,8 respectively. Difference of age between Group A and B was insignificant (t=0.53,P=0.60), though duration of low back pain of Group B was bigger than Group A(t=2.42, P=0.02). And gender between Group A and B was insignificant(x2=0.28, P=0.59).2. Comparison of Cobb’ angle, visual analogue scale, Oswestry disability index Cobb’ angle, visual analogue scale, Oswestry disability index were 19.73±5.14° (10.59°～36.36°),5.97±1.43(3～9) and 24.38±6.61 (13～37) before treatment, and 18.53±4.73°(10.29°～34.49°),3.22±1.85 (0-7) and 11.78±6.16(2-27) after treatment. Difference of Cobb’ angle after treatment was insignificant(t=1.77, P=0.17). The differences of visual analogue scale and Oswestry disability index were siginicant(t=23.18,17.72, all P<0.01). Difference of Cobb’ angle after treatment of Group A and Group B were insignificant(t=0.18,2.22, P=0.86、0.08). Difference of visual analogue scale after treatment of Group A and Group B were insignificant(t=12.83,12.14, all P<0.01). Difference of Oswestry disability index after treatment of Group A and Group B were insignificant(t=15.26,17.72, all P <0.01).3. Relationships of Cobb’ angle before treatment and visual analogue scale, Oswestry disability index were insignificant. Relationship of Cobb’ angle, variation of visual analogue scale and Oswestry disability index after treatment were insignificant.ConclusionDuration of low back pain of Group B was bigger than Group A, which mean patient with degenrative lumbar scoliosis of Cobb’ angle>20° had the longer history of low back pain than patient with degenrative lumbar scoliosis of Cobb’ angle 10°～20°. This showed that it was a continuous and dynamic process for appearance and development of Cobb’ angle. This study found that treatment of acupuncture for degenrative lumbar scoliosis could relieve efficaciously the pain and increase the mobility of lumbar. Difference of visual analogue scale, Oswestry disability index after treatment of Group A and Group B were insignificant. Relationships of Cobb’angle before treatment and visual analogue scale, Oswestry disability index were insignificant. Relationship of Cobb’ angle, variation of visual analogue scale and Oswestry disability index after treatment were insignificant, which indicated that severity of scoliosis did not correlate with disability of lumbar and acupuncture could not alleviate the Cobb’ angle.Part IV Relationship of efficacy of manipulation and extend of scoliosis in middle and old age patients with degenerative lumbar scoliosisObjectiveTo investigate efficacy prospectively treated with manipulation on middle-aged and elderly with degenerative lumbar scoliosis and relationships between severity of scoliosis and the clinical efficacy, to provide the clinical guidance and advisory opinion.Methods and materialsPatients with degenerative lumbar scoliosis was constructed from out-patient of department of orthopaedic of Hainan provincial hospital of traditional Chinese medicine during the period from January 2014 to July 2015, and were treated by manipulation. Data were collected for the basic condition and X-rays and MRI slices based on the electronic medical records. Also the clinical data included identity document, gender, age, time of low back pain, traveled distance, visual analogue scale, Oswestry disability index and others. Cobb’ angle, direction of lateral curvature and apex level were assess from X-rays in picture archiving and communication system.All patients were treated with manipulation by the same doctor. Points and area of manipulation were (1) pressing and kneading lumbar muscle as Ashi points of lumbar, Jiaji(EX-B2), Shenshu(BL2/3), Dachangshu(BL25), Huantiao(GB30), Wei- zhong(BL40), Zhibian(BL54), Baliao(BL31-34), Kunlun(BL60), manipulation on every points for 0.5 minutes till acid bilge feeling ouccred.(2) pressing, kneading and Gun manipulation on low extremities muscle for 10 minutes. (3) moving the lumbar on genuflex hip-flexion dorsal position. (4) rubbing the lumbar muscle till feeling of warm occurred. Treatment lasted uninterruptedly for 2 weeks one time a day. Cobb’ angle of Group A1 was 10°～20°, correspondingly Group B1>20°. Direction of lateral curvature on the left named Group A2, on the right named B2. Apex levels in superior lumbar named A3, in inferior lumbar named B3. Visual analogue scale, Oswestry disability index of all patients were evaluated before and after treatment, and also Cobb’angle of X-rays before and after treatment were compared.Data were analysed using SPSS 13.0 statistical software. The mean and standard deviation were calculated for description of variables. Parametric t-tests and x2 analysis were used to determine the differences between groups. Pearson correlation was used to inspect the relationships between Cobb’ angle and visual analogue scale, Oswestry disability index. All tests were two-tailed, and P< 0.05 was considered statistically significant.Results1.It included a total of 76 patients (49 women and 27 men) with an average age of 64.46±9.31 (40-79) years, duration of low back pain 36.53±24.55(8-120).44 patients had the apex of the curve on the left side, and 32 patients on the right side. 31 cases had the apex levels in superior lumbar and 45 inferior lumbar. Apex levelof L2, L2/3, L3, L3/4, L4 were 10,21,30,8,7 respectively. Difference of age between Group A and Group B was insignificant(t=0.05、0.30、0.21, P=0.96、0.76、0.84). And gender between Group A and Group B was insignificant(x2=0.36、0.63、0.23, P=0.38、0.29、0.41. Duration of low back pain of Group A1 was less than B1(t=3.66, P<0.01), though GroupA2,A3 andB2,B3 was insignificant (t=1.18、 0.33,P=0.24、 0.74).2. Comparison of Cobb’ angle, visual analogue scale, Oswestry disability index Cobb’ angle, visual analogue scale, Oswestry disability index were 18.30±4.11° (10.59°～36.77°),6.08±1.33(4-9) and 24.79±6.48(13-37) before treatment, and 18.07±3.89°(10.29°～35.81°),3.37±1.71(0～7) and 12.04±6.26(2～27) after treatment. Difference of Cobb’ angle after treatment was insignificant(t=1.88, P=0.06). The differences of visual analogue scale and Oswestry disability index were siginicant(t=24.64、19.34, all P<0.01). Differences of visual analogue scale and Oswestry disability index after treatment of Group A1,A2,A3 and Group B1,B2,B3 were insignificant.3. Relationships of Cobb’ angle before treatment and visual analogue scale and Oswestry disability index were insignificant. Relationship of Cobb’ angle, variation of visual analogue scale and Oswestry disability index after treatment were insignificant. Cobb’ angle before treatment correlated with duration of low back pain(r=0.71, P<0.01).ConclusionThis study found that treatment of manipulation for degenerative lumbar scoliosis could relieve efficaciously the pain and increase the mobility of lumbar. Difference of visual analogue scale and Oswestry disability index before and after treatment of Group A1 and Group B1 were insignificant, which mean. Relationships of Cobb’ angle before treatment and visual analogue scale and Oswestry disability index were insignificant. Relationship of Cobb’ angle, variation of visual analogue scale and Oswestry disability index after treatment were insignificant, which indicated that severity of scoliosis did not correlate with disability of lumbar and manipulation could not alleviate the Cobb’ angle. |
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