Correlation Study Between The Severity Of The Symptoms And The CT Signals Of The Lumbar Disc Protrusion Sufferers

Objectives1. To approach the correlations between the severity of the symptoms and the CT signals of nucleus pulposus herniation( NPH)of the lumbar disc protrusion sufferers and to find the closed CT signals to the severity of the symptoms of the lumbarl disc protrusion sufferers.2. To approach the correlations between the severity of the symptoms of the lumbar disc protrusion sufferers and massage therapy .It is helpful to choose the appropriate patients for the massage doctors.Methods1. data and case 129 patients who are diagnosed with lumbar disc protrusion sufferers and checked by CT from Nanfang Hospital.2. inclusion and exclusion criteria Patients who met the criteria of lumbar disc protrusion sufferers are checked by clinical and CT examinations in Nanfang Hospital. If the patients have more than one lumbar intervertebral protruding discs, we will choose the most serious one which is the most fit to the symptoms. Excluded patients such as: pregnant womman, psychiatric patients, severe osteoporosis patients, spondylolisthesis patiens, bone fracture patients, cancer patients, tuberculosis patients, spinal stenosis patients, data incompleted or lost. 3. score criteria of the severity of the symptoms and signs To use the low back pain assessment scale from Japanese Orthopedic Association. It have ten items including low back pain, numb,tenderness, strength of flexion and extension of hallux muscle, straight leg raising and the strengthening of the experiment, radiating pain, bending and lifting weights, walking distance or time, in bed time, working ability. Every item have 4 levels, the highest level is 3 points, the lowest level is 0 point. Getting more points means more serious. The total points of the assessment scale is 30. The mild level points are less or equal 10 points. The moderate level points are less or equal 20. The severe level points are more than 20 points. After massage therapy, if the symptoms of the lumbar disc protrusion sufferers are gone, it means the patients has been cured. If the points are less 10 points than prior-treatment, it means the effect is excellent. If the points are less 0-10 points than prior-treatment, it means the treatment effect is valid. If the points have no changes than prior-treatment, it means the treatment effect is invalid.4. CT signal According to the literature and clinical experience, there are ten signals including 31 performances which relate to the lumbar disc protrusion sufferers. Such as schmorl nodule or not, the NPH through bone or not, the Patho-type(Protrusion, Prolapse, Liberation, Shrink back), the NPH density(≤80,≤100, > 100), the NPH shape(arc, the edge is smooth; the edge is not smoth; cauliflower-like, island-like), the size of NPH of sagittal plane(1 level, 2 level, 3 level) , the size of NPH of horizontal plane(a domain, b domain, c domain, d domain), the size of NPH of frontal plane(1 zone, 2 zone, 3 zone, 4 zone) , the oppression of NPH to nerve root(close to nerve root, compression to nerve root, adhesion to nerve root), the oppression of NPH to dural sac(fat gap smaller, fat gap disappears, deformation to dural sac). 5. Measuring equipment of CT signals To scan L3-L4, L4-L5, L5-S1 vertebrals with Lightspeed 16 layer spiral CT scanner of GE company. The thickness of scan is 5mm, the layer spacing of scan is 0.1mm. To complete the measurement of the image data in the computer with the help of the PASC system of the image center in Nanfang hospital.6. Measurement of the CT signal (1)Schmorl nodul: the nucleus pulposus into the vertebral body. It appeared low-density lesion around with vertebral bone sclerosis at CT. (2) The NPH through bone: Free bone at the edge of vertebral. The degenerative nucleus pulposus has penetrated between epiphyseal and vertebral, which makes epiphysis free.(3). The Patho-type of protrusion:CT showed a arc-shaped soft tissue shadow with intact border connected with the disc, whose density consistent with the disc, prominents partially to the marginal median or the side of lumbar posterior and its edge and the posterior of annulus intersect into an acute angle . Prolapse: nucleus pulposus breakes annulus fibrosus into vertebral canal, protrution edge makes into acute angle with annulus fibrosus. liberation fragment: liberation fragment makes angulated or polyps high-density in the vertebral canal, intervertebral discs posterior border seems normal or posterior process slightly. Shrink back: The NPH is dehydration or ossification.(4). The shape of nucleus pulposus herniation To be soft tissue shadow of epidural gap. The density of nucleus pulposus herniation is higher than that of spinal dura mater and fat of epidural gap. The essence of soft tissue shadow of epidural gap is nucleus pulposus herniation. (5). The density of nucleus pulposus herniation When nucleus pulposus herniation appears, the change of posterior border of intervertebral discs is from flat to partly prominent. Measure the CT value of the protrusion. The normal situation is 50-100Hu. If CT value is higher than 100, it means the tissue has been ossification. (6). Anteroposterior axes level :There are 3 level in the anteroposterior axes. The intervertebral discs level is 1 level. The upper tier of intervertebral discs is from the inferior thyroid notch of upper vertebral body to the upper bound of intervertebral disc which we called 2 level. The underlayer of intervertebral discs is from the lower bound of intervertebral disc to the inferior thyroid notch of lower vertebral body which we called 3 level. (7). Horizontal position region There are 4 regions behind the posterior border of the vertebral body. To divide 3 equation between two pedicles of vertebral arch, the middle equation is called 1 region,the left or right one called 2 region.3 region is from exterior to interior of pedicle of vertebral arch. 4 region is outside the lateral pedicle of vertebral arch. (8). Z axes region To divide radius vector which is from center line of posterior border of the vertebral body to anterior border of vertebral plate of spinous process into 4 equation . We called it a,b,c,d domain separately from the front to the back.. (9). In the normal situation, density of nerve root is as seem as that of tissue contrast by epidural fat. It is in the intervertebral foramina of vertebral canal. The left one is symmetry to the right one. if nerve root has no shift in the lumbar disc protrusion sufferers, we call it'no change', if nerve root moved, we call it 'root compression', if nerve root are covered by NPH, we call it 'nianlian'. (10) The density of Dura mater and its contents is lower than that of the disc,the fat is filled with the district from the membranous sac and edge of the discs. The interfacing is clear because of the density difference. We divide 3 levels (the fat gap become smaller, the fat gap become disapear, spinal dura mater shift because of oppression)acording to the position relation between nucleus pulposus herniation and spinal dura mater.7. The massage (1). The patients is in the prone position,the doctor massage on their back from up to down with rolling and rotating maneuvers, especial low back living acupuncture point, giving consideration to acupoints and the Bladder Meridian of Foot-Taiyang and its points. The doctor relax the patients with rolling and rotating maneuvers along sciatic nerve, from Chengfu to Weizhong to Chengshan to Kunlun. The time is 10-15mins.(2). Patients is in the lateral position, with located in the down natural extension of the lower limb and lower limb above the knees hip flexor. The doctor stands facing patients, with one hand pressing the patient's shoulder anterior part, with another elbow resisting the patient's buttocks, For the slowly push on the opposite direction, which makes lumbar vertebrae moving slowly. When there is resistance, pull the last time by a substantial, pulled on the control of sudden. The right and the left would be down one time. We massage every patient two times every week and the treatment will last for 2 months.8. Error Control At single-blind conditions, CT signals are measured for 3 times, then averaged the results. It is not allowed to view the clinical assessment scale in the measurement, and we will select the most serious disc to measure if two or more intervertebral discs are prominent in patients.9. The course of the experiment According to the clinical data and experience, we maked sure CT signals related to the the lumbar disc heriation signs. At first we taked physical examinations to the patients from chinese medical department, learned the gravety of the symptoms,according to the waist assessment scales recommended from Japanese Orthopedic Association, we maked groups acccording to 3 degrees:light, moderate and heavy, and then we make a correlated-test and a logistic-test. We take the massage medical treatment, two mounths later, we maked a score on the gravety of the symptoms according to the waist assessment scales recommended from Japanese Orthopedic Association. The score of prior-treatment and post-treatment was tested by correlate-test to watch if massage therapy was effective . According to the results we choose the appropriate patients for the massage doctors.Results 1. There is no statistics significance between the schmorl and the severity of the symptoms of the lumbar disc protrusion,so is the NPH through bone and the size of NPH of sagittal plane.(p>0.05). But the patho-type,the NPH density, the NPH shape, the size of NPH of horizontal plane, the size of NPH of frontal plane, the oppressio of NPH to nerve root, the oppression of NPH to meninx fibrosa have the statiscs significance with the severity of the symptoms and signs of the lumbar disc herniation.(p<0.01).2. The size of NPH of horizontal plane, the size of NPH of frontal plane, the oppressio of NPH to nerve root have the statiscs significance with the severity of the symptoms and signs of the lumbar disc herniation. Compared to d domain, a domain and b domain and c domain could made the lumbar disc protrusion sufferers less serious(OR is0.003, 0.002, 0.008 separataly). Compared to 4 zone, 3 zone could made the lumbar disc protrusion sufferers more serious(OR is28.560). Compared to the adhesion to nerve root, compression to nerve root could made the lumbar disc protrusion sufferers more serious(OR is 8.882).3. 129 patients are carried by massage therapy. Based on the assessment scale, the severity of symptoms and signs for the light has 44 cases of patients, of which 15 were cured, 16 markedly effective, 8 effective, 5 null and void,the efficiency is 88.64%. The severity of symptoms and signs for the middle level has 61 cases of patients,of which 9 were cured, 23 markedly effective, 17 effective, 12 null and void, the efficiency is 80.16%. The severity of symptoms and signs for the severial level has 24 cases of patients, of which 2 were cured, 8 markedly effective, 6 effective, 8 null and void, the efficiency is 66.67%. The effect of the 3 groups is obviously different(P为0.007).Conclution1. The patho-type, the NPH density, the NPH shape,the size of NPH of horizontal plane, the size of NPH of frontal plane , the oppressio of NPH to nerve root, the oppression of NPH to meninx fibrosa effect the symptoms and signs of the lumbar disc herniation.2. The smaller is the size of NPH of frontal plane, the smaller is OR. 3 zone , the oppressio of NPH to nerve root could made the lumbar disc protrusion sufferers more serious.3. Massage is effective to lumbar disc herniation. The medical treatment is closely related to the gravity of the lumbar disc heriation signs. The lighter are the severity of the symptoms and signs, the better are the medical treatment effect.