| Research object:l.To find out the lesions of tendons nodes and the appearance regularity of relevant channel sinews by analyzing the frequency of the lesions of tendons nodes in Nonspecific Low Back Pain(NLBP) cases.2.To find out the pathological features of the lesions of tendons nodes of NLBP by ultrasonography on the lesions.Research methods:Studies of cases observation.Meterials and Methods:1. Source of cases:All cases came from the outpatients of Acumoxa Department of Guang’an men Hospital,116patients totally, and24of them received the high frequency ultrasonography.2.Diagnosis and Inclusion Criteria2.1Diagnosis:According to the diagnosis and classification of clinical guidelines of low back pain made by AHCPR in1994.(1)Patients claim repeated or continuous pain in one side or both sides of the waist, including the pain or muscle tension in the region between the costal margin to the gluteal sulcus, and associated with varying degrees of dysfunction of the waist;(2)Except the sciatic nerve pain and nerve root syndrome;(3)Except specific low back pain caused by tumor, infection or fractures.2.2Inclusion criteria(1)Comply with the diagnosis and classification of non-specific low back pain;(2)Between the ages of18-85years old;(3)Modern clinical diagnosis of myofascial pain syndrome of hip, buttocks fat hernia fascia, iliac crest syndrome, the third lumbar transverse process syndrome, dorsal branch entrapment syndrome, cutaneous nerve entrapment syndrome, shares lateral cutaneous nerve entrapment syndrome, lumbar muscle strain, lumbar sprain, third lumbar transverse process syndrome, piriformis syndrome, sacroiliitis, fascia septal syndrome, spine ligament injury, interspinous ligament injury gluteus medius syndrome etc;(4)Did not receive lumbar surgery2weeks before the treatment;(5)Volunteered to participate in this study, and signed informed consent.2.3Exclusion criteria:(1) Clinical imaging and laboratory examinations showed lower back pain caused by special lesions (eg spinal or pelvic tumors or tuberculosis, spinal cord inflammation, spinal cysts, spina bifida, mandatory spondylitis, rheumatic joint disease, syringomyelia, multiple sclerosis, etc.);(2)Patients with severe heart, lung, brain diseases;(3)patients with Partly lesions or wounds unfit for standard reporters.2.4Removal criteria:(1)included Patients who did not meet the inclusion criteria;(2) patients who met the inclusion criteria and were included but did not accept point marking of the lesions of tendon nodes or being documented.2.5Shedding criteria:(1) serious adverse events, complications, and special physiological changes, should not continue to accept the experimenter;(2) those who quit during the study themselves.3. Inspection methods:3.1inspection methods of lesions of tendon nodes:(1) Physical examination:the patient prone, the examining physician use the touch method, press the waist area with hand thumbs along the foot laiyang channel sinews.Mark the lesions of tendon nodes through the line followed by pressing tenderness in patients with obvious and palpable localized thickening or cords, cord shaped, cylindrical rod, tie bar lumpy bulge foci with violet blue cotton swabs.. Patients with decubitus, the examining physician look for and mark the lesions of tendon nodes along the waist area where the foot Shaoyang channel sinews and foot Shaoyin channel sinews travel along in the same way. (2) Marking:mark the area of cord-like, linear and cylindrical rod uplift with straight lines along the direction of channel sinews,mark the lumpy clumps of uplift along the outer edge of the circle,mark the area of only tenderness and thickening with dots tags.(3) Confirmation:two examining physicians marked and checked,and reviewed the different parts of the mark after palpation, until all markers were confirmed by two physicians.3.2High-frequency ultrasonic inspection methods:(1) Ultrasound:Patients in the prone position and lateral position, the sonographer held the probes to explore the marked points with alternate horizontal axis and vertical axis method along the spine on both sides of the erector spinae, gluteus medius, gluteus maximus, iliotibial muscle, the exploration depth ranged from skin to the fascia.(2) Marking:Researchers marked the thickened fascia and thickened ligament area under the ultrasound "x" with violet blue cotton swabs, fat nodules with "○" mark, and points of calcification with "●" mark.(3) Recording:measure and screenshot the abnormal area under the ultrasound and print it in the report.4Removal and shedding cases:0case excluded,1case shedded, accounting for0.86%of all cases; representing4.17%of the number of the ultrasound cases; the exit reason had nothing to do with the study measures.5. Statistical analysis:Using frequency statistics mainly, statistical content included channel sinews occurrence frequency, the number of lesions of tendon nodes of single case, and the occurrence frequency of different lesions of tendon nodes, different pathological changes occurred under the ultrasound and the lesion appearance, using non-parametric tests to analyze the difference between males and females of the above with the software SPSS19.0. Result:1.The distribution characteristics of channel sinews:In all of the115cases, except not any lesion in one case,the lesions of tendon nodes were found out in taiyang channel sinews in the low back region in114cases, accounting for99.13%of all the cases.Of them,22cases had lesions of tendon nodes in only one channel sinew,that was foot taiyang channel sinew, accounting for19.13%of the114cases.89cases had lesions of tendon nodes in both foot taiyang channel sinew and foot shaoyang channel sinew, accounting for77.39%;3cases had lesions of tendon nodes in three channel sinews, which were foot taiyang channel sinew,foot shaoyang channel sinew and foot taiyin channel sinew, accounting for2.61%. There was no significant difference in the distribution of affected channel sinews in male and female patients.2.The distribution characteristics of lesions of tendon nodes:2.1the number of lesions of tendon nodes of single case:90.43%of the NLBP cases had5to12lesions of tendon nodes in low back.2.2the distribution area of lesions of tendon nodes:93.91%of which had lesions of tendon nodes in the gluteus maximus distribution area,72.17%of which had lesions in the sacrospinous muscle area,70.43%of which had lesions beside the ilium and the gluteus medius muscle,15.65%of which had lesions on the ilium, and only5.22%of which had lesions under the gluteal and in front of the wing of the ilium.2.3the lesions of tendon nodes with high frequency:Among all the marked lesions of tendon nodes, which appeared mostly often was Pangguangshu,71.30%of the cases were affected here,and then Zhonglvshu, Zhibian, Yaoyi,Xiaochangshu.2.4the pathological features of the lesions of tendons nodes under the ultrasound:(1)kinds of pathological changes:through case study of23cases who received the high frequency ultrasonography,it was found that2cases were found out no any pathological change,and for the other21cases, there were four kinds of pathological changes in the lesions of the tendon sinews in the ultrasound, which were fascia muscularis thickening, fatty nodules, ligament thickening and calcification. Among them,78.26%of the cases had thickened fascia muscularis. but not all the lesions of tendon nodes in theses cases had thickened fascia muscularis, only10%to20%of the lesions of tendon nodess in72.22%cases had fascia muscularis thickening in the ultrasound, and20%to30%of the lesions of tendon nodess had fascia muscularis thickening in22.22%cases, the percentage of which was43.75%in only one case. About34.78%of the cases had fatty nodules in the lesions, while the thickening of the supraspinous and interspinous ligament turned a low frequency as13.04%.(2)The distribution characteristics of pathologic changes under the ultrasound:There were lesions distributed in the gluteus maximus area in all the21cases with pathological changes in the ultrasound, which accounting for91.30%of all the patients receiving ultrasonography.3cases had lesions in the supraspinous ligament and the interspinous ligament which accounting for13.04%of all the patients receiving ultrasonography.2cases had lesions in the sacrospinous muscle area, which accounting for8.70%of all the patients receiving ultrasonography.4cases had lesions in gluteus medius muscle or gluteus minimus muscle,which accounting fou17.39%of the cases who received ultrasonography. Among all the cases receiving ultrasonography, the lesion where had the most pathological changes was Xiaochangshu, which accounted for39.13%.Discussion:On the distribution of lesions,93.91%of the cases had lesions in the area of gluteus maximus, among the12lesions with the highest occurrence frequency, Pangguangshu,Zhonglvshu and Xiaochangshu were all in the sacrum ending of the gluteus maximus, the upper Bishu and inner Pishu were in the upper ending of the greater trochanter of the gluteus maximus, Zhibian was beside the ending of gluteus maximus. The three points with the most pathologic changes under the ultrasound-Xiaochangshu, Pangguangshu and Huantiao located in this area, revealing that the injury occurred most often next to the ending of the greater trochanter and sacrum edge of gluteus maximus, which was almost the same with the predilection sites of hip myofascial pain syndrome.On the12lesions of high frequency, Yaoyi was in the bony tube outlet of cutaneous nerve fibers, Zhongkong, Jiankua, inner Bishum, upper Bishu, Zhibian, Huantiao, Xiaochangshu were all in the area of superior clunial nerves, among which, Xiaochangshu, Yaoyi, Huantiao, Zhibian, inner Bishu, Zhongkong and Jiankua all had changes of fascia thickening, there appeared fat nodes in Xiaochangshu, Zhongkong and inner Bishu, and calcification was found in Xiaochangshu and Huantiao, all of the25lesions accounting for47.17%of all the lesions under the ultrasound.So it can be speculated that superior clunial nerve compression syndrome and hip myofascial pain syndrome may be the most common diagnosis in NLBP.It can be seen in the chart of lesions distribution of spine ligament and interspinous ligament that a normal distribution with the similar center of lumbar5and sacral1spinous illustrating that the lumbosacral joint is the predilection site of lumbar spinal injury.From the perspective of channel sinews, the foot taiyang channel sinew ends in the hip, the branch of foot shaoyang channel sinew travels along the lateral side of the thigh from the knee to Futu and Kou. It was pointed out in the book Explain Word that hip meant the part sitting on the stool, and Kou meant the spine end or the position entering the pelvis.the ending area of the two channel sinews was just the predilection site of lesions of tendon nodes. According to the predilection of lesions of tendon nodes, taking painful localities as acupoints, the accuracy of judgment can be improved, and the location of the lesions can be quickly determined.On the basement of grasp of the predilection sites of lesions of tendon nodes, manipulation of loosing nodes and regulating can be applied directly for the cause in clinic. Because of the accurate positioning of lesions, when applying acupuncture treatment,the number of acupuncture and treatment frequency can be reduced and efficiency of pain-relieving improved. For lesions of fascia thickening, ligament thickening and calcification under the ultrasound, the needles that are appropriate to release such as long circular needles should be priority. For patients with predilection of hip fat hernia,besides manipulation of loosing nodes and unblocking collaterals, we should also take into account the medication of fortifying the spleen and dissolving phlegm to reduce the appearance of such causes.Conclusion:1.Patients with NLBP manifests as low back pain of soft tissue, the channel sinew distribution regularity turns out to be the foot taiyang channel sinew and foot shaoyang channel sinew besing affected at the same time. To analyze from anatomy, the lesions of tendon nodes distribute mainly in the superior clunial nerves area. In the waist midline, the two lesions of tendon nodes in L5and Sl spinous process are the most easily affected. Which suggests that it should be from the hip to the waist, from the two sides to the midline.2.Above90%of the cases had5to12lesions of tendon sinews, which provided reference for selecting lesions of tendon nodes when operating the long-round needle in clinic.3.The high-frequency ultrasonography revealed that the pathological changes of the lesions of tendon nodes of patients with NLBP were fascia muscularis thickening, fatty nodules, ligament thickening and calcification. The specific manifestations of which had some significance for the choice of clinical treatment. |
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