1、1腰椎间盘突出症表面肌电临床研究中文摘要研究背景：腰椎间盘突出症指腰椎间盘退变后凸或破裂，压迫刺激脊神经根或马尾神经，引起腰背痛、坐骨神经痛、间歇性跛行、麻木、肌肉痉挛、肌肉瘫痪、马尾综合征、脊髓圆锥综合征、外周圆锥综合征及尾部疼痛等。腰椎间盘突出症的原因尚无明确定论，但是与脊柱结构异常、生理退变、种族、职业及外伤、劳损、吸烟、妊娠等因素有关。随着社会坐位工作时间明显延长，其他体位活动的减少，椎旁肌力量、协调性下降，椎间关节韧带松弛，椎间盘退变增快，腰椎间盘突出症发病率逐渐增高。中华骨科学会脊柱外科学组 1996 年统计显示全国每年每百万人中腰椎间盘突出症行手术治疗的约 120 人。祖国医学范
2、畴中，腰椎间盘突出症属“痹症” 。主要辩证为“气滞血瘀型、风寒湿型、肾虚型”三型。 “气滞血瘀型”多有明显外伤史，有脊柱侧弯，固定压痛点和放射痛，舌质紫暗，脉涩或弦数。 “风寒湿型”多无明显外伤史，腰腿痛症状渐出现并加重，有椎旁压痛和放射痛，遇天气变化症状加重，苔白腻，脉沉缓。 “肾虚型”多由急性损伤治疗失当或禀赋不足或久病致肾精亏损致经脉失养，症状时轻时重，缠绵数年，面色苍白，气短乏力。西方医学中，腰椎间盘突出症最早由 Mixter 和 Barr 在 1934 年提出，诊断主要依据典型临床症状、物理学检查、影像学检查、电生理检查。腰椎间盘突出症治疗，祖国医学和西方医学有不同的理论背景和特色治
3、疗手段，大家公认的治疗原则是保守治疗 6 个月，症状不缓解采取手术方法。手术治疗腰椎间盘突出症的术式和固定材料虽有长足发展，从单纯摘除到神经根管减压，从钢板、自体骨固定到 cage、人工椎间盘，依然不能理想解决腰椎间盘突出症手术效果、术后复发、并发症等问题。保守治疗仍是最常用的方法。目前保守治疗的方式方法多样，有牵引、理疗、按摩、正骨、药物治疗等多方面。如何评价治疗效果是多种治疗方法面临的客观问题，目前手术治疗效果常采用 JOA 评分、Oswestry 功能障碍评分、中华骨科学会脊柱学组腰背痛手术评定标准等。而保守治疗效果评定多采用自觉症状、直腿抬高试验角度（AOL） 、屈曲时指尖距离地面高度
4、（DFTF ）等。针极肌电图在定性检测腰椎间盘突出症根性损伤方面有明确意义，但是临床症状改善与其变化不相关。疗效评价缺乏敏感、客观、量化电生理指标。近年来对腰椎间盘突出症发病机理研究中，发现无症状椎间盘突出现象；部分接受手术治疗的患者术后影像学检查突出物与神经根之间关系并无明显改变而临床症状消失；高载荷工作人群的如战斗机飞行员腰椎间盘影像学普查椎间盘突出的发生率高达 30%，而椎间盘突出症的发生率远低于此数据。这些现象说明椎间盘突出症的发生与突出髓核的关系尚待进一步研究。而腰椎功能节段不稳可以对以上现象有所解释。现有的研究已经证明腰椎间盘突出症患者突出节段关节、腰背肌存在解剖结构和组织学的改变
5、，如关节韧带松弛、肌肉萎缩和肌纤维特征改变；还存在本体感受器的能力下降和运动反应时间的延长，如肌肉协调模式的改变。近年来在康复医学、神经科学、妇产科学、口腔科学、耳鼻咽喉科学、人体功效学及运动医学方面，用表面肌电图检测肌肉疲劳性和激动序列及协调性已经得到应用。国内外康复医学对腰椎间盘突出症椎旁肌测试研究虽有报道，但测量的2样本量小，测量的部位和测试方法及各指标的参数值并不相同，尚未形成统一的标准。我们回顾国内外相关研究结果，表面肌电图检测区分健康人和腰椎间盘突出症患者的敏感度和特异度指标，选择椎旁肌等长收缩时中位频率下降率（MFs） ，动态运动时屈曲伸直比例（FER）指标，对腰椎间盘突出症椎旁
6、肌电生理进行检查，使腰椎间盘突出症的疗效判断和机理研究提供客观敏感量化指标。研究目的探究表面肌电测量椎旁肌等长收缩和屈伸运动时表面肌电指标 MFs 和FER 的可重复性；测量诊断腰椎间突出症患者和正常人表面肌电指标，明确两者有无差异；对腰椎间盘突出症患者治疗前后进行表面肌电指标测量，同时记录 VAL、JOA 、AOL 、DFTF，明确两者有无相关性。研究内容和方法1正常人椎旁肌表面肌电特征及测量的可重复性研究1.1 研究内容测试正常人群椎旁肌等长收缩状态下双侧 MFs 值，腰部屈伸运动时平均肌电值，计算 FER。用重复测量可靠性检验 MFs 和 FER 的组内相关系数。1.2 研究方法1.2.
7、1 研究对象：符合正常人群条件的 18 名正常人。1.2.2 测试方法椎旁肌等长收缩状态中位频率测量：利用 Mega-T8 表面肌电测量仪对受试对象在等长收缩状态下双侧腰 4-5 平面椎旁肌表面肌电频率指标，具体方法参照 Biering-Srensen 测试。即受试者俯卧，髂嵴上缘以下的身体或腿的末端固定，手放于身体两侧或于胸前交叉抓住对侧肩部，记录受试者上身悬空 30 秒表面肌电频率变化值。测试 3 次，中间休息 5 分钟，以减少系统误差。测试结束后，获取原始数据文件，分析中位频率变化情况，获取 3 次测试指标的平均值作为该指标值。腰部屈伸运动时椎旁肌积分肌电指标屈曲松弛比的测量：方法参照S
8、ihvonen 提出的方法，受试者首先直立，然后躯干缓慢前屈至 90，停留 5s后恢复到直立体位，重复 5 次。1.2.3 指标计算MFs（中位频率斜率）：表示椎旁肌等长收缩时表面肌电频率指标的变化，单位为 Hz/m；FER（屈曲伸直比）：表示屈伸运动时椎旁肌屈曲动作时平均肌电值和完全屈曲时平均肌电值的比，反应腰椎屈伸运动协调性的指标，单位 uv/uv。1.2.4 正常人椎旁肌表面肌电指标的特征及可重复性分析对正常人的表面肌电原始信号进行定性定量分析，3 次测量可重复性分析。2腰椎间盘突出症患者和正常人表面肌电指标的差异性研究2.1 研究内容测试腰椎间盘突出症患者和正常人椎旁肌等长收缩状态及屈
9、伸运动时原始信号，计算 MFs 和 FER 指标。2.2 研究方法2.2.1 测试方法：同“1.1.1”的测试方法。2.2.2 研究对象：符合纳入标准和排除标准的 71 例腰背痛患者和 19 例正常人。32.3 腰椎间盘突出症患者表面肌电指标特征及其与正常人表面肌电指标的差异 分析描述腰椎间盘突出症患者表面肌电特征，与正常人之间数据进行比较。3腰椎间盘突出症患者病情和表面肌电指标之间的相关性研究3.1 研究内容测量腰椎间盘突出症患者保守治疗前后的表面肌电指标 MFs 和 FER，同时测量记录 VAL、JOA 评分，AOL、DFTF。3.2 研究方法：3.2.1 测试方法：同“1.1.1”的测试
10、方法。3.2.2 研究对象：符合纳入和排除标准的腰椎间盘突出症患者 81 人。3.2.3 研究疗前后 MFs、FER 差值和 VAL、JOA、AOL、DFTF 差值之间的相关性。结果1.正常人椎旁肌表面肌电特征及测量的可重复性研究1.1 正常人椎旁肌表面肌电特征：屈伸运动过程中，正常人完全伸直时和完全屈曲时，椎旁肌肌电活动基本消失，原始记录信号中规律出现的设备信号。等长收缩过程中，椎旁肌20%MVC 等长收缩过程中，肌电信号持续出现，其频率指标 MF 出现下降，双侧椎旁肌 MFs 值基本一致。1.2 正常人椎旁肌表面肌电活动可重复性：屈伸运动过程中，使用针对重复测量数据的一般线性模型（Gene
11、ral Linear Model for Repeated Measures） ，对三个不同时间点双侧屈曲伸直比的平均值进行了比较，左侧屈曲伸直比 P=0.697，右侧屈曲伸直比 P=0.532，P 值均大于0.05，无统计学差异，由此说明，总体上三个不同时间的测量数据没有显著性差异。三次数据的一致性分析，采用了组内相关系数（Intraclass correlation coefficient，ICC）分析法。对 Lfer 的 ICC=0.941， Rfer 的 ICC=0.981，检验 ICC的 P 值均小于 0.001，说明三次数据具有有高度一致，且具有显著性。等长收缩过程中，对 3 个不
12、同时间点 LIMMFs3 次数据均值用重复测量的一般线性模型（General Linear Model for Repeated Measures）进行统计分析，结果左侧 MFs 的 P=0.559，右侧 MFs 的 P=0.427，P 0.05，统计学差异不显著，说明三次不同时间测量数据差异不显著。其次组内相关系数（Intraclass correlation, ICC）分析一致性，计算组内相关系数，左侧 MFs 的 ICC=0.908，右侧 MFs 的ICC=0.997，检验 ICC 的 P 值0.001。说明三次测量间的一致性极佳，且有显著性。2.腰椎间盘突出症患者和正常人表面肌电指标的
13、差异性研究2.1 腰椎间盘突出症患者椎旁肌表面肌电特征：屈伸运动过程中，腰椎间盘突出症患者完全屈曲时，椎旁肌肌电活动依旧存在，信号中规律出现的设备信号不能分辨。等长收缩过程中，腰椎间盘突出症患者椎旁肌疼痛侧表面肌电中位频率下降率明显高于对侧。2.2 正常人双侧表面肌电指标比较：正常人左侧 FER=0.460.16，右侧 FER=0.470.14。正态性检验，左侧FER 的 P 值 0.819，右侧为 0.986，可认为两者服从正态分布，进行配对 t 检验，P=0.779，两者差异不显著，无统计学意义。正常人左侧 MFs=2.253.86，右侧 FER=1.623.55。正态性检验，左侧 MFs
14、 的 P 值 0.791，右侧为 0.892，可4认为两者服从正态分布，进行配对 t 检验，P=0.423，两者差异不显著，无统计学意义。2.3 腰椎间盘突出症患者双侧表面肌电指标比较：腰椎间盘突出症患者左侧 FER=0.900.28，右侧 FER=0.860.28。正态性检验，左侧 FER 的 P 值 0.972，右侧为 0.905，可认为两者服从正态分布，进行配对 t 检验，P=0.141，两者差异不显著，无统计学意义。腰椎间盘突出症患者左侧 MFs=-2.215.65，右侧 FER=-2.447.07。正态性检验，左侧 MFs 的 P值 0.814，右侧为 0.861，可认为两者服从正态
15、分布，进行配对 t 检验，P=0.810，两者差异不显著，无统计学意义。2.4 正常人和腰椎间盘突出症肌电指标比较：正常人和腰椎间盘突出症患者椎旁肌两侧 FER 值进行正态性检验，正常人P=0.934，腰椎间盘突出症患者 P=0.885，都可认为服从正态分布。正常人FER=0.470.15，腰椎间盘突出症患者 FER=0.880.28。对数据进行独立样本t 检验，正常人数据和腰椎间盘突出症患者数据方差不齐，P0.01，两者差异显著，有统计学意义。正常人和腰椎间盘突出症患者椎旁肌两侧 MFs 值进行正态性检验，正常人P=0.0.736，腰椎间盘突出症患者 P=0.680，都可认为服从正态分布。正
16、常人MFs=1.933.67，腰椎间盘突出症患者 MFs=-2.446.42。对数据进行独立样本 t 检验，正常人数据和腰椎间盘突出症患者数据方差不齐，P0.01，两者差异显著，有统计学意义。2.5 腰椎间盘突出症症状侧和对侧表面肌电指标比较：症状明显侧和对侧 FER 进行正态性检验，P 值分别为 0.977 和 0.784，都可认为近似正态分布。症状明显侧 FER 为 0.940.29，对侧 FER 为0.820.26。进行配对 t 检验，P0.01，两者差异有统计学意义。症状明显侧和对侧 MFs 进行正态性检验，P 值分别为 0.931 和 0.698，都可认为近似正态分布。症状明显侧 M
17、Fs=-4.906.56，对侧 MFs 为0.015.28。进行配对 t 检验，P0.01，两者差异有统计学意义。3.腰椎间盘突出症患者病情和表面肌电指标之间的相关性研究3.1 治疗前 FER、MFs 与 AOL、FTF、VOA、JOA 的相关性FER 与 AOL、FTF、VOA、JOA 的相关性。对数据进行正态性检验， P 值分别为 0.883、0.731、0.692、0.783、0.687，可认为近似服从正态分布。相关性分析 MFs 与 AOL、FTF 、 VAL、JOA 的相关系数分别为 0.208、-0.087、0.002、0.057。相关性不显著。MFs 与 AOL、FTF 、VOA
18、 、JOA 的相关性。对数据进行正态性检验，P 值分别为 0.888、0.731、0.692、0.783、0.687，可认为近似服从正态分布。相关性分析 MFs 与 AOL、FTF 、 VAL、JOA 的相关系数分别为-0.109、0.097、-0.037、-0.036。相关性不显著。3.2 治疗前后 FER、MFs 差值与 AOL、FTF、VOA、JOA 差值的相关性FER 差值与 AOL、FTF、 VAL、JOA 差值相关性，对数据进行正态性检验，P 值分别为 0.826、0.690、 0.685、0.953、0.705，可认为近似服从正态分布。相关性分析 FER 差值与 AOL、FTF
19、、VAL 、JOA 等差值的相关系数分别为0.382、0.387、0.248、0.323。其中 FER 差值与 AOL、FTF 相关系数显著性检验 P0.01， FER 差值与 VAL、JOA 相关系数显著性检验 P0.05。均有统计学差异。5MFs 差值与 AOL、FTF 、VAL、JOA 差值相关性，对数据进行正态性检验，P 值分别为 0.759、0.690、 0.685、0.953、0.705，可认为近似服从正态分布。相关性分析 FER 差值与 AOL、FTF 、VAL 、JOA 等差值的相关系数分别为0.586、0.413、0.425、0.510。相关系数显著性检验 P0.01。相关性
20、显著。结论：1.表面肌电测试系统测量椎旁肌等长收缩时 MFs 和屈伸运动时 FER 重复性佳，可用于临床测试。2.正常人和腰椎间盘突出症患者之间表面肌电指标 FER、MFs 存在差异，有统计学意义。正常人、腰椎间盘突出症患者双侧椎旁肌表面肌电指标 FER、MFs无明显差异。腰椎间盘突出症症状明显侧表面肌电指标与对侧差异显著。3.治疗前表面肌电指标 FER、MFs 与 AOL、FTF、VAL、JOA 相关性不显著。治疗前后表面肌电指标 FER、MFs 差值和 AOL、 FTF、VAL、JOA 差值之间相关性显著。FER 和 MFs 可以作为腰椎间盘突出症疗效评价敏感量化客观评价的指标。主题词：腰
21、椎间盘突出症，定量分析，定性分析，表面肌电6Abstract:Study background:Lumbar disc herniation(LDH) is feferred to the degeneration of lumbar intervertebral disc, such as bulging or rupture, spine nerve roots is pressed and stimulated, inducing low back pain, sciatic pain, intermittent neurogenic claudication, numbness, mu
22、scle spasm, muscle paralysis, and so on. Now there is not a definite conclusion about the cause of lumbar disc herniation. Abnormity structures of spine, physical degeneration, race, occupation, lumbar trauma, smoking, pregnancy etc are considered related to this disease. In accordance with sitting
23、working time prolonged, strength and accordance of paraspinal muscle decreased, ligament of intervertebral joints loosened, incidence of lumbar disc herniation increases gradually. In traditional Chinese medicine(TCM), LDH belongs to “stagnation syndrome of qi and blood”, there are main three types
24、about LDH as “blood stasis due to stagnation of qi”, “wind-cold-dampness” and “deficiency of the kidney”. For “blood stasis due to stagnation of qi”, there is often obvious history of hurt, spine lordosis or decline, fixed pain point and radiative pain, dark purplish tongue proper, astringe or strin
25、glike and frequent pulse. For “wind-cold-dampness”, there is often no obvious history of hurt, paraspinal muscle pain and radiative pain, the symptom of leg and back pain appears gradually and aggravates, cold weather could worsen the symptom, tongue is putrid and pale, pulse is slow and deep. For “
26、deficiency of the kidney”, it is often caused by improper treat for acute hurt or shortage of habitus or deficiency of kidney essence, symptom aggravates or alleviates, lasting for years, pale face, breathe heart and atony. In west medicine, LDH is proposed by Mixter and Barr in 1934, diagnoses main
27、ly depend on clinical symptoms, physical examination, image examination, electrophysiologic examination.As concerning the treatment of LDH, there are different theory background and specific methods for both TCM and WM, both of them agree surgery method if symptom alleviates little after 6 months co
28、nservative treatment. Although operation method has developed quiet great, this method cant deal with relapse and complication because of unstable spine. Conservative method is mostly used. At present, there are many kinds of quomodo such as traction, physical therapy, massage, chiropractic, medicin
29、e therapy and so on. How to evaluate the curative effect of kinds of therapy method is a problem, operation therapy usually adopts JOA score, Oswestry score. Conservative therapy usually adopts self symptoms, AOL, DFTF. Needle EMG has been used to determine whether nerve roots were scathed, but when
30、 clinical symptom alleviates, the outcome would not change correspondingly, so curative effect estimation lack sensitive objective and quantitative electrophysiology index.Recently, in the study of LDH pathogenesis, somebody propose LDH without symptoms. Parts of patients receive CT or MRI examinati
31、on after operation, the protrusion part does not change, but the clinical symptom ease. High G people such as fighter pilot, their CT or MRI examination show 30% LDH, but the incidence of LDH is not so high. These phenomena indicate correlation between LDH and protruded disc should be studied furthe
32、rmore. And unstable state of lumbar function unit could 7provide some explanation.Studies have demonstrated there are anatomical and histological change of protruded unit and lumbar back muscle in LDH patients, such as laxation of joints ligament, muscle atrophy, character of muscle fiber change, de
33、crease of noumenon receptive organ, delay of movement reaction time. Recently sEMG was applied greatly in health medicine, clinical neurology, gynecological medicine, stomatological medicine, otolaryngological medicine, sport medicine, ergonomics. Health medicine has studied studied paraspinal muscl
34、e in LDH patients, but sample size is small; detection position and detection method and index parameter did not agree, there is yet unitive stardand.We have retrospected interrelated studies, we select MFs(median frequency slope) when paraspinal muscle in isotonic station, FER(flexion and extension
35、 ratio), to examine paraspinal muscle in LDH patients, to provide sensitive objective and quantitative index to evaluat curative effect, to study the pathogenesis of LDH.Objective To study the reproducibility of sEMG index MFs when paraspinal muscle contract isotonically and FER when paraspinal musc
36、le flex and extend. To study MFs and FER, to determine whether there is difference between LDH patients and normal people. To study the correspondence between sEMG indexes (MFs and FER) and general indexes (VAL JOA AOL DFTF) before and after conservative treatmentContents and methods1. The reproduci
37、bility of sEMG index MFs when paraspinal muscle contract isotonically and FER when paraspinal muscle flex and extend1.1ContentsTesting MFs paraspinal muscle contract isotonically and FER when paraspinal muscle flex and extend in normal people. Adopting repeated measurement reliability testing intra
38、class coefficient.1.2Methods1.2.1Subjects18 normal people according with the standard of normal people.1.2.2Testing methodsMFs: Applying Mega-T8 sEMG monitor, we test frequency index when the subjects paraspinal muscle contract isotonically on double L4-5 level, referring to Biering-Srensen test: su
39、bjects prostrate on checking table, their hip and leg are fixed with straps down their iliac crest, hands are put aside body, recording frequency index for 30 seconds while upper body is supportless. In order to avoid system error, we test 3 times, each break is 5 minutes. After test, analyzing the
40、change of median frequency, regard the average of 3 times tests as MFs index.FER: Referring to Sihvonen test, first subjects stand erect, then body bend forward to 90and lasting for 5 seconds, at last stand erect, repeat for 5 times.1.2.3Calculating indexMFs: Measuring slope of median frequency, uni
41、t is Hz/m, indicating frequency index when paraspinal contract isotonically.8FER: Measuring AEMG of both bending phase and extending phase, computing ratio of bending phase to extending phase as FER, unit is uv/uv.1.2.4 Characteristic of normal peoples sEMG and the reproducibility of tests of 3 time
42、s.Describing characteristic of normal peoples sEMG and analyzing the reproducibility of tests of 3 times.2. Study on difference of sEMG indexes between LDH patients and normal people2.1 ContentsTesting MFs when paraspinal muscle contract isotonically and FER when paraspinal muscle flex and extend in
43、 normal people and normal people.2.2 Methods2.2.1Subjects18 normal people according with the standard of normal people and 71 LDH patients according with standard of LDH.2.2.2Testing methodsAccording with the methods “1.1.1”.2.3 Characteristic of LDH patients sEMG and difference between LDH patients
44、 and normal people.Describing characteristic of LDH patients sEMG and analyzing the difference between LDH patients and normal people.3. Study on coherence between sEMG indexes and LDH state of illness.3.1 ContentsTesting LDH patients on sEMG indexes MFs and FER, and on indexes of state of illness V
45、AL,JOA,AOL,DFTF before and after conservative treatment.3.2 Methods3.2.1 Subjects81 cases of LDH according with including and excluding standard of LDH.3.2.2 Testing methodsAccording with the methods “1.1.1”.3.2.3 Studying coherence between difference of MFs and FER before and after treatment and di
46、fference of VAL,JOA,AOL,DFTF before and after treatment.Results1. The reproducibility of sEMG index MFs when paraspinal muscle contract isotonically and FER when paraspinal muscle flex and extend.1.1 Characteristics of normal peoples sEMG.In the course of bending and extending movement, when fully s
47、tanding erect and bending fully, electrophysiological movement of paraspinal muscle almost disappears. In the course of contracting isotonically, when paraspinal muscle contract at 20% MVC, frequency index MF descend gradually, value of both sides almost the same.1.2 The reproducibility of sEMG inde
48、xFERWe first adopt General Linear Model for Repeated Measures to analyze the 9difference of repeated data, compare 3 distinct averages, the left side FER P=0.697, the right side FER P=0.532, both value of P are more than 0.05, there is no statistic difference. The result indicates there is no signif
49、icant difference as a whole. Then we adopt Intraclass correlation coefficient to analyze the coherence of 3 times data, left side ICC=0.941, right side ICC=0.981, p value of both sides ICC are less than 0.01, the result indicates not only the coherence of 3 times data is high, but also is significant.MFsWe first adopt General Linear Model for Repeated Measures to analyze the difference of repeated data, compare 3 distinct averages, the left side FER P=0.559, the right side FER P=0.427, both value of P are more than 0.05, there is no statistic difference. T
