Cervical spondylosis is one of the common and frequent diseases in clinical practice, and in recent years, with the change of people’s work nature and life rhythm, its incidence has been increasing year by year, as well as the trend of lowering the age of incidence. Through more than ten years of clinical application, acupuncture treatment is gradually becoming one of the main methods for treating cervical spondylosis because of its good efficacy, low price, simple operation and low recurrence rate.
In this paper, we will discuss the role of the basic theory of acupuncture medicine in the diagnosis and treatment of cervical spondylosis and how to improve the efficacy of acupuncture treatment of cervical spondylosis under the guidance of the basic theory of acupuncture medicine.
1.Pathogenesis of cervical spondylosis
1, 1 The exact etiology of the pathogenesis of cervical spondylosis is not fully understood, mainly
1.1.1 The theory of mechanical compression
This theory, through clinical studies [1] and animal experiments [2], suggests that developmental spinal stenosis is the main cause of spinal cord-type cervical spondylosis and bony compression is the main cause of vertebral artery-type cervical spondylosis;
1, 1, 2 Biological force balance imbalance theory [3][4][5]
This theory has been demonstrated through animal experiments that removal of soft tissues in the neck of animals can cause cervical spondylosis, and it is proposed that soft tissue defects in the neck are one of the causes of the development of cervical spondylosis;
1,1,3 Inflammatory mediator theory
This theory proposes that cervical spondylosis is caused by the release of a large number of inflammatory mediators [6][7] and an immune response caused by autoantigens [8].
In the author’s opinion, the above doctrine goes to study the pathogenesis of cervical spondylosis mainly through methods such as animal experiments and experimental studies, emphasizing the similarity between humans and experimental animals and ignoring the differences between humans and animals; emphasizing the importance of bone tissue in the pathogenesis of cervical spondylosis and ignoring the importance of soft tissue in the development of the disease. The pathogenicity of external factors is emphasized, and the importance of internal factors (self-healing and self-compensation) in the process of disease occurrence and development is ignored.
1, 2 The doctrine of dynamic equilibrium and disorders of force balance
Through a large number of clinical practices, acupuncture medicine [9] proposed that the dynamic balance of soft tissues in the neck and the imbalance of cervical force balance are the root causes of the pathogenesis of cervical spondylosis.
1,2,1 Definition of dynamic balance disorders of soft tissues and force balance disorders of bone tissues.
Dynamic balance refers to the various physiological functions that the body can accomplish under physiological conditions, and the opposite is a dynamic balance disorder. Force balance disorder refers to the disorder of soft tissue dynamic balance, the corresponding bone and joint stress changes, resulting in misalignment of bone and joint and osteophytes.
For the first time, acupuncture medicine proposes that osteophytes are the result of the body’s antagonistic regulation of abnormal stress, rather than the result of degeneration, thus giving patients with osteophytes hope for a cure and pointing out a new research idea and pathway for clinicians to diagnose and treat osteophytes.
1,2,2
The balance disorder theory of acupuncture medicine takes the soft tissue and hard tissue (bone) of the neck as a whole, studies the causes and pathogenesis of cervical spondylosis, analyzes the relationship and interaction between the soft – hard two tissues in the process of disease development, and proposes that the dynamic balance caused by soft tissue damage is the root cause of cervical spondylosis. It leads to the imbalance of force balance of bone and joint, causing micro dislocation of bone and joint and osteophytes.
In the pathological mechanism of cervical spondylosis, first of all, after the acute and chronic injury of the peri-vertebral soft tissues, the body repairs itself around the soft tissues of the injury site, and finally four major pathological mechanisms are formed: scar, adhesion, contracture, blockage (microcirculatory injury, metabolite accumulation), and the four major pathological factors can directly stimulate and jam the blood vessels and nerves that penetrate between them, and can also pull the vertebrae attached to them, resulting in the imbalance of the cervical vertebral force balance The cervical vertebral body is displaced in the horizontal, sagittal and coronal planes in a single or compound manner, leading to clinical manifestations.
With the development of the disease, the four major pathological factors can also cause changes in the stress on various parts of the vertebral body, and the body, in order to resist this abnormal stress, produces local sclerosis and calcification in the areas where the stress points are concentrated (e.g., the hook vertebral joint, the anterior and posterior edges of the vertebral body), eventually forming ossification (i.e., osteophytes). Osteomalacia can also stimulate compression of the surrounding cervical nerves, blood vessels, and spinal cord.
1, 2, 3 The role of the body’s self-regulatory ability in the development of cervical spondylosis
The basic theory of acupuncture medicine is a theory that was concluded through retrospective research after treating cervical spondylosis with acupuncture by directly using the human body as the experimental object. Since the degree of response to stimulation and injury is different for each individual, the compensatory capacity for stimulation and injury is different, and the degree of self-repair for injury is different, the clinical performance is different and the severity of the disease is different.
When such stimulation, soft tissue injury or osteophytes form and compress the neurovascular in between, but within the compensatory range of the human body, it will not cause the dynamic balance of soft tissues to be out of balance, so there will be no clinical symptoms, or mild clinical symptoms, and vice versa.
It can be seen that the absence of clinical manifestations is not the same as the absence of pathological manifestations of soft tissue injury (adhesions, scars, contractures and blockages), but only that such injury is within the compensatory range of the body, which does not require treatment at this time. Only when the injury exceeds the range of self-compensation, causing a dynamic imbalance and a force balance imbalance, external intervention is required and treatment is needed. In other words, external factors (adhesions, scars, contractures, osteophytes, etc.) are the conditions for things to change, while internal factors (the body’s self-compensation) are the determining factors for things to change, and external factors must work through internal factors.
1,2,4
The onset of cervical spondylosis starts from the point of soft tissue injury lesion (see Figure 1) The pathological process of each lesion point is the body’s self-repair after acute and chronic injury to soft tissues, which eventually results in four major pathological phenomena. With the development of the disease and the body’s self-repair, self-replacement triggers mutual adhesions and scar formation between the lesioned soft tissues and adjacent soft tissues, between the deep and shallow levels, and between the soft tissues and the attached cervical vertebrae, thus forming the entire pathological framework, leading to the imbalance of dynamic balance and force balance, and triggering clinical symptoms.
2.Cervical spondylosis typology
2.1 In the past, cervical spondylosis was divided into cervical, vertebral artery, nerve root, sympathetic nerve, spinal cord, and mixed types, and this classification has undoubtedly contributed to the research and treatment of cervical spondylosis. The affected tissues and organs are clearly described as follows.
Vertebral artery type: that is, the vertebral artery is squeezed, affecting the blood supply of the vertebral artery, causing a series of symptoms such as headache, dizziness and blurred vision; nerve root type: that is, the nerve root is squeezed, causing pain and numbness and dysfunction of the upper limbs; sympathetic nerve type: that is, the sympathetic nerve is affected (only in recent years has it been found that it is mainly pulled), causing a series of symptoms in the internal organs and the five senses; spinal cord type. The cervical spinal cord is squeezed and causes dysfunction of the limbs.
However, this typology still does not allow the problem to be completely solved, because it does not explain how these compressions and pulls are caused? What is the mode of compression? Why is there a disconnect between the site of extrusion and the clinical presentation? Why is the severity of clinical symptoms not proportional to the information provided by imaging? [2] This is related to the past focus on local bony lesions without understanding the important role of soft tissues in the pathogenesis of cervical spondylosis and the intrinsic relationship between soft tissue injury and osteophytes in the pathogenesis of cervical spondylosis.
For example, soft tissue injury at different sites can directly cause brachial plexus compression and clinical manifestations of neurogenic cervical spondylosis, or it can first cause imbalance in the force balance of the bony joints, leading to osteophytes and tiny misalignments of the bony joints, which compress the brachial plexus nerve and trigger clinical manifestations of neurogenic cervical spondylosis. Through the analysis of the pathological framework diagram of (see Figure 2) neurogenic cervical spondylosis, it can be seen that if the typing of neurogenic cervical spondylosis in Western medicine is completely followed and based entirely on the imaging manifestations, even if the intervertebral disc is removed using open surgery, the osteophytes are removed, and the cervical spinal canal is enlarged, the compression of the nerve root cannot be completely released because the soft tissue entrapment is not released, so the efficacy is poor and even leads to This also explains why the imaging performance is not proportional to the clinical performance.
2.2 Acupuncture medicine classifies cervical spondylosis into thirteen types based on the small displacement of the cervical bones and joints caused by soft tissue injury.
For example, lateral displacement of atlantoaxial cervical spondylosis is caused by acute and chronic injury to the peri-vertebral soft tissues of the upper cervical segment on one side (such as the vertebral occipital muscles – head, lower oblique muscles, large and small straight muscles behind the head, longest head muscles, head pinch muscles, head semispinal muscles, collar ligaments, etc.), which causes pathological changes such as adhesions, scars and contractures between the injured tissues and pulls the atlantoaxial spine in After acute and chronic injury to the cranial ligaments, it causes pathological changes such as adhesions, scars and contractures between the injured tissues, which can pull the atlantoaxial spine to shift to one side in the horizontal position, thus compressing and pulling the vertebral artery, occipital nerve, occipital nerve and cervical sympathetic ganglion through the suboccipital triangle, which can lead to the clinical manifestations of vertebral artery cervical spondylosis and sympathetic cervical spondylosis;
Another example is the rotational displacement type of cervical spondylosis, which is due to the adhesion, scarring, contracture and pulling of the soft tissues attached to the 2nd to 7th cervical vertebrae (behind: collateral ligament, interspinous ligament, multifidus muscle, piriformis muscle, lateral: many small muscles between the nodes before and after the transverse process, such as the longissimus dorsi, longissimus dorsi, anterior, middle and posterior oblique muscles, scapularis dorsi, longest head muscle, longest cervical muscle, etc.) after acute and chronic injury. When rotation causes displacement of the intervertebral foramen, it can compress the nerve roots passing through it and cause neurogenic cervical spondylosis; when rotation causes displacement of the transverse foramen of the cervical spine, it can compress or distort the vertebral artery passing through it and cause vertebral artery cervical spondylosis; when rotation of the vertebral body pulls the sympathetic nerve chain or sympathetic ganglion passing through the anterior side of the vertebral body, it can cause sympathetic cervical spondylosis. When the rotation of the vertebral body pulls the sympathetic nerve chain or sympathetic ganglion passing through the anterior side of the vertebral body, it causes sympathetic cervical spondylosis. In cervical spine orthopantomographs, the spinous process of the cervical vertebrae is deviated from the midline of the spinous process, the distance from the middle of the spinous process to the vertebral body edge line is unequal, the vertebral gap is unequal in width, and the hook joint gap is asymmetrical from left to right. The lateral view shows a “bilateral” sign at the posterior edge of the vertebral body and a “double protrusion” sign at the posterior articular eminence. Deformation of the intervertebral foramen can be seen in the oblique view.
Through the analysis of the typology of cervical spondylosis in acupuncture medicine, we can find the source and mechanism of the pathogenesis of the seemingly complex and serious mixed cervical spondylosis in clinical practice, and provide the basis for acupuncture treatment.
3.Acupuncture treatment
3.1 Purpose of acupuncture treatment
To restore the dynamic balance of the soft tissues of the neck and the force balance of the cervical spine. Needle knife does not remove any human tissue in the process of needle knife closed surgery, but exerts the cutting effect of scalpel and the stimulating effect of acupuncture, and through the comprehensive treatment of needle knife, manipulation and drug physiotherapy, peels off adhesions, cuts scars, loosens contractures, unblocks, corrects misalignments and unblocks meridians, so as to restore the biological balance of the neck and cure the disease.
3.2 Treatment principles of acupuncture
Acupuncture is the main treatment principle, supplemented by manipulation, drug physiotherapy and assisted by instruments. The four pathological mechanisms of the peri-vertebral soft tissues are the four pillars of the pathogenesis of cervical spondylosis, so the treatment principle of acupuncture is also formulated for the pathological changes of the soft tissues, and to realize the treatment principle of acupuncture, the comprehensive treatment of acupuncture from point – line – surface should be used to destroy The pathological framework of cervical spondylosis.
If the pathological framework of cervical spondylosis is compared to a building, the needle knife surgery first destroys the reinforced concrete support points (points) of the whole building – that is, loosens the adhesions, scars, contractures and blockages of the diseased soft tissues; then cuts their connecting lines (lines) – that is, to the different levels and the different levels of the spondylosis. -The needle knife surgery technique is to push down the residual part (surface) that has not completely collapsed – that is, to loosen the residual adhesions and scars between the soft tissues in the pathological framework, and to correct the small misalignment of the bone and joint; the drug physiotherapy It is to clean up the garbage after the building collapse – that is, through drug physiotherapy, to promote the body’s self-regulation and self-repair, promote local new into metabolism, accelerate the absorption of metabolic products, and for patients with bone and joint misalignment, use fixed devices to fix the misaligned cervical vertebrae to prevent re-displacement.
3.3 Acupuncture treatment
3.3.1 Position and anesthesia
Depending on the injured soft tissues to be released, different positions can be used: for example, to release the soft tissues on the posterior side of the neck, the prone low head position or the seat cervical vertical traction position can be used;
To release the soft tissues on the lateral side of the neck, the lateral or supine position or the cervical vertical traction position is preferred.
The needle knife surgery point is anesthetized with 1% lidocaine local infiltration, and 0.5-1 ml of anesthetic is injected at each point.
3.3.2 Positioning
1) For vertebral artery type cervical spondylosis, pressure points or hard nodes or striae can be found by palpating the inferior occipital bone, inferior collar line, posterior atlantoaxial tuberosity, transverse atlantoaxial process and spinous process of the cardinal vertebrae to determine the treatment point.
2) For nerve root type cervical spondylosis and spinal cord type cervical spondylosis, the three-step localization method [10] is applied for localization.
In the first step, nerve localization diagnosis: according to the patient’s complaints of pain and numbness and based on the distribution of the brachial plexus nerve and the muscles it innervates, a preliminary localization diagnosis of the diseased part of the cervical spine is made;
In the second step, according to the localization diagnosis result of the first step, the corresponding cervical vertebra and its upper and lower 2 vertebrae of the spinous process, interspinous process, articular process and transverse process should be examined by palpation, whether the spinous process is distorted, whether the articular process is elevated and whether the left and right transverse processes are symmetrical, if there is any abnormality, then it should be checked whether there is also pressure pain and pathological positive objects – If there is any abnormality, then it should be checked if there is also pressure pain and pathological positives – nodules, cords, abrasive sounds, etc;
The third step, imaging localization: observe the cervical spine X-ray five-position film, cervical spine CT or MRI film, pay attention to whether there is distortion of the spinous process, narrowing of the vertebral space, straightening of the physiological curvature, retroflexion, angulation, ligament calcification, double protrusion shadow, bilateral shadow, slippage of the vertebral body, osteophytes and cervical nerve root compression, if so, determine the site of its occurrence.
By combining the above three localization examinations, the lesioned cervical segment can be precisely located. If the patient’s symptoms and signs do not match with the imaging, the former is the main basis for localization.
3
) For sympathetic cervical spondylosis, pressure points or hard nodes and striae can be found by palpation on the C6-7 spinous process and both sides, the spinous process and both sides of the cardinal spine, or the C4 spinous process and both sides, and then according to the lateral cervical spine X-ray, we can carefully find whether there are tiny misalignments of the cervical spine in these three areas to determine the treatment site.
4 ) For mixed cervical spondylosis, the above localization means are integrated for localization.
3,3,3 Needle knife closed surgery
At the above treatment sites, treatment is performed according to the four-step needle approach protocol of needle knife closed surgery, the needle knife surgical approach and surgical method of the cervical spine [11]. To achieve the desired effect of needle knife surgery, familiarity with the fine anatomy of the neck, body projection is the basis, accurate positioning is the prerequisite, longitudinal sparing and transverse peeling, spade peeling and cutting are the means, and whether the needle knife is in place is the key.
3,3,4 Manipulation
According to the abnormalities of the bone and joint suggested by the cervical spine X-ray, the cervical spine manipulation in the acupuncture and knife medical technique is chosen to correct them respectively. It should be noted that for patients without osteoarticular misalignment, the extraction and stretching techniques of acupuncture should also be used after acupuncture surgery to loosen residual adhesions and scars. After the manipulation, all should be externally fixed with a neck brace for 7 days.
3,3,5 Pharmacological physiotherapy
After acupuncture, routine antibiotics were used for three days to prevent infection, and Chinese herbal medicine was used to remove tendons and activate blood.
3.3.6 Course of treatment
A course of treatment includes one acupuncture operation, one manipulation and post-operative physiotherapy with medicine. 3 times is a course of treatment, and each course of treatment is separated by 5-7 days. For mild and moderate cervical spondylosis, one course of treatment can cure it, and a few severe patients can be cured within two courses of treatment.
If the treatment is not effective in two courses, factors such as incorrect diagnosis, incorrect selection of acupuncture treatment points, inappropriate acupuncture surgery, or failure to correct the misalignment of the bone and joint by manipulation should be considered.
In summary, acupuncture medicine is an emerging medical discipline, because the study of acupuncture doctors belong to different specialties, Western medicine acupuncture doctors often pay attention to the role of acupuncture, but ignore the role of manipulation, Chinese medicine acupuncture doctors on the contrary, so the clinical often appear due to the different doctors, the efficacy of the phenomenon of great differences. Therefore, Western doctors should learn Chinese medicine meridian science, manual science and Chinese medicine, Chinese doctors should learn Western medicine, physiological anatomy, on-site first aid and other related knowledge.
In short, regardless of your past disciplines, as long as you use acupuncture to treat cervical spondylosis, you must master the basic theory of acupuncture medicine about the pathogenesis of cervical spondylosis, be familiar with the intrinsic relationship between the cervical spondylosis typology of acupuncture medicine and the western medicine cervical spondylosis typology, follow the treatment principles of acupuncture, acupuncture precise loosening, steady and accurate manipulation, and timely application of drug physiotherapy, only then can you achieve the expected curative effect.