中国康复研究中心北京博爱医院，中医康复科，脊髓损伤康复科，北区康复病房，北京市 100068

通讯作者：司同，男，1953年生，北京市人，汉人，1996年北京中医药大学毕业，副主任医师，主要从事脊髓损伤中医康复研究。
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中图分类号：R744 文献标识码：A 文章编号：1671-5962-（2005）29-0032-02 收稿日期：2004-12-25 修回日期：2005-03-08 
Comparison between the effects of acupotome lysis and muscle relaxant on the amelioration of complicated muscular spasm of spinal cord injury Si tong,Wang jia-zong,yan Zenghong,Lu Hu-ying,Department of Traditional Chinese Medicine Rehabilitation,Department of Traditional Chinese Medicine Rehabilitation,Department of Spinal Injury Rehabilitation Ward,Peking Boai Hospital,China Rehabilitation Research Center,Beijing 100068,China

Correspondence to:Si tong,Associate chief physician,Department of Traditional Chinese Medicine Rehabilitation, Peking Boai Hospital, Rehabilitation Research Center, Beijing 100068
Sitong628@126.com
Received:2004-12-25 Accepted:2005-03-08
Abstract
AIM:To observe the effect of acupotome lysis in the treatment of spinal injury complicated muscular spasm and compare with the effect of muscle relaxant
METHODS: The inpatients with spinal injury complicated muscular spasm from Yizhuang Inpatient Department of Peking Boai Hospital between January 2002 and March 2003 were selected and assigned randomly into acupotome group with 30 cases (cervical vertebra injury with 3 cases,thoracic spine injury with 27 cases) and control group with 20 cases (cervical vertebra injury with 4 cases,thoracic spine injury with 16 cases).Patients in acupotome group were touched and searched for node,hererotopic ossification point and trigger point on the two sides of spine and around muscle,articulation below the level of injury.Three to six points were selected every time.The orientation,disinfecting,and inserting were done according to the operating criterion of acupotomology.Afterentering into the rind acupotome was used to find lesion tissue.The brisement method such as:horrizm oscillation.transverse cut and spade etc.was performed acconding to situation.When part of tissue was floppy,acupotome was extracted.The general manipulation maneuver was applied for 3-5 times post-treatment in order to make better use of recobery.One operation every weed,different parts were selected lasting 3-5 times.Most or the whole of the node,hererotopic ossification point and trigger point etc.were found by touch was finished brisement.The effect was known 1 and 6 months after the last operation.Patients in control group were treated with anti-spasm drug Baclofen orally,firstly three times a day with 5 mg every time orally and later every 8 days5mg was added a day,till the dosage when the spasm significantly relieved,the was the maintenance dosage.The effect was known after 1 and 6 months.The conventional rehabilitation training was performed in the two groups.The grade of muscular spasm degree was evaluated by improved Ashworth Score.
RESULTS:Totally 50 patients were involved in the result analysis.The grade of muscular spasm degree in 6 month was improved than that in 1 month after treatment in patients in acupotome group and control group (acupotome group at 1,2,3,4grade with 11,8,7,4 cases respectively after 6month,15,9,5,1 cases respectively after 1 month;control group at 1,2,3,4 grade with 8,7,4,1 casesrespectively after 6 month,9,7,3,1 cases respectively after 1 month,P<0.01).The grade of muscular spasm degree was insignificant difference before and after treatment between the two groups(P<0.05).
CONCLUSION:The level of muscular spasm is similar between acupotome group and control group,but the anti-muscular spasm drug taking orally has big ill effect with high charge and the dosage is difficult to master.The acupotome lysis treatment is easy to perform with low injury and less lbleeding,can perform the operation repeatedly,safe having no ill effect and credible curative effect and is a new approach for spinal injury combining muscle spasm.

摘要
目的：观察针刀松解术治疗脊髓损伤并发肌痉挛的作用并与肌松剂效果作比较。
方法：选择2002-01/2003-03北京博爱医院亦庄住院部脊髓损伤并发肌痉挛的住院患者，随机分为针刀组30例（颈髓损伤3例，胸髓损伤27例）和对照组20例（颈髓损伤4例，胸髓损伤16例）。针刀组在损伤平面以下脊柱及肌肉、关节部位触摸寻找结节、异位骨化点、扳机点，每次选择3-6点，按针刀操作规范要求定位、消毒、进针、针刀进入皮下后寻找病变组织，根据情况行横向摆动、纵向切割、铲削等松解手法，局部组织松软后拔出针刀，术后应用一般推拿手法治疗3-5次，将触摸寻找的结节、异位骨化点、扳机点等大部或全部松解完毕。末次手术1个月或6个月后统计疗效。对照组口服抗痉挛药氯苯氨丁酸，先3次/d，5 mg/次口服，以后每隔7d每日增加5mg，至痉挛明显减轻时的剂量即为维持剂量。1个月至6个月后统计疗效。两组均进行常规康复训练。肌痉挛程度分级采用改良的Ashworth 评分法评定。
结果：50例患者均进入结果分析。针刀组及对照组患者在治疗后6个月肌痉挛程度分级评分均较治疗后1个月改善（针刀组1，2，3，4级6个月后分别有11，8，7，4例，1个月后分别有15，9，5，1例；对照组1，2，3，4级6个月后分别有8，7，4，1 例，1个月后分别有9，7，3，1 例，P<0.01）,两组之间治疗前后肌痉挛程度分级差异不显著（P<0.05）。
结论：针刀组改善肌痉挛的程度与对照组相当，但是口服抗痉挛药副药副作用大，费用高、剂量不易掌握。针刀松解术治疗简单易行、损伤小，出血少，可以反复施术，安全无副作用，且疗效可靠，是治疗脊髓损伤并发肌痉挛的又一新途径。

主题词：脊髓损伤；肌痉挛；针刀

肌痉挛是脊髓损伤患者的常见并发症之一，表现为受累骨骼肌的不自主收缩，常影响患者日常生活动作的完成和康复训练的进行，因此是康复治疗中亟待解决的一个重要问题。虽然肌痉挛对脊髓损伤患者有正反两方面的影响，但痉挛过重则会严重限制关节活动范围，引起疼痛和关节挛缩，影响患者完成日常生活动作。作者根据针刀医学关于软组织损伤的原理，对脊髓损伤并发肌痉挛进行针刀松解术治疗。

1 两组间治疗前后比较：治疗前：Rzhen=0.499，Rdui=0.5015, U=0.03502519,<1.96,P>0.05,差异无显著性，可以认为两组治疗前病情相同。治疗后：治疗后1个月及治疗后6个月两组比较，分别为Rzhen=0.491333,Rdui=0.513,U=0.080483,Rzhen-Rdui=R1-R2=0.021667和Rzhen=0.332,Rdui=0.31,Rzhen-Rdui=R1-R2=0.022.U=0.649561,均<1.96，P>0.05,差异无显著性。

两组各自治疗前后比较：针刀组治疗1个月及6个月前后比较：分别为R1-R2=0.191388,U=5.25055和R1-R2=0.14722297,U=3.84,均>2.58,P<0.01,差异极显著。对照组治疗1个月及6个月前后比较：分别为R1-R2=0.205625,U=4.43和R1-R2=3.9625,U=83.77,均>2.58,P<0.01,差异极显著。 3 讨论 痉挛是肌张力增高到一定程度的表现，而肌张力增高是牵张反射过程的结果。牵张反射的调节是通过γ-环路来实现的，其感受器是肌梭。目前对脊髓损伤并发肌痉挛的治疗有物理疗法，包括功能训练、水疗、交替电刺激等；口服或鞘内注射抗痉挛药如氯苯氨丁酸、局部神经阻滞如经皮注射酚溶液或肉毒素等均可改变神经肌肉接头的生理功能使肌痉挛缓解；直肠电刺激及神经根切断术、肌腱切断术等。这些方法都是通过不同的方式干扰或阻断脊髓反射中的γ-环路，使过高的肌张力降低，解除肢体痉挛。

根据针刀医学关于软组织损伤的原理，从临床中注意到：脊髓损伤后，患者的肢体失去自主运动，长时间固定在一种体位，失去了正常肢体的动态平衡，各软组织发生粘连、瘢痕、挛缩、堵塞，在脊柱两侧及肌肉、关节部位形成结节、异位骨化点、扳机点。这种病理变化刺激肌梭的感受器，肌梭的Ia类传入神经纤维将刺激传入脊髓后直接与支配本肌肉或协同肌的α神经元发生兴奋性突触联系而引发肌痉挛。近20年来关于肌筋膜出发点的研究，进一步揭示了软组织损伤引发疼痛与肌痉挛的病理机制与临床特点。Ia类神经纤维是脊髓反射中γ-环路的传入神经纤维，针刀松解术治疗即可以破坏肌梭的感受器、Ia类传入神经纤维，更重要的是可以松解由软组织损伤形成的，在脊柱两侧及肌肉、关节部位的结节、异位骨化点、扳机点，消除了引发肌痉挛的重要因素，从而阻断了脊髓反射中的γ-环路，解除肌痉挛，针刀松解术还可以通过直接把一部分痉挛紧张的肌肉纤维切断，剥离疏通肌肉和韧带的粘连、挛缩而缓解痉挛。 从本组的观察中可以看到，两组之间治疗前后肌痉挛程度分级差异不显著，针刀松解术治疗6个月后效果仍然显著。对照组口服抗痉挛药氯苯氨丁酸，其作用与针刀组相同，但是前者服药副作用大、费用高、剂量不易掌握是其缺点。针刀松解术治疗简单易行、损伤小，出血少，可以反复施术，安全无副作用，而且疗效可靠，是治疗脊髓损伤并发肌痉挛的又一新途径。

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