【作者】 潘文宇；

【导师】 庄礼兴；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2007， 硕士

【摘要】 椎动脉型颈椎病（Cerrical Spondylopathy of Vertebral Artery，CSA）是以颈椎间盘的退行性变为主，退变的组织和结构对颈部脊髓、神经、血管和软组织构成压迫或刺激，从而引致椎-基底动脉系统缺血而出现眩晕、耳鸣、呕吐、头痛、视力障碍、猝倒等一系列症状。据统计，我国目前颈椎病的发病率为17.3％，其中椎动脉型占20～30％，且不断上升，发病年龄也不断提前。椎动脉型颈椎病的研究受到国内外学者的广泛关注，现代医学对于椎动脉型颈椎病的治疗主要①应用血管扩张剂药物，如尼莫地平、西淇汀、西比灵、赛莱乐等，有一定的疗效，但易反复；②手术治疗，但大多数患者难以接受。椎动脉型颈椎病属祖国医学“眩晕”范畴。我们认为椎动脉型颈椎病，病位在颈，反映在脑，大脑血虚不荣为其致病本质，故“眩晕”的发生与脑髓不足的关系密切，正如《灵枢·海论》说：“髓海不足，则脑转耳鸣，胫酸眩冒，目无所见，懈怠安卧。”又如《灵枢·口问》说：“上气不足，脑为之不满，耳为之苦鸣，目为之眩。”而脑髓又与督脉关系密切，正如张锡纯所说：“督脉者又脑髓神经之所也。”我们知道，督脉是阳脉之海，总督人体一身的阳气，其所属穴位主治适应症广泛，尤其是在防治神经精神疾病方面。督脉“向后行于脊里，上行至顶后从风府进入脑内，上循巅顶”，可见督脉入络于脑，下贯脊柱，与脑、髓直接相关，具有补益脑髓，醒脑开窍，熄风止眩，安神定志的作用。根据“经脉所过，主治所及”理论，取督脉经穴治疗本病，创新了针灸治疗该病的配穴处方。针灸疗法治疗椎动脉型颈椎病已有多年历史，电针督脉经穴治疗椎动脉型颈椎病疗效确切，其疗效可靠，具有疗效高、整体调节及不易复发的优势。关于督脉经穴治疗椎动脉型颈椎病的临床报道尚不多见，为完善个体化诊疗体系，发扬中医“辨证施保”提高生存质量的应用体系，为了进一步科学评价运用督脉经穴治疗椎动脉型颈椎病的方法，本课题从电针督脉经穴对椎动脉型颈椎病的脑血流影响为切入点，研究针刺治疗本病的疗效和作用机理。本课题是在导师庄礼兴教授的指导下，在既往压灸百会穴为主治疗椎动脉型颈椎病临床研究的基础上，总结多年来电针督脉经穴的临床经验，对穴位进行筛选，使治疗更具有针对性，达到优化用穴的目的，并拟用血浆ET、PGI₂(6-keto-PGF_1a)的含量，观察电针督脉经穴对椎动脉型颈椎病的影响，借以阐明针灸治疗椎动脉型颈椎病的机理，科学验证“针灸通过整体调节，以神经-体液的途径，最终达到调节血管运动，改善动脉供血而治疗本病”的假设。本课题研究依据统一诊断标准、排除标准、纳入标准纳入研究对象，病例来源为广州中医药大学第一附属医院针灸科门诊病人。其中电针督脉经穴治疗组为50例，对照组电针颈4～6夹脊穴46例。两组病例一般情况经统计学处理P＞0.05，无显著性差别。电针督脉经穴的穴位是印堂、神庭、上星、百会、脑户、风府，配天柱双，其他配穴为：气血亏虚：足三里；肝肾不足：三阴交；痰湿阻络：丰隆；气滞血瘀：血海。选用28号1.0寸毫针，针刺上述穴位，得气（以局部有麻、胀感为度）后以180～200次／分的频率捻转2分钟，后接电针机，采用G6805-1治疗仪（中国青岛鑫升实业有限公司生产），用疏密波（频率为2～4Hz／50～100Hz），每次30分钟，每日一次，二周为一个疗程，休息3天后继续第二个疗程，共治疗三个疗程后统计疗效。在首次治疗前和末次治疗后分别检测血浆ET、6-keto-PGF_1a含量。对照组是电针颈4～6夹脊穴、天柱双，其他配穴同上。选用28号1.0寸毫针，针刺上述穴位，得气（以局部有麻、胀感为度）后以接电针机，采用G6805-1治疗仪（中国青岛鑫升实业有限公司生产），用疏密波（频率为2～4Hz／50～100Hz），每次30分钟，每日一次，二周为一个疗程，休息3天后继续第二个疗程，共治疗三个疗程后统计疗效。在首次治疗前和末次治疗后分别检测血浆ET、6-keto-PGF_1a含量。各项研究结果如下：1、根据国家中医药管理局1995年疗效标准并予以量化，评判各患者疗效，其中电针督脉经穴治疗组50例中临床治愈15例，显效25例，好转7例，无效3例。总有效率为94％。电针颈4～6夹脊穴对照组46例中临床治愈6例，显效13例，好转18例，无效9例，总有效率为80.43％。经统计学处理，两组治疗效果的差异有显著性意义（P＜0.05）。同时发现，治疗组疗效与中医证型的关系差别无意义，但对气血亏虚型疗效较好，肝肾不足型次之，气滞血瘀型再次之，痰湿阻络型最差。治疗组疗效与病程呈负相关，其中病程越短，疗效越显著。2、血浆ET、6-keto-PGF_1a检测结果：治疗组血浆ET由治疗前84.45±18.89（ng／L）显著下降到治疗后的57.81±14.36（ng／L），血浆6-keto-PGF_1a由治疗前105.88±54.35（Pg／ml）显著增加到治疗后的246.36±41.28（Pg／ml），治疗前后血浆ET、6-keto-PGF_1a含量变化有显著差异，以治疗组作用明显。更多还原

【Abstract】 Cervical Spondylopathy of Vertebral Artery(CSA)is a common disease basedon cervical spaine disks degeneration. The degenerated tissues and structurescompress or stimulate the cervical spinal cord, nerves, blood vessel, and softtissues. Thereby it leads to ischemia of vertebrobasilar system, and causes aseries of clinical manifestations such as dizziness, tinnitus, vomitting,headache, visual disorder, cataplexy, and so on. According to statistics, theincidence of cervical spondylosis is 17.3% in our country, of the total TypeVA is 20-30%. And the incidence is increasing while the patients are youngerand younger. Foreign and domestic scholars are widely concerned about theresearch of CSA. For CSA treatment, two means are used according to modernmedicine. First, vasodilator agent drugs such as Nimodipine, BetahistineHydrochloride, Flunarizine are applied. But it is unstable though has certaintherapeutic effect. Second, the operation treatment is applied to the patients,but most of them claim that it’s hard to accept the treatment.In the view point of Traditional Chinese Medicine(TCM), CSA classifies to"vertigo". We considered that CSA focused on the neck, and reflected in thebrain. Blood deficiency of brain was pathogenesis of CSA. Thus, the cause ofvertigo had a close relationship with the deficiency of brain marrow. Justas Lingshu·Hailun said "If the sea of marrow is deficient, we will feel vertigo,tinnitus, eyes blurred, and tired."Lingshu·Kouwen said" Tinnitus and eyesblurred are due to the deficiency of upper Qi in brain."There is a closerelationship between brain marrow and the Governor Vessel. Just as Xichun Zhangsaid "Where there is the Governor Vessel, there is the brain marrow and nerves."We know that the governor vessel is the sea of Yang meridians, it governs theYang Qi of our whole body. The indications of points of the governor vesselare widily used in clinic. Especially in treating with neuropathic mentaldisorders. The Governor Vessel ascends posteriorly along the interior of the spinal column to Fengfu at the nape, where it enters the brain, and it furtherascends to the vertex. So, the governor vessel has the effect of tonifying brainmarrow, regaining consciousness and stopping endogenous wind to lessenvertigo, and calming the nerves.According to the theory "The course of achannel is amenable to treatment", we used the Governor Vessel points to treatCAS, and brought a new idea about the coordination of acupoints for thisdisease.Acupunture as a therapy for CAS has had a history of certain years. The effectof electro-acupuncture on governor vessel points for CAS was affirmed. It hadascendancy of good therapeutic effect, holo-accommodation and uneasyrecurrence. There were few clinical reports about governor vessel points forCAS. In oder to consummate individuation therapeutic system, and develop thetheory "syndrome differentiation and treatment" of TCM to improve the appliedsystem of living quality, and to further evaluate and use acupoints of theGovernor Vessel for CAS treatment, we observed the influence ofelectro-acupuncture on governor vessel points on cerebral blood flow of theCSA. The research aims to evaluate the therapeutic effects and explore thetherapeutic mechanism.These studies were performed under the direction of Professor Lixing Zhuang,and based on the prior clinical researches on press and moxibustion on BAIHUI point as main therapy for CSA. The aim was to summarize the clinicalexperience of electro-acupuncture on governor vessel points in the past fewyears, and to screen the points. Thus it made the therapy more directly. Ittested the levels of plasma ET and PGI2 (6-keto-PGF1a) to observe the effectof electro-acupuncture on governor vessel points of the CSA. Then it clarifiedthe therapeutic mechanism on the effect of acupuncture therapy of the CSA,and verified the hypothesis that acupuncture therapy, which regulates thewhole body by neurohumoral pathway to treat CSA, adjusts the movement of bloodvessels and improves the supply of arteries.All the cases which were according to the unified diagnostic code, eliminationcode and internalize code, came from the out-patient clinic of acupunctureand moxibustion department in the First Affliciated Hospital of GuangzhouUniversity of Chinese Medicine. Among these, 50 cases of the therapeutic groupwere given electro-acupuncture on the acupoints of the Governor Vessel while46 cases of the control group were given electro-acupuncture on the acupoints of Neck 4-6 Jiaji. There was no significant difference as compared betweenthe two groups on the common situation(P＞0.05).The main acupoints of thetherapeutic group were Yingtang, Shenting, Shangxing, Baihui, Naohu, Fengfu,and double Tianzhu. And the modifications were as follows: Deficiency of Qiand Blood: Zusanli; Insufficiency of the Liver and Kidney: Sanyinjiao; Phlegmand dampness in the collaterals: Fenglong; Qi stagnation and blood stasis:Xuehai. Needles with gauge 28 in diameter and 1 cun in length are used toacupuncture the above mentioned acupoints. When Qi arrived(refers to thesensation of numbness and distension around the acupoint after the needle isinserted),the needle was twirled and rotated backward and forward with thefrequency of 180～200 times per minute. Then needles were connected to G6805-1Electro-acupuncture Stimulator(made in Qingdao Xinsheng IndustryCo, Ltd.,China) with the output wires. The disperse-dense waves were appliedwith the frequency 2～4Hz/50～100Hz once thirty minutes. It’s manipulated onceevery day and two weeks a course. With three days’ rest the second coursecontinued. Totally three courses were taken and after treatment thetherapeutic effect was checked according to statistics. The levels of plasmaET, 6-keto-PGF1a were tested before the first treatment and after the lasttreatment respectively. The main acupoints of the control group were Neck 4-6Jiaji and double Tianzhu. And the modifications were the same with thetherapeutic group. Needles with gauge 28 in diameter and 1 cun in length areused to acupuncture the above mentioned acupoints. When Qi arrived(refers tothe sensation of numbness and distension around the acupoint after the needleis inserted),the needle was twirled and rotated backward and forward with thefrequency of 180～200 times per minute. Then needles were connected to G6805-1Electro-acupuncture Stimulator(made in Qingdao Xinsheng IndustryCo, Ltd.,China) with the output wires. The disperse-dense waves were appliedwith the frequency 2～4Hz/50～100Hz once thirty minutes. It’s manipulated onceevery day and two weeks a course. With three days’ rest the second coursecontinued. Totally three courses were taken and after treatment thetherapeutic effect was checked according to statistics. The levels of plasmaET, 6-keto-PGF1a were tested before the first treatment and after the lasttreatment respectively. And the results were as follows:1. To quantize and judge therapeutic effect according to the therapeutic effectcriteria of State Administration of TCM in 1995. The result manifests that in 50 cases of therapeutic group, 15 cases were healed, 25 cases had markedtherapeutic effects;7 cases had certain improvement;3 cases did not respondto the treatment, the total efective rate was 94%. In 46 cases of controlgroup, 6 cases were healed,13 cases had marked therapeutic effects;18 caseshad certain improvement;9 cases did not respond to the treatment, the totalefective rate was 80.43%. All clinical information was handled by statistics.The result manifests that there was significant difference of therapeuticeffects between the two groups (P＜0.05). At the same time, it shown norelationship between therapeutic effect and TCM syndrome in therapeuticgroup. The therapeutic effect of deficiency of qi and blood was thebest;insufficiency of the liver and kindey came second while qi-stagnancy andblood stasis came third;and blockage of collaterals by phlegmatic hygrosiswas the last. There were negative correlation between therapeutic effect andthe course of disease in therapeutic group. As the course was shorter, thetherapeutic effect was better.2. The results of plasma ET and 6-keto-PGF1a: After treatment, the level ofplasma ET obviously decreased from 84.45±18.89 (ng/L) to 57.81±14.36(ng/L), while the level of plasma 6-keto-PGF1a significantly increased from105.88±54.35 (Pg/ml) to 246.36±41.28 (Pg/ml);the levels of plasma ETand,6-keto-PGF1a had significant differences as compared with pretherapyrespectively, and the difference of therapeutic group C was more obvious.更多还原