[Influence of acupotomy on postoperative musculoskeletal status following lumbar surgery and discussion on its theoretical mechanism in traditional Chinese medicine].

Abstract

Objective: To investigate the effects of acupotomy on the paraspinal muscle status via MRI and spinal pelvic parameters, as well as lumbar activity in patients with lumbar disc herniation (LDH) post-surgery, aiming to elucidate the relative correlation and the traditional Chinese medicine (TCM) theory "regulating tendons to treat bones".

Methods: Between December 2019 and December 2021, a total of 104 patients with LDH who underwent percutaneous transforaminal endoscopic discectomy (PTED) were enrolled via a prospective case-control study. They were randomly assigned to the acupotomy group (52 cases, 3 cases lost to follow-up) and the control group (52 cases, 4 cases lost to follow-up). There were 49 patients in the acupotomy group, including 38 males and 11 females, aged from 30 to 70 years with a mean age of (57.21±11.19) years and disease course ranged from 1 to 12 month with a mean of (4.83±1.31) months. The affected segments were L_3,4 in 3 cases, L_4,5 in 35 cases and L₅S₁ in 11 cases. Patients in the acupotomy group received one acupotomy intervention within 24 hours after PTED, and additional interventions were performed on postoperative day 7 and day 14 respectively. A total of 48 patients were enrolled in the control group, including 32 males and 16 females, aged from 30 to 69 years with an average age of (53.03±12.37) years old and disease course ranged from 1 to 12 month with a mean disease course of (5.14±1.43) months. The lesioned segments involved L_3,4 in 1 case, L_4,5 in 37 cases and L₅S₁ in 10 cases. All patients underwent PTED following the identical surgical procedures without acupotomy intervention, and the remaining rehabilitation and nursing protocols were consistent with those in the acupotomy group. Relevant evaluations were performed on patients before surgery as well as at 6 and 12 months postoperatively. The spinal pelvic parameters included lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT) and pelvic incidence (PI). Indicators of lumbar mobility include the Oswestry Disability Index (ODI) and the Japanese Orthopedic Association Scores (JOA). Pearson correlation analysis was used to study the relationship between spinal muscle structure parameters, spinal pelvic parameters and lumbar mobility function for the patients with LDH after acupotomy, and generalized linear regression analysis was used to study the effects of spinal paravertebral muscle structure on the spinal joint force lines for the patients with LDH after acupotomy.

Results: All patients completed 12-month follow-up. At 6 and 12 months after surgery, the multifidus muscle IF values at L_4,5 segment in the acupotomy group were (28.50±6.20)% and (26.43±8.80)%, which were significantly lower than the preoperative level of (45.16±10.45)% with statistically significant differences (P<0.01). Meanwhile, these values were obviously lower than those in the control group (40.14±15.16)% and (38.41±14.92)%, and the differences were statistically significant (P<0.01). At 12 months postoperatively, the LL of (47.48±6.49)° and SS of (35.10±7.01)° in the acupotomy group were higher than (43.06±4.22)° and (31.12±10.25)° in the control group respectively, with statistically significant differences (P<0.01). The PT of (13.73±4.66)° was lower than that of the control group (18.01±6.56)°, showing a statistically significant difference (P<0.05). There was no significant difference in PI between the two groups during the study period (all P>0.05). At 12 months postoperatively, IF was correlated with JOA and ODI (P<0.01), and PS was positively correlated with JOA (P<0.01). PT was correlated with JOA and ODI (both P<0.05), LL was positively correlated with JOA (P<0.01), SS was positively correlated with JOA (P<0.01), and SS was strongly positively correlated with JOA (r=0.91). IF was significantly correlated with LL, PT and SS (all P<0.01), PS was also significantly correlated with LL, PT and SS (all P<0.01), and PS was strongly positively correlated with LL (r=0.75). Regression studies showed that the degree of IF at L_4,5 segments had statistically significant effects on PT, and SS had statistically significant effects on JOA.

Conclusion: Acupotomy based on the theory of "regulating tendons to treat bones" can alleviate intramuscular fat infiltration of lumbar multifidus in post-PTED patients, thereby triggering favorable shifts in spinal-pelvic alignment and promoting lumbar functional recovery. Among them, the decrease in fat infiltration rate of multifidus(decreased by approximately 41% at the L_4,5 level at 12 months postoperatively) and the increase in SS (increased by approximately 21% at 12 months postoperatively) were the most prominent factors for the changes of spinal paravertebral muscle structure and spinal-pelvic alignment. The relationship between "regulating tendons first" and "treating bones later" in the TCM theory of "regulating tendons to treat bones" can also be explained from an anatomical perspective.