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Assess the treatment of cervical disc herniation by inflatable cervical traction collar in combination with conservative treatment regimen in the patient group.2.. Significance of the th

Spinal disc herniation is a fairly common disease, with themost prevalent type is cervical disc herniation, especially in peopleover 50 years of age

This condition usually manifests itself in the form of neckpain, neck-shoulder pain, neck-shoulder-arm pain, neck-shoulder-hand pain, hypoesthesia or paraesthesia, limbs weakness or paralysis,dizziness,nausea and vomiting, resulting in the reduction ofworkcapacity and quality of life and affecting the patients’ activities ofdaily living

The treatment of cervical disc herniation is aimed at restoringneurological functions, reducing pain and improving the patients’quality of life There have been many effective methods such asphysiotherapy, cervical traction, analgesics, anti-inflammatory drugs,muscle relaxants, cervical nerve root blockade procedure ordiscectomy, however, most patients respond well to conservativetreatment

Cervical traction is an effective conservative treatment due toits effects on the pathogenetic mechanisms of cervical discherniation The disadvantage of cervical tractiondevices such asbraces or beds is that treatment can only be performed in certainfacilities equipped with those equipment and patients must restcompletely during the traction process and wear a traction collar afterthe process To overcome this drawback, the inflatable cervicaltraction device has been put into use and initially proven to havemany advantages due to its flexibility, lightness, simplicity andconvenience The device can also be used at home but still ensure itstherapeutic effects

However, as these issues have not been systematicallyinvestigated, we conducted this research to:

1 Review the clinical features, results of magnetic resonance imaging (MRI) technique and several neurotransmission indicators in patients with cervical disc herniation.

2 Assess the treatment of cervical disc herniation by inflatable cervical traction collar in combination with conservative treatment regimen in the patient group.

2 Rationale

Cervical disc herniation is a spondylosis and herniated discdisease On the basis of spondylosis, it forms osteophytes stimulatingand compressing the nerve roots or narrowing the spinal diameter andcausing different degrees of cervical cord compression If it is leftuntreated, it often results in the reduction of work capacity andquality of life and affecting the patients’ activities of daily living.Although there have been many clinical, diagnostic and therapeuticstudies within Vietnamand around the world, more research needs to

be done to improve theeffective treatmentof this disease Therefore, asystematic evaluation of the outcomes of inflatable cervical tractioncollar in combination with conservative treatment regimenforcervical disc herniationin Vietnam is necessary as this is a simple yeteffective treatment method for this common disease

3 Significance of the thesis

The thesis provided information on the experience andeffects of traction methods using inflatable traction device in theconservative treatment of cervical disc herniation in Vietnam 2weeks after the treatment: 90.74% of patients in the treatment groupexperienced improvement of symptoms, 55.56% higher than thecontrol group (p <0.001) 6 months after the treatment: 100% of thepatients in the treatment group experienced improvement ofsymptoms, with up to 87% of which had very good improvements.During the treatment of cervical disc herniation using inflatablecervical traction collar in combination with conservative treatmentregimen, we did not encounter any accidents or complications

4 Structure of the thesis:

The thesis consists of 132 pages including: 2 pagesofbackground, 34 pages of literature review, 23 pages ofresearchobjects and methods, 39 pages of results, 30 pages of discussion, 3pages of conclusion and 1 page of recommendation

The thesis has 42 tables, 11 charts, 164 references including 14and 150 documents written in Vietnamese and English language,respectively.

CHAPTER 1 LITERATURE REVIEW 1.1 Anatomy profile, cervical spine function

1.2 Pathogenesis and aetiology of cervical disc herniation

1.2.1 Pathogenesis

Disc herniation is a consequence of the spondylosis processthat begins in the nucleus pulposus, followed by the annulus fibrosus

of the intervertebral disc and usually takes place after major traumas

or minor injuries The process of spondylosis progresses with age andoften develops in differentparts of the spine

1.2.2 Aetiology

There have been many studies investigating the causes andmechanism of cervical disc herniation Most authors emphasized twomechanisms of cervical spondylosis and trauma, of whichspondylosis played a major role Currently, the studies ofpathogenesis and aetiologyare still continuingly being conducted

1.3 Classifications of cervical disc herniation

1.4 Clinical symptoms

Cervical disc herniation has a very diverse clinical landscapethat varies depending on the location, type, severity and stage of thedisease The common clinical syndromes are: simple nerve rootcompression syndrome, simplecervicalcord compression syndrome,nerve root and cervical cord compression syndrome, dysautonomia.The majority of studies only described the first three syndromes.However, there are still some papers mentioning all four of thesesyndromes

1.5 Sub-clinical symptoms

Subclinical diagnostic methods include: routine X-ray,computer tomography (CT), MRI, electromyography, and nerveconduction studies

1.5.1 Routine X-ray of cervical spine

1.5.2 CT

1.5.3 MRI

1.5.3.1 Images of herniated disc on MRI films

On MRI films, the herniated discscoincide with the discsprotruding from the posterior longitudinal ligament and donot absorbMRI contrast agent.

+ The sagittal plane helps assess the entire cervical spine,including the positions and number of herniated discs

+ The axial plane shows the types of central, paracentral andsubarticular herniation A combination of both sagittal and axialplane can assess the extent of a herniated compression on the spinalcord and nerve root, causing compression of the cerebrospinal fluidand bone marrow edema at the same level

1.5.3.2 Classifications of cervical disc herniation based on MRI films

MSU classification

The MSU classification was based on both the size andposition of herniation displayed on the MRI film, in relation to theappropriate clinical symptoms to make surgical decision

“The degree of nerve compression” by Nguyen Van Chuong

In 2015, the author Nguyen Van Chuong proposed

using“The degree of nerve compression” displayed on the MRI

film to evaluate the degree of compression caused by herniated disc,ensure the risk of cervical cord and nerve root compression to be

similar with each other “The degree of nerve compression” can be

applied to diagnose and monitor the clinical treatment outcomes ofdisc herniation and should be investigated more for furtherimprovement

1.5.4 Electromyography

1.5.5 Nerve conduction studies

Nerve conduction studies in combination withelectromyography facilitate the diagnosis of neurological distributionloss Nerve conduction studies include the measurement of distallatency (motor and sensory), nerve conduction velocity (NCV)including motor conduction velocity (MCV), sensory conductionvelocity (SCV) and F-wave latency (motor) It can only be measured

on a certaintypes of nerves such as the median, ulnar and radial nervefor the upper limb, posterior tibial, sural/saphenous and superficialfibularor deep fibularnerve for the lower limb

1.6 Treatment

Current treatment methods for cervical disc herniation includeconservative treatment, surgical treatment and other interventions

1.6.1 Conservative treatment

1.6.1.1 Indications for conservative treatment

1.6.1.2 Conservative treatment methods

- Fixed cervical spine

- Medication

- Cervical spine traction

Cervical spine traction is a classic yet modern treatment method

The effects of cervical spine traction are:

+ reduction of the intradiscal pressure

+ adjustment of the protrusion of the vertebrae and spine + reduction of the nerve root compression

+ passive muscle relaxation

Clinically speaking, spinal traction brings about positive results: reduction of spinal pain syndrome, nerve root compression syndrome, scoliosis, muscle spasticity and increase of spinal mobility and flexibility.

There are many spinal traction methods such as continuoustraction, body weight traction, counterweight traction, underwatertraction, traction with impulses, with many different tractiondevices Each type of device has its own advantages anddisadvantages One of which is the inflatable traction device, whichhas been put into use and initially proven to have many advantagesdue to its flexibility, lightness, simplicity and convenience but stillremains its therapeutic effects The device Disk Dr CS-300 fromChangeui Medical brand (Korea) was made with the improvement intraction power as well as comfort for users during the treatmentprocess

- Physiotherapy

- Massage

According to some studies, message has proven to beeffective if done correctly

1.6.2 Minimally invasive interventions

1.6.2.1 Percutaneous laser disc decompression

1.6.2.2 Chemonucleolysis

1.6.2.3 Radiofrequency disc decompression

1.6.2.4 Percutaneous laparoscopic discectomy

1.6.3 Surgical treatment

CHAPTER 2 RESEARCH SUBJECTS AND METHODS

2.1 Research subjects

Including 99 patients having cervical disc herniation confirmed

by clinical diagnosis and CT scan All of these patients were treated atthe Neurology Department – Military Medical Hospital 103 and theNeurology Department - Military Medical Hospital 354 - GeneralLogistics Department from December 2012 to December 2015

2.1.1 Inclusion criteria

- Clinical

+ Had cervical spine syndrome

+ Had at least one of the following syndromes:

* Cervical nerve root compression syndrome

* Cervical cord compression

* Dysautonomia and Vertebrobasilar insufficiency syndrome

- Sub-clinical

+ Cervical disc herniation on CT film

+ Clinical symptoms and syndromes consistent with thelocation of herniation on MRI film

- Patients underwent spinal surgery due to disc herniationand trauma

- Patients under 18 and over 70 years of age

- Patients did not consent to the study

* Patients were randomised into two groups:

- Treatment group (54 patients):treated with inflatablecervical traction device in combination with conservative treatmentregimen.

- Control group (45 patients): patients treated withconservative treatment regimen only without inflatable cervicaltraction device

2.2.4.3 MRI scan for cervical spine

- MRI scan for cervical spine was carried out at theDiagnostic Imaging Department, Military Medical Hospital 103, attwo times (before the treatment and 2 weeks after the treatment).Particularly, for the treatment group, MRI scan was additionallyperformed 6 months after the treatment

2.2.4.5 Electromyography

The NIHON-KONDEN (Japan) device NEUROPACK wasused.It is positioned in a standard room (average temperature of 24-

260C) at the Neurology Department – Military Medical Hospital 103

Table 2.1 Normal values of motor nerve conduction

*: DML - distal motor latency

**: F-wave latency, average of the F-wave sequence obtained from

16 electrical stimulation

Table 2.2 Normal values of sensory nerve conductionMeasurements Median nerve Ulnar nervedistal sensory latency (DSL) (ms) 3.5 3.1

sensory conduction velocity (SCV)m/s 67,7 ± 8,8 64,8 ± 7,6

2.2.4.6 Conservative treatment regimen

The patients were treated according to a unified protocol atthe Neurology Department at Military Medical Hospital 103

2.2.4.7 Inflatable traction brace Disk Dr CS-300

The spinal traction brace Disk Dr CS-300 fromChangeuiMedicalbrand (Korea) can be used at home The traction power isapproximately 30 pounds, internal pressure is0,4kg/cm2 The braceshould be used 3 times per day (in the morning, noon and evening),

30 minutes each time, for 6 months

2.2.5 Indicators

Clinical indicators, MRIscan and Electromyography werecarried out before and 2 weeks after the treatment in both groups; theexamination was performed 6 months after the treatment with thepatients in treatment group

Table 3.5 Clinical syndrome before treatmentGroup

Syndrome

Treatmentgroup (n=54) group (n=45)Control (n=99)Total p

Cervical spine syndrome 54 100 44 97.78 98 98.99 0.46Nerve root compression 43 79.63 34 75.56 77 77.78 0.63

Pain in cervical spine 54 100 44 97.78 98 98.99 0.46

Table 3.7 Nerve root compression syndrome before treatment

Group

Symptoms

Treatmentgroup (n=54) Control group(n=45) (n=99)Total p

Table 3.8 Cervical cord compression syndrome before treatment

group (n=54) group (n=45)Control (n=99)Total p

Symptoms n % n % n %

Quadriplegia type "TW" 3 5.56 6 13.33 9 9.09 0.29

Increased tendon reflex of

Hypoesthesia below damaged

Sphincter disorders type “TW” 2 3.70 1 2.22 3 3.03 1.0

Table 3.9 Dysautonomia and Vertebrobasilar insufficiency syndrome

before treatmentGroup

Symptoms

Treatmentgroup (n=54) Control group(n=45) (n=99)Total p

Muscle strength

score

Treatment group(n=54) group (n=45)Control (n=99)Total p

3.3.1 Nerve conduction study results

Table 3.13 Motor conduction velocity before treatment

Comparative criteria group (n=54)Treatment

(± SD)

Control group(n=45)( ± SD)

Comparative criteria group (n=54)Treatment

(± SD)

Control group(n=45)( ± SD)

Table 3.15 F-wave valuebefore treatmentComparative criteria group (n=54)Treatment

(± SD)

Control group(n=45)( ± SD)

F-wave of

ulnar nerve

– Left arm

Fmean(ms) 26.16 ± 2.22 26.38 ± 3.04 26.26 ± 2.61 0.68F-fre (%) 59.39 ± 22.28 61.96 ± 19.91 60.56 ± 21.17 0.55

3.3.2 MRI film characteristics

Table 3.20 Severity of herniation on MRI filmGroup

Severity of

herniation

Treatmentgroup (n=54) group (n=45)Control (n=99)Total p

Control group(n=45) (n=99)Total p

3.3.3 The relationship between several clinical characteristics and

MRI film in the treatment group before treatment

3.4 Treatment results

3.4.1 2 weeks after the treatment

Table 3.29 Changes in clinical criteria2 weeks after the treatment

Criteria Treatment group(n=54) (± SD) (n=45) ( ± SD)Control group p

Table 3.31 Characteristics of MRI film of treatment group2 weeks

after the treatmentGroup

Comparative criteria

Beforetreatment (

±SD)

2 weeks afterthe treatment( ±SD)

treatment

Comparative criteria treatmentBefore

(n=54)(± SD)

Aftertreatment(n=45)( ±SD)

F-wave of

ulnar nerve –

Right arm

Fmean(ms) 26.21 ± 2.36 25.55 ± 3.83 0.12F-fre (%) 63.61 ± 25.08 71.39 ± 20.48 0.007

F-wave of Fmean(ms) 26.22 ± 6.75 25.55 ± 1.89 0.46