Nghiên cứu tác dụng điều trị thoát vị đĩa đệm cột sống cổ của phương pháp kéo giãn bằng nẹp không khí kết hợp phác đồ điều trị bảo tồn tt tiếng anh

BACKGROUND Spinal disc herniation is a fairly common disease, with the most prevalent type is cervical disc herniation, especially in people over 50 years of age This condition usually manifests itself in the form of neck pain, neck-shoulder pain, neck-shoulder-arm pain, neck-shoulderhand pain, hypoesthesia or paraesthesia, limbs weakness or paralysis, dizziness,nausea and vomiting, resulting in the reduction ofwork capacity and quality of life and affecting the patients’ activities of daily living The treatment of cervical disc herniation is aimed at restoring neurological functions, reducing pain and improving the patients’ quality of life There have been many effective methods such as physiotherapy, cervical traction, analgesics, anti-inflammatory drugs, muscle relaxants, cervical nerve root blockade procedure or discectomy, however, most patients respond well to conservative treatment Cervical traction is an effective conservative treatment due to its effects on the pathogenetic mechanisms of cervical disc herniation The disadvantage of cervical tractiondevices such as braces or beds is that treatment can only be performed in certain facilities equipped with those equipment and patients must rest completely during the traction process and wear a traction collar after the process To overcome this drawback, the inflatable cervical traction device has been put into use and initially proven to have many advantages due to its flexibility, lightness, simplicity and convenience The device can also be used at home but still ensure its therapeutic effects However, as these issues have not been systematically investigated, we conducted this research to: Review the clinical features, results of magnetic resonance imaging (MRI) technique and several neurotransmission indicators in patients with cervical disc herniation Assess the treatment of cervical disc herniation by inflatable cervical traction collar in combination with conservative treatment regimen in the patient group Rationale Cervical disc herniation is a spondylosis and herniated disc disease On the basis of spondylosis, it forms osteophytes stimulating and compressing the nerve roots or narrowing the spinal diameter and causing different degrees of cervical cord compression If it is left untreated, it often results in the reduction of work capacity and quality of life and affecting the patients’ activities of daily living Although there have been many clinical, diagnostic and therapeutic studies within Vietnamand around the world, more research needs to be done to improve theeffective treatmentof this disease Therefore, a systematic evaluation of the outcomes of inflatable cervical traction collar in combination with conservative treatment regimenfor cervical disc herniationin Vietnam is necessary as this is a simple yet effective treatment method for this common disease Significance of the thesis The thesis provided information on the experience and effects of traction methods using inflatable traction device in the conservative treatment of cervical disc herniation in Vietnam weeks after the treatment: 90.74% of patients in the treatment group experienced improvement of symptoms, 55.56% higher than the control group (p 4,0 > 6,0 motor conduction velocity (MCV) (m/s) 59,3 ± 7,0 58,9 ± 4,4 F-Latency** (ms) 26,6 ± 4,4 27,6 ± 4,4 *: 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 conduction Measurements Median nerve Ulnar nerve distal sensory latency (DSL) (ms) 3.5 3.1 SNAP Amplitude (µV) >20.0 > 17.0 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 at the 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 fromChangeui Medicalbrand (Korea) can be used at home The traction power is approximately 30 pounds, internal pressure is0,4kg/cm The brace should be used times per day (in the morning, noon and evening), 30 minutes each time, for months 2.2.5 Indicators Clinical indicators, MRIscan and Electromyography were carried out before and weeks after the treatment in both groups; the examination was performed months after the treatment with the patients in treatment group 2.3 Data analysis Using SPSS software version 20.0 2.4 Ethics - Ethics were ensured in this study PART RESULTS 3.2 Clinical results in the study subjects Table 3.5 Clinical syndrome before treatment Group Treatment Control Total group (n=54) group (n=45) (n=99) Syndrome n % n % n % Cervical spine syndrome 54 100 44 97.78 98 98.99 Nerve root compression 43 79.63 34 75.56 77 77.78 syndrome Cervical cord 7.41 13.33 10 10.10 compression syndrome Nerve root and cervical cord compression 12.96 11.11 12 12.12 syndrome Dysautonomia 15 27.78 11 24.44 26 26.26 Table 3.6 Cervical spine syndrome before treatment Group Treatment Control group Total group (n=54) (n=45) (n=99) Syndrome n % n % n % Pain and spasticity of 54 100 44 97.78 98 98.99 cervical spine Limited mobility of cervical 54 100 44 97.78 98 98.99 spine Pain in cervical spine 54 100 44 97.78 98 98.99 Table 3.7 Nerve root compression syndrome before treatment Group Treatment Control group Total group (n=54) (n=45) (n=99) Symptoms n % n % n % Nerve root paraesthesia 41 75.93 34 75.56 75 75.76 Increased pain when 5.56 0 3.03 coughing or sneezing Decreased pain during spinal 43 79.63 34 75.56 77 77.78 traction Upper limb numbness 43 79.63 33 73.33 77 77.78 Spurling’s sign 29 53.70 28 62.22 57 57.58 p 0.46 0.63 0.51 0.78 0.71 p 0.46 0.46 0.46 p 0.97 0.25 0.63 0.46 0.39 Doorbell sign 3.70 4.44 4.04 Cervical nerve root motor 14 25.93 11.1 19 19.19 disorder Cervical nerve root sensory 26 48.15 23 51.11 49 49.49 disorder Upper limb amyotrophy 7.41 6.67 7.07 Table 3.8 Cervical cord compression syndrome before treatment Treatment Control Total Group group (n=54) group (n=45) (n=99) Symptoms n % n % n % Quadriplegia type "TW" 5.56 13.33 9.09 Brown- Séquard symptom 1.85 0 1.01 Increased tendon reflex of 7.41 13.33 10 10.10 limbs Babinski reflex 7.41 11.11 9.09 Hoffmann’s sign 7.41 11.11 9.09 Functional Hoffman’s sign 5.56 11.11 8.08 Hypoesthesia below damaged 7.41 11.11 9.09 level Sphincter disorders type “TW” 3.70 2.22 3.03 Table 3.9 Dysautonomia and Vertebrobasilar insufficiency syndrome before treatment Treatment Control group Total Group group (n=54) (n=45) (n=99) Symptoms n % n % n % Occipital headache 17 31.48 13 8.89 30 30.30 Systemic vertigo 1.85 2.22 2.02 Unsystemic vertigo 13 24.07 10 22.22 23 23.23 Dizziness when changing 14 25.93 13 28.89 27 27.27 positions Tinnitus 0 4.44 2.02 Table 3.10 Visual analogue scale before treatment Group Treatment group Control Total (n=54) group (n=45) (n=99) Visual analogue scale n % n % n % Mild pain (VAS=1-2) 0 0 0 1.0 0.06 0.77 1.0 p 0.29 1.0 0.51 0.73 0.73 0.46 0.73 1.0 p 0.78 1.0 0.83 0.82 0.2 p 0.05 Severity of herniation Disc protrusion Disc herniation n % n % n % 3.70 2.22 3.03 52 96.30 44 97.78 96 96.97 Table 3.23 Types of herniation on MRI film Treatment Control group Total Group group (n=45) (n=99) p (n=54) Position of herniation n % n % n % Central 10 66.67 80.00 18 72.0 Right paracentral disc 13.33 20.00 16.0 C3- protrusion 0.31 C4 Left paracentral disc 3 20.00 0 protrusion 12.0 Total 15 100 10 100 25 100.0 Central 18 64.29 14 53.85 32 59.26 Right paracentral disc 10.71 26.92 10 18.52 C4- protrusion 0.31 C5 Left paracentral disc 25.00 19.23 12 22.22 protrusion Total 28 100 26 100 54 100.0 Central 17 40.48 19 51.35 36 45.57 Right paracentral disc 12 28.57 16.22 18 22.78 C5- protrusion 0.4 C6 Left paracentral disc 13 30.95 12 32.43 25 31.65 protrusion Total 42 100 37 100 79 100.0 Central 45.46 60.0 14 53.85 Right paracentral disc 27.27 13.33 19.23 C6- protrusion 0.64 C7 Left paracentral disc 27.27 26.67 26.92 protrusion Total 11 100 15 100 26 100.0 Table 3.25 Evaluation criteria on MRI film Treatment group Control group Comparative criteria p (n=54) (± SD) (n=45)( ± SD) Torg ratio 55.13 ± 14.23 58.02 ± 18.76 p= 0.39 Anteroposterior compression 38.70 ± 8.24 41.93 ± 8.46 p=0.06 ratio (APCR) Segmental Stenotic Index (SSI) 75.33 ± 10.59 79.51 ± 11.54 p=0.06 Degree of nerve compression 2.87 ± 0.80 2.84 ± 0.93 p=0.88 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 weeks after the treatment Table 3.29 Changes in clinical criteria2 weeks after the treatment Treatment group Control group Criteria p (n=54) (± SD) (n=45) ( ± SD) Before treatment 6.3 ± 1.5 5.73 ± 1.48 0.07 Visual (1) analogue scale After treatment(2) 2.76 ± 1.1 3.31 ± 1.29 0.02 VAS p (1.2) < 0.001 Before treatment 4.5 ± 0.77 4.6 ± 0.65 0.5 (1) Muscle strength score After treatment(2) 4.69 ± 0.54 4.64 ± 0.57 0.72 p(1.2) 0.001 Before treatment 28.19 ± 6.04 25.84 ± 5.65 0.05 (1) Neck disability After treatment(2) 16.44 ± 4.73 18.87 ± 5.82 0.02 index NDI p(1.2) < 0.001 Table 3.31 Characteristics of MRI film of treatment group2 weeks after the treatment Group Before weeks after p treatment ( the treatment Comparative criteria ( ±SD) ±SD) Torg ratio (n=50) 54.2 ± 14.07 54.8 ± 14.11 0.108 APCR (n=50) 38.42 ± 8.18 39.16 ± 8.32 0.003 SSI (n=50) 74.72 ± 10.65 74.86 ± 10.14 0.82 Degree of nerve 2.92 ± 0.78 2.78 ± 0.76 0.007 compression (n=50) Table 3.33 F-wave values of treatment group2 weeks after the treatment Comparative criteria F-wave of median nerve – Right arm F-wave of ulnar nerve – Right arm F-wave of median nerve – Left arm F-wave of ulnar nerve – Left arm Fmean(ms ) F-fre (%) Fmean(ms ) F-fre (%) Fmean(ms ) F-fre (%) Fmean(ms ) F-fre (%) 26.11 ± 2.13 After treatment (n=45)( ± SD) 25.87 ± 2.13 0.14 64.39 ± 24.98 26.21 ± 2.36 66.09 ± 19.39 25.55 ± 3.83 0.015 0.12 63.61 ± 25.08 26.22 ± 6.75 71.39 ± 20.48 25.55 ± 1.89 0.007 0.46 58.07 ± 25.30 26.16 ± 2.22 65.02 ± 18.36 25.85 ± 2.15 0.014 0.053 59.39 ± 22.28 68.15 ± 19.53 0.001 Before treatment (n=54)(± SD) p Table 3.35 Motor conduction velocity before and after the treatment in treatment group Before After treatment treatment (n=54) Comparative criteria p (n=54) ( ± SD) (± SD) Motor DML (ms) 3.78 ± 0.73 3.61 ± 0.54 0.05 conduction MAw (mV) 7.6 ± 4.71 7.41 ± 3.56 0.51 velocity of MAe (mV) 6.69 ± 3.92 6.62 ± 3.13 0.82 median MCV (m/s) 55.84 ± 4.68 56.81 ± 4.51 0.05 nerve – Right arm Motor DML (ms) 2.77 ± 0.77 2.61 ± 0.47 0.05 conduction MAw (mV) 4.55 ± 2.78 4.17 ± 2.44 0.09 velocity of MAe (mV) 4.05 ± 2.65 3.67 ± 2.4 0.08 ulnar nerve – MCV (m/s) 57.76 ± 6.18 59.11 ± 4.63 0.07 Right arm Motor DML (ms) 3.73 ± 1.03 3.66 ± 0.46 0.05 conduction MAw (mV) 6.94 ± 4.56 7.04 ± 3.59 0.76 velocity of MAe (mV) 6.15 ± 4.13 6.39 ± 3.23 median MCV (m/s) 57.26 ± 6.7 57.66 ± 4.18 nerve – Left arm Motor DML (ms) 2.88 ± 1.29 2.69 ± 0.41 conduction MAw (mV) 4.18 ± 2.32 4.18 ± 2.29 velocity of MAe (mV) 3.61 ± 1.89 3.71 ± 2.01 ulnar nerve – MCV (m/s) 58.78 ± 5.57 59.33 ± 5.46 Left arm Table 3.37 Sensoryconduction velocity before and after the treatment in treatment group Before treatment After treatment (n=54) (n=54) Comparative criteria (± SD) ( ± SD) Sensory DSL (ms) 2.79 ± 0.33 2.72 ± 0.33 conduction SA (μV) 17.28 ± 9.5 19.18 ± 9.82 velocity of SCV(m/s) 49.41 ± 6.41 50.32 ± 6.24 median nerve – Right arm Sensory DSL (ms) 2.3 ± 0.24 2.27 ± 0.22 conduction SA (μV) 14.15 ± 9.31 14.79 ± 9.40 velocity of ulnar SCV(m/s) 51.02 ± 4.71 52.04 ± 5.17 nerve – Right arm Sensory DSL (ms) 2.77 ± 0.35 2.7 ± 0.34 conduction SA (μV) 22.64 ± 12.28 23.25 ± 11.32 velocity of SCV(m/s) 49.91 ± 6.24 50.81 ± 6.22 median nerve – Left arm Sensory DSL (ms) 2.23 ± 0.24 2.29 ± 0.23 conduction SA (μV) 17.64 ± 10.24 18.05 ± 11.28 velocity of ulnar SCV(m/s) 51.43 ± 4.73 51.78 ± 4.88 nerve – Left arm 0.54 0.61 0.05 0.99 0.63 0.49 p 0.05 0.07 0.05 0.25 0.52 0.06 0.05 0.05 0.05 0.05 0.71 0.05 Table 3.38 Degree of improvement in clinical symptoms in general Group Treatment Control Total p Degree group group (n=45) (n=99) (n=54) Good+Very good Moderate Bad Total n 49 54 % 90.74 9.26 100 n 25 17 45 % 55.56 37.77 6.67 100 n 74 22 99 % 74.75 22.22 3.03 100 < 0.001 3.4.2 Treatment results after months Table 3.39.Several clinical characteristics and MRI film months after the treatment Group Before months after treatment the treatment Comparative criteria ( ±SD) ( ±SD) Visual analogue scale (n=31) 6.81 ± 1.85 0.81 ± 0.95 Muscle strength score(n=31) 4.39 ± 0.84 4.87 ± 0.34 Neck disability index (n=31) 29.9 ± 6.57 8.1 ± 4.17 TORG ratio(n=31) 53.58 ± 14.65 55.52 ± 15.38 APCR(n=31) 37.0 ± 8.71 39.39 ± 8.79 SSI(n=31) 71.81 ± 10.84 73.39 ± 10.47 Degree of nerve compression (n=31) 2.87 ± 0.76 2.48 ± 0.77 Table 3.40 F-wave value of treatment group6 months after the treatment Comparative criteria Before treatment After treatment (n=31) (n=31) (± SD) ( ± SD) F-wave of Fmean(ms 26.11 ± 2.22 25.75 ± 1.88 median nerve ) – Right arm F-fre (%) 64.35 ± 23.47 77.03 ± 15.07 F-wave of Fmean(ms 26.54 ± 2.31 26.71 ± 5.9 ulnar nerve – ) Right arm F-fre (%) 60.61 ± 27.47 83.19 ± 11.83 F-wave of Fmean(ms 26.0 ± 2.2 25.3 ± 2.03 median nerve ) – Left arm F-fre (%) 53.16 ± 23.66 70.74 ± 18.76 F-wave of Fmean(ms 26.29 ± 2.3 25.6 ± 2.29 ulnar nerve – ) p < 0.001 < 0.001 < 0.001 0.005 0.001 0.06 0.001 p < 0.001 0.001 0.17 < 0.001 0.05 0.04 < 0.001 Left arm F-fre (%) 56.42 ± 23.36 76.71 ± 16.18 0.001 Table 3.41 Motor conduction velocity before and months after the treatment Before After treatment treatment (n=31) Comparative criteria p (n=31) ( ± SD) (± SD) Motor DML (ms) 3.78 ± 0.59 3.73 ± 0.51 0.07 conduction MAw (mV) 6.51 ± 2.42 6.62 ± 2.26 0.74 velocity of MAe (mV) 6.06 ± 2.13 5.86 ± 1.71 0.54 median MCV (m/s) 56.7 ± 4.18 56.75 ± 3.76 0.95 nerve – Right arm Motor DML (ms) 2.70 ± 0.43 2.64 ± 0.24 0.11 conduction MAw (mV) 3.98 ± 2.16 4.07 ± 2.50 0.76 velocity of MAe (mV) 3.61 ± 2.07 3.64 ± 2.5 0.92 ulnar nerve – MCV (m/s) 57.81 ± 7.48 60.68 ± 4.06 0.06 Right arm Motor DML (ms) 3.8 ± 1.07 3.59 ± 0.58 0.19 conduction MAw (mV) 5.53 ± 2.32 6.18 ± 2.4 0.05 velocity of MAe (mV) 5.11 ± 2.2 5.64 ± 1.86 0.08 median MCV (m/s) 58.23 ± 7.76 57.3 ± 4.10 0.53 nerve – Left arm Motor DML (ms) 2.71 ± 0.56 2.64 ± 0.25 0.14 conduction MAw (mV) 3.79 ± 1.54 3.68 ± 1.46 0.69 velocity of MAe (mV) 3.39 ± 1.43 3.05 ± 1.33 0.13 ulnar nerve – MCV (m/s) 58.65 ± 6.26 59.95 ± 3.7 0.27 Left arm Table 3.42 Sensory conduction velocity before and months after the treatment Before treatment After treatment Comparative criteria p (n=31) (± SD) (n=31) ( ± SD) Sensory DSL (ms) 2.82 ± 0.33 2.77 ± 0.35 0.0 conduction velocity of median SA (μV) 18.11 ± 8.7 21.81 ± 11.37 0.0 nerve – Right arm Sensory conduction velocity of ulnar nerve – Right arm Sensory conduction velocity of median nerve – Left arm Sensory conduction velocity of ulnar nerve – Left arm SCV(m/s ) DSL (ms) 49.3 ± 6.46 50.34 ± 10.45 2.34 ± 0.24 2.31 ± 0.25 SA (μV) 14.79 ± 9.27 18.04 ± 10.13 SCV (m/s) DSL (ms) 51.33 ± 4.55 52.82 ± 4.04 2.82 ± 0.35 2.84 ± 0.27 SA (μV) 22.85 ± 12.08 24.58 ± 11.25 SCV (m/s) DSL (ms) 51.93 ± 6.19 52.84 ± 4.92 2.26 ± 0.22 2.25 ± 0.23 SA (μV) 19.69 ± 10.67 22.38 ± 11.3 SCV (m/s) 52.17 ± 4.13 52.25 ± 4.4 Figure 3.11 The degree of improvements in clinical symptoms in general after months CHAPTER DISCUSSION 4.1 General characteristics of treatment and control group 4.2 Clinical and neurotransmission characteristics and MRI film of both groups 4.2.1 Clinical characteristics 4.2.1.4 Clinical characteristics In our study, 98.99% of patients experienced cervical spine syndrome; 77.78% had signs of nerve root compression syndrome; 26.26% suffered from dysautonomia Other symptoms were less frequent There was no statistically significant difference between the two groups 0.5 0.0 0.0 0.11 0.1 0.2 0.1 0.3 0.1 0.2 Cervical spine syndrome In our study, 98.99% of patients had signs of cervical spine syndrome (such as pain in cervical spine, spasticity of cervical spine, limited mobility of cervical spine) Pain and spasticity of cervical spine were the most common and earliest syndrome in both groups, accounting for 100% of patients in the treatment group and 97.78% in the control group, the difference was not statistically significant between the two groups Nerve root compression syndrome The common sign of nerve root compression syndrome was nerve root paraesthesia (75.76%); upper limb numbness (77.78%), decreased pain during spinal traction (77.78%); Spurling’s sign (57.58%); cervical nerve root motor disorder (19.19%); cervical nerve root sensory disorder (49.49%) Cervical cord compression syndrome In our study, the proportion of patients presenting with cervical cord compression syndrome was not much Several signs of of simple cervical cord compression syndrome: increased tendon reflexes, Hoffmann’s sign and hypoesthesia below damaged level (together accounted for 9.09%) Other signs were less prevalent In addition, we also encountered the signs of dysautonomia and vertebrobasilar insufficiency syndrome in the treatment group, with the most common signs were occipital headache (30.30%), dizziness when changing positions (27.27%); systemic vertigo (23.23%) 4.2.1.5 Visual analogue scale, muscle strength score and neck disability index before treatment In our study, when assessing the pain level on VAS, the results showed the proportion of severe pain level or worse accounted for 63.64% Average pain score was 6.04 ± 1.51 Muscle strength scale before treatment: 88.89% of patients had muscle strength scores of 4-5 points Average muscular strength score was 4.55 ± 0.72 There were no cases of complete paralysis in either group Neck disability index: assessed the degree of improvement in cervical spine function based on the NDI In our study, the functional score in treatment group was 28.19 ± 6.04, which was higher than that of control group 25.84 ± 5.65 (p = 0.05) 4.2.2 Nerve conduction studies characteristics Distal Motor Latency – DML and Motor Conduction Velocity – MCV In our study, the median nerve’s DML of right and left arm was 3.69 ± 0.66 and 3.63 ± 0.83 ms, respectively The ulnar nerve’s DML of right and left arm was is 2.68 ± 0.68 and 2.79 ± 1.09 ms, respectively In our study, the median nerve’s MCV of right and left arm was 55.95 ± 4.37 and 57.17 ± 5.82 ms, respectively The ulnar nerve’s MCV of right and left arm was is 57.76 ± 5.72 and 58.33 ± 5.13 ms, respectively The results of our study showed the distal motor latency (DML) and the motor conduction velocity (MCV) of both median and ulnar nerve in right and left arms were not different DML and MCV values of both groups were equivalent to normal values Sensory Conduction Velocity - SCV Similar to the motor conduction velocity measurement, our results showed the distal sensory latency (DSL) and sensory conduction velocity (SCV) in both median and ulnar nerve in right and left arms had no difference However, both DSL and SCV values were equivalent to normal values Apart from that, our results showed there was no difference between the treatmentand control group on the value of F-wave inboth median and ulnar nerve in right and left arms 4.2.3 Characteristics of MRI results 4.2.3.1 Position of herniation Based on our analysis of MRI film, we found the proportion of herniation in C5-C6 segment was the highest at 77.78%; followed by C4 - C5 segmentaccounting for 52.53% Other positions were encountered with lesser proportions 4.2.3.2 Classifications of disc herniation In our study, the single disc herniation accounted for 38.38%; multiple disc (2-4) herniation accounted for 61.62% 100% of patients in both groups had posterior herniated disc The axial plane showed that: at all position of herniation, the central form of herniation always prevailed (72%, 59.26%, 45.57% and 53.85% in the C3-C4, C4-C5, C5-C6 and C6-C7 segment, respectively) followed by the form of left paracentral disc protrusion There was no difference in type of herniation between the treatment and control groups 4.2.3.3 Degree of nerve compression in MRI film In this study, we assessed the degree of nerve compression based on indicators on MRI film: - Torg ratio: Our results showed the Torg ratio in the treatment group was 55.13 ± 14.23 while that of the control group was 58.02 ± 18.76, before the treatment - Anteroposterior compression ratio (APCR):Our results showed the APCR in the treatmentand control group was 38.70 ± 8.24 and 41.93 ± 8.46, respectively, before the treatment - Segmental Stenotic Index (SSI): Our results showed the SSI in the treatment and control group was 75.33 ± 10.59 and 79.51 ± 11.54, respectively, before the treatment In this study, we further determined the degree of nerve compression by Prof Dr Nguyen Van Chuong The results showed the average "degree of nerve compression" in the treatment and control group was 2.87 ± 0.80 and 2.84 ± 0.93, respectively, before the treatment 4.3 The effectiveness of cervical disc herniation treatmentby inflatable traction method in combination with conservative treatment regimen 4.3.1 Clinical characteristics after the treatment - The VAS score in the treatment and control group was not statisticallysignificant before treatment, but became lower in the treatment group than the control group and statistically significant weeks after the treatment (p = 0.02) The average VAS score of the treatment group after the treatment was 2.76 ± 1.1, which was lower than before the treatment 6.3 ± 1.5 (p