复位手法对骶髂关节应力-应变的影响及骶髂关节稳定性的解剖学研究

Sacroiliac joint is difficult to be observed accurately and fully by radiological technique, with its deep location and complex anatomical structure. As a result, the concept of subluxation of the sacroiliac joint has long been doubted since it was put forward. In academic fields, there is still no consensus on subluxation of the sacroiliac joint, especially in naming, diagnostic criteria, clinical classifications, imaging evidences, subjective therapeutic effect assessments and confused definitions. In addition, the theoretical basis of subluxation of the sacroiliac joint and its manipulative therapy has not been validated by enough fundamental and experimental researches. Some scholars agree the concept believing that the sacroiliac joint is movable, and subluxation of the sacroiliac joint is possible and it can be replaced by manipulative therapy. While the others hold the opposite view that sacroiliac joint is so stable that subluxation and replacement would be impossible. Thus, in order to improve the theoretical basis of subluxation of the sacroiliac joint and experimental verification of sacroiliac joint reduction manipulations, the new subject needs to be explored further, especially in related anatomy and biomechanics. Consequently, based on our previous related researches, our group aims to confirm the anatomical characteristics, joint range of motion and radiological anatomy of sacroiliac joint by use of a series of approaches, such as biomechanics, radiological anatomy,three-dimensional finite element method, and so on. Besides, we plan to observe the effects on sacroiliac joint (stress-strain)during simulation of some kinds of sacroiliac joint reduction manipulations in order to provide theoretical basis and objective evidences for the diagnosis and treatment of subluxation of the sacroiliac joint.

骶髂关节位置深在、结构复杂，影像学难以全面准确的显示。因此，自从骶髂关节错位的概念提出以来，就伴随着各种质疑。这主要是由于学科界对本病缺乏共识，在命名、诊断标准、临床分型和疗效判定方面缺乏客观性依据。骶髂关节错位的理论基础和相应的复位手法也缺少基础研究和实验验证。肯定者认为骶髂关节可动，有可能发生错位，并可用相应的手法复位；而否定者认为骶髂关节以稳定为主，很难发生错位。因而，需要我们对此进行深入的研究，以完善骶髂关节错位的理论基础、诊断依据和手法复位的实验验证等，特别是相关的解剖学和生物力学基础研究。为此，本课题组在以往研究工作的基础上，拟以生物力学、放射解剖学和三维有限元分析等研究手段来明确骶髂关节的放射解剖学特点、活动度和运动规律；并模拟临床常用的几种骶髂关节复位手法，观测这几种手法过程中骶髂关节的应力-应变以及关节的活动情况，以期为骶髂关节错位及其复位手法提供理论依据。

背景：目前针对骶髂关节错位研究多集中于复位手法的临床疗效分析，基础研究甚少。然而，这些特异性复位手法到底是否真的扳动了骶髂关节已成为了推拿学科界的争议焦点。.目的：探索骶髂关节是否具有发生错位的解剖学基础，复位手法是否可以扳动骶髂关节，以期为骶髂关节疾病的诊疗提供解剖学基础和生物力学依据，提高本学科对骶髂关节错位的认识和诊疗水平。.方法：本研究分为放射与临床解剖学、生物力学及运动学等三个方面。（1）放射与临床解剖学：①在骨盆标本上测量骶髂关节间隙的走行特点，同时利用骨盆正位和斜位的X 线片研究二者相关性。②观测不同年龄、性别的骶髂关节CT 片上骶骨和髂骨软骨的厚度和分布规律、骶髂关节滑膜部和韧带部的比例等。③观测骶髂关节标本上各韧带的起止、走行等，以及骶骨、髂骨耳状面软骨组织学的特征和分布规律。（2）生物力学方面：①应用通用型机器人模拟各复位手法、非接触式光学应变技术捕捉并测量骶髂关节的应力-应变和关节的活动情况；②获取男女骨盆CT 扫描资料进行有限元建模，后分析缺少相关韧带及几种复位手法作用时，骶髂关节应力-应变及位移和旋转情况。（3）运动学方面，依次切开新鲜骨盆标本一侧骶髂关节韧带或耻骨联合，测量骶髂关节的应力-应变、活动情况，判断各其对骶髂关节稳定性的影响。 .结果：（1）骶髂关节错位的临床诊断需考虑髂后上棘和关节间隙形态的特殊性。斜扳法可致骶髂关节发生轻微的旋转和分离，这在耻骨联合或韧带损伤时增加，但近似于生理载荷的效应，且手法复原后该效应可能消失。(2)骶骨耳状面主要是透明软骨，髂骨耳状面主要是纤维软骨。（3）骨间韧带对骶髂关节的稳定性影响最大。（4）不同年龄、不同性别正常成年人骶髂关节间隙在水平面和冠状面上存在一定的差异。（5）不同的骶髂关节复位手法都会对周围韧带产生不同程度应变，这可能是减轻骶髂关节痛的机制，其中斜扳法产生应变最大，但其相对位移仍小于腰椎-髂嵴间的相对位移。.结论：基于对骶髂关节放射与临床解剖学、生物力学等方面研究，临床上出现骶髂关节错位的可能性不大，几种骶髂关节复位手法作用部位不是骶髂关节，而是腰骶关节。