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2023 , Vol. 51 >Issue 5: 104 - 111

DOI: https://doi.org/10.15983/j.cnki.jsnu.2023303

Ultrasonographic characteristics of thickness and elasticity of lateral abdominal muscles in adolescent with idiopathic thoracic scoliosis

  • LI Lingling 1 ,
  • FU Pingting 2 ,
  • YAN Bin , 3, * ,
  • LU Xinhai 3 ,
  • RU Shouhang 3 ,
  • JIAO Wei , 2, *
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  • 1 Sport and Health College, Guangzhou Sport University, Guangzhou 510500, Guangdong, China
  • 2 Sport Medicine and Rehabilitation College, Beijing Sport University, Beijing 100084, China
  • 3 Spine Surgery Department, Shenzhen Second People’s Hospital, Shenzhen 518025, Guangdong, China

Received date: 2022-07-23

  Online published: 2023-09-28

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Abstract

In order to investigate the morphological and biomechanical characteristics of anterolateral part of core muscles in adolescent idiopathic scoliosis (AIS), the muscle thickness and elasticity of obliquus externus (OE), obliquus internus (OI) and transversus abdominis (TrA) were measured using high frequency B-mode ultrasound and shear wave elastography in supine and standing positions, respectively. 25 patients aged 10~17 years with right-side thoracic scoliosis (Cobb angle was 21.36°±8.26°) and 25 healthy adolescents were observed in this study. Muscle thickness was recorded as the thickness value at the end of normal expiration and the contraction thickness difference (CTD, thickness difference between the end of maximum inspiration and the end of maximum expiration), and muscle elasticity was recorded as the measurement after the end of normal expiration. About thickness, the left OE was thinner (P=0.03) and had a greater CTD (P=0.04) than those in healthy group in supine position.Only TrA in side-difference (difference between convex and concave side) in scoliosis group was statistically significant (P=0.02). In standing position, there was no significant difference in absolute thickness and CTD between scoliosis and healthy group. For elasticity, scoliosis group had greater elasticity of the concave external abdominal oblique than the convex side in supine position (P=0.03); only left TrA in scoliosis group had greater elasticity than it in healthy group in standing position (P=0.03).It can be concluded that the thickness and elasticity of EO and TrA in adolescents with mild-to-moderate idiopathic thoracic scoliosis differ in varying degrees from those of healthy adolescents. More attention to those abdominal muscles could be paid in conservative treatment of scoliosis.

Key words： idiopathic scoliosis; core muscles; shear-wave elastography; adolescent; exercise therapy

Cite this article

LI Lingling , FU Pingting , YAN Bin , LU Xinhai , RU Shouhang , JIAO Wei . Ultrasonographic characteristics of thickness and elasticity of lateral abdominal muscles in adolescent with idiopathic thoracic scoliosis[J]. Journal of Shaanxi Normal University(Natural Science Edition), 2023 , 51(5) : 104 -111 . DOI: 10.15983/j.cnki.jsnu.2023303

青少年特发性脊柱侧弯(adolescent idiopathic scoliosis, AIS)是发生在青春前期或骨骼生长发育成熟之前不明病因的三维脊柱畸形,临床上以站立位全脊柱X线片Cobb角大于10°为诊断标准[1]。AIS的发病率为0.35%~13%,取决于地方筛查能力、筛查年龄和性别[2-3]。按照侧弯顶椎水平所在的脊柱节段分类,胸段AIS发生率最高,约占总人数的47.59%[3]。
核心肌群作为维持脊柱姿势稳定的主动子系统,其背部肌群在特发性脊柱侧弯患者中研究较充分[4-5],而前外侧腹壁肌群的特点研究相对较少[6-7]。目前,腹壁肌群功能障碍对AIS发生发展的影响已被证实[8-9]。前外侧腹壁肌群包括浅层的腹外斜肌(external oblique,EO)、腹内斜肌(internal oblique,IO)和深层的腹横肌(transversus abdominis,TrA),该肌群对维持各种姿势和运动时的脊柱稳定、调控腹内压及辅助呼吸较为关键[10-11]。研究发现AIS患者腹壁肌群形态与功能有不同程度的改变,与健康组相比静息时侧弯患者肌肉厚度更薄[12],而且不稳定姿势可能引起更大的腹肌激活[13]。现有研究大多观察AIS患者腹壁肌群在维持姿势稳定时的形态学特征,尚未探究侧弯畸形对腹壁肌群动态呼吸过程中肌肉活动能力的影响,对肌肉的力学性质如肌肉弹性、肌力等的研究较少。实时剪切波弹性成像(shear-wave elastography,SWE)技术是一种无创超声检查手段,可通过获取杨氏模量值反映肌肉组织的力学性质[14]。SWE测量的剪切模量与肌肉收缩的力矩呈线性相关[15],因而可用于推断肌肉张力或僵硬程度。已有研究证实了SWE技术评估AIS患者腹壁肌群弹性特点的可靠性[16],并且发现AIS患者凸凹两侧EO和TrA弹性不对称[17],但目前仍缺乏胸段脊柱侧弯患者腹壁肌群弹性特点的相关研究。
本研究利用高频B型超声和剪切波弹性成像来评估特发性胸段脊柱右侧弯患者仰卧位及站立位下腹壁肌群(EO、IO、TrA)的厚度及弹性特点,通过与健康青少年的比较,初步总结该类患者腹壁肌群形态学与内部生物力学的特点,为脊柱侧弯保守治疗提供方法依据。

1 资料与方法

1.1 病例资料

2021年6~10月,在深圳市青少年脊柱健康中心招募受试者50例,其中特发性胸段脊柱右侧弯患者25例,健康青少年25例。

1.1.1 纳入标准

侧弯组纳入标准:(1)门诊诊断为特发性胸段脊柱侧弯(右侧弯);(2)年龄10~17岁;(3)有近3个月内拍摄的站立位脊柱X线片;(4)未接受过手术治疗;(5)入选者及其家长均签署知情同意书。
健康组纳入标准:(1)年龄10~17岁;(2)近半年的学校筛查结果未显示疑似侧弯;(3) Adam前屈测试(Adam’s forward bend test)显示躯干旋转角小于5°;(4)无明显肩部、躯干、骨盆和下肢的体态异常;(5)入选者及其家长均签署知情同意书。

1.1.2 排除标准

侧弯组排除标准:(1)近3个月腰、骨盆、下肢有疼痛;(2)近3个月规律性单侧活动或运动,例如羽毛球、网球、高尔夫球等;(3)腹部脂肪较多,超声观察困难;(4)无腹部手术史及解剖结构异常。
健康组排除标准:(1)有明显高低肩、驼背、骨盆前倾和下肢不等长等体态异常;(2)近3个月规律性单侧活动或运动,例如:羽毛球、网球、高尔夫球等;(3)腹部脂肪较多,超声观察困难;(4)无腹部手术史及解剖结构异常。

1.2 方法

1.2.1 评估人员

操作者为康复医学技术中级治疗师,进行过系统的肌肉骨骼超声学习,并有肌骨超声操作经验。

1.2.2 设备与探头位置

使用迈瑞超声设备(Reasona 8PRO)中的B型模式进行仰卧位和站立位下最大吸气末和最大呼气末的前外侧腹壁肌群(EO、IO、TrA)厚度测量,使用STE模式(弹性剪切波)进行腹壁肌群的弹性测量。仰卧位时,探头位置位于髂嵴与12肋中间,腋前线往脐方向2.5 cm[18],用记号笔标注后使用线性探头(L9-3U)进行腹壁肌群的纵切扫描。因为受试者体型不一,因此探头在此位置下有1~2 cm的移动误差以便找到清晰的目标图像,具体图像以三块肌肉的上下四条筋膜线相对平行为止。

1.2.3 操作流程

受试者先呈仰卧位,膝关节屈曲90°,髋关节屈曲30°,上肢沿躯干两侧自然放置。超声探头横向置于标记点处,需轻放于身体表面,以避免压力对肌肉厚度的影响,要求其舒适地呼吸30 s后在连续3次正常呼气末时拍摄STE图像并存储。从身体两侧采集两幅独立的STE图像,扫描画面质量在4~5颗星,画面可信度90%以上,并检查每个图像是否有伪影和(或)缺失值(弹性图中的未填充区域)。弹性测量结束后,嘱受试者进行最大吸气,具体口头提示为“鼻子吸气鼓肚子,至最大,保持3 s”,连续3次最大吸气后进行高质量图像的采集;然后,嘱受试者进行最大呼气,具体提示为“嘴巴呼气缩肚子,缩到最底,保持3 s”,连续3次最大呼气后进行高质量图像的采集(如图1)。
图1 最大吸气末和最大呼气末超声图像

EO为腹外斜肌;IO为腹内斜肌;TrA为腹横肌。

Fig.1 Ultrasound image of lateral abdominal muscles at the end of maximum inspiration and expiration

仰卧位结束后更换至站立位,受试者双脚分开与肩同宽,双手位于身体两侧自然下垂,目视前方。以同样的方法进行站立位的弹性和肌肉厚度测量。在整个检查过程中,检查者对患者的个人数据和脊柱侧弯的特征不知晓。

1.2.4 测量与计算

每次测量均先从右侧开始,为避免探头位置移动带来的误差,在仰卧位和站立位测量最大吸气位和最大呼气位的腹肌厚度时,先同时在右侧两个呼吸位全部测量结束后再测量左边。两种体位下肌肉厚度与弹性的每次测量均先右后左。计算肌肉弹性时,在每个肌肉的上下筋膜间使用椭圆形工具圈出图片上每块肌肉筋膜内中间部分连续3处位置,超声设备会自动计算圆圈内的肌肉弹性并进行均值的计算,具体如图2。图片计算完弹性后,再使用原图像进行距离(即肌肉厚度)的测量。测量距离时,使用距离工具对图片上每块肌肉中段的上下筋膜进行标点测量并得出仰卧位和站立位下的肌肉厚度值。
图2 弹性模量值测量

注:网络版为彩图。

Fig.2 Measurement of elasticity

2 结果

使用SPSS 25数据统计软件进行数据分析。符合正态分布的计量资料采用(平均数±标准差)表示,不符合正态分布的计量资料采用(中位数±四分位间距)表示。侧弯组自身凹凸侧的肌肉厚度与弹性比较采用配对样本t检验,侧弯组与健康组腹壁肌群厚度与弹性的组间比较采用独立样本t检验,P<0.05为差异具有统计学意义。

2.1 基本信息

侧弯组与健康组的年龄、身高、体重和BMI无统计学差异,具体信息见表1。侧弯组(单胸弯型6名,占24%;胸主弯双弯型19名,占76%)平均Cobb角为21.36°±8.26°,其中男性7例,女性18例。健康组中男性9例,女性16例。
表1 受试者基本信息

Tab.1 General characteristics of participants

指标 侧弯组(n=25) 健康组(n=25) P值
年龄/岁 13.80±1.58 13.28±1.46 0.23
女∶男 18∶7 16∶9
身高/cm 164.22±6.03 163.90±7.81 0.87
体重/kg 48.56±9.69 48.99±6.80 0.86
BMI/(kg·m-2) 17.94±3.08 18.29±2.68 0.68
Cobb角/(°) 21.36±8.26

2.2 腹壁肌群厚度结果

仰卧位下,侧弯组患者左侧腹外斜肌绝对厚度值较健康组小(P=0.03),收缩厚度差较健康组更大(P=0.04)。与健康组相比,侧弯组患者两侧腹横肌存在显著不对称(P=0.02),站立位下,侧弯组腹壁肌群厚度与收缩厚度差均与健康组无明显差异,见表2。
表2 侧弯组与健康组腹壁肌群厚度差异

Tab.2 Thickness of abdominal muscles and the comparison between two groups

指标 位置 肌肉 仰卧位 站立位
侧弯组/mm 健康组/mm P值 侧弯组/mm 健康组/mm P值
绝对厚度值 右侧 EO 4.77±1.29 5.40±1.45 0.11 5.17±1.20 5.73±1.23 0.10
IO 6.20±1.62 6.36±1.42 0.82 6.27±1.36 6.40±1.28 0.63
TrA 2.72±0.46 2.89±0.82 0.37 2.88±0.78 2.92±0.71 0.11
左侧 EO 4.64±1.28 5.55±1.67 0.03* 5.42±1.40 5.68±1.41 0.52
IO 5.85±1.25 6.42±1.36 0.12 6.11±1.38 6.44±1.74 0.49
TrA 2.63±0.56 2.67±0.84 0.18 2.77±0.63 2.94±1.02 0.87
收缩厚度差 右侧 EO 0.98±0.99 0.48±0.87 0.07 0.57±1.25 0.26±0.94 0.33
IO 1.64±1.21 1.38±0.97 0.41 3.12±1.64 2.69±1.61 0.35
TrA 2.39±0.84 2.04±0.99 0.18 2.16±1.41 1.76±0.96 0.25
左侧 EO 0.80±0.99 0.28±0.83 0.04* 0.34±0.84 0.04±0.94 0.25
IO 1.69±1.07 1.68±0.65 0.96 2.17±1.22 2.55±1.65 0.36
TrA 2.19±0.92 2.17±0.85 0.92 1.79±1.08 1.98±0.91 0.50
厚度对称性 两侧 EO 0.13±1.32 -0.14±0.90 0.16 -0.25±0.92 0.06±0.98 0.26
IO 0.42±1.40 -0.08±0.95 0.16 0.09±1.22 -0.02±1.09 0.72
TrA 0.24±0.71 -0.22±0.68 0.02* 0.22±0.74 -0.14±0.79 0.08

注:EO为腹外斜肌、IO为腹内斜肌、TrA为腹横肌;收缩厚度差为呼气末肌肉厚度值减去吸气末肌肉厚度值;厚度对称性为右侧肌肉厚度值减去左侧肌肉厚度值;*P<0.05,差异具有统计学意义。

2.3 腹壁肌群弹性结果

2.3.1 左右两侧肌群弹性差异

仰卧位下侧弯组患者左侧(主弯凹侧)腹外斜肌弹性较右侧(主弯凸侧)大(P=0.03),差异具有统计学意义;而健康组左右两侧腹壁肌群弹性无明显差异,见表3。
表3 侧弯患者凹凸两侧腹壁肌群弹性差异

Tab.3 Elasticity of abdominal muscles and their side-difference of two groups

位置 肌肉 仰卧位 站立位
侧弯组/kPa 健康组/kPa P值 侧弯组/kPa 健康组/kPa P值
仰卧位 EO 18.31±5.12 21.37±7.24 0.03* 19.76±5.71 21.05±5.47 0.14
IO 20.79±7.06 21.17±6.71 0.43 18.90±6.52 19.69±5.88 0.41
TrA 23.08±11.02 23.35±9.98 0.66 20.04±9.82 21.02±9.24 0.62
站立位 EO 25.47±8.70 23.29±7.34 0.17 23.42±9.08 23.18±9.33 0.54
IO 25.07±7.89 24.61±8.71 0.72 22.03±6.63 21.40±6.82 0.53
TrA 28.97±8.01 30.32±10.77 0.41 25.75±8.92 24.50±8.28 0.37

注:EO为腹外斜肌、IO为腹内斜肌、TrA为腹横肌,*P<0.05,差异具有统计学意义。

2.3.2 侧弯组和健康组肌群弹性差异

站立位下侧弯组患者左侧腹横肌弹性较健康组更大(P=0.03),差异具有统计学意义(表4)。
表4 侧弯组与健康组腹壁肌群弹性差异

Tab.4 Elasticity of abdominal muscles and the comparison between two groups

位置 肌肉 仰卧位 站立位
侧弯组/kPa 健康组/kPa P值 侧弯组/kPa 健康组/kPa P值
右侧 EO 18.31±5.12 19.76±5.71 0.35 25.47±8.70 23.42±9.08 0.42
IO 20.79±7.06 18.90±6.52 0.33 25.07±7.89 22.03±6.63 0.15
TrA 23.08±11.02 20.04±9.82 0.31 28.97±8.01 25.75±8.92 0.19
左侧 EO 21.37±7.24 21.05±5.47 0.86 23.29±7.34 23.18±9.33 0.70
IO 21.17±6.71 19.69±5.88 0.41 24.61±8.71 21.40±6.82 0.15
TrA 23.35±9.98 21.02±9.24 0.39 30.32±10.77 24.50±8.28 0.03*

注:EO为腹外斜肌、IO为腹内斜肌、TrA为腹横肌;*P<0.05,差异具有统计学意义。

3 讨论

本研究利用高频B型超声和剪切波弹性成像评估特发性胸椎侧弯患者腹壁肌群的厚度及弹性。结果显示:与健康组相比,侧弯患者仰卧位下的凹侧腹外斜肌厚度更薄,且收缩厚度差更大;侧弯患者的两侧腹横肌厚度不对称性更大。侧弯患者仰卧位下左侧腹外斜肌较右侧更僵硬,站立位下左侧腹横肌较健康组更僵硬。

3.1 腹壁肌群厚度

仰卧位下侧弯组凹侧腹外斜肌的厚度较健康组小,在最大吸气和最大呼气过程中的收缩厚度差更大;且侧弯患者的两侧腹横肌厚度不对称性更大,反映出胸椎侧弯患者腹壁肌群形态及稳定控制能力的改变。对于此变化,主要考虑腹壁肌群的解剖和功能因素。本研究中纳入的患者均为胸椎右侧弯,侧弯处的椎体还会伴有水平面上向凸侧的旋转[19],进而引起胸廓和肋骨的旋转畸形[20]。解剖学上,腹外斜肌上束覆盖在第5~8肋骨(上位肋骨)外表面,因此凹侧腹外斜肌可能受胸廓畸形影响在测量位置被拉长,则表现为肌肉厚度的减小。此外腹壁肌群的主要功能是作为主动系统维持脊柱稳定[21],而侧弯患者由于肌肉厚度减小,可能引起维持脊柱稳定机制减少。从生物力学角度来看侧弯本身骨性结构的改变可能引起躯干稳定性下降,根据Panjabi的稳定模型理论[22],当被动子系统维持稳定性的能力不足时,更多地由主动子系统发挥作用。这可能导致侧弯患者在动态任务中肌肉活动更大,表现为凹侧腹外斜肌收缩厚度差更大。这与Borna等[23]的研究结果一致,不同的是该研究发现仰卧位下侧弯组左右两侧腹外斜肌厚度均较健康组更小,在完成缩腹动作过程中,两侧腹外斜肌厚度变化均更明显,这可能与其纳入实验对象的侧弯方向不一致有关。侧弯组患者除同侧肌肉厚度与健康组有差异外,两侧腹横肌对称性也较健康组更差。Kim等[24]和Linek等[25]的研究也发现在轻度侧弯患者中存在腹横肌的厚度不对称,但两个研究均未区分侧弯类型和侧弯方向。从解剖和功能特点来看,腹横肌的部分起点位于胸腰筋膜的前层,其收缩可增加胸腰筋膜中段张力[26],胸腰筋膜中段张力参与了脊柱冠状面稳定能力的40%,并参与控制特定椎体节段水平面上的旋转与平移[27],是影响脊柱稳定的重要因素。因此,脊柱畸形带来的不对称张力可能造成腹横肌的左右不对称。
与Linek等[12]的研究结果不同,本文研究结果未发现仰卧位下侧弯人群与健康人群腹内斜肌和腹横肌的厚度差异,分歧的原因可能是两项研究的侧弯类型或Cobb角的不同。对胸椎右侧弯患者来说,解剖学起点更靠近下位肋骨的腹内斜肌和腹横肌对胸廓畸形变化不如腹外斜肌敏感,轻中度的脊柱侧弯导致的胸廓骨盆的对位对线不良还不足以引起超声可见的该两块肌肉的厚度变化。
此外,本研究发现站立位下侧弯组患者腹壁肌群厚度及收缩厚度差与健康组无明显差异。分析其原因可能与体位变化增加了维持躯干稳定的前馈机制[28]有关。从较稳定的仰卧位到不稳定的站立位对肌肉激活的需求增加[29],侧弯组患者为维持躯干平衡腹壁肌群功能性增厚,因此未表现出与健康组的差异。而站立位下侧弯组凹凸两侧腹横肌不对称性也消失,考虑原因为腹横肌是局部抗重力肌[30],站立位下起维持直立姿势稳定的作用,因此由仰卧位变为站立位时不对称性会小消失。但并不能提示站立位下肌肉形态无差异,可能随着侧弯角度增加或样本量增大,站立位下的差异也会随之出现。

3.2 腹壁肌群弹性

本研究发现胸椎右侧弯患者仰卧位下凹侧腹外斜肌较凸侧更僵硬,即左侧腹外斜肌收缩能力较差。2020年,Linek等[17]在胸腰段脊柱右侧弯患者中观察到凸侧腹外斜肌较凹侧更僵硬,提示侧弯类型会影响凹凸两侧腹外斜肌的僵硬程度。由于其研究对象为胸腰段脊柱右侧弯,通常该类侧弯会伴有胸椎的左侧弯,即其患者胸椎凸侧为左侧,因此与本研究中结论一致,对胸椎侧弯患者而言,均为其凹侧腹外斜肌更僵硬。脊柱侧弯后被拉长的肌肉容易出现紧张性僵硬。由于腹肌在解剖上大多位于胸腰和腰段脊柱水平,因此这段脊柱的畸形方向对肌肉形态影响更大,例如胸椎右弯的患者其胸腰/腰段脊柱通常左侧弯(本研究中76%的胸右弯患者有胸腰或腰段的左侧代偿弯),因此左侧腹肌弹性更易紧张,即胸椎右弯患者的凹侧腹肌更易受影响。从功能角度分析一侧腹外斜肌收缩可使躯干向对侧旋转,而被拉长腹肌更僵硬可能是一种限制胸廓继续向该侧旋转的保护性张力。这也解释了本研究发现的站立位下侧弯组左侧腹横肌较健康组更僵硬的结果。
有研究指出肌肉大小(厚度、体积、横截面积等)与弹性可能存在相关性[31],本研究将厚度与弹性结果结合更全面客观地评价肌肉特征。胸椎右侧弯患者仰卧位下凹侧腹外斜肌厚度较健康组更薄,收缩厚度差更大,同时凹侧较凸侧更僵硬,反映出其形态、功能及内部生物力学的一致性。侧弯患者仰卧位下表现出两侧腹横肌厚度不对称,尽管站立位下这种不对称性与健康组没有差异,但凹侧腹横肌比健康组更僵硬,意味着体位变化对腹横肌影响较大。提示我们在保守治疗中要同时关注不同体位下肌肉厚度对称性及弹性的恢复。

4 结语

本研究首次观察了临床较常见的胸椎右侧弯患者腹壁肌群呼吸收缩厚度变化特点,并从厚度和弹性两个方面分析了侧弯对肌肉的影响,对胸椎侧弯患者保守治疗方案的制定有一定的理论指导意义。本研究仍有以下不足:首先,样本较单一,缺乏与其他弯型的比较,因此后续研究可以研究其他侧弯类型或不同Cobb角的侧弯患者,深入总结脊柱侧弯与腹壁肌群特点的相关性。其次,目前SWE 应用于肌肉骨骼系统的研究样本量均较少,难免存在一定的抽样差;肌骨软组织大多位置表浅,不可避免会受到外力等因素干扰影响弹性测值,导致假阳性或假阴性结果的产生。

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