News Letter, Vol. 2 (3), March, 2010, © Copyright
Jun Xu, M.D. Lic. Acup., Hong Su, C.M.D., Lic. Acup.
Rehabilitation Medicine and Acupuncture Center
1171 East Putnam Avenue, Building 1, 2nd Floor
Greenwich, CT 06878
Tel: (203) 637-7720
Jeffrey S. is a 35-year–old man who was involved in a motor vehicle accident from which he sustained a neck injury. He was stopped at a red light when another car rear-ended him. He did not lose consciousness, and though he was aware that his neck had shifted backward, he felt the injury was only minor at the time. When the police officers at the scene of the accident suggested that he go to the hospital for evaluation, he did not feel sufficient pain to warrant this; plus, he had a meeting scheduled.
About two weeks later, the initial neck pain had radiated down to his right shoulder, elbow and hand, and he also felt numbness and tingling. The pain occurred on and off, especially during the night. In the mornings when he woke up, his neck felt very stiff; the pain was severe and he could not lift heavy objects. At this point, he visited his primary care physician, who ordered an MRI and X-ray. These tests showed a herniated disc at C5 and C6 but no fracture. The patient was referred for physical therapy and to a neurosurgeon. The neurosurgeon prescribed two months of physical therapy, then a follow-up visit.
The patient attended physical therapy three times a week, but after a few weeks, the pain worsened, not only radiating down his right arm, but also between his shoulder blades. In addition, he felt stiff and had difficulty moving his head forward and backward. His neurosurgeon gave Jeffrey a neck collar, which also did not help. The doctor suggested that, since physical therapy had not worked, the patient should consider surgery. Jeffrey did not want surgery. He was a self-employed car dealer and could not afford to take the month off required for surgery and the recovery period.
He was subsequently referred to a pain-management physician who gave him epidural injections at C5-C6. These greatly alleviated Jeffrey’s neck pain; however, a month later the pain returned and was much more severe and Jeffrey did not know what to do next. He was referred to me for help and I was able to offer him an alternative treatment.
Common neck injuries:
Since the neck is very flexible and supports the head, it is extremely vulnerable to accidents and associated injuries. Car accidents, sports-related accidents, contact sports and force can result in different degrees of cervical (i.e. neck) injuries. The most common neck injuries after a car accident are:
- Soft tissue injury: involves the muscles and ligaments. Usually there is no pain radiating down to the shoulder and arm, and no numbness or tingling sensation; however, the patient feels neck pain localized on the cervical spine and posterior shoulder and experiences pain and neck weakness when he/she wakes up each morning.
- Herniated disc injury/cervical radiculopathy: caused by moderate to severe neck injury. The most common is C5-C6 herniated discs, which impinge the cervical nerves causing the pain to radiate down to the shoulder, arm and sometimes, wrist, making the injured sides feel heavy and weak. Very often, the patient feels pins, needles and burning sensations (cervical radiculopathy).
- Neck fractures or dislocations: severe neck injury will cause fractures or dislocations of the neck, which will in turn damage the spinal cord with more severe symptoms similar to the above. Often may cause paralysis.
Jeffrey’s injury falls into the second category: cervical radiculopathy with herniated disc.
Western medicine: diagnosis and treatment
If a patient experiences severe neck pain after a car accident, the doctor usually orders the following tests:
- X-ray: most common test. Checks for bone fractures. If the pain is not severe this test usually suffices.
- MRI: studies the spinal cord and nerve roots.
- CT scan: allows careful evaluation of the bony structure of the cervical spine.
- Myelography: dyed liquid is injected into the spinal cord to evaluate it and the nerve roots.
- EMG (electromyography): evaluates nerve and muscle function.
Jeffrey underwent the majority of these western medicine treatments, except surgery, including:
- Anti-inflammatory medication: Naproxen, Tylenol, Advil, etc. are administered to decrease neck inflammation. However, these medications usually just mask the pain, and incur many other side effects, such as stomach upset, peptic ulcer, and increased chance of blood clots. They cannot be expected to specifically treat the cause of the cervical herniated disc.
- Immobilization: most patients only need a soft collar, which gives psychological support to immobilize the neck. In other words, if the patient feels he/she can depend on the collar for some support, the perception of pain is usually decreased to a certain degree. In some cases, a solid cervical orthotic device might be used for unstable fractures of the cervical spine.
- Physical therapy: heating pads, ultrasound technology, stretching and strengthening exercises coupled with massages and range of motion exercises of the cervical spine. This helps if the patient has soft tissue injury without a severe herniated disc.
- Epidural injection: the patient is put under a specific, C-arm X-ray machine. Then, a trained physician injects the steroid into the herniated area and nerve root, which decreases the inflammation and pain. This treatment relies on the experience of the physician and the severity of the herniated disc and pinched nerve. If the injury is too severe, epidural injection might not help, especially if the physician cannot inject the steroid into the specific point.
- Surgery: there are two possible surgeries for this condition:
- Discectomy. The neurosurgeon might cut out only the injured portion of the disc, which will remove the pressure of the herniated disc from the nerve root. This may cause the symptoms to decrease or disappear. Sometimes, the entire herniated disc will disappear because of the degenerative changes in the disc tissue.
- Laminoctomy. Sometimes the disc degenerates or the nerve root impingement is very severe. In these cases, removing a part of the herniated disc through discectomy is not sufficient to relieve the pain. Thus, the surgeon may cut off a piece of the bone to open the nerve root outlet.
- Traction: recommended by doctors when the patient wants to avoid surgery. This treatment pulls and slightly separates the vertebrae of the neck so that the herniated disc might return to its original place, thus relieving the pain. The neck position is extremely important in this course of treatment, The neck should not be hyperextended and pressure must be tested before flexing the neck as this could cause further damage to the cervical vertebrae.
Traditional Chinese Medicine: diagnosis and treatment
Jeffrey underwent most of the treatments listed above, without experiencing significant improvements. Before undergoing surgery, he decided to consult me. After a thorough physical examination, I concluded that the patient had the symptoms of right C5 and C6 nerve distribution and the herniated disc was impinged at C5-C6 nerve roots. The following table is a description for the pathophysiology of the cervical radiculopathy, i.e. the neck nerve root impingement at different root levels.
|Nerve Root||Disc Lesion||Muscle involved||Reduced Reflex||Weakness||Numbness|
|C3/C4||C2/C3||Posterior and lateral scalp, temporal muscles||None||None||None|
|C5||C4||Rhomboids, Deltoid,Biceps brachii,
Infrasponatus, Brachilis, etc.
|Biceps brachii||Elbow flexion||Lateral arm|
|C6||C5||Deltoid,Biceps brachii, Brachioradialis
|Brachioradialis||Wrist extension||Lateral forearm|
|Triceps brachii||Elbow extension||Middle finger|
|None||Finger flexion||Middle finger|
FCR: Flexor Carpi Radialis
EDC: Extersor digitorum communis
FCU: Flexor Carpi Ulnaris
FDP: Flexor Digitorum Profundus
ADM: Abductor digiti minimi
PQ: Pronator quadratus
APB: Abductor pollicis brevis
An MRI of the cervical spine without contrast (i.e. there is no contrast material injected into the blood circulation; this type of MRI decreases the amount of toxic substances injected into the body and the subsequent side effects) was ordered for Jeffrey, and is pictured below:
From the above films, it is evident that there was a herniated disc at C4, which impinged the C5 nerve root and caused the symptoms Jeffrey complained of.
I employed acupuncture to treat the injury, following the cervical spine from C5-C6 up into the lateral portions of the shoulder, upper arm and forearm. Hua Tuo Jia Ji points are a set of specially designed points used to treat disc diseases. By palpation, you should feel the herniated disc spinal process, then insert the needles (about 0.5 inches deep) into the herniated disc, and the discs one level above and one level below the level of the herniated disc. Then, insert needles 0.5 inches from the lateral sides of each of the three initial needles. Thus, a total of 9 needles are inserted into the herniated disc and adjacent area.
For this particular case, I also extended this Hua Tuo Jia Ji to C4 and C7 levels. For the other parts of the body, I selected LI 15 Jian Yu, LI 11 Qu Chi, SJ 5 Wai Guan, and LI 4 He Gu. The C5-C6 nerves connect to the lateral shoulder and the lateral upper arm; all the above acupuncture points follow these nerve roots locally. The local acupuncture points will increase blood flow in the area, wash away inflammatory factors, and decrease the muscle spasms and inflammation. Distal acupuncture points such as the bilateral Tai Chong and He Gu should also be selected. These largely increase the amounts of endorphins secreted in the brain, which help to decrease pain.
Pic 4-1 Hua Tuo Jia Ji Points
|1||Hua Tuo Jia Ji||ExperiencedPoints||Along the spine, use the most painful vertebral spinal as the midpoint, then locate the upper and lower spinal process and points located 0.5 inches on either side. You may choose two spinal processes as the starting points. See Pic 4-1||Specifically treat for local neck and low back pain, and pain along the spine.|
|2||Tai Chong||Liv 3||See table 1-1/Pic 1-3||See table 1-1|
|3||He Gu||LI 4||See table 3-1/Pic 4-2||See table 3-1|
|4||Qu Chi||LI 11||Flex the elbow. The point is in the depression of the lateral end of the transverse cubital crease.||Sore throat, toothache, redness and pain of the eye, scrofula, urticaria, motor impairment of the upperextremities, abdominal pain, vomiting, diarrhea, febrile disease.|
|5||San Yin Jiao||Sp 6||3 inches directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibia.||Abdominal pain and distention, borborygmus, diarrhea, dysmonorrhea, uterine bleeding, morbid leucorrhea, prolapse of the uterus, delayed laboour, nocturnal emission, impotence, enuresis, dysuria, edema, hernia, pain in the external genitalia, muscular atrophy, motor impairment, paralysis and pain of the lower extremities, headache, dizziness and vertigo, insomnia.|
|6||Jian Yu||LI 15||Anterior-inferior to the acromion, on the upper portion of m. deltoideus. When the arm is in full abduction, the point is in the depression appearing at the anterior border of the acromioclavicular jointSee Pic 4-2||Shoulder and arm pain, motor impairment of the upper extremities, rubella, scrofula|
|7||Wai Guan||SJ 5||2 inches above outer wrist transverse crease; midpoint between the radius and ulnaSee Pic 4-2||Febrile diseases, headache, pain in the cheek, strained neck, deafness, tinnitus, pain in the hypochondriac region, motor impairment of the elbow and arm, pain of the fingers, hand tremor|
Pic 4-3 The patient underwent my treatment for a total of 20 visits (twice a week for ten weeks). Gradually, his pain decreased, the neck spasms and right-side arm weakness decreased, and the patient felt a large overall improvement.
Tips for both patients and acupuncturists:
I have found that the most efficacious treatment involves a combination of acupuncture, heating pads, massage and physical therapy. I do not recommend that a patient undergo surgery immediately. Studies have shown that surgery for this condition may show a marked improvement for about six months; however, after this period, the pain usually returns. After two years, the patients with or without surgery may have the same level of pain (patients who did not undergo surgery were instead treated with acupuncture, physical therapy, massage and chiropractic therapy). Therefore, I recommend that patients explore other options before jumping into surgery.
A clear diagnosis is the most important factor in these cases. For any acupuncturist to treat neck pain, he/she must first understand the mechanism of the pain. If the pain is moderate, acupuncture treatment alone may help. If it is more severe, it is important to refer the patient to a western doctor for evaluation. If there is a fracture, the patient could become paralyzed and it is therefore absolutely necessary to first employ MRIs, X-rays, and CT scans to rule out skeletal instabilities.