Chronic Low Back Pain-Herniated Disks and Pinch Nerves
Jason W is a 46-year-old male who has suffered low back pain, on and-
off, for about six months. He is a teacher for special education who caught a student when the student was falling and about to hit the corner of a desk, at which moment he felt sudden onset low back pain. The pain was so severe he was unable to stand, and felt weakness with the pain radiating to his left leg and causing a tingling and numbness sensation there. When he was brought to my office, he was unable to stand but had to talk to me from a prone position on an examining table.
About one year ago Jason had a similar experience with a student and, at that time, felt the same sensations of low back pain, which radiated to his left leg, and accompanied with tingling, tenderness, numbness and heaviness of his left leg. He consulted his primary care physician who diagnosed acute low back sprain, and prescribed anti-inflammatory medication and bed rest. After two days he felt a little better however, since then, he has experienced pain off and on and also feels his lower back is weak.
At present, he finds it difficult to hold his low back, and his left leg is heavy and he has difficulty raising it, he cannot bend forward with any ease and has trouble donning his pants. He also has difficulty picking up objects such as a pen from the floor and is experiencing a bit of urinary incontinence.
The patient is moderately obese and has a somewhat large abdomen, so I asked him to stand straight then bend forward. He was unable to perform this maneuver and immediately felt back weakness, and had difficulty bending forward more than 40 degrees. When I asked him to walk on his tiptoes and heels, he was unable to do so, and he reported when he walks on his heels he feels low back pain radiating down the left leg, especially around the lateral of the knee and lateral to lower leg. I also performed a straight leg raising test. On the right side the patient could do straight leg raising by about 80 degrees, however, only 50 degrees on the left side, at which point he feels the pain radiating again down to the leg and knee. I used a pinprick to check the patient’s response to sharpness and cotton ball to check his light touch sensation. Both tests showed decreased sensation along the left lateral thigh and leg. I also checked his deep tendon reflexes, which showed the left knee jerk and left ankle jerk to be about 1+. By examining the strength of his left leg, his ankle dorsal flexors are 3/5 and the ankle plantar flexors are 4/5, the knee flexors and extensors are 3/5, The rest are 5/5.
Because of the severity of his condition, I ordered a lumbar sacral MRI which showed severe L4/L5 herniated disc with a left protrusion.
From that above MRI pictures, you may see the arrows indicate the herniated disc from Jason’s Lumbar spine.
Jason appeared to have left L5 radiculopathy. Because the above image showed severe herniated disc between L4/L5, he was immediately referred to a neurosurgeon.
After careful examination by a neurosurgeon, he was advised to have emergency surgery for discectomy, i.e. a small incision to cut off part of his herniated disc, based on his emergency symptom, such as, severe low back pain radiating to left leg with numbness and tingling sensation, and slightly urinary incontinency. Jason agreed the surgery.
However, the insurance companies’ argument prevented him from immediate surgery. He went through two similar episode of the low back injury during work as I described above, the second worker’s compensation company requested the first worker’s compensation company to pay the medical expenses, they believed the second injury was the consequence of first injury. But the first worker’s compensation company refused the request. Therefore, Nobody would like to pay the expenses, and Jason was so painful, he could not wait for the final decision between the two worker’s compensation companies, Jason thought it would take months to solve the problem. The patient then called me and said, “ I am stuck here, nobody would like to pay for the expenses, I can not have surgery right now, could you please help me with acupuncture, I might avoid the surgery if it is possible?” I decided to accept the challenge then and I started to treat him right away.
Low back pain is the secondary most common injury to cause workforce loss in the US and almost everyone has experienced this kind of pain sometime in
Low back pain has many different manifestations, the causes of which follow:
1. Myofascial or tendon ligament sprain. This is acute pain in the muscles that can come from poor posture, tendon ligament injury, or from overuse or overstretching.
2. Radiculopathy which is a pinched nerve, usually originated from a herniated or slipped disc pinching one of the lumbar sacral roots as indicated from above MRI pictures.
3. Spinal stenosis and narrowing of the nerve opening either around the spinal cord or nerve roots that cause symptoms similar to pinched nerve.
4. Overuse and overstretch of ligaments of facet and sacroiliac joints.
5. Fracture of the vertebrae caused by significant force such as an automobile or a bicycle accident, or a fall.
6. Scoliosis or kyphosis, i.e. the spine curves changed in a wrong way.
7. Compression fracture, which is common among postmenopausal women with osteoporosis.
There are also some less common spinal conditions capable of causing low back pain, including:
1. Ankylosing spondylitis, which is a severe bony fusion of lumbar sacral spine and pelvic bone with unknown reasons, the patients have difficulty straight their back, and sometimes, are unable to look at sky.
2. Bacteria infection such as osteomyelitis, etc.
3. Spinal tumors.
4. Paget disease: a bone disease in which the bone is unable to keep the balance of remodeling process, i.e. to lay down new bone and take up old bone for the purpose of rebuilding the bone. As a result, the bone formation is abnormal with loose bone structure, and enlarged and low density bone, which are brittle and prone to fracture.
5. Scheurmann’s disease, in which bones of the spinal vertebrae develop wedge-shaped deformities, i.e. the vertebrae grow unevenly, that is, the anterior angle is often greater than the posterior, results in the wedging shape of the vertegbrae and kyphosis.
Diagnosis: The symptoms and physical exam usually give a good idea as to the correct diagnosis. However, it is important to also have the following tests performed:
1. X-rays will give evidence of the lumbosacral osteoarthritis and sacroiliac osteoarthritis and any degenerative changes of the disc.
2. MRI will indicate the hernia disc and nerve impingement, facet joint osteoarthritis and also give a clear view of degenerative changes of the disc.
3. Electromyograph (EMG) which is divided into two parts. The first is nerve conduction study in which electrical stimulation is used to stimulate the nerves in one extremity. The machine then checks the velocity of the nerve travel and the amplitude of each individual nerve, which is then compared to the opposite or paired extremity. If there is any difference in the velocity and amplitude, as well as the latency, it is possible to differentiate among the nerves and determine which are injured The second part consists of an electromyography, during which a small needle is inserted into certain muscles of the spine and extremities, if the muscle is injured, it will show up on the screen, which will pinpoint which nerve roots are injured.
4. Lumbar myography. This is radiographic examination of the lumbar spinal canal with intrathecal injection of contrast medium. After injection, X-rays are taken and show if any nerve roots are impinged.
Based on the clinical symptoms and physical examination plus one or all of the above tests, a clear diagnosis of lower back pain can be made.
Treatment by western medicine:
Generally speaking, lower back pain is categorized into two major types:
1. Nonsurgical. Most physicians recommend non-surgical treatment before resorting to surgery. The following are usually recommended:
a. Anti-inflammatory medications such as acetaminophenm Advil, naproxen, etc. and muscle relaxants such as Valium, Skelaxin, etc. which probably help relax lower back muscles.
b. For a more severe condition, a lumbosacral brace or binder is usually recommended, which gives the patient support in the lower back. However, continued use of the brace can lead to muscle weakness of the lower back and should therefore only be used for such activities as driving, lifting the baby or some heavy object, etc.
c. Traction. If the patient is diagnosed with a herniated disc, the usual treatment would be traction. The patient is placed on a folding bed, then the an attempt is made to slightly pull apart the patient’s vertebral body. It is possible for the herniated disc to return to its original position. The traction is not indicated for other lower back pain such as myofascial sprain, spinal stenosis, or spondylolithesis, and the traction must be guided by a physician.
d. Physical therapy, which helps the patient strengthen the abdominal and leg muscles, which will alleviate the back pain; a strong abdominal muscle helps in holding the entire trunk.
Treatment by acupuncture:
All the acupuncture points are chosen along the nerve distribution and it is typical to stimulate these points with electrical stimulation and combine this with Moxibustion and massage, all of which greatly helps the patient.
Hua Tuo Jia Ji points are sets of specially designed points used to treat disc disease. By palpation, you should feel the herniated disc spinal process, then insert the needles into the disc about 0.5 inch deep and one up and one lower levels of the herniated disc, plus 0.5 inch of the lateral sides of the three levels, i.e. total 9 needles inserted into the herniated disc and adjacent area. For Jason’ treatment, I inserted the needles to L4, also extended this Hua Tuo Jia Ji to L3 and L5 levels.
I also selected the following points: Sheng Shu, Qi Hai Shu, Chi Bian, Huan Tiao, Yang Ling Quan, Fei Yang, Jue Gu, and Cheng Fu.
|1||Hua Tuo Jia Ji||ExperiencedPoints||Along the spine, use the most painful vertebral spinal as midpoint, then locate the upper and lower spinal process and 0.5 inch on the either side, you may choose two spinal process as the starting points. See Pic 4-1||Specifically treat for local neck and low back pain, and pain along the spine.|
|2||Sheng Shu||UB 23||1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the second lumbar vertebrta||Nocturnal emission, impotence, enuresis, irregular menstruation, leucorrhea, low back pain, weakness of the knee, blurring of vision, dizziness, tinnitus, deafness, edema, asthma, diarrhea|
|3||Qi Hai Shu||UB 24||1.5 inch lateral to midline of spine at the level of the lower border of the spinous process of the third lumbar vertebra||Low back pain, irregular menstruation, dysmenorrheal, asthma|
|4||Zhi Bian||UB 54||Lateral to the hiatus of the sacrum, 3 inch lateral to the midline of spine||Pain in the lumbosacral region, muscular atrophy, motor impairment of the lower extremities, dysuria, swelling around external genitalia, hemorrhoids, constipation|
|5||Huan Tiao||GB 30||At the junction of the lateral 1/3 between the great trochanter and the hiatus of the sacrum.||Pain of h elumbar regiin and the thigh, muscular atrophy of the lower limbs, hemiplegia|
|6||Yang Ling Quan||GB 34||In the depression anterior and inferior to the head of the fibula||Hemiplegia, weakness, numbness and pain of the knee, beriberi, hypochondriac pain, bitter taste in the mouth, vomiting, jaundice, infantile, convulsion|
|7||Jue Gu( Xuan Zhong)||GB 39||3 inch above the tip of the external malleolus, in the depression between the posterior border of the fibula and the tendons of peronaeus longus and brevis||Apoplexy, hemiplegia, pain of the neck, abdominal distension, pain in the hypochondriac region, muscular arophy of the lower limbs, spastic pain fo the leg, beriberi|
|8||Cheng Fu||UB 36||In the middle of the transverse gluteal fold||Pain in the lower back and gluteal regioin, constipation, muscular atrophy, pain, numbness and motor impairment of the lower extremities|
If the above noninvasive treatment does not help the patient, then epidural injections are indicated. Epidural injections under fluoroscope and X-ray guided injections inject steroid and lidocaine into the facet joint or nerve root in order do decrease the nerve root inflammation as well as decrease the pain.
Surgery is the last resort and there are several surgical options.
1. Discoctomy surgically cuts into the herniated disc to decrease the compression of the nerve root.
2. Laminectomy is used if the discetomy is not successful; in this surgery a piece of the bone is out to release the impinged nerve root.
3. Fusion. If the vertebral body is unsteady, and cannot hold together, it is necessary to use a rod or bone chip to fuse the vertebrae which protects the nerve from further impingement.
Jason was diagnosed with left L5 radiculopathy. He was treated with me with the combination of both western and Chinese medicines. I first used Hua Tuo Jia Ji with 9 needles and other adjunct points as above, I also used heating pad, massage, traction machine for 90 lbs 20 min, for stabilizing his low back, I prescribed customized lumbosacral corset, i.e. back brace. He was treated with me three times per week for 8 weeks.
Gradually the pain subsided, Jason felt less weakness on the leg and the burning and tingling sensations went away and eventually he returned to work but continued his visits with me for maintenance once every two weeks or once a month. After 6 months, he then consulted the neurosurgeon again who felt surgery was no longer indicated, based on the low intensity of his lower back pain.
Tips for acupuncturist:
1. It is absolutely necessary to make a clear diagnosis, Differentiate acute and chronic lower back pain, differentiate muscle sprain from herniated disc and spinal stenosis and radiculopathy, because only in this way can the prognosis be predicted. For example, if the diagnosis is muscle spasm, acupuncture can make the patient experience a quick recovery and greatly lessen the pain, and he/she can most probably return to work after only one or two days. However, if the patient has a herniated disc or spinal stenosis, acupuncture probably will help, but it will be a long recovery, probably two or three months.
2. Treatment: Most patients opt for non-surgical treatment first. However, if the pain radiates down the leg, with numbness, tingling down the leg, combined with urinary incontinence, it is very important to have an MRI and CT scan or X-ray to make sure there is no significant herniated disc or spondylolisthesis or spinal stenosis. If a severe medical condition is confirmed, then it is best to refer the patient to a neurosurgeon.
3. Acupuncture can treat a herniated disc, especially if combined with traction and massage.
4. A lumbosacral corset is also a great tool to help a patient move around with less pain.
Tips for patients:
1. Identifying the symptom, if you feel your low back pain radiating down to the leg with numbness, tingling sensation and weakness, sometimes accompanied with slightly urinary incontinency, you have to make your doctor to order MRI to make a clear diagnosis.
2. If it is acute or chronic low back sprain, you may need a few acupuncture treatments with massage and heating pad, if it is low back pinch nerves or herniated disks with above symptom, you have to ask your acupuncturist to use Hua Tuo Jia Ji points accompanied with massage, heating pad, even traction machine, if they are legally allowed to do so.
3. Low back brace always helps you to reduce your pain, however, you can not use it for 24 hours a day, you should be aware that the brace has side effects, which may weak your low back and abdomen muscles if you use it too long time. You only can use it intermittently. While you are at home, do not use it.