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By Wang Heshan
Department of Medical Service,#C Training Bureau of the State Sports Committee,
Beijing 100061
Appearing originally in
The Journal of
Traditional Chinese Medicine
Satisfactory therapeutic effects were achieved in 116 cases with prolapse
of lumbar intervertebral disc treated with non- surgical therapy. The results
are reported as follows.
Clinical Data
There were 79 male and 37 female cases in this series of patients (116
cases). Their ages ranged from 20 to 70 years, with histories of the disease
for 3 days to 26 years. Of the prolapsed discs,
5 were at L#-[1-2],
12 at L#-[3-4],
42 at L#-[4-5],
23 at L#-[5]-S#-[1]
34 at L#-[4]-L#-[5]-S#-[1].
12 prolapsed discs were of central type, 43 of levo-posterior type and
61 of dextro-posterior type. Prolapse or ectasia was shown in all the affected
discs on CT and MRI scanning. 47 cases had history of apparent trauma or
sprain.
Methods of Treatment
Massage
Massage with traditional maneuvers
is applied from above downward along both sides of the spinal column to
relax the lumbar muscles. This was the preparatory step. Then, according
to the symptoms of individual cases, two to four of the following six maneuvers
can be selected.
- Digital pressing at the Juliao (GB 29) acupoint, and pushing and
pressing along the lumbar and sacral regions.
- Digital pressing at the
tender point, while asking the patient to stand upright, facing closely
to a wall.
- Ask the patient to take a sitting position. The massagist
sits at the back of the patient to swing the patient's lumbar region, press
and knead the affected part with his single hand, while the patient is
asked to flex and extent his waist.
- Laterally moving manipulation: Ask
the patient to take a lateral recumbent position, extent his lower limb
and flex the upper one. After the massagist puts his one hand at the buttock
and the other at the shoulder, moving the patient forward with one hand
and backwards with the other simultaneously. Sometimes a crack sound can
be heard during the manipulation. Then, the same manipulation is applied
to the opposite side.
- Reposition with rotating manipulation: Ask the
patient to sit upright on a square bench and slightly lower his head. An
assistant stands facing the patient and uses his both knees to press the
patient's left upper leg from both sides, in the mean time the assistant
holds the patient's left upper leg firmly with both of his hands to maintain
the patient sitting upright. The massagist stands behind the patient, stretches
his right arm under the right axilla of the patient and puts his palm against
the nape. While the massagist keeps holding at the L#-[4-5] lumbar spinal
process with his left thumb, he forcefully rotates the affected trunk with
his right arm posteriorly and medially and simultaneously pushes the spinal
processes with his left thumb. Reduction of the affected spinal process
can be felt by the thumb, and sometimes, a crack sound can be heard. The
same manipulation is then performed on the opposite side.
- Traction with
pushing and pressing: The patient takes a prone position, the massagist
pushes and presses the area of the affected vertebrae while two assistants
pull the patient's both legs.
Medication
According to the basic theories
of TCM and an overall analysis of symptoms and signs, the condition can
be divided into the following three types. - For patients with qi
stagnation and blood stasis, modified Shen Tong Zhu Yu Tang (Decoction
for Relieving Pantalgia due to Blood stagnation) and Shu Jin Huo Xue Tang
(Decoction for Relaxing Muscles and Tendons to Promote Blood Circulation)
are prescribed, which have the actions of promoting blood circulation,
removing blood stasis, invigorating qi and relieving pain.
- For
patients affected by wind, cold and dampness, the therapeutic principles
are to dispel wind and resolve dampness. Modified Du Huo Ji Sheng Tang (Pubescent
Angelica and Loranthus Decoction) is given.
- For patients with kidney
deficiency, the therapeutic principle is to strengthen the body resistance
to consolidate the constitution. Zuo Gui Yin (Decoction of Kidney YinTonic), You Gui Yin (the Kidney Yang Reinforcing
Decoction), Zhuang Yao Jian Shen Wan (Bolus for Strengthening the Loin and
Kidney) are prescribed with addition of herbs for promoting blood circulation,
removing blood stasis, dispelling wind and removing obstruction in the
channels.
Therapeutic Results
Criteria for therapeutic effects: By referring
Mensor's criteria for evaluation of the therapeutic effect on prolapse
of lumbar inter-vertebral disc by manual treatment, the following criteria
were formulated:
- Cure: Complete relief of pain, and no limitation of motion,
only with some neurological signs left behind (such as decreased tendon
reflex, slightly decreased sensitivity in affected skin areas, and decreased
myodynamia in extensors).
- Markedly effective: Occasional backache, or leg
pain which does not affect the activity of the limb. Improvement in lateral
bending and in LA's test.
- Effective: Various degrees of temporary backache
or pain in the lower extremities. The ache is not severe, and the patient
is capable of doing some work, but cannot lift heavy weights. Certain signs
still remain, such as limitation in lateral bending or movement because
of pain.
- Ineffective: After 3 sessions of treatment (once every other day),
no symptoms are alleviated or just mitigated for a very short time.
Therapeutic results: After treatment, the results were: cured in 52
cases, markedly effective in 41 cases, effective in 17 cases, and ineffective
in 6 cases.
Discussion The above non-surgical therapy
can replace the prolapsed intervertebral disc to its original position,
and eliminate the adhesive inflammation of the soft tissue surrounding
the nerve root. Traction can relax the tonic lumbar muscles and intensify
the posterior longitudinal ligament and transverse ligament of fibrous
ring to correct the lateral bending and posterior protruding abnormalities
of the vertebral column, enlarge the intervertebral space, enlarge the
dural capsule and intervertebral foramen, thus a negative pressure is produced
in the intervertebral space, that facilitates the replacement of intervertebral
disc, and in the meantime, lay a foundation for further manipulation.
Medication
according to differentiation of symptoms and signs can invigorate blood
circulation, remove blood stasis, activate qi flow, relieve pain,
dispel wind, disperse cold, resolve dampness, strengthen tendons and bones,
decrease local adhesion and edema. If the therapeutic effects are satisfactory,
at the local tender point, Radices Codonopsis Compositae or procaine
solution can be injected, and epidural block therapy at sacral region can
be applied. Procaine and steroids can inhibit the excitement of nerve endings,
improve blood circulation, thus yielding marked actions of anti-inflammation,
and alleviation of pain. The symptoms can be ameliorated quite soon. If
some cases with short disease course, severe symptoms are intolerable to
the general maneuver, the manipulation can be performed under extradural
anestheisa, or lumbar anesthesia. The lumbar muscular spasm should be fully
relaxed, and the intervertebral space enlarged, so as to facilitate replacement
of the prolapsed intervertebral disc, loose the nerve root adhesion, change
the relation between the nerve root and prolapsed disc, restore the normal
dynamic balance of vertebral column, and relieve or eliminate the clinical
symptoms. However, violently forceful maneuvers should be avoided, which may
induce iatrogenic injury.
Massage is contraindicated for senile patients
with cardiovascular diseases, cases with central prolapse, significant
bony proliferation or calcification of the prolapse, and cases who have
a prolonged disease course and have been treated many times without satisfactory
therapeutic results and with frequent recurrences.
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