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Home > Research > Low Back Pain

Non-Surgical Therapy For Prolapse of Lumbar Intervertebral Disc

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.

  1. Digital pressing at the Juliao (GB 29) acupoint, and pushing and pressing along the lumbar and sacral regions.
  2. Digital pressing at the tender point, while asking the patient to stand upright, facing closely to a wall.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

  1. 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.

  2. 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.
  3. 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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