Transcript Pathology and TCM Treatment of the Herniated Lumbar Disc

Differentiating Sciatica
Symptoms and TCM
Treatment
East-West Healing Center
By Dr. Leon Chen
www.eastwesthealingcenter.net
Definition in Traditional
Chinese Medicine (TCM)
• Sciatica Symptoms is called “BiZheng 痹症” in
•
Traditional Chinese Medicine (TCM).
The HuangDiNeiJin in 475-221 B.C.(The Yellow
Emperor’s Internal Classic) discussed the
syndrome of pain in the low back and leg.
Definition in Western Medicine
• Sciatica (radiculopathy) is a general term that
•
refers to pain caused by compression or
irritation of one or more nerves exiting the lower
spine that make up the sciatic nerve, and there
are a number of different conditions that can
cause this.
Sciatica is a set of symptoms: low back pain, leg
pain and tingling, numbness or weakness that
travels from the low back through the buttock
and down the leg or foot.
Ⅰ Lumbosacral Plexus
腰
骶
神
经
丛
Lumbar Plexus
L2~L5
骶
丛
神
经
Sacral Plexus
S1~S3
Lumbosacral Plexus
腰
丛
神
经
股神经
Femoral N:L2-L4
闭孔神经
Obturator N: L2-L5
坐骨神经
Sciatic N: L4,5;S1~3
Common
Peroneal N :L4~S2
Supercficial N
Deep N
Tibial N
L4~S3
Lateral
plantar N
Medial
plantar N
Figure of Lumbosacral Plexus
髂腹下神经
Iliohypogastric N
髂腹沟神经
Ilioinguinal N
生殖股神经
Genitofemoral N
股外侧皮神经
Lateral femoral
cutaneous N
股神经
Femoral N
闭孔神经
Obturator N
坐骨神经
Sciatic N
腹股沟韧带
Inguinal
ligament
阴部神经
Pudendal N
Sciatic Nerve
• The sciatic nerve is a large nerve that
runs down the leg. It is the longest single
nerve in the body.
• The sciatic nerve involves L4, L5 and S13 of the spinal nerves.
• It includes the common peroneal nerve
and the tibial nerve.
• It distributes to the skin of the posterior
surface of the leg and the sole of the foot.
Intervertebral Disc and Spinal Nerve Roots
LV2
LN3
LN4
LV3
LV4
LN5
LV5
SN1
SV1
C
4
C4 3
3
5 6
5
7
T1
2
8
3
45
C5
6
7
T1
10
C6
8
C8
11
12
L1
L2
9
C7
S2
S2
C8
C7
54 3
L4
L3
L4
S2
L5
S1
L5
L4
S1
L4
L5
L5
C6
坐骨大孔
Greater sciatic notch
股骨大结节
Greater trochanter
坐骨神经
闭孔
Obturator foramen
闭孔神经
Obturator N
股骨小结节
Lesser trochanter
坐骨神经
Sciatic N
胫神经
Tibial N
腓总神经
Common
Peroneal N
Sensory area of
Sciatic N
Ⅱ Differential Diagnosis of Sciatica
1. General symptoms:
The term sciatica describes the symptoms
of pain and possibly tingling, numbness or
weakness that travels from the low back
through the buttock and down the leg or
foot.
2. General Examination on the Sciatica
1) Mobility of Lumbar Vertebral Column and hip joint :
① Normal lumbar range of motion
Flexion 90°
Extension 30°
Side bend 20°-30°
Twist 30°
② Normal hip joint range of motion
Flexion 145 °
Extension 20-40°
Abduction 30-45 °
Adduction 20-30 °
Lateral rotation 40-50 °
Medial rotation 30-40 °
2) Pressure Points:
•If the lumbar disc is herniated, its
corresponding vertebra has an obvious
tender spot. When that point is pressed
pain occurs along the sciatic nerve
distribution, shooting down along the
lower limb.
• If the piriformis is pressed sciatic pain
occurs.
•If spots along sciatic and that is pressed
the pain occurs.
3) Lasegue’s test: (Supine) If there is pain in the
lumbar area and lateral leg on performing a straight
leg raise up to 70° or dorsiflexing the foot, the test is
positive.
4) Kernig’s test: (Supine) While bending the hip
joint and knee joint to 90° degrees, then extending
the knee, if pain is induced, the test is positive.
5) Abdominal pressure test: In the supine
position, the patient is asked to push the abdomen out
while holding breath in. If pain occurs at the lower
back or leg, the test is positive.
6) Lindner’s test: The patient’s neck is passively
flexed, gradually bringing the chin to the chest. If
pain occurs at the lower back and leg, the test is
positive.
7) Piriformis test: Patient side lie, sick leg up
and bend 90 °, push down lateral knee of sick leg,
if pain occurs at buttock and leg, the test is positive.
Lasegue Test
Kernig Test
Lindner Test
Piriformis Test
Ⅲ List of diseases related to sciatica
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Acute lumbar injury*
Lumbar spinal stenosis ***
Piriformis syndrome ***
Sciatic neuritis ***
Spinal tumors*
Sacroiliac joint injury (SI joint)*
Third lumbar transverse process syndrome**
Pelvic inflammatory disease (PID)*
Entrapment syndrome of superior cluneal nerve**
Entrapment syndrome of lateral femoral cutaneous nerve**
Greater trochanter bursitis**
Entrapment syndrome of common peroneal nerve***
Gluteus medius injury **
Herniated Lumbar Disc ***
Accord with sciatica symptoms *** 80-100%; ** 50-70%; * under 40%
1. Acute Lumbar Injury *
Acute lumbar injury include : lumbar muscle
strains and lumbar sprains.
• A low back muscle strain occurs when the
muscle fibers are abnormally stretched or torn.
• A lumbar sprain occurs when the ligaments, the
tough bands of tissue that hold bones together,
are torn from their attachments.
Diagnosis Points of Acute
Lumbar Injury
1) Indication of injury to the lumbar.
2) The pain is mostly in the lower back.
Sometimes the pain affects the leg, but there is
no shooting pain in sciatic nerve distribution.
3) Pain is aggravated by movement, alleviated by
rest.
4) An obvious tender area is easy to find at low
back.
5) CT or MRI does not show a disc herniation.
2. Lumbar Spinal Stenosis ***
Lumbar spinal stenosis can be caused by:
• Tumors or herniated discs
• Degenerative change (arthritis) made the
spinal canal narrow that occur with aging,
e.g. this is most common reason
Diagnosis points of Lumbar
Spinal Stenosis
1) Lumbar spinal stenosis occurs with aging.
2)
3)
4)
5)
Males are affected slightly more than females.
Lumbar spinal stenosis occurs mainly in the L3
- S1 region.
Lower back pain or leg pain (may have
shooting pain) often occurs when walking or
standing for a periods.
Intermittent claudication.
X-ray, CT or MRI can locate the areas of
narrow of the spinal canal.
Lumbar Spinal Stenosis Figure
3. Piriformis Syndrome***
• The piriformis syndrome is a condition in
which the piriformis muscle presses or
irritates the sciatic nerve, causing pain in
the buttocks and leg, with referred pain
commonly called sciatica.
Diagnosis points of Piriformis
Syndrome
1) History of injury to the buttock.
2) Patients generally complain of pain deep in the
buttock, which is made worse by sitting,
climbing stairs, or performing squats.
3) No low back pain.
4) Piriformis examination will be positive.
5) CT or MRI does not show a herniated disc.
Piriformis Figure
Greater sciatic notch
4. Sciatic Neuritis***
Sciatic pain mainly caused by viral infection,
which damages the sciatic nerve.
This is also called the primary infectious
cause of sciatic pain, and isn’t commonly
seen clinically.
5. Spinal Tumors*
• The cause of pain may be a spinal
tumor — a cancerous or noncancerous
growth that develops within or near the
spinal cord or in the bones of the spine, if
the spinal cord or nerve root is pressed
the low back pain or leg pain occur.
6. Sacroiliac Joint Injury*
• The sacroiliac joint (SI joint) is a firm,
minimally mobile joint that is at the
junction of the spine and the pelvis. The
sacroiliac joint does not move much, but it
is critical to transferring the load of your
upper body to your lower body.
Diagnosis Points of Sacroiliac
Joint Injury
1)
2)
3)
4)
5)
Indication of lumbar injury
Pregnancy or delivery may injure the SI joint
Pain on one side lower back, without leg pain
Faber’s test (“4” character test ) is positive.
Studies X-Rays, MRIs, CAT Scans, Bone Scans
are abnormal.
7. The Third Lumbar Transverse
Process Syndrome**
• The pain spot is at the third lumbar
transverse process, and also affects the
buttocks and lateral thigh. That is caused
by the friction between transverse process
and quadratus lumbolum muscles, which
causes inflammation. The third lumbar
transverse process may be normal in
length, or too long.
Diagnosis points of the third lumbar
transverse process syndrome
1) The pain can be on one or both sides of the third lumbar
region, and may radiate to the posteriolateral part of the
thigh in the severe cases.
2) The patient is unable to sit and stand for long, with pain
aggravated on sitting or standing and alleviated after
rest.
3) Pressure point at L3 transverse process.
4) A longer or normal transverse process of the third
lumbar vertebra is shown in the X-ray or MRI film.
Psoas major
Quadratus
lumbolum
Erector spinae
transverse process
8. Pelvic inflammatory disease*
Pelvic inflammatory disease (PID) is a
general term that refers to infection of the
uterus, fallopian tubes, vagina, bladder etc.
The inflammation can irritate the tissues and
the muscle, causing lower back pain.
Diagnosis points of PID
1)
2)
3)
4)
Lower back, with no history of injury.
Abnormal vaginal discharge.
Antibacterial treatment reduces the pain.
Laboratory examination and ultrasound or CT
exam reveals the problem.
9. Entrapment syndrome of
superior cluneal nerve**
• The medial branch of the superior cluneal
nerve passes over the iliac crest through a
tunnel (Osteofibrous tract ) down to the
buttocks. In that particular area the
superior cluneal nerves are compressed
easily when injured. They innervate the
skin of the upper part of the buttocks and
lateral thigh.
Diagnosis points of entrapment syndrome of
superior cluneal nerve
1) Indication of injury to low back.
2) The pain spot at 1/3 lateral of line, the line
3)
4)
5)
from L4 of spinous process to iliac crest.
It may also occur during pregnancy.
The pain occurs in the buttocks and radiates to
the lateral thigh.
Bending the waist and walking causes pain.
Also, changing posture from sitting to standing
is difficult.
iliac crest
The dorsal cutaneous
rami nerves
Trapezius
Superior cluneal nerve
Latissimus dorsi
Gluteus medius
Gluteus maximus
10. Entrapment syndrome of the
lateral femoral cutaneous nerve**
• It is a syndrome of pain in the lateral and anterolateral
•
•
thigh.
The lateral femoral cutaneous nerve passes through and
underneath the lateral aspect of the inguinal ligament,
and above the sartorius finally travels to innervate the
lateral thigh and the mid thigh.
If the nerve is pressed when injured, it causes burning
pain and numbness of the greater trochanter region and
the mid thigh.
Diagnosis points of Entrapment Syndrome of
the lateral femoral cutaneous nerve
1) Sports injuries such as trauma or muscle tears of the
2)
3)
4)
5)
lower abdominal muscles may also result in irritate to
the nerve.
It may also occur during pregnancy or procedures of
give birth.
It may also be caused by injury from surgical
procedures.
There is pain on deep pressure just below the anterior
superior iliac spine and from hip extension.
The pain is at the lateral thigh or anterolateral thigh
and down to the knee and also sometimes in the
inguinal region.
Sartorius (cut)
Rectus
femoris
Lateral femoral cutaneous N
Femoral N
Lateral femoral
cutaneous N
Femoral N
11. Greater trochanteric bursitis**
• Greater trochanteric bursitis is
characterized by inflammation of the bursa
located just superficial to the greater
trochanter of the femur.
• Patients typically complain of lateral hip
pain, although the hip joint itself is not
involved. Pain may radiate down to the
lateral thigh or lateral knee.
Diagnosis points of greater
trochanter bursitis
1) The typical symptom is pain at the greater
2)
3)
4)
trochanteric region.
Pain may radiate down the lateral aspect of the
thigh to the knee. Pain usually does not radiate
all the way into the foot.
Typically, symptoms worsen when the patient
is lying on side of affected bursa (eg, lying in
the lateral decubitus position).
Pain may awaken the patient at night.
Greater trochanter
12. Entrapment Syndrome of
Common Peroneal Nerve***
• The common peroneal nerve courses around the
fibular neck and passes through the fibro-
•
osseous opening (notch) in the superficial head
of the peroneus longus muscle. This opening
can be quite tough and result in the nerve
passing through it at an acute angle.
The common peroneal nerve gives off 2
branches: the superficial peroneal nerve (the
lateral cutaneous nerve of the calf ) and deep
peroneal nerve (the sural communicating branch
nerve )
Sciatic N
Tibial N
Common
peroneal N
Fibular neck
Superficial
peroneal N
Deep
peroneal N
Diagnosis Points of Entrapment Syndrome of
Common Peroneal Nerve
1) Common peroneal nerve injuries most causes
2)
3)
4)
are the fibular neck injury.
Chronic compression injury is the cause.
The calf or foot has tingling, numbness.
Ankle dorsiflexion weakness is often of most
concern to the patients.
Common
peroneal N
Superficial
peroneal N
Deep
peroneal N
Superficial
peroneal N
area
Common
peroneal N
area
Deep
peroneal N
area
13. The gluteus medius injury**
• Chronic or acute injury.
• Pain is referred from the lower back or tailbone
•
•
•
•
across the buttock to the hip and top of the
thigh, sometime pain is referred to below knee
in the fibular neck area.
Worse from activity or in the morning.
Trigger points.
Right gluteus medius injury occurs more often
than left.
Forward bend occurs pain in the low back,
buttock or thigh.
gluteus medius (cut)
gluteus maximus (cut)
gluteus minimus
piriformis
gluteus medius (cut)
greater trochanter
Iliotibial tract
14 Herniated Lumbar Disc***
Lumbar intervertebral disc injury leads to
• partial damage to or tears of the annulus
fibrosus
• protrusion of the nucleus pulposus
• compression of the spinal nerve roots
• lower back pain, leg pain (including shooting
pain)
• Most commonly seen in individuals aged 25-55
years
• Males are affected slightly more than females
Structure of the Intervertebral Disc
1) Hyaline Cartilage: is the cartilage of the superior and
inferior surfaces of the vertebral body. It also forms the
top and bottom border of nucleus pulpous. It bears the
weight and protects the annulus fibrosus and nucleus
pulpous.
2) Annulus Fibrosus: is a fibrous ring, like a radial tire. It
is elastic, embracing and holding the nucleus pulpous,
not letting it herniate.
3) Nucleus Pulpous: is a kind of gelatinous, flexible,
semifluid material, located in the center of the annulus
fibrosus. Both top and bottom surface are sealed by
hyaline cartilage.
Structure of the Intervertebral Disc
纤维环
髓核
纤维环
椎体
Centrum
透明软骨板
Hyaline Cartilage
纤维环
Annulus Fibrosus
Nucleus pulpous
Three patterns differentiated by the condition
of nucleus pulpous herniation
1)Protrusion or bulging: The annulus fibrosus is not torn
but protruding or bulging, compressing the nerve root.
2)Extrusion: The annulus fibrosus is torn, and the nucleus
pulpous herniated to compress the spinal cord or nerve
roots.
3)Sequestration: The annulus pulpous is ruptured, the
fragment of nucleus pulpous has traveled below the
posterior longitudinal ligament and herniated into the spinal
canal, compressing the spinal cord or nerve root.
椎间盘退化
(Protrusion or bulging) 膨隆型
破裂型
游离型
纤维环
髓核
椎间盘膨隆
正常椎间盘
protrusion or bulging
Normal disc
脊髓
神经根
破裂椎间盘
破裂型
extrusion
游离椎间盘
sequestration
受压的神经根
后纵韧带
前纵韧带
Anterior
Longitudinal
Ligament
Posterior
longitudinal
Ligament
Diagnosis of Herniated Lumbar Disc
• 1)
Low back pain: The pain is mainly located in the
lower back area; The painful area is deep, and it is
usually dull pain or severe (burning), acute pain.
• 2) Shooting pain in the lower limbs:
Lumbar disc herniation often occurs at the L4-5 or L5S1 level, causing lower back and hip pain radiating
down the thigh on the lateral and posterior sides,
down the lateral side of the lower leg, and to the
medial and or lateral side of the foot, and toes.
Coughing or sneezing can aggravate the pain, causing
shooting pain down the lower limbs.
C
4
C4 3
3
5 6
5
7
T1
2
8
3
45
C5
6
7
T1
10
C6
8
C8
11
12
L1
L2
9
C7
S2
S2
C8
C7
54 3
L4
L3
L4
S2
L5
S1
L5
L4
S1
L4
L5
L5
C6
Intervertebral Disc and Spinal Nerve Roots
LV2
LN3
LN4
LV3
LV4
LN5
LV5
SN1
SV1
3) Numbness and tingling:
• Herniation of lumbar discs causes
compression of the spinal nerve roots, and
local inflammation and swelling.
• Resulting nerve compression and lack of blood
circulation causes malnutrition to the nerves.
• The symptoms are tingling, numbness and
muscle atrophy; the worst is foot drop.
4) Abnormal spinal curvature:
After lumbar disc herniation, 64% of patients
have abnormal spinal curvature. The curve of the
vertebral column is the body’s way of protecting
(instinctive protecting) from low back pain and leg
pain. Lateral curvature can relax the nerve root
and relieve pain.
The disc
herniated at
medial side
below nerve
root
The curvature
protrudes to the
healthy side
The disc
herniated at
lateral side above
nerve root
The curvature
protrudes to the
damaged (pain)
side
Distribution of Disc Herniations and Their Frequency
The picture is in the
frontal plane
额状面（切掉椎体）
Side of spinal cord
Disc compression at
lateral side above of
nerve root
Spinal cord compression
Pedicle section
椎弓根截面
Disc compression at
medial side below
nerve root
Ligamentum flavum
Special Examination
•
•
•
•
Lasegue’s test
Kernig’s test
Abdominal pressure test
Lindner’s test
Imaging Examination
1) X-ray:
• The joint space between vertebrae is
uneven.
• The vertebral foramen is narrowed
• There is bone spurring.
• There is the spondylolysis: a defect in
the pars interarticularis of a vertebra.
L4
L5
S1
spondylolysis
2) CT scans and MRI’s provide clear
images to examine bone, water
(fluid), fat, muscle, blood, tendon,
ligament, etc.
MRI have three views: axial plane
(transverse), sagittal plane and frontal
plane (coronal plane).
T1
L4
L5
S1
L2
L3
L4
L5
S1
Ⅳ TCM Treatment for Sciatica
TCM treats sciatica with four methods:
• Acupuncture
• TuiNa
• Herbs
• Traction
Reset joint of the shoulder dislocation
唐代-蔺道人（公元 742-846 A.D）《仙授理伤续断秘方》
Counter traction for treatment of back pain
元代-危亦林（公元1277-1347 A.D）《世医得效方》
Waist belt for back pain
元代-危亦林（公元1277-1347 A.D）《世医得效方》
Effects of Acupuncture and TuiNa
1)
2)
3)
4)
5)
6)
7)
8)
9)
Balance body energy .
Adjustment hormones.
Relieve pressure (decompression).
Reduce pain.
Increase blood circulation in particular areas.
Activate the acupuncture channels (meridians).
Alleviate muscle spasm, relax muscles.
Repair damaged soft tissue.
Adjust joints.
Modern Research of Acupuncture
and TuiNa
1) Increases content of Beta-endorphin (END) and
Catecholamine (CA) in blood to help reduce pain.
2) Decreases content of 5-hydroxytryptamine (5HT) in the blood to reduce pain.
3) Increase blood circulation.
4) Help immunity function.
5) Relieve the pressure of local body
(decompression).
5-hydroxytryptamine (5-HT) is a monoamine
neurotransmitter synthesized in serotonergic neurons
in the central nervous system (CNS) and
enterochromaffin cells in the gastrointestinal tract of
animals including humans.
Beta-endorphin (END) is an endogenous opioid
peptide neurotransmitter found in the neurons of
both the central and peripheral nervous system.
Catecholamines (CA) are chemical compounds
derived from the amino acid tyrosine, Catecholamines
as hormones are released by the adrenal glands in
situations of stress such as psychological stress or
low blood sugar levels.
TuiNa Methods
1. Single manipulation:
1) Tui: pushing. ①Finger pushing. ②Palm pushing. ③
2)
3)
4)
5)
6)
7)
8)
Twin palms pushing.
Na: Grasping. ① Fingers. ② Twin palms.
An: Pressing. ① Finger pressing. ② Palm pressing. ③
Elbow pressing.
Mo: Rubbing.
Rou: Kneading.
Gun: Rolling. ① Side fist. ② Fist.
Dou: Shaking.
Da: Patting and pounding.
2. Combined manipulation:
1)GunRou: Rolling and Kneading.
2)NaRou: Grasping and Kneading.
3)Wave: Grasping, Pushing and Rolling.
4)AnRou: Pressing and Kneading.
3. Manipulation of joints:
1) BaShen: Counter traction. ①Joint
traction. ②Cervical traction. ③ Lumbar
traction.
2) Ban: Adjustment of joints.
3) YaoHuang: Rotating.
TuiNa treatment of Lumbar disc
herniation
1 GunRou for 3-5 minute in the low back area.
2 GunRou and AnRou for 3-5 minute along the
Sciatic nerve courses.
3 Traction and pressing.
4 Ban (Adjustment of joints).
5 Dou (Shaking).
Lumbar traction and pressing
牵引按压法
俯
卧
斜
扳
法
Adjustment of low back
Adjustment of low back
侧卧斜扳法
双人扳法
坐位斜扳法
单人扳法
Differentiation and Treatment of TCM
1. Wind-cold-damp pattern:
– May or may not have history of injury;
– Lumbar area and legs feel cold, painful and
heavy;
– If pain is chronic, symptoms are sometimes
severe, sometimes mild, worsened by cloudy
and rainy weather.
Tongue: white and greasy
Pulse: heavy and slow.
Acupuncture Treatment :
BL23 EX-B7(YaoYan) BL40 GB30 GB31
GB34 BL55 GB39.
Evenly supplement technique, needle
retaining 20 minutes, with moxibustion or
heating lamp.
Herbal Treatment: Du Hu Ji Sheng Tang,
Xiao Huo Luo Tang etc.
2. Qi and Blood Stagnation Pattern:
•
•
History of injury
Lower back pain occurs right
after the injury, worse with
movement, gradually radiating pain
in lower limb
•
Tongue: dark red
•
Pulse:
wiry and rapid.
Acupuncture Treatment:
EX-B7(Yaoyan) BL40 GB30 GB31 GB 32
GB34 BL55 ST36 GB39.
Reducing technique, no needle retaining or
keeping 5 min, with cold compress 10 min
then hot compress for 20 min.
Herbal Treatment: Yuan Hu Zhi Tong Tang,
Shen Tong Zhi Tong Tang and so on.
3. Qi and Blood deficiency Pattern:
• Aging
• Chronic pain on low back or leg
• The pain worsen in morning
• Cold and wind or damp can made pain worsen
• Tongue: white or light red
• Pulse:
weak and deep
Acupuncture Treatment:
BL23 EX-B7(YaoYan) BL40 GB30 GB31 GB34 BL55
GB39.
Evenly supplement technique, needle retaining 20
minutes, with moxibustion or heating lamp.
Herbal Treatment: zhuang gu guan jie wan; liu wei
di huang tang; jin gui shen qi wan
Ⅴ Cautions and Contraindications
• At the acute stage, don’t use heavy manipulation (TuiNa)
and traction, but you can do acupuncture and herbs .
• Surgery for herniated lumbar disc, if one of the following
happens:
①If symptoms are very severe, if symptoms occur
repeatedly for years, or if alternative treatment is not
working.
②If there is central herniation, with compression to cauda
equina nerves that causes sphincter dysfunction.
③If there is Nerve root compression with numbness and
foot drop.
Ⅵ Rehabilitation and Prevention
• During recovery from lumbar disc
herniation, focus on muscle exercise of
abdominal and lower back that can
balance the vertebral column and prevent
herniation.
• Avoid carrying heavy things.
• Periodic treatment (acupuncture or TuiNa
or massage ) for lower back.
• Prevent osteoporosis.
Thank you
Phone：630-916-0781
Web：www.eastwesthealingcenter.net