Transcript Pathology and Treatment of Herniated Lumbar Disc

Pathology and TCM Treatment
of the Herniated Lumbar Disc
East West Healing Center
By Dr. Leon Chen
www.eastwesthealingcenter.net
Definition in Western Medicine
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)
This is called Lumbar Disc Herniation Syndrome.
Definition in Traditional
Chinese Medicine (TCM)
• Lumbar Disc Herniation Syndrome 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.
Ⅰ Local anatomy
The Structure of Vertebral Column
The vertebral column in an adult typically
consists of 33 vertebrae arranged in five
regions: 7 cervical, 12 thoracic, 5 lumbar,
and 5 sacral, and 4 coccygeal. The
vertebral column is considered to have 26
vertebrae, because 5 vertebrae are fused
in adults to form the sacrum and 4
vertebrae are fused to form the coccyx.
Curvatures of the Vertebral Column:
The vertebral column appears straight from the
anterior and posterior position. Laterally, it has
three natural curves to balance the body:
cervical, thoracic, and lumbar curves. A straight
line from head to foot should run through the
crossing point of each curvature.
Physical Purposes of the Curvatures of
the Vertebral Column:
1) To increase the ability of vertebral column to support
weight; and balance the body.
2) To decrease the concussion to protect the head.
3) To strengthen the stability of the standing posture.
4) To spread body weight evenly throughout the
vertebrae and discs.
Measurement of lumbarsacral
angle can be found by drawing a
line along the sacral base (B) and
making a horizontal line (A).
Normal values lie between 26-57°
with a mean of 41°.
lumbarsacral angle
L3
The lumbar gravity line: the C line
from center of L3 body by drawing a
vertical line which pass through the
anterior lip of the sacral base (S1), if
this C line does not surpass 10 mm
that is all normal.
41°
A
B
C
Structure of Lumbar Vertebrae:
1) Lumbar vertebrae have massive and flat
bodies, because this shape helps to support
more body weight.
2) Each vertebrae includes the vertebral body
(centrum), vertebral foramen, pedicle, lamina,
articular facet, articular process, transverse
process and spinous process.
棘突
Spinous process
椎弓板Lamina
上关节突Superior articular
process
横突Transverse process
椎孔
Vertebral foramen
椎弓根Pedicle
椎体Centrum
椎弓根
Pedicle
椎体
Centrum
上关节突Superior
articular process
横突Transverse
process
棘突Spinous process
下关节突 Inferior
articular facet
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 pulposus. It bears the weight and
protects the nucleus pulposus.
2) *Annulus Fibrosus: is a fibrous ring, like a
radial tire. It is elastic, embracing and holding
the nucleus pulposus, not leting it herniate.
3) *Nucleus Pulposus: 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.
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
Thickness of Intervertebral Discs
The Thickness of IV Disc: total: 139mm.
Cervical IV disc, 3.85 mm.
Thoracic IV disc, 4.03 mm.
Lumbar IV disc, 12.7 mm.
Function of Intervertebral Discs ：
The function of lumbar IV discs is very
similar to the intervertebral (IV) discs of
the cervical and thoracic vertebra:
• To bear the weight of the trunk
• To connect to the limbs
• To perform normal physical posture and
movement.
Lumbar IV discs are the most important in
the vertebral column.
Function of Intervertebral Discs (2)
•
•
•
•
Uphold the length of the spinal column
and body height.
Connect with adjacent vertebrae.
Bear the weight evenly throughout the
vertebral bodies.
Act as a cushion or shock-absorber,
protecting the spinal cord and brain. (the
major purpose.
Structure of the Spinal Canal
1) The spinal canal is a passage, formed by
successive openings in the articulated
vertebrae through which the spinal cord
and its membranes (epidural space) pass.
Also called vertebral canal.
2) The spinal canal is made up of the
vertebral foramen, and ligamentum flavum,
and posterior longitudinal ligament.
flava ligament
posterior longitudinal ligament.
Pedicle
Superior articular facet
Ⅱ Biomechanics of the
vertebral column
•
The vertebral column has inner balance and
outer balance which helps the body to move in
a balanced way. Normally, both inner and outer
balance of the vertebral column keeps the
body in perfect balance.
1) Inner balance is formed by discs and facet
joints (zygapophysial joints) of vertebrae.
2) Outer balance is formed by dorsal and ventral
muscles.
Anterior longitudinal
ligament
Posterior longitudinal
ligament
Centrum
Back Muscles
Disc
Interspinales
ligament
Spinal Canal
abdomen
Spinous
process
Sacrum
Abdominal Muscles
Pelvis
身体平衡示意图
Balance of body
上肢Upper limbs
颈部 neck
胸腔thorax
腹腔abdominal cavity
横膈midriff
脊柱Vertebral
骨盆腔pelvis
Upper limb: Balance
Low limb: Support
Vertebral Column: Axis
Pelvis: Pivot
下肢
Low limbs
column
Muscles in the Outer- Balance of
Vertebral Column
1) Dorsal muscles:
• Psoas Major
• Quadratus Lunborum
• Sacrospinalis
• Latissimus Dorsi
• Trapezius
• Rhomboideus
2) Ventral muscles:
• Serratus posterior inferior
• Rectus Abdominis
• Transversus Abdominis
T12
L5
Iliac crest
腰大肌 Psoas Major
腰方肌 Quadratus Lunborum
T6
T12
L5
骶棘肌 Sacrospinalis
Thoracolumbar fascia
斜方肌 Trapezius
背阔肌 Latissimusdorsi
C4
T4
8
T11
12
L2
锯齿肌 Serratus posterior inferior
菱形肌 Rhomboideus
Xiphoid
process
5
7
pubis
腹直肌 Rectus abdominis
腹横肌 Transversus abdominis
Quadratus Lunborum
Latissimus dorsi
Transversus
abdominis
Psoas Major
Rectus abdominis
Ⅲ 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
腹股沟韧带
Inguinal
ligament
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
阴部神经
Pudendal N
Femoral Nerves
• The femoral nerve involves the ventral
rami of the spinal nerves of L2-L4.
• Distribution: Skin of anterior and medial
surfaces of thigh, leg, and foot.
• Supplies: the anterior muscles of the thigh
(Quadriceps femoris, Sartorius).
Femoral nerve
Anterior branches
Intermediate
cutaneous nerve
Medial cutaneous
nerve
Posterior branches
Saphenous nerve
股外皮神经
Lateral femoral
cutaneous N
股神经
Femoral N
Saphenous
nerve
Intermediate cutaneous
nerve
Medial cutaneous nerve
Sensory area of
Lateral femoral
cutaneous N
Sensory area of
Femoral N
Lateral femoral cutaneous nerve
• The lateral femoral cutaneous nerve
arises from the spinal nerves of L2 and L3,
and travels to innervate the lateral thigh.
It supplies the skin on the lateral aspect of
the thigh.
L2
L3
L4
Obturator Nerve
• The obturator nerve arises from L2-L4 –
the ventral rami of the spinal nerves. It
supplies the skin on the medial surface of
the thigh.
闭孔神经
Obturator N
Adductor brevis
Adductor longus
Adductor magnus
Sensory area of
Obturator N
Sciatic Nerve
• The sciatic nerve is a large nerve that runs
down the lower limb. It is the longest single
nerve in the body.
• The sciatic nerve involves L4, L5 and S1-3 –the
spinal nerves of the main sacral plexus.
• 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.
坐骨大孔
Greater sciatic notch
Greater trochanter
坐骨神经
股骨小结节
闭孔神经 闭孔
Obturator N
Obturator foramen
Lesser trochanter
Tuberosity of ischium
坐骨神经
Sciatic N
胫神经
Tibial N
腓总神经
Common
Peroneal N
Sensory area of
Sciatic N
Common Peroneal Nerve
• It has branches called the superficial and
deep peroneal nerves.
• The superficial peroneal supplies the
muscles of the lateral compartment of the
leg.
• The deep peroneal supplies the muscles
of the anterior compartment of the leg.
腓总神经
Common
Peroneal N
腓深神经
Deep nerve
腓浅神经
Superficial
nerve
腓浅N感觉支配区
腓深N感觉支配区
Tibial Nerve
• The tibial nerve supplies the muscles and
skin on the posterior surface of the leg and
the sole of the foot.
• The tibial nerve gives rise to the sural
nerve (which supplies the skin on the back
of the leg) and ends on the sole of the foot
as the medial and lateral plantar nerves.
胫神经
Tibial N
腓总神经
Common Peroneal N
感觉支配区
胫神经
Tibial N
足底外侧神经
Lateral plantar N
足底内侧神经
Medial plantar N
Location of vertebrae in relation to the
conus medullaris
• Cervical:
Cervical vertebrae: the number of the vertebra plus one
corresponds to the number of cervical conus medullaris.
• Thoracic:
Upper thoracic vertebrae: the number plus two corresponds to the
number of the thoracic conus medullaris.
Lower thoracic vertebrae: the number plus three corresponds to the
number of the thoracic conus medullaris.
• Lumbar vertebrae: correspond to the number 1~5 of sacral conus
medullaris.
CV2
C-CM8
T-CM2
T-CM8
TV1
CV7
TV6
L-CM1
L-CM3
TV12
LV1
S-CM1,5
Location of vertebrae in relationship to the conus medullaris
TV11
Intervertebral Disc and 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
C8
11
12
L1
L2
8
9
S2
54 3
S2
C8
C7
C7
L4
L3
L4
S2
L5
S1
L5
L4
S1
L4 L5
L5
C6
Ⅳ Patterns of Disc Herniation
• Three patterns differentiated by the
condition of nucleus pulposus herniation
• Five patterns differentiated by the location
and direction of nucleus pulposus
herniation
• Two patterns differentiated by ligament
damage
• Three patterns differentiated by
pathological stages of nucleus pulposus
Three patterns differentiated by the condition
of nucleus pulposus 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
pulposus herniated to compress the spinal cord or nerve
roots.
3)Sequestration: The annulus pulposus is ruptured, the
fragment of nucleus pulposus 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
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
Five patterns differentiated by the location
and direction of nucleus pulposus herniation
• Herniation of the nucleus pulposus can happen
in the anterior, posterior, or lateral direction
or in all four directons. Also there is a form of
herniation called herniation inside of the
vertebral body.
• Posterior herniation is divided into two patterns:
posteriolateral herniation and posteriocentral
herniation.
Posterior herniation
Posterolateral Herniation
Posterocentral Herniation
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
Disc herniation inside vertebral body
Schmorl’s
Node
Nucleus of disc
The nucleus of disc
drills through the
hyaline cartilage into
vertebral body
Two patterns differentiated by damage to the
posterior longitudinal ligament
• Subligamentous extrusion: the posterior
longitudinal ligament has not been torn,
but there is disc protrusion.
• Transligamentous extrusion: the disc has
torn through the posterior longitudinal
ligament pressing on the nerve root or
spinal cord, and there is disc extrusion.
The posterior longitudinal ligament is intact
nucleus
pulposus
Nerve root
Posterior longitudinal
ligament
Spinal cord
The posterior longitudinal ligament is torn
The posterior longitudinal ligament is torn
and the nucleus pulposus is fragmented
受压的神经根
后纵韧带
前纵韧带
Anterior
Longitudinal
Ligament
Posterior
longitudinal
Ligament
Three characteristic pathological
evolutionary stages of the nucleus
pulposus
1) Pre-herniation.
2) Herniation.
3) Post-herniation.
IV Etiology
1) Age and sex: Mostly it affects people in
middle age(30-50),males more than
females.
2) Location: Mainly occurs at L4-5 and at
L5-S1, and secondarily at L3-L4 or L2-L3.
3) Causes:
1)Degeneration of the disc.
2)Injury
Disc
Ⅴ Diagnosis
Symptoms:
1) Low back pain: The pain is mainly
located in the lower back area; the back
pain results from pressure on the
posterior longitudinal ligaments and
periphery of the annulus fibrosus. The
painful area is deep, and it is usually dull
pain or severe, acute pain.
2) Shooting pain in the legs:
Lumbar disc herniation often occurs at the L4-5
or L5-S1 level, causing lower back and 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
C8
11
12
L1
L2
8
9
S2
54 3
S2
C8
C7
C7
L4
L3
L4
S2
L5
S1
L5
L4
S1
L4 L5
L5
C6
3) Numbness and tingling:
Protrusion 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.
Clinical symptoms are tingling, numbness and
muscle atrophy.
4) Abnormal spinal curvature:
• After the lumbar disc herniation, 64% patients
have abnormal spinal curvature. The curve of the
vertebral column is the body’s way of protecting
against low back pain and leg pain. Lateral
curvature can relax the nerve root and relieve
pain.
• Clinically, disc protrusion is generally at the
lateral side above the nerve root (45%) A few
disc protrusions are at the medial side below the
nerve root (7%)
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
The disc presses at
lateral side above
nerve root
Spinal cord compression
Pedicle section
椎弓根截面
Disc compression of
medial side below
the nerve root
Ligamentum flavum
The protrusion
is at medial side
below nerve
root
The protrusion is
at lateral side
above nerve root
The curvature
protrudes to the
healthy side
The curvature
protrudes to the
damaged side
How to measure the curve
of the vertebral column
• To measure the curvature of the spinal
column, first find the centers of the two
areas of greatest curvature. Draw a
straight line throught these centers; from
these lines, create a perpendicular (90°)
line; cross both perpendicular lines and
you will get the measure of the curve.
Measure of curvature
of vertebral column
30
Ⅵ Special Examination
1) Mobility of Lumbar Vertebral Column:
Normal range of motion
Flexion 90°
Extension 30°
Side bend 20°-30°
Twist 30°
2) Points painful to pressure
If the lumbar disc is herniated, its corresponding
vertebra has an obvious tender area. When
that area is pressed, pain occurs along the
sciatic nerve distribution, shooting down along
the lower limb.
3) Abnormal tendon reflexes
• If the lumbar disk is herniated, the knee tendon reflex
or Achilles tendon reflex can be weak, absent, or
excessive.
• If the herniation is at L3-L4, the knee tendon reflex
can be weak or absent, and foot extension is weak;
• If herniation is at L4-L5, the knee tendon reflex and
Achilles tendon reflex is normal but toe extension is
weak;
• If herniation is at L5-S1, the Achilles tendon reflex
becomes weak or absent, and foot flexion becomes
weak.
4) Lasegue’s test: (Supine) If there is pain in the
lumbar area and lateral leg on performing a straight
leg raise up to 70° and dorsiflexing the foot, the test is
positive.
5) 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.
6) Wasserman’s test: (Prone) The hip joint is overextended. If pain presents at the anterior border of the
thigh, the test is positive.
7) 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 and leg, the test is positive.
8) 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, because of meningeal irritation.
Lasegue Test
Kernig Test
Lindner Test
Ⅶ Imaging Examination
1) X-ray:
•
•
•
•
The joint space between vertebrae is
uneven.
The vertebral foramen is narrowed
There is bone spurring.
There is spondylolysis--a defect in the
pars interarticularis of a vertebra.
L3
L4
S1
2) CT Scans and MRI’s provide
clear images to examine bone,
water, fat, muscle, blood, tendon,
ligament, etc.
CT and MRI have three views: axial
(transverse), sagittal and frontal planes.
L2
L3
L4
L5
S1
Ⅷ Differential Diagnosis
1 Acute lumbar injury
2 Lumbar spinal stenosis
3 Piriformis syndrome
4 Sciatic neuritis
5 Spinal tumors
6 Sacroiliac joint injury
7 Third lumbar transverse process syndrome
8 Pelvic inflammatory disease
9 Entrapment syndrome of superior cluneal nerve
10 Entrapment syndrome of lateral femoral cutaneous
nerve
11 Greater trochanter bursitis
12 Entrapment syndrome of common peroneal nerve
1. Acute Lumbar Injury
Acute lumbar injury is caused when:
• The waist is flexed
• The waist is rotated
• Lifting too much weight unbalances the
lumbar muscles and creates subluxation of
the lumbar facet joints, or lumbar muscle
sprain.
Diagnosis Points of Acute
Lumbar Injury
Indications of lumbar injury
1) The pain is mostly in the lower back. Sometimes
the pain affects the leg, but there is no shooting
pain in sciatic nerve distribution.
2) Pain is aggravated by movement, alleviated by
rest.
3) An obvious tender area is easy to find.
4) CT or MRI does not show a disc herniation.
2. Lumbar Spinal Stenosis
Lumbar spinal stenosis can be caused by:
• Tumors and herniated discs
• Degenerative changes (most common
cause) that occur with aging, e.g. arthritis
• Degenerative effects-- Narrowing of spinal
canal causes pressure on the spinal cord
or spinal nerve roots. This pressure can
lead to many problems that often occur
with long periods of walking or standing.
• Diagnosis points of Lumbar
Spinal Stenosis
1) Lumbar spinal stenosis occurs with aging.
Males are affected slightly more than females.
2) Lumbar spinal stenosis occurs mainly in the
L3 - S1 region.
3) Lower back pain or leg pain often occurs when
walking or standing for long periods.
4) Intermittent claudication.
5) X-ray, CT or MRI can locate the areas of
compression of the spinal canal.
Lumbar Spinal Stenosis Figure
3. Piriformis Syndrome
• The piriformis syndrome is a condition in
which the piriformis muscle irritates the
sciatic nerve, causing pain in the buttocks
and leg, with referred pain, commonly
called sciatica, along the course of the
sciatic nerve.
Diagnosis points of Piriformis
Syndrome
1) History of injury to the buttocks.
2) Patients generally complain of pain deep in the
buttocks, which is made worse by sitting,
climbing stairs, or performing squats.
3) No low back pain or spinal column curvature.
4) Special examination will be positive.
5) CT or MRI does not show a herniated disc.
Piriformis Figure
4. Sciatic Neuritis
Sciatic pain mainly is caused by viral
infection, which damages the sciatic
nerve. This is also called sciatic neuritis,
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.
• In most areas of the body, noncancerous
tumors aren't particularly worrisome. But
in the vertebrae both kinds of tumors are
of concern.
6. Sacroiliac Joint Injury
• The sacroiliac joint (SI joint) is a firm, small
joint that lies at the junction of the spine
and the pelvis. Most often when we think
of joints, we think of knees, hips, and
shoulders--joints that are made to undergo
motion. 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) Indication of lumbar injury
2) Pregnancy or delivery may injure the SI
joint
3) Pain on one side lower back, without leg
pain.
4) Faber’s test (“4” character test ) is
positive.
5) Studies (X-Rays, MRIs, CAT Scans,
Bone Scans) are often normal
7. The Third Lumbar Transverse
Process Syndrome
• The pain spot is at the third lumbar
transverse process area, and also affects
the buttocks and lateral thigh. That is
caused by the friction between transverse
process and 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
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) A longer or normal transverse process of
the third lumbar vertebra is shown in the
X-ray or MRI film.
8. Pelvic inflammatory disease
Pelvic inflammatory disease (PID) is a
general term that refers to infection of the
uterus, fallopian tubes and bladder.
The inflammation can irritate tissues and
muscle, causing lower back pain.
Diagnosis points of PID
1) Lower back or pelvic pain, with no history of
injury.
2) Abnormal vaginal discharge.
3) Antibacterial treatment reduces the pain.
4) Laboratory examination and ultrasoud 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 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 lumbosacral area.
2) The pain occurs in the specific area of the nerve
and radiates to the lateral thigh.
3) Bending the waist and walking causes pain.
Also, changing posture from sitting to standing is
difficult.
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 finally travels to innervate
the lateral thigh. It divides into anterior and
posterior branches and supplies skin from the
greater trochanter to the mid thigh.
• If the nerve is pressed when injured, it causes
burning pain and numbness of the greater
trochanter and the mid thigh.
Diagnosis points of entrapment syndrome of
the lateral femoral cutaneous nerve
1)
2)
3)
4)
5)
6)
This syndrome is most commonly seen in individuals
aged 20-60 years, but it can occur in people of all ages.
Sports injuries such as trauma or muscle tears of the
lower abdominal muscles may also result in injury to
the nerve.
It may also occur during pregnancy due to the rapidly
expanding abdomen in the third trimester.
It may also be caused by injury from surgical
procedures.
There is pain on deep palpation 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.
Lateral femoral cutaneous N
Femoral N
Lateral femoral
cutaneous N
Femoral N
11. Greater trochanteric bursitis
• Greater trochanteric bursitis is
characterized by painful 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 the
lateral aspect of the thigh.
Diagnosis points of greater
trochanter bursitis
1)
2)
3)
4)
5)
6)
With acute trauma, patients may recall specific details
of the impact.
The classic symptom is pain at the greater trochanteric
region at the lateral hip.
Pain may radiate down the lateral aspect of the
ipsilateral thigh. Pain usually does not radiate all the
way into the foot.
Typically, symptoms worsen when the patient is lying
on the affected bursa (eg, lying in the lateral decubitus
position).
Pain may awaken the patient at night.
Palpation also may reproduce pain that radiates down
the lateral thigh, but it does not go below the knee.
Greater trochanter
12. Entrapment Syndrome of
Common Peroneal Nerve
• The common peroneal nerve courses around
the fibular neck and passes through the fibroosseous opening 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 )
• Diagnosis Points of Entrapment Syndrome
of Common Peroneal Nerve
1) Peroneal nerve injuries are most common
peripheral nerve injuries in the lower limb after
multiple traumatic injuries.
2) Chronic compression injury is the cause.
3) The loss of sensation in the cutaneous
distribution of the superficial and deep
peroneal nerves may be noted, but 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
Ⅸ TCM Treatment of Disc
Herniation
TCM treats the herniated lumbar disc with
three methods:
• TuiNa
• Acupuncture
• Herbs.
According to Chinese medical research,
70% of herniated lumbar discs shows
good results with TCM treatments
TuiNa Actions
1) Reduce the pain.
2) Increase blood circulation in specific
areas.
3) Relax the muscles, activate the channels.
4) Reduce muscle spasm.
5) Repair damaged soft tissue.
6) Adjust joints.
Modern Research of TuiNa
1) Increases content of Beta-endorphin
(END) and Catecholamine (CA) in blood to
help reduce pain.
2) Decreases content of 5hydroxytryptamine (5-HT) in the blood, to
reduce pain.
TuiNa Methods
1. Single manipulation:
1)
2)
3)
4)
5)
6)
7)
8)
Tui: pushing. ①Finger pushing. ②Palm pushing. ③
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) BanFa: Adjustment of joints.
3) YaoHuang: Rotating.
牵引按压法
俯
卧
斜
扳
法
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: BL23 YaoYan BL40 GB30
GB31 GB34 BL55 GB39; evenly
supplement and reducing, needle retaining
20 minutes, with moxibustion or TDP.
• 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:
hesitant or wiry and rapid.
• Acupuncture Treatment: Yaoyan BL40
GB30 GB31 GB 32 GB34 BL55 ST36
GB39; reducing technique; no needle
retaining; with cold compress.
• Herbal Treatment: Yuan Hu Zhi Tong Tang,
Shen Tong Zhi Tong Tang and so on.
Ⅹ Cautions and Contraindications
• At the acute stage, don’t use heavy manipulation,
better to use rest, traction, acupuncture and
herbs .
• Surgery if one of the following happens:
①If the symptoms are very severe, occur
repeatedly in one year, alternative treatment is
not working.
②Central herniation, with compression to cauda
equina nerves that cause sphincter dysfunction.
③Nerve root compression with the numbness and
foot drop.
Ⅺ Rehabilitation and Prevention
• During recovery from lumbar disc herniation,
focusing on muscle exercise of lower limbs and
lower back can balance the vertebral column
and prevent herniation.
• Avoid carrying weight that could strain lower
back for a long period of time.
• Use periodic relaxation treatment (acupuncture
or TuiNa ) on lower back.
• Prevent osteoporosis
Thank you
Phone：630-916-0781
E-mail: [email protected]
Web：www.eastwesthealingcenter.net