Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6011_Библиотеки_им_академика_М_И_Перельмана.pdf
The Role of Spinal Injections
in Treating the Aging Spine
Jason Marchetti
19
k e y p o i n t s
Understand the indications, contraindications, and current evidence support
for commonly performed spinal procedures.
Understand the utility and limitations of spinal procedures in the overall
management of patients with degenerative conditions.
Improve patient selection for spinal procedures in the management of
degenerative conditions of the spine.
The use of invasive procedures for spinal conditions has proliferated over
the years, particularly with the advent of fluoroscopic guidance. The most
common spinal targets for injection are the epidural space, nerve root sheath,
facet joints, and the sacroiliac joints. There is much controversy regarding
the utility of these injections, however, both as diagnostic and as therapeutic
tools. For the surgeon, diagnostic considerations are important for determining a true “pain generator” before offering specific surgical recommendations.
This is vitally important because history, physical exam, and imaging studies
are often limited in specificity for individual pain conditions.
peutic value of interventions is important as an adjunct to other nonsurgical
treatments, particularly to help patients avoid surgery or to alleviate pain in
patients who are otherwise poor surgical candidates.
Modern guidelines and recommendations from various societies suggest that the use of fluoroscopic (or CT) guidance is mandatory (when not
contraindicated) to improve the accuracy and safety of these procedures.
Although ultrasound guidance has been explored, this modality is limited in
its ability to detect intravascular uptake.
described for all types of injections, the only ones that may be done without
image guidance with any acceptable chance of safe, proper needle placement
include lumbar interlaminar and caudal epidural steroid injections (ESIs).
Contraindications to steroid injections (and other invasive spinal procedures) include bleeding diathesis, anticoagulation, local or systemic
infection, uncontrolled diabetes or glaucoma, hypovolemia, and medical
instability; and high doses of local anesthetics should be avoided in patients
with multiple sclerosis.
avoided. Contraindications to fluoroscopy include pregnancy.
The purpose of this chapter is to review the current pertinent literature
regarding these interventions, particularly as they relate to degenerative spinal conditions.
1
Acute fracture and malignancy should also be
3
Despite “blind” techniques being
1,2
The thera-
1,2
EPIDURAL STEROID INJECTIONS
Epidural steroid injections are one of the most commonly performed interventions for the management of painful spinal conditions. Approaches to the
epidural space include interlaminar, transforaminal (or selective nerve root),
catheter directed, and the caudal approach for the lower lumbar segments.
A recent systematic review of relevant ESI literature by Salahadin et al.
highlights the variability in quality and relevance of studies looking at ESI
efficacy. A common pitfall when studying invasive procedures is considering the efficacy of the comparator procedure. For instance, many studies
evaluating ESI compare the procedure to epidural saline,
thetic without steroid,
medications (e.g., hyaluronic acid and Sarapin) or a combination of these
strategies.
therapeutic efficacy and are therefore not truly placebo. Matthews et al.
compared caudal ESIs to local anesthesia over the sacral hiatus (some were
at “tender spots,” however). This may be most consistent with a true placebo
comparator.
(reducing inflammatory chemicals at the site of injury/pathology and possibly contributing to neuronal stability), the expectation that any type of steroid injection, done one time, will result in more than 6 months of relief or
benefit is unrealistic.
other variables that must be considered when assessing the long-term efficacy of injections.
sidered: improvement in both reported pain and functional ability should
be considered when judging the efficacy of any procedure, including ESI.
6 weeks as “short term” and any time beyond 6 weeks as “long term.” Their
analysis, using commonly accepted “evidence-based medicine” definitions for
literature review, yielded ratings for each approach as outlined in Table 19-1.
Interlaminar and transforaminal ESIs in the low back and neck had “indeterminate” evidence for use in axial spine pain, postlaminectomy syndrome,
lumbar disc extrusions, and lumbar stenosis. Interestingly, caudal ESIs have
“moderate” evidence for short- and long-term improvement for chronic, axial
low back pain, and their “strong” and “moderate” short- and long-term ratings
for radicular pain also include patients with postlaminectomy syndrome.
outcome consideration. In this regard, at least transforaminal injections
(lumbar and cervical) have shown efficacy.
spine, has also been shown to be more effective for radicular pain than interlaminar ESIs.
injections. Current guideline recommendations (including Official Disability
Guidelines and International Spine Intervention Society[ISIS]) suggest that
repeated injections should be considered as symptoms recur, and the repeated
injections should not be considered in patients who do not demonstrate significant (usually defined as >50% short-term relief) transient improvement
following an initial injection. Similarly, the maximum number of injections that
an individual may undergo during a specific amount of time (such as during 1
year) has not been adequately studied, but consensuses from various guidelines
and societies suggest that no more than four injections should be considered
over the course of a year and that repeated injections should be separated by at
least one to two weeks. Riew et al.
nal ESIs were required to optimize therapeutic benefit (in this case, avoidance
4
of surgery) beyond 15 months, and the interval between injections ranged from
6 days to 10.5 months. This is also the only lumbar injection study
8,9
Many of these comparator procedures have demonstrated
Considering the proposed mechanism of action of steroid injections
In their review, Salahadin and colleagues
From the surgeon’s standpoint, avoidance of surgery is an important
There is no significant evidence to suggest a specific, fixed timing regimen of
6
injections into nearby tissues,7 alternative injected
1
Therefore the number and frequency of injections are
1,10
Consistency of outcome measures must also be con-
4
considered anything less than
11
This approach, in the lumbar
6
found that up to four lumbar transforami-
5
epidural anes-
12
to require
4
105
7
106
P A R T I I I Conservative Treatment Modalities
TA BL E 19 –1 Summ ary of Li teratu re Supp ort f or Vario us
ESI Appro aches for the Trea tmen t of Lumb ar and C ervi cal
“R adicu lar Pa in” as Outlined by S alahadi n et al.
Short-term Benefit Long-term Benefit
Lumbar interlaminar ESI Strong Indeterminate
Lumbar
transforaminal/SNRB
Caudal ESI Strong Moderate
Cervical interlaminar ESI Moderate Moderate
Cervical transforaminal/
SNRB
Strong Moderate
Moderate Moderate
4
a failure of 6 weeks of other nonoperative interventions including physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), bracing, or
a combination of the three. The integration of these other treatments with
injection therapies is therefore also poorly understood.
Complications of epidural injections include generic considerations for
any invasive procedure (local tissue trauma, bruising, pain, infection) as well
as those specific for trauma to the local spinal tissues, medication or steroid
related side effects, and those associated with x-ray exposure during fluoroscopy. Minor complications including dural puncture with subsequent “spinal headache,” increased pain, elevated blood sugar level or blood pressure,
sympathetic mediated symptoms such as flushing or vasovagal response and
acute insomnia have been described and occur infrequently. Botwin et al
reported an overall complication rate during fluoroscopically guided ESIs
as occurring in less than 10% for lumbar injections
for cervical ESIs.
15
15.6%,
lar needle placement has been noted in about 10% to 20% of lumbar injec-
17
tions.
Subarachnoid needle placement is also a concern, because it may
cause spinal anesthesia or arachnoiditis.
14
Caudal injections had a rate of minor complications of
and for the thoracic spine, a 20.5% rate was reported.16 Intravascu-
1
13
and approaching 17%
Major or severe complications are fortunately very rare when injections
are performed with fluoroscopy and by experienced interventionalists.
Potentially catastrophic injury can occur, however, including infarction of
central nervous system tissues (causing paraplegia, tetraplegia, or stroke syndromes), compression of neural elements or spinal cord by hematoma, CNS
infections, pneumocephalus, and chemical meningitis, to list a few. Transforaminal approaches, particularly in the cervical spine, likely carry the greatest
risk of these rare yet serious complications.
4
Predictors for negative outcome following ESI include poor education,
unemployed status, smoking, chronic or constant pain, high medication
usage, high number of previously attempted treatments, pain that is not
increased with activity or coughing, psychological disturbances, and nonradicular diagnoses.
18
FACET JOINT PROCEDURES
Approximately 20% of low back pain complaints can be attributed to the
zygapophyseal joints in the lumbar spine
higher rates of pain in the cervical and thoracic spines.
facet or z-joints, these joints become arthritic and potentially painful as with
any joint in the body, and consequently, older individuals may be expected
to be more likely to respond to facet blocks than younger patients.
fact, in a study of older Australians with non–injury-related chronic low
back pain, 30% of individuals reported at least 90% relief following placebocontrolled facet blocks.
21
Over the past 40 years, our understanding of the innervation of facet
joints and their potential as pain generators has greatly expanded.
know that even referred leg pain and hamstring tightness can be associated with facet joint pain and thus mimic features of sciatica. Cervical facet
joints may refer pain to the head, neck, and shoulder areas and have welldescribed referral pattern “maps,” whereas thoracic facet joints may produce
mid back pain with accompanying neuropathic symptoms as well.
1,19-22
and likely account for even
19,20,22
Also known as
20,21,23
2
We now
22
Along
In
with the evolution of this knowledge, so too have interventional approaches
in dealing with facet-mediated pain.
The specific diagnosis of facet-mediated pain is difficult and controversial,
however, because there are no reliable factors of patients’ history, physical exam,
or imaging studies to otherwise effectively determine pain of facet origin. Several studies have evaluated the use of single photon emission CT (SPECT) to
determine if abnormalities can predict facet joint disease and therefore predict
favorable response to joint injections. One study example by Pneumaticos et
24
al
determined that patients who had “hot” facet joints treated with steroid
injection responded more favorably than patients who also had non–hot joints
injected (joints were selected clinically by the attending physician as is done in
typical practice). Despite this and other positive results, SPECT is not routinely used, perhaps because of limited availability and expense.
For diagnostic injections, there is a high false-positive rate for single sets
of lumbar injections.
19
Therefore two positive diagnostic injections are felt
to be required before considering pain to be truly of facet origin, at least for
the purposes of clinical research. These injections should be low volume and
demonstrate a specific response based upon the expected duration of the
anesthetic used.
23,25
In clinical practice, this “double block” approach may
not required, or practical, given the relatively similar morbidity of rhizotomy
(the procedure that should be considered if diagnostic blocks are positive)
compared to injections. Others also argue that the improved specificity
of double blocks reduces the sensitivity and therefore denies a potentially
therapeutic procedure (rhizotomy) to some patients who would otherwise
benefit. Again, this approach assumes that the risks and comorbidity of performing rhizotomy in patients with false-positive results is not significantly
greater than performing the second diagnostic block.
Potential complications of facet joint procedures include those
described in the section on ESI that may be related to needle placement;
side effects of sedation, injected medication, or both; and radiation associated with image guidance.
22
Septic joints have been reported after intraarticular injections,26 whereas radiofrequency (RF) neurotomy procedures
have been associated with painful dysesthesia, anesthesia dolorosa, hyperesthesia, and nerve root injury
complications is very low.
Over the years, conflicting results have emerged regarding efficacy of facet
joint procedures.
2
et al
1
only considered prospective, double blind, randomized, placebo-
controlled trials in their evaluation, and determined that controlled, diagnostic
22
One of the most recent systematic reviews by Bogduk
22
; however, the overall rate of even minor
27
medial branch blocks are the only validated method of diagnosing facet mediated pain and that properly performed neurotomy is the only validated treatment for facet joint pain. A more encompassing review was done by Boswell
22
et al.,
and their results are included in Table 19–2. Their process was simi-
lar to the Salahadin et al. review discussed in the section on ESI,
term and long-term relief were defined as 6 weeks or less versus longer than 6
weeks duration for injections, respectively, and less than or more than 3 months
duration, respectively, for neurotomy procedures. Of note, achievement of
long-term relief with injection therapy often requires multiple injections. For
instance, in their study of cervical facet pain, Manchikanti et al.28 noted an average of 3.5 injections over the course of a year with an average duration of effect
of approximately 3.5 months per injection. Interestingly, this benefit of medial
branch blocks was noted with or without steroid. Findings, including number
of injections and duration of effect, were similar in their studies of lumbar and
thoracic medial branch blocks as well.
Medial branch blocks (MBB) in the lumbar spine have been repeat-
edly validated for diagnostic utility.
29
2
ISIS guidelines23 suggest that patients
should be evaluated for at least 2 hours postinjection, or until relief ceases
(whichever occurs first). To be truly diagnostic, relief should also be noted
while the patient is attempting activities that are typically aggravating. There
is debate regarding the amount of relief required to consider blocks success-
2,20
ful,
but 80% pain relief has typically been accepted as the standard for a
“positive” response. A recent retrospective study by Cohen et al.
indicates that the patients who reported 50% to 79% improvement following a single diagnostic block did as well with subsequent rhizotomy as
those who reported 80% or more relief following diagnostic block. It is also
unclear how much secondary factors, including the use of sedation, anesthesia, or both, during diagnostic blocks, affect the results.
20
The use of steroids and Sarapin have also been studied for medial
branch blockade both in the neck and low back. These substances have not
4
and short-
20
however,
C H A P T E R 1 9 e Role of Spinal Injections in Treating the Aging Spine
107
TA BL E 19 -2 Summ ary of Li teratu re Supp ort
for Variou s Fa cet Joint Pro cedures for the Treatmen t of
Chroni c Face togenic Pain as Outli ned by Boswel l et al
Procedure Short-term Relief Long-term Relief
Cervical intra-articular Limited Limited
oracic intra-articular Indeterminate Indeterminate
Lumbar intra-articular Moderate Moderate
Cervical MBB Moderate Moderate
oracic MBB Moderate Moderate
Lumbar MBB Moderate Moderate
Cervical MBN Strong Moderate (Strong
oracic MBN Indeterminate Indeterminate
Lumbar MBN Strong Moderate
*Long-term relief for cervical facet pain has strong evidence when a multiple lesion per level
strategy is used, as reported by Lord et al and advocated by others.
not commonly done in the United States and significantly increases operative time.
22
23,35
is procedure is
*
)
demonstrated improved or longer lasting efficacy as compared to bupivacaine alone in subjects identified as having facet-mediated pain with double
28,29
blocks.
Intraarticular steroid injections have been shown to be no more effec-
tive than saline injections into the facet joints.
26,30
Unfortunately the only
prospective, double-blind, randomized, placebo-controlled trial for intraarticular cervical facet injections was limited to MVC-related whiplash suf-
30
ferers.
The authors screened patients for facet-mediated pain with double
blocks and found no benefit from intraarticular steroid versus anesthetic.
Results of this study, however, should not be applied to degenerative cervical
facetogenic pain, which should be studied separately. A study by Kim et al.
evaluated intraarticular cervical facet injections in a variety of diagnoses and
found that those with “disc herniation” responded better than those with
myofascial or whiplash pain syndromes. Intraarticular hyaluronic acid injections were compared to lumbar facet joint steroid injections by Fuchs et al,
and no difference in efficacy was noted.
Radiofrequency neurotomy of the medial branch nerves (MBN) (and
dorsal ramus of L5) has been used extensively to denervate suspected painful
facet joints and remains the only available intervention that has demonstrated
substantial, long-term relief.
perpendicular to the path of the target nerve, have been criticized and often
demonstrate limited efficacy.
probe along the length of the suspected nerve path is recommended by the
International Spine Intervention Society
2
Early techniques, where an RF probe is placed
2
The more modern approach of placing the
23
and has been shown to coagulate
a greater length of the target nerves. Because repairing a greater length of
nerve will take longer than a shorter lesion, it can be expected that the “parallel
probe” technique can result in long-lasting improvement, as has been suggested in reviews of these techniques and studies.
ment, significant benefit (60%-80% improvement) may last 6 to 12 months or
even longer.
treatments, and no limit has yet been established as to how many treatments
may result in diminished returns.
33
Benefit has also been demonstrated with up to three repeated
33
Usual RF ablation involves lesioning at
80° C for 90 seconds at each site, but benefit has also been demonstrated with
“pulsed” RF current at 2 Hz for 4 minutes at 42° C.
2
With parallel probe place-
34
In the cervical spine, one prospective, double-blind, randomized, pla-
cebo-controlled trial has been conducted for assessing medial branch neu-
35
rotomy.
The authors determined that this treatment is effective in patients
who have MVC-related whiplash with demonstrated facet pain (at C3-C4
and C6-C7) using a triple block technique. This technique is similar to the
aforementioned double block, with the addition of a single placebo block
as well.
When done according to recommended ISIS guidelines,
23
no significant
complications of lumbar medial branch neurotomy have been described.
Debate exists as to whether it is acceptable to perform the procedure under
general anesthesia. This may increase the risk of nerve root injury with
improper probe placement, because the patient cannot sense and thus warn
of impending injury.
2
Testing the probe with varied frequency stimulation is
important to perform regardless of use of general anesthesia. This allows the
interventionalist to assess for motor activation of the nerve root, an important warning sign of probe misplacement.
Other studies have evaluated alternative means for neurotomy, includ-
ing cryoneurolysis
36
and percutaneous laser denervation.37 All three studies
have shown promising initial results for short- and long-term relief when
performed in the lumbar spine and may become more widespread options
in the future.
SACROILIAC JOINT PROCEDURES
Similar to facet joints, up to 20% of low back pain complaints can be attributed to the sacroiliac (SI) joint.
tic blocks, however, remain controversial because of insufficient study and
high false positive rates.
domized, placebo-controlled trial involving SI joint injections involved 10
patients with low back pain and spondylarthropathy, and they did not use
diagnostic blocks to screen patients. This study
injections of steroid versus saline and revealed statistically significant benefit
of steroid at 1 month.
Various radiofrequency denervation techniques have been described
for the SI joint, but little high-quality evidence exists to support their
use. A recent study by Cohen et al.
RF denervation technique of the lateral branches as they exit the upper
sacral foramen (instead of along the SI joint line, as is done in traditional
techniques). The benefit of the cooled RF lesion is that a larger “sphere”
of tissue may be lesioned, theoretically improving the chances that the
desired nerve branch may be included in the lesioned area. The results
of the study demonstrate greater than 50% pain relief, and significant
functional improvement, in the majority of patients at 6 months compared to only 14% of patients receiving a sham treatment. Results were
similar, however, at 1 month between the two groups. Further study is
31
obviously needed before more widespread acceptance (and coverage) of
this technology is seen.
SPECIFIC DEGENERATIVE CONDITIONS
32
1,38
The sensitivity and specificity of diagnos-
38
Similarly, the only prospective, double-blind, ran-
39
compared intraarticular
40
describes a novel “cooled-probe”
Degenerative Disc Disease
Approximately 40% of low back pain can be attributed to internal disc dis-
1
ruption
; however, there is controversy in this diagnosis because there is
no universally accepted gold standard diagnostic test for discogenic pain.
When strict interpretive criteria
cography has proven itself useful in identifying patients who benefit from
treatment.
42
Not all degenerative discs are painful, however, and it is typical
for sufferers of degenerative discogenic pain to have worse complaints during the early or middle stages of degeneration (typically 4th-6th decades)
followed by relative pain relief in later years when degenerative pathology
is most severe. Painful degenerative lumbar discs are noted to have higher
concentrations (relative to nonpainful discs) of sensory fibers at the endplates and nucleus and have higher concentrations of proinflammatory
chemicals.
1
For this reason, it makes sense to consider local injection of
steroid for therapeutic effect, either within or just posterior to the annulus.
Transforaminal lumbar ESIs have demonstrated excellent delivery to the
anterior epidural space, whereas lumbar interlaminar ESIs achieve ventral
flow in just over one third of attempts, and caudal ESIs have significantly
variable delivery locations.
Intradiscal procedures such as intradiscal electrothermal therapy
(IDET) and percutaneous radiofrequency neurotomy of the ramus communicans have shown modest benefit at 6 and 4 months (respectively) in
carefully selected patients. Intradiscal steroid injections have very limited
data and have not been shown to be more effective than intradiscal saline or
bupivacaine injections.
2
As discussed in the ESI section, only caudal ESIs have been studied sufficiently and demonstrated some benefit for axial LBP; however, a study by
44
41
are used (Table 19–3), however, dis-
43
108
P A R T I I I Conservative Treatment Modalities
TA BL E 19 -3 Intern atio nal S pine Interventi on Socie ty
Guidelin es for Disco graphy Int erpretati on, 2004
Discogenic
Pain
Unequivocal ≥7/10 <15 above opening
Definite ≥7/10 <15 above opening
Definite ≥7/10 <50 above opening
Probable ≥7/10 <50 above opening
Concordant
Pain Psi Pain Induction Control Discs
pressure
pressure
pressure
pressure
23
2 pain-free discs
1 pain-free disc
2 pain-free discs
1 pain-free disc &
1 with nonconcordant pain at
>50 psi
Manchikanti et al.45 revealed no difference in the improvement between discogram positive or negative patients. Although not well studied for axial low
back pain, because of their superior placement of medication in the ventral
epidural space, a trial of one to three transforaminal ESIs may be considered
for discogenic spine pain before consideration of surgery.
1
Degenerative Lumbar Spondylolisthesis
As lumbar degenerative spondylolisthesis is an anatomic condition with
variable symptomatology, it could be argued that diagnostic spinal injections,
and possibly discography, could be helpful in determining specific, structural
pain generators (i.e., facetogenic vs. discogenic pain) in patients with this
entity. Similarly, ESIs or SNRBs could be helpful for those patients who
suffer with radicular or neurogenic claudication symptoms. The efficacy of
these injections, however, particularly within the specific context of spondylolisthesis, is uncertain.
A recent (2008) literature review that yielded clinical guidelines regarding lumbar degenerative spondylolisthesis from the North American Spine
Society (NASS),
46
found a paucity of evidence to make any recommendations regarding such procedures in this setting. Unfortunately, the same was
true for all usual nonsurgical treatments including physical therapy, manipulation, bracing, TENS, or medications. Many of the studies to date have
compared “conservative” care to surgical interventions, but there have not
been any studies comparing injections to placebo. This includes the recent
SPORT study, which has provided significant evidence regarding surgery
for the condition.
47
Furthermore, data are lacking to accurately describe the
natural course of spondylolisthesis.
The NASS guideline developers suggest that spondylolisthesis should
be further studied according to symptom subsets (e.g., axial vs. radicular
pain, neurogenic claudication/stenosis).
Degenerative Lumbar Spinal Stenosis
With spinal stenosis, we again have an anatomic description of a problem with variable symptomatology and an unclear natural history. It is
well accepted that those who present with significant neural compromise
should be considered quickly for surgery. For ethical reasons, this category
of patients, therefore, will not likely be studied in placebo-controlled trials
and may not even be studied outside of surgical interventions (such as with
bona fide cauda equina). Spinal injections, however, may be considered for
diagnostic and therapeutic purposes for those who present without significant neurological compromise. Symptom subsets may again be considered
for further research to determine treatment response for axial pain, radicular
pain, or neurogenic claudication.
As with spondylolisthesis, many studies have concentrated on comparing conservative care with surgical intervention, including the recent
SPORT study.
stenosis were also developed by NASS.
48
In 2007, clinical guidelines regarding degenerative spinal
49
This group’s review of the available
literature led to a Grade B recommendation in favor of a single transforaminal ESI for short-term relief of radicular symptoms associated with stenosis.
A Grade C recommendation was made for multiple transforaminal or caudal ESIs to prolong pain relief from radiculopathy or neurogenic claudication associated with spinal stenosis. It should be noted that “multiple” in this
setting refers to repeated injections at times when the patient’s symptoms
return or worsen following initial injection(s). This is in contrast to previously described “series of 3” injections in which the intervention is repeated
at specified time intervals regardless of initial response. This approach had
been used extensively in the past when most injections were done without
image guidance in order to improve the rate of success. As discussed earlier
in the chapter, a fixed schedule for a series of 3 is no longer considered standard of care and is not supported by the literature.
CONCLUSION
Regardless of the underlying degenerative pathology, in patients who lack
emergent or urgent surgical indications, diagnostic or therapeutic spinal
injection therapy should be considered before surgical interventions. These
may help in identifying specific pain generators, may provide substantial
long-term pain relief in some patients (and therefore help avoid surgery),
and may identify patients who might respond to alternative interventions,
such as RF neurotomy.
References
1. DePalma, et al., Evidence-informed management of chronic low back pain with epidural steroid injections, Spine J. 8 (2008) 45–55.
2. N. Bogduk, Evidence-informed management of chronic low back pain with facet injections
and radiofrequency neurotomy, Spine J. 8 (2008) 56–64.
3. Galiano, et al., Real-time sonographic imaging for periradicular injections in the lumbar
spine: a sonographic anatomic study of a new technique, J. Ultrasound Med. 24 (2005)
33–38.
4. Salahadin, et al., Epidural steroids in the management of chronic spinal pain: a systematic
review, Pain Physician 10 (2007) 185–212.
5. Karppinen, et al., Periradicular infiltration for sciatica, Spine 26 (2001) 1059–1067.
6. Riew, et al., The effect of nerve-root injections on the need for operative treatment of lumbar
radicular pain, J Bone Joint Surg. Am. 82 (2000) 1589–1593.
7. Matthews, et al., Back pain and sciatica: controlled trials of manipulation, traction, sclerosant
and epidural injections, Br. J. Rheumatol. 26 (1987) 416–423.
8. Devulder, et al., Nerve root sleeve injections in patients with failed back surgery syndrome: a
comparison of three solutions, Clin. J. Pain. 15 (1999) 132–135.
9. Manchikanti, et al., Caudal epidural injections with sarapin steroids in chonic low back pain,
Pain Physician 4 (2001) 322–335.
10. Kolstad, et al., Transforaminal steroid injections in the treatment of cervical radiculopathy:
a prospective outcome study, Acta Neurochir. (Wien) 147 (2005) 1065–1070.
11. G.R . Butterman, Treatment of lumbar disc herniation: epidural steroid injection compared
with discectomy: a prospective, randomized study, J. Bone Joint Surg. Am. 86-A (2004)
670–679.
12. DePalma, et al., A critical appraisal for the evidence for selective nerve root injection in the
treatment of lumbosacral radiculopathy, Arch. Phys. Med. Rehabil. 86 (2005) 1477–1482.
13. Botwin, et al., Complications of fluoroscopically guided transforaminal lumbar epidural
injections, Arch. Phys. Med. Rehabil. 81 (2000) 1045–1050.
14. Botwin, et al., Complications of fluoroscopically guided interlaminar cervical epidural injections, Arch. Phys. Med. Rehabil. 84 (2003) 627–633.
15. Botwin, et al., Complications of fluoroscopically guided caudal epidural injections, Arch.
Phys. Med. Rehabil. 80 (2001) 416–424.
16. Botwin, et al., Adverse effects of fluoroscopically guided interlaminar thoracic epidural injections, Arch. Phys. Med. Rehabil. 85 (2006) 14–23.
17. Furman, et al., Incidence of intravascular penetration in transforaminal lumbosacral epidural
steroid injections, Spine 25 (2000) 2628–2632.
18. Hopwood, et al., Factors associated with failure of lumbar epidural steroids, Reg. Anesth. 18
(1993) 238–243.
19. Manchukonda, et al., Facet joint pain in chronic spinal pain: an evaluation of prevalence and
false-positive rate of diagnostic blocks, J. Spinal Disord. Tech. 20 (2007) 539–545.
20. Cohen, et al., Lumbar zygapophyseal (facet) joint radiofrequency denervation success as a
function of pain relief during diagnostic medial branch blocks: a multicenter analysis, Spine J.
8 (2008) 498–504.
21. Schwarzer, et al., Prevalence and clinical features of lumbar zygapophyseal joint pain: a
study in an Australian population with chronic low back pain, Ann. Rheum. Dis. 54 (1995)
100–106.
22. Boswell, et al., A systematic review of therapeutic facet joint interventions in chronic spinal
pain, Pain Physician 10 (2007) 229–253.
23. Bogduk, et al., International Spine Intervention Society Practice Guidelines for spinal
diagnostic and treatment procedures, 1st ed., San Francisco, 2004.
24. Pneumaticos, et al., Low back pain: prediction of short-term outcome of facet joint injection
with bone scintigraphy, Radiology 238 (2) (2006) 693–698.
25. N. Bogduk, Diagnostic nerve blocks in chronic pain, Best Pract. Res. Clin. Anaesthesiol 16
(2002) 565–578.
C H A P T E R 1 9 e Role of Spinal Injections in Treating the Aging Spine
109
26. Lilius, et al., Lumbar facet joint syndrome: a randomized clinical trial, J. Bone Joint Surg. 71B
(1989) 681–684.
27. Kornick, et al., Complications of lumbar facet radiofrequency denervation, Spine 29 (2004)
1352–1354.
28. Manchikanti, et al., Therapeutic cervical medial branch blocks in managing chronic neck
pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial
NCT0033272, Pain Physician 9 (2006) 333–346.
29. Manchikanti, et al., Evaluation of lumbar facet joint nerve blocks in the management of
chronic low back pain: preliminary report of a randomized, double-blind controlled trial:
clinical trial NCT00355914, Pain Physician 10 (2007) 425–440.
30. Barnsley, et al., Lack of effect of intraarticular corticosteroids for chronic pain in the cervical
zygapophyseal joints, N. Engl. J. Med. 330 (1994) 1047–1050.
31. Kim, et al., Cervical facet joint injections in the neck and shoulder pain, J. Korean Med. Sci
20 (2005) 659–662.
32. Fuchs, et al., Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular
pain in the lumbar spine, J. Vasc. Interv. Radiol. 16 (2005) 1493–1498.
33. J. Schofferman, G. Kine, Effectiveness of repeated radiofrequency neurotomy for lumbar facet
pain, Spine 29 (2004) 2471–2473.
34. Tekin, et al., A comparison of conventional and pulsed radiofrequency denervation in the
treatment of chronic facet joint pain Clin. J. Pain 23 (2007) 524–529.
35. Lord, et al., Percutaneous radiofrequency neurotomy for chronic cervical zygapophyseal-joint
pain, N. Engl. J. Med. 335 (1996) 1721–1726.
36. Birkenmaier, et al., Percutaneous cryodenervation of lumbar facet joints: a prospective clinical
trial, Int. Orthop. 2006.
37. Mogalles, et al., Percutaneous laser denervation of the zygapophyseal joints in the pain facet
syndrome, Zh. Vopr. Neirokhir. Im. N N. Burdenko 1 (2004) 20–25.
38. S.P. Cohen, Sacroiliac joint pain: A comprehensive review of anatomy, diagnosis, and treatment, Anesth. Analg. 101 (2005) 1440–1453.
39. Maguars, et al., Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study, Br. J. Rheumatol. 35 (1996) 767–770.
40. Cohen, et al., Randomized placebo-controlled study evaluating lateral branch radiofrequency
denervation for sacroiliac joint pain, Anesthesiology 109 (2008) 279–288.
41. Derby, et al., The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes, Spine 24 (1999) 364–371.
42. W.S. Oh, J.C. Shim, A randomized controlled trial of radiofrequency denervation of the
ramus communicans nerve for chronic discogenic low back pain, Clin. J. Pain 20 (2004)
55–60.
43. Bryan, et al., Fluoroscopic assessment of epidural contrast spread after caudal injection, ISIS,
7th Annual Scientific Meeting, Las Vegas, NV, August 1999.
44. Khot, et al., The use of intradiscal steroid therapy for lumbar spinal discogenic pain: a
randomized controlled trial, Spine 29 (2004) 833–836.
45. Manchikanti, et al., Effectiveness of caudal epidural injections in discogram positive and
negative chronic low back pain, Pain Physician 5 (2002) 18–29.
46. North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary
Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis. 2008.
47. J.N. Weinstein, J.D. Lurie, T.D. Tosteson, et al., Surgical versus nonsurgical treatment for
lumbar degenerative spondylolisthesis, N. Engl. J. Med. 356 (22) (2007) 2257–2270.
48. Weinstein, et al., Surgical vs nonsurgical therapy for lumbar spinal stenosis, N. Engl. J. Med.
358 (8) (2008) 794–810.
49. North American Spine Society, Evidence-Based Clinical Guidelines for Multidisciplinary
Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. 2007.
Acupuncture in Treatment of Aging
Spine–Related Pain Conditions
Chunbo Cai, Weibin Yang, Linqiu Zhou, Wei Huang, and James J. Yue
20
k e y p o i n t s
History of acupuncture and its development in Europe and North America.
Basic knowledge of operation and techniques of acupuncture treatment.
Application of acupuncture in treatment of spine-related pain conditions.
e concept of meridians and their application in acupuncture treatment of
spine-related pain conditions.
e limitation of this chapter in its scale to include the available
information on evidence-based medicine to demonstrating the efficacy of
acupuncture in management of spine-related pain conditions.
Acupuncture is an important component of Traditional Chinese Medicine
(TCM), which has been used in China and other regions for over 5000
years. A Chinese classic, Huang Di Nei Jing (黄帝内经), Yellow Emperor’s
Inner Canon in English translation, has been regarded as the earliest source
on acupuncture in writing. Compiled in circa 100 bc, this treasured classic
contains eighty-one treatises organized into two parts: Su Wen (素问) and
Lin Shu (灵枢). The latter is considered the bible for the application of acupuncture. The principles stated in the treatises still guide the practitioners
in modern times.
Acupuncture was introduced to Europe in the eighteenth century by
returning missionaries and was mentioned in a history of surgery published
in 1774 in France. In North America, widespread public and professional
awareness of acupuncture commenced in 1971 when James Reston reported
his observations in Beijing, as a sports journalist on a ping-pong tournament
trip, in The New York Times.
use of complementary and alternative medicine in the United States since
2
then.
Acupuncture is the most frequently used modality in complementary
and alternative medicine for the treatment of symptoms of osteoarthritis,
and especially in the treatment of back and neck pain, or other related pain
conditions, including radiculopathy resulting from disc herniations or spinal stenosis. Despite the vast application of acupuncture, evidence-based
clinical research in English publications, in which most authors used the
approaches of “Western style of acupuncture,” has show an inconsistent conclusion on the effectiveness of acupuncture. The Western approach of acupuncture was defined as conventional diagnosis followed by individualized
acupuncture treatment using a combination of prescriptive tender, local, and
distal points. This is in contrast to the approach in TCM, which would
formulate an individualized diagnosis based on TCM theories of meridians
and energy (or qi).
Acupuncture is the procedure of inserting and manipulating filiform
needles into various points (called acupuncture points) to relieve pain or
for other therapeutic purposes. According to TCM, acupuncture points are
the sites through which the vital energy, or “qi” and “blood,” are transported
throughout the body surface. In the basic framework of TCM, there is a
channel system with meridians connecting most of the acupuncture points
regulating the functions of the internal organs and musculoskeletal system
4
1
There has been a substantial increase in the
110
in a human body. The meridian system is believed to transport energy to
every part of the body to keep the physiological function in balance. Health
is regarded as a state of balanced homeostasis of the yin and the yang. Any
creature, including human beings, is presumed to suffer from diseases when
the energy is not flowing smoothly because it is blocked or stagnant along
the meridians, which in turn would result in disharmony in the body as a
whole. The etiology of disharmony is usually categorized as internal pathological excess, such as sadness, anger, or fear; and external assaults, such as
cold, heat, or dampness. Acupuncture is reports to restore the flow of vital
energy and to bring the human body to a new balanced state (homeostasis).
Despite the long history in the application of acupuncture in many clinical conditions, the mechanism behind it has not been fully understood and
explained within the framework of the Western medical system.
DESCRIPTION OF THE NEEDLE
An acupuncture needle is divided into five parts (Figure 20-1): tip, body,
root, handle, and tail. The tip and body of a needle are the parts being
inserted into the body of a subject on the acupuncture points. The handle
and tail of a needle are the parts used by a practitioner to manipulate the
needle. The root connects the body and handle of a needle. Commonly used
acupuncture needles are made of stainless steel, with sizes from 26 to 40
gauge and lengths from 0.5 inch to 2.5 inches. Because of the small size,
quite often people describe an acupuncture needle as a “painless needle.” The
tip of an acupuncture needle is blunt, even though it is very tiny. Compared
with the tip of a regular needle in the same gauge number, the tip of an acupuncture needle has less chance of cutting the tissue.
OPERATIVE TECHNIQUES
3
Depending on the location of acupuncture points, a patient can be placed
in supine, prone, recumbent, or sitting positions. Lying position is usually
preferred due to the possibility of fainting in some patients from needling
(Figure 20-2 ).
Needle Insertion Techniques
There are four common ways to insert a needle: finger pressing insertion,
pinching needle insertion, pinching skin insertion, and tight skin insertion.
The skin at the insertion site is cleaned with an alcohol pad. The needle
insertion angle can be perpendicular, oblique, or horizontal to the skin
surface with various depths, depending on the location of the acupuncture points, the medical conditions being treated, and the patient’s general
health.
Finger pressing insertion. is technique is used when a short needle
is used. Before inserting, the practitioner uses one fingertip (guiding finger)
of the assisting hand to gently press the acupuncture point. e needle is
then inserted into the skin of the acupuncture point along the edge of the
guiding finger.
C H A P T E R 2 0 Acupuncture in Treatment of Aging Spine–Related Pain Conditions
F IG UR E 2 0- 1 Acupuncture needle.
111
Needle Manipulation
In TCM, the outcomes of acupuncture treatment are believed to rely heavily
on the means of stimulations to the needles after insertion. There are two
basic methods of stimulating the needles: manual manipulation and electrical stimulation.
There are various techniques in manipulating the needles manually to
achieve the desired effects, which have been developed by generations of
acupuncturists over thousands of years. The techniques are grouped by the
needle effects, which are categorized as tonification (to treat deficiency),
sedation (to treat excess), or neutral. For example, in tonification, the needle
is inserted so that the angle of the needle is in the direction of energy flow
on a specific meridian, and then advance the needle slowly, turning it with
slow yet firm clockwise rotations as the needle is being advanced, and not
penetrating too deeply. The needle can be continuously manipulated or left
alone. When withdrawn, the needle should be removed quickly and the
skin at the insertion point should be covered by a finger and massaged in
a clockwise fashion. Sedation is the opposite of tonification. The needle is
angled against the direction of energy flow on the meridian and is inserted
quickly and deeply with rapid counterclockwise rotations. The needle
should be withdrawn slowly and the surface should not be touched after
removal of the needle. The duration of the treatment is usually 20 to 40
1
minutes.
Electric stimulation became available in modern times. The electrodes are connected to the needles. The negative lead is attached to
the needle(s) where the electron flow is started, whereas the positive
lead is attached to the needle(s) where the flow is directed to. The lowfrequency impulse, between 2 and 8 Hz, is considered to have the tonification effect. Higher frequency impulse, between 70 and 150 Hz, is used
on the points surrounding the painful area, especially in musculoskeletal
pain conditions.
1
F IG UR E 2 0- 2 A needle is inserted in a patient in the lying position.
Pinching needle insertion. is technique is used when an acupunc-
ture point is deep and a long needle is used. Once the acupuncture point is
identified, the thumb and index finger of the assisting hand hold the distal
part of the needle with sterile gauze or sterile cotton ball, and the dominant
hand holds the handle of the needle. e needle is then inserted with both
hands.
Pinching skin insertion. is technique is used when the skin and
muscles of the insertion site are thin or if the insertion point is close to
important organs, such as lungs or eyeballs. Once the acupuncture point is
identified, the skin and muscles are pinched or picked up with the thumb
and index fingers of the assisting hand. e needle is then inserted through
pinched skin with the dominant hand.
Tight skin insertion. is technique is used when the skin over the
acupuncture point is loose. Once the acupuncture point is identified, the
skin over the acupuncture point is stretched and tightened with the thumb
and index fingers. e needle is inserted with the dominant hand.
5
Other Modalities and Techniques Related to Acupuncture and the Meridian System
In addition to the commonly used body acupuncture needles and needling
techniques, there are other subsystems, such as ear acupuncture (auricular acupuncture), scalp acupuncture, hand acupuncture, three-sided needle
bleeding method, and seven star needle (brush of needles) tapping. Moxibustion, guasha, and cupping are also the techniques used in the comprehensive acupuncture regimen. One of the most commonly used techniques
is called Tui Na. According to one of the most popular teaching textbooks
used by many TCM medical schools in China, Tui Na is regarded as an
equally important method as acupuncture in the treatment of musculoskeletal disorders, especially in spine-related pain conditions.
8
Tui Na involves
deep tissue manipulation on the acupuncture points along meridians, also
manipulation of the joints, muscles, and tendons. The goal of Tui Na is to
restore the flow and balance of energy along the meridians and the biomechanical alignment. The application of Tui Na is essential in the treatment
of spine-related pain and other organ diseases, especially in the pediatric
population.
8
Presently, because of various reasons, Tui Na has been introduced to Western societies only as “acupressure” and categorized as a massage therapy with limited medical content.
Application of Meridian Theory in Spine-Related Pain Conditions
In TCM, the framework of diagnosis and point selection for treatment is
based on the theoretical network of the meridian system and the internal
organ subsystem related to the meridian system, where the names of the
internal organs are regarded as the names for the subsystem with particular
functionalities rather than the actual anatomic entities. For instance, Spleen
in TCM represents a functional subunit in the body to facilitate digestion
and transportation of the nutrients to the rest of the body via the meridians
in general, not the actual organ called the spleen in Western medicine. The
names of the internal organ subsystems that are used to name the meridians include Lung, Pericardium, Heart, Large Intestine, San Jiao (Triple
Heater), Small Intestine, Bladder, Gallbladder, Stomach, Spleen, Kidney,
and Liver. These twelve principal meridians are the primary subcircuits of
112
Posterior spinal segment
P A R T I I I Conservative Treatment Modalities
the structure and functions throughout the body, which consists of three
pairs of yin and yang meridians in a limb:
Hand Tai Yin—Lung, Hand Yue Yin—Pericardium, Hand Shao Yin—
Heart;
Hand Yang Ming—Large Intestine, Hand Shao Yang—San Jiao, Hand Yai
Yang—Small Intestine;
Foot Tai Yin—Spleen; Foot Yue Yin—Liver, Foot Shao Yin—Kidney;
Foot Yang Ming—Stomach, Foot Shao Yang—Gallbladder, Foot Tai
Yang—Bladder.
The three yin meridians of the hand begin on the chest and travel along
the medial and volar aspect of the arm to the hand. The three yang meridians of the hand begin on the hand and travel along the lateral and dorsal
aspect of the arm to the head. The three yin meridians of the foot begin on
the foot and travel along the frontal and medial aspect of the leg to the torso.
The three yang meridians of the foot begin on the face, and travel down
the body and along the lateral and posterior aspect of the leg to the foot.
There are two meridians along the midline of the body corresponding to the
anterior and posterior sagittal plane of the torso: the one on the posterior
surface of the body is called Du meridian (Governing Vessel) and the one
on the anterior surface is called Ren meridian (Conception Vessel), both of
which are very important meridians in the treatment of almost all medical
conditions, especially spine-related medical conditions.
Based on the framework described previously, clinical information is analyzed by clinicians to make TCM diagnoses of specific medical conditions and
to identify appropriate points to treat. For example, the symptoms and signs of
lumbar intervertebral disc herniation at a given spinal segment can be considered as pathological changes on Du meridian (on the midline in the back), Gallbladder meridian of Foot Shao Yang (on the lateral aspect of the leg), Bladder
meridian of Foot Tai Yang (on the posterior aspect of the back down the leg), or
Kidney meridian of Foot Shao Yin (on the medial aspect of the leg). The TCM
diagnosis can be classified into blood stagnation syndrome of Du meridian,
damp-heat excess syndrome of Gallbladder meridian, wind-cold-damp syndrome of Bladder meridian, and Kidney-Yang deficiency syndrome.
6
Then the
acupuncture treatment is delivered to the points on the related meridian(s).
Moreover, the core principle of TCM is to view a specific medical condition as a particular manifestation of imbalance in the whole body at a certain
level rather than only the disorder of a particular anatomic site or organ.
Take an example of the radiculitis resulting from a lumbar disc herniation
consistent with the Kidney-Yang deficiency, the points used are usually not
limited to the ones on the Kidney meridian of Foot Shao Yin. The points
on other synergistic meridians having the function of enhancing the KidneyYang energy would also be considered. For instance, the points on the Spleen
meridian of Foot Tai Yin are used to enhance the digestion system to supply
sufficient nutrients to correct the Kidney-Yang deficiency. Furthermore, acupuncture treatment, as in other components in TCM, is highly individualized. The treatment approaches are dynamically modified throughout the
course of follow-up visits according to the prognosis of the patient.
The therapeutic effect could also be enhanced by methods of Tui Na,
moxibustion, and Chinese medicinal herbs, under the guidance of the
meridian and internal organ subsystem.
Hua Tuo Jia Ji Points
Another set of points that is also commonly used for treatment of spine-related
medical conditions are the points at each vertebra along the spine, slightly lateral to the midline bilaterally, called Hua Tuo Jia Ji (华佗夹脊; HTJJ) points.
Hua Tuo Jai Ji points are believed to be named after Hua Tuo, one of the
most famous ancient Chinese physicians (110 ad to 207 ad) and is regarded
as the father of surgery in ancient Chinese medicine. Those points are not
only important in the treatment of spine-related pain condition, but also commonly used in treating other internal organ disorders. However, HTJJs were
only documented in a few books historically, despite their vast clinical application. Hua Tuo Jai Ji points are described as the points located from the first
thoracic vertebra to the fifth lumbar vertebra. It was recently proposed that the
landmarks of HTJJ points are the facet joints along the spine, including the
cervical region (Figure 20-3 ).
tively straightforward, because of its segmental distribution along the spine.
The targeting points usually correspond to the level of the vertebrae and nerve
7
The application of the HTJJ system is rela-
Seven cervical vertebrae
( C1-C7 )
Twelve thoracic vertebrae
C1
C7
T1
HTJJ
points line
T12
L1
L5
F IG UR E 2 0- 3 The landmarks of HTJJ points are the facet joints along
the spine, including the cervical region.
( T1-T12 )
Five lumbar vertebrae
( L1-L5 )
roots involved in the pathological processes. The hypothesized mechanism is
that stimulation of the HTJJ points affects not only the nerve roots but also
the paraspinal muscles and the chain of sympathetic ganglia along the spine.
7
RESEARCH BACKGROUND OF BASIC SCIENCES AND CLINICAL OUTCOMES
From the late 1950s, there has been a considerable amount of governmentfunded research in basic sciences and clinical outcomes of TCM in China,
especially of acupuncture. Since the early 1970s, more and more studies on
acupuncture have been published in the English literature from many disciplines of basic and clinical sciences. Acupuncture is probably the most
thoroughly researched physical modality in medicine for its analgesic effects.
The analgesic events observed from electrical acupuncture stimulation were
found to be related to the activities of the endogenous opioid peptide system. Animal studies also suggest that acupuncture-induced analgesia may
be mediated by substances released in the cerebrospinal fluid. Both low-frequency and high-frequency electric stimulation in rats could induce analgesia, but different frequencies produce different effects in terms of the types
of endorphins released. The animal studies indicate that the analgesic effect
of acupuncture can be considered a general phenomenon in the mammalian
1
world.
The development of neuroimaging tools, such as positron emission
tomography (PET) and functional magnetic resonance imaging (fMRI),
has taken the study of acupuncture’s effects on the activity of human brain
to another level. Studies using PET have shown that thalamic asymmetry
present among patients with chronic pain was reduced after acupuncture
treatments. There are studies that reported the relationships between particular acupuncture points and visual cortex activation on the fMRI. These
powerful new tools open the possibility to new scientific studies on this
ancient therapy.
There has been a large volume of reports and cohort studies reporting the effectiveness of acupuncture treating spine-related pain conditions,
especially neck and back pain.
9
1
It is difficult to design a double-blind study
C H A P T E R 2 0 Acupuncture in Treatment of Aging Spine–Related Pain Conditions
113
because of the lack of a true sham acupuncture technique. Only a few
randomized, controlled studies have reported that acupuncture is more
effective in the treatment of back pain than controls or placebo, in which
medications or usual care including physical therapy are used as the con-
10
trol
; whereas some other studies reported no better effectiveness of
acupuncture compared to controls or placebo.
4
The large-scale studies
are mostly conducted using the Western style of acupuncture. Some case
reports and cohort studies included the diagnoses of disc herniation, spinal
stenosis, and spondylolisthesis. However, most of the randomized and controlled studies in large cohorts focused on nonspecific neck and back pain,
and yet the objectives of the studies were the treatment of pain rather than
the possible pain generators or pathologies of the spine.
4,10
A recent study
demonstrated long-term pain relief by needle acupuncture compared with
placebo in patients with chronic low back pain. The authors concluded that
acupuncture did not seem to be a suitable treatment modality for neuropathic pain and it was sometimes indicated for the treatment of chronic
nociceptive pain.
11
COMPLICATIONS
Like other procedures using needles, such as trigger injections, there are
possible adverse events during acupuncture treatment: fainting, hematoma,
pneumothorax, and injuries to the nerve tissue, including spinal cord. Other
reported events include needlestick, bent needle, or broken needle left in
the body.
CLINICAL PRESENTATION AND DISCUSSION
Case One
A 45-year-old otherwise healthy white man who was an electrician presented with a 6-week history of low back pain radiating to the lateral aspect
of the left leg and down to the dorsum of the left foot and the great toe. His
visual analog pain score (VAS) was 6-8/10. He had temporary relief from
taking methylprednisolone (Medrol) for 7 days. On examination, he was
neurologically intact. The active range of motion in the lumbar spine was
limited in flexion, extension, and side flexion. His gait was antalgic. A lumbar spine MRI was ordered, which showed a large central and paracentral
disc herniation at L4-L5, encroaching on the left L5 root. He declined to
consider an epidural steroid injection or surgery because he preferred holistic health care. He also declined to consider pain medications and preferred
to seek acupuncture treatment. He then underwent acupuncture twice a
week for 2 weeks, with 50% reduction of pain, and then continued the treatments once a week for 4 weeks. At the follow-up visit in 6 weeks, he had only
residual pain with a VAS of 1-2/10 and planned to return to work. He was
advised to continue regular home exercises for spine conditioning.
Case Two
A 53-year-old white woman who was an anesthesiologist presented with a
4-month history of neck pain radiating into the medial aspect of the right
arm, with numbness, tingling, and hot sensation in the right hand. Her VAS
was 5-7/10. She had one cervical epidural steroid injection and a course of
physical therapy, which provided about 40% reduction of the pain temporarily. She had tried taking cyclobenzaprine (Flexeril) without much relief.
On physical examination, she was neurologically intact. The active range of
motion in her cervical spine was limited in flexion and side flexions, with
pain and a feeling of tightness on the right side of her neck. There was significant tightness in the paraspinal muscles and trapeziums on the right side
of her neck. A cervical spine MRI showed mild to moderate degenerative
changes, with moderate foraminal stenosis at multiple levels from C4-C5 to
C7-T1. She decided to try acupuncture treatment. Her symptoms subsided
after acupuncture treatments once a week for six sessions.
Case Three
A 75-year-old Asian man who was a retired accountant presented with
an 8-month history of persistent recurrent low back pain radiating in the
frontal aspect of his right thigh. He felt somewhat weak in the right knee.
He had tried pain medications and a prolonged course of physical therapy
without much relief. He had three lumbar epidural steroid injections, the
first two of which provided 70% pain reduction for 1 month each time. The
third injection did not provide any relief.
A lumbar spine MRI showed moderate to severe central stenosis with
grade I anterolisthesis at L3-L4 resulting in moderate foraminal stenosis.
Lumbar spine x-rays showed 5-mm slippage at L3-L4 without evidence of
instability on the flexion and extension views.
On physical examination, the active range of motion of the lumbar spine
was limited in extension because of the pain. The right knee reflex was
diminished. The muscle strength was tested at 4/5 in the right knee flexors
compared to the left ones. He was referred to see a spine surgeon, who recommended a spinal decompression and intervertebral fusion surgery. The
patient decided not to have the surgery and wanted to try any other regimen that could possibly be helpful. He started acupuncture treatment once
a week for 6 sessions, which provided 60% pain reduction. He was advised
to increase the intensity of the strengthening exercises learned from physical therapy. He then decided to have Tui Na treatments with acupuncture
once a week. His pain improved almost 90% at the follow-up visit 4 weeks
later. The strength was 5/5 in the right knee flexors. He was happy with his
progress.
Case Discussions
The three cases presented are to illustrate the typical scenarios in clinical
practice, in which acupuncture and other related techniques, such as Tui
Na, could play a role in the treatment of spine-related pain conditions.
The process in TCM diagnosis and the details in the treatment of
acupuncture and Tui Na are not within the scope of this chapter.
In Case One, it is apparent that the symptoms were related to a herniated disc. Besides the analgesic effect, the acupuncture treatment might
have played a role in the antiinflammatory and healing process through its
effect on blood circulation as reported in other articles that are not discussed in this chapter. However, one can argue that the improvement could
well be the part of the natural course of the symptomatology of lumbar disc
herniation. In Case Two, it is possible that the pain was not directly related
to the assaults on the nerve roots from the spinal pathology. The tightness
and spasm of the muscles and other soft tissues in the neck and shoulder
region could affect the nerves, or blood or lymphatic circulations in the
vicinity. All these factors discussed, alone or jointly, would result in the
symptoms in the arm and hand. Hence, in this case, the effect of acupuncture treatment might have been from the relaxation of the local muscles
and other soft tissues. In Case Three, the effects of acupuncture treatment
might have been achieved from the combination of the possible mechanisms discussed previously with the addition of the mechanical enforcement from Tui Na treatment, which might have also corrected the micro
biomechanical dislocation or malalignment of the tendons, ligaments, or
even facet joints despite the lack of evidence of a gross instability on the
x-rays.
Given the limitation of the scale of this chapter, it is impossible to
include all the information on the evidence-based medicine in demonstrating the application of acupuncture in the management of spinerelated pain conditions. Readers are referred to other sources in the
references.
CONCLUSIONS
Although the effectiveness of acupuncture in the treatment of spinerelated pain conditions remains controversial in English publications, the
clinical practice guideline from the American College of Physicians and
the American Pain Society favors the use of acupuncture. For patients
who do not improve with self-care options, clinicians should consider the
addition of nonpharmacologic therapy with proven benefits: for acute low
back pain, spinal manipulation; for chronic or subacute low back pain,
intensive interdisciplinary rehabilitation, exercise therapy, acupuncture,
massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality
evidence).
12
114
P A R T I I I Conservative Treatment Modalities
References
1. Joseph M. Helmes, Acupuncture energetic—a clinical approach for physicians, second ed.,
Medical Acupuncture Publishers, Berkeley, California, 1997.
2. D.M. Eisenberg, R.B. Davis, et al., Trends in alternative medicine use in the United States,
1990-1997: results of a follow up national survey, JAMA 289 (1998) 1569–1575.
3. E. Ernst, Acupuncture as a symptomatic treatment of osteoarthritis—A systematic review,
Scand. J. Rheumatol. 26 (1997) 444–447.
4. P. White, G. Lewith, P. Prescott, J. Conway, Acupuncture versus placebo for the treatment of
chronic mechanical neck pain, Ann. Intern. Med. 141 (12) (2004) 911–919.
5. Zhang Enqin, Chinese acupuncture and moxibustion, Publishing House of Shanghai
College of Traditional Chinese Medicine, , 1990, pp. 340–364.
6. L.P. Wang, Meridian differentiation of lumbar intervertebral disc herniation (Article in
Chinese), Zhongguo Gu Shang 22 (10) (2009 Oct) 777–778.
7. Chunbo Cai, Revisit of the anatomy of Hua Tuo Jai Ji points, Med. Acupunct. 19 (3) (2007)
125–128.
8. Dafang Yu, Tui Na Xue (in Chinese), Publishing House of Shanghai Sciences and
Technology (1984) 7–22.
9. J. Shen, Research on the neurophysiologic mechanisms of acupuncture: review of selected
studies and methodological issues, J. Altern. Complement. Med. 7 (Suppl. 1) (2001) S121–
S127.
10. D.C. Cherkin, K.J. Sherman, A.L. Avins, J.H. Erro, L. Ichikawa, W.E. Barlow, K. Delaney,
R. Hawkes, L. Hamilton, A. Pressman, P.S. Khalsa, R.A. Deyo, A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain, Arch.
Intern. Med. 169 (9) (2009 May 11) 858–866.
11. C. Carlsson, et al., Acupuncture for chronic low back pain: a randomized placebo-controlled
study with long-term follow-up, Clin. J. Pain 17 (4) (2001) 296–305.
12. R . Chou, A. Qaseem, V. Snow, D. Casey, J.T. Cross Jr., P. Shekelle, D.K. Owens, Clinical
Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel, Diagnosis and
treatment of low back pain: a joint clinical practice guideline from the American College of
Physicians and the American Pain Society, Ann. Intern. Med. 148 (3) (2008 Feb 5) 247–248.