Lumbar Disc Herniation - a Case Study

by Donna Dupre, L.Ac.

MEDICAL HISTORY

On October 9, 2006, a 34-year-old male patient presented with stiffness, soreness and muscle spasms in the low back. MRI revealed a 4 mm herniated disc between Lumbar 4 and 5. His low back pain started over two years ago. He also has bilateral neck and shoulder pain, and bilateral tightness along the medial borders of the scapula. He reports being treated by a Chiropractor and a Physical Therapist, which did not improve his condition. In 1996, the patient underwent knee surgery to correct a torn ACL, and began gaining weight post-surgery due to inactivity. The weight gain continued and he is now more than 100 lbs. overweight. He weighs over 300 lbs, and his height is 5'9". He reports being diagnosed with fatty liver or non-alcoholic steatohepatitis. He is also being tested for hemochromatosis. Laboratory tests revealed elevated serum ferritin and elevated liver enzymes (AST and ALT). He has received phlebotomy treatments to reduce ferritin levels in his blood and is currently being monitored by a MD. He is scheduled for a liver biopsy to confirm diagnosis of hemochromatosis and evaluate the extent of liver damage from fatty liver. He has been prescribed Toporal to treat high blood pressure, which is now in normal range of 130/78. He complains of itchy skin all over his body and muscle twitching and spasms. He has extreme fatigue and reports being diagnosed with chronic fatigue and fibromyalgia. He has sleep apnea which causes him to wake up frequently throughout the night and has trouble falling back to sleep. He has been prescribed Lexapro to treat anxiety. He also reports being diagnosed with Gastroesophageal Reflux Disease (GERD) for which he was prescribed Prevacid. He complains of dizziness and loss of balance. He reports excessive thirst and dry mouth. He reports feeling hot all the time and has night sweats, and frequent nocturia.

CHIEF COMPLAINT

The patient's chief complaint is stiffness, soreness, and muscle spasms in the low back that started more than two years ago. MRI revealed a 4mm herniated disc between L4 and L5. He reported the pain level as 7 out of 10 (10 being worst pain) on his first visit. He also has neck and shoulder pain and bilateral tightness along the medial border of the scapulas that started over two years ago. He also was diagnosed with chronic fatigue and fibromyalgia and reports feeling exhausted all the time. He is obese weighing 310 lbs. at a height of 5'9". He has been diagnosed with fatty liver or non-alcoholic steatohepatitis and has elevated liver enzymes (ALT and AST) and elevated serum ferritin levels which could indicate a hemochromatosis diagnosis. A gene study was positive for the mutation of Chromosome 6, but he has not had a liver biopsy to confirm diagnosis. A liver biopsy has been scheduled to evaluate extent of liver damage and to rule out hemochromatosis. He also complains of itchy skin and muscle twitching and spasms. He has insomnia due to sleep apnea and frequent nocturia, which causes him to wake frequently and has trouble falling back to sleep.

PHYSICAL EXAMINATION

• The patient is obese, and weighs 310 lbs., at a height 5'9" (over 100 lbs. overweight)
• Liver is enlarged on palpation
• Low back tender on palpation
• His tongue is Dusky with a red tip and a thick yellow coating
• Right Pulse: wiry, slippery, rapid
• Left Pulse: wiry, thready, slightly rapid

TCM DIAGNOSIS

• Qi and Blood Stagnation
• Damp Heat and Phlegm Accumulation
• Spleen Qi Xu
• Kidney and Liver Yin Xu with Xu Heat

WESTERN MEDICAL DIAGNOSIS

• MRI revealed 4 mm. Disc Herination between L4-L5
• Non-Alcoholic Steatohepatitis or Fatty Liver
• Elevated liver enzymes (AST and ALT)
• Chronic Fatigue
• Fibromyalgia
• Gastroesophageal Reflux Disease (GERD)
• High Blood Pressure

MEDICATIONS

• Toporal - for High Blood Pressure
• Lexapro - for Anxiety
• Prevacid - for GERD

TREATMENT PRINCIPLE

• Transform Damp Heat and Phlegm
• Move Qi and Blood Stagnation
• Tonify Spleen Qi
• Tonify Kid and Liver Yin and Clear Deficient Heat

TREATMENT PLAN

I have prescribed acupuncture two times per week and herbal formulas.

ACUPUNCTURE POINTS

Various combinations of the following points were used to treat this patient.

• UB23 with electro-acupuncture - Back shu of Kidney, Strengthens low back
• UB25 - with electro-acupuncture - low back pain
• DU4 and DU3 - Low back pain, strengthens low back
• Ashi Points low back electro-acupuncture - move qi and blood stagnation
• UB18 - Back Shu Liver, clears damp heat, moves stagnation, eliminates wind
• UB17 - Invigorates blood, clears heat, nourishes blood
• UB20 - Back Shu of Spleen, nourishes blood resolves damp
• SP9 and ST40 - move damp and phlegm
• UB40 Bloodletting - Low Back Pain, move blood stagnation, clears heat, relaxes sinews
• GB31 - Calms wind, itchy skin
• Liv 2 and LI 4 - Modified 4 gates, clear heat move liver qi stagnation
• Kid 6 - Tonify kid yin, frequent urination, insomnia
• GB34 - move stagnation, infuential point of tendons, moves liver qi, relaxes tendons
• LI11 - Clears heat, cools blood, benefits sinews and joints
• Cupping low back neck and shoulders - move stagnation, improve circulation

HERBAL PERSCRIPTIONS

Day Time Formula:

• Chai Hu - 9 g - Spreads liver qi and relieves constraint, for symptoms such as dizziness, chest and flank pain, liver and spleen disharmonies.
• Wu Wei Zi - 6 g - Tonifies the kidneys and builds up essence, inhibits sweating and generates fluids, especially when accompanied by thirst, quiets and calms spirit for insomnia due to blood and yin deficiency, improves liver function for patients with hepatitis.
• Yin Chen Hao -9 g - Clears damp heat from liver and gallbladder, dizziness
• Jue Ming Zi - 6 g - Clears liver, prevents artherosclerosis lowers blood pressure and cholesterol
• Pu Gong Ying - 11 g �Clears heat and relieves toxicity, dissipates nodules, clears heat and resolves dampness
• Dang Shen - 9 g - Tonifies the middle burner and augments qi, tonifies spleen and lung qi, for fatigue
• Shan Yao - 12 g - Tonifies Spleen, Kidney and Lung deficiency, wasting and thirsting disorder, frequent urination, and fatigue
• Huang Qi - 9 g - Tonifies Spleen and auguments qi, wasting and thirsting disorder and painful obstruction, tonifies qi and blood, generates flesh
• Yu Jin - 9 g - Invigorates the blood and breaks up stagnation, clears heat and cools the blood, anxiety, benefits gallbladder
• Bai Shao - 12 g - Nourishes blood and preserves the yin, calms the liver and sedates yang, and alleviates pain from constrained liver qi or disharmony between the liver and spleen
• Ban Xia - 6 g - Dries dampness, transforms phlegm due to dampness of the spleen dissipates nodule, and reduces pain due to phlegm
• Dan Shen - 9 g - Invigorates the blood and breaks up blood stasis, clear heat and soothes irritability, palpable masses, and pain due to blood stagnation, pain due to constrained liver qi with blood stagnation
• Ji Nei Jin - 6 g - Strongly reduces food stagnation and improves spleen transformation function, secures essence, frequent urination at night, transforms hardness and dissolves stones.

Patient is taking 3 grams of this formula, 3 times per day

Night Time Formula:

• Bai He - 15 g - Nourishes Yin, clears heat and calms spirit
• Mai Men Dong - 9 g �Clears heat and eliminates irritability, augment stomach yin and generates fluids for dry mouth
• Long Yan Rou - 6 g - Tonifies heart and spleen, nourishes blood, calms spirit, for insomnia, forgetfulness and dizziness
• Di Long - 6 g - Clears heat and unblocks the channels and collaterals, drains heat and stops spasms, recently used for hypertension and ascendant liver yang
• Gou Teng - 6 g - Extinguishes wind and alleviates spasms for liver heat patterns, drains liver and pacifies spasms
• Mu Li - 6 g - Settles and calms the spirit, benefits the yin and anchors floating yang, softens hardness and dissipates nodules, absorbs acidity and alleviates pain
• Sang Piao Xiao - 9 g - Tonifies the kidneys, assists the yang, restrains the essence, urinary frequency
• Zhi Zi - 6 g - Clears heat and eliminates irritability, drains damp heat, reduces swellings and moves blood stagnation, damp heat liver and gallbladder
• Han Lian Cao - 9 g �Tonifies the Liver and Kidneys, nourishes blood, and augments essence, for patterns of blood and yin deficiency.
• Shi Hu - 9 g - Nourishes yin, clear heat, and generates fluids. Strengthens lower back
• Jing Jie - 9 g - Vents rashes and alleviates itching

Patient is taking 4 grams of this formula at bedtime

MODALATIES

Electro-acupuncture - Electric stimulation attached to inserted needles or percutaneous application is used for analgesia and is commonly called electro-acupuncture. The use of electricity to treat pain was reported as early as the first century in the West when gout was treated with electric torpedo fish. Various machines were developed after the discovery of electricity in the late 1700's. Early devices used direct and alternating current, galvanic and static electricity, and capacity storage techniques. There was renewed interest in electro-acupuncture in France in the early 1800's. Sarlandiere le Chevalier (1825) of France and da Camino (1834, 1837) of Italy were the first to apply percutaneous electrical nerve stimulation (PENS). Interest in electro-acupuncture faded for many years until 1970 when it was discovered that it was being used for anesthesia during surgery in China.¹

Cupping - Is a therapeutic technique where a cup is inverted and heated up to create a vacuum and placed on various parts of the body. The vacuum is created when air cools the heated cup and is quickly placed on the skin. "The resultant low pressure under the cup causes localized expansion of tissue, which produces a profound vasodilatation reaction."² Cupping increases blood flow to constricted areas and reduces pain.

Bleeding or Blood Letting Therapy - Chapter One of the Spiritual Pivot (Ling Shu) states "when there is stagnated blood apply the bloodletting therapy."³ Bleeding or blood- letting techniques have been used since ancient times in expelling evil qi and blood from the body. The Su Wen, Chapter 41 states "When the Foot Taiyang Channel contracts disease, it will cause the patient to have lumbago, and the pain will make the patient to feel like something heavy; is on his neck, spine, buttocks and back. When treating, it should prick the Weizhong point (Popliteal Center BL 40) of the Foot Taiyang Channel until bleeding".⁴ Western medicine also practiced bleeding or bloodletting therapy in a much more aggressive manner which sometimes resulted in death.

WESTERN MEDICAL PERSPECTIVE

From a Western Medical perspective, a lumbar disc herniation is a protrusion of the nucleus of the intervertebral disk due to trauma or degenerative changes. If the herniated nucleus compresses or irritates the nerve root, it can cause pain, numbness or paresthesias, and eventually muscle weakness and atrophy. Western Medical diagnosis can be confirmed by X-Ray, CT scan, MRI, or a Myelography. Treatment includes bed rest and analgesics, and if condition worsens decompressive laminectomy surgery.⁵

Non-alcoholic steatohepatitis (NASH) is a chronic liver disease that was originally described in obese, diabetic females who denied alcohol use but had the hepatic histology consistent with alcoholic hepatitis. The typical patient profile has now been expanded to include normal weight males without overt abnormalities in carbohydrate metabolism. NASH was once thought to be benign, but is now recognized as a cause of progressive fibrotic liver disease with adverse health implications. It is the most serious type of non-alcoholic fatty liver disease. It is a consequence of insulin resistance and fat, inflammation and degeneration of liver cells due to oxidative stress. It can lead to cirrhosis and liver-related death. Obesity and type II diabetes increases this risk.⁶ Western Medical treatment includes medication to improve insulin sensitivity such as Metformin and weight loss if obesity is a factor.

Hemochromotosis (HH) is a mono-allelic genetic disorder caused by one of two genetic mutations of the hemochromatosis gene (HFE) which is present on chromosome 6. The most significant mutation is C282Y, which has been traced back a common Celtic ancestor who lived sixty to seventy generations ago. It is present in people of Scottish, Irish, English and French ancestry. About nine percent of this population is heterozygous and will be carriers, and 0.4 percent, or 1:200 individuals, are homozygous, and are diagnosed with HH. The second less serious mutation is H63D, which involves the same HFE protein is more common, but less serious. Diagnosis can be confirmed by a combination of the following tests: serum ferritin, serum iron and TIBC, genetic testing and liver biopsy. If the gene study is positive, ferritin is less than 300 micrograms per liter, and LFT is normal, the patient should be observed and retested in two years. If the gene study is positive, ferritin is 300 - 1000 micrograms per liter, and LFT are normal, phlebotomy is indicated to lower ferritin levels. If the gene study is positive, ferritin is greater than 1000 micrograms per liter, and/or LFT is abnormal, liver biopsy should be done to confirm iron overload and access for cirrhosis.

TCM PERSPECTIVE

From a TCM perspective the kidneys are the mansion of the low back and deficiency of kidney yin, yang or both is the most common cause of lumbar pain. Qi and blood stagnation is another common cause of low back pain that can be the result of long-term stagnation or the result of trauma. Wind, damp, or cold can obstruct the flow of qi and blood in the channels of the low back and cause pain. Internal or external damp heat evils can also inhibit the flow of qi and blood and cause low back pain.

NASH or fatty liver is associated with damp and heat evils, which can damage the blood, consumes the qi and obstruct the flow of qi and blood. Damp heat can be the result of over eating hot, spicy, fatty foods, which damage the spleen and creates dampness; which can transform into heat. Damp heat can also obstruct the flow of qi and blood and damage yin, blood and fluid resulting in yin and/or blood deficiency. Damp heat can also turn into phlegm and cause stagnation. Long-term spleen deficiency can lead to kidney deficiency.

Chronic Fatigue and Fibromyalgia are usually associated with liver and spleen disharmonies and in this case long-term stagnation in the liver, spleen qi deficiency, and damp heat. This is the result of years of overeating hot spicy, fatty foods causing obesity and putting his heath at serious risk.

This patient has a number of serious health concerns. His low back pain due to a herniated disc was his chief complaint, so the first step was to alleviate his back pain. I treated him with acupuncture, electro-acupuncture, cupping and bloodletting. He has had a positive response to treatment and reports more than a 50% reduction in pain. His low back pain level is now 3/10 (10 being worse).

I have also addressed the NASH with herbs and acupuncture and have talked to him about the importance of weight loss with his condition. Many of the symptoms associated with NASH such as itchy skin and fatigue have improved. He is scheduled for a liver biopsy in February to rule out HH and evaluate the extent of liver damage. If he does not loose weight, his health is in serious jeopardy and could lead to diabetes and possible cirrhosis of the liver. He is encouraged by the progress to date and now that he has more energy has agreed to make an effort to begin walking. He has a long way to go, but he is starting to feel better and has a new baby due in December so he has much to live for.

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