Donna Dupre, L.Ac., DAOM

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

TCM DIAGNOSIS

WESTERN MEDICAL DIAGNOSIS

MEDICATIONS

TREATMENT PRINCIPLE

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.

HERBAL PERSCRIPTIONS

Day Time Formula:

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

Night Time Formula:

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.

REFERENCES:

  • Anderson, N.C., Disorders of Iron Metabolism, NEJM, Dec 23, 1999, Volume 241:1986-1995. (Level 4 Evidence)
  • Bensky, Dan, Gamble, Andrew, Chinese Herbal Medicine, Materia Medica Revised Edition, Eastland Press, 1986
  • 1,2. Kendall, Donald E., OMD, Dao of Chinese Medicine Understanding an Ancient Healing Art, Oxford University Press, 2002
  • 3,4. Wu, Nelson Liansheng, Wu, Andrew Qi, English Transulation, Wang, Bing (Tang Dynasty) Original Note, Yellow Empero's Canon Internal Medicine, Chine Science & Technology Press, 2000
  • 5. Flaws, Bob, and Sionneau, Philippe, The Treatment of Modern Western Medical Diseases with Chinese Medicine, Second Edition, A Textbook & Clinical Manual, Blue Poppy Press, 2005
  • 6. Falck-Ytter y, Younossi ZM, Marchesini G, McCullough AJ, Clinical features and natural history of nonalcoholic steatosis syndromes, Schwartz Center for Metabolism and Nutrition, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, 2001;21(1):17-26
  • © Donna Dupre 2007-2012 All rights reserved.