Pathology and TCM Treatment of the Herniated Lumbar Disc

East West Healing Center

By Dr. Leon Chen

www.eastwesthealingcenter.net

Definition in Western Medicine

Lumbar intervertebral disc injury leads to • partial damage to or tears of the annulus

fibrosus • protrusion of the nucleus pulposus • compression of the spinal nerve roots• lower back pain, leg pain (including shooting

pain)

This is called Lumbar Disc Herniation Syndrome.

Definition in Traditional Chinese Medicine (TCM)

• Lumbar Disc Herniation Syndrome is called “BiZheng 痹症” in Traditional Chinese Medicine (TCM).

• The HuangDiNeiJin in 475-221 B.C.(The Yellow Emperor’s Internal Classic) discussed the syndrome of pain in the low back and leg.

Ⅰ Local anatomy

The Structure of Vertebral Column The vertebral column in an adult typically

consists of 33 vertebrae arranged in five regions: 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral, and 4 coccygeal. The vertebral column is considered to have 26 vertebrae, because 5 vertebrae are fused in adults to form the sacrum and 4 vertebrae are fused to form the coccyx.

Curvatures of the Vertebral Column:

The vertebral column appears straight from the anterior and posterior position. Laterally, it has three natural curves to balance the body: cervical, thoracic, and lumbar curves. A straight line from head to foot should run through the crossing point of each curvature.

Physical Purposes of the Curvatures of the Vertebral Column:

1) To increase the ability of vertebral column to support weight; and balance the body.

2) To decrease the concussion to protect the head.

3) To strengthen the stability of the standing posture.

4) To spread body weight evenly throughout the vertebrae and discs.

41°A

BC

L3

Measurement of lumbarsacral angle can be found by drawing a line along the sacral base (B) and making a horizontal line (A).Normal values lie between 26-57° with a mean of 41°.

The lumbar gravity line: the C line from center of L3 body by drawing a vertical line which pass through the anterior lip of the sacral base (S1), if this C line does not surpass 10 mm that is all normal.

lumbarsacral angle

Structure of Lumbar Vertebrae:

1) Lumbar vertebrae have massive and flat bodies, because this shape helps to support more body weight.

2) Each vertebrae includes the vertebral body (centrum), vertebral foramen, pedicle, lamina, articular facet, articular process, transverse process and spinous process.

椎体 Centrum

椎弓根 Pedicle

椎弓板 Lamina

横突 Transverse process

棘突Spinous process

椎孔Vertebral foramen

上关节突 Superior articularprocess

下关节突 Inferior articular facet

棘突 Spinous process

上关节突 Superior articular process

横突 Transverse process

椎体Centrum

椎弓根Pedicle

Structure of the Intervertebral Disc

1) *Hyaline Cartilage: is the cartilage of the superior and inferior surfaces of the vertebral body. It also forms the top and bottom border of nucleus pulposus. It bears the weight and protects the nucleus pulposus.

2) *Annulus Fibrosus: is a fibrous ring, like a radial tire. It is elastic, embracing and holding the nucleus pulposus, not leting it herniate.

3) *Nucleus Pulposus: is a kind of gelatinous, flexible, semifluid material, located in the center of the annulus fibrosus. Both top and bottom surface are sealed by hyaline cartilage.

Intervertebral Disc

椎体Centrum透明软骨板

Hyaline CartilageHyaline Cartilage

纤维环Annulus FibrosusAnnulus Fibrosus

纤维环

纤维环髓核

Nucleus

Thickness of Intervertebral Discs

The Thickness of IV Disc: total: 139mm.Cervical IV disc, 3.85 mm.

Thoracic IV disc, 4.03 mm.

Lumbar IV disc, 12.7 mm.

Function of Intervertebral Discs ：

The function of lumbar IV discs is very similar to the intervertebral (IV) discs of the cervical and thoracic vertebra:

• To bear the weight of the trunk• To connect to the limbs• To perform normal physical posture and

movement. Lumbar IV discs are the most important in

the vertebral column.

Function of Intervertebral Discs (2)

• Uphold the length of the spinal column and body height.

• Connect with adjacent vertebrae.

• Bear the weight evenly throughout the vertebral bodies.

• Act as a cushion or shock-absorber, protecting the spinal cord and brain. (the major purpose.

Structure of the Spinal Canal

1) The spinal canal is a passage, formed by successive openings in the articulated vertebrae through which the spinal cord and its membranes (epidural space) pass. Also called vertebral canal.

2) The spinal canal is made up of the vertebral foramen, and ligamentum flavum, and posterior longitudinal ligament.

Pedicle

Superior articular facet

flava ligament posterior longitudinal ligament.

Ⅱ Biomechanics of the vertebral column

• The vertebral column has inner balance and outer balance which helps the body to move in a balanced way. Normally, both inner and outer balance of the vertebral column keeps the body in perfect balance.

1) Inner balance is formed by discs and facet joints (zygapophysial joints) of vertebrae.

2) Outer balance is formed by dorsal and ventral muscles.

Pelvis

abdomen

SacrumSacrum

Disc

Centrum

Spinousprocess

Interspinalesligament

Spinal Canal

Posterior longitudinalligament

Anterior longitudinalligament

Abdominal Muscles

Back Muscles

身体平衡示意图Balance of body 颈部 neck

上肢 Upper limbs

胸腔 thorax

腹腔 abdominal cavity

骨盆腔 pelvis

下肢Low limbs

脊柱 Vertebral column

横膈 midriff

Upper limb: BalanceLow limb: Support Vertebral Column: AxisPelvis: Pivot

Muscles in the Outer- Balance of Vertebral Column

1) Dorsal muscles:• Psoas Major• Quadratus Lunborum• Sacrospinalis• Latissimus Dorsi• Trapezius• Rhomboideus

2) Ventral muscles:

• Serratus posterior inferior• Rectus Abdominis• Transversus Abdominis

腰大肌 Psoas Major 腰方肌 Quadratus Lunborum

Iliac crest

T12

L5

骶棘肌 Sacrospinalis 斜方肌 Trapezius

T6

T12

L5Thoracolumbar fascia

背阔肌 Latissimusdorsi

菱形肌 Rhomboideus 锯齿肌 Serratus posterior inferior

C4

T4

T11

L2

8

12

腹直肌 Rectus abdominis 腹横肌 Transversus abdominis

5

7

Xiphoidprocess

pubis

Psoas Major

Rectus abdominis

Quadratus Lunborum

Latissimus dorsi

Transversus abdominis

腰骶神经丛

Lumbosacral P

lexus

股神经Femoral N:L2-L4

闭孔神经Obturator N: L2-L5

坐骨神经Sciatic N: L4,5;S1,3

Common Peroneal N :L4~S2

Tibial NL4~S3

Lumbar P

lexus

腰丛神经L2~

L5S

acral Plexus

骶丛神经S

1~S

3

Ⅲ Lumbosacral Plexus

Supercficial N

Lateral plantar N

Deep N

Medial plantar N

坐骨神经Sciatic N

髂腹下神经Iliohypogastric N

闭孔神经

髂腹沟神经Ilioinguinal N

生殖股神经Genitofemoral N

股外侧皮神经

阴部神经Pudendal N

股神经

Figure of Lumbosacral Plexus

Obturator N

Femoral N

Lateral femoralcutaneous N

Inguinal ligament

腹股沟韧带

Femoral Nerves

• The femoral nerve involves the ventral rami of the spinal nerves of L2-L4.

• Distribution: Skin of anterior and medial surfaces of thigh, leg, and foot.

• Supplies: the anterior muscles of the thigh (Quadriceps femoris, Sartorius).

Femoral nerve

Anterior branches Posterior branches

Intermediate cutaneous nerve

Saphenous nerveMedial cutaneous nerve

Sensory area of Femoral N

股神经Femoral N

股外皮神经Lateral femoral cutaneous N

Saphenousnerve

Intermediate cutaneous

nerve

Medial cutaneous nerve

Sensory area of Lateral femoral cutaneous N

Lateral femoral cutaneous nerve

• The lateral femoral cutaneous nerve arises from the spinal nerves of L2 and L3, and travels to innervate the lateral thigh. It supplies the skin on the lateral aspect of the thigh.

L2

L3

L4

Obturator Nerve

• The obturator nerve arises from L2-L4 – the ventral rami of the spinal nerves. It supplies the skin on the medial surface of the thigh.

Sensory area of Obturator N

闭孔神经Obturator N

Adductor longus

Adductor magnus

Adductor brevis

Sciatic Nerve

• The sciatic nerve is a large nerve that runs down the lower limb. It is the longest single nerve in the body.

• The sciatic nerve involves L4, L5 and S1-3 –the spinal nerves of the main sacral plexus.

• It includes the common peroneal nerve and the tibial nerve.

• It distributes to the skin of the posterior surface of the leg and the sole of the foot.

坐骨神经

坐骨大孔Greater sciatic notch

闭孔Obturator foramen

闭孔神经Obturator N

股骨小结节Lesser trochanter

Greater trochanter

Tuberosity of ischium

Sensory area of Sciatic N

坐骨神经Sciatic N

腓总神经CommonPeroneal N

胫神经Tibial N

Common Peroneal Nerve

• It has branches called the superficial and deep peroneal nerves.

• The superficial peroneal supplies the muscles of the lateral compartment of the leg.

• The deep peroneal supplies the muscles of the anterior compartment of the leg.

腓浅 N 感觉支配区

腓总神经CommonPeroneal N

腓浅神经Superficialnerve

腓深神经Deep nerve

腓深 N 感觉支配区

Tibial Nerve

• The tibial nerve supplies the muscles and skin on the posterior surface of the leg and the sole of the foot.

• The tibial nerve gives rise to the sural nerve (which supplies the skin on the back of the leg) and ends on the sole of the foot as the medial and lateral plantar nerves.

感觉支配区

胫神经Tibial N

腓总神经Common Peroneal N

胫神经Tibial N

足底外侧神经Lateral plantar N

足底内侧神经Medial plantar N

Location of vertebrae in relation to the conus medullaris

• Cervical: Cervical vertebrae: the number of the vertebra plus one corresponds to the number of cervical conus medullaris.

• Thoracic:Upper thoracic vertebrae: the number plus two corresponds to the number of the thoracic conus medullaris.Lower thoracic vertebrae: the number plus three corresponds to the number of the thoracic conus medullaris.

• Lumbar vertebrae: correspond to the number 1~5 of sacral conus medullaris.

LV1

TV1

CV2

TV6

S-CM1,5

TV12L-CM3TV11

L-CM1

T-CM2

T-CM8

CV7

C-CM8

Location of vertebrae in relationship to the conus medullaris

Intervertebral Disc and Nerve Roots

LV5

SV1

LV4

LV3

SN1

LN5

LN4

LN3

LV2

S2

S1

45

C 34

5 67

8

34

5

C

S2

L1

L2

L3

L4

L5

S1

T1

T1 23

12

4 56

78

910

11

C5

C6C8

C7

C8

C7

C6

S2

L5

L4

L5

L4

L5L4

3

Ⅳ Patterns of Disc Herniation

• Three patterns differentiated by the condition of nucleus pulposus herniation

• Five patterns differentiated by the location and direction of nucleus pulposus herniation

• Two patterns differentiated by ligament damage

• Three patterns differentiated by pathological stages of nucleus pulposus

Three patterns differentiated by the condition of nucleus pulposus herniation

1)1)Protrusion or bulging: Protrusion or bulging: The annulus fibrosus is not torn The annulus fibrosus is not torn but protruding or bulging, compressing the nerve root.but protruding or bulging, compressing the nerve root.

2)2)Extrusion: Extrusion: The annulus fibrosus is torn, and the nucleus The annulus fibrosus is torn, and the nucleus pulposus herniated to compress the spinal cord or nerve pulposus herniated to compress the spinal cord or nerve roots. roots.

3)3)Sequestration: Sequestration: The annulus pulposus is ruptured, the The annulus pulposus is ruptured, the fragmentfragment of nucleus pulposus has traveled below the nucleus pulposus has traveled below the posterior longitudinal ligament and herniated into the spinal posterior longitudinal ligament and herniated into the spinal canal, compressing the spinal cord or nerve root. canal, compressing the spinal cord or nerve root.

椎间盘退化

膨隆型

破裂型

游离型

髓核

纤维环

脊髓神经根

椎间盘膨隆protrusion or bulgingprotrusion or bulging

破裂椎间盘

游离椎间盘sequestrationsequestration

正常椎间盘Normal disc

破裂型 破裂型 extrusionextrusion

Five patterns differentiated by the location Five patterns differentiated by the location and direction of nucleus pulposus herniationand direction of nucleus pulposus herniation

• Herniation of the nucleus pulposus can happen in the anterior, posterior, or lateral direction or in all four directons. Also there is a form of herniation called herniation inside of the vertebral body.

• Posterior herniation is divided into two patterns: posteriolateral herniation and posteriocentral herniation.

Posterior herniation

Posterolateral Herniation Posterocentral Herniation

Distribution of Disc Herniations and Their Frequency

The picture is in the frontal plane额状面（切掉椎体）

Spinal cord compression

Pedicle section椎弓根截面

Ligamentum flavum

Disc compression at medial side below nerve root

Disc compression at lateral side above of nerve root

Side of spinal cord

Disc herniation inside vertebral body

Nucleus of disc

Schmorl’s Node

The nucleus of disc drills through the hyaline cartilage into vertebral body

Two patterns differentiated by damage to the posterior longitudinal ligament

• Subligamentous extrusion: the posterior longitudinal ligament has not been torn, but there is disc protrusion.rotrusion.

• Transligamentous extrusion: the disc has torn through the posterior longitudinal ligament pressing on the nerve root or spinal cord, and there is disc extrusion.

Spinal cord

Nerve root

Posterior longitudinal ligament

nucleus pulposus

The posterior longitudinal ligament is intact

The posterior longitudinal ligament is torn

The posterior longitudinal ligament is tornand the nucleus pulposus is fragmented

后纵韧带PosteriorlongitudinalLigament

前纵韧带AnteriorLongitudinalLigament

受压的神经根

Three characteristic pathological evolutionary stages of the nucleus

pulposus

1) Pre-herniation.2) Herniation.

3) Post-herniation.

IV Etiology

1) Age and sex: Mostly it affects people in middle age(30-50),males more than females.

2) Location: Mainly occurs at L4-5 and at L5-S1, and secondarily at L3-L4 or L2-L3.

3) Causes: 1)Degeneration of the disc.

2)Injury

Disc

Ⅴ Diagnosis

Symptoms:

1) Low back pain: The pain is mainly located in the lower back area; the back pain results from pressure on the posterior longitudinal ligaments and periphery of the annulus fibrosus. The painful area is deep, and it is usually dull pain or severe, acute pain.

2) Shooting pain in the legs:

Lumbar disc herniation often occurs at the L4-5 or L5-S1 level, causing lower back and and hip pain radiating down the thigh on the lateral and posterior sides, down the lateral side of the lower leg, and to the medial and or lateral side of the foot, and toes. Coughing or sneezing can aggravate the pain, causing shooting pain down the lower limbs.

S2

S1

45

C 34

5 67

8

34

5

C

S2

L1

L2

L3

L4

L5

S1

T1

T1 23

12

4 56

78

910

11

C5

C6C8

C7

C8

C7

C6

S2

L5

L4

L5

L4

L5L4

3

3) Numbness and tingling:

Protrusion of lumbar discs causes compression of the spinal nerve roots, and local inflammation and swelling.

Resulting nerve compression and lack of blood circulation causes malnutrition to the nerves.

Clinical symptoms are tingling, numbness and muscle atrophy.

4) Abnormal spinal curvature:

• After the lumbar disc herniation, 64% patients have abnormal spinal curvature. The curve of the vertebral column is the body’s way of protecting against low back pain and leg pain. Lateral curvature can relax the nerve root and relieve pain.

• Clinically, disc protrusion is generally at the lateral side above the nerve root (45%) A few disc protrusions are at the medial side below the nerve root (7%)

Distribution of Disc Herniations and Their Frequency

The picture is in the frontal plane额状面（切掉椎体）

Spinal cord compression

Pedicle section椎弓根截面

Ligamentum flavum

Disc compression of medial side below the nerve root

The disc presses at lateral side above nerve root

Side of spinal cord

The protrusion is at lateral side above nerve root

The protrusion is at medial side below nerve root

The curvature protrudes to the damaged side

The curvature protrudes to the healthy side

How to measure the curveof the vertebral column

• To measure the curvature of the spinal column, first find the centers of the two areas of greatest curvature. Draw a straight line throught these centers; from these lines, create a perpendicular (90°) line; cross both perpendicular lines and you will get the measure of the curve.

Measure of curvatureof vertebral column

30

Ⅵ Special Examination

1) Mobility of Lumbar Vertebral Column:

Normal range of motion

Flexion 90°

Extension 30°

Side bend 20°-30°

Twist 30°

2) Points painful to pressure2) Points painful to pressure

If the lumbar disc is herniated, its corresponding vertebra has an obvious tender area. When that area is pressed, pain occurs along the sciatic nerve distribution, shooting down along the lower limb.

3) Abnormal tendon reflexes3) Abnormal tendon reflexes

• If the lumbar disk is herniated, the knee tendon reflex If the lumbar disk is herniated, the knee tendon reflex or Achilles tendon reflex can be weak, absent, or or Achilles tendon reflex can be weak, absent, or excessive. excessive.

• If the herniation is at L3-L4, the knee tendon reflex If the herniation is at L3-L4, the knee tendon reflex can be weak or absent, and foot extension is weak; can be weak or absent, and foot extension is weak;

• If herniation is at L4-L5, the knee tendon reflex and If herniation is at L4-L5, the knee tendon reflex and Achilles tendon reflex is normal but toe extension is Achilles tendon reflex is normal but toe extension is weak; weak;

• If herniation is at L5-S1, the Achilles tendon reflex If herniation is at L5-S1, the Achilles tendon reflex becomes weak or absent, and foot flexion becomes becomes weak or absent, and foot flexion becomes weak.weak.

4) Lasegue’s test: (Supine) If there is pain in the lumbar area and lateral leg on performing a straight leg raise up to 70° and dorsiflexing the foot, the test is positive.

5) Kernig’s test: (Supine) While bending the hip joint and knee joint to 90° degrees, then extending the knee, if pain is induced, the test is positive.

6) Wasserman’s test: (Prone) The hip joint is over- extended. If pain presents at the anterior border of the thigh, the test is positive.

7) Abdominal pressure test: In the supine position, the patient is asked to push the abdomen out while holding breath in. If pain occurs at the lower back and leg, the test is positive.

8) Lindner’s test: The patient’s neck is passively flexed, gradually bringing the chin to the chest. If pain occurs at the lower back and leg, the test is positive, because of meningeal irritation.

Lasegue Test

Kernig Test

Lindner Test

Ⅶ Imaging Examination

1) X-ray:

• The joint space between vertebrae is uneven.

• The vertebral foramen is narrowed

• There is bone spurring.

• There is spondylolysis--a defect in the pars interarticularis of a vertebra.

L3

L4

S1

2) CT Scans and MRI’s provide clear images to examine bone, water, fat, muscle, blood, tendon, ligament, etc.

CT and MRI have three views: axial (transverse), sagittal and frontal planes.

L2

L3

L4

L5

S1

Ⅷ Differential Diagnosis

1 Acute lumbar injury 2 Lumbar spinal stenosis3 Piriformis syndrome 4 Sciatic neuritis5 Spinal tumors6 Sacroiliac joint injury 7 Third lumbar transverse process syndrome 8 Pelvic inflammatory disease9 Entrapment syndrome of superior cluneal nerve 10 Entrapment syndrome of lateral femoral cutaneous

nerve11 Greater trochanter bursitis 12 Entrapment syndrome of common peroneal nerve

1. Acute Lumbar Injury

Acute lumbar injury is caused when:

• The waist is flexed

• The waist is rotated

• Lifting too much weight unbalances the lumbar muscles and creates subluxation of the lumbar facet joints, or lumbar muscle sprain.

Diagnosis Points of Acute

Lumbar Injury

Indications of lumbar injury1) The pain is mostly in the lower back. Sometimes

the pain affects the leg, but there is no shooting pain in sciatic nerve distribution.

2) Pain is aggravated by movement, alleviated by rest.

3) An obvious tender area is easy to find.4) CT or MRI does not show a disc herniation.

2. Lumbar Spinal Stenosis

Lumbar spinal stenosis can be caused by: • Tumors and herniated discs • Degenerative changes (most common

cause) that occur with aging, e.g. arthritis • Degenerative effects-- Narrowing of spinal

canal causes pressure on the spinal cord or spinal nerve roots. This pressure can lead to many problems that often occur with long periods of walking or standing.

• Diagnosis points of Lumbar Spinal Stenosis

1) Lumbar spinal stenosis occurs with aging. Males are affected slightly more than females.

2) Lumbar spinal stenosis occurs mainly in the L3 - S1 region.

3) Lower back pain or leg pain often occurs when walking or standing for long periods.

4) Intermittent claudication.

5) X-ray, CT or MRI can locate the areas of compression of the spinal canal.

Lumbar Spinal Stenosis Figure

3. Piriformis 3. Piriformis Syndrome

• The piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve, causing pain in the buttocks and leg, with referred pain, commonly called sciatica, along the course of the sciatic nerve.

Diagnosis points of Piriformis Piriformis Syndrome

1) History of injury to the buttocks.

2) Patients generally complain of pain deep in the buttocks, which is made worse by sitting, climbing stairs, or performing squats.

3) No low back pain or spinal column curvature.

4) Special examination will be positive.

5) CT or MRI does not show a herniated disc.

PiriformisPiriformis FigureFigure

4. Sciatic Neuritis

Sciatic pain mainly is caused by viral infection, which damages the sciatic nerve. This is also called sciatic neuritis, and isn’t commonly seen clinically.

5. Spinal Tumors

• The cause of pain may be a spinal tumor — a cancerous or noncancerous growth that develops within or near the spinal cord or in the bones of the spine.

• In most areas of the body, noncancerous tumors aren't particularly worrisome. But in the vertebrae both kinds of tumors are of concern.

6. Sacroiliac Joint Injury

• The sacroiliac joint (SI joint) is a firm, small joint that lies at the junction of the spine and the pelvis. Most often when we think of joints, we think of knees, hips, and shoulders--joints that are made to undergo motion. The sacroiliac joint does not move much, but it is critical to transferring the load of your upper body to your lower body.

Diagnosis Points of Sacroiliac Joint Injury

1) Indication of lumbar injury2) Pregnancy or delivery may injure the SI

joint 3) Pain on one side lower back, without leg

pain. 4) Faber’s test (“4” character test ) is

positive.5) Studies (X-Rays, MRIs, CAT Scans,

Bone Scans) are often normal

7. The Third Lumbar Transverse Process Syndrome

• The pain spot is at the third lumbar transverse process area, and also affects the buttocks and lateral thigh. That is caused by the friction between transverse process and muscles, which causes inflammation. The third lumbar transverse process may be normal in length, or too long.

Diagnosis points of the third lumbar

transverse process syndrome 1) The pain can be on one or both sides of

the third lumbar region, and may radiate to the posteriolateral part of the thigh in severe cases.

2) The patient is unable to sit and stand for long, with pain aggravated on sitting or standing and alleviated after rest.

3) A longer or normal transverse process of the third lumbar vertebra is shown in the X-ray or MRI film.

8. Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a general term that refers to infection of the uterus, fallopian tubes and bladder.

The inflammation can irritate tissues and muscle, causing lower back pain.

Diagnosis points of PID

1) Lower back or pelvic pain, with no history of injury.

2) Abnormal vaginal discharge. 3) Antibacterial treatment reduces the pain. 4) Laboratory examination and ultrasoud or CT

exam reveals the problem.

9. Entrapment syndrome of superior cluneal nerve

• The medial branch of the superior cluneal nerve passes over the iliac crest through a tunnel down to the buttocks. In that particular area the superior cluneal nerves are compressed easily when injured. They innervate the skin of the upper part of the buttocks and lateral thigh.

Diagnosis points of entrapment syndrome of superior cluneal nerve

1) Indication of injury to lumbosacral area.

2) The pain occurs in the specific area of the nerve and radiates to the lateral thigh.

3) Bending the waist and walking causes pain. Also, changing posture from sitting to standing is difficult.

The dorsal cutaneous rami nerves

Latissimus dorsi

Trapezius

Gluteus maximus

Gluteus medius

Superior cluneal nerve

10. Entrapment syndrome of the lateral femoral cutaneous nerve

• It is a syndrome of pain in the lateral and anterolateral thigh.

• The lateral femoral cutaneous nerve passes through and underneath the lateral aspect of the inguinal ligament, and finally travels to innervate the lateral thigh. It divides into anterior and posterior branches and supplies skin from the greater trochanter to the mid thigh.

• If the nerve is pressed when injured, it causes burning pain and numbness of the greater trochanter and the mid thigh.

Diagnosis points of entrapment syndrome of the lateral femoral cutaneous nerve

1) This syndrome is most commonly seen in individuals aged 20-60 years, but it can occur in people of all ages.

2) Sports injuries such as trauma or muscle tears of the lower abdominal muscles may also result in injury to the nerve.

3) It may also occur during pregnancy due to the rapidly expanding abdomen in the third trimester.

4) It may also be caused by injury from surgical procedures.

5) There is pain on deep palpation just below the anterior superior iliac spine and from hip extension.

6) The pain is at the lateral thigh or anterolateral thigh and down to the knee and also sometimes in the inguinal region.

Femoral N

Lateral femoral cutaneous N

Lateral femoral cutaneous N

Femoral N

11. Greater trochanteric bursitis

• Greater trochanteric bursitis is characterized by painful inflammation of the bursa located just superficial to the greater trochanter of the femur.

• Patients typically complain of lateral hip pain, although the hip joint itself is not involved. Pain may radiate down the lateral aspect of the thigh.

Diagnosis points of greater trochanter bursitis

1) With acute trauma, patients may recall specific details of the impact.

2) The classic symptom is pain at the greater trochanteric region at the lateral hip.

3) Pain may radiate down the lateral aspect of the ipsilateral thigh. Pain usually does not radiate all the way into the foot.

4) Typically, symptoms worsen when the patient is lying on the affected bursa (eg, lying in the lateral decubitus position).

5) Pain may awaken the patient at night.6) Palpation also may reproduce pain that radiates down

the lateral thigh, but it does not go below the knee.

Greater trochanter

12. Entrapment Syndrome of Common Peroneal Nerve

• The common peroneal nerve courses around the fibular neck and passes through the fibro-osseous opening in the superficial head of the peroneus longus muscle. This opening can be quite tough and result in the nerve passing through it at an acute angle.

• The common peroneal nerve gives off 2 branches: the superficial peroneal nerve (the lateral cutaneous nerve of the calf ) and deep peroneal nerve (the sural communicating branch nerve )

• Diagnosis Points of Entrapment Syndrome of Common Peroneal Nerve

1) Peroneal nerve injuries are most common peripheral nerve injuries in the lower limb after multiple traumatic injuries.

2) Chronic compression injury is the cause.

3) The loss of sensation in the cutaneous distribution of the superficial and deep peroneal nerves may be noted, but ankle dorsiflexion weakness is often of most concern to the patients.

Deep peroneal Narea

Common peroneal NareaSuperficial

peroneal Narea

Deep peroneal N

Superficialperoneal N

Common peroneal N

Ⅸ TCM Treatment of Disc Herniation

TCM treats the herniated lumbar disc with three methods:

• TuiNa

• Acupuncture

• Herbs.

According to Chinese medical research, 70% of herniated lumbar discs shows good results with TCM treatments

TuiNa Actions

1) Reduce the pain.

2) Increase blood circulation in specific areas.

3) Relax the muscles, activate the channels.

4) Reduce muscle spasm.

5) Repair damaged soft tissue.

6) Adjust joints.

Modern Research of TuiNa

1) Increases content of Beta-endorphin (END) and Catecholamine (CA) in blood to help reduce pain.

2) Decreases content of 5-hydroxytryptamine (5-HT) in the blood, to reduce pain.

TuiNa Methods

1. Single manipulation:1) Tui: pushing. ①Finger pushing. ②Palm pushing.

③Twin palms pushing.2) Na: Grasping. ① Fingers. ② Twin palms.3) An: pressing. ① Finger pressing. ② Palm pressing.

③ Elbow pressing. 4) Mo: Rubbing.5) Rou: Kneading.6) Gun: Rolling. S① ide fist. ② Fist.7) Dou: Shaking.8) Da: Patting and pounding.

2. Combined manipulation:

1)GunRou: Rolling and Kneading.

2)NaRou: Grasping and Kneading.

3)Wave: Grasping, Pushing and Rolling.

4)AnRou: Pressing and Kneading.

3. Manipulation of joints:

1) BaShen: Counter traction. ①Joint traction. ②Cervical traction. ③ Lumbar traction.

2) BanFa: Adjustment of joints.

3) YaoHuang: Rotating.

牵引按压法

俯卧斜扳

法

侧卧斜扳法

坐位斜扳法双人扳法 单人扳法

• Differentiation and Treatment of TCM

1. Wind-cold-damp pattern:

May or may not have history of injury

Lumbar area and legs feel cold, painful and heavy;

If pain is chronic, symptoms are sometimes severe, sometimes mild, worsened by cloudy and rainy weather.

Tongue: white and greasy

Pulse: heavy and slow.

• Acupuncture: BL23 YaoYan BL40 GB30 GB31 GB34 BL55 GB39; evenly supplement and reducing, needle retaining 20 minutes, with moxibustion or TDP.

• Herbal Treatment: Du Hu Ji Sheng Tang, Xiao Huo Luo Tang etc.

2. Qi and Blood Stagnation Pattern:

• History of injury

• Lower back pain occurs right after the injury, worse with movement, gradually radiating pain in lower limb;

• Tongue: dark red

• Pulse: hesitant or wiry and rapid.

• Acupuncture Treatment: Yaoyan BL40 GB30 GB31 GB 32 GB34 BL55 ST36 GB39; reducing technique; no needle retaining; with cold compress.

• Herbal Treatment: Yuan Hu Zhi Tong Tang, Shen Tong Zhi Tong Tang and so on.

Ⅹ Cautions and Contraindications

• At the acute stage, don’t use heavy manipulation, better to use rest, traction, acupuncture and herbs .

• Surgery if one of the following happens: ①If the symptoms are very severe, occur

repeatedly in one year, alternative treatment is not working.

②Central herniation, with compression to cauda equina nerves that cause sphincter dysfunction.

③Nerve root compression with the numbness and foot drop.

Ⅺ Rehabilitation and Prevention

• During recovery from lumbar disc herniation, focusing on muscle exercise of lower limbs and lower back can balance the vertebral column and prevent herniation.

• Avoid carrying weight that could strain lower back for a long period of time.

• Use periodic relaxation treatment (acupuncture or TuiNa ) on lower back.

• Prevent osteoporosis

Thank you

Phone ： 630-916-0781

E-mail: drchen12@yahoo.com

Web ： www.eastwesthealingcenter.net