Acupuncture in the Treatment of Sequestered Intervertebral Disk Herniation

Abstract

Objective: Most patients with sequestered intervertebral disk herniation (IVDH) are subjected to neurosurgery. This study was designed to demonstrate that acupuncture can be an effective treatment modality for patients with herniated disks unless the disease is complicated.

Materials and Methods: Three patients with IVDH received 2–3 courses of acupuncture treatment (12 sessions each) combined with pharmacopuncture with chondroprotector. Visual analogue scale (VAS) for pain and magnetic resonance imaging findings were used to test the effectiveness of the treatment.

Results: Decrease in pain severity has been observed from 7–8 points to 3–4 points in VAS after the first course of treatment. Complete resorption of hernia sequesters in 4–5 months after the treatment has been started.

Conclusions: Acupuncture is an effective alternative for patients with IVDH unless surgery is indicated. Acupuncture treatment results in resorption of hernia sequester and improves pain syndrome.

Introduction

For patients and physicians alike, diagnosis of “sequestered intervertebral disk herniation” (IVDH) is almost always associated with neurosurgery. Surgery is indicated when patients have intolerable pain that is not relieved by pain killers, pelvic disturbances, and increasing dysfunction of the peripheral nerve. However, recently magnetic resonance imaging (MRI) due to its good visualizing capacities has proven to be a valuable examen to show that damage to the disk can be different. There have been reports in the literature suggesting that conservative treatment could be used to reduce the size of hernia and sequesters.^1–3

The mechanism of developing intervertebral disk hernia in general and sequestered hernias in particular is as follows: normally nucleus pulposus (NP) is hermetically encased between two endplates of adjacent vertebras due to annulus fibrosus fibers. NP is a jelly-like substance, that is why it is also called gelatinous nucleus and can be considered as liquid. According to the laws of physics, liquid is uncompressible. When the disk becomes compressed, there is a great amount of pressure on the NP. This may lead to the breakdown of the annulus fibrosus with jelly-like material being forced out, which causes the disk to bulge. When NP components bulge out forward, ventral intervertebral hernia occurs, which is usually not accompanied by an acute syndrome. The most common conditions are the so-called dorsal hernias characterized by painful, myotonic, and autonomic nervous disorders.

When a large hernia migrates along the spinal canal upward or caudally, there occurs separation of hernia substance from the “maternal” disk, which is called sequestration. The severity of clinical symptoms depends on the size of the chipped fragment as well as its location in the spinal canal. With transverse location, compression of dural sac, liquor dynamics disturbance, and a great amount of pressure on the nerve roots result in severe pain syndrome, which makes the surgery inevitable. However, hernia sequester is frequently located in the space formed by the vertebral body (according to the stereometrics, vertebrae is a cylinder with concave sides) and spinal canal structures. In this case, neurosurgery may not be necessary.

It should be noted that the IVDH formed is a variable structure that undergoes some evolution. Hernia substance mostly composed of mucopolysaccharides becomes ‘the tissue that is leaked out and deposited exteriorly from the spinal column, and triggers the process of immune inflammation and neovascularization.’^4,5 NP is avascular. That is why immune system, which constantly tests cells and tissues in terms of “friend or foe,” is unfamiliar with its components. When the exposed tissue of the NP is found outside its normal anatomic location, the immune system responds to it as a foreign body.^6,7 Lysosomal enzymes of macrophages attack the tissue of hernia and its sequestered fragments, gradually lysing their size and density until they disappear completely.^8–10

It is important to understand that the inflammation process followed by proliferation and scarring in the hernia gate and decrease in the size of hernia and especially sequester is the most favorable outcome for a patient. It should be noted that the events already described result in closing and strengthening hernia gate, which reduces the risk of recurrent disease.

Mechanical removal of the herniated disk during surgical intervention leaves the gate open. Intensive hormone therapy with glucocorticoids can also have unfavorable outcomes due to the interruption of the inflammation process before proliferation and scarring occur. In other words, the cyclic process does not result in structure strengthening, the hernia gate (the opening where the NP is expelled) remains open, and the sequestered fragment does not decrease. To control the inflammation process intensity, we need to sail figuratively speaking between Scylla and Charybdis, that is, it is important to reduce the inflammation process rather than stop it completely.

According to Traditional Chinese Medicine (TCM), the condition already described is called “back pain” (Yao Tong) and might have the following variants:

• 1.Bladder and gallbladder meridians as well as Du Mai are affected by the “cold, dampness, and wind” (Han Shi Yao Tong).
• 2.Blood stasis due to trauma (Wai Shang Yao Tong).
• 3.Consumption of Kidney Essence (Shen Xu Yao Tong).¹¹

With the first syndrome, known as excessive, invasion of cold and dampness impedes Qi and Blood circulation causing pain. Patients usually show the white-coated tongue, slow, deep, and tense pulse, and increased susceptibility to the cold.

The second syndrome is referred to as fullness syndrome. The patients present with severe pain due to slow Qi and Blood circulation that exacerbates in recumbent position at night and improves during the day when a patient is moving. The tongue has a purple tint and pulse is deep and intermittent. The third type is known as insufficiency syndrome, which develops gradually.

With deficient Yang, patients experience weakness, cold sensation in the lower back, and frequent urination. The pulse is weak and thready, the tongue is pale with a thin white coat. With depleted Yin, the patients are restless and present with insomnia, dry mouth and throat, and yellow urine. The patients also have red tongue, and fast, weak, and thready pulse.

Western diagnostics and pathogenesis according to TCM allow us to conclude that IVDH and especially its sequestration match the description of the first two syndromes. The general treatment modality includes Qi activation, Blood circulation improvement, muscle and tendon relaxation, and collateral drainage. However, prolonged disease always results in kidney deficiency symptoms, especially Yang, which should be considered when choosing the treatment modality.

In Western medicine, the primary goal of treatment is to improve microcirculation in the area of the affected vertebral segments and along the peripheral nerve roots outgoing from their levels. This goal is achieved by anesthetizing and reducing painful spasm of muscles and blood vessels that results in restoring muscular–venous drainage and normalizing blood flow. Neovascularization process around IVDH has been recently reported to play a significant role. The more pronounced this process is the faster and more complete the resorption of herniated substrate.

Materials and Methods

We have analyzed the treatment results for three patients with IVDH. Before seeking the help of an acupuncturist, all the patients have had 1- to 3-month history of the disease. Before acupuncture, all patients received conventional medication treatment, including glucocorticoid hormones, nonsteroidal anti-inflammatory drugs (NSAIDs), myorelaxants, vitamins B₁, B₆, B₁₂ complex, and chondroprotectors. Each patient underwent 2–3 courses of acupuncture treatment including 10–12 sessions. The sessions were performed 3 times a week with the interval 4–5 months between courses.

During the first course of treatment, each patient received pharmacopuncture with chondroprotector “alflutop.” Then, 0.2–0.3 mL of the medicine was injected into each acupoint by insulin syringe with 4–5 acupoints for a session. In all cases, acupuncture was performed using steel disposable needles manufactured in China: needle diameter 0.2–0.3 mm and length from 40 to 75 mm.

On paired acupuncture channels, the points were applied bilaterally. At the beginning of treatment for severe pain, we used silver-plated needles (the same manufacturer) on the side of the lesion. The needles were inserted at the standard depth for each point until the needle sensation “De Qi” was reached. The exposition of the needles in the points was equal to 20–25 minutes. The second course of treatment included 10–12 acupuncture sessions performed every other day. The severity of pain syndrome was assessed with visual analogue scale (VAS): 0–1, no pain; 1–3, mild pain; 3–5, moderate intermittent pain; 5–7, moderate persistent pain; 7–9, severe; and 9–10, intolerable pain.

Cases

• 1.Patient B., male, 54 years, at the beginning of December 2017, was referred to the outpatient department complaining of pain in the lower back radiating to the outer right thigh and leg. The patient presented with 3-month history of low-back pain. He received different NSAIDs intramuscularly, lidocaine blockades with dexamethasone, and vitamins B complex. Pain severity decreased slightly, but working capacity was not restored. MRI showed IVDH L3–L4 sequester migrating upward along the spinal canal (Fig. 1). Also, since the patient had pituitary adenoma, he was recommended surgical treatment of hypophysis tumor and IVDH sequestration simultaneously. The neurosurgical intervention was scheduled at the end of January 2018.

FIG. 1.

Patient B. before treatment. All arrows in the figure indicate the location of hernias.

However, because of the severe pain syndrome (8 points in VAS), the patient received corporal acupuncture and pharmacоpuncture with alflutop. The sessions were conducted every other day (3 times a week). Bladder acupoints were selected at, above, and below IVDH BL24 (Qi Hai Shu), BL25 (Da Chang Shu), and BL26 (Guan Yuan Shu) for pharmacopuncture. Also acupoints GB30 (Huan Tiao), GB31 (Feng Shi), DU2 (Yao Shu), DU3 (Yao Yang Guan), DU4 (Ming Men), DU14 (Da Zhui), BL23 (Shen Shu), BL28 (Pang Guang Shu), BL60 (Kun Lun), KI 3 (Tai Xi), and LV3 (Tai Chong) were needled. GB34 (Yang Ling Quan) and BL28 (Pang Guang Shu) points were heated using the “hot needle” method by means of a piece of wormwood cigar placed on the needle handle (Fig. 2).

FIG. 2.

“Hot needles” at point BL28 (Pang Gung Shu).

Steady pain relief was noted after the sixth session. By the end of the treatment (12 sessions), overall regression of the pain syndrome was 85%–90% (1–2 points in VAS), according to the patient. In January 2018, the patient was referred to the regional hospital for neurosurgery, but he got flu. The surgery was cancelled. In April 2018, the patient sought the help of an acupuncturist because of leg pain exacerbation and received acupuncture treatment (10 sessions) that resulted in pain alleviation. In June 2018, he was admitted to the regional hospital for pituitary adenomectomy. Before surgery, MRI of the spine was performed that showed the absence of a previously detected hernia fragment (Fig. 3). That is why the patient underwent only adenomectomy.

FIG. 3.

Patient B. after acupuncture treatment. All arrows in the figure indicate the location of hernias.

• 2.Patient G., male, 59 years, had an acute condition in February 2019. Two days before the patient had a wind chill, and after lifting heavy things and turning simultaneously, he experienced sharp pain in the lower back radiating along the outer left leg to the foot.

MRI revealed peaked IVDH L4–L5, that is, compressing dural sac and narrowing left intervertebral foramen (Fig. 4).

FIG. 4.

Patient G. before treatment. All arrows in the figure indicate the location of hernias.

The patient rejected the recommended neurosurgery. The patient received nonsteroid anti-inflammatory medication (meloxicam), central muscle relaxant (mydocalm 100 mg i/m No. 10) and dexamethasone No. 5, 8 mg every other day. Medication treatment resulted in low-back pain relief, but the severity of the pain syndrome in the leg persisted with 7–8 points in VAS according to the patient. In the middle of March, the patient received corporal acupuncture sessions and pharmacopuncture with alflutop. Points were selected for the acupuncture protocol: BL23 (Shen Shu), BL28 (Pang Guang Shu), BL40 (Wei Zhong), BL60 (Kun Lun), GB30 (Huan Tiao), GB34 (Yang Ling Quan), GB41 (Zu Lin Qi), and SI5 (Wai Guan) bilaterally. Points BL24 (Qi Hai Shu), BL25 (Da Chang Shu), and BL26 (Guan Yuan Shu) on both sides were selected for pharmacopuncture. A total of 12 sessions were conducted every other day. The treatment resulted in pain regression to 3–4 points. Physiotherapy was recommended. During May 2019, the patient under his own initiative took 5 injections of diprospan (betamethasone—corticosteroid with prolonged effect). In June 2019, MRI (Fig. 5) was repeated that showed sequestered herniation L4–L5, caudally displaced and closely adjoining L5 vertebra. The severity of the pain was assessed at 1–2 points. Acupuncture treatment with 10 sessions was performed every other day. The acupuncture points already described were used. In October 2019, MRI showed sequester disappearance (Fig. 6). Despite the absence of pain syndrome, the patient received 7 sessions of acupuncture treatment.

FIG. 5.

Patient G. in 2 months after the first acupuncture course. All arrows in the figure indicate the location of hernias.

FIG. 6.

Patient G. after acupuncture treatment. All arrows in the figure indicate the location of hernias.

• 3.Patient B., female, 61 years, has been experiencing pain in the lower back and the right leg for several years. The pain aggravated in September 2018 after exposure to the cold while she was at work making a flower bed. At night, the pain in the leg became burning and intolerable. The patient was taken to the emergency department. Since the patient had severe pain syndrome, she was admitted to the neurology department. MRI showed sequestered herniated disk L4–L5 compressing the dural sac and the nerve in the right intervertebral foramen (Fig. 7).

FIG. 7.

Patient B. before treatment. All arrows in the figure indicate the location of hernias.

The patient received tramadol, dexamethasone, nonsteroid anti-inflammatory medications, central muscle relaxants, and vasodilators. The patient refused neurosurgery for removing sequester and hernia. At the time of discharge from the hospital, the pain in the leg improved slightly, but in 2–3 days it worsened to 8–9 points in VAS. The patient consulted an acupuncture doctor in the middle of October. The treatment was started with cupping and bloodletting from acupoints BL25 (Da Chang Shu) and BL28 (Pang Guang Shu) and inserting needles into acupoints DU14 (Da Zhui) and BL60 (Kun Lun, bilaterally). After the treatment, the pain improved significantly for a period of 12–14 hours. However, it worsened again but was not as severe as before the treatment. During the next sessions, the patient received acupuncture treatment and alflutop injections into local lumbar points, GB30 (Huan Tiao), BL23 (Shen Shu), BL28 (Pang Guang Shu), and BL57 (Cheng Shan) bilaterally. A total of 12 sessions were conducted every other day. During the last 2 sessions, contact moxibustion with moxa grains was applied bilaterally to the BL28 (Pang Guang Shu) and GB34 (Yang Ling Quan) acupoints until the spot burn scab (3–4 mm in diameter) appeared. Pain syndrome regressed to 3–4 points in VAS.

In March 2018, the patient underwent another acupuncture treatment as recommended. According to the patient, she had a significant and stable relief from the pain in 1.5 months after the first course of treatment with simultaneous scarring and epithelizing of acupoint GB34 (Yang Ling Quan). BL28 (Pang Guang Shu) epithelized 2 weeks earlier than GB34 (YangLingQuan). During the second course, the patient received 10 sessions of acupuncture treatment. The acupuncture protocol and treatment frequency were similar to that obtained during the first course of acupuncture, except for moxibustion. MRI conducted after the treatment revealed the absence of sequestered fragment and reduced and sealed hernia as well (Fig. 8)

FIG. 8.

Patient B. after acupuncture treatment. All arrows in the figure indicate the location of hernias.

Discussion

The patients included in the study had different symptoms of the disease and responses to the treatment.

The first patient had sequestered hernia combined with a large pituitary adenoma. Consequently, he suffered from lack of appetite, headache, and nausea before the second course of treatment. That is why he could not eat normally during the past 2–3 months. In other words, he became deficient in structural materials (proteins, fats, and complex carbohydrates) due to forced starvation. Probably this has helped the resorption of the sequestered hernia fragment despite its large size.

The second patient had 5 injections of diprospan once a week after acupuncture treatment. The injections were not prescribed by the physician. In our opinion, this might have been the reason why hernia resorption has stopped. Hormonal therapy suppressed the immune inflammation with the result that hernia evolution stopped (Fig. 5). Evolution resumed after the repeated acupuncture treatment. Three months later, hernia's sequester disappeared without application of chondroprotectors (Fig. 6).

The third patient was treated with acupuncture and pharmacopuncture combined with contact moxibustion with moxa grains. The treatment was chosen because the patient had spondylosis and spondylodiscitis L3/L4/L5 (Fig. 7), which required an intensive and long-term stimulation of microcirculation in the area of affected spine segment and nerve. Our observations demonstrate that contact moxibustion contributes to this effect.¹² It should be noted that moxibustion causes synchronization of inflammation processes in burned acupoint and in pathologic focus.

This synchronization is manifested in the fact that the skin defect does not close as long as the patient is experiencing pain from a hernia. Stable epithelization of acupoint occurs simultaneously with pain disappearance. These findings suggest that neovascularization plays an important role in hernia regression and resorption.

The role of chondroprotectors in treating IVDH, especially sequestered hernia, can be dual. First, this type of medicine represents a set of “construction materials” for the disk tissue (chondroitin and glucosamines), which provides plastic function in dystrophic and degenerated cartilage. Second, parenteral introduction of the medicine results in setting up immunocompetent cells against cartilage antigens of the hernia and its sequestered fragments. This mechanism might probably contribute to the herniated sequester resorption. However, this suggestion requires further investigation. In our study, we used the chemically complex medicine alpflutop, which is made of a hydrolysate of small sea fish tissues. This drug was used because it has a fairly liquid consistency to be injected by insulin syringe intra-acupoint unlike other jellylike chondroprotectors.

Moreover, many colleagues face the situation that is usually not described in investigation reports. We mean aggravation of disease symptoms, which usually occurs between the third and fifth treatment sessions. The first and the second acupuncture sessions give a pronounced analgesic effect with the result that a patient experiences pain relief and mood improvement. This is followed by a period of a few days, when the pain in the lower back and limbs might worsen. As a consequence, a patient experiences fatigue and weakness, the symptoms resembling those of virus infection (influenza).

Starting with the sixth to seventh sessions, patient's condition improves and this improvement increases within 2.5–3 months after acupuncture. The reason for the symptom aggravation already described is intensified microcirculation^13,14 (Qi and Blood) that changes the type of intracellular adenosine triphosphate synthesis in the pathologic focus from anoxic to oxygen glucose phosphorylation. This causes removal of toxic metabolism products (lactic and pyruvic acids) from cells, which is producing local and general intoxication.^15–17

In our opinion, local pain might also worsen due to the increased arterial blood flow in the tissue and its temporary domination over venous outflow. This causes the tissue to “swell,” which results in temporary pain increase because of the herniated disk and space deficit (especially with narrow spinal canal). Then the venous outflow levels off with arterial inflow, the tissue blood flow reaches a higher level, and the pain and edema decrease. In other words, we regard a temporary aggravation of symptoms as a favorable prognostic sign. This should be explained to the patient before the treatment begins.

Conclusion

• 1.Conservative treatment of IVDH is possible. It is performed if there are no absolute indications for neurosurgical treatment, such as pelvic dysfunction, increasing dysfunction of the peripheral nerve, and intolerable pain despite administration of adequate pain medications.
• 2.Acupuncture may promote resorption of a sequestered fragment of an intervertebral hernia as well as reducing the size of the hernia.
• 3.When treating both uncomplicated and sequestered intervertebral hernia, combination of acupuncture and pharmacopuncture with chondroprotectors is advisable.

Author Disclosure Statement

The authors declare that no competing financial interests exist.

Funding Information

No funding was received for this study.