Lumbar Disc

8/11/2019 Lumbar Disc

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Pathology and TCM Treatmentof the Herniated Lumbar Disc

East West Healing Center

By Dr. Leon Chenwww.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 shootingpain)

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.

Local anatomy

The Structure of Vertebral Column

The vertebral column in an adult typicallyconsists of 33 vertebrae arranged in five

regions: 7 cervical, 12 thoracic, 5 lumbar,and 5 sacral, and 4 coccygeal. Thevertebral column is considered to have 26vertebrae, because 5 vertebrae are fusedin adults to form the sacrum and 4vertebrae 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

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 linefrom 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, transverseprocess 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 articular

process

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

Intervertebral Disc

椎体 Centrum透明软骨板

Hyaline Cartilage

纤维环 Annulus Fibrosus

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 verysimilar to the intervertebral (IV) discs ofthe 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.

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.

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 keepsthe 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.

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: Balance

Low limb: SupportVertebral Column: Axis

Pelvis: 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

骶棘肌 Sacrospinalis斜方肌 Trapezius

L5Thoracolumbar fascia

背阔肌 Latissimusdorsi

腹直肌 Rectus abdominis 腹横肌 Transversus abdominis

Xiphoid

process

Psoas Major

Rectus abdominis

Quadratus Lunborum

Latissimus dorsi

Transversus

abdominis

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 femoral

cutaneous N

Inguinal

ligament

腹股沟韧带

Femoral Nerves

• The femoral nerve involves the ventralrami 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 nerveSaphenous nerveMedial cutaneous

Sensory area of

Femoral N

股神经

Femoral N

股外皮神经

Lateral femoral

cutaneous N

Saphenous

Intermediate cutaneous

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 ofthe thigh.

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

Common

Peroneal 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

• 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 Common

Peroneal N

腓浅神经

Superficial

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 onecorresponds to the number of cervical conus medullaris.

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

Lower thoracic vertebrae: the number plus three corresponds to thenumber of the thoracic conus medullaris.

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

medullaris.

Intervertebral Disc and Nerve Roots

Patterns of Disc Herniation

• Three patterns differentiated by thecondition of nucleus pulposus herniation

• Five patterns differentiated by the location

and direction of nucleus pulposusherniation

• Two patterns differentiated by ligamentdamage

• Three patterns differentiated bypathological stages of nucleus pulposus

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 bulging

破裂椎间盘

游离椎间盘 sequestration

正常椎间盘 Normal disc

破裂型 extrusion

Five patterns differentiated by the location

and direction of nucleus pulposus herniation

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

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

P t i h i ti

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 rootDisc compression at

lateral side above of

nerve root

Side of spinal cord

Disc herniation inside vertebral body

Nucleus of disc

Schmorl’s

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.• Transligamentous extrusion: the disc has

torn through the posterior longitudinal

ligament pressing on the nerve root orspinal 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

and the nucleus pulposus is fragmented

后纵韧带 Posterior

longitudinal

Ligament前纵韧带

Ligament

受压的神经根

Three characteristic pathological

evolutionary stages of the nucleuspulposus

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 atL5-S1, and secondarily at L3-L4 or L2-L3.

3) Causes: 1)Degeneration of the disc.

2)Injury

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 dullpain or severe, acute pain.

2) Shooting pain in the legs:

Lumbar disc herniation often occurs at the L4-5or 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 sideof the foot, and toes. Coughing or sneezing

can aggravate the pain, causing shooting pain

down the lower limbs.

4) Abnormal spinal curvature:

• After the lumbar disc herniation, 64% patientshave 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

• Clinically, disc protrusion is generally at thelateral 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 rootThe disc presses at

lateral side above

nerve root

Side of spinal cord

How to measure the curve

of 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.

Ⅵ Special Examination

1) Mobility of Lumbar Vertebral Column:

Normal range of motion

Flexion 90°

Extension 30°

Side bend 20°-30°

Twist 30°

3) Abnormal tendon reflexes

• If the lumbar disk is herniated, the knee tendon reflex

or Achilles tendon reflex can be weak, absent, orexcessive.

• If the herniation is at L3-L4, the knee tendon reflex

can be weak or absent, and foot extension is weak;

• If herniation is at L4-L5, the knee tendon reflex and

Achilles tendon reflex is normal but toe extension is

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

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 ispositive.

5) Kernig’s test: (Supine) While bending the hip joint

and knee joint to 90° degrees, then extending theknee, 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.

Lasegue Test

Lindner Test

Ⅶ I i E i ti

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.

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.

Ⅷ Differential Diagnosis

1 Acute lumbar injury2 Lumbar spinal stenosis

3 Piriformis syndrome

4 Sciatic neuritis

5 Spinal tumors6 Sacroiliac joint injury

7 Third lumbar transverse process syndrome

8 Pelvic inflammatory disease

9 Entrapment syndrome of superior cluneal nerve

10 Entrapment syndrome of lateral femoral cutaneousnerve

11 Greater trochanter bursitis

12 Entrapment syndrome of common peroneal nerve

1 Acute Lumbar Injury

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 injury

1) The pain is mostly in the lower back. Sometimesthe pain affects the leg, but there is no shooting

pain in sciatic nerve distribution.2) Pain is aggravated by movement, alleviated by

3) An obvious tender area is easy to find.

4) CT or MRI does not show a disc herniation.

2 Lumbar Spinal Stenosis

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 cordor spinal nerve roots. This pressure canlead to many problems that often occurwith 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 Syndrome

3. Piriformis Syndrome

• The piriformis syndrome is a condition inwhich the piriformis muscle irritates the

sciatic nerve, causing pain in the buttocks

and leg, with referred pain, commonlycalled sciatica, along the course of the

sciatic nerve.

Diagnosis points of 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.

4 Sciatic Neuritis

4. Sciatic Neuritis

Sciatic pain mainly is caused by viralinfection, which damages the sciatic

nerve. This is also called sciatic neuritis,

and isn’t commonly seen clinically.

5 Spinal Tumors

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 areof concern.

6 Sacroiliac Joint Injury

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, andshoulders--joints that are made to undergo

motion. The sacroiliac joint does not move

much, but it is critical to transferring theload of your upper body to your lower

Diagnosis Points of Sacroiliac

Joint Injury

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

3) Pain on one side lower back, without legpain.

4) Faber’s test (―4‖ character test ) ispositive.

5) Studies (X-Rays, MRIs, CAT Scans,Bone Scans) are often normal

Diagnosis points of the third lumbar

transverse process syndrome

1) The pain can be on one or both sides ofthe third lumbar region, and may radiate tothe posteriolateral part of the thigh insevere cases.

2) The patient is unable to sit and stand forlong, with pain aggravated on sitting orstanding and alleviated after rest.

3) A longer or normal transverse process ofthe third lumbar vertebra is shown in theX-ray or MRI film.

8. Pelvic inflammatory disease

Pelvic inflammatory disease (PID) is ageneral term that refers to infection of the

uterus, fallopian tubes and bladder.

The inflammation can irritate tissues andmuscle, causing lower back pain.

Diagnosis points of entrapment syndrome of

g p p y

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

Diagnosis points of entrapment syndrome of

the lateral femoral cutaneous nerve

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

2) Sports injuries such as trauma or muscle tears of thelower abdominal muscles may also result in injury to

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

4) It may also be caused by injury from surgicalprocedures.

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

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

Lateral femoral cutaneous N

Femoral N

Lateral femoral

cutaneous N

Femoral N

11. Greater trochanteric bursitis

• Greater trochanteric bursitis ischaracterized 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 thelateral aspect of the thigh.

Diagnosis points of greater

trochanter bursitis

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

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

3) Pain may radiate down the lateral aspect of the

ipsilateral thigh. Pain usually does not radiate all theway into the foot.

4) Typically, symptoms worsen when the patient is lyingon the affected bursa (eg, lying in the lateral decubitusposition).

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

• The common peroneal nerve courses aroundthe fibular neck and passes through the fibro-osseous opening in the superficial head of theperoneus longus muscle. This opening can be

quite tough and result in the nerve passingthrough it at an acute angle.

• The common peroneal nerve gives off 2branches: the superficial peroneal nerve (the

lateral cutaneous nerve of the calf ) and deepperoneal nerve (the sural communicatingbranch nerve )

• Diagnosis Points of Entrapment Syndrome

of Common Peroneal Nerve

1) Peroneal nerve injuries are most commonperipheral 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 concernto the patients.

peroneal N

Common

peroneal N

areaSuperficial

peroneal N

Superficialperoneal N

Common

peroneal N

Ⅸ TCM Treatment of Disc

Herniation

TCM treats the herniated lumbar disc withthree methods:

• TuiNa

• Acupuncture

• Herbs.

According to Chinese medical research,

70% of herniated lumbar discs showsgood 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.③

Twin 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.① Side fist.② Fist.

7) Dou: Shaking.8) Da: Patting and pounding.

2 Combined manipulation:

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:

3. Manipulation of joints:

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

traction.

2) BanFa: Adjustment of joints.3) YaoHuang: Rotating.

牵引按压法

俯卧斜扳

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

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 needleretaining; 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 andherbs .

• Surgery if one of the following happens:

①If the symptoms are very severe, occurrepeatedly in one year, alternative treatment isnot working.

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

③Nerve root compression with the numbness andfoot drop.

Thank you

Phone：630-916-0781

E-mail: drchen12@yahoo.com

Web：www.eastwesthealingcenter.net

Lumbar Disc

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