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Ouyang Hui
In corrective manipulation of the spine, correction of the lumbosacral vertebrae is much safer than cervical correction, but there are still risks. Spondylolisthesis is most commonly caused by degenerative changes in the spine. Degenerative spondylolisthesis occurs when intervertebral discs dry out and become thinner as the human body ages. The spine becomes unstable and vertebrae shift, causing them to slip. Degenerative diseases of the spine are most commonly seen and most severe in the lumbosacral area, which is the lowest part of the spinal column and supports the most weight. In the lumbosacral area, the fifth lumbar vertebra is most likely to slip as it is involved in the greatest range of motion in the lumbosacral line region. Degenerative spondylolisthesis often has a slow, long progression with relatively small vertebral shifts. Many experts do not believe that degenerative spondylolisthesis involves true dislocation, so they refer to it as pseudospondylolisthesis. Corrective manipulation is suitable for this kind of (pseudo) spondylolisthesis. In most cases of spondylolisthesis resulting from a new injury, there are vertebral arch fractures. Corrective manipulation can exacerbate the slippage, as well as the pressure on the spinal cord and nerve roots. Severe cases of true lumbar spondylolisthesis (grade III and up) require surgical treatment. Cases of old lumbar spondylolisthesis less than grade II can be treated with appropriate nonsurgical interventions, including careful corrective manipulation, even if they are true spondylolisthesis. Acupuncture plus movement, with the addition of stretching and compression, can reposition soft and hard tissue structures, replacing the actions and effects of most intensive chiropractic manipulations. Using symptombased acupuncture to treat lumbar spondylolisthesis is safe and reliable, but it does not do enough to correct the structure and is not sufficiently thorough as a treatment. By optimizing techniques and applying them flexibly, AcuChiro Therapy for lumbosacral disorders can not only treat the branch, but can also resolve the root cause.
The following is an actual case of diagnosing and treating true spondylolisthesis.
The patient was a 57yearold white female with a height of 163cm and a weight of 86kg. The chief complaint was chronic pain in the right lumbosacral area, which had recurred and worsened 3 weeks ago after work.
Current medical history: The patient had performed strenuous physical labor on farms in Texas since she was young. In 2005, she started to have lumbar pain after falling from a high platform. At that time, there was bruising and pain in the right lumbar and gluteal region; she did not seek professional treatment. The pain recurred 3 weeks ago after cutting flowers and trees in her yard, mainly due to repeated flexion and extension. This episode was the most severe recurrence. The pain was frequent (<75% but >50% of the time) and dull in the lumbosacral region, and referred to the right gluteal region, but did not radiate to the legs. Her condition had worsened since the onset of the episode, with a current pain level of 9/10 (using a pain scale of 0-10, with 10 being the most severe). The pain was relieved by standing straight and worsened by bending forward. It was especially difficult for the patient to get up from a prone position and the pain was worst when she was supine. She had taken over the counter medication, but had not received treatment. She was recommended to come directly to the clinic for treatment. Since the onset, she had not undergone any recent imaging tests. Her lumbar pain affected her sleep because it was difficult to lie supine. Her goals for starting treatment were to alleviate the pain and remove functional limitations.
Surgical history: The patients surgical history included the removal of a third kidney (on the right side) in 1964, pyeloplasty in 1985, and ureteral stump resection in 1986. The kidney surgeries occurred in childhood and adolescence, while the lumbar pain started in middle age.
Examination: A spinal examination showed lordosis and levoscoliosis of the thoracic and lumbar vertebrae, as well as tenderness/pressurepain in the lumbosacral region that involved the right gluteal region. L4/5 and the sacrum had restricted range of motion; the lumbosacral vertebrae and sacroiliac muscle tissues were very tense on the right side. There was no pain radiating to the legs. There was no sensory disorder in the groin area, and no fecal or urinary incontinence. The thoracic and lumbar vertebrae showed a moderate decrease in range of motion, with pain extending to the right gluteal region.
Forward flexion: 70° (normal is 90°) accompanied by pain;
Backward extension: 5° (30°) accompanied by pain;
Bending to the left: 15° (30°) accompanied by stiffness;
Bending to the right: 10° (30°) accompanied by stiffness;
Left rotation: 25° (30°) accompanied by stiffness;
Right rotation: 10° (30°) accompanied by stiffness.
The extensionrotation test was positive, showing functional impairment of the lumbosacral vertebrae, including the muscles of the lumbosacral area.The functional impairment of extension was due to sacrospinalis muscle damage; the impairment of contralateral rotation with simultaneous extension was due to multifidus muscle damage.
Diagnosis
Western medical diagnosis:
1. Degenerative disease of the lumbar (sacral) vertebrae
2. Damage to the sacrospinalis and multifidus muscles
3. Herniated intervertebral discs at L5 and S1
4. Lumbar spondylolisthesis at L5 (grade II anterolisthesis)
TCM diagnosis:
Lumbosacral symptoms (blood stasis and kidney vacuity)
Treatment and Outcomes
March 26th, 2019 (first treatment): In accordance with the safetyfirst principle of “AcuChiro Therapy”, acupuncture should be applied first to resolve spasms and relieve pain quickly, while chiropractic manipulation and tui na should be done with caution, especially intense corrective manipulation. At the same time, an xray exam should be requested. “Needle the Spine 3 Needles”: first, the distal point Shuigou (GV-26) was needled at the same time as the patient performed lumbar and leg stretches and movements. After the patient’s spastic muscles relaxed, acupuncture could be done in the prone position. Huatuojiaji points at L35 and trigger points for the multifidus and sacrospinalis muscles were selected as local points. Mingmen (GV-4), Yaoyangguan (GV-3), Shiqizhuixia, Shenshu (BL-23), Dachangshu (BL-25), and Ciliao (BL-32) were also needled.
March 27th, 2019 (second treatment): The patient’s pain level was 7/10. The lumbar and gluteal pain had decreased markedly since the previous treatment. After the xray exam, the lumbar pain and pain affecting the right gluteal area returned (because the patient had to turn over too much in the course of the exam).
Xray image (March 27th, 2019): L5 showed grade II anterolisthesis relative to S1, approximately 1.5cm. Bilateral defects were present in L5S1 vertebral arches. L5-1 were affected by degenerative disk disease with severe intervertebral disc space narrowing and endplate sclerosis. There was also mild diffuse facet arthropathy.
In terms of treatment, after acupuncture and movements, corrective manipulation was performed on the lumbosacral vertebrae, with hip and knee flexion as well as traction, compression, and repositioning.
March 29th, 2019 (third treatment): The pain involving the right gluteal area had decreased, but the lumbar pain was still present. The pain level was still 7/10.
April 3rd, 2019 (fourth treatment): The pain level was 3/10. The lumbar pain had decreased and the pain involving the right gluteal area was no longer noticeable.
April 12th, 2019 (fifth treatment): The pain level was 2/10. The lumbar pain decreased and there was no pain in the right gluteal area.
April 17th 2019 (sixth treatment): The pain level was 2/10. The lumbar pain decreased. A “lumbosacral workout” hip rotation movement for active muscle building was added to the treatment to increase the stability of the lumbosacral spine.
April 26th, 2019 (seventh treatment): The pain level was 1/10. The lumbar pain was essentially relieved. There was occasional knee pain.
From March 26th to April 26th, 2019, the patient was diagnosed and treated using AcuChiro Therapy. After the first treatment, her pain decreased markedly. She made progress with every treatment. After stopping treatment, the patient actively performed the “lumbosacral workout” exercises at home to increase the stability of the lumbosacral spine.
Followup and Prognosis：
August 15th, 2022 (phone followup): The lumbar pain was now bearable and did not impact daily activities. After the treatment on April 26th, 2019, there had been no subsequent major flareups and the patient had no intention of seeking surgery. The pain level was about 2/10 with occasional lumbar pain that did not exceed 4/10 and did not require treatment. During the pandemic, the patient exercised less and gained weight. The patient still felt that her lumbar muscles were weak and she was unable to do situps.
Questions and Experience：
Safety comes first. In terms of acupuncture and manipulation, during the acute phase acupuncture was used; vital points were needled to resolve tetany and relieve pain, and intensive manipulation was seldom used. After the acute phase, when the patient was fully relaxed, corrective manipulation was performed as appropriate. It turned out that the xray exam showed true grade II spondylolisthesis. Even diagnostic exams may aggravate the condition, to say nothing of treatment. The patient in this case experienced a recurrence of lumbar and gluteal pain after excessive turning over during the xray exam.
Efficacy comes second. Acupuncture plus movement, with the addition of stretching and compression, can reposition soft and hard tissue structures, thereby replacing the actions and effects of most intensive chiropractic manipulation. Any acupuncturist could perform these treatments; moreover, one could improve efficacy by optimizing ones techniques.
Degenerative changes in the spine cause disorders of the intervertebral discs, leading to spinal instability and spondylolisthesis. Ultimately, this makes the deep spinal muscles to become thin, weak, and damaged. Because the multifidus muscle is the most important deep muscle for stabilizing the spine, this muscle is one of the core muscles.
By grasping the core, one can stabilize the foundation. In restoring spinal stability, AcuChiro Therapy for lumbosacral disorders not only treats the branch, but also addresses the root. From passive stretching and compression to active movements and exercises, treatment is an orderly, gradual process of rehabilitation. Acupuncture can resolve tetany and relieve pain in the initial phase, and stimulate the muscles in later phases to increase muscle strength.
X-ray image (March 27th, 2019): L5 showed grade II anterolisthesis relative to S1, approximately 1.5cm. Bilateral defects were present in L5-S1 vertebral arches. L5-S1 were affected by degenerative disk disease with severe intervertebral disc space narrowing and endplate sclerosis. There was also mild diffuse facet arthropathy.
About the Author:
Hui Ouyang, M.D (China), L.Ac., D.C. Duel Licensee, Professor of DAOM. the current secretary of American TCM Association and has established the National Academic Forum for Acupuncture and TCM Orthopedics. teaches the doctoral degree programs at schools of acupuncture and Oriental medicine, including ACAOM, AAHW / AAAOM, ATOM and ACTCM. research fellow at UTMB.
腰椎滑脫的診治風險
歐陽暉
在脊柱的手法整復中，相對於頸椎整復，腰骶椎的整復安全得多，但是仍有風險。脊椎滑脫（Spondylolisthesis），最常見的是由脊柱的退行性改變所導致的。退行性脊椎滑脫，是隨着人體的衰老，椎間盤脫水變薄，脊柱不穩，脊椎移位而致滑脫。脊柱退行性疾病，以脊柱最下段的承重最大的腰骶部最為常見，也最為嚴重。腰骶部以活動最大的腰骶連線處的腰5椎的滑脫為最多。退行性腰椎滑脫，通常病程慢長，移位較小。不少專家並不認為退行性腰椎滑脫是真正的脫位，所以稱之為假性腰椎滑脫。手法整復適用於這類（假性）腰椎滑脫。新鮮的外傷造成的腰椎滑脫，多有椎弓的斷裂。手法整復，可能加重滑脫，以及對脊髓和神經根的壓迫。腰椎真性滑脫嚴重者（III度以上）需要手術治療。陳舊性腰椎滑脫小於II度者，即使是真性滑脫，可以實施對症的非手術治療，包括謹慎的手法整復。針灸加活動，再加上拉伸按壓也可以復位軟硬組織結構，替代大部分整脊重手法的作用和功效。針灸對症治療腰椎滑脫，安全可靠，但是對結構整復不足，治療不夠徹底。優化技術，靈活運用，針灸整脊診療腰骶病症，不僅治標，而且治本。
下面就是一個真性腰椎滑脫的診療實例。
一名 57 歲、身高 163cm、體重 86kg的白人女性。
主訴：右側腰骶部慢性疼痛，3週前勞作後復發並加劇。
現病史：病人從小在德州農場從事重體力勞動。2005年，她從高臺上跌下後開始腰痛。當時右側腰臀部淤青疼痛，並未正規治療。3週前在庭院修剪花木後，主要是身體反復屈伸後，疼痛發作。這次發作是最嚴重的一次。疼痛是一種頻繁的（< 75% 但> 50% 的時間）腰骶部鈍痛，牽涉至右臀部，但無下肢放射痛。 自發病以來病情加重，目前疼痛評分為 9/10（疼痛評估量表0-10，10為最嚴重）。 站直時緩解，向前彎曲時加重，臥倒後起身特別困難，仰臥疼痛最甚。她自服非處方藥，沒有接受治療，經介紹直接到針灸整脊診所求醫。自發病以來，沒有近期影像檢查。 她的腰痛，因仰臥困難而影響睡眠。 她開始治療的目標是減輕疼痛並且解除功能受限。
手術史：她的手術史包括1964年的第三腎臟（右側）切除術，1985年的腎盂成形術，1986年的輸尿管殘端切除術。腎臟手術發生在幼年和青年，腰痛則始於中年。
檢查：脊柱檢查顯示胸腰椎前凸並向左側彎曲，腰骶部觸痛/壓痛波及右臀部，腰4/5 和骶骨活動受限，右側腰骶椎和骶髂的肌肉組織張力高。沒有下肢放射痛。沒有馬鞍區感覺障礙，沒有大小便失禁。胸腰椎活動為中度減少，疼痛擴散至右臀部。
前屈：70°（正常90°）伴疼痛，
後伸：5°（30°）伴疼痛，
左側彎 ：15°（30°）有僵硬，
右側彎：10°（30°）有僵硬，
左旋轉：25°（30°）有僵硬，
右旋轉：10°（30°）有僵硬。
旋轉背伸直試驗陽性，提示包括腰骶部肌肉在內的腰骶椎功能障礙。背伸功能障礙是髂棘肌損傷；向對側旋轉並背伸障礙是多裂肌損傷。
診斷：
西醫診斷：
1. 腰（骶）椎退行性疾病
2. 髂棘肌和多裂肌損傷
3. 腰5，骶1腰椎間盤突出症
4. 腰5脊椎滑脫症（II度向前）
中醫診斷：
腰骶病症（淤血腎虛）
治療和結果
2019年3月26 日（首次治療）：根據“針灸整脊診療法”的安全第一的原則，針灸首先應用，解除痙攣和即時止痛。但對整脊推拿小心謹慎，尤其是重手法整復。同時開x線檢查單。 “針脊三針”首先遠道取穴針刺水溝（GV26），同時讓病人做腰腿部的拉伸和活動。病人痙攣的肌肉放鬆之後，可以俯臥針灸。局部取穴，華佗夾脊穴的腰3-5，多裂肌和骶棘肌的扳機點；命門(GV4），腰陽關(GV3），十七椎下，腎腧（BL23），大腸腧（BL25），次髎（BL32）。
2019年3月27 日（第二次治療）：疼痛評分為7/10。自上次就診後，腰臀痛明顯減輕，（由於X 線檢查過程中翻動過多），X線檢查後，腰痛及向右臀部的牽涉痛又回來了。
X 線攝片（2019年3月27日）：L5 相對於 S1 有II度向前滑脫，大約1.5cm。雙側L5-S1椎弓峽部存在缺陷。L5-S1有退行性椎間盤疾病，伴有嚴重的椎間盤間隙狹窄和終板硬化。 輕度彌漫性關節突關節病。
治療上，針灸活動後，實施腰骶椎整復手法，屈髖屈膝，牽壓復位。
2019年3月29 日（第三次治療）：右臀牽涉痛減輕，但是腰痛仍然存在。疼痛評分仍然為7/10。
2019年4月3日（第四次治療）：疼痛評分為3/10。腰痛減輕，右臀牽涉痛已不明顯。
2019年4月12 日（第五次治療）：疼痛評分為2/10。腰痛減輕，無右臀痛。
2019年4月17 日（第六次治療）：疼痛評分為2/10。腰痛減輕。治療加上病人主動肌肉鍛鍊的“腰骶操”的旋胯運動，增強腰骶脊柱穩定性。
2019年4月26 日（第七次治療）：疼痛評分為1/10，腰痛基本緩解，有時膝蓋疼痛。
病人自2019年3月26日至4月26日開始接受針灸整脊診療法的診斷和治療。在首診治療後，病人疼痛明顯減輕。每次治療都有進步。治療停止後，病人在家主動鍛鍊“腰骶操”，增強腰骶脊柱穩定性。
隨訪和預後：
2022年8月15 日（電話隨訪）；現在腰痛可以忍受，不影響日常生活。自2019 年 4月26日治療之後，沒有再大發作，沒有手術意願。疼痛評分為2/10左右，偶有腰痛，不超過4/10，無需就診。疫情期間，運動較少，體重增加。病人仍然感覺腰肌無力，無法做仰臥起坐。
質疑與體驗：
安全第一。針灸和手法，急性期主要先用針灸，點穴，解痙止痛，少用強扳重手法；急性期之後，充分放鬆的情況下，適當實施完全手法整復。結果，x線檢查顯示II度的真性滑脫。不僅是治療，診斷檢查也可能加重病情。本例病人由於x線檢查過程中翻動過多腰臀痛反復。
高效第二。針灸加活動，再加上拉伸按壓也可以復位軟硬組織結構。這樣可以替代大部分整脊重手法的作用和功效。針灸師都可以做這些治療，而且可以優化技術提高效率。
脊柱的退行性改變，椎間盤病變，脊柱不穩，腰椎滑脫。最終導致脊柱深層肌肉的薄弱和損傷。多裂肌是脊柱深層肌肉中穩固脊柱的最重要肌肉，所以多裂肌是核心肌肉之一。
掌握核心，穩固基本。回復脊柱的穩定性，針灸整脊診療腰骶病症，不僅治標，而且治本。治療從被動的牽拉按壓到主動的活動鍛鍊，是一個循序漸進的康復過程。針灸在初期可以解痙止痛，在後期可以刺激肌肉，增強肌力。
（2019年3月27日):L5相對於S1有I度向前滑脫，大約1.5cm。雙側L5-S1椎弓峽部存在缺陷。L5-S1有退行性椎間盤疾病，伴有嚴重的椎間盤間陳狹窄和終板硬化。輕度彌漫性關節突關節病。
作者簡介：
歐陽暉 博士，出身於中醫之家。中國中醫針灸本科，美國整脊博士學位。德州大學醫學分院針刺和電刺激的科研經歷。華美、美國和大西洋等中醫學院博士班導師。全美中醫藥學會秘書長，骨針康復專業委員會主任。德州針灸和整脊雙執照醫師。
