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 pseudospondylolisthesis. 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 symptombased 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 57yearold 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 patients 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/pressurepain 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 extensionrotation 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 26^th, 2019 (first treatment): In accordance with the safetyfirst 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 xray 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 L35 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 27^th, 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 xray 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).

Xray image (March 27^th, 2019): L5 showed grade II anterolisthesis relative to S1, approximately 1.5cm. Bilateral defects were present in L5S1 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 29^th, 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 12^th, 2019 (fifth treatment): The pain level was 2/10. The lumbar pain decreased and there was no pain in the right gluteal area.

April 17^th 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 26^th, 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 15^th, 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 flareups 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 situps.

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 xray 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 xray 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 ones 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 27^th, 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.