Acute severe lumbar disc herniation with needle picking and tui-na treatment ideas Fan Zhiyong1 Guan Debin1 Huang Weichang1 Miao Huiyu2 Instructor: Peng Xuming3 Fan Zhiyong, Department of Tui-na, Guangdong Provincial Hospital of Traditional Chinese Medicine 1, Department of Rehabilitation, Guangdong Provincial Hospital of Integrative Medicine (Nanhai, Guangdong 528200) 2, Department of Physical Injury, Department of Orthopedics and Traumatology, Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine (Guangzhou, Guangdong 510140) 3, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine Abstract: Acute severe lumbar disc herniation is a common clinical disease, currently Western medicine is based on dehydration and anti-inflammation, while conventional acupuncture and massage treatment of this disease, often with general efficacy, the author through from traditional Chinese medicine theory and anatomical and biomechanical analysis, by clinical findings, in the conventional acupuncture and massage treatment is ineffective, should follow the principle of pain relief before reset, the use of needle picking pain relief after The combination of the four methods of Tui Na with chiropractic can achieve satisfactory results. Keywords: acute severe lumbar disc herniation, needle-pricking, massage, Treating way of applying needle-pricking and massage to severe acute lumbar disc herniation Fan Zhi-yong1 Guan De-bing1 Wang Wei- Chang1 Miao Hui-yu2 Peng Xu-ming3 1 Department of rehabilitation, Guangdong Hospital of integrated western and traditional Chinese medicine ( Guangzhou Nanhai 528200 China) 2 Department of trauma–treating ,The orthopaedics and trauma Hospital, Guangzhou University of traditional Chinese medicine (Guangzhou Guangdong 510140 China) 3 Department of manipulation, The First Affiliated Hospital, Guangzhou University of traditional Chinese medicine (Guangzhou Guangdong 510407 China) Abstract: severe acute lumbar disc herniation is a commonly encountered clinical disease. While efficacy is often general when conventional acupuncture and massage is adopted to treat the disease. Based on the traditional Chinese medicine theory and the anatomy and biomechanics analysis, clinical found that when conventional Based on the traditional Chinese medicine theory and the anatomy and biomechanics analysis, clinical found that when conventional acupuncture treatment fails, following after disciplines “first analgesia then reduction”, and then recovering spine The clinical findings were that when conventional acupuncture treatment failed, following after disciplines “first analgesia then reduction”, and then recovering spine applying Needle- pricking combined ” four massage methods” may lead to satisfied results. Keywords: severe acute The main clinical manifestation of lumbar disc herniation (LDH) Needle-pricking Massage is lumbar pain, and the key manifestation of acute severe lumbar disc herniation is “acute” and “severe”. “The pain is unbearable, the patient’s expression is tense, sweating, trembling and moaning, even normal breathing makes the pain worse, and he is afraid of being touched by others. On physical examination, the spine is obviously scoliosis or lordosis, and the pressure pain is obvious at the lumbar spinous process (spine) and the sciatic nerve pathway (the pathway of the foot sun meridian such as the ring jump point, note: the ring jump point belongs to the foot less Yang bile meridian, which is the meeting point of the foot sun and the foot less Yang), and the straight leg raise test is often below 20. In severe cases, there is difficulty in urination and even painful shock [1], and according to Chinese medicine, this disease belongs to the category of “lumbar and leg pain”. 1.1 Lumbar disc herniation from meridian theory Meridians are physiologically the pathways that connect the internal organs, externally connect the limbs, and run qi and blood; pathologically they are the pathways for the transmission of disease and evil. The diagnosis is based on which meridian the disease appears in and which meridian the positive reaction point appears in. Low back and leg pain is most closely related to the foot and solar bladder meridians and the tendons of the foot and solar bladder meridians. The “Ling Shu – meridians” cloud [2]: “bladder foot solar veins, starting from the inner canthus of the eyes …… hold the spine to the waist, into the brawn, contact with the kidneys, belong to the bladder; its branches: from the waist, down hold the spine, through the hip, into the N. The branches of the …… follow the thighs outside the back of the Lian under the N in the …… following through the kick inside, out of the outer ankle after the …… spinal pain waist like folding, thighs can not be curved, N as knotted, kick like crack, is the ankle syncope “. The Ling Shu – Jing tendons: “The tendons of the Sun of the foot, starting from the little toe, knotted on the ankle, oblique knotted on the knee, the lower part of the lateral foot, knotted in the heel, on the heel knotted in the N; its other, knotted in the kick outside, on the N in the inner Lian, and N in and up knotted on the hip, the top of the spine; …… bone contracture, spinal reflexes. …… to pain as the acupuncture point, the name is also known as midsummer paralysis.” The disease should also be attributed to a lesion of the Governor’s Vessel, which travels in the middle of the back, supervising all the yang, and is the sea of the Yang Vessel. The “Su Wen – bone empty theory” “the Governor’s Vessel, from the less abdominal, the following bone central, …… man ridge to the waist, into the brawn contact kidney. “Ling Shu – meridians” “Governor’s vein of the other, the name said long strong, clip the spine on the top, …… real is the spine strong, deficiency is the head heavy, high shake of the, clip the spine of those who have over, take the difference.” The dorsal acupoints of the Governor’s Vessel and the Huatuo Pinch Spine points and the dorsal points of the Bladder meridian are all in the same plane, and their meridians are connected to each other, which are clinically common meridians and acupuncture points for the main treatment of lumbar and leg pathologies [3]. 1.2 Anatomical analysis of the lumbar-leg relationship The spinal nerve penetrates from the intervertebral foramen on both sides and is divided into two branches: the anterior branch of the lumbar 2-4 spinal nerve forms the femoral and foraminal nerves, which mainly innervate the medial thigh, calf and medial foot skin and the muscles under their control, and the anterior branch of the lumbar 4-sacral 3 spinal nerve forms the sciatic nerve, which mainly innervates the posterior thigh, calf and lateral foot skin and the muscles under their control. The posterior branch of the spinal nerve is divided into medial and lateral branches, and the lateral branch has most of the motor fibers, which innervate the movements of the erector spinae muscles, and from the innervation it is clear that the lumbar and leg are closely related [4]. 1.3 Pathogenesis in Chinese and Western medicine From the perspective of Chinese medicine, the pathogenesis of this disease is: the cause of the disease is trauma, the pathogenesis is qi stagnation and blood stasis, the meridians do not pass, and if they do not pass, it is painful. The location of the disease is the foot solar bladder meridian and meridian tendon, such as the meridian for the disease “spinal pain waist like folding, thigh can not be bent, N like knot, kick like cracking”; meridian tendon for the disease “small toe branch heel swelling pain, bone contracture, spine reflexive folding”. The disease is a severe pain in the back and legs, muscle spasm. Modern medicine believes that the main pathological mechanisms are [5]: (1) direct compression of the dural sac and nerve roots by the herniated material; (2) local microcirculatory disorders; (3) edema and aseptic inflammation of the nerve roots caused by nucleus pulposus irritation; (4) autoimmune reaction of the prolapsed nucleus pulposus. For example, mechanical compression of the nerve root by the herniated disc causes vascular stasis and plasma extravasation, resulting in chronic damage to the nerve root caused by the proliferation of fibrous tissue in the nerve root; there is also stimulation of the nerve root, resulting in a nonspecific inflammatory response to the nerve root, releasing histamine, and leukotrienes and other inflammatory substances, which can have a painful effect on the nerve root and clinical symptoms, so some scholars have achieved good results with anti-inflammatory and hydrophobic herbs [6]. From anatomical point of view, because the innervation of the lower limbs mainly originates from the lumbar sacral plexus nerve, therefore, when the lumbar back is diseased, it often affects the condition of the lower limbs and low back pain occurs. 2 Treatment ideas of needle picking and tui-na: 2.1 Needle picking and bleeding to stop pain The principle of stopping pain first and then restoring it should be followed, and needle picking should be used to treat severe pain caused by acute serious illness, firstly, the Qie points of the bladder meridian, Jinmen, and the Qie points of the bile meridian, Waiqiu, because “the Qie points of the Yang meridian are mainly used to treat acute pain evidence [7]”, and secondly, the selection of acupuncture points should be based on the foot solar meridian and the Governor’s vein, etc. When selecting acupuncture points The second acupuncture point is selected from the foot solar bladder meridian, such as Kidney Yu, and Wei Zhong; the foot Shaoyang gallbladder meridian, such as Huanjiao and Yanglingquan; and finally, the lumbar spine and A-Ye point. Needle picking treatment method, it is developed on the basis of “Nei Jing” “Luo stab”, “half stab” and other stabbing methods. In the book of “Ling Shu”, “Half-prick is a shallow and quick prick, no needles hurt the flesh, like plucking hair, in order to get the skin qi, this lung should also.” . “The luo pricker is to prick the blood vessels of the small luo.” . Needle picking therapy is to pick off the white fibrous tissue under the skin to achieve treatment by stimulation of the skin and subcutaneous [8]. In the Suwen-Tuning the Classic, it is said that “if there is a surplus of blood, the blood in the small veins will be diarrhea, and the bleeding …… will be calm. This disease is mostly caused by trauma resulting in localized qi stagnation and blood stasis, which causes severe lumbar pain and radiates to the lower extremities, resulting in leg pain, which is a real disease, “Shen has surplus”, so the diarrhea method should be used. The operation of needle picking therapy is: after routine disinfection, the skin of the picking point is picked vertically with a homemade picking needle, swinging it up and down, left and right, and making pulling movements about 10 times in each direction, usually the disease to pick off the subcutaneous white fibers shall prevail, in order to increase the amount of stimulation, the fibers can be picked off by rotational techniques, and then the wound is disinfected by using a fire cupping jar to suck out the blood stasis on the picked point [9]. 2.2 Needle picking mechanism According to Western medicine, the key to the treatment of acute phase of lumbar disc herniation is dehydration and anti-inflammatory and pain relief. Chen Dong et al [10] found that needle picking and bloodletting improved and promoted local and related blood circulation, accelerated inflammatory absorption and excretion of pain-causing substances, increased metabolism, and had a rapid pain-relieving effect, which facilitated the repair of lesions. According to Luo Jian [11], needle picking therapy has acupuncture effect, blood pricking effect, massage effect, and muscle stripping and relaxation effect. According to Chinese medicine, needle picking can adjust the yin and yang qi and blood, and relieve pain, and rapid pain relief is to create conditions for the next step of chiropractic manipulation. 2.3 The use of orthopedic massage techniques Manual repositioning should be used after the patient’s severe pain is improved. In clinical operation, we generally follow the sequence of pulling and stretching method – forced leg lifting method – lifting and rotating wrench method – stilting method. (1) The extraction and extension method is usually based on the unilateral lower limb: the purpose is to change the relative space position between the protruding disc tissue and nerve root, to reduce the compression and tension [12], to facilitate the nucleus pulposus to slide from the posterior edge to the anterior edge, and to loosen and rehabilitate the joint and the meridian tendon, generally using the extraction and extension of the affected limb first, and then the extension of the healthy limb [13]. The affected limb is usually extracted and stretched first, and then the healthy limb is extracted and stretched [13]. (2) Forced leg raising method: the angle of leg raising by forced leg raising method should be increased by 10°～20° on the basis of the original one, and gradually reach 70°. When the nerve root is compressed by the protruding object, edema and exudation, aseptic inflammation, etc. lead to nerve root adhesion, and the sciatic nerve cannot be extended, which makes straight leg raising difficult. Therefore, the forced leg lift method pulls the distal sciatic nerve trunk to force the sciatic nerve to slide and detach the adhesions [13]. (3) Lifting and rotating wrenching method: lifting and rotating wrenching method mostly uses explosive force maneuvers requiring one time in place, so that the patient’s trunk rotation force can be maximized on the lower part of the lumbar spine, reducing the impact on unrelated parts, with three effects of oblique wrenching, traction and positioning, which can minimize the pressure on the intervertebral disc [14]. (4) Stilts method: When stilts method is used, the patient should lie prone on the bed, with 3 to 4 pillows on the chest and thighs, and the abdomen should leave the bed, so that the lumbar region becomes anti-arch, and then the stilts method is used to act on the affected part, with the purpose of restoring the normal physiological curvature of the spine with external force, and forming the conditions and environment for the nucleus pulposus to slide from the posterior edge to the anterior edge under the pressure of the posterior edge [13]. Case study: Liu, a 33-year-old male vegetable farmer from Dongjiao Town, Meizhou, came to our department on July 10, 2005, complaining of “pain in the lumbar region and left lower extremity, and unfavorable movement for 3 hours”. The patient reported that he had sprained his waist while picking vegetables this morning and had pain in his waist and left lower limb, and the symptoms were not relieved by taking “Relifen”, so he came to our department today. CT showed: L4-L5 and L5-S1 disc herniation. Chinese medicine diagnosis: lumbar and leg pain, Western medicine diagnosis: acute severe lumbar disc herniation. (The treatment was conventional acupuncture points, and the symptoms were not alleviated after 1 day of acupuncture and thrust treatment.) After using acupuncture and pricking to relieve pain, the patient was combined with the four methods of orthopedic massage, in which the acupuncture and pricking was done twice a day, and 30 ml of blood was released each time for the first 3 days, after which the severity of symptoms determined whether to release blood, mainly to pick off the white fibers, and when the patient appeared in an active position, the patient’s pain was significantly reduced after one treatment, and healed after 10 treatments. The patient’s pain was relieved after 10 treatments. 3 Discussion of treatment ideas 3.1 Contraindications to treatment: For patients with acute lumbar disc herniation, acute cauda equina injury should be excluded first. The central herniation compressing the cauda equina nerve is an absolute indication for surgery, and conservative treatment is not advocated for such patients requiring immediate surgery, as it is difficult to recover and aggravate the condition once the opportunity for surgery is missed. 3.2 Analysis of treatment steps (1) For acute severe lumbar disc herniation, it is not advisable to use the method of pushing and repositioning first because the patient is in a passive position (protected position) in a lateral bending knee and bending hip position due to severe pain in the lumbar region. Therefore, manipulation cannot be performed without first stopping the pain, and even if it is done forcibly, the therapeutic effect cannot be achieved. The purpose of using needle picking and cupping first is to relieve pain by taking local acupuncture points and Yang meridian Qie points to treat acute pain evidence mainly. (Note: needle picking treatment should not be limited to once a day, depending on the pain situation can be 3-4 times a day, depending on the actual do not have to bleed every time, to pick off the white fibers mainly). (2) I found that the needle picking alone can not effectively improve the spinal problems, at this point the chiropractic manipulation is the key, when the pain is relieved to solve the problem of patient position, first of all, pulling and stretching method and forced leg lifting method, at this time the patient gradually appear active position, after the use of lifting rotational trigger method and stilt method, can obtain satisfactory results. If the tilt-trigger method is applied at the beginning, the patient often fails to reset due to incomplete cooperation, and the symptoms are aggravated, so the key to treatment is to grasp the passive position to active position. (Note: not to force the traction bed traction, not to apply the oblique trigger method or lumbar compression when the patient is in severe pain and passive position). 4 Conclusion In the treatment of acute severe lumbar disc herniation, needle picking therapy can regulate the qi and blood, and relieve pain, its specialty is rapid pain relief, creating conditions for orthopedic massage; orthopedic massage four methods can correct the internal and external balance of the spine, relieve the herniated intervertebral disc from compressing the nerve roots, and have the effect of “bone correct tendon softness”. However, needle picking only solves the problem of pain and tui na chiropractic only solves the problem of spinal misalignment, so the combination of needle picking for pain and tui na chiropractic is chosen to achieve the treatment purpose quickly. References: [1] Zhong Xian Yi. Non-surgical treatment of acute severe lumbar disc herniation [J]. 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