Case study: An existence of pain at the low back and sensitive & motor disorders on feet after an operation of lumbar intervertebral disk remove
Miss F. J., 26 years old post-graduate student is still leaving the constant pain at the low back and sensitive and motor disorders on the feet after an operation of lumbar intervertebral disk remove for four months.
Due to a recurrent back pain, she was diagnosed that a disk at the between 4-5 lumbar vertebrae was slipping out. Because the severe back pain couldn’t release and caused more and more remarkable pressed symptoms at her legs and feet. So an operation which removes the lumbar intervertebral disk has been done in Aug 2009. After an operation, she is still leaving the pain at the lumbosacral, accompany with numbness and cool feeling at the outsides of feet, weakness on both feet which can’t rise up to make her limp. Meanwhile, she suffers from an irregular menstruation which was circulated as 5 to 15 days of period during the 30-90 days of menstrual circulation without dysmenorrheal. When she visits me, she hasn’t had any period of more than two months. Many patches of acne are occurring on her face.
From examination, Dr. Jiang finds her limping while she is walking, both of feet are too weak to rise up, five toes at each foot can’t bend up which the small toes are worse; frozen palpation and no sensation on both of feet; there is an operative scar which is above 5 inches with a good healing and no palpable pain in the lumbar back; many papules and rashes on her face. Light red tongue with less white coating and wiry-fine pulse are found.
The diagnosis of CWM to her is that:
1. Post-surgery syndrome after an intervertebral disk is removed
2. The nerve which is pressed by intervertebral disk has been damaged
3. Irregular menstruation is caused by Polycystic Ovary, or possible PCOS.
The identification of patterns on TCM to her is that Kidney Qi and Yin deficiency, accumulation of dampness and stasis of blood. The treating principle is to expel the dampness and remove the stasis of blood, strengthen kidney Qi and nourish Kidney Yin.
Acupuncture:
Body acupuncture: Baihui(Du20), Pishu(Bi20), Kidneyshu(Bi23), Baliao(Bi31-34), Zhibian(Bi54), Weizhong(Bi40), Chengshan(Bi57), Kunlun(Bi60), Shenmai(Bi62) Shugu(Bi65) ; Yingu(Ki10), Taixi(Ki3), Zhaohai(Ki6) ; Yinlingquan(Sp6), Sanyinjiao(Sp6) ;
Zulinqi(Gb41), Jiaxi(Gb43).
Electric connection at the relevant points and moxibustion at the lumbar sacrum are added in each treatment.
Herbal medicine: The traditional main formula is based on the mixed Erxian Tang, Sanmiao Wan and Taohongsiwu Wan which is prescribed as below:
Yinyanghuo20, Xianmao10, Aiye10, Chuanxiong10, Shengdihuang15, Cangzhu10, Huangbai10, Yiyiren30, Danggui10, Chishao10, Taoren10, Honghua10, Guizhi3, Yimucao15, Mugua15, Jixueteng15, Zhigancao5.
Above herbs are decocted as a juice which is drunk twice daily. The 6 dosages are given per week.
After above integrated acupuncture and herbs are given for a month, she starts to feel warm on her legs and feet, the pain at the lumbar sacrum has gone completely; her period comes and acnes have gone. But her feet are still hard to rise up, special on the right food which causes her limping. When she is changed to patent herbal form, she stops her period and acnes appear again which shows that it is an insufficiency treatment with these patent herbal form. So a regular acupuncture and herbs in a decoction form keep to her for a course of three months, she feels better in general.