A Novel Acupuncture Technique for the Treatment of Refractory Radiculopathy and Radiculitis

by Dennis R. Tucker, PhD, LAc

Abstract

This article describes an acupuncture treatment technique that has proven successful in the treatment of diagnosed radiculopathy and radiculitis that have been established as chronic and severe despite multiple and varied forms of treatment. Key words: acupuncture, treatment, radiculopathy, radiculitis, chronic pain

Introduction

Patients in this category have exhausted commonly available options and are often heavily medicated with a frequent pattern of progressive debility and an increased probability for a host of secondary health complications.

Acupuncture is not commonly recognized as the treatment of choice for severe refractory pain patients. This is due to many factors: a lack of well designed studies using a clearly defined methodology that demonstrates efficacy, a commonly held belief (based upon the gate control theory and related endorphin and polypeptide research) that posits various CNS mediated opiate receptor mechanisms to explain the purported clinical effects of acupuncture as a limited short term palliative therapy, and, the central design flaw that persists in most otherwise well designed studies that does not acknowledge how diverse the clinical applications of acupuncture are, and hence, the inherent difficulty with generalizing from a study outcome to the field in general. This situation is further complicated by a plethora of acupuncture treatment methods that largely compete in a vacuum of credible research, impeding the practitioner, the medical community and the consumer in assessing clinical efficacy.

Two of the following case studies were diagnosed with severe spinal stenosis and secondary marked spinal pathology, which precluded surgical intervention. All prior therapeutic interventions had been unsuccessful. These case studies are not intended to demonstrate that the following technique is a panacea at this level of pathology but rather that even the most severe and chronic pain patients can be effectively treated with acupuncture.

Two case studies are presented with much less documented spinal pathology but long term debilitating levels of pain that were highly refractory to all forms of therapy. These case histories illustrate chronic severe radiculitis, a quite common result of severe trauma (that is not self limiting) and often is undiagnosed and poorly treated.

A well-designed outcome study with independent evaluation is the necessary next step in quantifying efficacy. It is the author's hope that this may be accomplished.

The technique herein described relies entirely on a specific use of palpation for point selection, which does not precisely correlate with conventional acupuncture topology and is unique to each patient. Moreover, distal point selection does not appear to be critical in terms of outcomes. (3) Therefore, conventional acupuncture point designations are not used for the local treatment zone and no argument over which of the many systems for distal point selection is made. The author has not found, for this form of treatment of chronic pain, any clear advantage of one system over another with respect to distal point selection theories although some form of meridian “drainage” is necessary to reduce discomfort following treatment. Spinal coordinates and dermatome referral patterns are the principle topographic references for the treatment zones.

Selection Criteria

• A well documented history of at least five years of chronic pain and/or severe dysesthesia and a history of poor response to all or most commonly available therapies.
• Radiological and clinical evidence for severe spinal pathology or severe idiopathic radiculitis.
• Must be, at least partially, ambulatory.
• No concurrent diagnosis of auto-immune disease or metastatic cancer.
• Signed informed consent and agreement to comply with scheduling, interim evaluation and the anonymous use of their case histories for research.

Method

The acupuncture technique utilized in this study involves careful palpation of the margin between the spinae erector and the spinous processes as well as the identification of associated myofascial trigger points. Clinicians lacking well-developed palpation skills will have difficulty using this assessment model, although the requisite palpation skills can be readily acquired through training and practice.

In most cases, patients were positioned on an abdominal support cushion for diagnostic palpation of radicular inflammation of the mid-thoracic to lumbosacral portions of the spine. This is often the only possible position patients can assume for the duration of the procedure, which may require up to forty minutes to complete. Moreover, the convex position of the spine expands the intervetebral space and enhances the accuracy of palpation. In cervical radiculopathies, the author uses a six-way adjustable face cradle and, if possible, employs a downward tilt with the forehead slightly below chest level, which also facilitates patient comfort and accurate palpation.

The patient is then given rudimentary directions for diaphragmatic breathing and muscle relaxation. While gently palpating the affected area, the author determines if the patient is "guarding," (unconsciously induced hypertonicity habituated by chronic pain). If so, he places his hand over the area to be examined and asks the patient to focus on relaxing until the soft tissue is pliant to the touch. Through gentle bilateral palpation (including adjacent areas), intrinsic induration can be quickly distinguished from guarding. It is critically important that the patient relax the musculature in the affected area completely. If this does not occur there is invariably some degree of recruitment that or with the spinae erector, which can potentially preclude successful localization of the affected spinal nerves.

Palpation is initiated in an up and down sequence over the intervertebral margin throughout the affected range starting with a light inward palpation with the tip of the index finger remaining in place on the skin (the finger does not glide over the surface but moves the myofascial tissue over the nerve pathway) feeling for subtle induration over the affected nerve roots. Using patient tolerance as a guideline, deeper palpation is progressively initiated as necessary. Initial detection of a clear threadlike induration of the superficial soft tissue directly above the involved spinal nerve is noted and marked with a dot. This threadlike induration is approximately one centimeter in length, two or three millimeters wide, and contiguous to the foramen. It is not uncommon to find evidence of radiculitis (no diagnosable spinal pathology but vertebral tenderness and palpation based evidence of nerve root inflammation adjacent to other spinal segments above and below the diagnosed pathology). These "secondary" spinal segments may be critically important in achieving a positive treatment outcome.

In the author's experience undiagnosed radiculitis is usually present in severe chronic spine related pain and often is expressed clinically by dermatome referral that is separate from the diagnosed radiculopathy. It is not uncommon to find evidence of undiagnosed scleratogenous nerve entrapment along the involved myotomes. The scalene (brachial plexus) in cervical brachial radiculopathy and the sacroiliac in sciatica are two common examples of critically important scleratogenous entrapment sites that cannot be diagnosed radiologically and may be more important in treatment then the documented spinal pathology.

Once the involved area is marked with small dots, the author lightly re-palpates the critical nerve roots and begins treatment. A great advantage in pre-mapping the treatment plan is prevention of palpation related pain to areas that already have been treated. All primary sites should be carefully identified before the first needle is placed. Needle size and penetration varies markedly with respect to the physical characteristics of the individual patient and the location of the spinal segments to be treated. In general, the needle is inserted a few millimeters lateral to the spinous process, directly above the threadlike induration of the inflamed nerve root and angled in towards the spine at approximately 20 degrees. A careful, slow, up and down needling technique is used until the patent notes a clear radiating nerve sensation. The needle is then left in-situ and the next location is treated in the same manner. Once the needles have been placed, including the distal and secondary areas of treatment, the patient is instructed to focus on rhythmic breathing and relaxation of the musculature until the needles are removed after approximately twenty-five minutes.

Although there are circumstances that would ideally suggest more than one treatment in a seven-day period, this is rarely necessary. The treatment is adjusted for each patient's tolerance and it is always wise to begin conservatively. In general, patients tolerate the treatment well, but they are cautioned (especially in the first few visits) to anticipate a variable increase in pain within the first twenty-four hours. This does not happen predictably, in fact, many patients will experience some degree of immediate relief. It is also common for patients to experience shifting referral and pain distribution in the first few weeks of treatment. They are asked to score their daily pain levels, note changes in neurological referral and be prepared to provide a succinct summary. A series of ten consecutive treatments is considered a clinical trial followed by an interim assessment. If within this series of treatments the patient has not demonstrated significant baseline response with respect to pain levels and dysesthesia, the author suggests that they are not likely to respond with further treatment. This happens rarely, usually in cases of severe spinal stenosis and surgical failures that involve significant nerve damage.

Once it is clear that a patient is responding in a progressive manner, treatment continues weekly until pain levels and neurological referral is in remission or progressive improvement is no longer apparent. An individualized flexion program is initiated only after pain levels are markedly reduced, followed by strengthening exercises and reintegration of permitted daily activities. When the patient has maximized response to therapy, a progressive out- scheduling program is initiated. If the patient is stable at six week intervals they are released and instructed to continue their home care program. More commonly, in the most damaged patients, it is necessary to provide some form of maintenance therapy, and this is usually once a month. Patients who met the selection criteria were established as permanent and stationary and frequently unable to work, perform light activity at home, and in many cases, even remain erect for more than a few minutes. Most patients in this category are off of all pain medications by the end of therapy, able to resume normal daily activities (with appropriate lifting restrictions) and in some cases, have returned to work.

Case Histories

(1) Female, age sixty, artist. This patient presented with an approximate thirty-year history of facial pain, chronic severe cervicalgia with right trapezius spasm and chronic paresthesia and asthenia of the right arm. Pain was rated at a 10 on a standard pain scale. Numerous interventions involving epidurals, nerve blocks, physical therapy, chiropractic and acupuncture had, at best, produced only short term mild lessening of symptoms. At the time she was seen she was poorly controlled on non- steroidal anti-inflammatory drugs, having demonstrated intolerance to opiate analogs. Diagnosis: chronic, severe cervical brachial radiculopathy with attendant chronic partial denervation in the distribution of C-6 bilaterally.

Radiology:

Summary of MRI of the Cervical Spine:

Diffuse posterior osteophyte formation associated with bulging at the C4-5, C5-6 and C6-7 levels. Mild spinal stenosis with moderate neural foraminal narrowing at C4-5 and posterior osteophyte formation and bulging at C5-6 producing severe spinal stenosis at C5-6 with the AP dimension of the thecal sac reduced to 8mm. Additionally, moderate to severe neural foraminal narrowing at the C5-6 level.

Summary of Cervical EMG:

The EMG reveals a pattern of chronic partial denervation in the distribution of C6 bilaterally.

Summary of Lumbosacral spine MRI:

L1-L2: 7-8mm left paracentral and left neural foraminal disc protrusion. Neural foraminal stenosis is identified on the left side.

L2-3: 3mm broad based disc protrusion with effacement of ventral thecal sac. Bilateral caudal neural foramina] narrowing is seen.

L3-4: 3-4 mm broad based disc protrusion with effacement of ventral thecal sac. Bilateral neural foramina[ narrowing is seen.

L4-5: 2-3 broad based disc protrusion is seen with effacement of ventral thecal sac.

Diagnosis: Diffuse multilevel foraminal stenosis causing bilateral lumbar radiculopathy.

Clinical Response:

Cervical-brachial radiculopathy:

No change demonstrated in the first two visits. By the 10th visit the left sciatica and chronic lumbalgia were in remission although she still complained of mild restless leg syndrome at night. Facial pain and right arm paresthesia were in complete remission and the prior severe chronic neck pain was low grade (pain scale 2 to 3).

Over the course of the next eight treatments, flexion and mild strength exercise was introduced and she was progressively out scheduled to once monthly treatments. Although increased daily activities produced mild aggravations in both areas, they were largely self-limiting.

She was released shortly thereafter and has only been seen on a few occasions in the last three years. She has largely remained off of all analgesic medication and has no neurological referral. The cervical and trapezius pain was largely in remission, although over-activity would produce mild discomfort (pain scale 2 to 3). Her lower back and leg symptoms remained in remission.

Commentary:

This patient is typical of many refractory pain patients in that there is multi-level spinal pathology that precludes good surgical options. It is remarkable how well many of these patients do with minimal or only episodic follow up. However, after optimal treatment response, it is imperative that they are consistent with standard spinal flexion exercise if they are to remain stable.

(2) Female, age 58, athlete. This patient had been unable to continue her many sports activities for 10 years due to progressive weakness and fasciculations in both legs. She also presented with incontinence, which seemed to wax and wane with the acuity of sciatica and persistent moderately severe lumbalgia, pain scale (4 to 8). Based upon her childhood history of mild polio and her grossly abnormal EMG she was diagnosed with "post polio syndrome." She was told that she had irreversible nerve damage that would be inevitably progressive. She was only partially ambulatory when she began treatment, having recently purchased an electric lift to enable her to use the second story of her home.

Radiology:

MRI of the lumbosacral Spine.

Only mild degenerative change in the L3-4 through L5-S1 discs with a mild central posterior bulge of the L4-L5 disc.

EMG report: 50% motor neuron loss in quadriceps, 30% neuron loss in the gastrocnemius (bilateral).

Given her prior history of polio and relatively positive MRI, she did not appear to be a good candidate for this form of therapy. However, the lumbalgia, and radicular symptoms (sciatica and incontinence) were not readily explained by the diagnosis. Moreover, palpation revealed acute hypersensitivity throughout the lumbar vertebrae.

Clinical Response:

Clear lessening of fasciculations, improved leg strength, and simultaneous lessening of sciatica and incontinence symptoms by the fifth treatment. Continued cumulative progress over the following ten visits with some lability largely due to greatly increased activity including an attempt to resume jogging.

Gradational introduction of flexion and strength exercises combined with a second course of ten treatments culminated in an almost complete absence of spinal tenderness and lumbar pain and a complete return of leg strength allowing for greatly expanded activities. She began to surf and swim again but jogging continued to be contraindicated so she began to power walk with hand weights with no adverse consequences. The sciatica, fasciculations and incontinence resolved. She remained stable over the next three years with minimal treatment.

Commentary:

Although this patient's primary pathology was neuronal impairment, she responded in a manner that is clearly suggestive that most, if not all of her symptoms were primarily secondary to lumbar radiculitis. The author has treated many highly refractory cases of neurological referral that were not explicable through documented spinal pathology. These patients had also proven resistant to the full gamut of standard orthopedic and physical therapy interventions and many (as with this patient) had also made numerous attempts through alternative means to remedy their problems, including multiple trials of acupuncture and chiropractic.

The clinical evidence suggests that this technique is effective in reducing or eliminating inflammation of spinal nerve roots. The treatment of many chronic spinal conditions, e.g., intercostal neuralgia, compression fractures, dermatome related pathology in demyelinating disease, etc, can often be effectively treated with this technique.

(3) Male, age 64, retired. This patient had a fifteen-year history of severe lumbalgia (pain scale 6 to 10) and chronic bilateral sciatica and leg paresthesia. All standard orthopedic and physical therapy interventions (except surgery) had proven largely ineffective, This patient was not considered a candidate for surgery due to the very severe multilevel spinal discopathy and preexisting cardiac disease. This patient had also tried acupuncture, massage, and chiropractic which had aggravated his symptoms.

Radiology Report: his most recent lumbosacral MRI revealed (in summary) the following:

L1, A left sided disk protrusion at the L1 interspace which impinges upon the left anterolateral aspect of the thecal sac causing mild central canal stenosis.

A broad based disc bulge at L2 with mild associated central canal stenosis and bilateral neuroforaminal narrowing.

L3-4, A large extruded and inferiorly migrated disc fragment, which causes severe spinal stenosis. Also there is a broad based disk bulge at the L3-4 interspace level with severe associated central canal stenosis.

L4-5, There is a focal central posterior disk protrusion at the L4-5 interspace level with moderate associated central canal stenosis and mild bilateral neuroforaminal narrowing.

Clinical Response:

Given the disc fragment and disc herniation mutually impinging on the spinal canal and causing severe spinal canal stenosis, the author was very surprised at his almost immediate response. In fact, he reported a marked lessening of paresthesia and lumbalgia from the first treatment. By the third treatment he was nearly free of symptoms. At the fourth treatment he stated that he felt well and intended to "motor home" indefinitely. The author cautioned this patient that it was highly unlikely that he would remain in remission for a significant period and would be less likely to do so if he did not participate in the second stage of treatment involving gradational use of flexion and strength training.

The last contact I had with this patient, almost one year after treatment, indicated that he was still in a largely remissive status.

Commentary:

This patient's case history was not included to be representative of treatment response when this degree of spinal pathology is present. Indeed, this degree of spinal pathology in most patients presents an obvious limiting factor in their overall response and (without maintenance therapy) their long-term prognosis. Rather, this patient's case is included as an example of a clinical response that would appear to be impossible given the dual severe encroachment of the spinal canal. The author's hypothesis is that the anti-inflammatory effect of treatment of the spinal nerve roots reduces the lumen of the nerve enough to allow decompression to occur restoring more normal nerve transmission and local tissue recovery.

(4) Male, age 63, sheriff, retired on disability. This patient presented with a thirty year history of chronic severe pain throughout the thoracic vertebrae largely left of midline radiating throughout the intercostal nerves and into the chest wall. He also complained of a severe focal pain proximal to the 12th rib and iliac crest and severe lower back pain. He stated that pain medications no longer controlled the pain, which he states was 8 to "off the chart."

Thirty years ago he was attacked in the course of apprehending a criminal who subsequently severely beat and kicked his left side.

He was intolerant of exercise and was largely restricted to a seated or recumbent posture.

Prior radiology revealed only mild disc narrowing, osteophytes with no foraminal or central nerve encroachment.

Physical examination revealed exquisite tenderness throughout the left thoracic vertebrae and bilateral tenderness in the lumbar spine.

Clinical Response:

Within the first five treatments all areas of pain were moderately reduced (pain scale 4 to 8). Progress was cumulative over the next five visits with marked reduction in pain (pain scale 2 to 4) and a light flexion and walking program was started.

Over the course of the next five treatments his pain levels were reduced to "barely noticeable" and he was out scheduled and subsequently released from care. No follow-up visits have been necessary.

Commentary:

In the author's experience chronic radiculitis is often confused with osteoarthritic changes that frequently occur at sites of severe injury. However, chronic extreme spinal sensitivity with intercostal referral invariably involves chronic radiculitis. Unlike the typical, even severely, osteoarthritic patient that will usually get significant relief from analgesics and anti-inflammatories, chronic severe radiculitis is often only marginally responsive to pain medications. Despite a paucity of radiological evidence, their pain is both very real and conventionally poorly treated. While epidurals are often temporarily effective for these patients they are obviously not the solution. Virtually all patients with severe refractory spine related pain that present at the author's clinic have had at least one series of epidurals. Here is a very safe low cost technique that can be of great value to these patients who suffer to a degree most can hardly imagine and have been literally been left without hope.

If these results can be demonstrated to be credible in a formal outcome study with third party evaluation, the very interesting question is what mechanisms could possibly explain these results? The author's hypothesis is that a unique, local, and very potent anti-inflammatory neurochemical response follows the very precise stimulation of the nerve root and that this response is separate from the CNS gate control model. The evidence is inconsistent with an endorphin model (generally patients will have an aggravation following treatment) and the results are simply too durable to understand within the CNS gate control theory of opiate analog analgesia.

It is well established that endorphin induced analgesic effects are prevented or reversed with Naloxone injections. It would be a simple matter to determine if this is also the case with the treatment model herein introduced. If indeed, these clinical effects are not Naloxone reversible, it would suggest that mechanisms yet to be discovered may reveal important local effects of acupuncture spinal nerve root stimulation that may prove of great benefit in unraveling the puzzle of chronic pain.

Dennis R. Tucker studied Acupuncture and Oriental Medicine in Japan from 1973 to 1979, initially as a Watson Fellow. He completed a six year course of study, which included a full clinical and research residency at the Amagasaki Prefectural Hospital (Research Institute of Oriental Medicine). He completed a Ph.D. in Health and Human Services at Columbia Pacific University in 1988. He has been in private practice in California from 1980 to date.

Footnotes:

1. Dubner R., Basbaum Al. In: Wail PD, Melzack R (Eds). Textbook of Pain, 3rd ed. Edinburgh: Churchill Livingston, 1994

2. Pomeranz B. In: Stux G, Hammerschlag R., ads. Clinical Acupuncture; Scientific Basis. Berlin: New York: Springer 2001

3. This comment is not intended to disparage the many approaches to distal point treatment, but rather to disassociate this technique from any necessary relationship to a particular distal point assessment model.