Low back pain

Left lower extremity radiating pain

Neurogenic claudication

Onset date

Early February 2020

This patient suffered from low back pain, which repeatedly improved and worsened. In early February 2020, she suddenly worsened more than usual during her daily activities. She visited a local anesthesiology hospital for an examination. As a result of lumbar spine radiography and MRI scans, she was diagnosed with degenerative changes in the spine, spondylolisthesis at L4, and LSS at L4–5 and at L5-S1. Although she received injection therapy and analgesic medicines orally several times, her pain did not improve. She was hospitalized at the Daegu Haany University Korean Medicine Hospital on June 8, 2020.

Osteoarthritis of both knees

Hyperlipidemia

Hypertension

Refer to Fig. 1.

Refer to Fig. 2.

The TEA was administered between June 8, 2020 and March 16, 2021 (the patient was hospitalized from June 8 to July 11, 2020 and received outpatient treatment thereafter). The TEA was performed once or twice a week (9 times) during hospitalization. During outpatient treatment, the patient visited the hospital for TEA once a week over 5 weeks, and then once a month (18 times). The TEA was performed 27 times in total.

A sterilized stainless-steel needle (Dongbang Medical, Bundang, Korea) was used. The TEA device was covered with a protective cap before use and comprised 4 parts: needle hub, needle, thread (polydioxanone suture thread), and sponge. The thread was absorbable when buried in the treatment areas. The needles were 27 gauge × 40 mm, and 27 gauge × 60 mm, and the thread length was 50 mm and 90 mm, respectively. Among the core muscle groups supporting the lumbar spine and pelvis, treatment was mainly applied to the painful side to reduce pain and scoliosis by strengthening the muscles [10–14]. Treatment was also performed on the other side of the lumbar spine and pelvis muscles to balance the muscle of the entire lumbar spine [14] (Fig. 3). After sterilizing the treatment site with povidone-iodine, the TEA needle was inserted toward the treatment sites. The tip of the needle was held according to the direction of insertion, the depth, and the shape of the muscle: perpendicular (90°), oblique (about 45°), and transverse (about 15°). When the needles were inserted into the treatment sites, the absorbable thread was internally buried in the areas that helped maintain the stability of the muscles until the thread was absorbed.

Acupuncture was performed on the day the patient did not receive TEA. During hospitalization, acupuncture was performed twice a day (morning and afternoon). During outpatient treatment, acupuncture was performed once a week on the day the patient did not receive TEA. For acupuncture, 0.20 × 30 mm disposable sterilized needles made of stainless steel (Dongbang Medical, Ungcheon, Korea) were used and kept in place for 15 minutes. Acupuncture was performed by choosing the acupoints between BL23, BL25, BL40, BL24, BL52, BL57, BL60, GB30, GB34, and ST36, which are frequently used in LSS treatment [6–8]. During the hospitalization period, 3 packs of herbal medicines were taken orally each day (approximately 120 cc per pack) after meals, this treatment lasted for 34 days in total. For 14 days, Hwallagtang (mainly consisted of Chaenomelis fructus 10 g, Corydalis yanhusuo 8 g, Chelidonii Herba 8 g, Paeonia lactiflora 6 g, Cyperus rotundus 6 g, Angelica japonica 6 g, Aralia cordata 4 g per day) was used for relieving pain in the acute phase. After that, Gamiganghwalsogdantang (mainly consisted of Phlomis umbrosa Turcz. 12 g, Eucommia ulmoides 8 g, Glehnia littoralis 6 g, Angelica japonica 6 g, Rehmannia glutinosa 4 g, Achyranthes 4 g, Clematis florida 4 g per day) was used for 20 days, to control pain and reinforce the lumbar spine. During the hospitalization period, analgesic medicine was administered orally whenever the pain was severe [more than numerical rating scale (NRS) score 7]. Traphen Tab (acetaminophen 325 mg, Tramadol hydrochloride 37.5 mg) was used to relieve worse pain. It was a medication the patient usually took at home whenever the pain worsened, and even though she was hospitalized, the pain was severe, so she carried on taking it. One dose was 1 tablet, and the daily dose did not exceed 3 tablets. Following 10 days after hospitalization, the patient stopped taking analgesic medicines because the pain had been relieved. During outpatient treatment, the patient stopped taking herbal medicines and analgesic medicine. Physical therapy including interferential current therapy and microwave therapy, dry cupping treatment, and percutaneous transdermal muscle thermotherapy (hot pack) were applied to the pain points in the lumbar region once a day after TEA or acupuncture during the hospitalization and outpatient treatment periods.

The questionnaire using the NRS was recorded before and after the treatment. In the NRS, 0 represents the painless state and 10 the most severe pain, and the patient indicated their pain using the scale accordingly. The NRS measurements were obtained at each treatment.

To evaluate the degree of improvement in claudication, the distance that could be walked without pain was evaluated. This was used to measure and evaluate the linear distance from the start of gait to the start of lameness, or to the time when pain occurred. The measurements were made based on patient statements and were recorded at each treatment.

Degenerative scoliosis in this patient was due to deformation and curvature at the part of the 3^rd and 4^th lumbar vertebrae, resulting in degenerative changes such as spondylolisthesis, intervertebral disc degeneration, LSS, and antalgic posture. Therefore, radiographical examinations were performed to observe recovery from scoliosis resulting from the treatment. Radiology was performed 4 times during the treatment period (at hospitalization, at the discharge from the hospital, at the outpatient visitation, and at the end of treatment) to observe changes in scoliosis (Fig. 4). The curvature was also compared with the onset period.