Failed back surgery syndrome (FBSS) is diagnosed when lumbago and lower limb pain and numbness persist or recur despite spinal surgery [1]. FBSS is associated with patient factors, surgical factors, poor technique, incorrect level of operation, surgical aim not achieve, progressive disease, epidural fibrosis, surgical complications, new spinal instability, and myofascial pain development [2]. Acupotomy was developed by Zhu Hanzhang in 1976 to remove adhesions, nodules, and scars of soft tissues using a special needle that combines a scapel and acupuncture needle [3,4]. Acupotomy combined with Korean medicine (KM) treatment can be effective in patients with FBSS experiencing uncontrolled symptoms even after multiple surgeries.

1. Case presentation

A 48-year-old male experienced lumbago and pain and numbness in his left leg while performing manual work on January 28, 2016. In February 2016, magnetic resonance imaging (MRI) revealed herniated intervertebral disc (HIVD) at the L4/5 level, leading to a left-sided partial laminectomy with discectomy at the L4/5 level. He was admitted to a local KM hospital in February 2016. In October 2016, MRI revealed a recurrent HIVD. Subsequently, he underwent a series of conservative treatments, including nerve blocks, pharmacological interventions, physiotherapy, and local injections. In October 2023, the patient reported an exacerbation of pain without any apparent precipitating factors. In April 2024, MRI confirmed an HIVD at the L4/5 level, leading to a left-sided percutaneous endoscopic lumbar discectomy at the L4/5 level. Owing to the exacerbation of postoperative pain, he was admitted to the Department of Neurosurgery at the Armed Forces Daejeon Hospital. Despite inpatient neurosurgical management, the patient’s pain persisted. Consequently, in pursuit of more effective pain management, the patient initiated treatment at the KM clinic (Fig. 1). The patient had no remarkable medical, family, or social history.

Figure 1. Timeline of treatment. Lt., left; HIVD, herniated intervertebral disc; Dx., diagnosis; PELD, percutaneous endoscopic lumbar discectomy; KM, Korean medicine; IR, infrared.

This retrospective chart review was approved as a review study by the Armed Forces Medical Command Institutional Review Board (AFMC IRB 2024-07-004-001). A verbal informed consent was obtained from the patients for the publication of this case report.

2. Clinical findings

Upon initial examination, the patient’s lumbar range of motion was normal, except for a limited flexion of 30°. Straight-leg raising (SLR) and manual muscle testing were normal bilaterally. Pain was positive on the left side on Patrick’s test, and the dermatome was assessed as 50% reduced on the left side compared with the right side in L3, L4, L5, and S1. Pain was positive on palpation of the left sacroiliac joint (SIJ). The Oswestry Disability Index (ODI), which measures disability and quality of life in patients with low back pain, was 26. Lumbar MRI performed before and after surgery confirmed the presence of HIVD protrusion type L4/5 (Fig. 2). However, a specific lumbar segment was not the cause. Two operations targeting L4/5 failed, the SLR test result was normal, and the entire L3, L4, L5, and S1 dermatomes deteriorated. The positive left Patrick’s test and pain on palpation of the left SIJ led to the diagnosis of left SIJ dysfunction as the primary cause of the patient’s symptoms.

Figure 2. Magnetic resonance imaging of lumbar spine. (A) Preoperation (April 8, 2024) sagittal view. (B) Preoperation (April 8, 2024) L4/5 transverse view. (C) Postoperation (April 9, 2024) sagittal view. (D) Postoperation (April 9, 2024) L4/5 transverse view. Arrow, herniated intervertebral disc.

3. Therapeutic interventions

The patient provided consent after the procedure, precautions were fully explained to the patient, and acupotomy was performed. The operator was a certified KM doctor and specialist in acupuncture and moxibustion medicine. At each visit, acupotomy was performed using disposable needles (stainless, 0.5 × 40 mm, WOOJEON and 1.0 × 80 mm, Dongbang) at different sites and depths each time. The acupotomy sites were determined according to the patient’s change in symptoms and tenderness. Before treatment, the treatment sites were sterilized with a disposable medical alcohol swab. After the needle contacted the target ligament, the ligament was dissected 5–10 times in the vertical and longitudinal directions. To reduce pain, 10 or 20 stainless-steel disposable needles (0.25 × 40 mm, Dongbang) were inserted into the acupotomy site after hemostasis, and electroacupuncture and infrared therapy were performed simultaneously for 15 minutes. To improve the motility of the SIJ and vertebral body, acupotomy was performed after chuna therapy (cervical, thoracic, and lumbar myofascial release technique, high-velocity, low-amplitude technique, pelvic myofascial release technique, and Thompson technique) at all visits, except for the 1st visit.

4. Follow-up and outcomes

Pain was measured using the numerical rating scale (NRS) with maximum and minimum of 10 and 0 points, respectively [5]. Simultaneous palpation was performed in the same area of each leg to measure sensory loss based on normal sensation (100%). Compared with normal, the patient’s subjective sensation was measured on a scale of 10%. NRS and sensory were measured at each visit. The Korean version of the ODI was administered every 1–2 weeks to measure interference in daily life [6].

At the initial visit, the patient reported pain when lying on the side (NRS 8) and pain and numbness in the left lower limb (NRS 8). Range-of-motion assessment revealed flexion limited to 30°, with no limitations in other movements. Physical examination showed a positive Patrick test on the left side and significant left SIJ tenderness (+++). Treatment initiated with acupotomy performed on 9 points, complemented by acupuncture in the same area for pain reduction. Acupotomy points were adjusted at each visit based on the symptoms and tenderness (Fig. 3).

Figure 3. Acupotomy treatment points for each treatment.

At visit 2, the patient’s left low back pain improved to NRS 5 and left lower extremity pain and numbness improved to NRS 2 (Fig. 4). Sensory loss also improved to 70–80% overall (Fig. 5). Physical examination revealed tenderness at T7–T12, and chuna treatment was performed. At the 3rd visit, the lumbago improved to NRS 4, the left lower limb pain and numbness decreased to NRS 0, and the left calf pain remained at NRS 2. Overall sensory loss improved to 80–90%. The patient complained of instability in daily activities. At the 6th visit, he walked 9,000 steps and was pain free, and her left lumbago improved to NRS 2, and left calf pain improved to NRS 1. At the 7th visit, pain on walking significantly reduced, and the left lumbago improved to NRS 1 and the left calf pain improved to NRS 1 with occasional pulling. Sensory loss based on dermatomes improved to 90% in L3, 90% in L4, 100% in L5, and 100% in S1 and was maintained thereafter. Two to three days before the 8th visit, back pain occurred after physical work (NRS 4) when he extended his back after sitting for a long time. At the 9th visit, left lumbago (NRS 8) occurred after sitting and shoveling. At the 12th visit, the lumbago improved (NRS 2); however, his body remained tilted. In the past, he had experienced weakness and limping in his left leg when driving for long periods; however, at the time of the visit, he had driven for approximately 50 minutes and felt no discomfort. At the 13th visit, he had left back pain and tilting discomfort (NRS 2) and no lumbago (NRS 0). The ODI was 26 at the 1st, 20 at the 4th, 17 at the 7th, and 16 at the 12th visit (Fig. 6).

Figure 4. Numerical rating scale for each treatment.

Figure 5. Sensory test for each treatment.

Figure 6. Korean version of the ODI. ODI, Oswestry Disability Index.

FBSS is characterized by symptoms that do not resolve, recur, or newly develop after spinal surgery. The causes of FBSS include misdiagnosis, improper technique, focalization, and surgical complications such as recurrent HIVD, instability, scar adhesions, epidural adhesions, and infection [7]. Studies of reoperations for FBSS have reported that only 36% of patients are candidates for reoperation [8]. Pain control in FBSS is very difficult and can lead to narcotic addiction [9]. Acupuncture studies on pain control in FBSS have been conducted for electroacupuncture [10], whereas studies on acupotomy are scarce.

Hackett et al. [11] suggested interspinous ligament, sacroiliac area, zygapophyseal joint, iliolumbar ligament, dorsal sacroiliac ligament, SIJ, sacrospinal ligament, and sacrotuberous ligament as possible origins of lumbago and referred pain. The zygapophyseal joint and SIJ are the main origin of lumbago and referred pain [12,13]. In addition, the referral pattern of muscle trigger points can cause pelvic pain [14]. Among the various provocation tests, Patrick’s test demonstrates the highest sensitivity [15].

Acupotomy combines acupuncture and surgical therapy to dissect the adherent tissue and restore the dynamic state, which helps improve the symptoms of lumbar HIVD [16]. The spine is composed of curves of cervical lordosis, thoracic kyphosis, and lumbar lordosis, which are shock absorbers and are in balance with each other, and any misalignment can cause pain and functional limitations, which can be improved by chuna therapy [17]. Electroacupuncture is effective in controlling pain through its antinociceptive effects on the spinal cord, central nervous system, and peripheral nervous system [18].

Herein, the patient underwent repeated nerve blocks and reoperation owing to non-improvement of symptoms after surgery. The laminectomy performed during the first surgery may have induced spinal instability. Based on the pain in the left low back and SIJ and physical examination, acupotomy was implemented focusing on the tenderness of ligaments surrounding the SIJ, and after two treatments, the left lumbago, which was the main complaint, decreased from NRS 8 to 4, and the left lower limb pain and numbness disappeared. The treatment methodology involved selecting either a 40 mm or 80 mm needle, depending on the target depth. After the 13th treatment, the lumbago disappeared (NRS 0), and posture-related back pain (NRS 2) and slight discomfort in the left calf (NRS 1) remained. The sensory loss on the left side recovered to 90% for L3 and L4 and 100% for L5 and S1 after the 13th treatment.

In clinical practice, the use of percentages to assess subjective sensations has limitations. For an objective case report, an objective index was needed. However, no commonly used standard scale has compared the degree of hypoesthesia caused by peripheral nerve injury to the normal side. Therefore, an objective measurement index is needed. Despite the inherent limitations of a single case report, it is significant that a patient with severe, persistent lumbago of over 8 years duration, refractory to two surgical interventions, demonstrated marked improvement after 13 acupotomy treatment sessions. Acupotomy is more invasive because the needles are thicker and sharper than the regular acupuncture needles. In the future, ultrasound-guided acupotomy should be used to objectify myofascial structures, muscles, and ligaments with adhesions and make the treatment safer. Further large-scale clinical trials on the efficacy of acupotomy for FBSS are needed.

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The author has no conflicts of interest to declare.

None.

This retrospective chart review was approved as a review study by the Armed Forces Medical Command Institutional Review Board (AFMC IRB 2024-07-004-001). A verbal informed consent was obtained from the patients for the publication of this case report.