Case Report

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Journal of Acupuncture Research 2025; 42:53-58

Published online February 4, 2025

https://doi.org/10.13045/jar.24.0057

© Korean Acupuncture & Moxibustion Medicine Society

Ultrasound-guided Caudal Epidural Pharmacopuncture Injection and Comprehensive Korean Medical Treatment for Spinal Stenosis: A Case Report

Gi-Tae Park1 , Myung-In Jeong1 , Hyun-Il Jo1 , Cheol-Ju Kim1 , Jung-Hyun Kim2 , Eun-Yul Han2

1Department of Acupuncture and Moxibustion Medicine, Daejeon Jaseng Hospital of Korean Medicine, Daejeon, Korea
2Department of Rehabilitation Medicine of Korean Medicine, Daejeon Jaseng Hospital of Korean Medicine, Daejeon, Korea

Correspondence to : Gi-Tae Park
Department of Acupuncture and Moxibustion Medicine, Daejeon Jaseng Hospital of Korean Medicine, 58 Munjeong-ro, 48beon-gil, Seo-gu, Daejeon 35262, Korea
E-mail: apmit@naver.com

Received: October 29, 2024; Revised: November 29, 2024; Accepted: December 4, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The present case report evaluated the effects of ultrasound-guided caudal epidural pharmacopuncture injection combined with integrative Korean medicine treatment on pain relief and functional recovery in a patient with spinal stenosis. A patient with chronic low back pain and radiating leg pain received pharmacopuncture via the caudal approach under ultrasound guidance. The treatment effects were assessed by the changes in the European Quality of Life 5-Dimension 5-Level scores, numeric rating scale scores, Oswestry Low Back Pain Disability Index, and range of motion (ROM). After treatment, the patient had significant pain reduction and improvements in ROM and functional status. Our data suggest that the combination of caudal epidural pharmacopuncture injection and integrative Korean medicine treatment may be an effective therapeutic approach for managing pain and functional recovery in patients with spinal stenosis.

Keywords Caudal epidural injections; Epidural, injections; Pharmacopuncture; Spinal stenosis; Ultrasound-guidance

Spinal stenosis is common among elderly individuals and is characterized by the narrowing of the lateral recess, intervertebral foramen, or spinal canal, compressing the dural sac or nerve roots and causing symptoms, such as low back pain, radiating leg pain, and claudication [1]. Lumbar spinal stenosis is treated with surgical and conservative approaches, with surgery considered when symptoms persist after conservative treatment (e.g., physical therapy or medication) [2]. Korean medicine treatments include herbal medication, acupuncture, pharmacopuncture, and physical therapy [3]. Epidural injections are classified by their entry route into transforaminal, interlaminar, and caudal approaches. The caudal approach involves inserting a needle into the sacral canal through the sacral hiatus [4]. It is effective for chronic low back pain [5], relatively easy to perform, and carries a lower risk of dural puncture [6]. Recent studies have shown successful caudal epidural injections (CEIs) under ultrasound guidance [7]. CEIs typically require the administration of steroids and local anesthetics; however, frequent steroid use can have adverse effects, including infections and tissue damage [8]. Although Korean medicine treatments for spinal stenosis have been reported, research on ultrasound-guided caudal epidural pharmacopuncture injections (CEPIs) is lacking. In the present report, pharmacopuncture for steroid and local anesthetic administration was used in ultrasound-guided CEIs for a patient with spinal stenosis. The effectiveness and potential benefits of this approach were evaluated by documenting the patient’s clinical progress and outcomes.

1. Patient

The patient was a 76-year-old female.

2. Diagnosis

The patient was diagnosed with L3-4-5 broad-based disc herniation and right and left foraminal stenoses (Fig. 1).

Fig. 1. Magnetic resonance imaging, coronal view. The yellow arrow indicates the foraminal spinal stenosis. Right L4–5 foraminal spinal stenosis (A). Left L4–5 foraminal spinal stenosis (B).

3. Principal complaints

She complained of low back pain, bilateral lower extremity radiating pain, and reduced upper and lower extremity muscle strengths.

4. Onset

Her symptoms started on February 1, 2024.

5. Present illness

The patient was diagnosed following magnetic resonance imaging performed on the onset date. In February 2024, she underwent ligament removal surgery for the lumbar spine (L-SPINE), but her symptoms did not improve. From February 1, 2024, to April 5, 2024, she visited a local hospital 10 times for injections, physical therapy, and oral medications without improvement. She received inpatient treatment at Daejeon Jaseng Hospital of Korean Medicine from April 10, 2024, to June 15, 2024.

6. Medical history

For her L-SPINE stenosis, she underwent an L-SPINE stenosis operation. She also had undergone vertebroplasty for an L-SPINE fracture.

7. Magnetic resonance imaging

Magnetic resonance imaging (MRI) was performed to evaluate the patient’s lumbar spinal stenosis. The coronal view MRI images indicate foraminal spinal stenosis at the L4–5 level (Fig. 1).

8. Treatment

1) Acupuncture

Acupuncture was administered twice daily during hospitalization. Each session lasted for 10–15 minutes. Disposable sterilized needles (0.25 × 30 mm; Dongbang Acupuncture Co.) were used. The acupuncture points included BL23, BL24, BL25, BL26, GV3, BL31, GB30, and BL54.

2) Pharmacopuncture treatment

Pharmacopuncture was performed using a 10-mL disposable syringe and a 26-G, 60-mm sterile needle (Sungshim Medical Co.). The patient was placed in the prone position, and the sacral hiatus was identified by ultrasound (V8; Samsung Medison). No local anesthesia was used. The needle was positioned up to GV1 (Changqiang), as the dural sac ends at the second sacral vertebra. The needle was inserted at a 45–60° angle to the skin surface until it penetrated the sacrococcygeal ligament (Fig. 2); then, the needle was lowered to 15–30° and advanced for another 1 cm. A 10-mL volume of Shinbaro pharmacopuncture (Jaseng Wonoe Tangjunwon) was injected. The site was sterilized and covered with gauze and adhesive tape to prevent infection. One practitioner who did not participate in the treatment evaluation performed the procedure. The patient provided consent after the procedure was explained to her.

Fig. 2. Pharmacopuncture administration procedure.

The white arrow shows the needle inserted parallel to the sacral base. On ultrasound, the needle appears as a hyperechoic structure; however, the portion of the needle within the caudal epidural space is not visible under ultrasound (Fig. 3) [9].

Fig. 3. Image of the ultrasound-guided procedure. (A) Sonographic image showing the needle inserted at a 45–60° angle to the skin surface, penetrating the sacrococcygeal ligament. (B) Schematic illustration of the caudal epidural space and pharmacopuncture injection technique.

3) Herbal medicine

The patient took Cheongpajeon-H (120 mL per pack) 30 minutes after meals three times a day from April 12, 2024, to June 14, 2024 (Table 1).

Table 1 . Herbal composition of Cheongpajeon-H

Crude drug nameAmount (g)
Lasiosphaera fenzlii11.25
Lycium chinense7.5
Eucommia ulmoides7.5
Saposhnikovia divaricata7.5
Acanthopanax sessiliflorus7.5
Achyranthes bidentata7.5
Atractylodes macrocephala3.75
Amomum villosum3.75
Hypericum monogynum3.75
Glycyrrhiza uralensis2.625
Zingiber officinale1.875
Scolopendra subspinipes mutilans0.375


4) Physical therapy

Interferential current therapy, dry cupping on the lumbar bladder meridian, and transcutaneous infrared therapy on the lumbar area were performed.

9. Assessments

1) European Quality of Life 5-Dimension 5-Level questionnaire

The European Quality of Life 5-Dimension 5-Level questionnaire (EQ-5D) is used to evaluate an individual’s quality of life according to the following five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [10]. In the present report, it was utilized to compare the patient’s health status before and after treatment. The scores obtained at admission, on day 7, and at the time of discharge were recorded.

2) Numeric rating scale

The numeric rating scale (NRS) is an 11-point scale that quantifies subjective pain, with 10 indicating the worst pain and 0 as having no pain [11]. The NRS scores were recorded at 7 am daily during hospitalization to assess for pain relief and treatment effectiveness.

3) Oswestry Low Back Pain Disability Index

The Oswestry Low Back Pain Disability Index (ODI) consists of the following 10 items for assessing daily activities: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling [12]. The scores range from 0 to 5, with higher scores indicating greater pain and disability. A standardized Korean version of the ODI was used in the present investigation. The scores were recorded at admission, on day 7, and at the time of discharge.

4) Range of motion

The lumbar spine range of motion (ROM), including flexion, extension, lateral bending, and rotation, was measured in degrees, along with pain during active movement. ROM was measured at 7 AM daily during hospitalization.

10. Progress

On admission, the patient’s EQ-5D, NRS, and ODI scores were 0.342, 7, and 68.89, respectively. The lumbar ROM included flexion of 60°, extension of 20°, lateral bending of 30°, and rotation of 45°. The patient felt tightness along the bilateral erector spinae muscles extending to the bilateral thighs and was unable to sit due to pain. From April 12 to 16, a total of four CEPIs were performed. On April 16, the patient’s EQ-5D, NRS, and ODI scores were 0.766, 4, and 44.44, respectively. From April 17 to 27, a total of five CEPIs were administered. On June 12, at discharge, the patient’s EQ-5D, NRS, and ODI scores were 0.837, 1, and 33.33, respectively (Table 2, Figs. 4, 5). The lumbar ROM improved to a flexion of 80°, and pain disappeared in all movements. No adverse events, including infection, bleeding, or nerve injury, were observed after the CEPIs.

Fig. 4. Changes in the NRS and ODI scores at admission, on day 7, and at the time of discharge. Left axis, NRS scores; right axis, ODI scores. NRS, numeric rating scale; ODI, Oswestry Low Back Pain Disability Index.

Fig. 5. Changes in the EQ-5D scores at admission, on day 7, and at the time of discharge. EQ-5D, European Quality of Life 5-Dimension 5-Level questionnaire.

Table 2 . Changes in EQ-5D, NRS, ODI, and range of motion scores during treatment of a patient with spinal stenosis

MeasurementAdmissionDay 7Discharge
EQ-5D0.3420.7660.837
NRS741
ODI68.8944.4433.33
Flexion (°)607090
Extension (°)202030

Admission: April 10, 2024; Day 7: April 16, 2024; Discharge: June 15, 2024.

EQ-5D, European Quality of Life 5-Dimension 5-Level questionnaire; NRS, numeric rating scale; ODI, Oswestry Low Back Pain Disability Index.


Lumbar spinal stenosis causes nerve compression and neurogenic symptoms, such as intermittent claudication, and walking short distances results in leg stiffness and tightness. These symptoms can be alleviated by stopping walking, bending forward, or squatting, which increases the size of the lumbar space [13].

CEIs are used for lumbosacral spinal pain, especially in patients with spinal stenosis. Large medication volumes (≥ 10 mL) can be injected to deliver medications across the lumbar level. This approach is safer because of its lower risk of injuring the nerve roots exiting the cauda equina or spinal cord. CEIs work by separating epidural adhesions, blocking sympathetic nerve reflexes using local anesthetics, and decreasing inflammatory responses and nerve root edema [14].

The present case suggests the potential anti-inflammatory and cartilage-protective effects of Shinbaro pharmacopuncture in a CEPI (Table 3). Based on its reported anti-inflammatory and pain-relieving properties, CEPI is hypothesized to possibly alleviate the symptoms of spinal stenosis by reducing inflammation, decreasing nerve root edema, improving local blood flow, and potentially minimizing epidural adhesions. Nevertheless, further research is warranted to elucidate these mechanisms and validate their clinical relevance [15]. Comprehensive Korean medical treatment uses acupuncture on points recognized as involved in lumbar pain [16]. The clinical progress of our patient confirmed the effectiveness of combining CEPI with comprehensive Korean medical treatment. The patient showed significant improvements in the EQ-5D 4-Level Scale, NRS, and ODI scores, with a marked improvement in ROM (Figs. 4, 5). No serious adverse reactions, including infection, bleeding, or nerve injury, were observed post-injection, indicating that CEPI is relatively safe for patients with spinal stenosis. Follow-up assessments during hospitalization indicated considerable improvements in the patient’s clinical outcomes. However, considering the potential for temporary effects in cases of severe nerve compression, long-term follow-up studies are required to confirm the sustained efficacy and safety of this treatment approach.

Table 3 . Shinbaro composition

NameComponent
ShinbaroCibotii Rhizoma, Ledebouriellae Radix, Eucommiae Cortex, Acanthopanacis Cortex, Achyranthis Radix, Scolopendra subspinipes mutilans, Ostericum koraenum (Max) Kitagawa, Aralia continentalis, Paeonia lactiflora


In conclusion, we propose that combining ultrasound-guided CEPI with comprehensive Korean medical treatment may be an effective therapeutic option for managing chronic low back and radicular pain, restoring ROM, and improving patients’ quality of life. However, further studies with larger sample sizes and control groups are needed to validate the efficacy and safety of this approach.

Conceptualization: GTP. Data curation: All authors. Formal analysis: GTP, MIJ, HIJ. Resources: GTP, MIJ, HIJ. Supervision: GTP. Visualization: GTP, CJK, JHK, EYH. Writing – original draft: GTP. Writing – review & editing: GTP.

This study was approved by the Institutional Review Board of Daejeon Jaseng Hospital of Korean Medicine (IRB File no.: 2024-08-031), and the patient’s personal information was protected. A written informed consent was obtained from the patient for the publication of this case report.

  1. Korean Spinal Neurosurgery Society. The textbook of spine. 2nd ed. Koonja Publishing. 2013:676-688.
  2. Ammendolia C, Stuber KJ, Rok E, Rampersaud R, Kennedy CA, Pennick V, et al. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev 2013;8:CD010712. doi: 10.1002/14651858.CD010712.
    Pubmed KoreaMed CrossRef
  3. Cha JD, Jeong SM, Kim GO, Kim GW, Kim NO. The comparison of effectiveness between acupuncture and its cotreatment with bee venom acua-acupuncture therapy on the treatment of herniation of nucleus pulpous. J Korean Acupunct Moxibustion Soc 2004;21:149-158.
  4. Chen CP, Tang SF, Hsu TC, Tsai WC, Liu HP, Chen MJ, et al. Ultrasound guidance in caudal epidural needle placement. Anesthesiology 2004;101:181-184. doi: 10.1097/00000542-200407000-00028.
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  5. Tsui BC, Tarkkila P, Gupta S, Kearney R. Confirmation of caudal needle placement using nerve stimulation. Anesthesiology 1999;91:374-378. doi: 10.1097/00000542-199908000-00010.
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  6. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. A prospective evaluation of complications of 10,000 fluoroscopically directed epidural injections. Pain Physician 2012;15:131-140. doi: 10.36076/ppj.2012/15/131.
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  11. Dietrich TJ, Moor BK, Puskas GJ, Pfirrmann CW, Hodler J, Peterson CK. Is the lateral extension of the acromion related to the outcome of shoulder injections?. Eur Radiol 2015;25:267-273. doi: 10.1007/s00330-014-3403-7.
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  12. Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980;66:271-273.
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  13. Hall S, Bartleson JD, Onofrio BM, HL, Okazaki H, O'Duffy JD. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med 1985;103:271-275. doi: 10.7326/0003-4819-103-2-271.
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  14. Winnie AP, Hartman JT, HL, Ramamurthy S, Barangan V. Pain clinic. II. Intradural and extradural corticosteroids for sciatica. Anesth Analg 1972;51:990-1003.
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  16. Lim JY, Choi JE, Kim MJ, Kim SH, Kim YJ, Do HK, et al. Comparative effectiveness research of conservative treatment and rotator cuff repair for the patient with rotator cuff tears. National Evidence-based Healthcare Collaborating Agency. 2016:1-135.

Article

Case Report

Journal of Acupuncture Research 2025; 42(): 53-58

Published online February 4, 2025 https://doi.org/10.13045/jar.24.0057

Copyright © Korean Acupuncture & Moxibustion Medicine Society.

Ultrasound-guided Caudal Epidural Pharmacopuncture Injection and Comprehensive Korean Medical Treatment for Spinal Stenosis: A Case Report

Gi-Tae Park1 , Myung-In Jeong1 , Hyun-Il Jo1 , Cheol-Ju Kim1 , Jung-Hyun Kim2 , Eun-Yul Han2

1Department of Acupuncture and Moxibustion Medicine, Daejeon Jaseng Hospital of Korean Medicine, Daejeon, Korea
2Department of Rehabilitation Medicine of Korean Medicine, Daejeon Jaseng Hospital of Korean Medicine, Daejeon, Korea

Correspondence to:Gi-Tae Park
Department of Acupuncture and Moxibustion Medicine, Daejeon Jaseng Hospital of Korean Medicine, 58 Munjeong-ro, 48beon-gil, Seo-gu, Daejeon 35262, Korea
E-mail: apmit@naver.com

Received: October 29, 2024; Revised: November 29, 2024; Accepted: December 4, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The present case report evaluated the effects of ultrasound-guided caudal epidural pharmacopuncture injection combined with integrative Korean medicine treatment on pain relief and functional recovery in a patient with spinal stenosis. A patient with chronic low back pain and radiating leg pain received pharmacopuncture via the caudal approach under ultrasound guidance. The treatment effects were assessed by the changes in the European Quality of Life 5-Dimension 5-Level scores, numeric rating scale scores, Oswestry Low Back Pain Disability Index, and range of motion (ROM). After treatment, the patient had significant pain reduction and improvements in ROM and functional status. Our data suggest that the combination of caudal epidural pharmacopuncture injection and integrative Korean medicine treatment may be an effective therapeutic approach for managing pain and functional recovery in patients with spinal stenosis.

Keywords: Caudal epidural injections, Epidural, injections, Pharmacopuncture, Spinal stenosis, Ultrasound-guidance

INTRODUCTION

Spinal stenosis is common among elderly individuals and is characterized by the narrowing of the lateral recess, intervertebral foramen, or spinal canal, compressing the dural sac or nerve roots and causing symptoms, such as low back pain, radiating leg pain, and claudication [1]. Lumbar spinal stenosis is treated with surgical and conservative approaches, with surgery considered when symptoms persist after conservative treatment (e.g., physical therapy or medication) [2]. Korean medicine treatments include herbal medication, acupuncture, pharmacopuncture, and physical therapy [3]. Epidural injections are classified by their entry route into transforaminal, interlaminar, and caudal approaches. The caudal approach involves inserting a needle into the sacral canal through the sacral hiatus [4]. It is effective for chronic low back pain [5], relatively easy to perform, and carries a lower risk of dural puncture [6]. Recent studies have shown successful caudal epidural injections (CEIs) under ultrasound guidance [7]. CEIs typically require the administration of steroids and local anesthetics; however, frequent steroid use can have adverse effects, including infections and tissue damage [8]. Although Korean medicine treatments for spinal stenosis have been reported, research on ultrasound-guided caudal epidural pharmacopuncture injections (CEPIs) is lacking. In the present report, pharmacopuncture for steroid and local anesthetic administration was used in ultrasound-guided CEIs for a patient with spinal stenosis. The effectiveness and potential benefits of this approach were evaluated by documenting the patient’s clinical progress and outcomes.

CASE REPORT

1. Patient

The patient was a 76-year-old female.

2. Diagnosis

The patient was diagnosed with L3-4-5 broad-based disc herniation and right and left foraminal stenoses (Fig. 1).

Figure 1. Magnetic resonance imaging, coronal view. The yellow arrow indicates the foraminal spinal stenosis. Right L4–5 foraminal spinal stenosis (A). Left L4–5 foraminal spinal stenosis (B).

3. Principal complaints

She complained of low back pain, bilateral lower extremity radiating pain, and reduced upper and lower extremity muscle strengths.

4. Onset

Her symptoms started on February 1, 2024.

5. Present illness

The patient was diagnosed following magnetic resonance imaging performed on the onset date. In February 2024, she underwent ligament removal surgery for the lumbar spine (L-SPINE), but her symptoms did not improve. From February 1, 2024, to April 5, 2024, she visited a local hospital 10 times for injections, physical therapy, and oral medications without improvement. She received inpatient treatment at Daejeon Jaseng Hospital of Korean Medicine from April 10, 2024, to June 15, 2024.

6. Medical history

For her L-SPINE stenosis, she underwent an L-SPINE stenosis operation. She also had undergone vertebroplasty for an L-SPINE fracture.

7. Magnetic resonance imaging

Magnetic resonance imaging (MRI) was performed to evaluate the patient’s lumbar spinal stenosis. The coronal view MRI images indicate foraminal spinal stenosis at the L4–5 level (Fig. 1).

8. Treatment

1) Acupuncture

Acupuncture was administered twice daily during hospitalization. Each session lasted for 10–15 minutes. Disposable sterilized needles (0.25 × 30 mm; Dongbang Acupuncture Co.) were used. The acupuncture points included BL23, BL24, BL25, BL26, GV3, BL31, GB30, and BL54.

2) Pharmacopuncture treatment

Pharmacopuncture was performed using a 10-mL disposable syringe and a 26-G, 60-mm sterile needle (Sungshim Medical Co.). The patient was placed in the prone position, and the sacral hiatus was identified by ultrasound (V8; Samsung Medison). No local anesthesia was used. The needle was positioned up to GV1 (Changqiang), as the dural sac ends at the second sacral vertebra. The needle was inserted at a 45–60° angle to the skin surface until it penetrated the sacrococcygeal ligament (Fig. 2); then, the needle was lowered to 15–30° and advanced for another 1 cm. A 10-mL volume of Shinbaro pharmacopuncture (Jaseng Wonoe Tangjunwon) was injected. The site was sterilized and covered with gauze and adhesive tape to prevent infection. One practitioner who did not participate in the treatment evaluation performed the procedure. The patient provided consent after the procedure was explained to her.

Figure 2. Pharmacopuncture administration procedure.

The white arrow shows the needle inserted parallel to the sacral base. On ultrasound, the needle appears as a hyperechoic structure; however, the portion of the needle within the caudal epidural space is not visible under ultrasound (Fig. 3) [9].

Figure 3. Image of the ultrasound-guided procedure. (A) Sonographic image showing the needle inserted at a 45–60° angle to the skin surface, penetrating the sacrococcygeal ligament. (B) Schematic illustration of the caudal epidural space and pharmacopuncture injection technique.

3) Herbal medicine

The patient took Cheongpajeon-H (120 mL per pack) 30 minutes after meals three times a day from April 12, 2024, to June 14, 2024 (Table 1).

Table 1 . Herbal composition of Cheongpajeon-H.

Crude drug nameAmount (g)
Lasiosphaera fenzlii11.25
Lycium chinense7.5
Eucommia ulmoides7.5
Saposhnikovia divaricata7.5
Acanthopanax sessiliflorus7.5
Achyranthes bidentata7.5
Atractylodes macrocephala3.75
Amomum villosum3.75
Hypericum monogynum3.75
Glycyrrhiza uralensis2.625
Zingiber officinale1.875
Scolopendra subspinipes mutilans0.375


4) Physical therapy

Interferential current therapy, dry cupping on the lumbar bladder meridian, and transcutaneous infrared therapy on the lumbar area were performed.

9. Assessments

1) European Quality of Life 5-Dimension 5-Level questionnaire

The European Quality of Life 5-Dimension 5-Level questionnaire (EQ-5D) is used to evaluate an individual’s quality of life according to the following five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [10]. In the present report, it was utilized to compare the patient’s health status before and after treatment. The scores obtained at admission, on day 7, and at the time of discharge were recorded.

2) Numeric rating scale

The numeric rating scale (NRS) is an 11-point scale that quantifies subjective pain, with 10 indicating the worst pain and 0 as having no pain [11]. The NRS scores were recorded at 7 am daily during hospitalization to assess for pain relief and treatment effectiveness.

3) Oswestry Low Back Pain Disability Index

The Oswestry Low Back Pain Disability Index (ODI) consists of the following 10 items for assessing daily activities: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling [12]. The scores range from 0 to 5, with higher scores indicating greater pain and disability. A standardized Korean version of the ODI was used in the present investigation. The scores were recorded at admission, on day 7, and at the time of discharge.

4) Range of motion

The lumbar spine range of motion (ROM), including flexion, extension, lateral bending, and rotation, was measured in degrees, along with pain during active movement. ROM was measured at 7 AM daily during hospitalization.

10. Progress

On admission, the patient’s EQ-5D, NRS, and ODI scores were 0.342, 7, and 68.89, respectively. The lumbar ROM included flexion of 60°, extension of 20°, lateral bending of 30°, and rotation of 45°. The patient felt tightness along the bilateral erector spinae muscles extending to the bilateral thighs and was unable to sit due to pain. From April 12 to 16, a total of four CEPIs were performed. On April 16, the patient’s EQ-5D, NRS, and ODI scores were 0.766, 4, and 44.44, respectively. From April 17 to 27, a total of five CEPIs were administered. On June 12, at discharge, the patient’s EQ-5D, NRS, and ODI scores were 0.837, 1, and 33.33, respectively (Table 2, Figs. 4, 5). The lumbar ROM improved to a flexion of 80°, and pain disappeared in all movements. No adverse events, including infection, bleeding, or nerve injury, were observed after the CEPIs.

Figure 4. Changes in the NRS and ODI scores at admission, on day 7, and at the time of discharge. Left axis, NRS scores; right axis, ODI scores. NRS, numeric rating scale; ODI, Oswestry Low Back Pain Disability Index.

Figure 5. Changes in the EQ-5D scores at admission, on day 7, and at the time of discharge. EQ-5D, European Quality of Life 5-Dimension 5-Level questionnaire.

Table 2 . Changes in EQ-5D, NRS, ODI, and range of motion scores during treatment of a patient with spinal stenosis.

MeasurementAdmissionDay 7Discharge
EQ-5D0.3420.7660.837
NRS741
ODI68.8944.4433.33
Flexion (°)607090
Extension (°)202030

Admission: April 10, 2024; Day 7: April 16, 2024; Discharge: June 15, 2024..

EQ-5D, European Quality of Life 5-Dimension 5-Level questionnaire; NRS, numeric rating scale; ODI, Oswestry Low Back Pain Disability Index..


DISCUSSION

Lumbar spinal stenosis causes nerve compression and neurogenic symptoms, such as intermittent claudication, and walking short distances results in leg stiffness and tightness. These symptoms can be alleviated by stopping walking, bending forward, or squatting, which increases the size of the lumbar space [13].

CEIs are used for lumbosacral spinal pain, especially in patients with spinal stenosis. Large medication volumes (≥ 10 mL) can be injected to deliver medications across the lumbar level. This approach is safer because of its lower risk of injuring the nerve roots exiting the cauda equina or spinal cord. CEIs work by separating epidural adhesions, blocking sympathetic nerve reflexes using local anesthetics, and decreasing inflammatory responses and nerve root edema [14].

The present case suggests the potential anti-inflammatory and cartilage-protective effects of Shinbaro pharmacopuncture in a CEPI (Table 3). Based on its reported anti-inflammatory and pain-relieving properties, CEPI is hypothesized to possibly alleviate the symptoms of spinal stenosis by reducing inflammation, decreasing nerve root edema, improving local blood flow, and potentially minimizing epidural adhesions. Nevertheless, further research is warranted to elucidate these mechanisms and validate their clinical relevance [15]. Comprehensive Korean medical treatment uses acupuncture on points recognized as involved in lumbar pain [16]. The clinical progress of our patient confirmed the effectiveness of combining CEPI with comprehensive Korean medical treatment. The patient showed significant improvements in the EQ-5D 4-Level Scale, NRS, and ODI scores, with a marked improvement in ROM (Figs. 4, 5). No serious adverse reactions, including infection, bleeding, or nerve injury, were observed post-injection, indicating that CEPI is relatively safe for patients with spinal stenosis. Follow-up assessments during hospitalization indicated considerable improvements in the patient’s clinical outcomes. However, considering the potential for temporary effects in cases of severe nerve compression, long-term follow-up studies are required to confirm the sustained efficacy and safety of this treatment approach.

Table 3 . Shinbaro composition.

NameComponent
ShinbaroCibotii Rhizoma, Ledebouriellae Radix, Eucommiae Cortex, Acanthopanacis Cortex, Achyranthis Radix, Scolopendra subspinipes mutilans, Ostericum koraenum (Max) Kitagawa, Aralia continentalis, Paeonia lactiflora


In conclusion, we propose that combining ultrasound-guided CEPI with comprehensive Korean medical treatment may be an effective therapeutic option for managing chronic low back and radicular pain, restoring ROM, and improving patients’ quality of life. However, further studies with larger sample sizes and control groups are needed to validate the efficacy and safety of this approach.

AUTHOR CONTRIBUTIONS

Conceptualization: GTP. Data curation: All authors. Formal analysis: GTP, MIJ, HIJ. Resources: GTP, MIJ, HIJ. Supervision: GTP. Visualization: GTP, CJK, JHK, EYH. Writing – original draft: GTP. Writing – review & editing: GTP.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

FUNDING

None.

ETHICAL STATEMENT

This study was approved by the Institutional Review Board of Daejeon Jaseng Hospital of Korean Medicine (IRB File no.: 2024-08-031), and the patient’s personal information was protected. A written informed consent was obtained from the patient for the publication of this case report.

Fig 1.

Figure 1.Magnetic resonance imaging, coronal view. The yellow arrow indicates the foraminal spinal stenosis. Right L4–5 foraminal spinal stenosis (A). Left L4–5 foraminal spinal stenosis (B).
Journal of Acupuncture Research 2025; 42: 53-58https://doi.org/10.13045/jar.24.0057

Fig 2.

Figure 2.Pharmacopuncture administration procedure.
Journal of Acupuncture Research 2025; 42: 53-58https://doi.org/10.13045/jar.24.0057

Fig 3.

Figure 3.Image of the ultrasound-guided procedure. (A) Sonographic image showing the needle inserted at a 45–60° angle to the skin surface, penetrating the sacrococcygeal ligament. (B) Schematic illustration of the caudal epidural space and pharmacopuncture injection technique.
Journal of Acupuncture Research 2025; 42: 53-58https://doi.org/10.13045/jar.24.0057

Fig 4.

Figure 4.Changes in the NRS and ODI scores at admission, on day 7, and at the time of discharge. Left axis, NRS scores; right axis, ODI scores. NRS, numeric rating scale; ODI, Oswestry Low Back Pain Disability Index.
Journal of Acupuncture Research 2025; 42: 53-58https://doi.org/10.13045/jar.24.0057

Fig 5.

Figure 5.Changes in the EQ-5D scores at admission, on day 7, and at the time of discharge. EQ-5D, European Quality of Life 5-Dimension 5-Level questionnaire.
Journal of Acupuncture Research 2025; 42: 53-58https://doi.org/10.13045/jar.24.0057

Table 1 . Herbal composition of Cheongpajeon-H.

Crude drug nameAmount (g)
Lasiosphaera fenzlii11.25
Lycium chinense7.5
Eucommia ulmoides7.5
Saposhnikovia divaricata7.5
Acanthopanax sessiliflorus7.5
Achyranthes bidentata7.5
Atractylodes macrocephala3.75
Amomum villosum3.75
Hypericum monogynum3.75
Glycyrrhiza uralensis2.625
Zingiber officinale1.875
Scolopendra subspinipes mutilans0.375

Table 2 . Changes in EQ-5D, NRS, ODI, and range of motion scores during treatment of a patient with spinal stenosis.

MeasurementAdmissionDay 7Discharge
EQ-5D0.3420.7660.837
NRS741
ODI68.8944.4433.33
Flexion (°)607090
Extension (°)202030

Admission: April 10, 2024; Day 7: April 16, 2024; Discharge: June 15, 2024..

EQ-5D, European Quality of Life 5-Dimension 5-Level questionnaire; NRS, numeric rating scale; ODI, Oswestry Low Back Pain Disability Index..


Table 3 . Shinbaro composition.

NameComponent
ShinbaroCibotii Rhizoma, Ledebouriellae Radix, Eucommiae Cortex, Acanthopanacis Cortex, Achyranthis Radix, Scolopendra subspinipes mutilans, Ostericum koraenum (Max) Kitagawa, Aralia continentalis, Paeonia lactiflora

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Jan 07, 2025 Volume 42:1~130

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