Lumbar herniated intervertebral disc (LHIVD) is one of the most common degenerative spinal disorders, often resulting in considerable lower back pain. It is characterized by disc inflammation and nerve root compression, which are the primary contributors to the pain experienced by patients [1].

Except for the patients who are indicated for emergency surgery, such as those with cauda equina syndrome, conservative treatment is the first-line approach. However, a surgical intervention is indicated for cases showing no response to more than 6 weeks of conservative treatment or for those with worsening lower limb motor paralysis [2]. Korean medicine treatments, such as acupuncture, pharmacopuncture, and herbal medicine, are effective therapies for LHIVD [3-5]. Acupotomy, developed in 1979 by combining traditional acupuncture with modern surgical techniques, is an effective treatment method that addresses chronic pain by performing adhesiolysis or incisions in soft tissues [6]. Bee venom (BV) pharmacopuncture is a treatment that injects venom isolated from the BV’s sac into the acupoint. Its active components, such as melittin and apamin, exert anti-inflammatory effects and promote recovery [7].

Although previous studies have examined the effects of acupotomy on LHIVD with pain lasting for > 6 weeks [8-10], no study has been conducted on patients with muscle weakness. Additionally, while BV pharmacopuncture has been partially applied in patients with lower limb weakness, the treatment duration was relatively prolonged, averaging 37 days [11-15].

The present study reports the cases of two patients with severe neurological symptoms, such as lower limb weakness and sensory loss, who showed short-term improvement without surgery through Korean medicine treatments, including acupotomy and BV pharmacopuncture.

1. Case 1

1) Patient

The patient is a 42-year old male.

2) Chief complaint

He complained of low back pain, left lower limb pain and numbness, left ankle weakness, and hypoesthesia in the left plantar region.

3) Medical history

He had no particular medical history.

4) Present illness

The patient had been experiencing chronic lower back pain and left lower limb pain and numbness for approximately 6 years. He was diagnosed with LHIVD at the L4–5 and L5–S1 levels based on the results of the magnetic resonance imaging (MRI) scan performed at a local hospital in 2019. In December 2023, the patient’s pain worsened after prolonged driving. At the same time, weakness in the left ankle and hypoesthesia in the left plantar region also occurred. The patient’s ankle movement was limited to only 60% of the normal range against gravity because of muscle weakness. Owing to 6 years of chronic pain and recent worsening of ankle weakness, the patient was advised to undergo surgery, but he chose to undergo conservative treatment instead.

5) Treatment duration

The patient received conservative treatment from December 11, 2023 to December 22, 2023 (12 days of hospitalization).

6) Imaging results

The MR images of the lumbar spine were acquired on August 31, 2023. Central canal zone herniations with protrusion and extrusion were observed at the L4–5 and L5–S1 levels, respectively (Fig. 1).

Figure 1. T2-weighted magnetic resonance image of Case 1. (A) shows the sagittal view of a LHIVD at the L4–5–S1 level (green arrows). (B) and (C) are axial views of the LHIVD, with (B) at the L4–5 level and (C) at the L5–S1 level. The scans show central canal zone herniations with protrusion at the L4–5 level and extrusion at the L5–S1 level, respectively (green arrows). LHIVD, lumbar herniated intervertebral disc.

2. Case 2

1) Patient

The patient is a 45-year-old male.

2) Chief complaint

He complained of low back pain, left lower limb numbness, left ankle weakness, and hypoesthesia of left lower limb.

3) Medical history

The patient had been diagnosed with myocardial infarction and is currently on medication.

4) Present illness

The patient, who had been experiencing chronic lower back pain and left lower limb numbness for approximately 10 years, experienced a sudden increase in pain without any apparent cause on May 3, 2024. Along with the worsening pain, he also had decreased ankle strength and generalized sensory loss in the left lower limb. The patient was only able to move his ankle within half of the normal range against gravity due to muscle weakness. He also experienced nocturnal awakening approximately four times due to worsening left lower limb numbness at night. On May 7, 2024, he was diagnosed with LHIVD at the L1–2, L3–4, L4–5, and L5–S1 levels based on the results of the MRI scans performed at a local hospital. Owing to worsening chronic pain, along with newly developed lower limb muscle weakness, the patient was advised to undergo surgery, but he chose to undergo conservative treatment instead.

5) Treatment duration

He received treatment from May 13, 2024 to May 22, 2024 (10 days of hospitalization).

6) Imaging results

The MR images of the lumbar spine were obtained on May 7, 2024. Subarticular zone herniation with protrusion was observed at the L1–2 and L4–S1 levels, whereas extraforaminal zone herniation with protrusion was observed at the L3–4 level (Fig. 2).

Figure 2. T2-weighted magnetic resonance image of Case 2. (A) shows the sagittal view of a LHIVD at the L1-2, L3-4-5-S1 levels (green arrows). (B–E) are axial views of the LHIVD. (B), (D), and (E) show subarticular zone herniation with protrusion, while (C) shows extraforaminal zone herniation with protrusion (green arrows). LHIVD, lumbar herniated intervertebral disc.

3. Treatment

1) Acupotomy

A disposable 0.75 × 80-mm blade-edge needle (Dongbang Medical Co., Ltd.) was used. Acupotomy was performed at GV3, GV4, GV5, and Ex-B2 at the L3, L4, and L5 levels as well as on the tender points. The acupoints were selected based on the HIVD levels. The needle was inserted transversely to a depth of 7 cm to cut the adhesions around the facet joint and to avoid nerve root injury. Subsequently, the bony surfaces above and below the spinous process were incised to release the adhesions surrounding the interspinous ligament. The cases underwent one and two acupotomy sessions, respectively.

2) Bee venom

BV pharmacopuncture was administered bilaterally to BL24, BL25, and BL26 and unilaterally to GV3 and GV4. An equal amount of BV was injected at each point. The total amount of BV, calculated as the product of the concentration and dosage, was gradually increased and administered every 2–3 days. The concentration of BV was progressively increased from 1:20,000 to 1:200 (Table 1).

Table 1 . Bee venom injection.

Date	Bee venom concentration	Volume (cc)
Case 1
December 11, 2023	20,000:1	1.00
December 13, 2023	20,000:1	1.00
December 14, 2023	5,000:1	1.00
December 18, 2023	1,000:1	0.40
December 20, 2023	500:1	0.30
Case 2
May 13, 2024	1,000:1	0.45
May 16, 2024	500:1	0.35
May 18, 2024	200:1	0.22
May 20, 2024	200:1	0.34

3) Electroacupuncture

Stainless steel needles with sizes of 0.25 × 40 mm and 0.30 × 40 mm (Dongbang Medical Co., Ltd.) were used. Acupuncture was performed twice daily for 15 minutes per session at the following sites: bilaterally at BL23, BL24, BL25, and BL26; unilaterally at GB31, GB32, GB34, and GB35; and on the tender points on the hamstrings and gastrocnemius. Using an STN-330 (Stratek), electrical stimulation (3 Hz) in the continuous wave mode was applied once daily to B24–B25.

4) Herbal medicine

Whallak-tang and Ojeoksan were prescribed for both cases (Table 2). The patients took the herbal medicines three times a day.

Table 2 . Composition of three herbal medications for daily dosage.

Whallak-tang (Case 1: December 11–13, 2023; Case 2: May 13–17, 2024)	Amount (g)	Ojeoksan (Case 1: December 13–22, 2023; Case 2: May 17–22, 2024)	Amount (g)
Chaenomelis fructus	20	Atractylodis rhizoma	16
Chelidonii herba	20	Clematidis radix	12
Corydalis tuber	16	Pinelliae tuber	8
Osterici radix	16	Poria sclerotium	8
Clematidis radix	12	Paeoniae radix rubra	8
Angelicase gigantis radix	12	Ephedrae Herba	8
Paeoniae radix rubra	12	Aurantii pericarpium	8
Angelicae pubescentis radix	12	Angelica gigantis radix	8
Rehmanniae radix siccus	12	Cnidii rhizoma	8
Citri unshius pericarpium	8	Cinnamomi ramulus	8
Atractylodes Rhizome	8	Allii macrostemi bulbus	8
Olibanum	8	Aurantii fructus immaturus	6
Glycyrrhizae radix	8	Zingiberis rhizoma	6
Galli stomachichum corium	8	Zingiberis rhizoma recens	6
Hordei fructus germiniatus	8	Platycodonnis radix	6
Crataegii fructus	8	Angelicae dahuricae radix	6
Massa medicata fermentata	8
Myrrha	6
Carthami flos	6
Amomi fructus	4

5) Physiotherapy

Transcutaneous electrical nerve stimulation was performed on the lumbar region for 15 minutes daily to alleviate pain.

4. Evaluation

1) Manual muscle test

Manual muscle test is a clinical assessment tool used to evaluate the strength and function of muscles by applying resistance and observing a patient’s ability to perform specific movements (Table 3). Muscle strength was assessed every 7 days.

Table 3 . Manual muscle test grades.

Grade		Function of the muscle
Grade 0	Z	No visible or palpable muscle contraction
Grade 1	T	Feel contraction with palpation; no visible movement
Grade 2-	P-	Less than full ROM in a gravity-eliminated plane
Grade 2	P	Full ROM in a gravity-eliminated plane with no resistance
Grade 2+	P+	Full ROM in a gravity-eliminated plane, breaks upon minimum resistance
Grade 3-	F-	Less than full ROM against gravity, but more than 50%
Grade 3	F	Full ROM against gravity with no resistance
Grade 3+	F+	Full ROM against gravity, breaks upon minimum resistance
Grade 4	G	Full ROM against gravity with moderate resistance
Grade 5	N	Full ROM against gravity with maximum resistance

Z, zero; T, trace; P, poor; ROM, range of motion; F, fair; G, good; N, normal..

2) Numerical rating scale

Subjective pain intensity was assessed using a numerical rating scale (NRS), with 0 representing no pain and 10 representing severe pain. The evaluations were conducted daily.

3) Subjective sensory evaluation

The areas of sensory deficit were stimulated with a needle to measure the intensity of the sensation, with normal sensation rated as 10 and complete insensibility rated as 0. The evaluations were performed every 3 days.

5. Patient’s progress during treatment

In Case 1, the patient showed significant reductions in the NRS score, with the intensity of lower back pain decreasing from 6 to 2 and that of lower limb pain from 6 to 1 (Fig. 3). The sensory scores on the L4 and L5 dermatomes improved (Fig. 4), and ankle strength increased from grade 3 to grade 5 (Table 4). In Case 2, the intensity of lower back pain decreased from 7 to 3 and that of lower limb pain decreased from 7 to 2 (Fig. 5). The sensory scores improved across multiple dermatomes (Fig. 6), and ankle strength increased from grade 3 to grade 5 (Table 4).

Figure 3. Change in the NRS score in Case 1. Changes in the NRS score from December 11 to December 22. NRS, numerical rating scale; LBP, low back pain; BV, bee venom.

Figure 4. Change in the subjective sensory score in Case 1. Changes in the subjective sensory score from December 11 to December 20.

Figure 5. Change in the NRS score in Case 2. Changes in the NRS score from May 13 to May 22. NRS, numerical rating scale; LBP, low back pain; BV, bee venom.

Figure 6. Change in the subjective sensory score in Case 2. Changes in the subjective sensory score from May 13 to May 22.

Table 4 . Manual muscle test results.

Movement	Case 1			Case 2
	December 11, 2023	December 18, 2024		May 13, 2024	May 20, 2024
Hip flexion	N/N	N/N		N/N	N/N
Hip extension	N/N	N/N		N/N	N/N
Knee extension	N/N	N/N		N/N	N/N
Knee extension	N/N	N/N		N/N	N/N
Ankle dorsiflexion	N/F-	N/N		N/F-	N/N
Ankle plantarflexion	N/F-	N/N		N/F-	N/N

N, normal; F, fair..

LHIVD refers to the rupture of the annulus fibrosus of the intervertebral disc, leading to the herniation of the nucleus pulposus beyond the intervertebral disc space. Degeneration due to age-related loss of hydration in the nucleus pulposus is the most common cause [16]. In addition, the herniated disc material can provoke an inflammatory response by releasing cytokines and other pro-inflammatory mediators, which contribute to nerve irritation and pain [17]. LHIVD leads to several symptoms including pain, weakness, and hypoesthesia. Computed tomography or MRI are the diagnostic tools of choice, as they can assess the location and extent of disc herniation [18]. Conservative treatment is prioritized; however, surgery is indicated in patients with cauda equina syndrome, lack of pain improvement after 6 weeks of conservative treatment, or progressive or severe muscle weakness [19].

Our patients were advised to undergo surgery for severe muscle weakness, but they chose conservative treatment instead. Korean medicine treatments, including electroacupuncture, herbal medicine, BV pharmacopuncture, and acupotomy, were used. Both patients experienced improvements in pain, muscle strength, and sensory deficits. Electroacupuncture was performed to alleviate pain and reduce inflammation [20]. Whallak-tang and Ojoeksan were prescribed to improve blood circulation and alleviate muscle stiffness.

Each treatment likely contributed to the observed improvements. However, the most notable changes were observed after BV and acupotomy. In Case 1, there was only minimal improvement until after the third BV session, at which point the NRS score began to gradually improve. Following the first acupotomy session, a marked reduction in the NRS score and considerable sensory improvements were observed. In Case 2, the patient showed an initial decrease in the NRS score after the first acupotomy session, with further gradual improvements in pain and sensory function following the second to fourth BV treatments. During the treatment period, the patient showed gradual recovery of the range of motion and muscle strength of the ankle, and by the end of the treatment, full muscle strength was restored.

This analysis suggests that BV and acupotomy played pivotal roles in the treatment outcomes. The mechanisms underlying these treatments differ, but they complement each other. BV, through its active components, such as melittin and apamin, exerts anti-inflammatory effects and promotes blood circulation, which is particularly effective in alleviating pain associated with acute inflammatory responses [7]. Acupotomy disrupts fibrotic and adherent tissues resulting from repeated injuries, degeneration, or impaired circulation, thereby relieving pressure. It also reactivates the halted wound healing cascade by creating microinjuries [6]. The improvements in pain, muscle strength, and sensory function suggested that the targeted release of the adhesions was successful.

This is the first study to apply acupotomy to LHIVD patients with lower limb weakness. Although there have been studies applying BV pharmacopuncture to LHIVD patients with lower limb weakness, they required a prolonged treatment period, averaging 37 days. The patients in this study exhibited severe neurological symptoms, including lower limb weakness and sensory loss. Notably, the progressive lower limb weakness was an indication for surgery, and both patients were advised to undergo surgical intervention. However, within an average of 11 days, they showed recovery in muscle strength and sensation, along with improvements in pain. This study suggests that Korean medicine treatments, centered on acupotomy and BV pharmacopuncture, may offer a potential short-term therapeutic option for LHIVD patients with lower limb weakness requiring surgical intervention. However, a limitation of this study lies in its small sample size, which consisted of only two cases. Future studies involving larger cohorts are needed to confirm these observations and better delineate the specific effects of the individual Korean medicine treatments, including the isolated impact of acupotomy and BV pharmacopuncture.

Conceptualization: TRL. Data curation: TRL. Formal analysis: TRL. Investigation: TRL. Methodology: TRL. Resources: TRL. Visualization: TRL. Writing – original draft: TRL. Writing – review & editing: YHN, CHH, YKK, YYC, JHK, HYR, HL.

The authors have no conflicts of interest to declare.

None.

This study was exempt from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board. To protect the patient’s personal information, medical records were obtained from the Cheonan Korean Medicine Hospital of Daejeon University Institutional Review Board (IRB No. DJUMC-2024-BM-10).