Ossification of the posterior longitudinal ligament (OPLL) causes posterior longitudinal ligament to lose its elasticity and narrows the spinal canal, creating neurological symptoms [1]. Symptoms of OPLL range from simple cervical pain to radiculopathies such as paresthesia in the hand, pain in the upper extremities, pain in the neck and scapula, and myelopathies such as weakness in the lower extremities, gait disorders, and difficulty in urinating, which can manifest as compression of the spinal cord [2].

Computed tomography (CT) is the best diagnostic method for OPLL because it can clearly identify the shape and size of the ossified part, spinal canal stenosis, and spinal cord compression. Magnetic resonance imaging (MRI) can be used to identify the degree of compression, edema, and atrophy of the spinal cord. However, the contours of the bone cortex cannot be clearly visualized using MRI [1].

Currently, conservative treatment is generally recommended for OPLL in the absence of neurological symptoms or myelopathy. In conservative treatment, interventions such as braces or halter traction are used to stabilize the spine to alleviate the symptoms, which are otherwise affected by mechanical pressure and friction of ossified parts. In addition, analgesics, steroids, and local anesthetics are injected into painful sites. Surgical treatment is recommended for patients diagnosed with myelopathy on MRI because of advanced neurological symptoms. Surgical treatments consist of anterior decompression, which directly removes the ossified part, and posterior decompression, which indirectly results in the decompression effect [2-4]. Traditional Korean Medicine (TKM) treatment includes acupuncture, chuna therapy, and herbal medicine. However, no studies have reported using only complex acupuncture treatments such as acupuncture, acupotomy, and pharmacopuncture. Therefore, the authors report the cases of 2 patients diagnosed with cervical OPLL, who had been recommended surgery or conservative treatment, and both patients refused the advised intervention for personal reasons, opted for complex acupuncture treatment, and obtained significant improvements.

1. Case presentation

Two patients who received outpatient treatment at Daegu Korean Medicine Hospital at Daegu Haany University for cervical pain and upper limb radiating pain after being diagnosed with cervical OPLL on C-spine CT scans from May 2021 to June 2022 participated in this study.

2. Medical histories

Patient 1 was a 39-year-old male who complained of cervical pain and upper limb radiating pain which worsened around May 4, 2021. He visited a radiology clinic and was diagnosed with OPLL after a whole-spine CT scan. Surgical intervention was advised; however, he opted not to undergo surgery for personal reasons and visited the outpatient clinic for TKM treatment on May 31, 2021. Physical tests, such as compression, distraction, Spurling, and Adson tests performed at the outpatient clinic, were negative. In addition, a range of motion (ROM) test indicated full ROM, although he complained of pain while moving his neck.

Patient 2 was a 58-year-old male with complaints of cervical pain and upper limb radiating pain who was diagnosed with cervical OPLL after a C-spine CT scan at a local hospital in 2018. In May 2022, the cervical pain and upper limb radiating pain worsened, and he visited a local hospital. He was advised to undergo conservative treatment. He did not receive any treatment for personal reasons and visited the outpatient clinic for TKM treatment on June 16, 2022. The physical examination performed at the time of the outpatient visit was positive on the left side of the Spurling test, but other physical tests were negative. In addition, the ROM test showed full ROM, but his neck movements were painful, and hypoesthesia was observed in 30% of the left first and second fingers.

3. Computed tomography

Before visiting the outpatient clinic, CT scans were performed, and the patients were diagnosed with cervical OPLL (Figs. 1, 2).

Figure 1. Cervical spine computed tomography of Case 1 (May 4, 2021). Ossified parts of the posterior longitudinal ligament are indicated by the arrows. (A) Sagittal view. (B) Transverse view of the C4. (C) Transverse view of the C5.

Figure 2. Cervical spine computed tomography of Case 2 (June 14, 2021). Ossified parts of the posterior longitudinal ligament are indicated by the arrows. (A) Sagittal view. (B) Transverse view of the C4. (C) Transverse view of the C5. (D) Transverse view of the C6.

4. Treatment

All complex acupuncture treatments were performed once a day at each outpatient visit. In Case 1, the patient received 8 sessions of treatment on May 31 and June 2, 5, 8, 14, 16, 18, and 28, 2021, based on the progress of his symptoms. In Case 2, the patient received 9 sessions of treatment on June 16, 18, 20, and 23; July 2, 16, and 23; and August 6, and 20, 2022, based on the progress in his symptoms.

0.20 × 30 mm disposable, sterilized, stainless-steel needles (Dongbang Medical Co., Ltd.) were used for acupuncture, which was performed by local acupoint stimulation with a retention time of 15 minutes. The acupoints at which treatment was administered were GV14, GB20, GB21, and TE14. Additionally, electroacupuncture was administered at an intensity of 2 Hz on both sides of GB20, which was a painful spot for both patients (Fig. 3).

Figure 3. Treatment areas for complex acupuncture treatment. The treatment areas using each treatment method are marked in separate figures. ●, acupuncture points; ▲, acupuncture, electroacupuncture, and pharmacopuncture point; ■, acupotomy points and muscles (marked unilaterally).

Each patient was positioned in the sitting position, the cervical part was disinfected with disposable alcohol (Sungkwang pharmaceutical alcohol stick with 80% ethanol), and 0.50 × 50 mm disposable, sterilized, stainless-steel needles (Dongbang Medical Co., Ltd.) were used to perform acupotomy.

Acupotomy was performed with the aim of stimulating the rectus capitis posterior major, obliquus capitis inferior, supraspinous ligament, and facet joints. Depending on the patient’s symptoms, treatments of the anterior and middle scalene muscles and longus coli were also integrated (Fig. 3). There was no retention time for the treatment, and the patients’ local and systemic abnormalities were monitored.

Sulfur pharmacopuncture (Kirin Wonoe Tangjunwon) was also performed at both the GB20 and ashi acupoints (Fig. 3). 0.1 mL was injected at each point with a total of 0.5 mL, using a disposable 30 G × 8 mm syringe (Shin Chang Medical Inc.).

5. Assessments

Both patients were assessed at approximately 2-week intervals.

The visual analog scale (VAS) has scores ranging from 0 points, which is the pain-free state, to 10 points, indicating the most severe pain. The patients were instructed to directly mark their degree of pain on an unmarked bar, following which the distance from the starting point to the marked point was measured [5].

The neck disability index (NDI), a multiple-choice questionnaire consisting of 10 questions related to activities of daily living, was completed by the patients. After the patients scored each question from 0–5 points, the scores were added (Table 1) [5].

Table 1 . Neck disability index.

1. Pain intensity	⓪ I have no pain at the moment ① The pain is very mild at the moment ② The pain is moderate at the moment	③ The pain is fairly severe at the moment ④ The pain is very severe at the moment ⑤ The pain is the worst pain imaginable at the moment
2. Personal care	⓪ I can look after myself normally without causing extra pain ① I can look after myself, but it causes extra pain ② It is painful to look after myself and I am slow and careful	③ I need some help but manage most of my personal care ④ I need help every day in most aspects of self-care ⑤ I do not get dressed; I wash with difficulty and stay in bed
3. Lifting	⓪ I can lift heavy weights without extra pain ① I can lift heavy weights, but it gives me extra pain ② Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (like on a table)	③ Pain prevents me from lifting heavy weights, but I can manage light-to-medium weights if they are conveniently positioned ④ I can lift very light weights ⑤ I cannot lift or carry anything at all
4. Reading	⓪ I can read as much as I want with no neck pain ① I can read as much as I want with slight neck pain ② I can read as much as I want with moderate neck pain	③ I cannot read as much as I want because of moderate neck pain ④ I can hardly read at all because of severe pain in my neck ⑤ I cannot read at all
5. Headaches	⓪ I have no headaches at all ① I have slight headaches that come infrequently ② I have moderate headaches that come infrequently	③ I have moderate headaches that come frequently ④ I have severe headaches that come frequently ⑤ I have headaches almost all of the time
6. Concentration	⓪ I can concentrate fully when I want with no difficulty ① I can concentrate fully when I want to with slight difficulty ② I have a fair degree of difficulty concentrating when I want to	③ I have a lot of difficulty concentrating when I want to ④ I have a great deal of difficulty concentrating when I want to ⑤ I cannot concentrate at all
7. Work	⓪ I can do as much work as I want ① I can only do my usual work, but no more ② I can do most of my usual work, but no more	③ I cannot do my usual work ④ I can hardly do any work at all ⑤ I cannot do any work at all
8. Driving	⓪ I can drive my car without any neck pain ① I can drive my car as long as I want with slight neck pain ② I can drive my car as long as I want with moderate neck pain	③ I cannot drive my car as long as I want because of moderate neck pain ④ I can hardly drive at all because of severe neck pain ⑤ I cannot drive my car at all
9. Sleeping	⓪ I have no trouble sleeping ① My sleep is slightly disturbed (less than 1 hour sleepless) ② My sleep is mildly disturbed (1 to 2 hours sleepless)	③ My sleep is moderately disturbed (2 to 3 hours sleepless) ④ My sleep is greatly disturbed (3 to 5 hours sleepless) ⑤ My sleep is completely disturbed (5 to 7 hours sleepless)
10. Recreation	⓪ I am able to engage in all my recreation activities with no neck pain ① I am able to engage in all my recreation activities with some neck pain ② I am able to engage in most, but not all, of my usual recreation activities because of neck pain	③ I am able to engage in a few of my usual recreation activities because of neck pain ④ I can hardly do any recreation activities because of neck pain ⑤ I cannot do any recreation activities at all because of neck pain

The Japanese Orthopedic Association (JOA) score was evaluated out of a total of 17 points. Scores of 0–4 points were assigned based on the patients’ subjective expression, walking ability, motor function of the upper and lower extremities, sensory function of the upper and lower extremities and body trunk, and bladder function (Table 2) [5].

Table 2 . Criteria for evaluation of cervical myelopathy based on Japanese Orthopedic Association.

Upper extremity function	0. Impossible to eat with either chopsticks or spoon
	1. Possible to eat with spoon, but not chopsticks
	2. Possible to eat with chopsticks, but inadequate
	3. Possible to eat with chopsticks, but awkward
	4. Normal
Lower extremity function	0. Impossible to walk
	1. Need cane or aid on flat ground
	2. Need cane or aid only on stairs
	3. Possible to walk without cane or aid, but slow
	4. Normal
Sensory	A. Upper extremity
	0. Apparent sensory loss
	1. Minimal sensory loss
	2. Normal
	B. Lower extremity
	Same as A
	C. Trunk
	Same as A
Bladder function	0. Complete retention
	1. Severe disturbance
	(1) Inadequate evacuation of the bladder
	(2) Straining
	(3) Dribbling of urine
	2. Mild disturbance
	(1) Urinary frequence
	(2) Urinary hesitance
	3. Normal

6. Progress notes

The VAS scores of patient 1 were 7, 5, and 3.5 before treatment and after 5 and 8 treatments, respectively. The NDI scores were 30, 28, and 14 before and after 5 and 8 treatments, respectively. However, the JOA score results for patient 1 remained unchanged because they indicated no problems to begin with (Table 3).

Table 3 . The change of VAS score, NDI score, and JOA score in Case 1.

Assessment	2021/05/31	2021/06/14	2021/06/28
VAS	7	5	3.5
NDI	30	28	14
JOA score	17	17	17

VAS, visual analog scale; NDI, neck disability index; JOA, Japanese Orthopedic Association..

The VAS scores of patient 2 were 8, 6, 5, 4, and 3.5 before treatment and after 5, 6, 8, and 9 treatments, respectively. NDI scores were 24, 20, 17, 16, and 11 before treatment and after 5, 6, 8, and 9 treatments, respectively. The JOA score for patient 2 increased from 14 to 15 after 8 treatments, because the hypoesthesia in the distal end of the left first and second fingers had reduced from approximately 30% to about 15% (Table 4).

Table 4 . The change of VAS score, NDI score, and JOA score in Case 2.

Assessment	2022/06/16	2022/07/02	2022/07/16	2022/08/06	2022/08/20
VAS	8	6	5	4	3.5
NDI	24	20	17	16	11
JOA score	14	14	14	15	15

VAS, visual analog scale; NDI, neck disability index; JOA, Japanese Orthopedic Association..

Conservative treatment is the recommended treatment for OPLL if the patient suffers only from neuromuscular symptoms or in the absence of neurological symptoms or symptoms of spinal cord compression. Surgical treatment should be considered in cases of severe progressive myelopathy and evidence of increased cord edema on MRI [1,6]. However, according to long-term study, the ossified portion may expand and press against the spinal cord, resulting in myelopathy symptoms. In addition, OPLL is known to progress more rapidly in patients who receive surgical treatment than in those who receive conservative treatment [7]. A systematic review by Pham et al. [6], which observed patients with OPLL who received conservative treatment, reported that conservative treatment was recommended for JOA scores of 14 or higher. Therefore, conservative treatment is the preferred treatment choice whenever possible.

Acupuncture, pharmacopuncture, acupotomy, chuna therapy, and herbal medicine are conservative TKM treatments used to treat OPLL. Park et al. [5] reported a case of acupotomy treatment, while Lee et al. [4] reported a case of chuna therapy with other TKM treatments; both studies demonstrated reductions in VAS and NDI scores. A study by Namgoong et al. [8], 78 OPLL patients who were treated with TKM during their hospital stay experienced a reduction in their NRS (numerical rating scale) and NDI scores, with further reductions in NRS and NDI scores experienced by most patients upon long-term follow-up. However, none of these studies used complex acupuncture treatment alone. Hence, this is probably the first study to report that complex acupuncture treatment, consisting of acupuncture, pharmacopuncture, and acupotomy, can reduce OPLL-related pain and enhance the quality of life.

Acupuncture treatment has anti-inflammatory and analgesic effects, and hence, is usually used to treat musculoskeletal pain. Pharmacopuncture is used to induce the chemical effects of herbal medicines through mechanical procedure of acupuncture. This is achieved by injecting herbal extracts into the acupuncture points [9]. In this study, sulfur pharmacopuncture was used for anti-inflammatory action. Sulfur pharmacopuncture contains 10 μg/mL sulfur with a purity of 99% or more and is known for its efficacy in treating inflammation and pain owing to its anti-inflammatory and detoxifying effects [10]. Acupotomy treatment is known to restore the biodynamic balance in muscles, recover muscle strength, reduce muscle fatigue, improve circulation in lesions, and provide stronger stimulation than compared to acupuncture treatment [11]. In this study, the treatment points selected were adjacent points, ashi acupoints, and tenderness points where the patients complained of pain.

This study was limited by the fact that there were only 2 cases and the absence of a control group. In addition, although the patients’ symptoms showed remarkable improvement, their residual symptoms persisted, necessitating long-term follow-up for symptom change. Finally, there were no control groups for each acupuncture treatment, making it difficult to specify which acupuncture treatment played a major role. Large-scale clinical studies are required to confirm the effectiveness of each treatment for OPLL.

Conceptualization: JHK, HJL, JSK. Methodology: JHK, HJL, JSK. Formal investigation: JHK, HJL, JSK. Data analysis: JHK, HJL, JSK. Writing – original draft: JHK, HJL, JSK. Writing – review & editing: All authors.

The authors have no conflicts of interest to declare.

None.

This research did not involve any human or animal experimentation. Hence, this study was exempt from approval by the Institutional Review Board of Daegu Korean Medicine Hospital at Daegu Haany University (IRB no.: DHUMC-D-23005-ETC-01).