Anterior cervical discectomy and fusion (ACDF), a key intervention in spine surgery and neurosurgery, is performed for cervical radiculopathy [1]. ACDF alleviates nerve root or spinal cord compression by decompressing the cervical spinal cord and nerve roots, combined with discectomy to stabilize the affected vertebrae [2]. The anterior approach, preferred over the posterior, offers advantages such as thorough disc and osteophyte removal, smaller incisions, and reduced surgical trauma [3]. Despite these benefits, ACDF can lead to complications like postoperative axial pain, pseudoarthrosis, and adjacent-level disc degeneration [4], with facet joint pressure being a significant risk factor for axial pain [5]. The overall complication rate post-ACDF, including dysphagia, hematoma, and recurrent laryngeal nerve palsy, is 19.3% [3]. Patients with preexisting myelopathy have higher risks of complications and mortality, with a 0.9% incidence of worsening during procedures [6]. Given the limited evidence on integrative Korean medicine treatment for post-ACDF complications, exploring traditional approaches is crucial. A prior study showed that auricular acupuncture for ACDF-related axial pain improved pain control and biological markers like interleukin (IL)-1β, IL-6, and tumor necrosis factor-α [7]. However, broader research on integrative Korean medicine for post-ACDF complications remains scarce. One retrospective study showed improvements in visual analog scale and Neck Disability Index (NDI) scores following ultrasound-guided soyeom pharmacopuncture in the cervical facet joint for acute cervical pain after traffic accidents [8]. Additionally, hypertonic saline injections in the peripheral coccygeal area reportedly alleviate chronic low back pain, possibly due to reduced intradiscal pressure [9]. Based on these findings, ultrasound-guided bamboo salt pharmacopuncture and integrative Korean medicine treatment were employed. This report details a case of postoperative cervical and radiating arm pain post-ACDF that was relieved by integrative Korean medicine treatment.

1. Patient

OOO (male/56).

2. Chief complaint (onset)

The patient complained of cervical and radiating right arm pain in September 2023.

3. Social history/past medical history

The patient is 171.1-cm tall with a weight of 71.8 kg. He does not smoke or consume alcoholic drinks. He owns a business. He had previously undergone appendectomy in 2009 as well as septoplasty and inferior turbinate reduction in 2010. He was also diagnosed with benign prostatic hyperplasia in and thyroid adenoma in 2011.

4. Present illness

The patient underwent C5/6 ACDF surgery in June 2023 at OOO Hospital, Seoul for chronic cervical pain due to a herniated intervertebral disc disease at C5/6 and congenital cervical ankylosis at C6/7. Despite undergoing postoperative physical and pharmacological treatments at OOO Hospital, Yangsan, and outpatient sessions, his right-sided arm pain persisted, which led to further treatment at OOO University Korean Medicine Hospital, with admission on November 8, 2023, after an initial visit on November 6, 2023.

5. Duration of treatment

He was hospitalized for 30 days from November 8, 2023 to December 7, 2023.

6. Radiology

The results of the cervical X-ray (Fig. 1) and magnetic resonance imaging (Fig. 2) on February 8, 2023 were as follows: mild bulging at C3–C5, disc herniation and central spinal stenosis at C5/6; and ankylosing myelopathy at C6/7.

Figure 1. Lateral and anteroposterior X-ray views of the cervical spine. Imaging was performed on February 8, 2023.

Figure 2. T2-weighted images in the sagittal and coronal planes of the cervical spine. Imaging was performed on February 8, 2023.

7. Treatment

1) Pharmacopuncture therapy

Pharmacopuncture therapy was administered under ultrasonographic guidance (LOGIQ P9; GE Healthcare), ensuring precision in needle insertion to an approximate depth of 5 cm into the right side of the posterior tubercle region (Fig. 3). Subsequently, a 2.5-mL aliquot of 1.8% bamboo salt pharmacopuncture solution (comprising 0.018 g of bamboo salt; Jahwang Herb Dispensary) was injected. A short-axis ultrasound view with an in-plane approach was used (Fig. 4). This therapeutic intervention was performed twice a week. During the patient's hospitalization, a comprehensive series of 12 pharmacopuncture sessions were conducted.

Figure 3. The areas where pharmacopuncture and acupotomy therapy were applied are marked. The triangles and circles indicate areas treated with pharmacopuncture and acupotomy, respectively.

Figure 4. Short-axis ultrasound image at the right-sided C5 level. PT marks the posterior tubercle and the dashed line indicates the needle. Injection was performed using the short-axis, in-plane technique.

2) Acupotomy therapy

Acupotomy therapy was applied to the right-sided zygapophyseal joints (Fig. 3) using a 0.50 × 60-mm needle (Dongbang Medical Co., Ltd.) inserted to a depth of 5 cm, with four sessions completed during the patient's stay.

3) Acupuncture therapy

Acupuncture targeting cervical acupoints was performed daily in the afternoon, except on days for acupotomy and pharmacopuncture. Single-use stainless steel needles (0.30 × 50 mm and 0.35 × 60 mm; Dongbang Medical Co., Ltd.), sterilized with gamma radiation, were used. An infrared ray apparatus enhanced efficacy. Focus areas included capitis, cervicis, sternocleidomastoid, scalenus, and trapezius muscles. Needles were retained for 20 minutes to elicit Deqi (得氣).

4) Cupping therapy

Dry cupping therapy applied to the cervical region was performed twice daily, with each session lasting for 5 minutes. For this procedure, sterilized plastic cups (Dongbang Medical Co., Ltd.) were used. The therapy aimed to target specific areas within the cervical region to induce a beneficial effect.

5) Herbal medicine

The patient received three 4.35-g packets of O-jeoksan (Hankookshinyak Pharmaceutical Co., Ltd.) daily for pain relief, covered by National Health Insurance. After one day, a tailored 120-mL herbal decoction, Jaeum-Ganghwatang, was administered three times daily after meals for the patient’s ‘Yinxuhuowang’ (陰虛火旺) pattern. Jaeum-Ganghwatang was consistently given throughout hospitalization. Ingredients of the herbal medications are listed in Table 1.

Table 1 . Composition of the Jaeum-Ganghwatang herbal medicine and its treatment duration.

Herbal medicine	Herbal components
Jaeum-Ganghwatang tid pc (2023/11/16 evening dose–2023/12/07 lunchtime dose)	Atractylodes macrocephala 9 g, Angelica sinensis 8 g, Rehmannia glutinosa 6 g, Ophiopogon japonicus 6 g, Atractylodes macrocephala 6 g, Rehmannia glutinosa 4 g, Citrus reticulata 4 g, Anemarrhena asphodeloides 3 g, Phellodendron amurense 3 g, Glycyrrhiza uralensis 3 g, Zingiber officinale 6 g, Ziziphus jujuba 4 g

The herbal components correspond to the dose per decoction at a ratio of two decoctions to three sachets. The total daily dose is equivalent to two decoctions..

tid pc, ter in die post cibum: three times a day after meals..

8. Evaluation

1) Numerical Rating Scale

The Numerical Rating Scale (NRS) was used to measure the severity of the patient’s subjective pain, scored from 0 to 10, with 10 indicating the worst imaginable pain and 0 indicating no pain. The NRS was evaluated daily, from admission to discharge [10].

2) Neck Disability Index

The NDI multiple-choice questionnaire, comprising 10 questions related to activities of daily living, was completed by the patients. A higher NDI score indicates greater severity of neck pain and more significant functional limitations of the neck. The NDI scores were calculated at admission and discharge [10].

3) Patients’ Global Impression of Change

The Patients’ Global Impression of Change (PGIC) is a self-assessment tool that captures patients' perceptions of their condition before and after an intervention. Participants rate their improvement or deterioration using one of the seven categories, ranging from “very much improved” to “very much worse.” This systematic categorization facilitates a nuanced global assessment, crucial for evaluating treatment effectiveness [11].

4) Self-drawn pain site picture

The patient carefully documented the evolution of the radiating arm pain through self-drawn pictures, providing a unique and subjective visual representation of the pain experience on a weekly basis. Specifically, the patient focused on illustrating the site variations of the radiating pain on the right arm, offering a dynamic and personalized account of the pain's progression and regression throughout the treatment course. The collection of these drawings at key intervals—admission day, weekly during hospitalization, and discharge—created a comprehensive timeline of the patient's pain experience.

9. Progress note

Before admission, the patient had severe cervical and arm pain following C5/6 surgery, which was managed by regular pain medications. Upon admission, the patient reported severe pain with NRS score of 8 and considerable disability with NDI score of 19. The inpatient treatment included discontinuation of painkillers, initially leading to an expansion in pain sites, which by the fourth week of hospitalization, decreased in number and intensity, with NRS scores decreasing to 3 and 2 (Fig. 5) and the NDI score improving to 8 (Table 2). Functional recovery was notable, particularly in the patient’s handwriting, which improved considerably by the third week. The patient also reported the ability to perform refined finger movements. At discharge, the patient reported “much improved” on the PGIC scale, indicating major improvement in symptoms.

Figure 5. Changes in the NRS score for neck and radiating arm pains. NRS, Numerical Rating Scale; Rt., right.

Table 2 . Changes in the NDI from admission to discharge.

Day	NDI
Admission (day 1)	19
Discharge (day 30)	8

NDI, Neck Disability Index..

ACDF surgery is a well-recognized intervention for cervical spinal pathologies; however, it can be accompanied by postoperative adverse effects, including severe cervical and radiating arm pain. The present report describes the case of a patient who lacked symptom relief for 2 months after undergoing an ACDF surgery in September 2023, but he recovered following an integrative Korean medicine treatment.

The patient underwent an integrative Korean medicine treatment regimen including pharmacopuncture therapy guided by ultrasonography, acupotomy targeting facet joints, and systematic acupuncture in the cervical area, which were all aimed at alleviating pain. The changes in the radiating pain sites were reported by the patient via self-drawn illustrations. The illustrations showed the initial expansion of the pain areas until the third week, despite the reduction in pain intensity. By the fourth week, the patient reported the absence of radiating pain during daily activities, marking a considerable recovery milestone from expanded pain sites to their complete cessation.

During hospitalization, the patient received Jaeum-Ganghwatang, a herbal medicine, aimed at enhancing overall constitution rather than directly relieving pain. The patient's symptom improvement was primarily due to the external treatments received, including pharmacopuncture, acupotomy, and acupuncture, which provided targeted relief and considerably alleviated symptoms.

The present case illustrates that integrative Korean medicine treatment may improve the persistent symptoms post-ACDF surgery, but this report still has limitations. First, its generalizability is limited by its single-patient design, and individual responses can vary, which complicates the broad application of the study results. Additionally, the format of the present investigation does not establish a causal link between treatments and outcomes, and it is unclear which treatment method was most effective. Further research with larger, controlled studies is needed to validate these findings and clarify the impact of each treatment.

This work was supported by a clinical research grant from Pusan National University Hospital in 2023.

Conceptualization: TL. Data curation: YO. Formal analysis: TL, JK, SKA. Investigation: JK, SKA. Methodology: GYY. Project administration: YO. Resources: GYY. Visualization: KHK. Writing – original draft: TL, EK. Writing – review & editing: KHK.

The authors have no conflicts of interest to declare.

Written informed consent was obtained from the patient for the utilization of his data obtained from his electronic medical records. The study received approval from the Institutional Review Board of Pusan National University Korean Medicine Hospital (PNUKH IRB No. 2024-05-001).