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J Acupunct Res > Volume 31(3); 2014 > Article
Kim, Yuk, Kim, Kim, and Jeon: A Case of Cauda Equina Syndrome Cared with Acupuncture, Sweet Bee Venom Pharmacopuncture, Herbal Medicine Combined Treatment

Abstract

Objectives :

This study was done to determine the effect of Korean medical treatment to patient diagnosed as cauda equina syndrome (CES) suffering from both lower limb dysesthesia, saddle dysesthesia, buttock dysesthesia, dysuria, dyschezia and gait disturbance.

Methods :

A patient with CES was treated with acupuncture, sweet bee venom pharmaco-puncture, herbal medicine from February 2 to April 9 at Department of Acupuncture & Moxibustion, Daejeon Korean Hospital of Daejeon University. Patient received acupuncture treatment (CV1, CV3, CV4, CV6, ST36, BL31, BL32, BL33, BL34) 12 times a week, bee-venom pharmacopuncture (BL23, BL28) was conducted twice a week, herbal medicine (Samilsingihwan decoction) was applied to patient thrice a day for nine weeks. The following symptoms were observed saddle, and lower limb dysesthesia, dysuria, dyschezia and gait disturbance.

Results :

After treatment, dysesthesia, dysuria, dyschezia and gaiting developed good outcome. But anal reflex remained still.

Conclusions :

Acupuncture, bee-venom pharmacopuncture, herbal medicine combined treatment might be effective to patients with CES.

Fig. 1.
Pre-Op state L-spine MRI (2013. 12. 7)
acupunct-31-3-91f1.gif
Fig. 2.
Post-Op state L-spine MRI (2014. 1. 11)
acupunct-31-3-91f2.gif
Fig. 3.
Changes of area of disturbance of coldness, warmth, pain sense (unit 10 μg)
acupunct-31-3-91f3.gif
Table 1.
Clinical Progress
1st week (2. 4∼10) 2nd week (2. 11∼17) 3rd week (2. 18∼24) 4th week (2. 25∼3. 3) 5th week (3. 4∼10) 6th week (3. 11∼17) 7th week (3. 18∼24) 8th week (3. 25∼31) 9∼10th week (4. 1∼9)
Bee-venom pharmacopuncture Conducted 0.5 ml at acupoint BL23, BL28. Conducted 1.0 ml at acupoint BL23, BL28 Conducted 2.0 ml at acupoint BL23, BL28
Gait Able to walk on flat surfaces. Using walker because of stumbling. Unsteady gait become stable. Stopped using walker. Available to walk on stairs.
Micton Voluntary voiding is partly possible. But using diaper due to urination hesitancy, urinary incontinence Voluntary voiding came ease. urination hesitancy was reduced. Daytime uracratia was decreased. But night uracratia remained stiil. Symptom of Urinary incontinence got well except the condition of increasing abdominal pressure. Urinary hesitancy was improved. Stress incontinence was decreased. Hesitancy was improved. Nocturnal incontinence lasted. Nocturnal incontenence was improved. Uracratia was intermittently showed.
Defecation Couldn’t feel the sense of stool. Volunraty defecation was impossible. Had to use diaper. Felt tiny sense around anus. Part of dull esthesia was reduced. Could feel the sense around anus. Fecal incontinence reduced. Felt bowel’s urge. Started to constirict anal sphincter. Started using toilet, after felt like defecating.
Sense of lower limb Painful, cold, warm sensory around saddle, buttock, great part of area around lower limbs was deprived. Sense got back, left thigh, front side of right thigh, partial area of calf and toes. Sensory of back side of right thigh improved. Become aware feeling of sole. Pain sense of calf except front side of left calf was improved. Painful, cold, warm sense of calf improved. Sensed dull feeling on both dorsum of foot. Remaining dullness of top side of right foot, sensed most part of legs. Dysesthesia was almost improved with the exception of area of peni, anus.
Physical examination DTR KJ −/ −
AJ −/ −
ADF+/−
APF +/−
Anal reflex −
DTR KJ −/ −
AJ −/ −
ADF sl./ −
APF sl./ −
Anal reflex −
DTR KJ −/ −
AJ −/ −
ADF−/ −
APF sl./ −
Anal reflex sl.
Table 2.
Systemic Reviews of Traditional Korean Medicine Treatment for Cauda Equina Syndrome
Authors Symptoms Treatment Clinical progress Duration of treatment Acupoints Herbal medicine Tool for evaluation
Hwang6) (2001) Dysuria, dyschezia, both lower limb weakness, both lower limb radating pain. Acupuncture, moxiustion. herbal medicne, physical therapy. Gait disturbance was improved patient could gait about 20 m without walker. Lower limb dysesthesia and radiating pain were decresed. Voluntary miction became possible but incontinence was remained. The number of defecation was fixed and bowel incontinence was decreased. Adm. 2001. 5. 21∼7. 17 (58 days) Ryounggol, Daebaek, Jeonggeun, Jeongjong BL56, BL57, SP3, KI7 Palmijihwang-hab-j echeonjeon decoction Analysis of subjective improvement, pulse diagnosis, tongue diagnosis. Sensory improvement using dermatome figure.
Byun7) (2002) Dysuria, dyschezia, both lower limb dysestihesia, low back pain, both lower limb pain. Bee-venom pharmacopuncture, acupuncture, moxibustion. Herbal medicne, physical therapy. Could walk alone without help. Voluntary voiding becaome possible with residual urine. Saddle and lower limb dysesthesia was recoverd with the exceoption of the area around anus. Adm. 2002. 5. 25∼6. 24 (31 days) BL22, BL23, BL25, BL28, GV3 Gamihwalhyul decoction Clinical observation.
Park8) (2003) Dysuria, dyschezia, gait disturbance, both lower limb radiating pain. Acupuncture (Hapgokja, warming technique), herbal medicne, Physical therapy. Walking got ease. Gait could void without foley-catheter, and urinary output was increased. Adm. 2003. 3. 31∼4. 3. 2003. 4. 8∼5. 20 (47 days) CV3, CV4, KI11, KI12 Yeosinyangyoungjeon decoction Clinical observation.
Seo9) (2005) Dysuria, dyschezia, low back pain, both liwer limb radating pain, both lower limb weakness. Carthami semen pharmacocpuncture acupuncture, moxibustion. Herbal medicne, physical therapy. Lumbago was improved. Gaiting 30 minute with out walker become possible. Urinary incontinence disappeared. Adm. 2005. 7. 15.∼29 (15 days) CV6, ST36 SP9, SP6, CV3, CV4 Yeosinyangyoungjeo n decoction VAS, improvement index. ODI ROM variation, Sensory improvement using dermatome figure, Subjective Improvement of miction and defecation.
Lee10) (2008) Dysuria, dyschezia, low back pain, Rt. lower limb dysesthesia, saddle dysesthesia. Scolopendrid pharmacopuncture. Acupuncture, moxiustion. Herbal medicne, physical therapy. Low back pain, voiding, dysesthesia got partly improved. Adm. 2007. 5. 30∼7. 15 (47 days) LI4, LR3, KI6, ST36, GB30 Bojungikgi-gagamba ng decoction SF36, fecal incontinence score improvement index, bristol stool chart, sensory improvement using dermatome figure.
Hwang11) (2009) Dysuria, dyschezia, low back pain, Lt. lower limb dysesthesia, saddle dysesthesia. Acupuncture, moxiustion. Herbal medicne, physical therapy, cupping therapy. Low back pain was improved. Self-gaiting became possible. Saddle and lower limb dysesthesia was recovered. Voluntary voiding could be done. Could feel regulation of anal sphincter. Adm. 2008. 8. 7∼12. 12. (128 days) Opd. 2008. 12. 15∼2009. 1. 12. (29 days) BL23, BL24, BL25, BL26, BL52, CV1, GV1, LI4, LR3, BL40, GB34,ST36, BL57,GB39, BL60, CV13,CV12, CV10, Ryenggol, Daebaek, Sangbaek, Joongbaek, Wansoon Youkmijihwangwon-gagam decoction VAS, ODI.
Kim12) (2011) Dysuria, Dyschezia, Both lower limb dysesthesia, Low back pain, Saddle dysesthesia. Hominis Placenta Pharmacopuncture, Acupuncture, Moxiustion. Herbal medicne, physical therapy, Cupping therapy. Could make miction with out foley-ctheter. When voiding, stool came out and patient could not hold stool. Adm. 2011. 03. 02.∼4. 26. (56 days) BL22, BL23, BL25, BL28, GV3, BL31, BL32, BL33, BL34, LI4, LR3, BL40, GB34, ST36, BL57, CB39, BL60, SI3, TE3 Palmigamibang-hab-Jecheonjeon decoction VAS, ODI, sensory improvement using dermatome figure.
This case (2014) Dysuria, Dyschezia, saddle dysesthesia, both buttock dysesthesia, both lower limb dysesthesia. Bee-venom pharmacopuncture, Herbal medicine. Dysesthesia was almost improved with the exception of area of genitals, anus. Voluntary voiding was simply done. Uracratia was intermittently showed. Started to constirict anal sphincter. Started using toilet, after felt like defecating. Adm. 2014. 2. 5.∼4. 09. (64 days) CV3, CV4, CV5, CV6, ST36 BL31, BL32, BL33, BL34, Samilsingihwan decoction Objective analysis of sensory improvement using dermatome figure.

VAS : visual analogue scale. ODI : oswestry disability index. ROM : range of motion.

V. References

1. The Korean Orthopaedic Association. Orthopaedics, 6. The Korean Orthopaedic Association. 2006:250, 623, 1000.

2. Fuso FA, Dias AL, Letaif OB, et al. Epidemiological study of cauda equina syndrome. Acta otrop Bras. 2013;21(3):159–62.
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3. Cho YH, Chang SA, Park JY, et al. Posterior epidural migration of a sequestratd intervertebral lumbar disc with cauda equina syndrome; two cases report. Journal of Korean Orthop Surgery. 2008;15(4):277–80.

4. Park BM, Won YY. Clinical obserbation on 8 cases of cauda equina syndrome. J Korean Orthop Surgery. 1988;23:184–92.
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5. Lindsay KW, Bone I, Fuller G. Neurology and neurolsurgery illustrated. Seoul: Panmun Education. 2013:538542–3.

6. Hwang HJ, Kwak MA, Lee EJ, et al. One case study on the cauda equina syndrome. Korean J Orient Int Med. 2001;22(4):767–72.

7. Byun IJ, Lee SN, Ahn KH, et al. A clinical observation on the case of cauda equina syndrome with bladder incontinence using Korean bee-venom acupuncture. The Journal of Korean Acupuncture & Moxibustion Society. 2002;19(6):205–13.
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8. Park JS, Kim WY, Song IK, Lee SD. The clinical observations of cauda equina syndrome patient’s bladder incontinence improved with Hapgokja and the warming acupuncture. The Journal of Clinical Thesis Korean Acupuncture & Moxibustion Society. 2003;0:8–15.
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9. Seo BM, Lee YK, Kim SW, et al. A case of cauda equina syndrome treated with addditional carthami semen herbal acupuncture therapy. The Korean Journal of Merodian & Acupoint. 2005;22(1):33–41.
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10. Lee HY, Cho YH, You JS, et al. A clinical observation on the case of cauda equina syndrome using scolopendrid pharmacopunture. Journal of Pharmacopuncture. 2008;11(2):117–24.
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11. Hwang HS, Jeon JC, Cah JH, et al. The clinical report in 1 case of failed back surgery syndrome who were diagnosed as the cauda equina syndrome. The Journal of Korean Acupuncture & Moxibustion Society. 2009;26(1):187–96.
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12. Kim SP, Kim JH, Ryu HS, et al. The clinical report on 1 case of failed back surgery syndrome who were diagnosed as the cauda equina syndrome using hominis placenta pharmacopuncture. The Journal of Korean Acupuncture & Moxibustion Society. 2011;28(5):135–42.
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13. Song KJ, Kang HK, Hong GS. Dorsally migrated sequestrated lumbar disc herniation with cauda equina syndrome: two cases report. Journal of Korean Spine Surg. 2000;7(3):396–400.

14. Kostuik JP, Harrington I, Alexander D, et al. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg. 1986;68A:386–91.
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15. Floman Y, Wiesel SW, Rothman RH. Cauda equina syndrome presenting as a herniated lumbar disk. Clin Orthop. 1979;147:234–7.
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16. Jin SS. Practical Chinese internal medicine. Il-jungsa. 1983;276–85.

17. Korean Acupuncture & Moxibustion Society Textbook Compilation Committee. The acupuncture and moxibustion medicine. Gyeonggi: Jipmoondang. 2012:245.

18. Lee HS, Lee JD, Koh HK. The review int the study of bee venom in the domestic papers. The Journal of Korean Acupuncture & Moxibustion Society. 2003;20(3):154–65.
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19. Kwon SK, Lee HY, Kang MJ, Kim DI. Effect of herb-medicine on seminal parameters in male infertility patients. The Journal of Oriental Obstetrics & Gynecology. 2005;18(3):184–91.
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20. Doo HK. Oriental nephrology. Sungbosa. 2006;90:93–7.

Appendices

Appendix 1.

Dermatome

Sense of cold Sense of warmth Sense of pain
0 day acupunct-31-3-91i1.gif acupunct-31-3-91i2.gif acupunct-31-3-91i3.gif
9 days acupunct-31-3-91i4.gif acupunct-31-3-91i5.gif acupunct-31-3-91i6.gif
19 days acupunct-31-3-91i7.gif acupunct-31-3-91i8.gif acupunct-31-3-91i9.gif
29 days acupunct-31-3-91i10.gif acupunct-31-3-91i11.gif acupunct-31-3-91i12.gif
40 days acupunct-31-3-91i13.gif acupunct-31-3-91i14.gif acupunct-31-3-91i15.gif
50 days acupunct-31-3-91i16.gif acupunct-31-3-91i17.gif acupunct-31-3-91i18.gif
61 days acupunct-31-3-91i19.gif acupunct-31-3-91i20.gif acupunct-31-3-91i21.gif
Appendix 2.

Satorius MC210s

acupunct-31-3-91i22.gif


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