Introduction
Cervical spondylotic myelopathy (CSM) is a common, age related degenerative spinal cord disease which causes a combination of changes such as mechanical spinal cord compression due to degenerative changes in the cervical spine, and herniation of the intervertebral disc, ossification of the posterior ligament, ischemic damage due to blood circulation disorders in the spinal cord, and trauma [
1]. CSM is a chronic disease that progresses slowly and is without an effective cure. In addition, CSM is becoming a public health concern as the morbidity rate increases with age and the population is aging [
2]. Causes of cervical myelopathy include spinal trauma (for example, a road traffic accident), stenosis, infection, and cancer. Treatment goals are to manage and relieve symptoms of CMS and cervical myelopathy. Chief complaints include gait disturbance, and hand movement and sensory disorders, which cause discomfort in daily life. In severe cases, permanent sequelae may remain, thus an accurate diagnosis and treatment are required. Based on the degree of injury, CSM and cervical myelopathy can be treated either conservatively or surgically. If symptoms are severe, surgical treatments such as central-separated laminectomy, interbody fusion, and osteotomy, are considered [
3,
4]. Conservative treatments include drug therapy, injection therapy, and physical therapy, amongst others [
5]. Conservative treatment is more effective than surgical treatment in patients with mild symptoms [
3,
4].
Recently, Korean medicine treatments including acupuncture, moxibustion, and acupotomy have been studied for the treatment of various spinal diseases [
2,
5–
7]. Acupotomy has been used to restore soft tissue damage, and the original dynamic state of abnormal lesions of the body by removing adhesions, nodules, and scars [
5]. However, reviews report that there are only a few studies using combined Korean medicine treatment including acupotomy for the cervical region [
6,
7]. Therefore, this report describes the results for 2 patients 1 with CSM and 1 with cervical myelopathy, who were treated with combined Korean medicine including acupotomy.
Results
Case 1 showed gradual improvement in the VAS score, the mJOA scale score, and the Nurick grading system score (
Table 1;
Fig. 4). Pain and discomfort in daily life gradually improved from a VAS score 6 to a VAS score 3 after the 7
th treatment, and to VAS score 2 after the 9
th treatment, and no re-exacerbation of pain occurred. The mJOA scale began to change after the 4
th treatment, when it was within the moderate range of the mJOA scale, and at the 8
th treatment it was within the mild range of functional status. Changes in the Nurick grading system for difficulty in walking showed improvement in gait from Grade 2 (slight difficulty in walking which did not prevent full-time employment) to Grade 1 (signs of spinal cord disease but no difficulty in walking) after the 6
th treatment. Improvement in walking was maintained during Treatment 6 to Treatment 10). She initially complained of a deteriorating upper and lower limb muscle strength, it also improved almost normally, especially in the lower extremity and the grasping power increased 22 kg/11 kg to 22 kg/19 kg (
Table 2).
Case 2 showed overall improvement in VAS scores, and the mJOA scale score improved and was maintained from Treatment 8 to Treatment 10. Pain and discomfort in daily life gradually improved, reflected in a reduction from VAS score 6 to VAS score 4 after the 6
th treatment. After the 8
th treatment, there was a re-exacerbation, but after the 10
th treatment, it improved and maintained at a VAS score 3 compared with the first treatment. The mJOA scale showed a change in sensory dysfunction in gait evaluation items, and the values improved from 14 (moderate) to 15 (mild) which was maintained after the 8
th treatment. He had no motor loss and motor change, which was reflected in the Nurick grade not changing. The ASIA impairment scale showed C5 neurological sensory loss, but gradually the range and degree of impairment was reduced, and there was almost no sensory loss after the 10
th treatment (
Table 3;
Fig. 5). The ASIA impairment scale did not change from a D, but the score did improve from Day 102 to Day 108.
In both cases, the patients felt pain, redness, and swelling at the insertion sites during the acupotomy procedure, but this improved and there were no further complaints, or mention of other side effects.
Discussion
CSM belongs to a category of spondylosis, which refers to age related spinal degeneration and its surrounding structures [
1,
12]. CSM is caused by a combination of factors such as mechanical spinal cord compression due to degenerative changes in the cervical spine, degeneration, and herniation of the intervertebral disc, ossification of the posterior ligament, ischemic damage due to blood circulation disorders in the spinal cord, and trauma [
12–
14]. CSM causes pain and motor and sensory deficits in the area corresponding to the affected spinal cord segment. Symptoms of motor deficits include loss of fine motor skills affecting activities such as writing or buttoning, steps imbalance, and instability when performing movements such as climbing stairs. Symptoms of sensory deficits include loss of pain, temperature, sense of vibration, decrease in 2-point senses, tingling, and paresthesia [
1]. In severe cases, the urination sphincter may be affected showing symptoms such as urinary urgency, urination, frequent urination, and incontinence [
1,
12]. A cause of cervical myelopathy not related to age is spinal trauma (for example, a road traffic accident). Based on the degree of injury, CSM and cervical myelopathy can be treated either conservatively or surgically. If symptoms are severe, surgical treatments such as central-separated laminectomy, interbody fusion, and osteotomy are considered [
4]. When symptoms are mild, conservative treatment has been reported to be more effective, and less risky than surgical treatments [
3,
4]. Conservative treatment of CSM and cervical myelopathy include drug therapy, injection therapy, and physical therapy, among others [
3]. Korean medicine treatment includes herbal medicine, acupuncture, moxibustion, pharmacopuncture, traction, and acupotomy [
7]. Of which, acupotomy has been studied since 2006, with studies reported in 2007, 2014, 2017, and 2018 [
5,
7]. Of these 5 studies, 4 were conducted in China and 1 was conducted in Korea where only 1 case was reported [
5].
Since its first introduction in China in 1987, acupotomy has been used to treat patients with pain caused by various diseases [
5]. The treatment mechanism is to recover the original dynamic state by removing the adhesions of the tissue, and the recovered tissue can freely change its position in the body during activity. Consequently, the pain is removed and function is restored [
6].
In Case 1, the primary treatment sites were C4–5 (❻, ❼) and the additional treatment sites were the transverse processes of both C5–6 (⓬,⓭). Improvement was observed and persisted. After 8 weeks of treatment, the patients perceived pain level was a VAS score 2 compared with a VAS score 5–6 before the treatment. The patient’s lower extremity muscle strength also increased, reducing discomfort during walking by 30%. The improvement in symptoms was maintained even after 16 weeks of treatment.
In Case 2, the primary treatment sites were C5–6 spinous processes (❻, ❼, ❽), and the additional treatment sites were C2–4 transverse processes (⓫,⓬). In this case, overall during the treatment period, there was improvement in the level of pain and discomfort in daily life. However, there was a deterioration in the numbness and discomfort in the hands but by the end of the treatment period, there was improved sensation on the deteriorated side up to 90%.
In both cases, they did not complain of side effects such as dizziness, fainting, and shortness of breath except for slight pain, redness, and swelling in the insertion site during the procedure. Given that acupotomy treatment is more invasive than other Korean medicine treatments, sufficient explanation, and guidance the pain to expect, and side effects (including the risk of pneumothorax) to the patient is needed before the procedure [
6].
For both cases, the superficial ligament, interspinous ligament, posterior joint, stenosis, and surrounding soft tissue adhesions were resolved with acupotomy. After acupotomy, both patients experienced an improvement in symptoms and overall reduced discomfort. The duration of treatment was not the same.
In the treatment of CSM and cervical myelopathy, acupotomy was performed selecting the protuberance of 1.0 cm acupotomy to 1.5 cm outside of the cervical spinous process as the acupuncture area, and the cervical nuchal ligament, trapezius, and cervical erecting muscles were used as the treatment sites [
5,
7]. Further studies are warranted to select, and treat the site according to symptoms and causes, and to prove the effect of acupotomy treatment alone. In this study, the improvement of symptoms was observed at the treatment sites according to 9 primary and 5 additional designated treatment sites for acupotomy, and selecting the treatment sites based on the spine level.
This study was limited because it did not focus only on acupotomy, but rather a combination of acupuncture, herbal medicine, physical therapy, and acupotomy. Therefore, the precise effect of acupotomy was not determined. To derive more objective results, acupotomy needs to be used exclusively as the conservative treatment [
5–
7]. Furthermore, studies for acupotomy that are appropriately adjusted variables and randomized controlled clinical trials are necessary for conducting high-quality research.