Case‧病案‧0609A

Patient Stats: Male, 54-year-old, software engineer. Complaints: Lower back pain for four years, intermittence. In the past 2 months the pain increased and sometimes radiated to the thigh on both sides, and could not stand long and had sedentary. The examination of M.D. showed a slipped disc between 4 and 5 lumbar vertebrate. After taking painkillers for two weeks, the situation showed no significant improvement, so the M.D. suggested him acupuncture. Chinese Medicinal Assessments: Physical examination: lumbar paravertebral tenderness 3,4 and 5, positive straight leg raising test on both sides. Tongue: light color and teeth mark, and coating was thin and white. Pulse: Deep and slightly slippery. TCM Diagnosis: lower back pain, bi syndrome. Syndrome: spleen and kidney yang-deficiency type stasis. Treatment: tonify kidney and spleen yang to expel dampness, and clear the meridian. Treatment: acupuncture 22.04, 22.05, 77.18, SP7, SP6, BL65 and other points. Patient felt 90% relieved after treatment. The pain disappeared after two weeks of treatment. This showed clinical cure. He came back once after two months and has had no recurrence.

男，54歲，軟體工程師。 腰痛四年，時好時壞。近二月疼痛感加重，有時並會放射到大腿兩旁，無法久站久坐。經西醫檢查，腰4、5椎間盤突出，服用止痛藥兩週，情況無明顯改善，西醫建議針灸治療。 查體：腰3、4、5椎旁壓痛，直腿抬高試驗兩側陽性。舌質淡有齒痕，苔淡白，切診：沉稍滑。 中醫診斷：腰痛、痹證。證屬：脾腎陽虛挾瘀滯型。 治療：補腎助陽，健脾化濕，通經活絡。治療：毫針刺靈骨、大白、腎關、漏谷、三陰交、束骨等穴。治療一次後病患自覺疼痛有 90%明顯緩解。再持續治療兩週，疼痛消失，臨床治愈，兩個月後回診一次，無復發現象。