L5/S1 disc herniation s/p laminectomy

Chief Complaint: chronic low back pain

Western diagnosis: L5/S1 disc herniation s/p laminectomy

Medical History: Patient is 31 yr. old female with two year hx of low back pain as a result of a fall at work 9/99. Diagnosed with L5/S1 disc herniation and radiculopathy at same level. Laminectomy performed 5/00. 14 months later low back, bilateral leg pain and left foot numbness continues.

Questioning exam: Other medical history significant for daily headaches, irregular dizziness, poor appetite, insomnia and bi-polar disorder.

Pulse exam: Overall rapid - heart, kidney yin & yang pulses empty. Spleen pulse slippery and forceful.

right-sided subcostal tension with bilateral tenderness at ST 27 area along with CV 2-6 area. Several tender spots revealed in ow back area from L2 - S1 bilaterally.

right-sided auricular tenderness at kidney, shenmen, subcortex, neuro-sensorial & cerebral corresponding areas.

Tongue exam: body - pale with red raised 'dots' over much of body and tip of tongue, tongue tip slightly darker than body. Thin white coating.

OM Diagnosis: Local Qi/blood stagnation s/p traumatic injury and surgery. Kidney/Heart Yin deficiency based on pulse & tongue.

Treatment Principle: Move qi/blood locally, tonify kidney, calm spirit, cool heat

Point Prescription: Lu7 w/ Kd6, Li4 & 4.5 with San Char (opposite side), Ht7, Kd3, Bl 13, 14, 15, 17, 18, 20, 23, 31, 40, 60, Yintang, GV 14 - 11 (not all points used at same time)

Gua Sha at low & upper back

Moxibustion at low back

Herbal Formula: no herns given/used

Aside: goal of patient was to come off of pain medication (neurontin & vicodin)

Lifestyle prescription: Low back stretching, increase fluid intake (patient was not willing to adjust diet)

Results: Following 3 months of treatment (2x/week) patient was complaining of occasional and mild pain locally, no lower extremity pain/numbness and was not using any pain medication. Her appetite has returned, she is sleeping a good 7 hours/night and denies having headaches. She is seen on an as needed basis currently.

Synopsis: Patient (and practitioner) are happy with her progress.