The Third Lumbar Transverse Process Syndrome Treated by Electroacupunctur at Huatuojiaji Points

　　By Wang Shengxu et al.

32 cases of the third lumbar transverse process syndrome were treated mainly by
electroacupuncture at Huatuojiaji point of the first and second lumbar vertebrae, and
another 30 cases of the syndrome by conventional acupuncture as the controls. The results showed that treatment by electroacupuncture at Huatuojiaji points was superior in analgesic effect and clinical total effective rate to that by conventional acupuncture. It is considered that the mechanism of treatment by electroacupuncture at Huatuojiaji point is related to the trunk of posterior ramus of the spinal nerve where the points are located.

Clinical Data.
Among the 62 cases in this series, 35 cases were male and 27 female, ranging in age
from 22 to 34 years, with an average of 4l years. The shortest duration of illness was 2
days, and the longest 7 years. The patients were randomly divided into two groups according to the present pain intensity (PP). 32 cases were in the treatment group, and 30 cases in the control group. There was no significant difference in age and duration of illness between the two groups. The patients suffering from prolapse of lumbar intervertebral disc, lumbar muscular fibrositis, lumbar muscle strain, hypertrophic spondylitis, and lumbago due to the kidney and gynecological diseases and those who could not stick to the treatment were excluded.

Diagnostic Criteria
l). The pain in unilateral or bilateral lumbar region may radiate to posteriolateral part of the leg above the knee joint level in severe cases, but is not exacerbated while increasing the abdominal pressure.
2) The patient is unable to sit and stand for long, with pain exacerbated after tiredness and alleviated after rest.
3) There is obvious tenderness at the tip of the third lumbar transverse process, and
tension or spasm of the muscle. On palpation, there is a tubercular or cord-like mass. 4) Longer or normal transverse process of the third lumbar vertebra is showed in the X-ray film. Erythrocyte sedimentation rate, antistreptolysin O test, and rheumatoid factor are normal.

Method of Treatment
For the treatment group bilateral Huatuojiaji points (Extra) of the first and second lumbar vertebrae were selected as the main points, and the tenderness points at the third lumbar transverse process of the affected side as the auxiliary points. Filiform needles were inserted perpendicularly into the points, so that the tip of needles got to the vertebral lamina. After insertion, the needles were slowly twirled till the needling sensation transmitted towards the third lumbar transverse process. The tenderness points at the third lumbar transverse process were also punctured. The needle was inserted obliquely at an angle of 60" to reach the tip of the process. Twirling reducing manipulation was performed for one minute. Then, the handles of the needles were connected to an electroacupuncture apparatus for 20 minutes. In the control group, Shenshu (BL 23), Weizhong (BL 40), and tenderness points were selected as the main points. Needles were perpendicularly inserted into Shenshu (BL 23) and Weizhong (BL 40) to a depth of 0.5-l.0 cun. The method and parameters used in electroacupuncture at tenderness points on the third lumbar transverse process were identical with those in the treatment group.
The treatment was given once daily, l0 sessions constituting one course of treatment with a 3-day interval between courses.

Criteria for Therapeutic Effect
McGill Pain Questionnaire (MPQ) was adopted for comprehensive evaluation.
Cured: All the clinical symptoms and signs disappeared, and the functional movement became normal.
Markedly effective: The clinical symptoms and signs basically disappeared, with normal functional movement. There was tenderness on the third lumbar transverse process in varying degrees.
Effective: Clinical symptoms were alleviated, with improved functional improvement and unchanged signs.
Ineffective: No obvious improvement.

Therapeutic Results
The comparison of analgesic effects between the two groups (See Table l):

Table 1. Comparison of the Difference in Pain Integration 
Before and After Treatment Between the Two Groups

* P<0.05, ** P<0.0l, compared with the control group

As shown in Table l, the differences in every index, except emotional score of pain rating index between the treatment and control groups, were significant or very significant (P<0.05 or P<0.0l), indicating that electroacupuncture at Huatuojiaji points was superior in analgesic effect to the control group (common selection of points).
Comparison of therapeutic effects in treatment of the third lumbar transverse process syndrome between the two groups was listed in Table 2.

Table 2. Comparison of Therapeutic Effects between the Two Groups

Comparison of the total effective rate between the two groups, x 2=5.2l, P<0.05

As shown in Table 2, the total effective rate in the treatment group was significantly higher than that in the control group.

Discussion
The third lumbar transverse process syndrome is a common disease in patients with lumbago or lumbocrural pain. Its pathogenesis is related to the anatomical and physiological characteristics of the third lumbar vertebra, which is in the middle of the physiological lordosis of the lumbar vertebrae, serving as an axis of movement of the lumbar region. Therefore, the traction stress borne by both of its transverse processes are the strongest among the lumbar vertebrae. In addition, the transverse processes of the third lumbar vertebra are the longest among all the transverse processes of the lumbar vertebrae. Lever effect on the transverse processes of the third lumbar vertebra is the strongest. Pulling forces borne by the ligaments, muscles, fasciae, and aponeuroses adhered to the transverse processes are the strongest as well. Therefore,
transverse processes of the third lumbar vertebra are the most vulnerable when the muscles and fasciae connected with the transverse processes are pulled, contracted suddenly or with abnormal loading, which may lead to laceration, hemorrhage, and hematoma on the area connecting the muscles with the transverse processes, followed by muscular tension and spasm, and stimulation or compression of lateral branch of the posterior rams of spinal nerve, thus resulting in pain in the regions of the transverse processes, buttock, and thigh.
Shao Zhenhai, et al. found though clinical and anatomical researches that mechanical
stimulation of the trunk of posterior ramus of the lumbar nerve was the most common cause of nonspecific lumbago. It was also found that the 1umbago could be relieved by low-temprature freezing of posterior ramus of the spinal nerve. Superior clunial nerves come out of intervertebral foramens of the first, second, and third lumbar vertebrae, pass through transverse ligaments and bone interfibrous foramen, run along the dorsal aspects of the first, second, and third lumbar transverse processes and close to the periosteum, go through intertransverse sulci, and then pierce the muscles originating form the transverse processes to their dorsal parts. Superior clunial nerve is easy to be injured where it passes the root segment of the third lumbar transverse processes.
Chen Zhishen determined the pulling force borne by posterior ramus of the spinal nerve in three-dimensional movement of the lumbar vertebrae in fresh corpse. It was found that the stress on its trunk was the strongest, and then the trunk was the most vulnerable. Pulling force borne by one pair of posterior ramus of the second lumbar nerves was the most strongest among five pairs of posterior ramus of the lumbar nerves. It is apt to be injured where it passes the root segment of the third lumbar transverse processes. These findings tally with the fact that there is tenderness over the area of the third lumbar transverse process in most of the patients with nonspecific lumbago. In the light of the findings mentioned above, it is considered that the lateral branches of posterior ramus of the second and third lumbar nerves pass the third lumbar transverse processes, and pain in the region of the third lumbar transverse processes may be resulted, if their trunks are stimulated. Therefore, we treated the third lumbar transverse process syndrome by electroacupuncture at Huatuojiaji points of the first and second lumbar vertebra with satisfactory effects, which might result from the needling sensation radiating to the pain area.
In our clinical practice, some patients with the syndrome were treated only by electroacupuncture at Huatuojiaji points, and satisfactory effects were also obtaind with rapid analgesic effect, which showed that stimulation of the trunk of posterior ramus of the spinal nerve positively contributed to nonspecific lumbago. However, there was obvious pathologic change in the area of the third lumbar transverse process in most of the patients. Accordingly, we punctured local Ashi tenderness points to enhance the therapeutic effect. The present study showed that instant and satisfactory therapeutic effect featured this therapy with both the principal and secondary aspects of the disease treated simultaneously. It was superior to the method by conventional selection of points.