A 16-year-old girl with a two-month history of severe lower back and sacroiliac joint pain driven by early active ankylosing spondylitis was successfully managed using a phased heat-clearing and Kidney-tonifying herbal strategy.

Case ID: CHC-0066

Case Summary

This case describes a 16-year-old girl who presented with sudden, severe lower back and sacroiliac (SI) joint pain. Laboratory and imaging tests confirmed an early, active phase of Ankylosing Spondylitis (AS) with visible bone erosion. The original report documented a conventional diagnosis of Ankylosing Spondylitis (early active phase) and a TCM assessment of Spine Impediment (Ji Bi) driven by Wind-Damp-Heat obstructing the collaterals. She was managed through a highly strategic, phased herbal approach: initially clearing the acute inflammatory heat and toxicity, and then transitioning to deeply warming and tonifying the Spleen and Kidneys to consolidate the Governing Vessel (Du Mai), resulting in a complete clinical remission.

Patient Presentation

• Patient: 16-year-old female (Surname: Yang).
• Main Complaint: Severe lower back and sacroiliac joint pain for 2 months, accompanied by a heat-like pain sensation, dry throat, and low-grade fever.
• History: The patient sought initial consultation on November 20, 2016. She was generally of a quiet, sedentary disposition. Two months prior, without any obvious trigger, she developed sudden lower back pain that was particularly severe in the sacroiliac joints.
• Examination & Labs: Her Erythrocyte Sedimentation Rate (ESR) was highly elevated at 80 mm/h, and she tested positive for HLA-B27. A CT scan of the sacroiliac joints showed bilateral bone erosion and sclerotic changes (more pronounced on the right), indicating an active lesion, along with slightly blurred thoracic, lumbar, and SI joint surfaces. She had a daily low-grade fever (36-37°C in the morning, 37-38°C in the afternoon). Her menstrual cycle was irregular (every 2-3 months) with dark, scanty flow and a history of dysmenorrhea.

Examination and Diagnosis

• Conventional Diagnosis: Ankylosing Spondylitis (Early active phase).
• TCM Tongue and Pulse: The tongue body was red with a white coating. The pulse was sunken, slippery, and stringy (脉沉滑弦).

TCM Assessment

The original practitioner interpreted the presentation as Spine Impediment driven by Wind-Damp-Heat Obstructing the Collaterals (脊痹病 – 风湿热痹阻经络).

According to the holistic principles of yin and yang Chinese Medicine the Governing Vessel (Du Mai) runs straight up the spine and governs the body’s Yang energy. The true root of Ankylosing Spondylitis is a deep internal deficiency of the Spleen and Kidneys. Because her foundational Kidney energy was weak (evidenced by her irregular menses and sedentary nature), external Wind, Dampness, and Heat pathogens were able to invade and lodge deep within her spine.

During this acute, active phase, these pathogens transformed into “damp-heat and stasis toxins,” fiercely battling her righteous Qi. This intense localized battle caused the severe pain, bone erosion, and daily low-grade fever. The red tongue and sunken-slippery-stringy pulse provided objective confirmation of deep-seated damp-heat and trapped fluid/stasis within the meridians.

Treatment Approach

The primary treatment principle was dynamic. In the acute phase, the strategy was to clear heat, resolve toxicity, and unblock the Governing Vessel (清热解毒，通调督脉). Once the active inflammation subsided, the strategy shifted entirely to warming the Spleen and Kidneys, nourishing blood, and deeply rebuilding the spine’s essence.

Herbal Formulas and Modifications

• Initial Formula (Acute Phase – November 20, 2016): A 14-herb decoction to aggressively clear the active joint inflammation.
  • Clearing Heat and Damp-Toxicity: Huang Bo (10g), Ge Gen (20g), Yi Ren (20g), and Yin Hua Teng (Honeysuckle Stem, 20g) formed a cooling core to purge the damp-heat from the joints and stop the low-grade fever.
  • Nourishing Yin and Unblocking Collaterals: Di Huang (20g) and Bai Shao (20g) protected the Yin fluids from the heat. Gou Ji (15g), Sang Ji Sheng (10g), Wei Ling Xian (10g), Hai Tong Pi (10g), Niu Xi (10g), Gui Zhi (10g), and Xi Xin (3g) targeted the spine and lower body to unblock the deep impediment and stop the pain. Gan Cao (10g) harmonized. (7 doses prescribed).
• Third Visit (December 4, 2016 – Transition Phase): The fever disappeared and her pain was reduced, but her ESR remained at 50 mm/h. She experienced severe fatigue when walking. The practitioner shifted the principle to strengthening the Spleen, warming the Kidneys, and benefiting Qi. The formula heavily tonified the root: Sheng Di Huang (20g), Shu Di Huang (20g), Huang Qi (20g), Dang Gui (10g), Lu Jiao Shuang (15g), and Chao Du Zhong (10g) were utilized to rebuild her stamina and blood.
• Fourth Visit (December 12, 2016 – Winter Flare-up): Cold weather triggered a mild relapse of SI pain, accompanied by loose stools, cold limbs, and pre-menstrual abdominal pain (ESR 26 mm/h). Recognizing this as Spleen/Kidney Yang deficiency with Du Mai stasis, the practitioner aggressively warmed her Yang using heavy medicinals: Lu Jiao Jiao (Deer Antler Glue, 30g), Xian Ling Pi (Epimedium, 10g), Rou Gui (5g), and Gu Sui Bu (15g).
• Fifth & Sixth Visits (Consolidation Phase – Late December): The acute phase passed entirely, and she entered a stable phase (ESR 24 mm/h). The pain was virtually gone. To fully consolidate the cure, the practitioner prescribed a massive essence-building formula heavily reliant on animal products to rebuild the bone marrow: Lu Jiao Jiao (30g), Gui Jia Jiao (Tortoise Shell Glue, 30g), Zi He Che (Placenta, 30g), He Shou Wu (30g), and Wu Gong (Centipede, 3 pieces – to powerfully unblock deep collaterals).
  • Administration: These herbs were ground into a fine powder, packed into large capsules, and taken as 4 pills (3g each) twice daily with warm water or yellow wine for three continuous months.

Follow-Up

• Subsequent long-term follow-ups confirmed the patient had basically recovered. She resumed normal studying and daily life, and experienced absolutely no relapses in the following years.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the masterful, phased management of Ankylosing Spondylitis (AS).

Professor Zhao emphasizes that AS often has a very long early-to-mid stage. If it is only treated superficially to stop the pain, the disease will progress until the spinal ligaments ossify, causing severe permanent deformity (“bamboo spine”). In this case, the practitioner correctly recognized the initial presentation as an acute, active fire (Damp-Heat) and strictly used cooling herbs to put out the “fire” and drop the ESR. However, once the fire was extinguished, he didn’t stop treatment. He recognized the patient’s underlying weakness and pivoted to heavy, Yang-warming, marrow-filling animal medicinals (Lu Jiao Jiao, Gui Jia Jiao, Zi He Che) in capsule form for three months. This long-term structural rebuilding is what ultimately halted the disease process and prevented permanent disability in a young teenager.

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Source Original source: Zhanjiang Second Hospital of Traditional Chinese Medicine / Guangdong Provincial Administration of Traditional Chinese Medicine Original title: 【以案说医】招仕富：中医治疗强直性脊柱炎验案 Practitioner: Professor Zhao Shifu (招仕富) Publication date: 2024-08-28 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation