A 59-year-old man with a two-year history of severe spinal and joint pain complicated by profound Spleen and Kidney deficiency (severe fatigue, sweating, and digestive issues) was successfully managed using a Qi-boosting herbal strategy combined with spinal adjustment and acupuncture.

Case ID: CHC-0076

Case Summary

This case describes a 59-year-old man with a military background who presented with a two-year history of recurrent neck, shoulder, lower back, and leg pain following a physical trauma. Recently, his condition had severely deteriorated, accompanied by extreme fatigue, shortness of breath, profuse sweating, and poor digestion. The original report documented a complex conventional diagnosis of cervical spondylotic myelopathy (ruptured and herniated cervical disc), lumbar disc herniation, and bilateral patellar chondritis. The TCM assessment identified Impediment Syndrome (Bi Syndrome) driven by Spleen and Kidney Qi Deficiency with a failure of Middle Jiao transport. He was managed through a highly integrative approach utilizing “Zhao’s Balanced Spinal Adjustment” to correct the mechanical spinal faults, alongside targeted acupuncture and a modified Buzhong Yiqi Tang (Tonify the Middle and Augment Qi Decoction) to aggressively rebuild his foundational energy.

Patient Presentation

• Patient: 59-year-old male (Surname: Shen).
• Main Complaint: Recurrent neck, shoulder, lower back, and leg pain for over 2 years, recently worsening with severe fatigue, profuse sweating, and poor appetite.
• History: The patient sought his initial consultation on April 16, 2021. With an occupational military background involving long-term overwork, he had a history of neck and lower back injuries from a fall two years prior. Recently, his pain had worsened alongside severe systemic symptoms: extreme fatigue, profuse sweating, a lack of appetite (especially refusing dinner), and shortness of breath and weakness when climbing just two flights of stairs. His bowel movements were abnormal (3–4 times a day, small amounts), though urination was normal.

Examination and Diagnosis

• Conventional Diagnosis: 1. Cervical spondylotic myelopathy (ruptured/herniated cervical disc); 2. Lumbar disc herniation; 3. Bilateral patellar chondritis (knee inflammation).
• TCM Tongue and Pulse: The tongue body was pale white with little coating and distinct teeth marks (齿印) on the edges. The pulse was slightly slow, stringy, and weak (脉稍缓弦无力).

TCM Assessment

The original practitioner interpreted the presentation as Impediment Syndrome driven by Spleen and Kidney Qi Deficiency and Failure of Middle Jiao Transport (痹证 – 脾肾气虚，中焦失运).

According to the holistic principles of Chinese Medicine, the Kidneys are the “Congenital Root” (providing foundational Yang energy to the spine and bones), and the Spleen is the “Acquired Root” (responsible for digestion and producing Qi and Blood). In this patient, severe overwork in the military followed by physical trauma caused deep Wind-Cold-Dampness to invade his spine, leading to chronic “Spine Impediment” (脊痹).

Because the condition dragged on for years, it completely exhausted his Spleen and Kidneys. The weak Spleen failed to transport fluids (causing the loose stools, poor appetite, and splashing sounds in the abdomen), while the depleted Kidney Yang failed to secure his exterior (causing the profuse sweating, shortness of breath, and aversion to cold/air conditioning). The pale tongue with teeth marks and the slow-weak pulse provided textbook objective confirmation of this profound systemic Yang and Qi collapse.

Treatment Approach

The primary treatment principle was to invigorate the Spleen and boost Qi, warm the meridians and unblock the collaterals, and dispel dampness to stop the impediment (健脾益气，温经通络，祛湿止痹). The strategy focused on “treating the root”: mechanically realigning the spine while heavily tonifying both the Congenital (Kidney) and Acquired (Spleen) foundations simultaneously to give the body the energy it needed to heal the severe structural damage.

Interventions and Herbal Formulas

• Zhao’s Balanced Spinal Adjustment & Acupuncture:
  • Manual Therapy: The practitioner applied the specialized spinal adjustment to realign the vertebrae, combined with local acupressure massage on the head and bilateral knees.
  • Acupuncture: Initially focused on the Hua Tuo Jiaji points alongside the spine to unblock the local meridians. In later visits, warm needle moxibustion was added at the Jiaji points, Zusanli (ST36), and Sanyinjiao (SP6), along with abdominal acupuncture to deeply regulate the internal organs.
• Initial Herbal Formula (April 16, 2021): A 14-herb decoction acting as a modified Buzhong Yiqi Tang (Tonify the Middle and Augment Qi Decoction).
  • Huang Qi (20g), Dang Shen (20g), Bai Zhu (15g), Fu Ling (30g), and Zhi Gan Cao (10g) heavily boosted the central Spleen Qi to stop the fatigue and shortness of breath.
  • Bai Bian Dou (30g), Huai Shan (Chinese Yam, 30g), and Xin Hui Chen Pi (5g) strengthened digestion and dried the dampness causing the loose stools.
  • Du Zhong (10g), Xu Duan (10g), and Ba Ji Tian (10g) warmed the Kidneys and strengthened the spinal bones and sinews.
  • Gui Zhi (10g), Fang Feng (10g), and Mu Gua (Papaya, 15g) warmed the meridians, dispersed the trapped wind-dampness, and relaxed the muscle spasms.
• Phased Adjustments (Visits 2 & 3 – Late April):
  • As the patient’s appetite improved but sweating and cold aversion persisted, the practitioner aggressively increased the Yang-warming and essence-building components.
  • Gan Jiang (Dried Ginger, 10g) and Rou Gui (Cinnamon Bark, 5g) were added to strongly warm the Spleen and Kidney Yang. Gao Li Shen (Korean Ginseng, 10g) replaced Dang Shen for a more powerful Qi boost.
  • Tie Pi Shi Hu (Dendrobium, 15g) and Wu Wei Zi (Schisandra, 10g) were utilized to nourish Yin and strictly astringe the severe sweating. Heavy Kidney tonics like Shu Di (15g), Shan Yu Rou (10g), and Sang Ji Sheng (15g) were added to fill the marrow and repair the herniated discs.

Follow-Up

• Fourth Visit (May 1, 2021): After two weeks of treatment, the neck, shoulder, back, and knee pain were basically relieved. The patient’s appetite was good, the abnormal sweating had significantly improved, and his bowel movements normalized to 1-2 times per day.
• Fifth Visit (May 6, 2021): The spinal and leg pain was significantly better. He slept well, the sweating was vastly reduced, and his spirit was excellent. The formula was adjusted slightly for consolidation (increasing Shu Di to 20g and adding Rou Cong Rong 10g to further nourish the Kidneys).
• Outcome: A follow-up one week later confirmed that the symptoms had essentially disappeared and he was basically recovered. He was advised to begin light morning jogging, evening walks, and careful diet regulation to prevent relapse.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is treating severe, multi-level structural spinal disease (cervical myelopathy and lumbar herniation) by focusing on systemic internal medicine.

In conventional orthopedics, a patient with ruptured cervical discs and lumbar herniations would primarily be evaluated for surgery. However, Professor Zhao’s clinical wisdom recognizes that the spine is the “pillar of life,” and its health is entirely dependent on the internal organs. This patient’s spine collapsed because his “Acquired Root” (Spleen) and “Congenital Root” (Kidneys) were completely exhausted from military overwork. If a doctor only treats the local pain or only performs surgery without addressing the profound Qi and Yang collapse (the sweating, diarrhea, and extreme fatigue), the patient will never heal. By masterfully combining local mechanical bone-setting with heavy, internal Spleen/Kidney tonification (using Buzhong Yiqi Tang and Korean Ginseng), the practitioner restored the body’s foundational vitality, allowing the spine to repair itself in just over three weeks.

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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：治疗脊柱相关性脾肾虚损案 Practitioner: Professor Zhao Shifu (招仕富) Publication date: August 17, 2024 Original language: Chinese ChineseHerb.org version: English translation and editorial adaptation