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Pudendal nerve electroacupuncture for

lumbar spinal canal stenosis--a case series
Authors: Motohiro Inoue, Tatsuya Hojo, Miwa Nakajima, Hiroshi Kitakoji, Megumi Itoi and
Yasukazu Katsumi
Date: July 2008
From: Acupuncture in Medicine(Vol. 26, Issue 3)
Publisher: British Medical Acupuncture Society
Document Type: Clinical report
Length: 2,184 words

Full Text:

Abstract

Objective To investigate the effectiveness of pudendal nerve electroacupuncture for lumbar and
lower limb symptoms in patients with lumbar spinal canal stenosis for whom acupuncture of the
lumbar and lower limb muscles had been ineffective.

Methods Nine patients with lumbar spinal canal stenosis for whom conventional acupuncture at
the lumbar and lower limb muscles had no effect. Pudendal nerve electroacupuncture was
performed eight times (once per week). VAS scores and continuous walking distance were used
to evaluate changes in symptoms. Results The following changes in symptoms occurred after
pudendal nerve electroacupuncture: low back pain was improved from 45.3 [+ or -] 17.4mm
(mean [+ or -] SD) to 39.2 [+ or -] 14.0mm, lower limb pain was improved from 61.1 [+ or -]
5.6mm to 35.4 [+ or -] 11.9mm, lower limb dysaesthesia was improved from 63.9 [+ or -] 8.4mm
to 46.9 [+ or -] 16.2mm, and continuous walking distance was improved from 100.0 [+ or -]
35.4m to 250.0 [+ or -] 136.9m. Conclusion Pudendal nerve electroacupuncture may be an
effective treatment for lumbar and lower limb symptoms due to spinal canal stenosis, and is
potentially useful in patients who have not responded to conventional acupuncture.

Keywords

Electroacupuncture, spinal canal stenosis, pudendal nerve.

Introduction

Lumbar spinal canal stenosis is a condition in which the lumbar spinal canal becomes narrower,
and is commonly associated with degenerative changes of the spine. This narrowing
compresses the cauda equina and/or the nerve roots inside the spinal canal, resulting in low
back pain and lower limb symptoms. There have been several reports of the efficacy of
acupuncture stimulation of lumbar muscles as a treatment for lumbar and lower limb symptoms
due to lumbar spinal canal stenosis. (1;2) However, since there are many cases for which this is
not effective, there is a call for a more effective acupuncture treatment.

Acupuncture stimulation of the pudendal nerve has been applied to the symptoms of neurogenic
bladder dysfunction and chronic pelvic pain syndrome. (3-6) We have found through our clinical
experience that some patients with neurogenic bladder dysfunction who have received
acupuncture stimulation of the pudendal nerve reported improvement in their low back or lumbar
symptoms. Taking into consideration the above, to clarify the clinical effect of pudendal nerve
electroacupuncture, we studied the effect of electroacupuncture stimulation of the pudendal

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nerve in patients for whom acupuncture of the lumbar and lower limb muscles was ineffective.

Methods

Participants

The participants were nine patients (five males, four females, mean age 72.6 [+ or -] 5.3 years,
and mean duration of disorder 65.7 [+ or -] 25.0 months) who complained of lumbar and lower
limb symptoms; who had x ray film and MRI findings of lumbar spinal canal stenosis; and who
had not been relieved by acupuncture treatment of lumbar and lower limb muscles innervated by
damaged lumbar nerves. Of nine patients included in the study, five complained of intermittent
claudication. Patients had all received eight conventional acupuncture treatments, once a week
for eight weeks, but had shown an improvement of less than 20% in pain in the back or lower
limbs, lower limb dysaesthesia and continuous walking distance.

Conventional acupuncture treatment of lumbar and lower limb muscles was given at the spinal
segmental level of the disorder, as determined from clinical symptoms, physical findings and x
ray film and MRI results. The basic location for needle insertion were the extra points Hua Tuo
Jia Ji (0.5cun, 1-2cm in adults, lateral to the lower border of the relevant spinous process) with
an insertion depth of 2cm at the spinal level of the disorder. Stimulation was also conducted in
areas of the erector spinae muscle of the spine, quadratus lumborum muscle, gluteal muscles
and iliopsoas muscle (to reach the iliopsoas muscle, the needle was inserted at the lower border
of the inguinal ligament and immediately lateral to the femoral artery) where palpation revealed
tension or tenderness, or where pressure induced recognised symptoms (trigger point). For
lower limb treatment, acupuncture stimulation was performed at muscles innervated by the
relevant peripheral nerves, taking into consideration the symptoms, neurological findings and
imaging findings. All the acupuncture needles were inserted with an intention to obtain de qi and
left in place for 10 minutes before being removed.

All the procedures in the present study were approved by the Ethics Committee of Meiji
University of Integrative Medicine.

Pudendal nerve electroacupuncture method

Pudendal nerve electroacupuncture was commenced one week after the acupuncture treatment
of lumbar and lower limb muscles had finished. The point for acupuncture stimulation to the
pudendal nerve is located in the gluteal region (at a point 50-60% of the distance along a
straight line from the posterior superior iliac spine to the lower inner edge of the ischial
tuberosity). An acupuncture needle (0.25mm in diameter) was inserted perpendicularly to a
depth of approximately 6-7cm in this region. (6-8) When the needle reaches the pudendal nerve,
a feeling of stimulation arises in the pudendal area. Then the second acupuncture needle was
inserted in the same area, close to (within 5mm) the first needle and these two needles were
used as electrodes for low frequency electroacupuncture treatment (stimulation frequency: 10
Hz; duration: 10 minutes; and intensity: sufficient for stimulation in the pudendal area to be felt).
A total of eight sessions of pudendal nerve electroacupuncture (once per week) were performed,
on the same side as the lumbar and lower limb symptoms (Fig 1).

Assessment

There were three assessments: before the start of acupuncture sessions to the lumbar and
lower limb muscles (time TO); after eight acupuncture sessions to the lumbar and lower limb
muscles (T1); and after eight sessions of the pudendal nerve electroacupuncture (T2). Self-
assessments of low back pain, lower limb pain and lower limb dysaesthesia (explained to the
subject as Shibire, a kind of numb or tingling sensation) were performed using a visual analogue
scale (VAS). The VAS featured a 100mm straight line, with the left end of the line representing
no symptoms at all and the right edge the worst symptoms imaginable. In five subjects who

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complained intermittent claudication, self-reported continuous walking distance was also

recorded.

Statistical analysis

All data were expressed as mean values [+ or -] standard deviation. Paired t test was used to
detect significant changes in low back pain, lower limb pain, lower limb dysaesthesia and
continuous walking distance between T0, T1 and T2. A P value of less than 0.05 was
considered statistically significant, and significance probabilities in each test were corrected
using the Bonferroni method.

Results

All patients completed the eight sessions of electroacupuncture to the pudendal nerve. The VAS
values for low back pain, lower limb pain and lower limb dysaesthesia at TO before conventional
acupuncture were 46.3 [+ or -] 17.4mm (mean [+ or -] SD), 62.9 [+ or -] 7.4mm and 64.9 [+ or -]
8.8m respectively. Mean continuous walking distance (N=5) at time TO was 96.0 [+ or -] 36.5m.
Changes in symptoms at times T1 and T2 were as follows: the VAS values for low back pain
changed from 45.3 [+ or -] 17.4mm (mean [+ or -] SD) to 39.2 [+ or -] 14.Omm, for lower limb
pain from 61.1 [+ or -] 5.6mm to 35.4 [+ or -] 11.9mm, for lower limb dysaesthesia from 63.9 [+
or -] 8.4mm to 46.9 [+ or -] 16.2mm, and for continuous walking distance from 100.0 [+ or -]
35.4m (mean [+ or -] SD) to 250.0 [+ or -] 136.9m (Tablel, Fig 2 and 3).

The numbers of patients who showed an improvement of 30% or more at T2 after pudendal
nerve electroacupuncture following lower limb and lumbar acupuncture were: six out of nine
(lower limb pain), four out of nine (dysaesthesia) and four out of five (continuous walking
distance). No one showed improvement of more than 30% in low back pain.

Discussion

We observed that pudendal nerve electroacupuncture significantly improved low back pain,
lower limb pain, lower limb dysaesthesia and continuous walking distance in patients who
previously had no response to acupuncture to the lumbar and lower limb muscles.

The first choice treatment for symptoms due to spinal canal stenosis is conservative therapy,

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which generally consists of administering various anti inflammatory agents or intravenous

injection of prostaglandin E1, performing epidural block or root nerve block, or conducting
orthotic and other treatments. When no effect is observed with these conservative treatments, or
when bladder or bowel function is affected, surgical operations such as decompressive
laminectomy or decompressive laminoplasty are performed. However, laminectomy and
laminoplasty procedures have considerable risks, and reoperation for postoperative recurrence
is difficult. For these reasons, alleviating symptoms with conservative treatment is of great
clinical significance, and acupuncture could now be considered as a treatment option in these
patients.

The mechanism of acupuncture's effect in this condition is not known. Cauda equina intermittent
claudication, a characteristic finding of spinal canal stenosis, is thought to be due to ischemia of
the cauda equina, nerve root, sciatic nerve and other areas as a result of stenosis of the spinal
canal compressing the cauda equina. If this is the case, one could speculate that electrical
stimulation of the pudendal nerve in some way influences cauda equina and sciatic nerve blood
flow, perhaps by inducing autonomic changes affecting the blood flow, in similar fashion to
pudendal nerve stimulation influencing bladder activity. (9) It is not known how relevant these
vascular changes could be for symptoms of nerve root compression. In a companion paper, we
investigate this possibility using rats. (10)

These results, if confirmed, indicate that electroacupuncture of the pudendal nerve could be an
effective treatment for lumbar and lower limb symptoms due to spinal canal stenosis. Since it
can be performed using acupuncture needles, it enables non-surgical, percutaneous approach
which is a much simpler and safer method of treatment than surgery. However, one adverse
reaction is that during stimulation the patient may experience an unpleasant sensation in the
pudendal area. For this reason, it is thought that this method of treatment should be used as a
second choice treatment for cases that do not respond to acupuncture stimulation of the lumbar
and lower limb muscles.

This study has clarified to a certain degree the effectiveness of electroacupuncture of the
pudendal nerve. To further explore its place in clinical practice, however, future studies should
investigate the therapeutic effect of electroacupuncture of the pudendal nerve alone, and should
compare this treatment with sham acupuncture and with other available treatments.

Conflict of interest

The authors declare no conflict of interest.

Summary points

Spinal canal stenosis is one cause of lumber and lower limb pain

Conventional acupuncture is sometimes unsuccessful Electroacupuncture given in the region of

the pudendal nerve gave significant pain relief in six out of nine cases

Acknowledgements

We are grateful to Dr N Ishizaki (The Department of Clinical Acupuncture and Moxibustion, Meiji
University of Oriental Medicine) for his valuable suggestions and review of the manuscript.

Reference list

(1.) Witzmann A. Acupuncture and other forms of treatment for patients with chronic back pain.
Wien Med Wochenschr 2000;150(13-14):286-94.

(2.) Kasuya D, Takeuchi F, Yamamoto K, Ito K, Sakai T. A clinical study of acupuncture therapy

4 of 7 13/02/2023, 13:36
Firefox h�ps://go.gale.com/ps/i.do?p=HRCA&u=googlescholar&id=GALE|A...

for lumbar spinal canal stenosis. J Jph Soc Balneol Climatol Phys Med 1999;62(4):201-6.

(3.) Sugimoto Y, Honjo H, Kitakoji H, Nakao M. The effect of pudendal nerve electrical
acupuncture stimulation on perineal discomfort in patients with chronic pelvic pain syndrome--an
analysis using a visual analogue scale. J Japan Soc Acupunct Moxibustion 2005;55(4):584-93.

(4.) Yamagiwa K, Kitakoji H, Sasaki K, Isimaru K, Oyama Y, Kinoshita M et al. Acupunctural

stimulation of the pudendal nerve for treatment of urinary disturbances. J Japan Soc Acupunct
Moxibustion 1993;43(2):53-7.

(5.) Sato A, Sato Y, Suzuki A. Mechanism of the reflex inhibition of micturition contractions of the
urinary bladder elicited by acupuncture-like stimulation in anesthetized rats. Neurosci Res
1992;15(3):189-98.

(6.) Spinelli M, Malaguti S, Giardiello G, Lazzeri M, Taramola J, Van Den Hombergh U. A new
minimally invasive procedure for pudendal nerve stimulation to treat neurogenic bladder:
Description of the method and preliminary data. Neurourol Urodyn 2005;24:305-9.

(7.) Kitakoji H, Kitamura S, Matsuoka K, Kaneda M, Nakamura T. [Anatomical consideration of

the acupuncture to the pudendal nerve]. J Japan Soc Acupunct Moxibustion 1989;39(2):221-8.

(8.) Schmidt RA. Technique of pudendal nerve localization for block or stimulation. Ural
1989;142(6):1528-31.

(9.) Reitz A, Gobeaux N, Mozer P, Delmas V, Richard F, Chartier-Kastler E. Topographic

anatomy of a new posterior approach to the pudendal nerve for stimulation. Eur Urol
2007;51(5):1350-6.

(10.) Inoue M, Hojo T, Nakajima M, Kitakoji H, Itoi M, Katsumi Y. The effect of electrical
stimulation of the pudendal nerve on sciatic nerve blood flow in animals. Acupunct Med
2008;26(3):145-8.

Motohiro Inoue

research associate licensed acupuncturist

Department of Clinical

Acupuncture and Moxibustion

Meiji University of Integrative Medicine

Kyoto, Japan

Tatsuya Hojo

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professor orthopaedic surgeon

Faculty of Health and Sports Science

Doshisha University

Kyoto, Japan

Miwa Nakajima

licensed acupuncturist

Department of Orthopaedic Surgery

Hiroshi Kitakoji

professor licensed acupuncturist

Department of Clinical Acupuncture and

Moxibustion

Megumi Itoi

professor orthopaedic surgeon

Department of Orthopaedic Surgery

Yasukazu Katsumi

professor orthopaedic surgeon

Department of Orthopaedic Surgery

Meiji University of

Integrative Medicine

Kyoto, Japan

Correspondence:

Motohiro Inoue

mo_inoue@meiji-u.ac.jp

Table 1 VAS scores and walking distance

Before treatment

Low back
pain (mm) 46.3 [+ or -] 17.4
Lower limb
pain (mm) 62.9 [+ or -] 7.4
Lower limb
dysesthesia (mm) 64.9 [+ or -] 8.8
Con�nuous walking
distance (m) 96.0 [+ or -] 36.5

A�er lumbar and lower

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limb muscle acupuncture

Low back
pain (mm) 45.3 [+ or -] 17.4
Lower limb
pain (mm) 61.1 [+ or -] 5.6
Lower limb
dysesthesia (mm) 63.9 [+ or -] 8.4
Con�nuous walking
distance (m) 100.0 [+ or -] 35.4

A�er pudendal nerve

electroacupuncture

Low back 39.2 [+ or -]

pain (mm) 14.0 * ([dagger])
Lower limb 35.4 [+ or -] 11.9 **
pain (mm) ([dagger][dagger])
Lower limb 46.9 [+ or -] 16.2 **
dysesthesia (mm) ([dagger][dagger])
Con�nuous walking 250.0 [+ or -] 136.9 *
distance (m) ([dagger])

Values are means [+ or -] SI); * P<0.05 vs before treatment;

** P<0.01 vs before treatment; ([dagger]) P<0.05 vs a�er
lumbar and lowre limb muscle acupuncture; ([dagger][dagger]) P <0.01
vs a�er the lumbar and lower limb muscle acupuncture.

Copyright: COPYRIGHT 2008 British Medical Acupuncture Society

http://www.medical-acupuncture.co.uk
Source Citation (MLA 9th Edition)
Inoue, Motohiro, et al. "Pudendal nerve electroacupuncture for lumbar spinal canal stenosis--a
case series." Acupuncture in Medicine, vol. 26, no. 3, July 2008, pp. 140+. Gale OneFile:
Health and Medicine, link.gale.com/apps/doc/A187327587/HRCA?u=googlescholar&
sid=googleScholar&xid=acd965b1. Accessed 13 Feb. 2023.

Gale Document Number: GALE|A187327587

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