WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Parul et al. SJIF Impact Factor 2.786 Volume 4, Issue 04, 1207-1212. Case Report ISSN 2278 4357 Article Received on 26 Jan 2015, Revised on 19 Feb 2015, Accepted on 15 March 2015 *Correspondence for Author Dr. Parul Sharma Near Durga Mandir, Opposite Jamuna Palace, Vikas Colony, Haridwar, Uttarakhand, India. MANAGEMENT OF POST OPERATIVE COMPLICATIONS IN MENINGOMYELOCELE THROUGH PANCHKARMA Dr. Parul Sharma 1*, Dr. Ved Bhushan Sharna 2 1 M.D.(Ay.) Panchkarma, Medical Oficer, Deptt. of Panchkarma, Rishikul Govt. P.G. Ayurveda College, Haridwar, Uttarakhand, India. 2 M.D.(Ay.) Ras shastra & Bhaisajya kalpana, Medical officer, deptt. of Agad tantra, Rishikul Govt. P.G. Ayurveda College, Haridwar, Uttarakhand, India. ABSTRACT Meningomyelocele is a congenital defect occurs because the caudal neural tube fails to close properly. It is characterized by herniation of spinal meninges and spinal cord through a posterior vertebral defect to form a cyst like pouch. Because such lesion exposes the central nervous system to outside environment, infection is a common complication. Other major manifestation includes paraplegia, disturbance in bladder and bowel control. The treatment is surgery to excise the redundant membranes. Repeated orthopaedic & urological surgeries are necessary to rectify the orthopaedic defect and urinary incontinence. Here a female patient of neurogenic bowel and bladder with weakness in lower limbs (complication of operated meningomyelocele) is treated with Ayurvedic measurements. As the symptoms reveals the involvement of Vata, so the treatment to disintegrate the pathology of vitiated Vata is planned for the patient. She is treated with Abhyang, Swedan, Awagahan, Parisheka and Basti. And the patient gained much relief in her signs and symptoms. KEYWORDS: Meningomyelocele, Paraplegia, Neurogenic Bowel and Bladder, Swedan, Parisheka, Basti. INTRODUCTION Spina bifida is a congenital defect in the posterior bony wall of spinal canal involving the laminae, commonly seen in lumbosacral region. [1] The content of canal protrude through the defect. Its incidence is 0.1%. The types of spina bifida are. [2] www.wjpps.com Vol 4, Issue 04, 2015. 1207
1. Spina bifida occulta No protrusion of the cord or membranes. 2. Meningocele Protrusion of meninges only. 3. Meningomyelocele Protrusion of spinal cord alongwith the meninges. 4. Syringomyelocele Protrusion of spinal cord with peripheral nerves. 5. Myelocele Besides bony defect, the spinal cord is not developed. Meningomyelocele is a condition in which the normally developed spinal cord ( cauda equina) is protruded alongwith the meninges and these structures may be adherent to posterior aspect of the sac. [3] It is associated with infection, rupture, paralysis of lower extremities, urinary incontinence, disturbed bowel control and the absence of reflexes. It can be diagnosed prenatally through amniocentesis, sonography and mother s blood test for elevated levels of maternal alpha fetoprotein (AFP). The treatment includes surgery. But the neurogenic bowel/bladder and paraplegia remains unchanged. Here a female patient of operated meningomyelocele came to Ayurvedic hospital for the further management of residual paraparasis and neurogenic bladder/bowel complaints. CASE REPORT A female patient of age 20 years with complaints of paraparesis, bladder & bowel disturbance due to having meningomyelocele at birth. Although she operated 3 times for it, but she has not recovered with the residual complications. She was not able to micturate and defecate by herself. She used to do catheterization for removal of urine every 3 hourly and manual removal of stool. She did not feel the urge of defecation, and the rectum had not the ability to be empty by itself. She used to get urinary tract infection too. On examination, G.C. - Average General examination- NAD Systemic examination- CNS- Motor system- Muscle wasting present in B/L lower limbs Muscle tone Flaccidity in B/L lower limbs Muscle strength- 3/5 in B/L lower limbs Reflexes- diminished in B/L lower limbs Sensory system Sensation - diminished in B/L lower limbs www.wjpps.com Vol 4, Issue 04, 2015. 1208
Investigation-(done previously) NCV Study Normal conduction parameter 99 m T C GHA Dyanamic and spect study- Overall normal renal function status. Excretion from both kidneys is delayed. M.R.I. (L-S Spine)- Lipomeningomyelocele with tethered cord L 5 -S 1 level. Pathogenesis This disease comes under Adibala pravritta roga, occurring due to unwholesome food and regimen by pregnant woman, also known as congenital deformity. It is of two types- Rasakrita and dauhridya avamanana (not fulfilling the desire of pregnant woman). It can be co-related with Pangu (Paraplegia). The treatment advised for that is virechana, asthapan basti, swedan, use of guggulu, and sneha basti. [4] Treatment The patient was planned for panchkarma therapy for 2 weeks. In Ist week, the treatment given was Kati basti with bala oil for 8 days Parisheka (sarvang dhara) with decoction of Rasna, Dashmula and Erand balamula with prior Sarvang Abhyang for 8 days In 2 nd week, the treatment planned was Kati basti with bala oil for 8 days Sarvang Patra Pottali sweda for 8 days Yoga basti with 5 Matra Basti and 3 Asthapan basti each on alternate day. Matra Basti is given with Erand oil(castor oil)- 50 ml. The constituents of Asthapan basti were Honey 60 ml Saindhav salt- 5 gm Castor oil- 80 ml Mustaka Punarnavadi kalka 20 gm Erand mula kwath 250 ml The matra basti was given just after taking light meal, and the Asthapan basti was given empty stomach when prior taken food is digested. www.wjpps.com Vol 4, Issue 04, 2015. 1209
TREATMENT IN FIRST WEEK Kati basti Sarvang Abhyang Parisheka (sarvang dhara) with decoction TREATMENT IN SECOND WEEK Kati basti Sarvang Patra Pottali sweda Yoga basti with Matra Basti and Asthapan basti RESULT After completion of therapy in first week, the improvement noticed was that the patient was able to feel the urge of micturation and defecation. The patient can judge the time to go to washroom. But the self urination and defecation was yet not attained. She has to do manual evacuation for stool and catheterization for urine. In next sitting of treatment, the patient was able to pass stool spontaneously without much effort, with no need of manual extraction. It was the first miracle in her life span that she felt the urge of defecation with natural expulsion of waste product by body itself. The sensation in lower limbs was improved. Besides it, she got lightness in body and good psychology. She was discharged with some shaman medicines as Punarnavadi and varunshigru kwath- 50 ml twice daily empty stomach. aswagandha churn- 2 gm twice daily with milk Trayodasang guggulu- 250 mg twice daily with lukewarm water. Haritaki churn 3 gm at bed time with lukewarm water. The patient called for review after 3 months. In next visit after 3 months the patient was much improved in her signs and symptoms. She was again given the same panchkarma therapy for 16 days. Pathya-apathya- The patient was advised to take light meals, liquid or semisolid diet and lots of water per day. She should avoid heavy and oily food, carbonated drinks and non veg. diet. DISCUSSION Probable Etiopathogenesis & Line of treatment Due to injudicious food & regimen or not fulfilling the desire of pregnant mother, there is vitiation of doshas leading to congenital defect in newborn. [5] It is also proved by the fact that the diet lacking in Folic acid can lead to impairment of development of spinal cord. The vitiated vata in the Kati region contract the vessels, muscles, and tendons of thighs resulting in panguta. [6] Associated features are bladder and bowel dysfunction, recurrent www.wjpps.com Vol 4, Issue 04, 2015. 1210
U.T.I. etc. As all the complications are the features occurring due to vitiated vata, so the treatment given is that of Vata chikitsa upkrama. As the line of treatment of pangulya( paraplegia) is virechana, asthapan, swedan, use of guggulu, and sneha basti. So here Abhyang, swedan with Kati basti, patra-pottali or parisheka, matra & asthapan basti were given. Mode of action of treatment given In first half of treatment, the Kati basti and Abhyang with bala oil helps to provide the nourishment at the level of lesion of cystic swelling. For the vitiated vata, the oil is best for treating it. [7] It also control the vitiation of vata, soften the body and removes the obstruction of waste products. [8] The swedan helps to removes throbbing pain, anga-graha, stiffness, inflammation and soften the body. [9] it stimulate the nerve endings and rejuvenate them for their sensory and motor activity. Thus help in improving the weakness of lower limb. The Basti is the chief therapy for vitiated vata. [10] Basti not only removes the obstruction in channels but also control the normal movement of excretory waste by making apan vayu in equilibrium. The Basti helps in excretion of mala, pitta, kapha, vayu and mutra, strengthing the body, and curing all the diseases. [11] The principle seat of vata is pakwashaya. The active principle of given basti reaches to whole body through micro-channels just as water irrigated in root circulate in whole plant. [12] It could be proved by the fact that besides local action it exerts more systemic action probably influencing Autonomic nervous system through Enteric nervous system around Gut.(Gut Brain theory). [13] The shaman medicines like punarnava and varunashigru kwath is beneficial in mutragata roga, they help in curing urinary tract infection by diuretic action. The ashwgandha is balya and nervine tonic so strengthen the lower limb and boost the nervous system. Trayodasang guggulu is potent vata shamak. Haritaki churn acts as vata-anuloman and mild laxative so removes vibandh(constipation) CONCLUSION Meningomyelocele is a type of birth defect in which the spinal canal and the backbone don t close before birth. The spinal cord and the meninges may actually protrude through the back. The affected body parts are specifically the legs, bladder and bowel. The surgery is essential as exposed membranes can cause infection like meningitis. The other complications like weakness in lower limbs, disturbed bowel and bladder control can be managed by following www.wjpps.com Vol 4, Issue 04, 2015. 1211
the line of treatment of vitiated vata i.e. snehan swedan, basti, and use of guggulu etc. The disease can be prevented by proper intake of folic acid supplements during pregnancy. REFERENCES 1. Somen Das, A concise text book of surgery, 3 rd edition, Calutta, Dr. S.Das, year 2001,page no.-503. 2. Ibid 1, page no. 503. 3. Ibid 1, page no. 505. 4. Bhavamishra, Bhavaprakasha, Chaukhambha Sanskrit Sansthan, Varanasi, U.P. India, 1972, Madhyam khand, verse no. 24/152. 5. Sushrut, Ambika dutta Shastri, Sushrut samhita, part1,13 th edition, 2002, Chaukhambha publications, Delhi, verse Su.Su.24/6, page 100. 6. Sushrut, Ambika dutta Shastri, Sushrut samhita, part1,13 th edition, 2002, Chaukhambha publications, Delhi, verse Su.Ni. 1/77, page 235. 7. Agnivesha, Charak, Dridhbala, Charak Samhita, 2004 edition, Chaukhambha Bharati Academy, Varanasi, verse no. Ch.Chi. 28/180, Page-807. 8. Agnivesha, Charak, Dridhbala, Charak Samhita, 2004 edition, Chaukhambha Bharati Academy, Varanasi, verse no. Ch.Si. 1/7 page-960. 9. Ibid 6 verse no. Ch.Chi. 28/80, Page-791. 10. Ibid 7 verse no. Ch.Si. 1/39 page-971. 11. Ibid 7 verse no. Ch. Si. 1/28 page no. 969. 12. Sushrut, Ambika dutta Shastri, Sushrut samhita, part1, 13 th edition, 2002, Chaukhambha publications, Delhi, verse Su.Chi. 35/25, page 155. 13. Prof. R.H. Singh, Panchkarma therapy, 2007 edition, Chaukhambha Krishanadas academy publishers, Varanasi. www.wjpps.com Vol 4, Issue 04, 2015. 1212