management of post operative complications in meningomyelocele

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
Parul et al.
World Journal of Pharmacy and Pharmaceutical Sciences
SJIF Impact Factor 2.786
Volume 4, Issue 04, 1207-1212.
Case Report
ISSN 2278 – 4357
MANAGEMENT OF POST OPERATIVE COMPLICATIONS IN
MENINGOMYELOCELE THROUGH PANCHKARMA
Dr. Parul Sharma1*, Dr. Ved Bhushan Sharna2
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
Article Received on
26 Jan 2015,
Meningomyelocele is a congenital defect occurs because the caudal
Revised on 19 Feb 2015,
Accepted on 15 March 2015
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
*Correspondence for
nervous system to outside environment, infection is a common
Author
Dr. Parul Sharma
complication.
Near Durga Mandir,
disturbance in bladder and bowel control. The treatment is surgery to
Opposite Jamuna Palace,
excise the redundant membranes. Repeated orthopaedic & urological
Vikas Colony, Haridwar,
Uttarakhand, India.
Other
major
manifestation
includes
paraplegia,
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]
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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 examinationCNSMotor 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 –
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Sensation - diminished in B/L lower limbs
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Investigation-(done previously)
NCV Study – Normal conduction parameter
99 m TC – 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 L5-S1 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 typesRasakrita 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 2nd 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.
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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
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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
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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, 3rd 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, part1,13th edition, 2002, Chaukhambha
publications, Delhi, verse Su.Su.24/6, page 100.
6. Sushrut , Ambika dutta Shastri, Sushrut samhita, part1,13th 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, 13th 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.
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