|Year : 2014 | Volume
| Issue : 1 | Page : 53-56
Ayurvedic management of postlumbar myelomeningocele surgery: A case study
Savita Butali1, Annapurna R Patil1, MD Aziz Arbar1, MD Veena Tonne2
1 Department of Kaumarbhritya, KLEU's Shri BMK Ayurveda Mahavidyalaya, Shahapur, Belgaum, India
2 KLEU's Shri BMK Ayurveda Mahavidyalaya, Shahapur, India
|Date of Web Publication||4-Feb-2015|
KLEU's Shri BM Kankanawadi Ayurveda Mahvidyalaya, Shahpur, Belgaum - 590 002, Karnataka
Source of Support: None, Conflict of Interest: None
A 11-year-old male child presented with the complaints of urinary incontinence, passing hard stools associated with weakness in lower limbs, deformity of feet, reduced sensation below ankle joint since he was 5 years of age as noticed by parents. The clinical features were seen as postlumbar myelomeningocele surgery and child had congenital talipus equinovarus. For this, he was administered anulomana, sarvāṅga abhyaṅga (oleation / massage), saṅgraha cikitsā, avagāha sveda (sudation) and matrā basti (type of oleaginous enema). After the treatment, child was able to get control over his bladder, he started feeling sense the fullness of the bladder, there was a desire to void urine and a reduction in a number of voids in daytime and a reduced degree of wetness
Keywords: Anyonyāvaraṇa, apānāvṛtavāta, lumbar myelomeningocele, sangrahi cikitsā
|How to cite this article:|
Butali S, Patil AR, Aziz Arbar M D, Veena Tonne M D. Ayurvedic management of postlumbar myelomeningocele surgery: A case study. Ancient Sci Life 2014;34:53-6
| Introduction|| |
Neural tube defects (NTDs) account for most of the congenital anomalies of the central nervous system, resulting from failure of the neural tube to close spontaneously between the 3 rd and 4 th week of in-utero development. Myelomeningocele (MMC) accounts for most serious forms among them. This is a condition in which there is herniation of the spinal cord and membranes through a defect in the spinal cord. Incidence of MMC is approximately 1/4000 live births.  MMC has been described even in the times of Hippocrates and Aristotle, who even recommended killing of the children having such defects. 
The etiology of this disease is unknown in 95% of cases. There may be genetic causes, in that, a previous child born NTD and parental consanguinity tends to increase incidence. Environmental causes include folic acid deficiency during the first trimester, use of teratogenic drugs such as valproate, carbamazepine. We also observe a higher prevalence in lower socioeconomic groups. MMC is associated with neural elements as also the meninges. Majority of defects occur in the lumbosacral area. Neurological deficits distal to a defect are most severe.
Clinical features and tridoṣa diagnosis
Location: Spine but commonly lumbosacral (75%) region is involved. Fluid filled swelling at the back, flaccid paralysis of the lower extremities, absence of deep tendon reflexes, lack of response to touch and pain, high incidence of postural abnormalities of the lower extremities (e.g., clubfeet and subluxation of the hips). Constant urinary dribbling, relaxed anal sphincter may be evident. 
Among tridoṣa, vāta doṣa plays an important role both in physiological and pathological actions in its normal and aggravated conditions.  Apānavāyu circulates below the umbilicus and is located at about the region of the bladder, performing the functions of absorbing nutrients from digested food and eliminating the waste products from the body via purīṣa (stool) and mūtra (urine). Vyānavāyu circulates throughout the body and is functional in the entire body including all indriyas.  In āvaraṇa (obstruction episodes), the doṣa that obstructs is aggravated and the one that is obstructed is said to be innocent (pure normal). Based on this, the signs and symptoms in MMC can be correlated with apānāvṛtavyānavāta (where one doṣa is obstructed by other doṣa ). These symptoms may develop due to pūrīṣāvṛtavāta.  Therefore to release apānavāyu, anulomana cikitsā followed by saṅgraha cikitsā is administered.
| Case report|| |
An 11 years old, moderately built male child presented with urine incontinence. He also had the problem of passing hard stools associated with weakness in both of the lower limbs. He was born with a lumbar MMC, which was pea sized at the time of birth which had gradually increased in size. The complaints were present ever since he got operated for lumbar MMC at the age of 6 months with a nearby doctor.
Family history: No significant history.
Ante-natal history: Mother was healthy, no exposure to radiations or other medications.
Birth history: Full term, type of delivery: Lower segment caesarean section, birth weight was not known.
Obstetric history: Gravida 4, para 4, live 3 abortion 0. G1-male - died within a week after birth, reasons not known. G2-15 years female - normal. G3-13 years female - normal. G4-present child.
Developmental history: Gross motor: Delay in walking; Fine motor: social and language milestone attained at appropriate age.
Personal history: Vegetarian diet, good appetite, sound sleep, reduced activity, incontinent bowel.
O/E: Gait: Limping, clubbing of feet present (TEV). DTR: Absent in lower limbs, lack of response to touch and pain at feet.
Respiratory and cardiovascular system examinations were normal.
Prakṛti: vātapittaja vikṛti
Vāta: apāna vāta, vyāna vāta
Vyāyāma śakti: alpa
Āhāra Śakti: madhyama
Pramāṇa: 17 kg.
Koṣṭha śodhana with Gandharva hastādi tailam (10 ml + 15 ml milk) for 1 day.
Sarvāṅga abhyaṅga with Balāśvagandhā tailam for 7 days.
Śaṣṭika śāli piṇḍa sveda for 7 days.
Matrā basti: Śuddhabalatailam (40 ml)for 8 days.
Physiotherapy: Bladder facilitation technique, B/L foot mobilization, pelvic floor strengthening exercises for 7 days.
Naturopathy: Spinal massage with prasariṇītailam, alternate leg raising exercise for 7 days.
āsana and bandha: Bhujaṅgāsana and Mūlabandha (contraction and relaxation of anus) for 7 days.
Mātrā basti retention time increased to 30 min
Ability to control urine increased and can sense the fullness of the bladder.
The number of voids in day and night and degree of wetness has reduced.
| Results|| |
On the day of admission, child was unable to control bladder and retention of mātrā basti was very minimal. After the treatment, gradually he was able retain the mātrā basti for 30 min. This signifies improvement in bladder and anal sphincter strength. There was also increased range of movement of both ankles.
The patient discharged with following medications.
Śuṇṭhi kaṣāya 10 ml bd. śilājit 250 g twice a day, Bilva Avaleha 2 tsf twice a day for 1 month.
Sarvāṅga abhyaṅga with Balāśvagandhātaila. Avagāha sveda with daśamūla kaṣāya. Mātrā basti with śuddhabalataila 40 ml for 1 month.
Outcome and follow-up
During follow-up, after 1 month the child presented with significant improvement by subjective assessment and second course of anulomanacikitsā, sarvāṅga abhyaṅga (massage), avgāhasveda and mātrā basti (oleaginous enema) was administered.
| Discussion|| |
The extent and degree of the neurologic deficit in MMC depend on its location. If the damaged spinal cord is covered, survival is assured but leaves the patient vulnerable to pressure ulcers on anesthetic areas of the body, as also to neurogenic bladder and deformities of the wasted, paralyzed limbs. A lesion in the low sacral region causes bowel and bladder incontinence associated with anesthesia in the perineal area but with no impairment of motor function. For aggressively treated children, the mortality rate is approximately 10-15%. Most deaths occur before age 4 years, at least 70% of survivors have normal intelligence but have learning problems, seizure disorders and suffer from long term effects. As MMC is a chronic handicapping condition, periodic multidisciplinary follow-up is required for life. 
Constipation and overactive bladder are two conditions that illustrate the relationship between the bowel and the bladder. The complex physiology of urologic and gastrointestinal function is interrelated and this has implications for the management of disorders affecting both organ systems. Convergent dorsal root ganglia neurons receiving sensory input from multiple pelvic organs have been identified in the colon, bladder, and reproductive organs. Cross-sensitization between neural pathways in the pelvic organs is necessary for the routine mediation of bladder, bowel, and sexual function. This crosstalk, however, also provides a pathway for abnormal function of these organs, with the potential for dysfunction of one pelvic organ leading to functional changes in another. 
There is no direct reference to MMC in ayurveda, but considering the manifestations of disease, it can be considered as vāta-pradoṣajavikāra. More related to apāna and vyānavāta. The function of apānavāta, is to lead downwards, and vyānavāta should be spread out in all the directions.  Vyānavāta āvaraṇa (covering) by apānavāta, produces excessive discharge of urine.  In the discussion of paρcavātāvaraṇa (occlusion) dīpana (digestive stimulation) and grāhicikitsā have been prescribed for apānavāta which gets obstructed by vyāna vāta. For purīṣāvṛtavāta (vāta doṣa obstructed by purīṣa) eraṇḍataila (castor oil) and udavartaharacikitsā is mentioned.  Hence, on the day of admission, for anulomana was done using Gandharvahastādi tailam (rasa madhura, anurasa kaṭu, kaṣāya, uṣṇa vīrya, madhuravipāka)  along with milk. Starting the second day we administered sarvāṅga abhyaṅga (massage) with Balāśvagandhātaila (ingredients: Balā [Sida cordifolia], āśvagandhā [Withania somnifera], rāsnā [Pluchea lanceolata]), dadhimastu is as the taila (oil) is vātashāmaka (reduces vitiated vāta doṣa) and balya (gives strength). Mātrā basti with śuddhabalātailam (ingredients: balā [S cordifolia] guḍūci [Tinospora cordifolia] rāsnā [pluchea lanceolata] dadhimastu etc.) because thistailam is a vātashāmaka (reduces vitiated vāta doṣa). Mātrā basti is a type of Anuvāsana basti (oleaginous enema). The classics say that this type of Basti (enema) can be given to almost everybody, in all the seasons and it is Niṣparihārya, i.e. is can be given with maximum ease and has no complication thereafter. Mātrā basti was administered here to enhance the tonocity of anal sphincter muscle. Sneha (oil) used in basti softens the mala (feces) to pass easily without any discomfort. Physiotherapy exercises help in pelvic floor strengthening, foot mobilization, and bladder control. Nature care, spinal massage with light pressure relieves tension of the nerves and soothes them. Bhujaṅgāsana helps to strengthen the abdominal and pelvic muscles. Mūlabandha (sphincter relaxation and tightening techniques) enhances the sphincter reflex and controls apānavāta.
The follwing medicines were prescribed at the time of discharge:
Bilvāvaleha contains bilva (Aegle marmelos) and guḍa (jaggery) for saṅgrahaṇa action which helps control incontinence. This was prescribed ot be taken on alternate days (at bed time) as there was constipation as a chief complaint. Its main ingredient bilva (Aegle marmelos) being madhura, tikta rasa, śītavīrya, kaṭuvipāka) grāhī . For dīpana śuṇṭhi (Zingiber officinalis) kaṣāya (rasa kaṭu, madhuravipāka, uṣṇavīrya) and avagāha sveda (tub bath) with daśamūla (roots of 10 drugs altogether) kaṣāya (decoction) (madhura , tikta , kaṣāya rasa) was prescribed. Avagāha sveda is prescribed for trimarmīyacikitsā (for 3 vital organs) among the three, basti (bladder) and guda (anal region) were treated here. Avagāha sveda (tub bath) is also mentioned in the context of vātavyādhicikitsā. Sensations arising from the bladder induce combined activation of sympathetic skin responses and pelvic floor activity. This coherence indicates synchronized activation and inactivation of the autonomic and somatic pathways necessary for appropriate urine storage and coordinated voiding. Śilājit (Asphaltum punjabianum) capsule was prescribed for its balya (strength-giving), yogavāhi (catalytic) and rasāyana (rejuvenator) properties.  Mātrā basti (type of oleaginous enema) was prescribed to be continued at home for 10 days daily and subsequently with a gap of 10 days for 1 month.
At the end of treatment, child had the ability of initial bladder filling sensation, and strong desire to void the urine, reduced degree of wetness and reduction in a number of voids in daytime.
Take home message
The patients affected with NTDs are generally young children. The treatment (internal and external) cannot cure the cause but the quality of life can be improved, and dependency is minimized. Thephysical disability is minimized and health and well-being are improved. Hence, early recognition and inference is essential.
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