|Year : 2018 | Volume
| Issue : 1 | Page : 26-31
Ayurvedic management of lumbar disc disease - A case report
Vaidya Yogesh Kumar Pandey, Neha Kaushik
Department of Kayachikitsa, Ch. Brahm Prakash Ayurved Charak Sansthan, New Delhi, India
|Date of Submission||28-Dec-2017|
|Date of Decision||20-Apr-2018|
|Date of Acceptance||04-Jan-2022|
|Date of Web Publication||08-Oct-2022|
Dr. Vaidya Yogesh Kumar Pandey
Department of Kayachikitsa, Ch. Brahm Prakash Ayurved Charak Sansthan, New Delhi
Source of Support: None, Conflict of Interest: None
Lumbar disc disease (LDD) is a common cause of chronic or recurrent low back and leg pain most likely to occur at the L4-L5 and L5-S1 levels. The pain may be located in the lower back only or may refer to the leg, buttocks, or hip. There is less improvement with modern medicines and recurrence due to surgical decompression. Various Ayurvedic drugs along with required pañcakarma procedures have been proved useful for these manifestations. We present a case of LDD (kaṭi asthi sandhi gata vᾱta) having acute severe lower back pain above left hip joint radiating towards the left thigh and calf muscle since 14 days. His visual analog scale (VAS) score was 10 when he arrived at the hospital. The case was treated for 3 months with a combination of ᾱyurvedic drugs and pañcakarma procedures. Ayurvedic treatments, in this case, were directed toward alleviating pain and to reduce disability to walk. The patient was considered suffering from kaṭi asthi sandhi gata vᾱta (vᾱtaj disorder involving lumbar region) and was given harītakī cῡrṇa 5 g with lukewarm water on the first night for vᾱtᾱnulomana. ekāṅgavīra rasa, punarnavādi maṇḍūra, rᾱsnᾱsaptaka kvᾱtha, balāriṣṭa, ajamodādi cūrṇa, orally have been given with saindhavādi taila for local application for 3 months. For śodhana cikitsā sarvāṅga abhyaṅga and sarvāṅga patra piṇḍa svedana (PPS), kaṭi basti with pañcaguṇa taila and kᾱla basti (nirῡha with rᾱsnᾱ eraṇḍādi kvᾱtha and anuvᾱsana with dhānvantaraṃ taila) for 16 days is given. Patient's condition was assessed for symptoms of kaṭi asthi sandhi gata vᾱta and VAS scale for pain, Fukushima lumbar spinal stenosis scale-25, and 6 min walking test before and after the treatment which showed substantial improvement. This study shows that the cases of lumbar disc disease which may be successfully managed with ayurvedic treatment.
Keywords: kaṭi asthi sandhi gata vāta, lumbar disk disease
|How to cite this article:|
Pandey VY, Kaushik N. Ayurvedic management of lumbar disc disease - A case report. Ancient Sci Life 2018;38:26-31
| Introduction|| |
Lumbar disc disease (LDD) is a common cause of chronic or recurrent low back and leg pain most likely to occur at the L4-L5 and L5-S1 levels with the symptoms include abnormal posture, limitation of spinal movements (particularly flexion), or radicular pain. The pain may be located in the lower back only or may refer to the leg, buttocks, or hip. A sneeze, cough, or trivial movement may cause the nucleus pulposus to prolapse pushing the frayed annulus posteriorly or may protrude through the annulus to lie as a free fragment in the spinal canal. Although inner annulus fibrosus and nucleus pulposus are normally devoid of innervation, the pro-inflammatory cytokines within the ruptured disc and ingrowths of nociceptive (pain) nerve fibers into an inner portion of diseased disc may be responsible for pain. Nerve root injury (radiculopathy) from disc herniation may be due to compression, inflammation, or both. According to the study of Global Burden of Disease 2010, it has been estimated that low back pain (LBP) is ranked highest in terms of disability (years lived with disability) and sixth in terms of overall burden (disability-adjusted life years). The global point prevalence of (LBP) is estimated to be 9.4%. It was higher in men compared to women. Prevalence peaked at around 80 years of age. There is no satisfactory improvement in symptoms with the modern medicines. The rate of recurrence is high with the surgical interventions. Therefore, there is a need of ayurvedic treatment to improve the quality of life hampered due to associated pain and to limit the further insult to spine. The condition of annular tear due to excessive physical stress (ᾱghᾱta) on the vertebral bodies (local asthi dhᾱtu) in any way (like wrong postures, long standing or sitting, or trauma) lead to tear of annulus fibrosus and release of pro inflammatory cytokines (vᾱta prakopa, i.e., vᾱta vṛddhi in kaṭigata asthi and sandhi due to dhātu kṣaya). The cytokines are akin to vāta doṣa. It produces symptoms of prakupita vᾱta in lumbar region (kaṭi pradeś) such as pᾱda bhraṃśa, pᾱda suptatᾱ, pṛṣṭhagraha, khañjatā, kubjatᾱ, vedanāyukta prasᾱraṇa (extension) and ᾱkuῆcana (flexion), asvapana (sleeplessness), satata ruk (continuous pain).
| Patients information|| |
- Demographic information– Patient 42-year-old Indian, married, nonsmoking, nonalcoholic male. Patient is a banker by profession. He consulted in Out-Patient Department of Ch. Brahm Prakash Ayurveda Charak Sansthana on 14 June 2017 for severe low back ache above left hip joint radiating towards the left thigh and calf muscle since 14 days
- Patient was asymptomatic until 30 May 2017 when during demonetization he had to sit continuously for 8–10 h a day; he developed pain in lower back
- There was no history of trauma.
Main concerns of patient – Patient arrived with acute severe pain in lower back region. The pain was present above the left hip joint radiating toward the left thigh and calf muscle from the last 14 days. He came assisted with the help of stick as he was unable to walk and stand due to pain. He could not perform his daily personal work. He had disturbed sleep due to painPatient has no significant medical, family and psychosocial historyPast interventions
- Patient took tablet Ultracet (tramadol hydrochloride 37.5 mg and acetaminophen 375 mg) and cap.myoril (thiocolchicoside 8 mg) for pain management
- He underwent physical therapies such as lumbar traction (details not available), (inter lumbar traction), (transcutaneous electrical nerve stimulation) for 5 days (June 7, 2017–June 13, 2017).
| Clinical Findings|| |
The patient had severe pain in lower back region mostly at the level above the left hip joint radiating towards the left thigh and calf muscle. The patient often experienced maximum pain and stiffness in lower back and left leg at the midnight on bed. The patient was unable to move himself at the time of pain. Pain used to aggravate after long duration of standing, lying straight, and by squatting. Pain diminished in sitting posture (vajrāsana/Diamond pose). There was no sensory deficit present. At the time of examination, patient was found to be anxious with pain. His posture was stooped and he had a limping gait.
- Blood pressure 130/90 mmHg
- Pulse rate-90/min
- Respiratory rate 20/min
He had a moderate appetite, krῡra koṣṭha (bowel hard to purgate) with normal micturition. The tongue was coated, the voice was clear. Patient had vᾱtakapha prakṛti with madhyama (medium) sᾱra (purest body tissue), madhyama saṃhanana (medium body built), sama pramᾱṇa (normal body proportion), madhyama sᾱtmya (homologation), madhyama satva (mental strength), avara vyᾱyᾱma śakti (least capability to carry on physical activities), madhyama āhāraśakti and jaraṇa śakti (medium food intake and digestive power).
| Locomotor Examination|| |
- Straight leg raising (SLR) in right is at 80° and in left leg it is positive at 30°
- Lasegue's test was negative bilaterally
- Muscle power and tone in lower limb were 3/5
- Hip joint movements were compromised due to pain
- Knee reflex and ankle reflex could not be elicited in the left leg but normal on the right side. No external physical abnormality was seen.
| Timeline|| |
a. Diagnostic methods-We used the following assessment tools for the assessment of disability and pain:
1. Visual Analogue Scale (VAS) (0–10)
2. Fukushima lumbar spinal stenosis scale (FLS-25) questionnaire
3. SLR test with Lasegue's test.
4. 6 min walking test
Magnetic resonance imaging (MRI) revealed broad-based posterior and foraminal disc bulge with posterior annular tear and postero-central disc protrusion at L5/S1 level and hypertrophy of ligamentum flavum causing thecal sac indentation producing a canal diameter of approx. 1.2 cm done on 06/6/2017.
b. Diagnostic reasoning-Symptoms such as asthiparva bheda (pain in articulating bones), sandhi śūla (pain in joints), māṃsa bala kṣaya (muscle atrophy and loss of muscle power), asvapna (disturbed sleep due to pain), satata ruk (continuous pain) are the characteristic features of vedanā(pain) caused by the vᾱta. The vᾱta doṣa is vitiated in kaṭi (lower back) and the structures surrounding it such as kaṭi gata asthi (lumbar vertebrae and lumbo sacral joint), snᾱyu (ligaments and tendons). Therefore, these symptoms of pain due to vᾱta doṣa along with symptoms of sandhigata vᾱta as prasāraṇa ākuñcanayoḥ vedanā (pain during flexion and extention of leg) and kubjatᾱ (forward bending) suggests the diagnosis kaṭi asthisandhigata vᾱta.
c. Differential diagnosis-Differential diagnosis includes sciatica and (osteoarthritis [OA]). Since the MRI reports show no vertebral deficit and osteophyte formation, therefore, OA is ruled out. MRI suggests disc bulge with posterior annular tear confirms the LDD (lumbar disc disease).
5. Therapeutic focus and assessment
- snehana (oleation), svedana (sudation), and mṛdu virecana (mild purgation) are the line of treatment in vᾱta vyᾱdhi. tikta basti is also indicated for bony pathology. At the beginning of treatment, the patient was constipated and appetite apparently reduced. In this case, mṛdu virecana with harītakī cῡrṇa was given in the dose of 5 g with Luke warm water for the first night. Oral Ayurvedic drugs ekāṅgavīra rasa 500 mg in two divided doses, punarnavādi maṇḍūra 750 mg in 3 divided doses, rᾱsnᾱsaptaka kvᾱtha 120 ml in 2 divided doses, saindhavᾱdi taila for L/A twice a day, triphalᾱguggulu 1 g in 2 divided doses, balāriṣṭa 15 ml twice a day with equal amount of water for 3 months. The patient was treated with patra piṇḍa svedana (sudation with medicated cooked leaves) for 16 days and kaṭi basti with pañcaguṇa taila for 16 days. kᾱla basti (enema with medicated decoction and oil for 16 days schedule) karma was given in which nirūha basti was given with rᾱsnᾱ eraṇḍādi kvᾱtha and anuvᾱsana with dhānvantaraṃ taila for 16 days. After completion of these pañcakarma procedures, we discharged the patient on June 30, 2017. At the time of discharge, there was significant relief in pain
- At time of discharge, VAS score reduced to 3, FLS-25 was 34 and the patient was able to walk 324 m without support. On examination SLR-Rt. +at 80°, Lt. + at 60°. During the treatment period, no analgesics were taken by the patient. The patient was advised to continue oral medications for the next 3 months along with the follow-up. During the treatment period, no analgesics were taken by the patient [Table 2] and [Table 3].
|Table 2: Ayurvedic management for the case of kaṭi asthi sandhi gata vᾱta|
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|Table 3: pañcakarma procedure for the management of kaṭi asthi sandhi gata vᾱta|
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6. Follow-up and outcomes
- The patient was re-examined for the pain, stiffness, and walking difficulty. After treatment patient was able to perform his daily work without any assistance. Constipation has also been subsided. Functional capacity and global condition of the patient were improved.
- [Table 4]
- Patient tolerated the interventions well. No adverse or anticipated event was noticed.
|Table 4: Before treatment and after treatment comparison of lumbar disc disease|
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| Discussion|| |
a. Strengths and limitations
This case got no relief with the allopathic oral medication and only short-term relief in pain could be achieved with physiotherapy. This case was effectively managed with oral ayurvedic medication and paṁckarma therapy.
-Patient came up with the acute pain which was effectively treated with in first few days and quality of life has been improved significantly.
-The case is still under follow-up therefore, long-term adverse effects of the treatment cannot be observed yet.
b. Medical literature
The radiological findings and the symptoms of the patient signifies that there is a vāta prakopa which may have occurred due to dhātu kṣaya. sthānasaṃśraya took place at the level of kaṭi gata asthi and sandhi (overuse or misuse of the lower back during long sitting of about 8–10 h continuous). Physical inactivity and bad dietary practices (adhyaśana, ajīrṇāśana) must have led to agnimāndya. It further caused āma avasthā, which lead to abhiṣyandana and srotāvarodha (heaviness in channels of nutritional circulation). As kapha is the main doṣa present in sandhi, accumulated vāta (apāna vāta and vyāna vāta) and kapha (śleṣaka kapha) causes continuous insult (alters the normal functioning) of the structures involved (kaṭi gata asthi and sandhi). śotha (swelling) develops simultaneously as result of release of inflammatory mediators). It further leads to vāta prakopa (sensitization of sensory afferent nociceptors to increase their frequency of firing for all stimulus intensities) producing symptoms of extreme pain, stiffness, restriction of movements.
c. Rationale for conclusion
Therefore, samprāpti vighaṭana revolves around three principles–
- To prevent sañcaya (accumulation) of doṣa.
- Pacifying sañcita (accumulated) and prakupita (aggravated) doṣa.
- Removing causes of kha vaiguṇya (favorable site of pathogenesis) at kaṭi region so as to prevent the recurrence of the disease
1. To prevent further doṣa sañcaya, agnimāndya and vāta should be managed. harītakī cūrṇa was given (5 g at night) for vātānulomana and to subside vibandha. rasa sindūra (component of ekāṅgavīra rasa), ajamodādi cūrṇa, punarnavādi maṇḍūra ignite the agni causing the pācana of āma i.e., digestion of non-metabolized or mal-metabolized products) lead to laghutᾱ (proficiency) in srotas (microchannels will get patent again). It results in the proper metabolism of food as well as the medications. Therefore, the process of doṣa sañcaya gradually decreases. These drugs also lead to the pācana of the sañcita doṣa (accumulated)
2. To pacify the prakupita doṣa drugs, which have been specifically mentioned to act on vāta, have been used along with kāla yoga of basti (best treatment for vāta vyādhi).
ekāṅgavīra rasa-It contains bhasma, which are āśukāri (quick acting) and pacify vāta and kapha. Its main action is on vātavāhinī nāḍī as it depresses the exaggerated impulses in the nerves. It contains kucalᾱ (Strychnos nuxvomica L.) and dhattūra (Datura metel L.) which are very effective pain relievers. It is also viṣaghna so it prevents secondary infections and inflammation at the lumbar region. Its balya (anabolic) and vājīkaraṇa (aphrodiastic) properties provide strength to weakened portion of the body.
punarnavādi maṇḍūra contain punarnavᾱ (Boerhavia diffusa L. nom. cons), gokṣura (Tribulus terrestris L.) which have maṇḍūra rasa and vāta kapha hara properties. It is well-known śothahara drug. Both of them are rasāyana and they act at dhātu level to heal and nourish them thus, reducing inflammation (śotha)
nirūha with rāsnā eraṇḍādi kvātha which contain eraṇḍa (Ricinus communis L.) (vṛṣya vᾱta harᾱnᾱma) and rᾱsnᾱ (Pluchea lanceolata Cass.) pacifies vᾱta. anuvᾱsana with dhānvantaraṃ taila serves the purpose of bṛṃhaṇa (nourishment of tissue factors).
patra piṇḍa svedana (PPS) made of vᾱtahara dravya and sarvāṅga abhyaṅga with saindhavᾱdi taila contains lavaṇa (saindhava, sauvarcala, viḍa). When applied locally it increases the permeability of the skin and provides passage. It reduces the pain, muscle spasm, and swelling.
kaṭi basti subsides the inflammation of ligaments and tissues connected to the lumbar vertebras.
3. To achieve the third objective of maintaining samāvasthā of doṣa at kaṭi (lumbar) region:
balāriṣṭa contain balᾱ (Sida Cordiafolia L.) and aśvagandhā (Withania Somnifera L.) which provide nutrition to the to the dhᾱtus (specially asthi) and strength to the surrounding connective tissues of the vertebral column hence it relieves direct stress of spinal cord. aśvagandhā and balᾱ are known analgesic herbal drugs.
triphalā guggulu contain triphalᾱ (ᾱmalakῑ, vibhῑtaki, harītakī) and is used for vᾱtᾱnulomana (easy passage of flatus) and vibandha hara (relieving constipation). It ignites agni. It has rasᾱyana properties (provide nourishment at the level of agni, dhātu and manages the doṣa and mala). guggulu (Commifora Mukul) will pacifies vᾱta and improve the microcirculation. It is effective therapeutic agent for vᾱta (various tendon and ligament disorders), asthigatavᾱta (disorders of bone), majjagatavᾱta (disorders of bone marrow), khañjavᾱta (limping disorders), and various other vᾱta disorders (neurological, rheumatic, and musculoskeletal diseases). Hence, triphalᾱ guggulu has been given during follow-up period to maintain the state of equilibrium of bodily humors and prevent the reversal of the pathogenesis.
rāsnā saptaka kvātha which contains rᾱsna and eraṇḍawill alleviate pain. This treatment along with some lifestyle modifications improved the symptoms of pain, stiffness, and restricted movements considerably.
At present, the patient is under continuous observation and oral treatment. There is no worsening of any symptoms and sign until September 23, 2017. The quality of life of the patient has improved. This is an important finding considering the prognosis and unsatisfactory treatment in modern medicine.
d. Take away lesson
The ayurvedic drugs combined with pañcakarma procedures found very effective in treating the patient with lumbar disc disease. The treatment has considerably improved the quality of life of the patient. There were no side effects noticed during treatment and even during the follow-up period.
The patient was satisfied with the treatment and was able to walk without any aid, stiffness was reduced in the lower back.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Written permission for publication of this case study had been obtained from the patient.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]