Post Lumbar Myelomeningocele Surgery: Ayurvedic Management

* Dr. Anvar A.M.  Chief Physician & CMDPunarnava Ayurveda Hospital Pvt. Ltd. Kochi, Kerala, India.

A 5 year 2 months old male child approached us with complaints of weak bilateral lower limbs, inability to walk independently, neurogenic bowel and bladder, paraparesis of both lower limbs, reduced sensation below both hip joints. The parents noticed the above complaints since the child was 2 years. The clinical features were seen as post lumbar myelomeningocele surgery and child had congenital hydrocephalus. In response to these complaints, the patient was administered with  Rooksha swedam (dry potali), Mild udwarthanam (powder massage), Ksheeradhaara(medicated milk therapy), Abhyangam (oil massage), Avagaham, Siropichu,Spinepichu, Matravasti, Elakizhi, Njavarakizhi, Sirovasthi, Mamsakizhi. After the treatment, the child was able to walk independently, gait and posture showed improvement and the patient was more stable with 75% improvement in sensory reception.

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

Etiology and Description

Myelomeningocele is a hernial protrusion of the spinal cord and its covering membranes (meninges) through a congenital defect in the bone of the spine (spina bifida). The meningomyelocele forms a swelling under the skin and the condition is usually associated with a severe neurological disturbance with loss of function in the legs and bladder. Folic acid taken just before, and during the first few weeks of, pregnancy can eliminate this disaster

Case report

History-The patient approached a hospital in Oman with severe complaints of persistent vomiting since day one with no diarrhea and fever. He has done Repair of L-S meningomyeloecele with hydrocephalus on 15/10/2011 and right-sided VP shunt insertion on 29/10/2011. Flap covers in the lumbar region on 12/11/2016. Gradually his condition improved after intensive multi-disciplinary rehabilitation treatments. As per the discharge summary from the hospital the condition of the patient was Congenital myelmeningocoele associated with anal incompetence, deformed feet, knees hyperextended, hips hyperflexed, paraparesis of lower-limbs and closure of Spina bifida defect done on the 3rd day as per the history of the reports. The mother did not take folic acid before or during pregnancy and the child was born term with apgar 9 and 10 at 1 and 5 minutes respectively. There was leaking meningmyelocele with hip flexion and internal rotation and bilateral ankle planter flextion, HC -33.5 cm, moving upperlimb well and was kept on cefotaxime, cloacillin and gentamycin.

Presenting complaints

After 4 days prior to his surgery in Oman he was admitted to our hospital for complaints of weakness of bilateral lower limbs. He was unable to walk independently, and experienced neuropathic bowel and bladder and paraparesis of both lower limbs.

Dosha Dominance and Diagnosis

As the case was congenital type and if a child is born with myelomeningocele, future children in that family have a higher risk than the general population exists. Majjagata sroto dushti was considered and as the site of the lesion is kunkundara  marram (Lumbo sacral area) vata vyadhi in kukundara marma  line of management was adopted.

Family history: No significant history.

Ante-natal history: Mother was healthy, no exposure to radiations or other medications except mother did not took folic acid before or during pregnancy.

Birth history: Full term, type of delivery: Lower segment caesarean section, Apgar 9 and 10 at 1 and 5 minutes respectively, birth weight is not recorded in the reports.

Obstetric history: 32 year old mother G6P3A2

Developmental history: Gross motor: Delay in walking; Fine motor: social and language milestone attained at appropriate age.

Personal history: Non-vegetarian diet, good appetite, sound sleep, reduced activity, incontinent bowel.

Micturition: Incontinent.

Systemic examination

Patient was conscious and oriented. On examination his vitals were normal. All hematological and biochemical blood parameters were within normal limit except Vit D insufficiency, Vit.D3-15.32ng/ml,Serum ASO Titre-618 IU/MIL,Serum Uric Acid:3.3mg/dl

CVS-S1 S2 heard, BP: 120/80mm of Hg, Pulse rate: 111/minute, Saturation 98%,Wt-15 kg,O/E: Conscious, Oriented, Chest – Clear NVBS.Hip flexion, extension, abduction, adduction (2/5), Knee –Flexion ,extention (2/5)  .Both ankle- Plantar flexion(0/5), Dorsiflexion(1/5) .

O/E: Gait: Limping, Lack of response to touch and pain at hips and feet.

Respiratory and cardiovascular system examinations were normal.

USG revealed Mild left hydronephrosis,normal posterior urethra.

Therapeutic focus and assessment

Within a period of five years he underwent treatments in 3 hospitals. Master Al Khalili Ghasun Hamood Salim Hamood, 5yr 2 months old  male patient, was treated as a case of Majja vaha sroto dushti and vatavyadhi in kukundara marma in Punarnava Ayurveda Hospital, and subjected to both internal and external treatments along with physiotherapy and rehabilitation. The treatments done were Rooksha swedam, Mild udwarthanam, Ksheeradhaara, Abhyangam, Avagaham, Siropichu, Spinepichu, Matravasti, Elakizhi, Njavarakizhi, Sirovasthi, Mamsakizhi.

Assessment

Sl.no Course of improvement
Day 1 Moves mostly on buttocks by dragging legs, VP Shunt in situ, Flat foot, Foot Drop, Hip flexion, extension, abduction, adduction (2/5), Knee –Flexion ,extention (2/5). Both ankle-plantar flexion(0/5), dorsiflexion(1/5), diminished sensation over lower limbs.
D 1-3 Can move with holding furniture sideways by waving the hip, mild improvement in muscle tone
D 4-6 Muscle power slightly improved, matra vasti held for only 1 minute
D 7-9 Marked change in muscle spasm, CP Standing frame training started.
D 10-13 Buckling of knee mildly reduced, ankle foot othotics and  parallel bar walking started
D 14-16 Walking easily with support in parallel bars.
D 23-25 Standing with self-support, trunk balance improved
D 29-31 Walking in treadmill with maximum speed of more than 20 minutes
D 35-40 Muscle bulk improved, Joint mobility improved, walking with support, muscle power improved
D 41-43 Started walking independently upto 10 steps, gait improved, posture improved
                         Second Course in 2017
Day 1 Walking independently since 9 months, bowel bladder incontinence
D 2-D15 Follow up treatments made the patient more stable.75%  improvement in sensory reception.

Results

On the day of admission, child was unable to walk independently with Neuropathic bowel and bladder. After the treatment, the patient was admitted and evaluated and was given tridoshahara line of management with supportive therapies. He was discharged after 41 days of 1st session and 18 days of second session as he was evaluated to be stable with his condition and was advised for further follow-up. At the time  of discharge, weakness of both lower limbs reduced. Muscle power, bulk and strength of lower limbs increased. Joint motion, trunk balance and posture improved. Slight increase in the muscle tone was noted. He was able to stand without support for few minutes. Gait improved. He was able to walk without support up to 10 steps . Both lower limbs- Hip flexion, extension, abduction, adduction (3/5), Knee –Flexion, extension (3/5). Both ankle-plantar flexion(1/5), Dorsiflexion(2/5). He was able to walk on treadmill with minimum speed for more than 20 minutes. Could maintain upright kneeling position. After the first session the patient was seen walking independently and the follow up treatments made the patient more stable with 75% improvement in sensory reception

Discussion

Neural tube defects (NTDs) accounted for most of the congenital anomalies of the central nervous system, resulting from failure of the neural tube to close spontaneously between the 3rd and 4th week of in-utero development. Myelomeningocele accounts for most serious forms among them. MMC has been described even in the times of Hippocrates and Aristotle, who even recommended killing of the children having such defects. 5 Abnormal function of these organs, with the potential for dysfunction of one pelvic organ leading to functional changes in another can be attributed to Convergent dorsal root ganglia neurons receiving sensory input from multiple pelvic organs which has been identified in the colon, bladder, and reproductive organs..6Among tridoṣa, vāta doṣa plays an important role both in physiological and pathological actions in its normal and aggravated conditions7.Vata is also the  driving force for the functioning of all the organs and organ systems.

Acharya Charaka has mentioned repeated use of snehana, svedana, Vasti and mrudu virechana for the treatment of Vatavyadhi. But due to the Kapha dominance in the initial stages rookshana line of treatment is preferred initially with physiotherapy. The internal and external treatments were mainly based on immuno-modulatory action along with the sensory and motor rehabilitation. At the end of treatment, the child had the ability to walk without support with better sensory perception in lower limbs. The causative factor of the disease cannot be completely cured as it is genetic but the quality of life can be improved with minimal reliance on others. Early recognition and inference in these cases is known to increase the prognosis in these types of cases.

 

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