Post-Traumatic Quadriparesis due to Cervical Vertebrae Fracture

Spinal cord injury (SCI) due to fracture of the vertebrae is a common incident after blunt trauma. The intensity of disability is determined by the level of trauma to spine and the degree of damage of spinal cord. A case report on the multi-dimensional approach to spinal cord injury post RTA with quadriparesis reveals the scope of ayurveda rehabilitation in improving the Quality of life  of affected individual and its promising effects in reducing the associated morbidity of the individual. Ayurveda methods are implemented globally to treat such patients. A case of SCI was observed for 45 days with conservative ayurvedic rehabilitation with a composite treatment plan which involved Ayurvedic oral medications as well as Panchakarma procedures along with physical therapy.

Introduction:

Cervical fracture catastrophes involve multiple dimensions that severely affects the quality of life of the patient. It is not just fatal by making the patient immobile, but also affects the sensory and autonomous control based on the intensity of the injury. The pathophysiology of SCI is considered biphasic in nature. Primary injury results from a mechanical force injuring the spinal cord. Secondary injury occurs via the subsequent edema, reduced blood supply to the injured part of the spinal cord and inflammation. The incidence of a cervical spine injury is reported as 2-4% in all blunt trauma including road traffic accidents and it is remarked as one of the most debilitating musculo-skeletal injury among all external traumas. Fracture or dislocation of the cervical spine should be suspected in any patient involved in a high-velocity injury. The clinical outcome after a cervical spinal injury is related to the level and severity of the injury. Incomplete spinal cord injuries, as defined by the objective motor or sensory preservation below the level of trauma, have great potential for recovery.Rehabilitation is increasingly recognized as a measure to the overall management of such conditions. In general, the sooner the evidence of return, the better the overall prognosis, though recovery may continue for one year or longer, provided the patient gets enough and good rehabilitative treatment.

Case Report:

A 63-year-old female patient presented with weakness of bilateral upper and lower limbs with difficulty to sit, stand or walk with support was admitted to our hospital in mid-February 2018. She was mostly confined to bed and attempted to sit for a while with maximum support. She was completley conscious and awake but was unable to move her body. The entire spinal area was stiff and she was unable to turn on the bed or to sit even with support. There was no autonomic dysfunction and the patient was able to feel the urge for micturition and defecation. Also, there was no added sensory loss anywhere else in the body.

Her history revealed that she was apparently normal before 3-01-2018, before she met with a car  accident and had a fracture dislocation of the cervical vertebrae at the level of C4- C5 and subsequent Quadriparesis below the level of Injury. Her Cervical spine MRI showed severe cord injury in the form of an edema, swelling and hematoma extending from C3 to C7 levels. She underwent emergency anterior decompression surgery with reduction of the subluxation along with Anterior Cervical Discectomy and Fusion surgery of  C4-C5 with bone grafting and plating. Now, she required intense rehabilitative care for which she visited our hospital.

On physical examination, she was conscious,  oriented to time and space and responded to verbal commands and her higher mental functions were intact. No respiratory or cardio vascular involvement was noted.

On neurological examination

  • Cranial nerve functions were intact.
  • Motor examination revealed the following findings.

Bulk and Tone of muscles- reduced

Power: Right Upper limb and Lower limb – 3/5

Left  Upper limb and Lower limb- 1/5

Deep tendon reflexes were diminished

Babinsky sign and  Hofmans sign positive.

Pronator reflex of left upper limb Absent but present in right upper limb, No clonus,.

Blood investigations done were all found within normal levels except for a low haemoglobin count.

Her clinical condition was diagnosed as Post-Traumatic Quadriparesis-status post cervical vertebrae fracture  andanalysed  in ayurveda purview as abhighataja janya vata vyadhi and a general and classical  line of management  for vātavyādhi was adopted to treat this condition.

Management

  1. Internal medicines: Initially agni deepana and pachana kashayas like gandharvahastaadi kashaya, vaiswanara choorna were given and subsequently vatanulomanamedicines and medicines which aids in the strengthening of asthi (bones and joints)were  This also includedmustaadimarmakashaya and maharasnaadi kashaya, and concentrated special oil preparations (Avarthy) like dhanwantara andsahacharadi were also included. Then Guggulutiktaka ghritam was given and sandhanakara dravyas were also advised.
  2. External therapies: Treatments specified in vata vyadhi were given after analyzing the physical strength of the patient and this included snehana, swedana, and brumhana therapies to improve the muscle bulk, strength and motor functions.
  3. Physiotherapy: Sitting training, standing training on tilting bed, balance training, grip training, strengthening exercises and passive and active mobilization were given consecutively based on the day-to-day improvements noted in the patient.

Result:

In a period of 45 days, the patient showed gradual progress in her physical condition.She showed mild movements in her lower limbs in the initial 10 days itself which, later on increased day-by-day. She could now turn on the bed to both sides on her own. Gradually, she also made attempts to get up from the bed with support and later on, on her own which indicated that her upper limb muscles were progressing eventually. In two weeks she started to sit without support. With progressive intensive ayurveda rehabilitative therapies, she started to stand with external support. At the beginning of the fourth week, she made her first step with support and then the accelerated systematic training and treatment on subsequent days allowed her to walk with support and finally she was seen sitting on the floor and getting up from it with minimal support. Above all,the patient became cooperative and happy and gained enough confidence level to lead an independent life.

Table 1. Clinical Assessment and  Changes noted before and after treatment

Sl no: Signs and Symptoms Before treatment After 45 days of treatment
1 Ability to turn on the bed Affected Normal
2 Ability to sit with support Affected Normal
3 Ability to stand with support Affected Normal
4 Ability to walk Affected Normal
5 Giddiness Nil nil
6 Right hand grip 3/5 5/5
7 Left hand grip 0/5 3/5
8 Muscle coordination Affected Normal
9 Muscle Power -upper limb right 3/5 5/5
10 Muscle Power – upper limb left 1/5 3/5
11 Muscle Power – Lower limb right 4/5 4/5
12 Muscle Power -Lower limb left 1/5 3/5
13 Bowel and Bladder control Present Present
14 Muscle bulk Minimal wasting Improved
15 Tone Hypertonic Normotonic

Discussion:

The case was diagnosed as Abhighatajavatavyadhi affecting the entire body.The rehabilitative techniques adopted in such conditions are composed of various classical  taila treatments  externally, oil and herbal decoction treatments done internally in addition to oral medications. The general line of the treatment as in pacifying any vatavyadhi included snehanaswedana and matravasthi that were included in the treatment line.Patra potala sweda was aimed at giving a snigdha sweda thereby improving the circulation and also clearing all the channels of circulation thus attaining vata anulomata.Shasthika saali treatment was aimed at giving more strength to the muscles and also providing nourishment to the deeper tissues. Internal medicines that were included were maharasnaadikashayagandhataila and avarthy, all of which aimed at dhatu poshana and vatanulomana.The approach adopted in neuro-rehabilitation was multi-disciplinary and it involved  the above said Ayurvedic treatment modalities, Accupunture and physio-therapy.

Conclusion:After 45 days of Ayurvedic therapy, the patient was found to have substantial recovery of neurological deficits. Improvement was assessed by observing the level of independence achieved after the therapy. She was able to turn on the bed unaided, able to sit unaided for more than 30 min and was able to walk with support. She was able to move all the joints of the four limbs and was able to move her fingers. She was able to hold objects using both hands and was able to eat with her hands with minimal support. After the course of treatment, the patient who was previously bed ridden had become more or less independent in daily activities that drastically and satisfactorily improved her quality of life. This case report provides the scope of ayurvedic management towards tough to treat spinal cord injuries induced quadriparesis. The vast reach of Ayurveda in the management of traumatic spinal cord injuries or other neurological and musculo-skeletal condition provided effective result that helped to improve the quality of her life. The scope and scientific approach of ayurveda in such managements is becoming more globally accepted in these days.

Dr.A.M Anvar , BAMS,MD

Chairman & Managing Director,

Punarnava Ayurveda Hospital, Kochi, Kerala

dranvarmd@gmail.com, 9447062087

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