Sciatica-3

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Table of Contents
Casestudies of Contents

Brief Medical History

Presenting Complaints

  • Low back pain radiating to left leg since 8-9 yrs high severity.
  • Numbness in legs since 8-9 yrs
  • On and Off Vibrating feeling in both legs on standing since 2 yrs
  • Nervousness and forgetfulness
  • Burning sensation in chest
  • Irregular bowels habits (mostly constipation)
  • Rapid visual loss of in right eye 4yrs back

Brief Relevant Medical History (Onset, Duration, Ag/Rel Factors, OTT, Prior Confirmed Diagnoses if applicable):

Patient was suffering from severe pain in low back since 2006 and had undergone a spinal surgery at L5-S1 level. As the symptoms reappeared, patient got hospitalized again in 2012 September and was investigated with MRI which showed Left foraminal stenosis and degenerative disc disease at L5-S1for which he underwent open foraminal decompression and fusion at L5-S1.He did not improve even after the second surgery. He then approached AyurVAID with above-mentioned presenting complaints.

K/C/O Optic atrophy OD H/O Modern medicine induced Rapid visual loss 4yrs back

Current medication :

  • Pariet 20 mg 1/day
  • Rameron 50 mg 0-0-1 since 5 yrs
  • Olfen 50 1-0-1 SOS
  • Tab.Inderal 10 m 1-0-1 since 5yrs
  • Faverin 50 mg 0-3-1 since 5yrs

Integrated Summary

Clinical Status
Allopathy Ayurveda
Vital Parameters

1. BP:120/80 mm of hg
2. Pulse:76/min
3. Weight:89.6 kg
4. Height192 cm
5. BMI:24.30
Astasthana Pariksha

- Nadi:vatha pitha
- Malam:Saama
- Mutra:Prakrutha
- Jihva:Swetha
- Shabda:Sadharana
- Sparsha:Prakrutha
- Drik:Prakrutha
- Akruti:Madhyama
Examinations

- GC:Fair
- CVS:NAD
- RS:NAD
- PA:Soft, tenderness++ Epigastric region,Right iliac region
- RS: NVBS

Gait: AntalgicSLR :Left leg – Less than 45 degree. Numbness- ++ on holding left leg for 2-3 seconds in same position Right leg- 70 degree pain starts in back of thigh and lower back
CNS Examination:Sensation over right foot: Superficial sensation present
Deep sensation: Altered
Reflex: Ankle joint reflex absent
Dasa Vidha Pariksha

1. Prakriti:Vatha pitha
2. Vikriti:vatha
3. Sara:Asthi sara
4. Samhanana:Avara
5. Pramana:Madhyama
6. Satmya:Madhura, Lavana
7. Satva:Madhyama
8. Aharashakti:Avara
9. Vyayam Shakti:Avara
10. Vaya:Madhyama
11. Desha:Jangalam
12. Kala:Greeshma
Rogi Bala - Madhyamam
Roga Bala - Balwan
DSQ findings Rating
1. ADRS
Med
2. ADSS
High
NidanaPanchaka

1. Nidana - Rooksha aahara, Athyayana, Athichinthanam
2. Purvaroopa - Shoola
3. Roopa - Shoola, Daha
4. Updrava:Kukshishoola, Supthatha
5. Arishta Lakshana:NA
6. Samprapti
A. Dosha - Vatha vrudhi Kapha kshaya
B. Dushya - Rasa raktha mamsa asthi sira kandara
C. Agni - Vishamagni
D. Ama - Saama
E. Srotas - Mamsavaha, Asthivaha
F. Sroto Dushti Prakara - Sanga
Lab Tests: Nil
RogaSamprapti Flow Chart

- Rooksha, katu aahara +Athi chinthana+Athi ayana
- Vata vrudhi
- Kapha kshaya
- Vata vikara
Differential Diagnosis with reasoning

Lumbago :
Pain felt in the low back area and tends to radiate into the groin, buttock and upper thigh. The pain often moves around, and radiates below the knee.

Sciatica :
Radicular pain that radiates down the leg along the specific course of a compressed spinal nerve.
Differential Diagnosis with reasoning
Vatha vyadhi-Gradhrasi
Khanja
Pangu
Evidence Based Diagnosis with References
Lumbago
Digestive disorders
Evidence Based Diagnosis with References
Vatavyadhi-Gradhrasi
Agnimandhya
ChikitsaVivechana: Ahara+Vihara+Aushadh+Kriya
Details of Allopathy medicine if continued

Pariet 20 mg 1/day
Rameron 50 mg 0-0-1
Tab.Inderal 10 m 1-0-0
Faverin 50 mg 0-0-1

Type – IPT
Duration – 13 days

Primary Treatments: Choorna pinda sweda,Vasti poorva karmas

Main Treatments:Abhyanga,Jambeera pinda sweda,Kati vasthi,Lepa,Kayaseka,Vasthi,Shastika shali pinda sweda.

Post Treatments:

Paschatha karmas of vasthi

FROM DATE TO DATE PROCEDURE TREATMENT MEDICINES
18/04/15
24/04/15
Sarvanga abhyanga
Body-Sahacharadi taila+Narayana taila+karpasasthyadi taila, head-Dhanwantaram taila
18/04/15
18/04/15
Choornapinda sweda
Kottamchukkadi choornam+ shatapushpa choorna
19/04/15
24/04/15
Jambeera pinda sweda
Sahacharadi taila+Narayana taila+Karpasasthyadi taila
19/04/15
Kativasti
Kottamchukkadi taila+Murivenna taila+karpasasthyadi taila
19/04/15
Lepam
Murivenna taila+ Kottamchukkadi choornam+Marma gulika+ Egg white
25/04/15
Kayaseka
Body-Sahacharadi taila+Narayana taila+karpasasthyadi taila, head-Dhanwantaram taila
23/04/15
25/04/15
Vasti
A.V- Dhanwantaram mezupakam+Pippalyadi taila, K.V- Erandamoola kashaya+Dhanwantaram mezupakam+Pippalyadi taila+Shatapushpa kalka+madhu+saindhava lavana
25/04/15
30/4/15
Shashtikashalipinda sweda

Chikitsa Paddhati with details of dose of medicine.

Internal medicines during IP treatments:

  • Guggulu thikthakam Kashayam -15ml+Maharaja prasarinyadi thailam-10 drops at 7 AM
  • Maharasnadi kashayam-10 ml+Punarnavadi kashayam-10 ml+Yogaraja guggulu-2 11 AM
  • Dhanuantharam Kashayam-15 ml+Chandraprabha vati -2 at 6 PM
  • Manasamithra vatakam-2 warm milk at bedtime
  • Palsineuron after 2-0-2 after food

 

Internal medications after discharge date for 2 months:

  1. Maharasnadi kashayam -15ml+Dhanwantharm 101-10 drops+ ½ glass warm water- mixed together and to be taken at 7 a.m and 11 a.m.
  2. Dhanwantaram kashayam-15 ml+ Tab. Yogaraja guggulu -2+ ½ glass warm water- mixed together to be taken at 6 p.m or 7 p.m.
  3. Tab. Palsineuron 2-0-2, after breakfast and dinner.

External medications:

  • Mahanarayana taila+ karpasasthyadi taila- mixed together; warm the oil and aplly over low back, hip joints and legs 30 min before bath.

Outcome

  1. Samyak Lakshanas achieved (Control Charts Summary attached)
  2. Standardised Outcome Scale-Low back Abredien Scale
Before treatment After treatment
Back pain severity score
76%
45.3 %
Other outcomes as per following table to be duly filled
# Outcome Parameters N R TSD T TED
1.
Sleep (Nidra)
Avara
Pravara
Pravara
Pravara
Pravara
2.
Appetite (Agni)
Fair-Vishamagni
Fair
Good
Poor
Good-Samagni
3.
Bowels (Mala)
Constipated-Saama
Clear
Clear
Clear
Clear-Niraama
4.
Urination (Mutra)
Prakrutha
Prakrutha
Prakrutha
Prakrutha
Prakrutha
5.
Stress (Manas)
Stressed
Stressed
Relaxed
Relaxed
6.
Vitality (Ojus)
Less
Less
Good
Good
Good
7.
BP
120/80
124/84
120/80
120/80
120/80
8.
Pulse
76
-
-
-
72
9.
Weight, Kg
89.6
-
-
-
85.2
10.
Diet (Ahara)
Poor
-
-
-
Good
11.
Exercise (Vyayama)
No exercise
-
-
-
No exercise
11.
Lifestyle (Vihara)
Poor
-
-
-
Good

Patient’s Outcome Scale

# Presenting Complaint Weightage Status_TSD Status_TED Status_1 Week Status_1 Month
1.
Low back ache radiating to LEFT LEG
60%
1
4
Awaiting
-
2.
Numbness legs
-
1
4
Awaiting
-
3.
Vibrating feeling on legs
30%
1
2
Awaiting
-
4.
Nervousness
-
1
3
Awaiting
-
5.
Irregular bowels
10%
1
3
Awaiting
-
6.
Burning sensation in chest and stomach pain
-
1
3
Awaiting
-
WEIGHTED AVERAGE SCORE-----> -
-
-
-
-
-
IMPROVEMENT SCORE----->
-
-
0.0
2.0
2.0
IMPROVEMENT %----->
-
-
0%
100%
100%

Adverse Incident Report (Drug or Treatment): No adverse incidents reported

Attachments

Conclusion

During treatment period he has well responded for all treatments. His pain and numbness were gradually reducing during the treatment days, and he was not under NSAID during the treatment period. Basti karma has stopped on 3rd day as patient not willing to continue the same. Patient did not have any adverse events during the course of treatments. His pain in low back has reduced from 8 to 3 on VAS (0-10) along with significant reduction in numbness and no vibrations in lower limbs. His back pain severity score has reduced from 76 to 45.3%. He found overall improvement in his quality of sleep, improved digestion and general health. Further he is advised to continue all his internal medication along with diet and regimen for another 2 months for sustained relief.

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