IMPROVEMENTS ACHEIVED WITH AYURVEDIC TREATMENT IN " THE PARAPLEGIA POST SPINAL TUBERCULOSIS" .

CASE NUMBER : 3
CASE : PARAPLEGIA POST KOCHS SPINE.

Before i discuss about the case details which are in an organized manner, i will say the story of the patient, cause every patient is a human being, not a machine, with emotions and experiences attached to him. You got to know it and respect it too for the treatment to become successful ! This patient came to our hospital , being referred by a famous surgeon in Madurai, who happend to know about our hospital and the more had belief in ayurveda. He himself was a great advocator of acupuncture and even spend some time with me, to teach me the basics of acupuncture. As a doctor, i think acupuncture is a potent analgesic, other than that i have doubts (?). So the patient was a famous enterpreuner running a mill, who had caught this kochs disease of spine. He was absolutely paralysed below the diaphgram. He had no bowel or bladder control. He was catheterised. He was positive about his condition, but not at all worrisome, thats the way a patient should be ! With submitting all the confidence in the doctor ! He got the results for showing belief and faith in the doctor and treatment. 

Description of disease :
Spinal tuberculosis is common in the developing countries and also seen sporadically in well-developed countries. Lately the incidence is on the increase, world over, with the emergence of AIDS. About 60 % of cases are below the age of 20 years in developing countries. In developed countries the older people are more commonly affected.
About   20% of the patients have multiple lesions. 
Most are caused by the human strain. The bovine type is probably responsible for less than 5 %, especially in Europe. Isolated cases due to atypical mycobacteria are also seen.

Pathology:Microscopically, there is central coagulative necrosis surrounded by epitheloid cells, Langhans giant cells(as shown by the arrowin the picture) and an admixture of lymphocytes and plasma cells. There may be satellite lesions and perivascular infiltrations
Tuberculosis may involve the vertebra, epidural space, dura, arachnoids, or spinal cord.
A) Vertebral involvement:

It is the commonest. It is also the commonest form of skeletal tuberculosis with an incidence of up to 50% of all skeletal tuberculosis. In general it is a disease of the young adult in the developing countries. In developed countries it affects more commonly, the elderly. Due to the emergence of HIV infection the incidence of all forms of tuberculosis is further aggravated all over the world. Both sexes are equally effected.

The spinal disease is always secondary to a primary lesion and occurs due to hematogenous spread. The primary focus may be active or quiescent and may be in the lungs, mediastinal lymph nodes, kidneys and other viscera. On an average, an involvement of 3 - 4 vertebrae at the time of presentation has been reported. As elsewhere, the spinal tuberculosis is a granulomatous disease. Marked exudative reaction is a common feature of spinal tuberculosis. A cold abscess mostly comprised of serum , leucocytes, caseous material, bone debris and bacilli, penetrates the ligaments and migrates along the facial planes often presenting far from the site of infection.

Clinically there are four types :

1. Para discal lesion begins in the metaphysis, erodes the cartilage and destroys the disc, resulting in narrowing of the disc space.

2. Central type begins in the midsection of the body which gets softened and yields under gravity and muscle action, leading to compression, collapse and bony deformation.

3. Anterior lesions lead to cortical bone destruction beneath the anterior longitudinal ligament. Spread of the infection is in the subperiosteal and sub ligamentous planes resulting in the loss of periosteal blood supply to the body with resultant collapse. Other factors such as periarteritis and endarteritis contribute to the collapses.

4. In appendicle type, the infection settles in the pedicles, the laminae, the articular processes or the spinous processes and causes initial ballooning of the structure followed by destruction.

Tuberculous spondylitis commonly occurs in the thoracic, followed by lumbar and cervical spines which more often occurs in the pediatrics group.

Clinical features:

1. Back pain is a predominate (70%) feature with stiff spine and Para vertebral muscle spasm. A soft tissue swelling or mass is often obvious. There is 20% incidence of cold abscess and about 90% incidence of angulations of the spine in the form of kyphosis or gibbus.

2. Systemic symptoms may or may not be there.

3. The most serious is the neurological involvement with overall incidence of about 30% and the deficit depends on the site, the direction of spread and pathological changes produced. The risk is highest in the region of cervico-thoracic region.

The cord may be involved in any phase, the active phase within the first 2 years or in later years after the disease has become quiescent. The cause in most cases is compression, which may be an abscess, granulation tissue, sequestrated bone and disc or pathological subluxation in active disease.
In healed diseases the deficit may be due to transverse ridge of bone anterior to the cord, due to angulations of the spine or healing, stretching or attrition of the cord due to spinal deformity and or fibrosis of the dura.
In a given case more than one factor may contribute to the pathogenesis. Non compressive causes such as endarteritis, periarteritis or thrombosis of the arterial supply of the cord.
As mentioned earlier, cervical spine involvement is rare (1%) more often seen in children. It is characterized by a more diffuse involvement of the lower cervical spines the formation of retropharyhngeal abscesses, often causing respiratory distress. The adult form is usually confined to a single body and more commonly results in kyphosis and cord compression.
TB of CV may cause atlanto axial subluxation, upward translocation of the dens, cervico medullary compression of tuberculous abscess or direct invasion by the disease. The disease infiltrates the ligaments which give way. Incidence of associated lesions vary between 40 - 50%.Simultaneous involvement of other bones has been reported to be between 12-15%.
Diagnosis:
Suspicion is the first step in diagnosis. No diagnostic procedure either singly or in combination will provide an unequivocal diagnosis.
The erythrocyte sedimentation rate is often raised. The mantoux test is generally positive.
A negative mantoux does not rule out a tuberculoma. ELISA (enzyme linked immunoabsorbent assay) tests of the serum and CSF may be help.
General investigations should include a search for a primary.
CT and MRI have helped in early diagnosis and follow-up with medical management. Multiple lesions are often seen. 

NAME : MR.KALANITHI
AGE : 45/MALE
STATURE : SLIM

C/O

-inability to stand/walk with or without support for past 8 months

-reduced bowel/bladder control for past 8 months

H/O

Above said problems occured after occurence of spinal tuberculosis. Consulted allopathy doctors done surgery/seizure occured 14 days back . Hyponatraemia.

M/H

T.Pan 40 1 bd

T.Eltroxin 100mcg 1 od

T.Rcinex 600mg 1od

T.Benadon 1mg 1/2 od

T.Lyrica 75mg 1 HS

T.Evion LC 1mg 0-1-0

T.Eptoin 100mg 2 HS

T.Roliflo 4mg 1od

T.Nitrovit 10mg 1 HS

T.Ramatox 8mg 1 HS

T.Allegra 60mg 1od

T.Glavis met 50/500mg 1od

O/E

UL POwer : 4/5  4/5

UL Grip  : 4/5  4/5

LL Power : 1/5  1/5

LL Grip  : 1/5  1/5

DTR      : brisk

G/E

Appetite : reduced

Bowel    : constipated

Sleep    : reduced

Urine    : bladder incontinence

BP       : 130/90 MMHG

Pulse    : 80/MT

PARAPLEGIA POST KOCHS DISEASE

KNOWN CASE OF DM/HYPOTHYROIDISM

MRI DORSAL SPINE ON 18/7/2014

Post anterior carpectomy D5 stabilisation

Post operative changes with gibbus deformity at D4D5

Degenerative changes in C4C5, C5C6

CT BRAIN WITH CONTRAST ON 19/7/2014

Illdefined hypodense lesion in right pareital region

BLOOD REPORT ON 7/8/14

ESR-40/85

RBS-86

UREA-25

CREATININE-0.9

ALP-151

SGOT-28

SGPT-16

CALCIUM-9.8

TOTAL CHOLESTROL-186

SODIUM-128

POTASSIUM-3.9

CHLORIDE-94

HB-10.6

RBC-3.3

PLT-208

BLOOD REPORT 9/8/14

SODIUM-131

POTASSIUM-4.4

CHLORIDE-97

BLOOD REPORT ON 15/8/14

NA-132

K-4.0

CL-98

BLOODREPORT 0N 18/8/14

FBS-76

NA-136

K-3.5

CL-100

TC-5.7

HB-11.3

RBC-3.6

PLT-210

DC-NORMAL

BLOOD REPORT ON 4/9/14

NA-137.1

K-3.64

CL-102

URINE ROUTINE

Colour-pale yellow

Appearance-normal

Reaction-acid

Albumin-trace

Sugar-nil

Bile salt-negative

Bile pigment-negative

Pus cells-numerous (100-120)

Epithelial cells-15 to 20

Others-bacteria present (++)

Red cells- 2 to 3

BLOOD REPORT ON 9/9/14

NA-138.8

K-42

CL-102.6

URINE ROUTINE

Colour-pale yellow

Appearance-slightly cloudy

Reaction-acid

Albumin-trace

Sugar-nil

Bile salt-negative

Bile pigment-negative

Pus cells-25-30

Epithelial cells-4-6

Others-bacteria present

Red cells-3-5

AYURVEDIC TREATMENTS GIVEN :

Abhyangam        : 06 days

Exercise         : 35 days

Pizhichil        : 08 days

Njavara kizhi    : 07 days

Choorna swedam   : 19 days

Mamsa kizhi      : 10 days

Anuvasana vasti  : 05 days

Rajayapana vasti : 02 days

DURATION OF IN-PATIENT TREATMNET- 30 DAYS !

INTERNAL MEDICATION DURING TREATMENT : 

Vidaryadi ks 15ml 6am/6pm BF

Cap.Nervin        1-1-1 AF

Cap.Rootz         1-1-1 AF

Tab.Histantin     1-1-1 AF

MEDICATIONS GIVEN AFTER DISCHARGE : 

Vidaryadi ks  15ml 6am/6pm BF

Cap.Nervin    1-1-1 AF

Nimliv syrup  15ml tds AF

Cap.Rootz     1-1-1 AF

Sahacharadi+Dhanwantaram thailam

Pinda thailam