AYURVEDIC MANAGEMENT OF DISC PROLAPSE

Vaidya Ruchi Gulati MD(Ayu)Sukh Ayurveda

GRDHRASI Pain originating from the regions of

kati(waist) gets referred or travels down to the Sakti(thighs), Janu(knees), Gulpha(ankles), and to the Pada gradually causing much agony to the patient.

Repetitive mechanical activities – Frequent bending, twisting, lifting, and other similar activities without breaks and proper stretching can leave the discs damaged.

Living a sedentary lifestyle – Individuals who rarely if ever engage in physical activity are more prone to herniated discs because the muscles that support the back and neck weaken, which increases strain on the spine.

Traumatic injury to lumbar discs- commonly occurs when lifting while bent at the

waist, rather than lifting with the legs while the back is straight.

Causes

Obesity – Spinal degeneration can be quickened as a result of the burden of supporting excess body fat.

Practicing poor posture – Improper spinal alignment while sitting, standing, or lying down strains the back and neck.

Tobacco abuse – The chemicals commonly found in cigarettes can interfere with the disc’s ability to absorb nutrients, which results in the weakening of the disc.

Mutation- in genes coding for proteins involved in the regulation of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation.

Causes

DISC LOAD IN DIFFERENT BODY POSTURE

When the spine is straight, such as in standing or lying down,

internal pressure is equalized on all parts of the discs.

While sitting or bending to lift, internal pressure on a disc can move from 17 (lying down) to over 300 psi (lifting with a rounded back).

Cellular and Biochemical Changes of the Intervertebral Disc

Decrease proteoglycan content.

Loss of negative charged proteoglycan side chain. Water loss within the

nucleus pulposus. Decrease hydrostatic property. Loss of disc height. Uneven stress distribution on the

annulus.

Disc herniation can occur in any disc in the spine, but the two most common forms are lumbar disc herniation and cervical disc herniation.

The former is the most common, causing lower back pain (lumbago) and often leg pain as well, in which case it is commonly referred to as sciatica.

Lumbar disc herniation occurs 15 times more often than cervical (neck) disc herniation, and it is one of the most common causes of lower back pain.

The following locations have no discs and are therefore exempt from the risk of disc herniation: the upper two cervical intervertebral spaces, the sacrum, and the coccyx.

Epidemiology

Most disc herniations occur when a person is in their thirties or forties when the nucleus pulposus is still a gelatin-like substance.

With age the nucleus pulposus changes ("dries out") and the risk of herniation is greatly reduced.

After age 50 or 60, osteoarthritic degeneration (spondylosis) or spinal stenosis are more likely causes of low back pain or leg pain.

4.8% males and 2.5% females older than 35 experience sciatica during their lifetime.

Of all individuals, 60% to 80% experience back pain during their lifetime.

In 14%, pain lasts more than 2 weeks. Generally, males have a slightly higher incidence

than females.

Epidemiology

The patient has severe back pain and is unable to straighten up.

Radiating pain to the buttock and lower limbs and is associated with paraesthesia or numbness in the legs or foot( sciatica) and occasionally there is muscle weakness.

Both backache and sciatica are made worse by coughing or straining.

Cauda equina compression is rare but may cause urinary retention and perineal numbness.

Clinical Features

The patient usually stands with a slight list to one side(‘sciatic scoliosis’).

Sometimes the knee on the painful side is held slightly flexed to relax tension on the sciatic nerve; straightening the knee makes the skew back more obvious.

All back movements are restricted, and during forward flexion the list may increase.

Clinical Features

There is often tenderness in the midline of the low back, and paravertebral muscle spasm.

Straight leg raising is restricted and painful on the affected side; dorsiflexion of the foot may accentuate the pain.

Sometimes raising the unaffected leg causes acute sciatic tension on the painful side (‘crossed sciatic tension’).

With a high or mid-lumbar prolapse the femoral stretch test may be positive.

Clinical Features

.

FEATURES OF CAUDA EQUINA SYNDROME

Bladder and bowel incontinencePerineal numbnessBilateral sciaticaLower limb weaknessCrossed straight-leg raising signNote: Scan urgently and refer urgently if a large central disc is revealed.

Degeneration Loss of fluid in nucleus pulposus.

Protrusion Bulge in the disc but not a complete rupture.

Prolapse Nucleus forced into the outermost layer of the

annulus fibrosus- not a complete rupture. Extrusion

the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.

Sequestration Disc fragments start to form outside of the disc area.

Classification of Herniations

Types of Herniation posterolateral disc herniation –

protrusion is usually posterolateral into vertebral canal, compress the roots of a spinal nerve.

protruded disc usually compresses next lower nerve as that nerve crosses level of disc in its path to its foramen. (eg.protrusion of fifth lumbar disc usually affects S1 instead.

central (posterior) herniation: less frequently, a protruded disc above second lumbar

vertebra may compress spinal cord itself or or may result in cauda equina syndrome.

in the lower lumbar segments, central herniation may result in S1 radiculopathy.

lateral disc herniation: may compress the nerve root above the level of the herniation L4 nerve root is most often involved & patient typically have intense radicular pain.

Distribution of load in the intervertebral disc. (A) In the normal, healthy disc, the nucleus distributes the load equally throughout the anulus. (B) As the disc undergoes degeneration, the nucleus loses some of its cushioning ability and transmits the load unequally to the anulus. (C) In the severely degenerated disc, the nucleus has lost all of its ability to cushion the load, which can lead to disc herniation.

Location The majority of spinal disc herniation cases

occur in lumbar region (95% in L4-L5 or L5-S1).

 The second most common site is the cervical region (C5-C6, C6-C7).

The thoracic region accounts for only 0.15% to 4.0% of cases.

. posterolateral

herniation between two vertebrae will actually impinge on the nerve exiting at the next intervertebral foramen down.

Occasionally an L4/5 disc prolapse compresses both L5 and S1.

Diagnosis is based on the history, symptoms, and physical examination.

At some point in the evaluation, tests may be performed to confirm or rule out other causes of symptoms such as spondylolisthesis,degeneration, tumors, metastases and space-occupying lesions.

Diagnosis

Finding include positive straight leg raise (lasegue sign) which is the most predictive finding if it reproduces leg pain with L5 or S1 radiculopathy.

as this finding has low specificity; however, it has high sensitivity.

Thus the finding of a negative SLR sign is important in helping to "rule out" the possibility of a lower lumbar disc herniation.

Physical Examination

X-Ray : lumbo-sacral spine; Narrowed disc spaces. Loss of lumber lordosis. Compensatory scoliosis.

MRI lumber spine; Intervertebral disc protrusion. Compression of nerve root.

CT scan lumber spine; It can show the shape and size of the spinal canal, its contents, and the structures around it, including soft tissues. Bulging out disc.

Myelogram; pressure on the spinal cord or nerves, such as herniated discs, tumors, or bone spurs.

Imaging

Normal MRI

.

Bed rest. Non-steroidal anti-inflammatory drugs (NSAIDs). Patient education on proper body mechanics. Physical therapy, to address mechanical factors, and may

include modalities to temporarily relieve pain (i.e. traction, electrical stimulation massage).

Oral steroids (e.g. prednisone or methylprednisolone). Epidural cortisone injection. Intravenous sedation, analgesia-assisted traction therapy

(IVSAAT). Weight control. Tobacco cessation. Lumbosacral back support. anti-depressants.

Conventional Medical Treatments

Chikitsa Sutra Ama Pachan-reduce inflammation and

pain Shodhan- Detoxification & elimination of

toxins from the body Brmhanam- Prevention of further

deterioration in joints and rejuvinates the damaged cartilages

Management at Sukh Ayurveda Detox Panchkarma Therapies Proper Nutrition Ayurveda Herbs Lifestyle and Daily Routine Yoga Strengthening Body’s Self Repair

Mechanisms

Detox Panchkarma Therapies

Vasti Kayaseka or Pizhichil Patrapinda Swedanam or Ilakzihi Shalishasti Pinda Svedanam or

NavraKizhi Kadi vasti

Pizhichil Procedure:

Warm healing oil is poured over the body in a rhythmic pattern. A gentle massage revives the body.

60 minutes

Patrapinda Swedanam or Ilakzihi Procedure: Herbal

leaves and spices are bound into a bundle, a herbal bun, and soaked in warm medicated oils. A skilled therapist applies this to your body with focus on painful areas.

60 minutes

Shalishasti Pinda Svedanam/Navra Kizhi

Kadi vasti Procedure: Specially

prepared, warm medicated oil is poured over the lower back and then kept in place by a flour dough boundary. Also, a full body oil massage is done for complete healing. . A series of treatments are recommended to treat the back pain and spinal disorders.

75 minutes

Proper Nutrition

Proper use of spices

Herbal preparations to improve digestion

Proper spacing between breakfast, lunch and dinner

Favoring foods which stimulate digestion

Reducing consumption of foods that depress digestion

Proper food combinations to avoid indigestion

Non-dietary regiments to improve digestive strength including

exercise, specific yoga asanas etc.

Ayurveda Herbs

Maharasnadi Kashayam Sahacharadi Kashayam Tryodashang Guggulu Shefalika patra Kashyam

Lifestyle and Daily Routine

Do not bend, lift, or sit in a soft, low chair; the pain will get worse.

The affected individual may feel better lying on his or her back on a firm surface with a pillow under his or her knees. Another option is lying on one's side with a pillow between the knees to keep the back straight. 

Take it easy, but do not simply lie in bed because this has been shown to actually worsen the condition. Do activities one is able to tolerate, and do not expect to feel better overnight. 

Yoga

Shallabh asana

Nauka asana

Bhujang asana

Sukh Ayurveda Outcomes Reduction in pain especially the radiating

pain Relief in burning sensation & numbness Increased Range of Movements (ROM)

Other Ayurveda Treatments Marma Chikitsa Rakta mokshan