Indian Journal of Ayurveda & Research

Ayurveda management of chronic non healing pressure ulcer at foot, secondary to tethered cord syndrome – A case report
Ramesh Killedar1, Rajashekhar Sanapeti2, Pradeep Shindhe1
1. Department of Shalya Tantra, KAHER’s Shri B M Kankanwadi Ayurved Mahavidyalaya, Belgavi, Karnataka, India, Pin – 590003.
2. Department of Panchakarma, KAHER’s Shri B M Kankanwadi Ayurved Mahavidyalaya, Belgavi, Karnataka, India, Pin – 590003.

Address for correspondence: Dr Ramesh Killedar, Department of Shalya Tantra, KAHER’s Shri B M Kankanwadi Ayurved Mahavidyalaya, Post-Graduate Studies And Research Centre, Belgavi-03, Karnataka, India.
Email-id : drramesh39@gmail.com

Abstract
Pressure ulcers are classic chronic ulcers that appear over the areas of pressure and trauma in the skin that has lost sensation. Tethered cord syndrome is a rare etiology of chronic pressure ulcer originating from the central nervous system. Surgical treatment adopted is release of the tethered cord which promotes healing of the foot ulcers.We report a case of chronic pressure ulcer at foot since 8 years which was secondary to tethered cord syndrome. The case was diagnosed as dustavrana (non healing ulcer) as per classics and treatment was planned with Ksharakarma, Vimlapana and Basti. Local and Systemic treatment of pressure ulcer took 3 months for complete healing but there were no significant changes in reduced sensation of foot and thigh.The ulcer was successfully managed with Ayurveda treatment.

Key words – Pressure ulcer, Adult tethered cord syndrome (TCS), Dustavrana, Basti, Ksharakarma, Vimlapana

How to site this article : Killedar R, Sanapeti R, Shindhe P, Ayurveda management of chronic non healing pressure ulcer at foot secondary to tethered cord syndrome – A case report. Indian J Ayurveda Res2018;1:62-66

Introduction
Pressure ulcer is defined as per the “European Pressure Ulcer Advisory Panel” as damage to a localized area of skin and tissue structures caused by shear, friction and pressure. Incidence rates in the inpatient department is reported ranging from 0.4% to 38% and prevalence rate as 3.5% to 69%. Pressure sores are grades as non-blanchable erythema (grade 1), abrasion or blister (grade 2), superficial ulcer (grade 3), deep ulcer grade 4.[1] TCS is one among the causative factors  for occurrence of neurotropic ulcer which is defined as functional disorder of the spinal cord caused by stretching and anchorage of caudal part by inelastic structure. Presentation of TCS ranges from early childhood to 8th decade.[2]The symptoms of congenital TCS occurs mostly in childhood, but few of the patients remain undiagnosed until adulthood as symptoms are over looked.[3]The presentation mainly depends on the pathology which ranges from backache, lower limb pain, skin related signs, muscle weakness, bony deformities, urinary dysfunction and neurological deficits.[2] Sensory deficits are present in two thirds of all patients but ulcers are rarely observed. Standard treatment remains controversial for Adult TCS and surgical intervention is opted based on disease progression. [4] Here we report a case of 8 years chronic pressure ulcer at foot, diagnosed as adult tethered cord syndrome was successfully managed by Ayurveda treatment.

Patient information
A 39 year old female non diabetic, non-hypertensive patient presented with  non-healing ulcer at ball of right foot , swelling at right ankle region, watery discharge, foul smell, numbness at thigh, calf and foot region of right lower limb since 8 years. The case was treated at KLE  Ayurved  Hospital, Belagavi, Karnataka from 26th June 2017 to 10th September 2017 (OPD -12313/17, IPD – 4202)

Clinical findings
Patient had a history of trauma with stone since then she developed non healing ulcer with foul smelling and watery discharge which required two times dressing daily due to soakage. Patient took conservative treatment but did not got complete relief, so discontinued medicines. Surgeons advised her to undergo surgery because she was a diagnosed case of adult tethered cord syndrome which is the reason for wound chronicity and numbness of thigh, calf and foot. General examinations revealed moderately built with good nutrition, vitals were normal. Systemic examinations like central nervous system, cardiovascular and respiratory were normal. Local examination revealed a single spherical shaped non healing ulcer over ball of right foot, size of 3x3x1.5 cm, punched out edges, serosangueonus discharge, pale unhealthy granulation tissue at floor. Palpatory findings were callus surrounding wound, no tenderness, no local rise of temperature, calcaneal bone as base, pitting type of edema at right ankle region. Peripheral arteries like dorsalis pedis, anterior and posterior tibial artery, popliteal artery on both limbs were found to be normal. Sensory examination findings showed reduced sensation at anterior aspect of right thigh, medial side of knee joint, calf and foot. Bladder and bowel control were normal which is usually affected in tethered cord at L4 region.

Timeline
Patient developed loss of sensation; heaviness in Right Lower Limb two months after hysterectomy in 2008 and in 2009 there was heaviness and reduced skin sensation in right lower limb. In 2010 she ended up with non healing ulcer at right foot with reduced sensation at thigh, calf and foot from 2011 to 2016 she took treatment at various hospitals and discontinued medicines due to no improvement, in 2017 underwent MRI Lumbar spine (30/ 01/2017), Colour Doppler study of Right lower limb (6/7/2017) and consulted for Ayurveda treatment and underwent wound biopsy (29/07/2017).

Diagnostic focus and Assessment
Patient had underwent following investigations i.e MRI lumbar spine suggesting low lying conus medularis with apparent tethered cord at L4 region, Colour doppler of right lower limb suggesting mild varicosity of great saphenous vein with no DVT. Wound biopsy was advised to rule out any malignancy as it was chronic but the report suggested as chronic nonhealing ulcer with no malignancy. Blood parameters showed raised ESR i.e 18mm at 1st hour and rest of parameters were normal. Analyzing the above laxana of Vrana we came to a diagnosis of dustavrana with Kaphadosha and Kleda predominance, Dushya as Rasa, Rakta, Mamsa and accordingly the treatment protocol was planned.

Therapeutic focus and Assessment
The treatment was focused considering the stage of Dosha, longstanding history, so Internal and External purificatory measures along with oral medications was planned. Amongst Internal purificatory measure basti modality was selected considering the strength, stage of disease and also it is indicated in ulcer of lower limb. Ksharakarma, Vimlapana was opted as local treatment for shodhan and ropana of  dustavrana. The procedures were carried out as per the Ayurveda classics.[5] (Table 1)

Manjistadi Kshara Bast i– The Constituents of basti are Madhu (Honey) – 80 ml , Saindhava lavana (Rock salt) -5 grams , Nimbamrita taila – 40 ml, Kalka – Shatapuspa choorna (Anthum sowa Kurz) (5 grams), Arjuna choorna (Terminalia arjuna Roxb.) (5grams), Manjista choorna (Rubia cordifolia Linn.) (5 grams), Nimba choorna (Azadiracta indica A. Juss) (5 grams), Shunti choorna (Zingiber officinale Rosc) (2grams), Haridra choorna (Curcuma longa Linn.) (2 grams). Kashaya (200 ml) Manjista Kwata churna (Rubia cordifolia Linn.)(20 grams), Arjuna (Terminalia arjuna Roxb.) (10 grams), Patola (Trichosanthus dioica Roxb) (10 grams), Nimba (Azadiracta indicaA. Juss) (10 grams), Yastimadhu (Glycyrrhiza glabra Linn.)(10 grams), Amruta (Tinospora cordifolia Willd) (5 grams), Katuki (Picrorhiza keuroa Royle ex Benth.)(5 grams), Madanaphala (Randia dumetorum lam.) (5 grams), Goarka (distilled cow urine)25ml
The wound took total 3 months for complete healing with minimal scar; significant improvement in the numbness was not seen, so the patient was advised to opt surgery if she develops loss of bladder or bowel control. After 1 year of follow up with proper foot care advice recurrence was not seen and the patient is able to manage her routine activities.

Discussion
In this case as the patient was non diabetic and has reduced sensation in the affected limb and disease chronicity made us to rule out malignancy so wound biopsy was done. The patient was advised to undergo surgery but she refused due to medical expenses and fear of surgery. The sampraptighataka (components of a disease pathogenesis) were assessed as Kaphavata dosha with Kleda predominance, sanga as srotodusti, according to that treatment was planned. Local treatment as Ksharakarma with tikshna Apamarga Kshara is indicated in Katina (hard), chirotittha vrana (longstanding).[6] Kshara possess chhedana (excision), Bhedana (incision), Lekhana (scrapping) along with Tridoshhara (equilibrium of Vata, Pitta, Kapha) properties. It is non-invasive procedure without major complications; remove all slough/dead tissue thus considered as a good curative measure for local treatment of Dushtavrana.[6]
In Vimlapana with Jatyaditaila uniform pressure is exerted over wound area which increase local temperature and helps to relive local vasoconstriction thereby improving the micro & macro circulation to the wound site, Increased blood circulation provides required oxygen and essential nutrients and combats the anoxic condition of the wound and helps in removal of local stagnated toxins and inflammatory mediators, thus reducing inflammation and accelerating healing process.[7] Sadyovirechana is the therapy in which the medicine is processed with oil or decoction and administered orally  which improves the Agni (metabolism) of the individual. Sadyovirechana before basti karma was planned to achieve maximum benefits, eranda taila is madhura,tikta in rasa, tridoshahara and sukha virechaka. Triphala kashaya (TK) is a kind of Ruksha virechana to overcome kledata present in the vrana. Researches on TK has proved its antifungal activity and its effectiveness against Gram-positive and Gram-negative bacteria.[8]
Bastikarma is mentioned in the context of Vraṇa Chikitsa as shodhana (specific purification therapy) where medicines are administered through rectal route. Basti is indicated in Vata, Pitta, Kapha dosha and Adhakayajanya Vraṇa (ulcers prone to lower limbs).[9] Manijistadi Ksharabasti comprising of drugs like Manjista[10], Shatapushpa[11], Katuki[12], Goarka possess Ushna virya, Katu rasa, laghu ruksha guna which does Srotomarga vishodana, Vrana shodhana, Raktaprasadana. The drugs like Patola[13], Nimba[14], Amruta[15], Yastimadhu[16] contain Tikta rasa, Madhura vipaka which acts as Kledahar, Kledashoshaka. Arjuna[17], Yastimadhu[16], Haridra[18], Manjista[10] helps in Raktaprasdana resulting in better healing  and nourishment of tissues. The drugs used in the basti are proved to possess the activity like wound healing, Anti-inflammatory, Antifungal, Antibacterial, Antioxidant and Antitumour.[19,20] Gomutra Haritaki is indicated for Granthi, Arbuda, Apachi, Pandu, Sotha, Arsha. It has Ushna, Tikshna, Kshara, Deepana, Pachana and Vatanulomana, Kapha-Vata Shamaka property, therefore it alleviate Kapha Prakopa, remove Ama and clears Srotorodha.[21] Panchatikta ghrita guggulu contains Panchatikta gana dravyas, ghee & Guggulu which are having tiktarasa, laghu & ruksh guna, so it has kleda & vikrut meda upashoshan, vrana shodha property.[22]

Patient Consent
Informed consent regarding documentation and publication of the case was obtained from the patient.

Conclusion
The quality of life is hampered by the chronicity of the ulcer, diagnosing cause and proper management followed with patient education regarding proper foot care is of prime importance. The pressure ulcer in this single case study was successfully managed by the help of Ayurveda and in the follow up period of 1 year there was no recurrence.

Financial support and sponsorship – nil

Conflicts of interest – none 

 

Table 1 Intervention schedule

Plan of care Procedure Duration (Days)
1 2 3 4 5 6 7 8 9 10 11 12 – 32 33 34 35 36 37 38 39 40 41 42 43 44 – 70
Vrana shodhana Kshara karma* 
Vrana
 Ropana
Vimlapana
Sadyo Virechana GT with TK#
Basti   Kala basti N N N N N N N N N N N N N N N N
A A A A A A A A A A A A A A A A
Gomutra haritaki 250 mg
TID A/F@
Tab PTGG^ 250 mg
TID A/F
Proper foot care
N – Niruha Basti (Manjistadi Kshara basti)  A – Anuvasana basti (Triphala taila 40 ml)
*Kshara karma – with Apamarga teekshna Pratisaraniya kshara
# GT with TK – Gandarvahastyadi taila with triphala Kashaya 75 ml and 2 gms shuntichurna
@ TID A/F –  Thrice daily after food with warm water
^Tab PTGG – Pancha tikta guggulu ghrita
Proper foot care – To avoid walking on barefoot, to avoid moisture and  to reduce physical activity in order to reduce pressure over foot.

Table 2 Follow up and Outcomes

Wound Parameters Duration (Days)
Assessment
Day
1 4 7 10 12 33 36 39 42 45 71 90 120 150 210 270 330
Size * 3 x 3 3 x 3 3 x 3 2.7 x 2.7 2.5 x 2.5 2 x 2 1.7 x 1.7 1.5 x 1.5 1.3 x 1.3 1x 1 0.5 x 0.5 0 0 0 0 0 0
Shape Transversely oval Transversely oval Spherical
Depth** 25 25 23 23 20 15 14 13 11 10 05 0 0 0 0 0 0
Discharge Sero sanguineous Serous
Edge Punched out Punched out Sloping Sloping
Floor Slough # PGT PGT ##  RGT RGT
Odour Foul smell
^ AK 10 10 10 10 10 9 9 9 9 9 8 8 8 8 8 8 8
@ N + + + + + + + + + +
* Size – length x breadth in centimetres
# PGT – Pale granulation tissue , ## RGT – Red granulation tissue
@ N – Numbness in the thigh, calf, foot assessed with present (+) and improved (-)
^ A K – Ankle edema – circumference in centimeters
**Depth – measured in milimetre

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