Featured Case

MODERN DIAGNOSIS: SCIATICA

About The Disease: 

Sciatica is pain experienced due to an injury or irritation to the sciatic nerve that has its origin in the buttock/gluteal area. The sciatic nerve is the longest and thickest (almost finger-width) nerve in the body. Compression or pinching of the nerve can also cause this type of pain. The most common cause of nerve compression or pinching can be caused by a slipped disc or a herniated disc.

Diagnostic Criteria: History taking and physical examination are the basis for diagnosis. Subjective and objective assessments are the primary diagnostic criteria. In the subjective assessment, SLR with clinical presentations is considered. In the objective assessment, Imaging may be advised to assess the severity of the damage.

Prognosis & Treatment: A recent systematic review found that conservative treatments do not clearly improve the natural course of sciatica in most patients or reduce symptoms. Strong evidence of effectiveness is lacking for most of the available interventions. There is a little difference in the effect on pain and functional status, between bed rest and staying active. As a result of this finding, bed rest—for a long time the mainstay of treatment for sciatica—is no longer widely recommended. Analgesics, non-steroidal anti-inflammatory drugs, and muscle relaxants do not seem to be more effective than placebo in reducing symptoms. Evidence for opioids and various compound drugs is lacking. (Diagnosis and treatment of Sciatica; BW Koes et al.Clinical Review)

In this case report, a 44 year old male patient presented with severe pain in lower back radiating to left leg till ankle joint since 1 month. He took some analgesics for pain management. As the condition persisted, he opted for Ayurvedic management and approached Dr Ravisankar Pervaje. Based on the investigation reports and clinical examination, the physician confirmed the biomedical diagnosis as Sciatica and Ayurvedic diagnosis as Vata kaphaja gridhrasi. 

Image 1. MRI scan of LS Spine at baseline dated 13.8.2023

Image 2. Blood reports at baseline dated 13.8.2023

Table 1. The clinical findings at baseline 

AYURVEDA DIAGNOSIS: Gridhrasi- Vata kaphaja

ABOUT THE DISEASE:

Gridhrasi is Vata Nanatmaja Vyadhi.

पार्ष्णिप्रत्यङ्गुलीनांतुकण्डरायाऽनिलार्दिता|
सक्थ्नःक्षेपंनिगृह्णीयाद्गृध्रसीतिहिसास्मृता||७४||(Su. Ni 1/74)

The condition in which Vata invades the Kandaras (tendons) of the ankles and toes produces kshepam (decreased movement)in the thighs is known as Gridhrasi.

Adhishtana of the disease; According to Cakradatta, kati and sphik are the initial sites of manifestation. According to Susruta, kandara of parshni, pada and anguli are affected.

Symptoms of Gridhrasi:

स्फिक्पूर्वाकटिपृष्ठोरुजानुजङ्घापदंक्रमात्|
गृध्रसीस्तम्भरुक्तोदैर्गृह्णातिस्पन्दतेमुहुः||५६||
वाताद्वातकफात्तन्द्रागौरवारोचकान्विता| (CS. Ci 28.56-57)

The common symptoms of Grdhrasi are–pain radiating from Sphik (buttock) the to kati, prsta, uru, janu, jangha and pada associated with stambha (stiffness), toda (pricking pain), spandana (twitching) and causes the Sakti utksepanigraha(restricted movement of the lifting of the leg). Commentator Arunadatta mentions the inability of the patient to lift his leg when affected with this condition. Specific symtpoms like ‘dehasya vakrata’ and kati- janusandhi sphuranam are mentioned as symptoms in vataja grdhrasi. Depending upon the dosa responsible for the pathology, the respective symptoms will be produced. 

In this case report, a 44 year old male patient presented with severe pain in lower back radiating to left leg till ankle joint since 1 month. He took some analgesics for pain management. As the condition persisted, he opted for Ayurvedic management and approached Dr Ravisankar Pervaje. Based on the investigation reports and clinical examination, the physician confirmed the biomedical diagnosis as Sciatica and Ayurvedic diagnosis as Vata kaphaja gridhrasi. 

Generally there are 2 presentations of Grdhrasi- kevala vata or vata kapha. Here Vata kapha has been specifically mentioned by the treating physician. In Vataja type, the symptoms are curved posture (altered gait) due to pain, severe stiffness, pulsation in back, hip, thigh, knee and foreleg. In Vata kaphaja type, along with the above mentioned symptoms, indigestion, drowsiness, nausea, anorexia, heaviness of the leg and freezing sensation in the lower limbs are complained. Hence the symptoms in this patient can be correlated with the presentation mentioned in Vatakaphaja type. 

Sadyasadhyata

A separate prognosis has not been mentioned for Gridhrasi. It may be said that gridhrasi, in which the vitiated vata is seated in majjadhatu or if gridhrasi is accompanied with khuddavata, angasosha and stambha may or may not be cured even after appropriate management. But if this condition occurs in a strong person and is of recent origin and without any associated disease, then it is curable. Sushruta mentions that a patient of vatavyadhi, if developed the complications like shuna, suptatvacha, bhagna, kampa, and pain in internal organs, then he will not survive.

नवान्बलवतस्त्वेतान्साधयेन्निरुपद्रवान्||७४|| (CS.Ci. 28/74)

Cikitsa of Gridhrasi

Gridhrasi being a Vata vyadhi, the general treatment followed is that of pacifying Vata. The first and foremost principle to be adopted in treatment is to avoid the nidana that causes gridhrasi.
According to the Dosha Kopa, Gridhrasi can be divided into three stages. It should be studied carefully before starting the treatment as the stage varies from time to time.
Stages of Dosha prakopa Treatment

1. Mild (vata) prakopa- Langhana
2. Moderate-  Langhana-Pachana
3. Severe-  (ama/vata kapha) Shodhana.

In all stages of Gridhrasi, except in Amavastha, oil preparations are suggested by all Acaryas, both externally and internally. The stage of gridhrasi in the patient was not specified by the treating physician.

In Charaka Samhita Bastikarma (Niruha and Anuvasana basti), Siravedha and Agnikarma (between kandara and gulpha) have been advised. Sushruta has advised Siravedha at janu after flexion. Astanga sangraha and Astanga Hrdaya have also advised Siravedha four angula above the janu. Yogaratnakara has recommended siravedha in the area of four angula around vasti and mutrendriya; if this fails, agnikarma in the little finger of the leg is advised.

Treatment & Rationale of treatment; Vangasena mentions Dipana, pacana, vamana, virecana, vasti and siravyadha as the line of treatment. This being a vatavyadhi, the basic treatment target is to pacify vata.

Table 1. The medicines/therapies chosen and their specific rationales explained by the physician

Apart form this, specific Pancakarma procedures were also planned, targeting the symptoms and pacification of Dosas. 

Table 2. The medicines/therapies chosen and their specific rationales explained by the physician

OUTCOME MEASURES

In this case report, a 44 year old male patient presented with severe pain in lower back radiating to left leg till ankle joint since 1 month. He took some analgesics for pain management. As the condition persisted, he opted for Ayurvedic management and approached Dr Ravisankar Pervaje. Based on the investigation reports and clinical examination, the physician confirmed the biomedical diagnosis as Sciatica and Ayurvedic diagnosis as Vata kaphaja gridhrasi.

Assessment: Both objective and subjective parameters were assessed to analyse the outcome of the ayurvedic treatment. 

Subjective parameters: After 3 days of starting ayurvedic treatment, there was a significant reduction in back pain and the posture improved. After 12 days of ayurvedic treatment, the patient got complete relief from pain. 

Objective parameters: VAS was recorded at baseline and at endpoint

Table 1. Observations and clinical findings recorded throughout the treatment