MYELOPATHY CASE PRESENTATION

1. CASE
PRESENTATION
FINAL YEAR P.G. SCHOLARS
DEPARTMENT OF PG STUDIES IN KAYACHIKITSA
SKAMCH&RC
VIJAYANAGAR
BENGALURU
1

2. ATURA VIVARANA
2
 Name : Mr. P. K. Raju
 Age : 55 Years
 Sex : Male
 Religion : Hindu
 Socio economic status : Middle class
 Marital status : Married
 Occupation : Peon in BBMP

3. 3
 Address : Sunkadakatte
Bengaluru
 Source of history : Patient
 O.P No :E19392
 I.P. No : 2445/17
 Ward : Male General ward
 Date of admission : 16/06/17
 Date of discharge :

4. 4
 Case taken on : 30/06/17
 Consultant doctor : Dr. Byresh A

5. PRADHANA VEDANA
5
C/O Pain in the neck region radiating to B/L upper limbs
Since 5 months.
Weakness in B/L upper limbs Since 5 months.

6. ANUBANDHA VEDANA
6
C/O burning sensation, numbness and tingling sensation in B/L upper
limbs and lower limbs.
Unable to do daily activities like taking bath, wearing shirt, holding
objects, eating etc., with respect to both upper limbs.
Increased frequency of micturition with increased volume, increased
thirst and sweating aggravated since 5 months
Constipation Since 5 months
C/O cyst over left eyebrow since 1 week

7. VEDANA VRITTANTA
7
 The patient is a K/C/O DM since 8 years presented with a
history of sudden development of shocking type of pain in
the neck region radiating to both upper limbs while carrying
files at office 5 months before (Feb 2017). The pain was so
severe that he dropped the files and there was a sort of
sudden weakness in both upper limbs and couldn’t move the
hands. But there was no H/O fall/ LOC/ headache/ giddiness.

8. 8
he found difficulty in walking also and there was increased
frequency of urination. For these complaints, he was
admitted in Sindhi hospital for a day and was later referred
to Sita Bhateja Hospital and was admitted for 10 days,
necessary investigations done and conservatively treated.
After discharge, the weakness of the upper limbs still
persisted, but was able to walk. The weakness of the upper
limb hampered his daily activities like taking bath, wearing

9. 9
shirt, holding of objects, eating etc., Also he developed
constipation and disturbed sleep. Frequency of micturition
also persisted. So, he consulted a folklore practitioner in
Yentaganahalli where he was treated with some oil
application, coin and bandage application. But there was no
improvement noted.
Aggravating factors: The pain and numbness increases on
exposure to cold water , fan.

10. 10
By the suggestion of their relative, he came to
SKAMCH&RC for further management. After admission,
he developed cyst over left eyebrow since 1 week.

11. POORVAVYADHI VRITTANTA
11
 K/C/O DM since 8 years. Initially was on OHA for 5
years, on insulin for 3 years. Stopped Insulin 4 months
back and now only OHA.
 H/O Surgery for low back ache - around 6 years back.
 H/O cyst mid back ,done excision 4 years back
 H/O of repeated cyst over left eyebrows – managed
with I&D since 2 years.

12. CHIKITSA VRITTANTA
1
 In Sita Bhateja Hospital (7/2/17 to 16/2/17)
Diagnosis- Central cord syndrome, Uncontrolled DM, oral
candidiasis, LRTI
Treatment given: IV Fluids
Inj.Tramadol
Inj.C Tri
Inj. Dexa
Inj.Solumedrol
Inj.Optineuron

13. • Inj. Flucon
• Inj.H.Actrapid
• Inj.Human Insulin
• Tab.Ecosprin AV
• Tab. Glychek M forte
• Tab. Neurica M
• Tab. Janumet
• Tab.Wysolone
• Syp.Ambrolite
• Incentive Spirometry
• Asthalin Nebulization
• Duolin Nebulization
• Chest and limbs-
physiotherapy
13

14. ON MEDICATIONS
1
Tab.Ecosprin AV 0-0-1
Tab. Glychek M forte 1-0-1
Tab. Neurica M 75 mg 1-0-1
Tab. Janumet 50/500 0-1-0

15. KOUTUMBIKA VRITTANTA
15
 All family members are said to be healthy.

16. VAIYAKTIKA VRITTANTA
16
 Ahara : Non-Vegetarian ( Twice/week).
 Mala Pravrutti : Once in 5 days
(Irregular, hard stools)
 MutraVisarjana : 10-12 times / day
3- 4 times / night
 Nidra : Disturbed due to pain and burning
sensation

17. VAIYAKTIKA VRITTANTA
17
 Vyasana : Coffee (2-3 times /day)
Beedies- 20 since 20 years,
Cigarrete – 10-15 /day since 5 months
Alcohol – 250 ml/day since 15 years

18. ROGI PAREEKSHA
18

19. ATURA BHOOMI DESHA PAREEKSH
19
 Jatatah : Sadharana
 Samvardhitah : Sadharana
 Vyadhitah : Sadharana

20. ASTHA STHANA PARIKSHA
20
 Nadi :68/min
 Mutra :10-12 times / day, 3-4 times / night
 Jihva : Lipta
 Mala : Once in 5 days (irregular, hard stools)
 Sabdha : Prakruta
 Sparsha : Anushna sheeta
 Druk : blurrness in left eye
 Aakruti : Madhyama

21. DASHAVIDA PAREEKSHA
21
1) Prakriti : Pitta kapha
2) Saara : Madhyama
3) Samhanana : Avara
4) Pramana : Madhyama (Height: 167cm, Weight :
78.7kg)
5) Saatmya : Vyamishra
6) Satva : Madhyama
7) Aahara Shakti :
Abhyavaran Shakti : Avara

22. 22
8) Vyayama Shakti : Avara
9) Vaya : Madhyama
10) Vikriti : pravara
Hetu : rooksha, virudhahara sevana,
vishamashana
Dosha :tridosha(vatapitta)
Dooshya : shareera kleda, lasika, Rasa, Rakta,
abadha Mamsa, abadhameda, vasa,majja,
ojas,Asthi

23. 23
8) Desha : Sadharana
Bala : Avara
Kala :varsha
Prakriti : vikruti vishama samavaya

24. SAMANYA PARIKSHA
(GENERAL PHYSICAL EXAMINATION)
24
Patient is conscious, alert, oriented to time, place and
Person.
 Built : moderately built
 Nourishment : Moderately -Nourished
 Pallor : Absent
 Oedema : Mild pitting oedema in b/l hands
 Cyanosis : Absent
 Nail : No clubbing or koilonychia
 Icterus : Absent
 Lymphadenopathy : Absent

25. 25
 Temperature : Afebrile
 Pulse : 78 bpm.
 BP : 130 / 90 mmHg.
 R/R : 16b/min
 Tongue :coated
 Height :167cm
 Weight :78.7
 BMI :28.3

26. VISHISHTA PARIKSHA
(SYSTEMIC EXAMINATION)
26
 PER ABDOMINAL EXAMINATION
Inspection - Shape- distended
Umbilicus- Centrally placed, inverted
No Scar marks, No hyper pigmentation
Auscultation - Bowel sounds heard .
Palpation - Soft
No Tenderness
No organomegaly
Percussion - Tympanic

27. 27
 RESPIRATORY SYSTEM
Inspection –
Shape of chest –B/L symmetrical
Chest movements- Symmetrical
Respiratory rate-18/min
Palpation - Trachea - Centrally placed
Chest Expansion - Symmetrical
Tactile vocal fremitus - Normal
Percussion - B/L Resonant
Auscultation - B/L Normal Vesicular Breath Sounds heard

28. 28
 CARDIO VASCULAR SYSTEM
Inspection – No scar marks
Palpation - Apex beat felt @ 5th intercostal space lateral to
left mid-clavicular line
Percussion – Cardiac dullness noted
Auscultation - S1, S2 heard, No added sounds

29. LOCOMOTOR SYSTEM EXAMINATION
29
GAIT Normal
Inspection :
Shoulder ,upper limbs and hand muscle atrophy present
No scars seen over neck, shoulder and arms,
Swelling noted over bilateral hands
Palpation :
No tenderness, warmth, mass felt. Muscle atrophy felt
over shoulder, arm, forearm and hand muscle,

30. 30
Shoulder joint :
All Range of movements
Restricted and painful
Spine examination:
Inspection
Old surgical scar seen over spinous
process of lumbar vertebrae, excision scar
over midback.
No scoliosis / lordosis/ kyphosis noted

31. 31
Palpation
No Warmth, No mass, No Swelling
No tenderness
Range of motion
All cervical spine and lumbar spine motion
Possible and painless

32. CENTRAL NERVOUS SYSTEM
EXAMINATION
32
(A)HIGHER MOTOR FUNCTIONS
Consciousness – Fully conscious
Orientation to -time, place and person is Intact.
Memory -immediate, recent and remote is Intact.
Intelligence- Intact
Hallucination & Delusion- Absent
Handedness-Right

33. 33
(B) CRANIAL NERVE EXAMINATION
All cranial nerves Intact
(C) MOTOR SYSTEM
1)Involuntary movements – fasciculations Present over
upperlimbs
2)Muscle bulk – Rt Lt
Biceps 28.5cm 29cm
Forearm 22cm 21.5cm
Mid Thigh 44cm 46cm
Calf Muscles 33cm 32cm
3)Muscle tone Hypotonia present

34. 34
Rt Lt
4)Muscle strength
a)Elbow -flexion 3/5 3/5
-extension 3/5 3/5
b)Wrist -flexion 3/5 3/5
-extension 3/5 /5
c) Finger abduction
d)Opposition of thumb not possible
e) Test of grip

35. 35
Rt Lt
Hip -adduction 5/5 5/5
-abduction 5/5 5/5
-flexion 5/5 5/5
-extension 5/5 5/5
Knee -flexion 5/5 5/5
-extension 5/5 5/5
Ankle -dorsiflexion 5/5 5/5
-plantarflexion 5/5 5/5

36. 36
5)Coordination
Finger nose test
Rapid alternative movements – not possible
Heel to shin test - possible
Intention tremor - absent
Tandem walking – rate-slow-Possible
Rhomberg test - Negative
Pronator drift – Absent, Rebound phenomenon – absent.

37. 37
6)Gait- normal
7)Reflexes
Superficial Reflexes
a)Corneal -present
b)Abdominal -present

38. 38
Rt Lt
Deep Reflexes (2 + indicates normal)
a)Biceps jerk +++ +++
b)Triceps jerk +++ +++
c)Knee jerk +++ +++
d)Ankle jerk - -
e)Clonus (ankle) Absent Absent
Plantar reflex - not able to elicit dorsiflexion

39. 39
(D) SENSORY SYSTEM
1)Superficial:
a)Touch -Intact
b)Temperature -Intact
c)Pain - hyperasthesia present
2)Deep:
a)Vibration - present
b)Position sense -present
c)Pressure sense -present

40. INVESTIGATIONS
40

41. 41
MRI cervical spine on 7th feb 2017
Impression :-
Long segmental focal T2 hyperintensity
involving the cord extending from c2 to c7
level ischaemic etiology ?
Posterior, central and b/l para central disc
protrusions at c4-c5 and c5–c6 level causing
moderate thecal compressions.
Posterior right para central disc protrusions at
c6-c7 level causing significant right lateral
recess nerve root compression.

42. ROGA PAREEKSHA
42

43. NIDANA PANCHAKA
43
Nidana – Madhumeha+ virudhahar, vishamashana
 Purvaroopa - karapadadaha
 Roopa- karmakshaya of bahu( gatisanga), balamamsa
kshaya in urdhwa shakha, sarvanga daha, suptata, harsha
Atisweda, trushna, aruchi, klama, mootraatipravruthi, vit
sanga
Anupasaya: sheeta jala, sheetavayu samsparsha

44. Tridosha
prakopa(vatapitta)
Madhumeha Amotpathi
Prameha pidakas,
prabhuta mootrata,
pipasa, swedadikyada,
indriyaupalepa
44
Circulates through
out the body
Sthanasamshraya over
trika sandhi
greevapradesha
Avarana
Nidana
Vikruthi in
tiryak gata
dhamanais
Sarvanga
daha,atisweda, supti,
harsha,klama

45. 45
Sira,snayu,kandara
shosha
Kramaath shoola,
karmakshaya of bahu,
bahushosha Sparshajnana
vikruti,
Rasadeemshcha
upashoshayeth to greeva-
urdhwa shakha
Vishwachi,
bahusheershagata
vata
Hampers the
nourishment to the
kaphasthana-trika
sandhi

46. Samprapthi ghataka
• Dosha -Tridosha (vatapitta)
• Avaraka dosha- pitha and kapha
• Avrutha dosha- samana, vyana, apana
• Dooshya - shareeraja kleda, lasika rasa,rakta,
abadha mamsa, abadha meda, majja, asthi,
• Agni -Jataragni, dhatvagni
• Ama - Jataragnimandhyajanya
• dhathwagnimandhyajanya
46

47. • Srothas - rasavaha, raktavaha, mamsavaha,
medovaha, astivaha, mootravaha, udakavaha, swedavaha
• Srotho dushti prakara – sanga
• Udbava sthana -Amashaya and pakwashaya
• Vyaktha sthana - sarvashareerea
• Adhishtana - greeva and basti
• Marga - Madhyama
• Sadhyasadhyatha - kashtasadhya
47

48. VYAVACHEDAKA NIDANA
48

49. 49
Vyadhi
Avabahuka bahupraspaditahar
a
kramaathshoola
vatarakta Vidaha, vedana,
sweda,
trushna,shosha
Tasya sthanam
karou
padavangulya,
sarvasandhi
Pakshagha
ta
Sira snayu
vishoshana,
sandhibandha
vimokshayan,
karmakshaya
Ardhakaya
akarmanya and
vichetana

50. 50
Bahushosh
a
Amsabandhana
shosha, bahushosha,
savedana
Vishwachi Bahukarmakshaya,
kramathshoola.
Madhumeha
upadrava
Prameha pidakas,
trushna, daha,
dourbalya, arochaka,
avipaka

51. 51
DIFFERENTIAL DIAGNOSIS

52. 52
Radiculopathy Myelopathy
Pain, Burning, tingling,
numbness in neck region
with radiation into arm and
generally unilateral
associated with paresthesia
and weakness
Bilateral weakness with neck
pain
Paraesthesia in bilateral
upper limb and lower limb
Often with urinary
incontinence
Sudden onset
Deep tendon Reflexes
exaggerated with extensor
plantar response

53. 53
Neuropathy Mechanical neck pain
Paresthesia
Weakness and atrophy more
distal than proximal
Sensory deficits commonly
in stock and glove pattern
Mostly distal parts of lower
limbs are involved
Deep tendon reflexes are
diminished
Neck pain
Muscle spasm, stiffness,
tightness in upper back and
shoulder lasting upto 6
weeks
No neurological deficits.

54. 54
Multiple sclerosis Acute transverse
myelitis
Insidious over days to
weeks
Age of onset is 20-45 yrs
Common in females
Bladder dysfunction
Sensory disturbances
Ataxia, spastic paraplegia
Optic neuritis, scanning
speech
Neurological deficits are
seen
Symmetrical numbness
and weakness
With bladder dysfunction

55. 55
Gullian barre syndrome Motor neuron disease
Weakness and muscle
wasting
Bilateral ascending motor
paralysis
Deep tendon reflexes are
absent
Self limiting and
recovery in 2-4 weeks
Wasting of muscles
Insidious onset
Deep tendon reflexes are
diminished in upper half
of body and exaggerated
in lower half of body
No sensory impairement

56. 56
CVA
Reduced strength of b/l
upperlimbs,Deep tendon
reflexes exaggerated,
Babinski sign present
Presentation is
commonly hemiplegic
with altered gait, Spastic
plegia.

57. VYADHI NIRNAYA / DIAGNOSIS
57
Vishwachi, bahushosha, madhumeha upadrava
Cervical Myelopathy
 Diabetic Neuropathy


58. DATE CHIKITSA OBSERVATION
19/06/1
7
•Continue same treatment
( Stop Sarvanga CPS with kottamchukkadi
churna and jadamayadi churna )
• Niruha basti with dashamoola kwatha 500ml
and gandharvhastyadi taila 100ml-stat
• sarvanga abhyanga with moorchita taila
followed by patra potli sweda (for 10 days)
C/o pain in the neck
region radiating to both
upper limb reduced 10
percent
Basti pratyagamana kala 5
min
Number of Evacuation 2 .
20/06/1
7-
26/6/16
Continue same treatment
Nasya karma
(mukha abhyanga with ksheerbala taila
followed by naadi sweda followed by nasya
with mahamasha taila 15 drops to each
nostril (for 10 days)
C/o pain in the neck
region radiating to both
upper limb persisting
disturbed sleep, fatigue
Bowel- not passed
58

59. DATE CHIKITSA OBSERVATION
16/06/1
7
to
18/06/1
7
1) Greeva basti with mahavishgarbha
tailam (for 10 days)
2) Sarvanga CPS with kottamchukkadi
churna and jadamayadi churna (for 5
days)
3) Dhandhanyadi kashayam 3tsf with 9
tsf water (7am and 6pm)
4) Cap – palsineuron (one cap tid)
5) Gandharvhastyadi taila and dashmoola
kwatha choorna
(1tsp kwatha choorna with 100ml water boil
and reduce to 50ml. Filter and add 2 tsp
gandharvhastyadi oil to be taken two
times daily.
Pain in neck region radiating
to both upperlimb associated
with tingling sensation,
burning sensation, reduced
strength in b/l upperlimb, not
able to hold any objects,
Incomplete evacuation- once
in 5 days, hard stools
Bladder- 10- 12 times day/ 3-
4 times at night
Reduced appetite
Disturbed sleep
59

60. DATE CHIKITSA OBSERVATION
27/06/17 Continue same treatment
• Refered to physiotherapy
• Referd to shalya dept
Nodular swelling over left upper
eyelid
Bowel- passed
Disturbed sleep
28/06/17 Continue same treatment Fatigue+
Radiating pain to b/l upperlimb
reduced by 25%
Burning sensation persisting all
over the body
29/6/17 Continue same treatment
Went to shalakya dept
Adviced excision of cyst
Stopped nasya
60

61. DATE CHIKITSA OBSERVATION
30/06/17 No panchkarma treatment
1) Dhandhanyadi kashayam 3tsf with 9 tsf
water (7am and 6pm)
2) Cap – palsineuron (one cap tid)
3) Gandharvhastyadi taila and dashmoola
kwatha choorna
(1tsp kwatha choorna with 100ml water boil
and reduce to 50ml. Filter and add 2 tsp
gandharvhastyadi oil to be taken two
times daily.
Pain in the neck region
both upperlimb
persisting
Cystic swelling not
operated
Bowel- passed
Sleep disturbance
61

62. DATE CHIKITSA OBSERVATION
1/07/17-
2/7/17
CST
Tab.hifenac p sos
Tab augumed cv 625mg bd A/F
Excision of cyst done in
shalya opd
Under local anesthesia
3/7/17 CST
Kamadugda rasa with mukta1-1-1 a/f
dressing done
Aruchi+
Fatigue
Burning sensation
Bowel not passed
62

63. PROPOSED TREATMENT PLAN
FIRST LINE OF TREATMENT
Sarvanga Parisheka with patoladi gana + dashamoola
ksheera paka 7 days
SHAMNOUSHADHI
• Dhanadanayanadi Kashaya + prasarynyadi Kashaya
2tsp each Kashaya+ 12 tsp water mrg and evg empty
stomach
• Gandharvahasta taila 20ml with ksheera 50ml at night.
63

64. SECOND LINE OF TREATMENT
Sarvanga Abhayanga triphala taila followed by shashtika
shali pinda sweda for 7 days
• Dhanadanayanadi Kashaya + prasarynyadi Kashaya
2tsp each Kashaya+ 12 tsp water mrg and evg empty
stomach
or
Bhadradarvyadi+ maharasnadi Kashaya
2tsp each Kashaya+ 12 tsp water mrg and evg empty
stomach
Yavanna
64

65. THIRD LINE OF TREATMENT
• Mukhabhyanga with Karpasathyadi thaila and Nasya
with ksheerabala 101 avarthi/ maharajaprasarini thaila
8 bindu pramana sayam kaala after food for 7 days
• Bhadradarvyadi+ maharasnadi Kashaya
2tsp each Kashaya+ 12 tsp water mrg and evg empty
stomach
• Trayodashanga guggulu
2-2-2 A/F
65

66. FOURTH LINE OF TREATMENT
• Madhutailika basthi for kala basthi
• Madhu – 80ml
• Moorchita tila Taila-80ml
• Saidhavalavana-12gm
• Kalka(shatapushpa kalka)-20gm
• Dashamoola kwatha- 300ml
• Anuvasana with moorchita tila taila- 40ml 66

67. • Bhadradarvyadi+ maharasnadi Kashaya
2tsp each Kashaya+ 12 tsp water mrg and evg empty
stomach
• Trayodashanga guggulu
2-2-2 A/F
Rasayana prayoga
Shilajathu prayoga- 12gms with milk
67

68. 68