1. Jithesh et al., 2015 / Cauda Equina Syndrome and its management
International Research Journal of Pharmaceutical and Biosciences (IRJPBS) 2 (4) 34-39 34
RESEARCH ARTICLE
International Research Journal of Pharmaceutical and Biosciences
Pri -ISSN: 2394 - 5826
http://www.irjpbs.com e-ISSN: 2394 - 5834
Cauda Equina Syndrome and its Management – A Case Report
Jithesh M1, Nayana S2, Gayathri Jayan3
PG Department of Manasroga, VPSV Ayurveda college, Kottakkal, Kerala, India
Article info Abstract
Article history:
Received 01 August 2015
Accepted 08August2015
*Corresponding author:
drjitheshm@gmail.com
Copyright  2015 irjpbs
Cauda equina syndrome (CES) is a serious neurologic condition
in which damage to the cauda equina causes acute loss of functions of
lumbar plexus, (nerve roots) of spinal cord below termination (conus
medullaris).CES is a lower neuron lesion which mainly caused severe
back pain, saddle anaesthesia,(including perineum, external genetalia
and anus, mostly numbness),bowel and bladder dysfunction usually
incontinence, sciatica, absence of Achilles reflex and sexual dysfunction.
As this syndrome has an insidious onset, allopathic physician advises
immediate surgery of spine.
From Ayurvedic perspective disease can be discussed under
marmaabhighata, kateegraha, and pakwasaya gata vatha, which may be
effectively managed accordingly. A selected Ayurvedic protocol with
internal medication and panchakarma procedures has been found
effective in curbing the symptoms and progression of disease.
Here is the case of a 32 year old woman, who underwent spinal
surgery for the CES and was bedridden with persisting symptoms
including sphincter dysfunction. She persuaded 3 months Ayurvedic
treatment along with yoga and returned to her normal life.
Key words : Cauda equina syndrome, Pakwasaya gatha Vatha,
Kukundara marma, oorusthamba
Case History
A 32 year old female apparently healthy before one year, developed a low back pain of
insidious onset. She took allopathic medication and got non considerable relief. A few days later,
pain aggravated and she couldn’t rise from bed, and then was taken to allopathic hospital and given
analgesic injections. The pain subsided, but immediately she developed incontinence of urine as
well as the bowel. She was soon taken to a reputed super speciality hospital of the state and was
admitted for emergency surgery, for a prolapsed disc for the purpose of decompression. After the

2. Jithesh et al., 2015 / Cauda Equina Syndrome and its management
International Research Journal of Pharmaceutical and Biosciences (IRJPBS) 2 (4) 34-39 35
surgery, LBA was relieved to some extent, but she developed weakness of both lower limb
associated with paraesthesia over posterior aspects of thigh, leg, groin and buttocks and also had
bowel and bladder incontinence. The patient was brought to the OPD of this hospital on wheelchair
in a state of mild depression as well. She was catheterised with rubber catheter 3-4 times a day and
digital evacuation of the stools were also carried out at least in 3 days. She was diagnosed as Cauda
Equina Syndrome1. Patients, who present with bowel or bladder disturbances, leg weakness, or
rectal and genital sensory changes after manipulation, be recognized as experiencing a cauda
equina syndrome.
Clinical Examination
Vitals - pulse rate 70/ml, regular full volume
HR – 70/min, BP-110/70 mm Hg right arm sitting, Temp – 98.4°F (armpit), Respiration rate
14/min
Sensory system was impaired in both the lower limbs with high stepping gait.
Loss of sensation, touch, temperature and pressure in dorsal aspect and lateral aspect of
both feet and along the lateral aspect of thighs, gluteal and perineal aspects. There was motor
weakness with grade II, in both the lower limbs with restricted dorsiflexion of the foot. SLR was not
able to perform and there was grade II tenderness on L4 and L5 regions. Deep Tendon Jerks were
not elicitable in both the lower limbs. She was able to stand with support.
Assessment was made using the JOA Back Pain Evaluation questionnaire after 45 days of
treatment and on the 90th day2. The psychological status on assessment using the PHQ-9 Patient
Depression Questionnaire pointed to the status of moderate depression3.
Table 1. JOA SCORE FOR LOW BACK PAIN
SYMPTOM BASELINE SCORE SCORE 1ST
ASSESSMENT
S SCORE 2ND
ASSESSMENT
Low-back pain 0 2 3
Leg pain and tingling 0 1 2
Gait 0 1 2
SLR 0 1 2
Sensory disturbance 0 1 1

3. Jithesh et al., 2015 / Cauda Equina Syndrome and its management
International Research Journal of Pharmaceutical and Biosciences (IRJPBS) 2 (4) 34-39 36
Motor disturbance 0 1 2
ADL restriction 2 1 1
Bladder dysfunction 6 3 3
Management
The initial line adopted was of oorusthamba4 which includes rookshana both internal as
well as externally. Along with the same, Marmaghata with special reference with kukundara marma
was also adopted5. Simple counselling was also conducted with the postgraduates from the
department. With all these the primary correction of agni as well as ama was kept in mind while
selecting the medicines. Later the protocol was changed as per the management of Vathavyadhi.
Table -2: Internal medicines
Formulation Duration (days) Rationale
Mustadi marma
kwatha
30 Marmabhighata chikitsa
Chirivilwadi kwatha 30 Anulomana
Hinguvachadi choorna
with hot water
30 Deepanam and pachanam
Dhanvantaram kashayam 31-90 Kateegraha chikitsa
Balarishtam 31- 90 Pakwasayagata vata chikitsa
Tab chandraprabha 31- 90 Mootraghata chikitsa
Vasthyamayantaka gritha 31-90 Mootraghata chikitsa
Kanmadha bhasma 31-90 Rasayana
Panchakarma and allied procedures
Table 3: Panchakarma Procedures done
Procedure Medicine Duration(days) Rationale

4. Jithesh et al., 2015 / Cauda Equina Syndrome and its management
International Research Journal of Pharmaceutical and Biosciences (IRJPBS) 2 (4) 34-39 37
Udwarthana Yavakolakulathadi choornam
7 Rookshana
Snehapana Sahacharadi tailam sevyam 5 Snehana
Avagaha Sweda Dasamoola, eranda 3 Swedana
Virechana Eranda sukumara 25ml 1 Sodhana
Choornapinda sweda
(snigdham)
Kolakulathadi choornam
5 Vatha vyadhi
chikitsa
Kayasekam Dhanvantaram tailam 7 ,,
Shashtika panda swedam Mahamasha tailam 7 ,,
Matra vasti
Dhanvantaram mezhuku
pakam
2 ,,
Ksheeravasti Sahacharadi ksheera kashayam 3 ,,
We started with rookshana which brought considerable changes in the sensory perception
of the lower limb. The takrapana relieved her distaste and enhanced her appetite. This was
followed by snehana and swedana. Avagaha sweda was selected with Dasamoola and eranda
kwatha in consideration with the reported sphincter disturbances6. After this the patient, started
feeling micturition sensation and gained Grade II power in the lower limb. Snigdha virechana which
is ideal for Vatha kopa in the pakwasaya was selected in this case for the expulsion of the
accumulated doshas7. Three days rest was given and the patient was maintained on strict diet of
rice gruel, cooked vegetables, especially fibre rich ones (for enhancing the the bowel movements)
with minimal oil and salt and green gram soup.
3 days after the sodhana, Choorna pinda swedam was done after applying mahamasha
tailam. General body strength of the patient was improved and she was able to stand giving
strength to her lower limb and feet. This was succeeded by Kayasekam for 7 days followed by
Ksheera vasthi with preceeded anuvasana8. She started walking with ataxic gait and the pain
reduced.
Considering the urinary incontinence, she was advised with Kegel’s exercise twice daily for
20 times. Pichu with Dhanvantaram taila, intra vaginally had been a routine procedure for these
days9. Along with the same, Pichu on low back region and abhyanga with murivenna and
sahacharadi tailam was given locally for 14 days. Later shashtika pinda swedam was done for 7

5. Jithesh et al., 2015 / Cauda Equina Syndrome and its management
International Research Journal of Pharmaceutical and Biosciences (IRJPBS) 2 (4) 34-39 38
days which provided an overall improvement in the motor and sensory attributes of the patient.
She was practised with selected yoga procedures for Low Back Pain along with breathing exercises
and discharged with advice for follow-up on the 90th day10. She continued with the internal
medicines.
Result
After 3 months of treatment, patient got relief from the major symptoms like parasthesia,
difficulty in walking and her sensory and motor attributes of lower limb improved. She had
improvement in the overall muscle strength. Though she had little relief from the faecal and
urinary incontinence, there was an improvement with a vague sensation of the urges. She was able
to pass urine and faeces with little effort without any need of catheterisation or digital evacuation.
Quality of life of the patient greatly improved and after discharge, in the follow up after 3 months,
she was able to do her routine works. She was psychologically normal and got rid of her
depression.
Discussion and Conclusion
Cauda Equina Syndrome was not correlated to any particular disease .The compression
which occurred in the the cauda equina was considered as kateegraha due to abhighata and
marmabhighata chikitsa was considered in the primary level. The symptoms like urinary and faecal
incontinence, as well as the loss of strength, in the lower limbs is mentioned, in the injury of
kukundara marma, by Vaghbata. Similar symptoms are also a feature of disturbed Vatha in
Pakwasaya. The treatment was planned as mentioned above in a systematic manner giving due
importance to the agni and attained upasaya in the stage of the treatment.
This case report can be considered as a ray which can brighten the shady areas were
allopathic medicine’s reach, is not as expected. But considering the symptoms and the cause, any
disease can be approached with the Ayurvedic concepts of pathophysiology and management. This
has to be followed by continuous administration of internal medicines. The treatment protocol can
be repeated based on the attained improvement after an year. The earlier intervention also aids in
a better prognosis. The unexplored treasure of Ayurveda in the area of complicated diseases like
CES has to be brought to light and the possibilities of the Ayurvedic treatment modalities in
similar cases has to be studied and reported for the benefit of the society, so as to improve the
quality of life of the affected.

6. Jithesh et al., 2015 / Cauda Equina Syndrome and its management
International Research Journal of Pharmaceutical and Biosciences (IRJPBS) 2 (4) 34-39 39
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