This article explains the orthopedic approach to limping in children. This is a review article including a selected collection of new articles extracted from PubMed and Google Scholar searched for clinical points and ...This article explains the orthopedic approach to limping in children. This is a review article including a selected collection of new articles extracted from PubMed and Google Scholar searched for clinical points and beneficial approaches to limping children. In this paper, limping is divided into two categories, painful and painless. After stating the important points in the patient’s medical history and explaining specific examinations in this area, different gait types in children are explained and the best evaluation method for them is presented. Then, paraclinical examinations and imaging are described in a practical evaluation, high-risk etiologies of limping such as infections, tumors, and fractures are explained in detail and red flags are considered at each step. The algorithms and the list of differential diagnoses for each age group are included, which can provide physicians with a more comprehensive approach to limping in children.展开更多
Typically situated posterolateral in the spinal canal, intraspinal facet cysts often cause radicular symptoms. Rarely, the midline location of these synovial or ganglion cysts may cause thecal sac compression leading ...Typically situated posterolateral in the spinal canal, intraspinal facet cysts often cause radicular symptoms. Rarely, the midline location of these synovial or ganglion cysts may cause thecal sac compression leading to neurogenic claudication or cauda equina syndrome. This article summarizes the clinical presentation, radiographic appearance, and management of three intraspinal, midline facet cysts. Three patients with symptomatic midline intraspinal facet cysts were retrospectively reviewed. Documented clinical visits, operative notes, histopathology reports, and imaging findings were investigated for each patient. One patient presented with neurogenic claudication while two patients developed partial, subacute cauda equina syndrome. All 3 patients initially responded favorably to lumbar decompression and midline cyst resection; however, one patient required surgical stabilization 8 mo later. Following the three case presentations, we performed a thorough literature search in order to identify articles describing intraspinal cystic lesions in lateral or midline locations. Midline intraspinal facet cysts represent an uncommon cause of lumbar stenosis and thecal sac compression. Such entities should enter the differential diagnosis of midline posterior cystic lesions. Midline cysts causing thecal sac compression respond favorably to lumbar surgical decompression and cyst resection. Though laminectomy is a commonly performed operation, stabilization may be required in cases of spondylolisthesis or instability.展开更多
BACKGROUND Ligamentum flavum cysts,which are most common in mobile junctional levels of the spine,can be a rare cause of spinal stenosis.There have been several case reports of ligamentum flavum cysts.However,there is...BACKGROUND Ligamentum flavum cysts,which are most common in mobile junctional levels of the spine,can be a rare cause of spinal stenosis.There have been several case reports of ligamentum flavum cysts.However,there is yet to be a documented case report of a calcified ligamentum flavum cyst.Herein,we report the first case of a calcified ligamentum flavum cyst causing ankle and toe weakness.CASE SUMMARY A 66-year-old male visited our hospital complaining of claudication as well as thigh and calf pain in his left leg,all beginning two weeks prior.Physical examination revealed motor weakness of the left ankle dorsiflexion and great toe dorsiflexion.Lumbar spinal computed tomography scans showed spinal stenosis combined with a calcified mass at the left side of the L4-5 level.Magnetic reso-nance imaging showed dural sac compression caused by the calcified mass at the left ligamentum flavum of the L4-5 level.We performed decompressive laminectomy and excision of the calcified mass combined with posterior lumbar interbody fusion at the L4-5 level.Intra-operatively,we found a firm and nodule like mass originating from the ventral surface of ligamentum flavum.Pathological examination suggested a calcified pseudocyst without a capsular lining.After the operation,the patient’s motor weakness in the ankle and great toe improved gradually.CONCLUSION The patient’s ankle and great toe weakness were improved successfully after surgical removal of the calcified cyst.展开更多
Cystic adventitial disease （CAD） is a rare condition characterized by cyst!c lesions of the non-axial blood vessels adjacent to joints;j the majority of cysts are in the lower limb, with popliteal artery predominanc...Cystic adventitial disease （CAD） is a rare condition characterized by cyst!c lesions of the non-axial blood vessels adjacent to joints;j the majority of cysts are in the lower limb, with popliteal artery predominance. Here, we report a case of cystic adventitial disease in a 47-year-old man who was misdiagnosed and performed percutaneous transluminal angioplasty （PTA） in other hospital. He was eventually treated successfully with incision and evacuation of the popliteal cyst and ligation of communicating channels to the knee joint and remains asymptomatic 1 year later.展开更多
Spinal arteriovenous malformation (AVM) is a rare disease that arises more commonly from the lower thoracic and upper lumbar spine. It is classified based on the development pattern and the shunt location. The develop...Spinal arteriovenous malformation (AVM) is a rare disease that arises more commonly from the lower thoracic and upper lumbar spine. It is classified based on the development pattern and the shunt location. The developmental mechanism of the symptoms is thought to be as follows. Spinal venous return is impaired by high-pressure arterial blood flowing into the coronary sinus via a shunt and venous pressure is promoted, which causes spinal cord symptoms to progress gradually. Listlessness, pain, and an abnormal sensation of the lower limb are possible initial symptoms. Spinal AVM may cause intermittent claudication and bladder and rectal disturbance, and differentiation from lumbar degenerative diseases and arteriosclerosis obliterans is required, which may cause difficulty with diagnosis. We encountered a patient in whom intermittent claudication was treated with lumbar decompression and fixation at another hospital, but symptoms did not improve. The patient was diagnosed with spinal AVM at our hospital and symptoms were improved by surgery. Because the symptoms did not improve despite being treated with surgery for spinal canal stenosis, we strongly suspected spinal intermittent claudication, and we performed a spinal CT and MRI after myelography for the entire spinal cord, and identified the lesion in the thoracic spinal cord. Regarding the postoperative outcome and prognosis of spinal dural AVF, early diagnosis and early treatment have been proposed as prognostic factors because the postoperative outcome is poor in patients with high preoperative severity and a long duration of illness. In our patient, the preoperative JOA score was 6, showing high preoperative severity, and the duration of illness was 1.5 years before diagnosis, which may explain the limited improvement of the JOA score to 20 at final follow-up. In a case with these characteristics, we suggest that close examination of the entire spinal cord is needed for effective treatment.展开更多
A narrative review of the data provided by Randomised Controlled clinical trials and meta-analyses was undertaken to assess how much reliance a clinician could place on these in selecting a treatment for patients with...A narrative review of the data provided by Randomised Controlled clinical trials and meta-analyses was undertaken to assess how much reliance a clinician could place on these in selecting a treatment for patients with disease of the Femoral artery. An attempt was made to detect and review every clinical trial and meta-analysis published on treatments relating to disease of the femoral artery but not relating to drug treatment. Disease of the femoral artery in >65 years age group occurs in approximately 20% of the population but symptomatology was present in 40%. In almost all trials the predominant (>90%) indication for treatment was intermittent claudication. In this setting, clinical benefit was limited and did not extend beyond 12 months. Mortality, from co-morbidities was high. The Basil Trial was the only one to examine intervention for critical limb ischemia. The results for Bypass surgery and Percutaneous transarterial balloon angioplasty (PTA) were equivalent. There is little evidence to support the use of PTA or stenting other than in the treatment of patients with critical limb ischemia.展开更多
Background: Despite awareness about the impact of intermittent claudication (IC) on mobility, balance and quality of life;the underlying pathophysiology and alterations in muscle architecture secondary to the disease ...Background: Despite awareness about the impact of intermittent claudication (IC) on mobility, balance and quality of life;the underlying pathophysiology and alterations in muscle architecture secondary to the disease are often overlooked. This review aimed to summarize the pathophysiological muscle changes present secondary to IC. Methods: The electronic databases, Medline, EMBASE, Cinahl and AMED, were searched for studies from 1967 to August 2011. Search terms included exercise, intermittent claudication and muscle. Studies about IC which were focused on muscle histology, muscle architecture, blood flow or changes with exercise were included. Results: Of 434 studies identified, 135 unique results were found. Only 78 of these were suitable from abstract review, of which 15 were unobtainable and a further nine were identified from hand-searching references. Studies in animal models demonstrated a predominance of type II muscle fibres and an improvement in animal exercise tolerance secondary to training. Exercise alone was never able to improve distances to that of healthy controls, however a lower limb fistula along with exercise did. Lower limb blood flow was demonstrated to be affected regionally, and most evident during exercise with a prolonged return to normal in patients with IC. At a cellular level, the myocytes metabolism increased in those with IC, but returned to normal post-revascularization. Conclusion: Treatment for claudicants includes either revascularization or exercise. Successful revascularization has demonstrated a return to normal muscle metabolism;the underlying physiological improvement secondary to exercise still requires clarification.展开更多
Peripheral arterial disease (PAD) affects 12% - 20% of the population over 65 years. PAD is a component of systemic atherosclerosis and is associated with increased rate of all-cause mortality and cardiovascular event...Peripheral arterial disease (PAD) affects 12% - 20% of the population over 65 years. PAD is a component of systemic atherosclerosis and is associated with increased rate of all-cause mortality and cardiovascular events, compared with those without PAD. The strongest risk factors for PAD are older age and cigarette smoking. PAD accelerates functional decline leading to physical disability. Many randomized clinical trials demonstrated that treadmill walking training increases pain-free and maximal walking distances in patients with PAD. Exercise intervention is strongly recommended for patients with PAD and symptoms of intermittent claudication (IC). The need to provide an exercise training program to patients with peripheral arterial disease is essential, as almost half of these patients will eventually develop coronary artery disease. There are many existing treadmill walking protocols for patients with PAD. Most of these are based on claudication severity. We present a case of significant improvement of pain-free distance and maximum treadmill walking distance in a patient with PAD after 12 weeks of walking training program utilizing the “2/3 claudication distance” formula.展开更多
Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism be treated in elderly patients with peripheral arterial disease (PAD). Statins reduce the incidence of intermittent claud...Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism be treated in elderly patients with peripheral arterial disease (PAD). Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all persons with PAD. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol lengthen exercise time until intermittent claudication develops. Chelation therapy should be avoided.展开更多
BACKGROUND Synovial chondromatosis(SC)is a rare benign lesion first reported by Ambrose Pare in 1558.It is most common in the knee joint,followed by the hip joint and elbow joint.It is characterized by the presence of...BACKGROUND Synovial chondromatosis(SC)is a rare benign lesion first reported by Ambrose Pare in 1558.It is most common in the knee joint,followed by the hip joint and elbow joint.It is characterized by the presence of multiple pearl-like osteochondral bodies in the joint.The incidence in children is extremely low.CASE SUMMARY We report a 6-year-old Chinese boy who presented to our hospital with left hip joint pain and claudication for more than one year.We performed total surgical resection of SC tissue in the left hip.A good prognosis was confirmed at the 6-wk follow-up.Pain and swelling symptoms were totally relieved,range of motion of his left hip returned to normal,and there was no clinical evidence of lesion recurrence at last follow-up.Our case is the youngest reported patient with SC occurring in the hip.CONCLUSION SC is a rare disease and can be easily misdiagnosed.When we encounter children with hip pain and claudication,increased vigilance and a comprehensive physical examination and imaging examination should be considered,in order to avoid misdiagnosis and delayed treatment in patients.展开更多
Lumbar Spinal Stenosis(LSS)is the major cause of Neurogenic Claudication(NC).It is common in the elderly and has an increasing incidence.In 2021,the United States Association for the Study of Pain published new eviden...Lumbar Spinal Stenosis(LSS)is the major cause of Neurogenic Claudication(NC).It is common in the elderly and has an increasing incidence.In 2021,the United States Association for the Study of Pain published new evidence-based clinical practice guidelines to provide more effective nonsurgical treatment of LSS-induced NC.Based on a thorough reading of the latest guidelines,combined with new clinical developments,and in collaboration with the 2011 North American Spine Society,NASS guidelines(hereinafter referred to as the 2011 Guidelines)were compared with the 2019 Danish Health Authority(DHA)Guidelines(hereinafter referred to as the 2019 Guidelines),and the clinical diagnosis and treatment of NC caused by LSS were reviewed and suggestions were put forward.展开更多
Peripheral vascular disease with increasing prevalence rate is one among many conditions where a dependable cure is still elusive.Peripheral arterial disease(PAD),of which is a common form that results from atheroscle...Peripheral vascular disease with increasing prevalence rate is one among many conditions where a dependable cure is still elusive.Peripheral arterial disease(PAD),of which is a common form that results from atherosclerosis of arteries leading to reduced blood flow to the extremities.Commonly affecting the lower extremity,PAD presents with pain during ambulation,which is known as“intermittent claudication”which later manifests into“rest pain”.Due to the cry of the dying nerves,the pain is so severe that even common analgesics fail to relieve it.It is observed that the pathogenesis and clinical manifestation of PAD has striking similarities with“gambhira vatarakta”which is characterised by burning sensation,severe pain,excessive sweating,thirst,suppuration and tenderness.Keeping this view in mind the patients diagnosed with vatarakta were selected for jalauka avacharana(Leech therapy)followed by manjishtadi kshara basti(Decoction enema prepared by adding several drugs).This protocol showed remarkable results in relieving pain and ultimately vyadhi upashaya.展开更多
文摘This article explains the orthopedic approach to limping in children. This is a review article including a selected collection of new articles extracted from PubMed and Google Scholar searched for clinical points and beneficial approaches to limping children. In this paper, limping is divided into two categories, painful and painless. After stating the important points in the patient’s medical history and explaining specific examinations in this area, different gait types in children are explained and the best evaluation method for them is presented. Then, paraclinical examinations and imaging are described in a practical evaluation, high-risk etiologies of limping such as infections, tumors, and fractures are explained in detail and red flags are considered at each step. The algorithms and the list of differential diagnoses for each age group are included, which can provide physicians with a more comprehensive approach to limping in children.
文摘Typically situated posterolateral in the spinal canal, intraspinal facet cysts often cause radicular symptoms. Rarely, the midline location of these synovial or ganglion cysts may cause thecal sac compression leading to neurogenic claudication or cauda equina syndrome. This article summarizes the clinical presentation, radiographic appearance, and management of three intraspinal, midline facet cysts. Three patients with symptomatic midline intraspinal facet cysts were retrospectively reviewed. Documented clinical visits, operative notes, histopathology reports, and imaging findings were investigated for each patient. One patient presented with neurogenic claudication while two patients developed partial, subacute cauda equina syndrome. All 3 patients initially responded favorably to lumbar decompression and midline cyst resection; however, one patient required surgical stabilization 8 mo later. Following the three case presentations, we performed a thorough literature search in order to identify articles describing intraspinal cystic lesions in lateral or midline locations. Midline intraspinal facet cysts represent an uncommon cause of lumbar stenosis and thecal sac compression. Such entities should enter the differential diagnosis of midline posterior cystic lesions. Midline cysts causing thecal sac compression respond favorably to lumbar surgical decompression and cyst resection. Though laminectomy is a commonly performed operation, stabilization may be required in cases of spondylolisthesis or instability.
文摘BACKGROUND Ligamentum flavum cysts,which are most common in mobile junctional levels of the spine,can be a rare cause of spinal stenosis.There have been several case reports of ligamentum flavum cysts.However,there is yet to be a documented case report of a calcified ligamentum flavum cyst.Herein,we report the first case of a calcified ligamentum flavum cyst causing ankle and toe weakness.CASE SUMMARY A 66-year-old male visited our hospital complaining of claudication as well as thigh and calf pain in his left leg,all beginning two weeks prior.Physical examination revealed motor weakness of the left ankle dorsiflexion and great toe dorsiflexion.Lumbar spinal computed tomography scans showed spinal stenosis combined with a calcified mass at the left side of the L4-5 level.Magnetic reso-nance imaging showed dural sac compression caused by the calcified mass at the left ligamentum flavum of the L4-5 level.We performed decompressive laminectomy and excision of the calcified mass combined with posterior lumbar interbody fusion at the L4-5 level.Intra-operatively,we found a firm and nodule like mass originating from the ventral surface of ligamentum flavum.Pathological examination suggested a calcified pseudocyst without a capsular lining.After the operation,the patient’s motor weakness in the ankle and great toe improved gradually.CONCLUSION The patient’s ankle and great toe weakness were improved successfully after surgical removal of the calcified cyst.
文摘Cystic adventitial disease （CAD） is a rare condition characterized by cyst!c lesions of the non-axial blood vessels adjacent to joints;j the majority of cysts are in the lower limb, with popliteal artery predominance. Here, we report a case of cystic adventitial disease in a 47-year-old man who was misdiagnosed and performed percutaneous transluminal angioplasty （PTA） in other hospital. He was eventually treated successfully with incision and evacuation of the popliteal cyst and ligation of communicating channels to the knee joint and remains asymptomatic 1 year later.
文摘Spinal arteriovenous malformation (AVM) is a rare disease that arises more commonly from the lower thoracic and upper lumbar spine. It is classified based on the development pattern and the shunt location. The developmental mechanism of the symptoms is thought to be as follows. Spinal venous return is impaired by high-pressure arterial blood flowing into the coronary sinus via a shunt and venous pressure is promoted, which causes spinal cord symptoms to progress gradually. Listlessness, pain, and an abnormal sensation of the lower limb are possible initial symptoms. Spinal AVM may cause intermittent claudication and bladder and rectal disturbance, and differentiation from lumbar degenerative diseases and arteriosclerosis obliterans is required, which may cause difficulty with diagnosis. We encountered a patient in whom intermittent claudication was treated with lumbar decompression and fixation at another hospital, but symptoms did not improve. The patient was diagnosed with spinal AVM at our hospital and symptoms were improved by surgery. Because the symptoms did not improve despite being treated with surgery for spinal canal stenosis, we strongly suspected spinal intermittent claudication, and we performed a spinal CT and MRI after myelography for the entire spinal cord, and identified the lesion in the thoracic spinal cord. Regarding the postoperative outcome and prognosis of spinal dural AVF, early diagnosis and early treatment have been proposed as prognostic factors because the postoperative outcome is poor in patients with high preoperative severity and a long duration of illness. In our patient, the preoperative JOA score was 6, showing high preoperative severity, and the duration of illness was 1.5 years before diagnosis, which may explain the limited improvement of the JOA score to 20 at final follow-up. In a case with these characteristics, we suggest that close examination of the entire spinal cord is needed for effective treatment.
文摘A narrative review of the data provided by Randomised Controlled clinical trials and meta-analyses was undertaken to assess how much reliance a clinician could place on these in selecting a treatment for patients with disease of the Femoral artery. An attempt was made to detect and review every clinical trial and meta-analysis published on treatments relating to disease of the femoral artery but not relating to drug treatment. Disease of the femoral artery in >65 years age group occurs in approximately 20% of the population but symptomatology was present in 40%. In almost all trials the predominant (>90%) indication for treatment was intermittent claudication. In this setting, clinical benefit was limited and did not extend beyond 12 months. Mortality, from co-morbidities was high. The Basil Trial was the only one to examine intervention for critical limb ischemia. The results for Bypass surgery and Percutaneous transarterial balloon angioplasty (PTA) were equivalent. There is little evidence to support the use of PTA or stenting other than in the treatment of patients with critical limb ischemia.
文摘Background: Despite awareness about the impact of intermittent claudication (IC) on mobility, balance and quality of life;the underlying pathophysiology and alterations in muscle architecture secondary to the disease are often overlooked. This review aimed to summarize the pathophysiological muscle changes present secondary to IC. Methods: The electronic databases, Medline, EMBASE, Cinahl and AMED, were searched for studies from 1967 to August 2011. Search terms included exercise, intermittent claudication and muscle. Studies about IC which were focused on muscle histology, muscle architecture, blood flow or changes with exercise were included. Results: Of 434 studies identified, 135 unique results were found. Only 78 of these were suitable from abstract review, of which 15 were unobtainable and a further nine were identified from hand-searching references. Studies in animal models demonstrated a predominance of type II muscle fibres and an improvement in animal exercise tolerance secondary to training. Exercise alone was never able to improve distances to that of healthy controls, however a lower limb fistula along with exercise did. Lower limb blood flow was demonstrated to be affected regionally, and most evident during exercise with a prolonged return to normal in patients with IC. At a cellular level, the myocytes metabolism increased in those with IC, but returned to normal post-revascularization. Conclusion: Treatment for claudicants includes either revascularization or exercise. Successful revascularization has demonstrated a return to normal muscle metabolism;the underlying physiological improvement secondary to exercise still requires clarification.
文摘Peripheral arterial disease (PAD) affects 12% - 20% of the population over 65 years. PAD is a component of systemic atherosclerosis and is associated with increased rate of all-cause mortality and cardiovascular events, compared with those without PAD. The strongest risk factors for PAD are older age and cigarette smoking. PAD accelerates functional decline leading to physical disability. Many randomized clinical trials demonstrated that treadmill walking training increases pain-free and maximal walking distances in patients with PAD. Exercise intervention is strongly recommended for patients with PAD and symptoms of intermittent claudication (IC). The need to provide an exercise training program to patients with peripheral arterial disease is essential, as almost half of these patients will eventually develop coronary artery disease. There are many existing treadmill walking protocols for patients with PAD. Most of these are based on claudication severity. We present a case of significant improvement of pain-free distance and maximum treadmill walking distance in a patient with PAD after 12 weeks of walking training program utilizing the “2/3 claudication distance” formula.
文摘Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism be treated in elderly patients with peripheral arterial disease (PAD). Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all persons with PAD. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol lengthen exercise time until intermittent claudication develops. Chelation therapy should be avoided.
基金Supported by Natural Science Foundation of Hunan Province,No.2019JJ50324.
文摘BACKGROUND Synovial chondromatosis(SC)is a rare benign lesion first reported by Ambrose Pare in 1558.It is most common in the knee joint,followed by the hip joint and elbow joint.It is characterized by the presence of multiple pearl-like osteochondral bodies in the joint.The incidence in children is extremely low.CASE SUMMARY We report a 6-year-old Chinese boy who presented to our hospital with left hip joint pain and claudication for more than one year.We performed total surgical resection of SC tissue in the left hip.A good prognosis was confirmed at the 6-wk follow-up.Pain and swelling symptoms were totally relieved,range of motion of his left hip returned to normal,and there was no clinical evidence of lesion recurrence at last follow-up.Our case is the youngest reported patient with SC occurring in the hip.CONCLUSION SC is a rare disease and can be easily misdiagnosed.When we encounter children with hip pain and claudication,increased vigilance and a comprehensive physical examination and imaging examination should be considered,in order to avoid misdiagnosis and delayed treatment in patients.
基金China Academy of Chinese Medical Sciences"predominant disease-hospital preparation-new drug"research and development project(No.ZZ15-XY-PT-12)。
文摘Lumbar Spinal Stenosis(LSS)is the major cause of Neurogenic Claudication(NC).It is common in the elderly and has an increasing incidence.In 2021,the United States Association for the Study of Pain published new evidence-based clinical practice guidelines to provide more effective nonsurgical treatment of LSS-induced NC.Based on a thorough reading of the latest guidelines,combined with new clinical developments,and in collaboration with the 2011 North American Spine Society,NASS guidelines(hereinafter referred to as the 2011 Guidelines)were compared with the 2019 Danish Health Authority(DHA)Guidelines(hereinafter referred to as the 2019 Guidelines),and the clinical diagnosis and treatment of NC caused by LSS were reviewed and suggestions were put forward.
文摘Peripheral vascular disease with increasing prevalence rate is one among many conditions where a dependable cure is still elusive.Peripheral arterial disease(PAD),of which is a common form that results from atherosclerosis of arteries leading to reduced blood flow to the extremities.Commonly affecting the lower extremity,PAD presents with pain during ambulation,which is known as“intermittent claudication”which later manifests into“rest pain”.Due to the cry of the dying nerves,the pain is so severe that even common analgesics fail to relieve it.It is observed that the pathogenesis and clinical manifestation of PAD has striking similarities with“gambhira vatarakta”which is characterised by burning sensation,severe pain,excessive sweating,thirst,suppuration and tenderness.Keeping this view in mind the patients diagnosed with vatarakta were selected for jalauka avacharana(Leech therapy)followed by manjishtadi kshara basti(Decoction enema prepared by adding several drugs).This protocol showed remarkable results in relieving pain and ultimately vyadhi upashaya.
