INTRODUCTION:

The butterfly vertebra or hemivertebra is a congenital deformity which includes two hemivertebrae emerging as a butterfly wing from central cleft which forms scoliosis or kyphosis like deformity in later stage. The malformations and imbalance in the growth plate formed by the secondary bone ossification centres leads to the congenital deformity. Secondary centres are responsible for bone ossification which develops the growth plate. Malformations and imbalance in these growth plates leads to congenital defects. This malformation has been reported to be exceptionally rare in the literature. Hemivertebrae, especially in the mid thoracic or in the lower lumbar area of the spine are usually solitary finding.Occasionally they can be related with other congenital deformities, such as musculoskeletal, cardiac and genito-urinary anomalies.

A number of syndromes are related to hemivertebrae such as Jarcho Levin syndrome, Klippel-Feil syndrome, VACTERL (vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies, and limb abnormalities) and cloacal exstrophy (OEIS) complex.¹ The incidence of karyotypic abnormalities in foetuses with single vertebral malformations is thought to be low.Hemivertebrae are vertebral anomalies that can be detected sonographically at second trimester. Normal vertebral development occurs in three stages (1) a mesenchymal stage (2) a cartilaginous stage (3) ossification.The formation of cardiac, pulmonary, and renal tissue is also a function of the mesoderm, which explains the strong correlation between spinal malformations and problems with another vital organ.Failure of formation, failure of segmentation, and neural tube abnormalities are the three categories under which spinal deformities typically fall. It has been proposed that butterfly vertebrae develop as a result of formation failure.² Butterfly vertebrae can be compared to neighbouring hemivertebrae because they both develop through a similar process in which a single chondrification centre fails to move medially.³

Informed consent:

Before starting treatment, the patient received a clarification of all the information pertaining to disease management. The consent contained an explanation of each benefit and drawback. Also, obtained approval for the case study's publication as well.

Patient’s information:

A 28-year-oldnaturally conceived primi gravida visited to Aaddyaayuvedic clinic with obstetric ultra sound report dated 02/06/2022 which show butterfly vertebra/ hemivertebra anomaly in foetus.Patient’s LMP was 11/01 /2022. Patient was not having any complaints.

Age of patient-28yr; Occupation –dentist; Marital history-married (dated 15-06-2020); Aakruti-medium; Desh-sadharan; Prakruti-pitta-vata; Pregnancy in situ; Menstrual history-regular 28 days cycle; Menarche-at 13 yrs of age;

Family history- no any major history of both paternal and maternal side;

Past history-patient does not have any major illness

General examination:

Patient was afebrile; B.P.: 110/72mm Hg; Pulse: 84/min; Temperature: 98.8⁰F; R.R.: 24/min; General Appearance: healthy; Weight: 54.1kg and height 5’.

Systemic examination:

Cardiovascular system: S1S2+. NAD; Central nervous system: NAD; Respiratory system: NAD, AEBE normal; Per Abdomen: Soft.

Ashtavidha Priksha:

Nadi (Pulse): Piita vataj; Mala (Stool): Prakrita (normal), Mutra (Urine): Prakrita(Normal), Jinhva (Tongue): Nirama, Shada (Voice): Prakrita (Normal), Sparsha (Touch): parkrita (normal), Drika (Vision): Prakrita (Normal), Akruti (Buit): Madhyam (Medium)

Dashavidh Pariksha:

Prakruti (constitutional status): pittapradhanVataj prakriti, Sarata (status of tissue and its related system): madhyam, Satva (mental state): madhyam, satmya (diet status): uttam, Vyayam shakti (physical capacity): madhyam, Vaya (age factor): madhyam, Vikruti: Vata pradhan, Abhyavaharan (diet capacity) and Jaran shakti (digestive capacity): uttam.

Diagnosis- According to Ayurveda the diagnosis was garbhashay astha asthi vikruti.

As per anomaly scan in second trimester foetus had butterfly vertebra in 2-3 lower thoracic vertebral bodies with non- fusion of ossification centres. Echogenic intra cardiac focus.

Figure 1: USG report of 21 weeks 1 day revealing the segmentation deformity in lower 2-3 thoracic vertebral bodies and echogenic intracardiac focus.

Prognosis- Structural deformities can be seen like scoliosis, kyphosis, disc herniation. Klippel-Feil syndrome^4,congenital spondylolisthesis⁵ Spina bifida⁶

Investigation:

Table 1: Sonography reports done throughout the treatment.

Date	USG Report	Finding
23/04/22	2/3 Trimester Scan Report at 14 week and 6 days.	Intrauterine live single foetus of avg. ultrasound.
02/06/22	2/3 Trimester Scan Report at 20 weeks 1 day	Intrauterine live single fetus with vertebral segmentation defect in 2-3 lower thoracic vertebrae and tiny intra-cardiac focus 1 in each ventricle.
08/06/22	Obstetric Ultrasound Examination Report at 21 weeks and 1 day of gestation.	Non fusion of ossification centres of 2-3 lower thoracic vertebral bodies Echogenic intra-cardiac focus.
23/07/2022	2/3 trimester Scan report at 27 weeks 6 day of gestation.	Segmentation deformity noted in single thoracic vertebra (D8-9). No echogenic intra-cardiac focus.
01 /11/22	Baby’s 2D, Ultrasound Imaging of Spinal Cord at age of 1 month 6 days.	Essentially normal neonatal spine ultrasound.

Figure 2: USG report of 27 weeks and 6 days i.e. 6 weeks after treatment revealing that segmentation deformity noted in single thoracic vertebra with NO any intracardiac focus.

Figure 3: USG report of baby done after the 1 month of delivery showed normal neonatal spine.

Table 2: Timeline of treatment was as follows

Sr no	Date	Intervention	Dose	Frequency
1	06-06-2022	Ashtimajjpachakvati Tapyadilohavati Suvarnamalinivasant	250 mg 250 mg 125mg	BD BD OD
2	06-07-2022	Astimajjapachakvati Tapyadilohavati Suvarnamalinivasant	250mg 250 mg 125mg	BD BD OD
3	23/ 07/2022	Same as above	Same as above	BD
4	07-08-2022	Asthimajjapachakvati Tapyadilohavati Suvarnamalinivasant	250mg 250 mg 125mg	BD BD OD
5	07/09/2022	Asthimajjapachakvati Tapyadilohavati Suvarnamalinivasant	250mg 250 mg 125mg	BD BD OD

Therapeutic intervention:

Diagnosis of butterfly vertebra was made as per the radiology finding at 21 weeks and 1 day of ANC. The condition was corelated to the garbhashay astha asthi vikruti according to Ayurveda. Initiation of treatment was done with asthiposhan, pachanand brings out sandhan karma for both asthi and Hridaya as there was intracardiac focus. Gives strength to the sapta dhatu, mainly rasa, rkta and mansa and meda dhatu which are the poshak ghatak for asthi dhatu.

Follow up and outcome:

After 6 weeks of treatment, at the time of 2^nd follow up the ultrasonography vertebral deformity was reduced from 2-3 lower thoracic vertebrae to single thoracic vertebra and showed no evidence of intracardiac focus as previous.The baby was delivered at the 8^th month of ANC and the treatment was discontinued. At this time the pt was not taking any medications. The USG of newborn was repeated at 1month and 6 days of age, which revealed the normal neonatal vertebra.

DISCUSSION:

Ayurveda goes beyond being merely a healthcare system designed to address illnesses; it is a comprehensive ideology and way of life. It serves as an art of living that encourages individuals not only to lead a healthy life personally but also to assist others in achieving harmony in their daily lives through the practice of self-awareness and self-care methods.⁷The resurgence of herbal medicine is evident, with a growing influx of patients turning to alternative medicine clinics due to the concerning side effects associated with synthetic drugs. Ayurveda and herbal medicine, deeply rooted in the use of medicinal herbs, have been longstanding practices for centuries.⁸Ayurvedic treatment along with conventional ANC protocol was given to 27 year old female, primi gravida patient whose obstetric USG report revealed Segmentation deformities in multiple lower thoracic vertebrae. Within 6 weeks, treatment turned out to be effective and deformities were reduced from multiple to single. The baby was born structurally and functionally normal. Also, USG spine report of a baby done after 1 month revealed no evidence of any deformity.

Detection of butterfly shaped vertebra in early pregnancy is highly related to spine abnormalities.⁹The deformity should be treated, in order to prevent structural and chromosomal abnormalities and to ensure the normal development of spine. Hemivertebrae result from a lack of formation of one side of a vertebral body. This abnormality is caused by failure of formation or segmentation of somites during osteogenesis.¹⁰Asper ayurveda drugs promoting the osteogenesis should be the 1^st line of treatment. Asthimajjapachakvati, Tapyadilohavati and Suvarnamalinivasant rasawere advised at 1^st visit. Asthimajjapachak contains Guduchi, Amalaki, Musta. Guduchi and Amalaki both are (Rejuvenator) rasayan¹¹and antioxidant dravyas.^12,13Guduchi uplifts cell growth, increases alkaline phosphatase and helps in mineralization of bone matrix and acts as bone protector.¹⁴It has antioxidant property and useful in various bone diseases such as rheumatoid arthritis.^15,16 This indicates that it has a great potential for osteogenesis.^17,18Amalaki (Emblica officinalis Gaertn.) is responsible for bone formation, induction of osteoblast activity and reduces osteoclast activity.¹⁹Musta (Cyperus rotundus) helps in osteoporotic conditions.²⁰Tapyadiloha mainly acts on rakta dhatu. Which is a precursor of sira (tubes that carry blood) and kandara (tendon). These sira and kandara are important structures for formation of bone and ligaments. Also, the Tapyadiloha accelerates the blood circulation, improve raktadhatwagni (metabolism of blood) and provides energy to body tissue.²¹Suvarnamalivasant rasa is beneficial for maintaining the stability of fetus and the ojovrudhi occurs as a result of the existence of Suvarnamaoutikadi Vishaghna (antipoisionus) Dravyas. Anatomical and physiological disorders are alleviated by the combination of Suvarna, Rasaka, and Hingula. The combination of Maricha (enhances digestion and immunomodulator)^22, and Nimbu enhances Dhatwagni²³Navanit is responsible for nourishment to dhatu i.e acts as Dhatu poshaka²⁴

CONCLUSION:

The modern medicine includes only symptomatic treatment in later ages of life such as physiotherapy and NSAIDs for the complications of butterfly vertebra. But this study suggests that, the Fetal anomaly can be effectively and successfully treated through Ayurveda management as Ayurveda has explained garbhavyapad too broadly in the ancient era. Future generation can be generated healthy by integrating traditional knowledge of Ayurveda along with modern investigative methodologies

CONFLICT OF INTEREST:

The authors declare no conflict of interests.

ACKNOWLEDGEMENT:

We would like to acknowledge Dr. Aishwarya Gajanan Masal PG Scholar Department of Agadtantra, Dr. D.Y. Patil College of Ayurved and Research Centre, Pimpri, Pune-18 for her valuable efforts in final editing of manuscript and grammar check.

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Received on 04.11.2023 Modified on 23.05.2024

Research J. Pharm. and Tech 2024; 17(11):5375-5378.

DOI: 10.52711/0974-360X.2024.00821