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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 95-103

A comparative study of aspiration followed by Agnikarma with aspiration in the management of ganglion - A randomized clinical trial


1 Department of Sangyaharana, KLEU's Shri B. M. Kankanawadi Ayurved Mahavidyalaya, Belgaum, India
2 Department of Shalyatantra, BVVS Ayurveda Medical College, Bagalkot, Karnataka, India

Date of Web Publication17-Jan-2016

Correspondence Address:
A Amruta Wali
KLEU's Shri B. M. Kankanawadi Ayurved Mahavidyalaya, Shahapur, Belgaum, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.174236

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  Abstract 

Background: Classical texts explain the Agnikarma in detail for the management and eradication of various ailments with the limitation to understand its application and standardized methodology for each ailment. Ganglions are the most common cystic swellings, especially found in dorsum aspect of wrist which is well known for recurrence. Hence, to avoid the complications of surgery and to reduce the social burden of the patient, an effort is made to establish and modify the Agnikarma methodology in ganglion.
Methods: 30 patients fulfilling the inclusion criteria of ganglion were randomly selected and divided into Group 1 and Group 2 comprising of 15 patients each. Clinical sign and symptoms were given suitable grades according to their severity and assessed based on relief after treatment. The results showing P value < 0.05 were considered as statistically significant in this study.
Results: After the treatment by Agnikarma on post-operative first day there was no change in pain, size of swelling was significantly resolved by 100% and tenderness was significantly increased. Complete relief (100%) was found in pain, size of swelling and tenderness on post-operative Seventh day. On first month size of swelling was increased by 28%. Pain was significantly reduced after three months by 92% and size of swelling was increased by 43%.
Interpretation and Conclusion:

  1. Recurrence was seen in the patients treated with Agnikarma but there was significantly reduction in the size after three months
  2. This technique avoids the scar mark to the cosmetic area compared with conventional ganglionectomy
  3. Hence, this technique can be still modified for minimal invasive technique.

Keywords: Agnikarma , aspiration, ayurveda, ganglion, granthi, shalyatantra


How to cite this article:
Wali A A, Dongargoan N T, Emmi V S, Kulkarni S Y, Shindhe S P, Mudakappagol Y S. A comparative study of aspiration followed by Agnikarma with aspiration in the management of ganglion - A randomized clinical trial. Indian J Health Sci Biomed Res 2015;8:95-103

How to cite this URL:
Wali A A, Dongargoan N T, Emmi V S, Kulkarni S Y, Shindhe S P, Mudakappagol Y S. A comparative study of aspiration followed by Agnikarma with aspiration in the management of ganglion - A randomized clinical trial. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2019 Dec 6];8:95-103. Available from: http://www.ijournalhs.org/text.asp?2015/8/2/95/174236


  Introduction Top


Ganlions are the most common cystic swellings, [1] especially sixty to seventy percent of ganglion cysts are found in the dorsal aspect of the wrist and communicate with the joint via a pedicle. [2] The pathogenesis of ganglia is unclear. [3] It contains a clear gelatinous fluid or viscous fluid. It is surrounded by a fibrous capsule, and it possesses small pseudopodia. [4] Incidence is seen more where increased movements of the wrist joint are contributed by frequent wriggling of clothes, in computer data operating personnel, in tennis, badminton sports persons, etc. [2] Historical evidence suggests the incidence of 25-43 individuals per lakh population. Its prevalence is not known as many people live comfortably with no recourse to medical referral, but it is more prevalent in the female sex, giving a female, and male sex ratio of 1.7:1, respectively. [5]

Acharya Sushruta, for therapeutic purpose, explained a parasurgical procedure named as Agnikarma (cauterization). It is adopted when the disease is not cured by Bheshaj (medicines), Shastra (surgery) or Ksharkarma (chemical cauterization) because there will be no recurrence of the disease (apunarbhava) and with this promising prognosis it compares favorably with the conventional treatment. [6]

In modern science aspiration and excision are described measures to tackle ganglion. Aspiration is commonly practiced treatment which resolves in a few [1] and recurs in some others. The conventional surgical practice, that is, excision of ganglion is having its own limitations and is not completely free from recurrence. Also, a higher risk of complications such as neuroma, infection, unsightly scar, and stiffness are encountered. [7]

To reduce these complications, there is a need to assess the minimal invasive, nonrecurring, uncomplicated technique of Agnikarma contributed by Acharya Sushruta as a standard protocol in the management of ganglion. Diagnosed ganglion patients were selected for study irrespective of sex, occupation, etc., at the outpatient department (OPD) level. To assess the efficacy of Agnikarma in the ganglion, another comparative group was taken, and it was treated with aspiration only.


  Methodology Top


Inclusion criteria

  • Consented individuals
  • Age group between 20 and 50 years of both sexes
  • Site - dorsum of wrist joint
  • Size - approximately within 2 cm × 2 cm.


Exclusion criteria

  • Patients having infective ganglion
  • Patients who have previously undergone surgical procedure
  • Tubercular ganglions
  • Diabetic patients.


Laboratory investigation

  • Blood routine
  • Urine routine
  • Ultrasonography of ganglion to confirm cyst size pre and postoperatively.


Sampling method and research design

Thirty patients diagnosed as ganglion cyst were registered with the help of research proforma prepared for the study. They were randomly assigned into two groups, that is, Group 1 (aspiration) and Group 2 (aspiration followed by Agnikarma) consisting of 15 patients each.

Type of randomization - computerized block randomization.

Materials

Sterile gloves, betadine solution, spirit, gauze pieces, sponge-holding forceps, sterile drapes, 18 gauge needle, 5cc syringe, bipolar electrocautery, and prepared instrument.

Methodology for Group 1 - Aspiration

  • Preoperative
  • Occupational therapy (OT) consent
  • Injection tetanus toxoid (TT) 0.5cc intramuscular (IM)
  • Operative
  • Under all aseptic precautions, operated area was painted with betadine and spirit, followed with draping
  • The prominent site of ganglion and area devoid of veins were selected and aspirated with 18 gauge needle to drain the fluid [Figure 1] and [Figure 2]
  • Postoperative
  • Tight bandaging was done.
Figure 1: Ganglion cyst before aspiration

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Figure 2: Ganglion cyst during aspiration

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Methodology for Group 2 - Aspiration followed by Agnikarma

  • Preoperative
  • OT consent
  • Injection TT 0.5cc IM
  • Injection lignocaine 2% test dose - 0.2cc I/D
  • Operative
  • Under all aseptic precautions, operated area was painted with betadine and spirit, followed with draping [Figure 3]
  • Injection lignocaine 2% with adrenaline 1cc was infiltrated subcutaneously over the ganglion
  • The prominent site of ganglion and area devoid of veins were selected and aspirated with 18 gauge needle completely
  • After aspiration syringe was disconnected keeping behind the needle at ganglion site and copper filament was introduced
  • The instrument was kept in situ for 5 s on 40 No. the power of coagulation mode and Agnikarma was done [Figure 3],[Figure 4] and [Figure 5]
  • Then instrument along with needle was removed
  • Postoperative
  • Kumari (aloe vera) with Haridra (turmeric) was applied at Agnikarma site to pacify the burning sensation
  • Appropriate bandaging was done.
Figure 3: Ganglion cyst before aspiration followed by Agnikarma

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Figure 4: Ganglion cyst during aspiration before Agnikarma

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Figure 5: Ganglion cyst during Agnikarma were copper filament was introduced

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Criteria of assessment

Subjective criteria

  • Pain.


Objective criteria

  • Size of swelling
  • Tenderness
  • Fluctuation
  • Consistency.


Gradation index

To give some objectivity to the symptoms and signs for the statistical analysis grading was assigned as shown in the table.

Grading's

Assessment of pain

Grade 0 No pain

Grade 1

Localized feeling of pain during movements only but not feeling during rest

Grade 2 Localized feeling of pain during rest

Grade 3 Localized continuous feeling of pain.

Assessment of size of swelling

Grade 0 No swelling

Grade 1 0.5-1 cm

Grade 2 1.1-1.5 cm

Grade 3 1.6-2 cm.

Assessment of tenderness

Grade 0 Absent

Grade 1 Present.

Assessment of fluctuation

Grade 0 Negative

Grade 1 Positive.

Assessment of consistency

Grade 0 Absent

Grade 1 Cystic

Grade 2 Hard.

Follow-up study

After the completion of treatment, all the patients were advised to attend the OPD on the postoperative 1 st day, 3 rd day, 7 th day, 15 th day, 1 st month, and 3 rd month.

Statistical analysis

For the statistical analysis of data, student t-test was applied.

Paired t-test - was applied to analyze the treatment within the groups.

Unpaired t-test - was applied to analyze the treatment between the groups.


  Results Top


Symptoms recorded in the patients of ganglion showed that all the patients (100%) suffering from swelling. Out of remaining symptoms, 77% of patients had pain during movement of the wrist joint and no patient had rest pain [Table 1].
Table 1: Symptoms recorded in 30 patients of ganglion

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Effects of the treatments

Thirty patients of ganglion were studied in two groups of the treatment. The results obtained in each group during the follow-ups are described below.

Effect of aspiration in ganglion

Fifteen patients of ganglion were treated with aspiration and follow-up was done up to the 3 months. The effect of aspiration was assessed with various parameters as follows.

Effect on pain

After aspiration, the pain was increased on the postoperative 1 st day by 33%. On the 3 rd day, the pain was reduced by 45%. Complete relief (100%) of pain was recorded on the 7 th day of treatment which continued up to 1-month. Again on 3 rd -month, the pain was recurred by 10% [Table 2].
Table 2: Effect of Group 1 on pain of 15 patients of ganglion

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Further consideration showed that pain was present in 80% of patients on the postoperative 1 st day and 33% of the patient on the 3 rd day. After a 7 th day up to 1-month pain relieved in 100% of patients. After 3 months, again the pain was present in 7% of patients [Table 7].

Effect on size of swelling

After aspiration size of swelling was significantly resolved by 100% up to postoperative 7 th days. On 15 th day size of swelling was increased by 23%, after 1-month by 46% and after 3 months by 65% [Table 3].
Table 3: Effect of Group 1 on Size of swelling of 15 patients of ganglion

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Further consideration showed that the swelling was resolved in 100% of patients up to a postoperative 7 th day. On the 15 th day swelling was observed in 40% of patients, on 1 st month observed in 80% of patients and remained same after 3 months [Table 7].

Effect on tenderness

After aspiration, the tenderness was increased on the postoperative 1 st day up to a 3 rd day. It was reduced by 100% on the 7 th day up to 3 months [Table 4].
Table 4: Effect of Group 1 on tenderness of 15 patients of ganglion

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Further consideration showed that tenderness was present in 73% of patients on the postoperative 1 st day and 7% of the patient on the 3 rd day. After a 7 th day, up to 3 months tenderness was relieved in 100% of patients [Table 7].

Effect on fluctuation

After aspiration fluctuation was absent by 100% up to a postoperative 7 th day. On the 15 th day fluctuation was present by 40% and after 1-month up to 3 months by 80% [Table 5].
Table 5: Effect of Group 1 on fluctuation of 15 patients of ganglion

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Further consideration showed that the fluctuation was absent in 100% of patients up to a postoperative 7 th day. On the 15 th day, the fluctuation was present in 40% of patients, on 1 st month present in 80% of patients and remained same after 3 months [Table 7].

Effect on consistency

After aspiration consistency was absent by 100% up to a postoperative 7 th day. On the 15 th day, consistency was present by 40% and after 1-month up to 3 months by 80% [Table 6].
Table 6: Effect of Group 1 on consistency of 15 patients of ganglion

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Further consideration showed that the consistency was absent in 100% of patients up to a postoperative 7 th day. On the 15 th day, consistency was present in 40% of patients, on 1 st month present in 80% of patients and remained same after 3 months [Table 7].
Table 7: Follow up wise symptoms recorded in Aspiration group

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Effect of Agnikarma in ganglion

Fifteen patients of ganglion were treated with aspiration followed by Agnikarma and follow-up was done up to the 3 months. The effect of Agnikarma was assessed with various parameters as follows.

Effect on pain

After aspiration followed by Agnikarma, there was no change in the pain on the postoperative 1 st day. On the 3 rd day, the pain was significantly reduced by 78%. Complete relief in pain was recorded on the 7 th day of treatment which continued up to 1-month. Again on 3 rd month, the pain was recurred by 8% [Table 8].
Table 8: Effect of Group 2 on pain of 15 patients of ganglion

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Further consideration showed that the pain was present in 93% of patients on the postoperative 1 st day and 20% of the patient on the 3 rd day. After a 7 th day up to 1-month pain relieved in 100% of patients. After 3 months, again the pain was present in 7% of patients [Table 13].

Effect on size of swelling

After aspiration followed by Agnikarma size of swelling was resolved by 100% up to postoperative 7 th days. On the 15 th day size of swelling was increased by 11%, after 1-month by 28% and after 3 months by 43% [Table 9].
Table 9: Effect of Group 2 on Size of swelling of 15 patients of ganglion

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Further consideration showed that the swelling was resolved in 100% of patients up to a postoperative 7 th day. On 15 th day, swelling was observed in 20% of patients, on 1 st month observed in 53% of patients and after 3 months observed in 73% of patients [Table 13].

Effect on tenderness

After aspiration followed by Agnikarma, the tenderness was increased on the postoperative 1 st day. It was reduced by 100% on the 3 rd day up to 3 months [Table 10].
Table 10: Effect of Group 2 on tenderness of 15 patients of ganglion

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Further consideration showed that tenderness was present in 87% of patients on the postoperative 1 st day. After a 3 rd day, up to 3 months tenderness was relieved in 100% of patients [Table 13].

Effect on fluctuation

After aspiration followed by Agnikarma, the fluctuation was absent by 100% up to a postoperative 7 th day. On 15 th day fluctuation was present by 20%, after 1-month by 53% and after 3 months by 73% [Table 11].
Table 11: Effect of Group 2 on fluctuation of 15 patients of ganglion

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Further consideration showed that the fluctuation was absent in 100% of patients up to a postoperative 7 th day. On 15 th day fluctuation was present in 20% of patients, on 1 st month present in 53% of patients and after 3 months in 73% of patients [Table 13].

Effect on consistency

After aspiration followed by Agnikarma, consistency was absent by 100% up to a postoperative 7 th day. On the 15 th day, consistency was present by 20%, after 1-month by 53% and after 3 months by 73% [Table 12].
Table 12: Effect of Group 2 on consistency of 15 patients of ganglion

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Further consideration showed that the consistency was absent in 100% of patients up to a postoperative 7 th day. On the 15 th day, consistency was present in 20% of patients, on 1 st month present in 53% of patients and after 3 months in 73% of patients [Table 13].
Table 13: Follow up wise symptoms recorded in Aspiration followed by Agnikarma group

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Comparison of results between Group 1 (aspiration) and Group 2 (aspiration followed by Agnikarma)

Comparison of results of pain

Statistical comparison of results between the groups on pain shows the significant difference on the postoperative 3 rd day. There was no significant difference seen in the results of both groups from a 3 rd day up to the 3 months [Table 14].
Table 14: Comparison of both the groups for pain

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Comparison of both the groups for size of swelling

There was no significant difference seen in the results of both groups for the size of swelling [Table 15].
Table 15: Comparison of both the groups for size of swelling

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Effect of Group 1 and Group 2 during follow-ups: [Table 16].
Table 16: Effect of Group 1 and Group 2 during follow ups

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  Discussion Top


The Ayurvedic literature explains about various types of granthi which can be usually correlated to the swellings or lump. However, it is very difficult to correlate ganglion cyst with a particular type of granthi explained in Ayurveda, except its cardinal feature "swelling which feels like a knot," which is directive for such a conclusion. The features of Kaphaja and Medaj granthi viz, sheeta (cold), avivarna (skin color or slightly abnormal in color), Ghana, with little pain or not associated with pain, pashana, when bursts it discharges white or black ghanameda which are more suggestive toward the features of ganglion.

Acharya Charaka mentioned that ripened granthi should be excised, and the kosha should be burnt otherwise it again recurs slowly. [8] Ganglion is well known for its recurrence. So, this may be the reason that in case of ganglion there are high chances of recurrence after aspiration and also after excision. There may be the less chance or no chances of a recurrence if we burn the capsule of ganglion. Hence, the Agnikarma is ultimate for granthi and can be applied to avoid the recurrence.

In Ayurvedic classics, the Agnikarma is explained for the management of various ailments and its wide utility in the eradication of complete disorders such as granthi, arbuda, etc. However, the difficulty in its application and lack of standardized methodology creates a major hindrance for the practice of Agnikarma in the routine practice.

It is explained that if it is not located on marmasthana then excision should be done following Agnikarma. [9] Majority of the situation of ganglion cysts are at joint areas (marma). Excision and cauterization are in practice in contemporary science. However, the procedure has its own surgical complications like a hindrance to the daily activities, scar formation, infection, nerve damage, etc.

Hence to avoid the complications and to reduce the social burden of the patient, an effort is made to establish, and modify the Agnikarma methodology in the ganglion.

Discussion on results

  • Pain in both groups was significantly reduced by 90% in Group 1 and 92% in Group 2 may be because of release of pressure over the tendon sheath and peripheral nerve
  • Swelling recurred in 40% of patient in Group 1 and 20% in Group 2 after 15 days. This may be because in Group 1 only by the aspiration there is a chance of early re-epithelization leading to recurrence. But in Group 2, as the sac is burnt so takes more time for re-epithelization of sac or there will be no re-epithelization leading to no collection in sac
  • In both groups, recurrence was observed that is 80% in Group 1 and 73% in Group 2 after 3 months
  • Postoperatively in aspiration group collection of fluid within the tendon sheath was noted may be because the capsule of the cyst was remained as it is
  • In the present study, recurrence was also seen in Agnikarma group. This may be because as it is a blind procedure the tip of the instrument may or may not be touched the capsule, or the capsule was not burnt. Hence, further study can be undertaken to overcome this limitations
  • The ganglion was resolved in 27% of subjects of Group 2 and reduced in size when compared to Group 1, may be because after Agnikarma the part of the capsule will burn, and the area will become avascular. So there will be less chances of rejoining the capsule.


Overall effect

The overall effect of the therapy was drawn after the follow-up of 3 months in relation to the swelling and pain. At the end of the 3 months, it was found that 15 patients who treated with aspiration followed by Agnikarma out of them, the ganglion is resolved in four patients and recurred in 11 patients. However, it is reduced in the size after 3 months as compared to the size before treatment. Since, the pain during the movement of wrist joint before treatment didn't recur after 3 months.


  Conclusion Top


In this clinical trial, recurrence is seen in both groups. But in the patients treated with Agnikarma found that there is significantly reduction in the size after 3 months.

Hence, this technique can be still modified by using ultrasound for minimal invasive technique.

Acknowledgment

(1) Dr. B. S. Prasad, Principal, KLEU's Shri BMK Ayurved Mahavidyalaya, Belgaum. (2) Mr. Vivek Wali and KLES Sheshgiri Engineering College Students, for supporting in grounding equipping the Agnikarma instrument.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Russel RC, Williams NS, Bulstrode CJ. Bailey and Love′s Short Practice of Surgery. 24 th ed. London: Hodder Education; 2004. p. 530.  Back to cited text no. 1
    
2.
Warren Gude, Vincent Morelli. Ganglion cysts of the wrist: Pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med 2008;1:205-11.  Back to cited text no. 2
    
3.
Margaret F, Bendan M. Farquharson′s Textbook of Operative General Surgery. 9 th ed. London: Edward Arnold Publishers; 2005. p. 44.  Back to cited text no. 3
    
4.
Das S. A Concise Textbook of Surgery. 6 th ed. Calcutta: Dr. S. Das; 2010. p. 366.  Back to cited text no. 4
    
5.
Janzon L, Niechajev IA. Wrist ganglia. Incidence and recurrence rate after operation. Scand J Plast Reconstr Surg 1981;15:53-6.  Back to cited text no. 5
    
6.
Acharya VY, Ram N, editors. Sushruta Samhita of Shushruta, Sutrasthana; Agnikarma Vidhi Adhyaya. Ch. 12, Ver. 3. Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 51.  Back to cited text no. 6
    
7.
Gude W, Morelli V. Ganglion cysts of the wrist: Pathophysiology, clinical picture, and management. Curr Rev Musculoskelet Med 2008;1:205-11.  Back to cited text no. 7
    
8.
Acharya VY, editor. Charak Samhita of Charaka and Dridabala, Chikitsasthana; Swayathu Chikitsitam Adhyaya. Ch. 12, Ver. 82-83. Varanasi: Chaukhambha Surbharati Prakashana; 2011. p. 489.  Back to cited text no. 8
    
9.
Acharya VY, Ram N, editors. Sushruta Samhita of Shushruta, Nidansthana; Granthiapachiarbudagalagandanam Nidana Adhyaya. Ch. 11, Ver. 9. Varanasi: Chaukhambha Sanskrit Sansthan; 2012. p. 311.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16]



 

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