THE FACET SYNDROME

Dr (Maj) Pankaj N Surange
MBBS, MD, FIP
Interventional pain and spine specialist
Introduction


The facet joints are a pair of joints in the posterior aspect of the spine. Although these joints are most commonly called the facet joints, they are more properly termed the zygapophyseal joints (abbreviated as Z-joints), a term derived from the Greek roots zygos, meaning yoke or bridge, and physis, meaning outgrowth. The term facet joint is a misnomer because the joint occurs between adjoining zygapophyseal processes, rather than facets, which are the articular cartilage lining small joints in the body (eg, phalanges, costotransverse and costovertebral joints). This joint is also sometimes referred to as the apophyseal joint or the posterior intervertebral joint.
As is true of any synovial joint, the facet-joint is a potential source of pain. In fact, the facet-joint is one of the most common sources of low back pain (LBP). The first discussion of the facet-joint as a source of LBP was by Goldwaith in 1911. (1) In 1927, Putti (2) illustrated osteoarthritic changes of facet-joints in 75 cadavers of persons older than 40 years. In 1933, Ghormley(3) coined the term facet syndrome, suggesting that hypertrophic changes secondary to osteoarthritis of the zygapophyseal processes led to lumbar nerve root entrapment, which caused LBP. In the 1950s, Harris and Mcnaz (4) and McRae (5) determined that the etiology of facet-joint degeneration was secondary to intervertebral disc degeneration. Hirsch et al were later able to reproduce LBP with injections of hypertonic saline solution into the facet-joints, thus affirming the role of the facet-joints as a source of LBP (6)
Functional Anatomy
The spine is composed of a series of functional units. Each unit consists of an anterior segment, which is made up of 2 adjacent vertebral bodies and the intervertebral disc between them, and the posterior segment, which consists of the laminae and their processes. One joint is formed between the 2 vertebral bodies, whereas the other 2 joints, known as the facet-joints, are formed by the articulation of the superior articular processes of one vertebra with the inferior articular processes of the vertebra above. Thus, the facet-joints are part of an interdependent functional spinal unit consisting of the disc-vertebral body joint and the 2 facet-joints, with the facet-joints paired along the entire posterolateral vertebral column.(7)
Facet joints are well innervated by the medial branches of the dorsal rami. In the thoracic and lumbar spine, the facet joints are in¬nervated by medial branches of the dorsal rami of the spinal nerves except at L5 lev¬el (8). After the medial branch splits off from the dorsal ramus, it courses caudally around the base of the superior articular process of the level below toward that level's Z-joint (e.g., the L2 medial branch wraps around the L3 superior articular process to approach the L2-L3 facet-joint). The medial branch then continues in a groove between the superior articular process and transverse process (or, in the case of the L5 medial branch, between the superior articular process of S1 and the sacral ala of S1, which is the homologous structure to the transverse processes of the lumbar vertebrae). As it makes this course, the medial branch is held in place by a ligament joining the superior articular process and the transverse process, termed the mamillo-accessory ligament (MAL).
The MAL is so named because it adjoins the mamillary process of the superior articular process to the accessory process of the transverse process. The MAL is clinically important because it allows precise location of the medial branch of the dorsal ramus using only bony landmarks, which is essential for fluoroscopically guided procedures.
After passing underneath the MAL, the medial branch of the dorsal ramus gives off 2 branches to the nearby facet-joints. One branch innervates the facet-joint of that level, and the second branch descends caudally to the level below. Therefore, each medial branch of the dorsal ramus innervates 2 joints—that level and the level below (e.g., the L3 medial branch innervates the L3-L4 and L4-L5 facet-joints). Similarly, each facet-joint is innervated by the 2 most cephalad medial branches (e.g., the L3-L4 facet-joint is innervated by the L2 and L3 medial branches). Medial branch also innervates the multifidus, interspinales, and intertransversarii mediales muscles, the interspinous ligament, and, possibly, the ligamentum flavum. (9)
This has several important clinical implications. First, pain relief from anesthetizing the medial branch does not necessarily implicate the facet-joints as the primary pain generator, because one of the other structures innervated by the medial branch may have been the pain generator. Second, denervation of the medial branch by RFA may affect the nerve supply to the multifidus muscle. This is important because lumbosacral radiculopathy is often another consideration in the differential diagnosis of LBP.
The L5 dorsal ramus divides into me¬dial and lateral branches, with the medi¬al branch continuing medially, innervat¬ing the lumbosacral joint.

Pathogenesis
As with any synovial joint, degener¬ation, inflammation and injury of facet joints can lead to pain upon joint motion. Pain leads to restriction of motion, which eventually leads to overall physical decon¬ditioning. Irritation of the facet joint in¬nervation in itself also leads to secondary muscle spasm. It has been assumed that degeneration of the disc would lead to as¬sociated facet joint degeneration and sub¬sequent spinal pain. These assumptions were based on the pathogenesis of degen¬erative cascade in the context of a three joint complex that involves the articula¬tion between two vertebrae consisting of the intervertebral disc and adjacent fac¬et joints, as changes within each mem¬ber of this joint complex will result in changes in others (10, 11). It was also the view of Vernon-Roberts and Pi¬rie (12) that disc degeneration causes os¬teophyte formation and facet joint chang¬es, because facet joints at relatively normal disc levels are either normal or only slight¬ly degenerate.

The Facet joint is a common pain generator in the lower back. The 2 common mechanisms for this generation of pain are either (1) direct, from an arthritic process within the joint itself, or (2) indirect, in which overgrowth of the joint (e.g., facet joint hypertrophy or a synovial cyst) impinges on nearby structures. (13)
The Facet-joints are diarthrodial joints with a synovial lining, the surfaces of which are covered with hyaline cartilage, which is susceptible to arthritic changes and arthropathies. Repetitive stress and osteoarthritic changes to the facet joint can lead to zygapophyseal hypertrophy. Like any synovial joint, degeneration, inflammation, and injury can lead to pain with joint motion, causing restriction of motion secondary to pain and, thus, deconditioning. In addition, facet-joint arthrosis, particularly trophic changes of the superior articular process, can progress to narrowing of the neural foramen. In addition, as is the case for any synovial joint, the synovial membrane can form an outpouching and, thus, a cyst. Facet-joint cysts are most commonly seen at the L4-L5 level (65%), but they are also seen at the L5-S1 (31%) and L3-L4 (4%) levels. These synovial cysts can be clinically significant, particularly if they impinge on nearby structures (e.g., the exiting nerve root).
Facet-joint hypertrophy or a synovial cyst can also contribute to lateral and central lumbar stenosis, which can lead to impingement on the exiting nerve root. Thus, facet-joint pain can occasionally produce a pain referral pattern that is indistinguishable from disc herniation.
Numerous other causes, including rheumatoid arthritis, ankylosing spondy¬litis and capsular tears, etc., also have been described as sources of facet joint pain (14).

Facet joints have been implicated as responsible for spinal pain in 15% to 45% of patients with low back pain (15), 54% to 67% of patients with neck pain and 48% of patients with thoracic pain in controlled stud¬ies. These figures were based on respons¬es to controlled diagnostic blocks of these joints, in accordance with the criteria es¬tablished by the International Associa¬tion for the Study of Pain


Diagnosis

Clinical
Establishing a diagnosis of lumbosacral facet syndrome is difficult because the findings are nonspecific and correlation between the history and physical examination findings is poor. However, obtaining a detailed history and performing a physical examination help rule out other entities and assist with guiding the examiner in establishing the diagnosis of facet-joint–mediated LBP.
Although no single sign or symptom is diagnostic, Jackson et al demonstrated that the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular facet-joint injection (16):
1. Older age
2. Previous history of LBP
3. Normal gait
4. Maximal pain with extension from a fully flexed position
5. The absence of leg pain
6. The absence of muscle spasm
7. The absence of exacerbation with a Valsalva maneuver
Facet-joint pathology should be considered if the patient describes nonspecific LBP with a deep and achy quality that is usually localized to a unilateral or bilateral Paravertebral area.

The common referral areas for facet-joint–mediated pain are flank pain, buttock pain (often extending into the posterior thigh, but rarely below the knee), pain overlying the iliac crests, and pain radiating into the groin.

The pain is often exacerbated by twisting the back, by stretching, by lateral bending, and in the presence of a torsional load. Some patients describe their pain as worse in the morning, aggravated by rest and hyperextension, and relieved by repeated motion. Often, this lumbosacral facet syndrome may occur after an acute injury (e.g., extension and rotation of the spine), or it
may be chronic in nature.

Unlike other lumbar spine pathologies such as disc herniation, facet-joint–mediated pain likely will not worsen with an increase in intra-abdominal and thoracic pressure. Therefore, worsening of pain with coughing, laughing, or a Valsalva maneuver is suggestive that the facet-joint is not the primary pain generator.

Examination
• Sensory examination: Sensory examination (i.e., light touch and pinprick in a dermatomal distribution) findings are usually normal in persons with facet-joint pathology.
• Muscle stretch reflexes: Patients with facet-joint–mediated LBP usually have normal muscle stretch reflexes. Radicular findings are usually absent unless the patient has nerve root impingement from bony overgrowth or a synovial cyst.
• Straight leg–raise test: This maneuver is usually normal for facet-joint–mediated pain. However, if facet-joint hypertrophy or a synovial cyst encroaches on the intervertebral foramen, causing nerve root impingement, this maneuver may elicit a positive response.

Diagnostic blocks

It has been postulated that for any structure to be deemed a cause of back pain, the structure should have been shown to be a source of pain in patients, using diagnostic techniques of known reliability and validity (25). The diagnostic blockade of a structure with a nerve supply with the ability to generate pain can be performed to test the hypothesis that the target structure is a source of a patient’s pain

The choice between intraarticular blocks and medial branch blocks is to some extent preference and training of the physician. However, various considerations apply in choosing either intraarticular injection or medial branch. Intraarticular injections are more difficult and time consuming than nerve blocks because they require accurate placement of the needle within the joint cavity with care not to over distend the joint. In contrast, medial branch blocks are expeditious and carry no risk of over distention. Furthermore, at times joint entry may be impossible because of the severe age related changes or post traumatic arthropathy; no such processes affect access to the nerves .Significant leakage of intraarticular injected fluid into epidural space and spillage over to the nerve roots has been described. With appropriate care this is minimal with medial branch blocks. Finally, intraarticular blocks are appropriate if intraarticular therapy is proposed but if radiofrequency therapy is proposed, medial branch blocks become the diagnostic procedure of choice. In addition, in the past only intraarticular injections were considered as therapeutic. However, recent evidence has shown that medial branch blocks have better evidence for the therapeutic effectiveness than intraarticular blocks (17).

o Valid information is only obtained by performing controlled blocks, either in the form of placebo injections of normal saline or comparative local anesthetic blocks, in which on two separate occasions, the same joint is anesthetized using local anesthetics with different durations of action. . In a double-block protocol, the patient is given an injection with a short-acting anesthetic (e.g., lidocaine) and records the duration of pain relief in a diary. On a follow-up visit (typically 1-2 wk later), a second injection is performed, using an anesthetic with a different duration of action (e.g., bupivacaine, which has a longer half-life than lidocaine), and the patient again should chart pain relief in a diary. A patient is diagnosed as having a positive block if they receive pain relief (typically >80%) for both injections for a length of time corresponding to the duration of action of the medication. (18, 19,20) Given the dual innervation of each Z-joint, one must anesthetize or block the cephalad and subadjacent medial branches (eg, anesthetize the L3 and L4 medial branches for the L4-L5 Z-joint). Injections are diagnostic if patients report significant relief of symptoms, usually at least a 50% reduction in pain.
Lab Studies
• Laboratory studies are not generally necessary for the diagnosis of lumbosacral facet joint syndrome.
Imaging Studies
• Plain radiography
•
o Plain radiographs are traditionally ordered as the initial step in the workup of lumbar spine pain. The main purpose of plain films is to determine underlying structural pathologic conditions. These studies are not generally recommended in the first month of symptoms in the absence of red flags. An exception to this would be if the low back symptoms are related to a sports injury and a fracture is suggested.
o Three views are commonly obtained, including an anteroposterior (AP), lateral, and oblique; however, the utility of oblique views has been questioned.
o Plain radiographs may reveal degenerative changes, but these findings have not been found to correlate with facet-joint–mediated pain.
• Bone scanning
•
o Bone scanning can be helpful when a tumor, infection, or fracture (occult or traumatic) is suggested.
o Bone scanning is not usually indicated in the initial workup, and the results are normal in persons with lumbosacral facet joint syndrome.
o Bone scan findings have not been found to correlate with facet-joint–mediated pain.
• Computed tomography (CT) scanning
•
o Generally, CT scanning is not necessary unless other bony pathology (eg, fracture) must be excluded.
o A CT scan of the lumbosacral spine provides excellent anatomic imaging of the osseous structures of the spine, especially to rule out fractures or arthritic changes. Single-photon emission CT (SPECT) images may offer better resolution if spondylolysis is suggested.
o With facet-joint pathology, one may find arthritic changes in the facet-joints and degenerative disc disease; however, facet-joint pathology is also frequently seen in asymptomatic patients, and, therefore, abnormal findings on a CT scan are not diagnostic.
o Despite the excellent imaging of the bony anatomy of the facet-joint, CT scans are not useful for the diagnosis of the facet-joint as a pain generator. For example, Schwarzer et al found no correlation between facet-joint pathology on a CT scan and those patients who responded to diagnostic facet-joint blocks. (21) .Therefore, the correlation of an abnormal facet-joint anatomy as observed on CT scans with true facet -joint–mediated pain is poor.
• Magnetic resonance imaging (MRI)
o In general, MRI is not indicated for the evaluation of nonradicular LBP.
o The main utility of MRI is for excluding pathologies other than facet-joint arthropathy, because many degenerative changes in the facet-joint are asymptomatic. Similarly, true facet-joint–mediated pain may be present despite a normal MRI examination.
o MRI provides detailed anatomic images of the soft structures of the spine, such as the intervertebral discs, which often show degenerative changes before facet-joint pathology. (22)
o MRI also may illustrate nerve root entrapment secondary to facet-joint hypertrophy or a synovial cyst and may help visualize the intervertebral foramen; however, facet-joint pathology may be present despite normal imaging study findings.
o MRI is particularly useful for the evaluation of a synovial cyst emanating from a facet-joint and for distinguishing a synovial cyst from other abnormalities. Gadolinium enhancement is useful in the evaluation of a potential synovial cyst. Also helpful is to make the radiologist aware that a synovial cyst is part of the differential diagnosis because this entity is often overlooked.
Other Tests
• Electrodiagnosis
o Electro diagnostic studies, such as nerve conduction studies and needle EMG, are not usually indicated for possible lumbosacral facet syndrome. However, these studies should be considered if the history and physical examination findings suggest nerve root impingement or if the diagnosis remains unclear.
o Persons with facet-joint pathology typically present with normal sensory and motor examination findings; however, some patients describe the pain as radiating in nature and others report a positive straight leg–raise test result. Thus, electro diagnostic testing may be helpful for excluding other causes of pain, such as radiculopathy.
o RFA of the medial branch of the dorsal ramus affects the innervation of not only the facet-joint, but also the multifidus muscle. Normally, denervation potentials in the multifidus muscles in the setting of LBP are most commonly associated with lumbosacral radiculopathy. In the setting of a patient who has had previous RFA, however, the denervation potential is likely secondary to denervation from the procedure and not a radiculopathy.
TREATMENT
Therapeutic Interventional Techniques
The requirements for safe use of therapeutic interventions include a sterile operating room or a procedure room, appropriate monitoring equipment, radiological equipment; special instruments based on technique, sterile preparation with all the resuscitative equipment, needles, gowns, injectable drugs, intravenous fluids, anxiolytic medications, and trained personnel for preparation and monitoring of the patients. Minimum requirements include history and physical examination, informed consent, and appropriate documentation of the procedure.

Facet joint pain may be managed by intraarticular injections, medial branch blocks, or neurolysis of medial Branches (Facet denervation). (24)

Based on the available literature and scientific application, the most commonly used formulations of long-acting steroids, which include methylprednisolone (Depo-Medrol), triamcinolone diacetate (Aristocort), triamcinolone acetonide (Kenalog), and betamethasone acetate and phosphate mixture (Celestone Soluspan), appear to be safe and effective (23)

Based on the present literature, it appears that if repeated within 2 weeks, betamethasone may be the best choice in avoiding side effects; whereas, if treatment is carried out at 6-week intervals or longer, any one of the 4 formulations will be safe and effective.

Facet Joint Injections and Medial Branch Blocks

♦ In the diagnostic phase, a patient may receive 2 procedures at intervals of no sooner than 1 week or preferably 2 weeks.
♦ In the therapeutic phase (after the diagnostic is completed), the suggested frequency would be 2–3 months or longer between injections, provided that >50% relief is obtained for 6 weeks.
♦ If the interventional procedures are applied for different regions, they may be performed at intervals of no sooner than 1 week or preferably 2 weeks for most types of procedures. It is suggested that therapeutic frequency remain at 2 months for each region. It is further suggested that all regions be treated at the same time, provided all procedures can be performed safely.
♦ In the treatment or therapeutic phase, the interventional procedures should be repeated only as necessary according to the medical necessity criteria, and it is suggested that these be limited to a maximum of 4 to 6 times for local anesthetic and steroid blocks over a period of 1 year, per region.
♦ Under unusual circumstances with a recurrent injury or cervicogenic headache, procedures may be repeated at intervals of 6 weeks after stabilization in the treatment phase.



Medial Branch Neurotomy (Facet denervation)
♦ The suggested frequency would be 3 months or longer (maximum of 3 times per year) between each procedure, provided that > 50% relief is obtained for 10 to 12 weeks.
♦ The therapeutic frequency for medial branch neurotomy should remain at intervals of at least 3 months for each region. It is further suggested that all regions be treated at the same time, provided all procedures are performed safely.


Contraindications
Contraindications include ongoing bacterial infection, possible pregnancy, bleeding diathesis, and anticoagulant therapy. Precautions are warranted in patients with anticoagulant or antiplatelet therapy, diabetes mellitus and artificial heart valves.

Special Concerns:
Always obtain informed consent for any interventional procedure. In addition, patients must be informed of the risks, benefits, and potential outcomes associated with the procedure.
Patients with LBP who demonstrate red flags, such as unexplained weight loss, fever, and chills, should be further evaluated to rule out malignancy or occult infectious processes.
Interventional procedures with anesthetics and corticosteroids, can lead to transient lower-extremity weakness, insomnia, headache, fluid and electrolyte disorders (especially in patients with congestive heart failure), GI upset, bone demineralization, and impaired glucose tolerance (patients with diabetes). Less common effects are mood swings, increased appetite, and, the most serious, adrenocortical insufficiency. Dural puncture can lead to infection and an increased incidence of headaches.

References:

1. Goldwaith JE. The lumbosacral articulation: an explanation of many cases of "lumbago," "sciatica" and "paraplegia". Boston Med Surg J. 1911;164:365-72
2. Putti V. New conceptions in the pathogenesis of sciatic pain. Lancet. 1927; 2:53-60.
3. Ghormley RK. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933; 101:1773-7.
4. Harris RI, Macnab I. Structural changes in the lumbar intervertebral discs; their relationship to low back pain and sciatica. J Bone Joint Surg Br. May 1954; 36-B (2):304-22.
5. McRae DL. Asymptomatic intervertebral disc protrusions. Acta radiol. Jul-Aug 1956;46(1-2):9-27
6. Hirsch C, Ingelmark B E, Miller M. The anatomical basis for low back pain. Studies on the presence of sensory nerve endings in ligamentous, capsular and intervertebral disc structures in the human lumbar spine. Acta Orthop Scand. 1963;33:1-17
7. Bogduk N. The zygapophysial joints. In Clinical Anatomy of the Lumbar Spine and Sacrum, Third edition. Churchill Living¬stone, New York, 1997, pp 33-41.
8. Dreyfuss P, Schwarzer AC, Lau P et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. Spine 1997; 22:895-902.
9. Dreyfuss P, Schwarzer AC, Lau P et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks. Spine 1997; 22:895-902.
10. Fujiwara A, Tamai K, Yamato M et al. The relationship between facet joint osteoar¬thritis and disc degeneration of the lum¬bar spine: An MRI study. Eur J Spine 1999; 8:396-401
11. Fujiwara A, Lim T, an H et al. The effect of disc degeneration and facet joint os¬teoarthritis on the segmental flexibility of the lumbar spine. Spine 2000; 25:3036-3044
12. Vernon-Roberts B, Pirie CJ. Degenerative changes in the intervertebral discs of the lumbar spine and their sequelae. Rheum Rehabil 1977; 16:13-21.
13. Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. Mar 2007; 106(3):591-614.
14. Bogduk N. Low back pain. In Clinical Anatomy of the Lumbar Spine and Sa¬crum, ed. 3. Churchill Livingstone, New York, 1997; pp 187-214.
15. Manchikanti L, Singh V, Pampati V et al. Evaluation of the relative contributions of various structures in chronic low back pain. Pain Physician 2001; 4:308-316
16. Jackson RP, Jacobs RR, Montesano PX. 1988 Volvo award in clinical sciences. Facet joint injection in low-back pain. A prospective statistical study. Spine. Sep 1988; 13(9):966-71.
17. Boswell MV, Colson JD, Sehgal N, Dunbar E, Epter R. Systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10:229-253.
18. Bogduk N, McGuirk B. Management of Acute and Chronic Neck Pain. Evidence- Based Approach. Elsevier, 2006.
19. Bogduk N. International Spinal Injection Society guidelines for the performance of spinal injection procedures. Part 1: Zygapophyseal joint blocks. Clin J Pain 1997; 13:285-302.
20. Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: A systematic review of evidence. Pain Physician 2005; 8:211-224.
21. Schwarzer AC, Wang SC, O'Driscoll D, et al. The ability of computed tomography to identify a painful zygapophysial joint in patients with chronic low back pain. Spine. Apr 15 1995;20(8):907-12
22. D'Aprile P, Tarantino A, Jinkins JR, Brindicci D. The value of fat saturation sequences and contrast medium administration in MRI of degenerative disease of the posterior/perispinal elements of the lumbosacral spine. Eur Radiol. Feb 2007;17(2):523-31
23. Rozenberg S. Glucocorticoid therapy in common lumbar spinal disorders. Rev Rhum Engl Ed 1998; 65:649-655
24. Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician 2007; 10:7-111 • ISSN 1533-3159
25. Pang WW, Mok MS, Lin ML, Chang DP, Hwang MH. Application of spinal pain mapping in the diagnosis of low back pain—analysis of 104 cases. Acta Anaesthesiol Sin 1998; 36:71-74.

YOGA AND THE MEDICAL SCIENCE



Modern medical science and Yoga are rational, scientific and universal in outlook and hence are natural allies. Their combination has the potential to provide us with a holistic health science that will be a boon for the psychosomatic health of our masses. Yoga involves a holistic approach to healing and integrates healing with the culture, diet, environment, and tradition.
Modern allopathic medicine that originated from Greco-Roman Medicine and Northern European traditions is built on the science of anatomy, physiology, and biochemistry and the structure-function relationship between cells, tissues, and organs. Allopathic medicine focuses on diagnosis, treatment, and cure for acute illnesses via potent pharmaceutical drugs, surgery, radiation, stem cell and other treatment modalities.
Modern medical advancements provide the rationale for the integration of various traditional healing techniques including Yoga to promote healing, health, and longevity. It is imperative that advances in medicine include the holistic approach of Yoga to face the current challenges in health care. The antiquity of Yoga must be united with the innovations of modern medicine to improve quality of life throughout the world.
Modern medicine has the ultimate aim and goal of producing a state of optimum physical and mental health thus ultimately leadings to the optimum well being of the individual. Yoga also aims at the attainment of mental and physical well being though the methodology differs. While modern medicine has a lot to offer mankind in its treatment and management of acute illness, accidents and communicable diseases, Yoga has lot to offer in terms of preventive, promotive and rehabilitative methods in addition to many management methods to tackle emerging challenges like Obesity, Diabetes, Heart, Joint and Psychosomatic Disorders etc to modern medical science.

ANATOMY AND PHYSIOLOGY:
The study of anatomy and physiology is a great meeting point for modern medicine and Yoga. Yoga therapists and practitioners can benefit from the intricate and detailed ‘break-down study’ of modern medicine where the body is broken down into many systems, then into many organs, many tissues and finally into billions of cells including the emerging concept of stem cells. On the other hand the Yogic “ holistic” view of the Pancha Kosha (the five sheathed existence) can help modern doctors realize that we are not just, ‘one-body’ organisms but have four more bodies that are equally if not more important. We are a manifestation of the Divine and have, not only the physical body but also an energy body, a mental body, a body of wisdom and a body of eternal bliss. An understanding of the psychic anatomy and physiology of Nadis, Chakras and Bindus when coupled with the practical understanding of the details of the physical body can inspire real knowledge of the self in all health care personnel. Maharishi Mahesh Yogi has tried to correlate 37 areas of human physiology with 37 areas of intelligence or consciousness as available in Vedic literature. Some of the examples are the correlation between Nyaya and the Thalamus as well as Samkya and the types of neuronal activity.

In his excellent book, “The Shambala Guide to Yoga”, Dr. George Feuerstein says, “Long before physicists discovered that matter is energy vibrating at a certain rate, the Yogis of India had treated this body-mind as a playful manifestation of the ultimate power (Shakti), the dynamic aspect of Reality. They realized that to discover the true Self, one had to harness attention because the energy of the body-mind follows ‘attention’. A crude example of this process is the measurable increase of blood flow to our fingers and toes that occurs when we concentrate on them. Yogis are very careful about where they place their attention, for the mind creates patterns of energy, causing habits of thought and behavior that can be detrimental to the pursuit of genuine happiness”. Professor Dr SV Rao, an eminent medical doctor and Yoga Scientist says, “Yoga is a science because it is verifiable. Yoga as a science of living is also an art. Yoga, therefore, may be defined as the science and art of optimum living”

PREVENTION OF DISEASE:

As per the concept of great Maharishi Patanjali, Yogic lifestyle that includes the Yama and Niyama can help prevent a great many of the modern diseases like Hepatitis B and AIDS. Cleanliness that is taught through Soucha can help prevent and limit the spread of contagious and infectious diseases. Mental peace and right approach to Yoga such as Samatvam (equanimity of mind) and Vairagya (dispassionate detachment) can help prevent many of the psychosomatic ailments running wild in the modern world. If these Yogic values as well as practices such as Asanas, Pranayamas, Kriyas and Dhyana are inculcated in the modern human race, we can prevent virtually all diseases that abound today. However the ‘will’ to do so is also of paramount importance as there is no money or fame in prevention and we don’t know what we have prevented because we have prevented it from happening!
To quote the eminent neurosurgeon Dr B Ramamurthi, “The widespread revival of the Science of Yoga by modern Yogic teachers and Gurus, bodes good for mankind. The only way to keep fit & healthy is through the Science of Yoga, which transcends all religions and cults. It is a science of the mind and the body and needs to be practiced by all human beings to ensure their own future”.

PROMOTIVE HEALTH:
The practice of Yoga leads to the efficient functioning of the body with homeostasis through improved functioning of the psycho-immuno-neuro-endocrine system. A balanced equilibrium between the sympathetic and parasympathetic wings of the autonomic nervous system leads to a dynamic state of health. Yoga not only benefits the nervous system but also the cardiovascular, respiratory, digestive, muscular, endocrine and immune system.
Hath Yoga introduced by Yogi Swatmarama, a sage of 15th century India, in his book Hatha Yoga Pradipika, is the most practiced form of body discipline. In the last forty to fifty years, Hath Yoga has also been accepted as “ Therapeutic Modality” all over the world , supported by many scientific studies Various types of yogic ‘ Kriyas’ or techniques, may be Asans, pranayama, mudras, bandhas and Meditation etc have been administered to demonstrate their effect on health and diseases in a scientific manner.

DISEASE REVERSAL
Yoga has a lot to offer in terms of psychosomatic disorders and in stress related disorders such as diabetes, asthma, irritable bowel syndrome, epilepsy, hypertension, back pain and other functional disorders. Yoga can help reduce and in some cases eliminate drug dosage and dependence in patients suffering from diabetes mellitus, hypertension, epilepsy, anxiety, bronchial asthma, constipation, dyspepsia, insomnia, arthritis, sinusitis and dermatological disorders.
Asanas are probably the best tool to disrupt any learned patterns of wrong muscular efforts. Pranayama and Pratyahara are extremely efficient techniques to divert the individual's attention from the objects of the outer environment, to increase a person's energy potential and 'interiorize' them, to achieve control of one's inner functioning.
We must remember Plato’s words when he said, “The treatment of the part shouldn’t be attempted without a treatment of the entirety,” meaning that the treatment of the body without treating the mind and soul would be waste of time. Efficient medical scientist does the same. A smiling, caring physician with sweet voice and gentle touch is more of a Yogic therapist.
Yoga can help those recovering from accidents and physical traumas to get back on their feet faster and with better functional ability.


KUNDALINI JAGRAN
Lajpat Rai, an eminent Physiologist has conducted extensive study on Chakras and Kundalini Jagran. According to Kundalini Yoga, the potential energy located in the Chakras can be converted into kinetic form either spontaneously or by meditational practices. This phenomenon of conversion of potential energy into kinetic energy has been termed as “Awakening of Kundalini” which leads to self actualization. Kundalini Chakras are claimed to be vortices of energy spinning in circles like transformers. They are said to govern and regulate the flow and dispersion of power (etheric or pranic energy of yoga) in an electrical human infrastructure comprised of an extraordinary circuitry of 72 thousand subtle channels (sukshama prana nadis). Quantitatively, the five chakras on the spine are further claimed to be endowed with the qualities and attributes possessed and manifested by five cosmic elements of earth, water, fire, air and ether respectively. Intensive meditation on the chakras sites at spine and cranium by way of visualization of a given chakra symbolically in terms of a number of petals of a lotus, its colour, sound and other ingredients surcharges the body-mind-consciousness complex at all the five levels.



HEALTHY DIET:

Yoga teaches us that the cause of most disease is through under (Ajjeranatvam), over (Atijeeranatvam) or wrong (Kujeeranatvam) digestion. Yoga also teaches us about the approach to food, the types of food as well as the importance of timings and moderation in diet. A combination of the modern aspects of diet with a dose of Yogic thought can help us eat not only the right things but also in the right way and at the right time thus assuring good health and longevity. Eminent Physiologist Prof Lajpat Rai in his vast scientific studies has given great importance to Yogic Dietary Regimen and has observed the effect of Fasting Therapy to buildup the internal milieu by restoring the homeostatic mechanisms.

RELAXATION:
Relaxation is a key element of any Yoga therapy regimen and must not be forgotten at any cost. Shavasana has been reported to help a lot in hypertensive patients and practices such as Savitri Pranayama, Chandra Pranayama, Kayak Kriyas, Yoga Nidra, Anulom Viloma Prakriyas and Marmanasthanam Kriya are also available to the person requiring this state of complete relaxation. It is important to remember that relaxation on its own is less effective than relaxation following activity.

AGING:

Aging is inevitable and Yoga can help us to age gracefully. Healthy diet, regular exercise, avoidance of negative thoughts & habits and cultivation of the positive attitude and a healthy lifestyle can help us to age with dignity. Yoga can also help our ‘silver citizens’ retain their mental ability and prevent degenerative disorders such as Parkinson’s disease, Alzheimer’s and various other aging problems. Swami Gitananda Giri, Yogashri Krishnamacharya, Kannaiah Yogi, Swami Suddananda Bharathi, Yogeshwarji, Yogendraji, Swami Ram Dev and Padma Bhushan BKS Iyengar are but a few of the Yogis who have shown us that its is possible to grow old without losing any of the physical or mental faculties of youth.

LIFE STYLE CHANGES:

Yoga helps patients to learn to make an effort and change their life style for the better so that their health can improve. Life style modification is the buzzword in modern medical circles and Yoga can play a vital role in this regard. Yogic diet, Asanas, Pranayamas, Mudras, Kriyas and relaxation are an important aspect of lifestyle modification. Dr Dean Ornish, an eminent American medical doctor who has shown that Yogic lifestyle can reverse heart disease. He says, “Yoga is a system of perfect tools for achieving union as well as healing.”
Scientists such as Dr BK Anand, Dr KK Datey, Dr KN Udupa, Dr B Ramamurthy, Dr W Selvamurthy, Dr T Desiraju, Dr Nagendra, Dr Nagaratna, Dr Shirley Telles, Dr MV Bhole, Dr Rajapurkar, Dr Mittimohan, Dr Lajpat Rai and Dr Madanmohan and Yogacharya Dr.Ananda Balayogi Bhavanani have contributed extensively towards the scientific understanding of Yoga Vidya and Yoga Vidhi
Dr VSSM Rao writes that, “The tradition of Yoga is so perfect that we have to seek ways of expounding it in modern scientific terminology instead of simply evaluating it in terms of current concepts of science, which is expanding so rapidly that a time may come when man would like to live by his intuition rather than by scientific planning, bristling with conflicts and balancing a number of variables not completely understood.”
This is because Yoga has a sound system of etiology, diagnosis and pathogenesis of disease. Thus, we have a complete system by itself in Yoga
Kundalini Jagran
The importance of Yoga in India is known from the time of Krishna which is evident from Gita.
Lord Krishna in Bhagavad Gita (vs. 16-17, Chapter VI) has said, “Yoga is not for him who eats too much or too little. It is not for him who sleeps too much or too little. It is for him who is temperate in food and recreation, temperate in his exertion at work, temperate in sleep, yoga puts an end to all sorrows”

With the increasing evidence gathered by modern medical scientists in coordination with Yoga practioners, they have no hitch to say their patients ‘Never fear shadows. They simply mean there is light somewhere nearby’


‘I burn my candle at both ends;
It may not last the night.
But oh! my friends, and ah! my foes,
It makes a lovely light!’
 Anonymous



Oh God! Lead us: from ignorance to knowledge, from Untruth to Truth, from Fragility To Eternity

NEW WAYS TO DEAL WITH PREMATURE EJACULATION ARE AVAILABLE NOW DAYS. YOU CAN USE MEDICATED CONDOMS ALSO OR ALSO FEEL BETTER WITH ANXIETY RELIVING DRUGS.

Mango
Dr.Eknath G.Kulkarni,

The nutritional value of mangoes
Besides being tasty mango has nutritional &medicinal values.
A fully ripe mango is high in Vitamin A (beta-carotene), which is a cancer-fghting agent, Vitamin C, Vitamin B1, and B2, niacin, potassium, iron and fiber. Green mangoes have a higher proportion of Vitamin C. Mangoes are good for the kidneys, digestive system of the body and the skin. It relieves clogged skin pores, reduces cysts, excess body heat and fever. All parts of the mango have medicinal uses.

Unripe mangoes have oxalic, citric, malic, tartaric and succinnic acids which results in its sour taste. As such, it is acidic, astringent and antiscorbutic. The ripe fruit is full of sugar.

The ripe mango is antiscorbutic, diuretic, laxative, invigorating, fattening and astringent. It tones up the heart muscle, improves complexion and stimulates appetite. Eating ripe mangoes in a season provides enough Vitamin A to last a whole year possibly.

The mango kernel or seed contains over 8% protein besides other vitamins and minerals. Dried mango flowers and the bark of the mango tree are astringent and useful in treatment of many ailments. The gum is used in dressing kibes and scabies. It is also considered anti-syphilitic.

Mango in Ayurveda
Mango is extensively used in Ayurvedic cures. Mangoes have the properties of ‘heating’. Mangoes are good for excess wind (vata) and mucas(kapha). A ripe mango helps the body to generate blood. If a glass of lukewarm milk is taken after eating a ripe mango then it energizes the entire system, especially the intestines. Mango increases the seven dhatus. It cleanses the body by eliminating toxins. It cures constipation. The emergence of boils on the body after eating mangoes indicates the cleansing action of mangoes. It is a good cure for loss of weight. This fruit checks premature aging.

Medicinal Uses
Heat Stroke
Boil raw mangoes in water till cooked. Extract the juice, and mix with sugar, water, salt and a pinch of cumin seeds. Drink this consistently in the hot summer, especially when you suffer a heat stroke or get prickly heat.

Digestion
Aamchur or sun-dried raw mango powder is great to aid the digestive system. Eating one or two small tender mangoes in which the see is still not fully formed, with salt and honey is an effective medicine for summer diarrhea, dysentery, piles, morning sickness, chronic dyspepsia and indigestion.

Blood Disorders
Raw mangoes increase the elasticity of the blood vessels, and help the formation of new blood cells. It aids absorption of food iron. It increases resistance against TB, anemia, cholera and dysentery.

Bilious Disorders
The acids contained in the green mangoes increase the secretion of bile and act as an intestinal antiseptic. Have it with honey and black pepper daily. This paste is also good for toning the liver.

Eye Disorders
Mango Milkshakes are very good for the eyes, due to Vitamin A. Night blindness, dryness of the eyes, itching and burning of the eyes.

Loss of weight
Mango with milk, or preferably, Soya milk gives an ideal mixture of sugar and protein for under-weight people. Consuming this three times a day for a month will lead to better health, weight gain and vigor.

Diabetes
The tender leaves of the mango tree are used to prevent and control early symptoms of diabetes. Soak the fresh leaves in water overnight and squeeze them in water before straining it the next morning. Alternatively, these leaves should be dried, powdered and preserved. Take half a teaspoon of this powder twice a day.

Spleen enlargement, dysentery and diarrhea
The mango stone should be dried and powdered. (you may do the same with the jamun seeds). Mix this powder with a big tablespoon of curd to cure spleen enlargement, dysentery and diarrhea.

Throat disorder
The mango bark is very effective in the treatment of diphtheria and other throat diseases.

Gum inflammation
Boil two tablespoons of mango flowers and tender buds in two cups of water and use as a mouth-wash regularly to cure the infammation of the gums

Skin disorders
The gum of the mango tree and the resinous substance exuded from the stem end of the fruits can be mixed with lime juice and use to heal coetaneous infections and scabies.

Almost every part of the mango tree is used to cure common diseases. Thus a mango tree has immense practical use in our daily lives.

1. What is achalasia?
The esophagus (also called the gullet), is a muscular tube that moves food down to the stomach. There is a valve at the junction of the esophagus and stomach called the lower esophageal sphincter that normally relaxes when food passes through. The condition of achalasia occurs when there is a failure of relaxation of this sphincter. Food passage gets obstructed and there is difficulty in swallowing (we call this symptom dysphagia). Dysphagia is initially to solids and progresses on to affect liquids as well. Eventually the esophagus dilates as a result of this blockage.
2. How is achalasia diagnosed?
If we suspect this, the best investigation is a gastroscopy, where we pass a long, thin, flexible telescope down the upper gastrointestinal tract. A barium swallow, a radiological study where contrast is swallowed while X-ray pictures are taken, can also diagnose this condition clearly. A manometry study to record the motility of the esophagus is sometimes also required to establish the diagnosis.
3. How is achalasia treated?
Achalasia is progressive and debilitating if not treated. There is no cause for this condition in the majority of true achalasia, but in our local experience, about 50% of patients who appear to have achalasia actually have a malignancy causing the obstruction (what we call pseudo-achalasia). The first thing we need to do is to rule out conclusively that a cancer is not the actual problem. We may need to do a CT scan or even a diagnostic laparoscopy to be absolutely sure.
Some doctors try treating achalasia with medication or an injection of Botox through the endoscope to relax the sphincter. The results of these options are not long-lasting in our experience. Another endoscopic treatment is a forceful dilatation of the tight sphincter with a balloon passed through the scope. About 60-80% of patients will have good results after balloon dilatation. There is, however, a 5% risk of perforating the esophagus during dilation and a 20% chance that multiple sessions are required.
Many experts believe that surgery is the best treatment. However, this is a more invasive option and it is reasonable to try balloon dilatation first if you want to avoid surgery. Younger patients tend to do better with surgery rather than dilatation and it is our preference to offer surgery as a first-line treatment if you are young and fit for surgery. Surgery also tends to be less complicated if we offer this upfront compared to doing a salvage procedure for a patient that has failed dilatation and has a scarred esophagus.
4. What surgery can be done for achalasia?
The operation needed is called an esophageal myotomy, where the tight muscles of the sphincter is divided. The conventional way to do this is through a long opening in the rib cage or upper abdomen. We prefer a keyhole approach by a procedure called laparoscopic myotomy. We also combine this operation with a wrap of the top of the stomach around the esophagus to prevent reflux symptoms after surgery.
Most of our patients are admitted on the day of surgery and stay in hospital for 1-2 days after. Recovery is rapid as only small incisions are used compared to conventional open surgery. About 90% of patients will have excellent long term results.