www.wjpr.net Vol 6, Issue 3, 2017. 1701
STUDY OF
SAMUDGA SANDHI
W.S.R TO CHANGES IN SACROILIAC
JOINT IN ANKYLOSING SPONDYLITIS
Gawande P. A.1*,Shelke D. S.2, Meshram D. S.3 and Shukla D. V.4
1
P G Scholar, Department of Rachana Sharir, R A Podar (Ayu) Medical College, Worli,
Mumbai-18, Maharashtra, India. 2
Associate Professor, Department of Rachana Sharir, R A Podar Medical College, Worli,
Mumbai -18, Maharashtra, India.
3
Assistant Professor, Department of Rachana Sharir, R A Podar Medical College, worli,
Mumbai-18, India.
4
HOD & Professor, Department of Rachana Sharir, R A Podar Medical College, Worli,
Mumbai-18, Maharashtra, India.
ABSTRACT
Sacroiliac joint is very important as it transfers the weight and forces
between upper body and lower extremities. Ankylosing spondylitis is a
sero-negative arthropathy of unknown origin. Sacroiliac joint is the site
of earliest manifestation in ankylosing spondylitis. Aim Study of
samudga sandhi w.s.r to changes in sacroiliac joint in ankylosing
spondylitis. Method Observational study, x-rays of 30 diagnosed
patients of ankylosing spondylitis are collected and analyzed. Result
X-ray of pelvis shows following changes in sacroiliac joint – erosion,
pseudo-widening, sclerosis, Ankylosis. Conclusion 1.Sacroiliac joint
falls under the samudga type of sandhi. 2. Nitamb can be correlated
with sacroiliac joint.
KEYWORDS:- Sandhi, samudga sandhi, sacroiliac joint, ankylosing spondylitis.
INTRODUCTION
Ayurveda the science of life is traced back to vedic time about 500 B.C. the great thinkers of
Ayurveda devoted their time for maintenance and longevity of life and freedom from disease.
Ayurvedic principles are potent even in 21 century man, whose lifestyle has entirely changed
compared to the ancient one.
Volume 6, Issue 3, 1701-1711. Research Article ISSN 2277– 7105
*Corresponding Author
Dr. Gawande P. A.
P G Scholar, Department of
Rachana Sharir, R A Podar
(Ayu) Medical College,
Worli, Mumbai-18,
Maharashtra, India. Article Received on 19 Jan. 2017,
Revised on 09 Feb. 2017, Accepted on 01 March 2017
For the up gradation of any science it is necessary to clarify certain unsaid facts so it is
essential to understand the anatomy of Samudga sandhi & to establish its co-relation with
sacro-iliac joint.
AIM
Study the Samudga sandhi w.s.r to changes in sacro-iliac joint in ankylosing spondylitis.
OBJECTIVES
1. To study the structural anatomy of samudga sandhi (through literature & dissection) &
elaborate co-relation with sacro-iliac joint.
2. Detail study of sacro-iliac joint to assess anatomical changes w.s.r to ankylosing
spondylitis.
SANDHI.[1]
According to the description given by B G Ghanekar while commenting on sushrut samhita
sharirsthan; when two or more objects articulates with each other in the body, it is known as
sandhi.
Classification of sandhi.[2]
Sushruta divided sandhi mainly into 2 types according to their movement
1. Cheshtavanta sandhi
2. Sthira sandhi
According to structure, sandhis are further divided into 8 types –
1)Kora 2)Ulukhala
3)Samudga 4)Pratara
5)Tunnasevni 6)Vayastunda
7)Mandala 8)Shankhavarta
Among these samudga sandhi is selected for study.
SAMUDGA SANDHI
Samudga means sharava samput or an enclosed shell.Those sandhis which form an enclosed
shell like structure comes under the term samudga sandhi.
Gananath sen says that, samudga sandhis are present at shronichakra, ansachakra showing
very little movement.
SACROILIAC JOINT.[3]
Sacroiliac, weight-bearing synovial joint that articulates, or connects, the hip bone with the
sacrum at the base of the spinal column. Strong ligaments around the joint help to stabilize it
in supporting the weight of the irregular surfaces of the sacrum, which closely articulate with
the ilium. The sacroiliac’s movement is consequently very slight or none at all. The space
between the sacrum and the hip bone is occupied by a small cavity filled with synovial fluid
and by a fibrous mass of strong cartilage.
MATERIAL AND METHODS
A) Materials
Sample size – 30
1) literature review
Ayurvedic literature - Study of samudga sandhi from classical texts.
Modern literature - Study of anatomy of joints and their classification with special reference
to sacroiliac joint is done.
2) Dissection – Instruments needed for dissection like scalpel, forceps, scissors, bone cutter,
chisel, hammer etc.
3) Photographs – Photographs of dissection were taken.
4) Observational study –
- 30 diagnosed patient of ankylosing spondylitis were selected from O.P.D and I.P.D of our
hospital.
- Individual case papers are prepared containing all information.
- Collected data was analyzed and presented.
5) X – ray – X-ray of 30 patients were studied and analyzed.
B) METHODS
1. Study design – open study
2. Place of study – R.A.Podar ayurved medical college.
CRITERIA FOR SELECTION OF PATIENTS
A) Inclusion criteria
1. Sex – Both males and females
2. Age group – 18 to 50 year.
3. Diagnosed patient of Ankylosing Spondylitis.
4. Patient willing for undergoing the study & ready to give full informed written consent.
B) Exclusion Criteria
1. Patient below age of 18 and above age of 50 years.
2. Pregnancy and lactation.
3. Patient having other system disorder i.e. DM, CA, T.B., Hepatitis, etc.
4. Patient having HIV, AIDS and other STDS.
C) Assessment of parameters-
1. Pain :-For assessment of pain
Visual Analogue Scale[4]
The following scale will used to help out assessing the severity of pain. Patients were asked
to locate a finger at any of the numerical over the scale and the severity of pain was assessed
according to that for which the numerical are labeled.
0 1 2 3 4 5 6 7 8 9 10
No pain Mild Discomforting Distressing horrible Excruciating
Nil Mild Moderate Severe
2. Morning stiffness
Absent (0) : No
Mild (1) : >1/2 hr but <1 hr
Moderate (2) : >1 hr but <6hr
Severe (3) : All day
3. General function
Absent (0) : All activities without difficulty.
Mild (1) : Most activities with difficulty.
Moderate (2) : Few activities care for self
FABER TEST[5] Positive / Negative
D) Consent form - Written informed consent of the patient included in the study are taken.
E) Case record forms- Records of all patients included in the study are documented and
maintained.
F) Laboratory investigations-
HLA B27 TEST –
X-RAY of Sacroiliac joint – AP view
- Lateral view
G) Photographs - Photographs of dissection are taken.
OBSERVATIONS AND RESULTS
Regarding observational study of patients with ankylosing spondylitis
30 patients of Ankylosing Spondylitis were observed and analyzed according to various
factors.
Distribution of cases on the basis of symptoms
In the study group of 30 patients, all were having the symptom pain, and 90% were having
stiffness, 83.33% were having functional disability.
Distribution of cases on the basis of symptom- Pain
In above study, 36.66% patients were found to have distressing type of pain, 26.66% were
having horrible type of pain, 16.66% were having discomforting pain, 13.33% were having
excruciating type of pain and 6.66% were having mild pain.
Distribution of patients on the basis of symptom-Morning stiffness
In above study, 36.66% of patients were having moderate stiffness in the morning, 30% were
having severe, 23.33% were having mild and 10% of patient were having no morning
stiffness.
Distribution of cases on the basis of functional disability
In above study; 40% of patients were having mild functional disability, 33.33% were having
moderate, 10% were having severe functional disability while in 16.66% patients functional
disability was absent.
Distribution on the basis of FABER Test
Distribution on the basis of radiological findings
In above study; 43.33% patients were having findings of grade I (some blurring of the joint-
suspicious), 26.66% were having findings of grade IV (complete ankylosis), 13.33% were
having grade II findings (minimal sclerosis with some erosion), 10% were having grade III
findings (definite sclerosis on both side of joint, severe erosions with widening of joint space
with or without ankylosis) and 6.66% were having grade 0 finding (normal SI joint.
DISCUSSION
‘‘STUDY OF SAMUDGA SANDHI W.S.R TO CHANGES IN SACROILIAC JOINT IN ANKYLOSING SPODYLITIS’’
The topic is studied and presented mainly in three subtitles as
1. Discussion on literature.
2. Discussion on dissection.
3. Discussion on clinical study.
Discussion on literature
Acharya sushruta classified sandhi into 8 types (on the basis of structure). One of them is
samudga sandhi.
This dissertation is all about the study of samudga sandhi.
Samudga means samput i.e cavity or space between two hemispherical bowl like structure.
It is also described as sagarshuktisamputgatam i.e cavity enclosed in a sea shell.[6]
This topic is elaborated by Dalhana by explaining exact meaning of samudga. Shape of this
joint resembles with an enclosed shell.
Gananath sen has stated that, these joints have articulating ends which look like samudgak
(cavity) and has slight movement i.e. alpacheshta. They are present at shronichakra,
ansachakra.[7]
So we can say that samudga sandhi resembles with an enclosed shell like joint in which one
articulating end is having a fossa or cavity and the other end is slightly elevated.
Samudga sandhi is found at ansapith, guda, bhaga, nitamb.
Pith can be considered as an enclosed structure so we can say that ansapith is a joint present
at ansapradesh.
Guda is also called as payu, sthana of apan. Guda is present in posterior part of pelvis and it
eliminates flatus and feaces and attached to large intestine. So the samudga sandhi is present
in close relation with the structure which eliminates flatus and feaces.[8]
According to shabdakosha, a place where upastha, Medhra (Male genital organs) and payu
i.e anal sphincture are found called as bhaga. It is situated anteriorly in the pelvis.
According to sushrut it is Present above the pelvis, covering the internal organs and attached
to the flanks. So nitamba sandhi is present in the upper part of pelvic girdle bilaterally. These
are two in number and cover internal organs anteriorly.
Nitamb is present in the posterolateral part of katipradesh.[9]
In context of aim and objectives, brief study of sacro-iliac joint is done.
Sacroiliac joint is present in pelvic region formed by
1. The auricular surface of the sacrum, which is covered with fibrocartilage.
2. The auricular surface of the ilium, which is covered with hyaline cartilage. The space
between the sacrum and the hip bone is occupied by a small cavity filled with synovial
fluid and by a fibrous mass of strong cartilage. Strong ligaments around the joint help to
stabilize it in supporting the weight of the irregular surfaces of the sacrum, which closely
articulate with the ilium.
Sacroiliac joints are paired C-shaped / L-shaped joints, capable of a small amount of
movements (~ 2-4 mm) in any direction. The Sacroiliac joint actually contains a mobile
ventral aspect and an ossified dorsal aspect.
Correlation between Samudga sandhi and sacroiliac joint
Features of samudga sandhi according to different Acharyas –
1. Looks like an enclosed shell
2. One surface resembles with fossa / cavity and other side is slightly elevated so that they
can articulate.
3. Alpacheshta- shows slight movement.
This study of sacroiliac joint shows that
1. The articular surfaces of sacroiliac joint are ear shaped, containing irregular ridges and
depressions. Its concave sacral surface is covered with thick hyaline cartilage and its
convex iliac surface lined with thin fibrocartilage.
2. The anterior and the lower half of the joint is a typical synovial joint. It has hyaline
cartilage on the joint surface filled with synovial fluid.
3. It is slightly flexible joint which shows movement of approximately 2-4 mm in any
direction.
4. Sacroiliac joint is present in postero-lateral aspect of pelvic girdle.
According to modern literature, Sacroiliac joint is a synovial joint of plane variety. But
characteristics of sacroiliac joint change according to age. These joint surfaces are flat /
planar in early life. But as child starts walking the joint surfaces develop distinct angular
orientations and lose their planar or flat topography.
This study reflects that Sacroiliac joint can be co-related with Samudga sandhi.
We can also say that sacrococcygeal joint is samudga sandhi because it is present in the
posterior aspect of pelvic girdle, it is in close contact with rectum and anal canal, it shows
slight movement in early age of life and articulating ends form an enclosed shell like
structure. It can be correlated with Guda.
Similarly, pubic symphysis joint can be considered as samudga sandhi as it is present most
anteriorly in pelvic girdle. So it can be correlated with bhaga. It shows slight movement,
articulating surfaces shows irregular ridges and grooves.
Discussion on dissection
According to the title of dissertation, sacroiliac joint is dissected, its relation were studied.
Joint present in shroni i.e. pelvic girdle are included in samudgasandhi is stated by sushruta.
They are called as samudga sandhi because they look like samput i.e. enclosed shell; formed
by articulating ends one having fossa or cavity and other having slight elevation. Exactly the
same structure is found in dissection. Samudga sandhi allows very limited movement.
While dissection it is noted that bones are secured with ligaments. It provides flexibility to
Ligaments of sacroiliac joint
Fibrous capsule
Ventral sacroiliac ligament Interosseous ligament Dorsal sacroiliac ligament
It consists of- short posterior Sacroiliac ligament, long posterior sacroiliac ligaments
Vertebropelvic ligament Iliolumbar ligament Sacrotuberous ligament Sacrospinous ligament
Discussion of observational study
After a detailed study of clinical aspect of Ankylosing Spondylitis, case record form was
prepared and to find out the anatomical changes in sacro-iliac joint x-ray pelvis was done.
Clinical features
1. 1.100% patients presented with pain at buttock. (Sacroiliac joint)
On the basis of symptoms most of the patients are found to have distressing / horrible
type of pain according to VAS scale.
2. 90% of patients presented with morning stiffness.
3. 83.33% of patients complained of functional disability.
4. The FABER test performed was found to be positive in all 30 patients. (100%)
Discussion on observation of radiological findings
1. Sacroilitis – it occurs early in the course of Ankylosing spondylitis and is redarded as a
hallmark of the disease.
Radiographics of the sacroiliac joints in early disease show –
2. Erosion – radio graphically, the earliest sign of sacroilitis is indistinctness of the joint;
i.e. blurring of margins, irregular subchondral erosions. Erosion is bilateral and
symmetrical. Seen first on iliac side and then on sacral of sacroiliac joint.
3. Spuedo-widening – progressive subchondral bony erosion leads to widening of joint. It is
small and localized which is not very important. This increased joint space is not
4. Sclerosis – Bony erosions are followed by subchondral sclerosis and bony proliferation.
First seen in lower third (synovial part) of sacroiliac joint. Both sacroiliac joints are
characteristically involved, but findings may appear on one side.
5. Ankylosis - With progression, sclerosis becomes more marked, the joint space is lost. As
a result Sacrum and ilium being so joined together that no motion can take place between
them and later osteoporosis appears.
CONCLUSION
1. Study of samudga sandhi shows following co-relations-
Nitamba can be correlated with sacroiliac joint
Guda can be correlated with sacrococcygeal joint,
Bhaga can be correlated with pubic symphysis,
2. According this study sacroiliac joint falls under the samudga type of sandhi.
3. Various anatomical changes are found in sacroiliac joint due to ankylosing spondylitis
which shows –
Erosion Sclerosis
Speudowidening Ankylosis
4. Though Ankylosing spondylitis is not exactly mentioned in samhitas, it can be studied
under Vatvyadhi.
REFERENCES
1. B G Ghanekar, Commentary on shushrut samhita sharir sthan, Meharchand lachmandas
publication, Varanasi, 1992; 164-167
2. Anantram Sharma, Sushrut samhita, Chaukhamba surbharti publication, Varanasi, 2013;
pg no.78-79.
3. B D Chaurasia’s, Human Anatomy part- II, CBS publishers & distributors, 4th Edition, pg
no.395-397.
4. Anna Maria Carisson, assessment of chronic pain aspect of reliability & validity of VAS,
Elsevier Biomedical press, 1983; (87-101).
5. www.physio-pedia.com/FABERTest
6. V S Apte’s, Revised and enlarged edition of Sanskrit-english dictionary, volume-III,
7. Gananath Sen, Pratyaksha sharir part-I, Sushil kumar sensharma publication, Calcutta, 4th
edition, pg no.117.
8. P K Shrikanthamurthy, Illustrated sushrut samhita, Chaukhamba orientalia, Varanasi,
2010; 111.
9. P K Shrikanthamurthy, Illustrated sushrut samhita, Chaukhamba orientalia, Varanasi,