A Trailblazer in OrthopedicsUsing simple radiological tools for research to transform international methodologies in orthopedics

Dr. S. Rajasekaran, Ganga Hospital, India

January 22, 2014 | Dr. S. Rajasekaran of Ganga Hospital, Coimbatore, used simple radiological tools for research to transform international methodologies in orthopedics.  


Text: Swati Prasad
Photos: Arush Mayank

Ganga Hospital in India
Ganga Hospital registration area

Dr. S. Rajasekaran’s office on the ground floor of Ganga Hospital on Mettupalayam Road, Coimbatore, is quite spacious. Yet, display space is almost running out for awards won by Rajasekaran, Chairman of the Department of Orthopedic and Spine Surgery, and his teams.
Private hospitals in India rarely undertake medical research. But Ganga Hospital is definitely a cut above the rest, and research has played a key role in its success. It was set up in 1978 by Rajasekaran’s father, Dr. J. G. Shanmuganathan, an anesthetist. Rajasekaran, who joined Ganga in 1991, ensured that the hospital has the right blend of clinical and academic activities. Today, when Rajasekaran adopts a methodology, it impacts on the international community.

Award Winning Expert
Rajasekaran’s interests relate to spinal tuberculosis, open fractures, genetic studies, back pain and disc degeneration, disc diffusion studies, computer-assisted orthopedic surgery, and diffusion imaging of the spinal cord. His research has won him numerous international awards including the prestigious ISSLS (International Society for the Study of Lumbar Spine) Prize for Spine Research for 2004, 2010, and 2013; the EuroSpine Open Paper Award for 2008; the MacNab LaRocca Research Award, Canada, 2005; and the ISSLS Sofamer Danek Award for 1996, 2002, and 2006.

Dr. S. Rajasekaran on his research in orthopedics
Dr. S. Rajasekaran

Radiology in Research
In 1991, when Dr. S. Rajasekaran and his brother Dr. S. Rajasabapathy, a plastic surgeon, returned to India from the UK, they decided to convert their father’s polyclinic into a specialty hospital for orthopedics and plastic surgery. After his return to India, Rajasekaran realized the huge difference in the approaches adopted by orthopedics in India and their peers in the West. While those in the West believed surgery was the answer to most ailments, orthopedics in India were busy attending to trauma and accident cases. “Mere mention of spine surgery in India would scare patients,” says Rajasekaran.


Advancements in Orthopedics Research
Even today, very little is understood about back pain. “A magnetic resonance exam may show some changes in the spine, but the pain may be coming from somewhere else – the joint, the disc, nerves, muscles – or the problem may be in the brain. You can also experience pain due to depression, stress, or anxiety.” That was why Rajasekaran decided to get into research. His first published research – The Natural History of Childhood Spinal Tuberculosis – proved that kyphosis progresses in one third of the children even after complete cure of tuberculosis. Rajasekaran also described four radiological signs by which children at risk of kyphosis could be identified. These ‘spine-at-risk’ signs are now widely used throughout the world. Rajasekaran has also undertaken considerable research on measurement of disc nutrition, disc degeneration, enhancement of disc nutrition, as well as compression and endplate breaks. Research not only prevents the onset of professional fatigue, it gives medical practitioners a fresh perspective. “You start analyzing. And then every patient looks interesting,” says Rajasekaran.

MRI plays an important role in research in orthopedics
MRI plays a significant role in research at the hospital.

Understanding Diseases Through Radiology
Radiology plays a key role in research at Ganga. Rajasekaran uses computed tomography (CT), magnetic resonance imaging (MRI), and X-ray systems for his research. “Radiology was previously only meant for diagnoses. Today, it is also being used to understand diseases and their aspects,” says Rajasekaran. Siemens’ systems have played a significant role in all of the research. In fact, Rajasekaran has undertaken a great deal of his research on a MAGNETOM® Symphony 1.5-tesla MRI eco system. “For the spine, the 1.5-tesla provides excellent clarity,” he says.

Ganga Orthopedics Research and Education Foundation
In 2002, the hospital founded the Ganga Orthopedics Research and Education Foundation (GOREF), funded by Rajasekaran’s family. The next step was to utilize hospital resources for research. The MRI eco system, for instance, was relatively free after 8.30 p.m. “We convinced our consultants to charge less for research,” he says. Today, GOREF has grown and has to its credit various activities such as supporting the academic training of the hospital staff, holding scientific meetings and conferences, funding on-going research activities, and social projects at the hospital.
Ganga Hospital provides fellowship to senior residents from all across India. It has a team of international students coming in every year to learn new techniques in spine surgery. “In the last 15 years, we trained 463 doctors from 42 countries,” Rajasekaran says.

Ganga Orthopedics Research and Education Foundation, India
Entrance area of Ganga Hospital

Turning to Sub-Specialties
Since 1991, Ganga Hospital has grown from a 42-bed hospital with four operating rooms to a 426-bed hospital with 18 operating rooms. More importantly, its approach is very different from other private hospitals. For instance, Ganga Hospital never turns away patients – even if they can’t afford the treatment. It organizes donors for the poor. Overall, the treatment costs are affordable.
News about Ganga has spread by word of mouth. Even today, Ganga Hospital does not have a marketing department and has never advertised. But still, 30 percent of Ganga Hospital’s turnover comes from patients who do not reside in Tamil Nadu.

Looking to the Future
For Ganga Hospital, Rajasekaran feels the scope for expansion is huge. However, it must be dovetailed to the needs of the various strata of society. “We need to be aware of the different affordability levels and needs,” he says. “Our health delivery model has to be different from the West.” Rajasekaran is convinced that the private sector must focus on the needy.
Rajasekaran is now looking at the next big step. “We have concrete plans to get into sub-specialties,” he says. He is examining whether there is scope for a 300-bed spine hospital, a 300-bed joint replacement hospital, and a 500-bed accident hospital in Coimbatore. “It may not happen today, but it will happen in the next three to four years,” says Rajasekaran.

Imaging Techniques Used by Dr. Rajasekaran

Rajasekaran’s research proved that kyphosis (a condition of over-curvature of the thoracic vertebrae) progresses in one-third of children even after complete cure of tuberculosis. He also described four radiological signs that identified children who are specifically at risk of severe deformity. These ‘spine-at-risk’ signs are now widely used throughout the world.

Lower back pain is the most common musculoskeletal pathology and disc degeneration is the most common cause of back pain. Discs are the largest avascular structures in the body and completely depend on a phenomenon called ‘diffusion’, through which important substances like glucose and oxygen are transported to the inner core of the vertebral disc. Diffusion is difficult to measure in a living person. Dr. Rajasekaran and his team effectively found a method of measuring and documenting disc diffusion over 24 hours. This research led to numerous other benefits and research spin-offs:

a) Discs at risk: MRI allowed identification of even minor endplate breaks that were not visualized in a normal MRI. It helped identify discs that were at risk of degeneration.
b) Differentiation between early degeneration and aging: A normal MRI cannot help differentiate between early degeneration and changes associated with normal aging. Rajasekaran was able to show different diffusion patterns in discs with aging changes and discs with degenerative changes.
c) Enhancement of disc nutrition: Rajasekaran and his team demonstrated for the first time that vessels can be dilated using Nimodipine – an oral drug that increases the blood supply to the brain. Nimodipine can increase the diffusion of water and glucose into the disc.
d) Compression and endplate breaks: Clinicians believed that mechanical stress damages endplates, leading to early degeneration. Rajasekaran and his team studied the effects of mechanical stress in in-vivo conditions in patients with lumbar scoliosis. MRI studies were helpful in demonstrating that even minimal compression resulted in multiple endplate breaks. It also helped in proving the deleterious effects of trunk imbalance. Trunk imbalance was included as an important indication of early surgical intervention in scoliosis.

1. The problem of deformity in spinal tuberculosis. Rajasekaran S. Clin Orthop Relat Res. 2002 May;(398):85-92.
2. ISSLS prize winner: A study of diffusion in human lumbar discs: a serial magnetic resonance imaging study documenting the influence of the endplate on diffusion in normal and degenerate discs. Rajasekaran S, Babu JN, Arun R, Armstrong BR, Shetty AP, Murugan S. Spine. 2004 Dec 1;29(23):2654-67.
3. ISSLS Prize Winner: The anatomy of failure in lumbar disc herniation: an in vivo, multimodal, prospective study of 181 subjects. Rajasekaran S, Bajaj N, Tubaki V, Kanna RM, Shetty AP. Spine. 2013 Aug 1;38(17):1491-500.
4. Diffusion tensor imaging of the spinal cord and its clinical applications. Rajasekaran S, Kanna RM, Shetty AP. J Bone Joint Surg Br. 2012 Aug;94(8):1024-31.

Swati Prasad is a freelance business journalist based in Delhi. She reports from India for several publications overseas and has worked as a correspondent and editor for The Economic Times, Business Standard, The Indian Express, and Business Today.