Neurosurgery at Narayana Hrudayalaya Institute of Neurosciences

in the context of Indian Neurosurgery

Komal Prasad C, M.ChBangalore

India

• India is one of the oldest civilizations in the world with a kaleidoscopic variety and rich cultural heritage. It has achieved all-round socio-economic progress during the last 62 years of its Independence.

• India has become self-sufficient in agricultural production and is now one of the top industrialized countries in the world and one of the few nations to have gone into outer space to conquer nature for the benefit of the people.

India

• As the 7th largest country in the world, India stands apart from the rest of Asia, marked off as it is by mountains and the sea, which give the country a distinct geographical entity.

India• India accounts for a meager

2.4 per cent of the world surface area. Yet, it supports and sustains a whopping 16.7 per cent of the world population

• The population of India, which at the turn of the twentieth century was around 238.4 million, increased to reach 1,028 million at the dawn of the twenty-first century

Ancient IndiaIf one were to believe mythology, the history of Indian Neurosurgery goes back to the time of Lord Shiva when he transplanted the head of an elephant on Ganesha.Lord Ganesha is the elephant-headed God, the embodiment of wisdom, knowledge and bliss; the remover of obstacles.

Ancient IndiaJivaka was the physician of kings, noblemen and the Buddha. The Buddhist texts mentions that he did trephination and successfully removed two tumors from the brain of a rich merchant.

Ancient India

• Archeological excavation of trephined skulls from the pit-dwellers of Burzahom in the northwestern Himalayan region (present day Kashmir Valley) suggests that trephination might have been practiced in prehistoric India (4000 to 4300 years ago) for acquired neurological ailments

Ancient IndiaThe Neurosurgical accomplishments of Sushruta are documented in the Sushruta Samhita which was written around 3rd or 4th Century AD. He vividly described cranial nerves and their specific sensory functions through cadaveric dissections. He had a method for management of spinal injuries; but on the whole, believed fractures of the spine to be hopeless.

Early Indian Neurosurgery• Neurosurgery in India is a post World War II

development, resulting from the keen desire of the new rulers of independent India, that the country should keep up with all the modern advances in every field of medicine

Early Indian Neurosurgery• Prior to independence in 1947, there was no trained

neurosurgeon in the country. • There were however, general surgeons who attempted

neurosurgery as and when required and some even had papers published on the subjects.– 1935, Col Anderson performed Trans-sphenoidal

Hypophysectomy– Bombay: Ardeshir P Bacha, GV Deshmukh, RN Cooper, AV

Baliga– Madras: NS Narasimhan, CP Vishwanatha Menon, U Mohan Rao– Amritsar: Lt Col R Mirajkar, Baldev Singh– Bangalore: Balakrishna Rao

Early Indian NeurosurgeryNeurosurgery as we know it today started in India in 1949• 1949- First Department of Neurosciences in India- by Jacob

Chandy at the Christian Medical College and Hospital, Vellore

• 1950- B Ramamurthi established Department of Neurosurgery at Madras Medical College and General Hospital, Madras (Chennai)

• 1953- Ram Ginde set up Department of Neurosurgery at Seth GS Medical College and King Edward Memorial Hospital, Mumbai.

Only three qualified Neurosurgeons in the country till 1957.90% of patients seen were blind; facilities for diagnosis and

therapy were few; and operative mortality was high.

Early Indian Neurosurgery Neurosurgery Departments were established by early

leaders in different parts of the country-• Col Ray: 1st Indian Army Neurosurgeon• R N Chatterjee, Calcutta (1955)• Victor Rao, Delhi (1956)• Balaparameswara Rao, Vishakapatnam(1956)• Dayanand Rao, Hyderabad (1957)• Homi Dastur, Bombay (1958)• R M Varma, Bangalore (1958)• P N Tandon, Lucknow (1961)• Desraj Gulati, Chandigarh (1962)

Prof. B. Ramamurthi• 1922–2003 • Hony President of the World Federation of

Neurosurgeons in 1989• 1950- started the neurosurgical service at

the Government General Hospital, Chennai.• 1951 -Neurological Society of India-founder

Secretary• First editor of Neurology India• 1970, Institute of Neurology

1st comprehensive neurosciences centre, South Asia

• The story of neurosurgery in India is closely linked to the formation and growth of the Neurological Society of India (NSI).

• Four individuals met at the residence of Dr. S.T. Narasimhan in Madras on 8th December 1951 and formed the NSI.– Dr. Jacob Chandy (Neurosurgeon, Vellore)– Dr. Baldev Singh (Neurologist, Vellore)– Dr. S.T. Narasimhan (Physician and Electrophysiologist, Madras)– Dr. B. Ramamurthi (Neurosurgeon, Madras Medical College) • They enrolled themselves as members and formulated the

constitution.

NSI Conference, Calcutta, 1962Front row (left to right) Drs A K Bagchi, R G Ginde, Baldev Singh, G Arjundas, N H Wadia, E P Barucha, J Abraham, T K Ghosh. Rear row (left to right) Drs K S Mani, B Ramamurthi, V Virmani, R N Chatterjee, Jacob Chandy, P N Tandon, G M Taori and A K Banerji

• 1989, New Delhi• Society (NSI) played host to the Congresses of

the-– WFNS- World federation of Neurological Societies– World Federation of Neurology and – International Epilepsy Association

1953- The Journal Neurology India was launched . Presently it is renowned and indexed journal with free access online.

1972- The Society sponsored publication of the Textbook of Neurosurgery edited by Dr. B.Ramamurthi and Dr. P.N.Tandon

Past Office Bearers of the NSI

• Neurosurg. Rev. 6 (1983) 85-92

Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp. 332-335Neurosurgery in IndiaNadkarni TD, Goel A, Pandya SK

“The development of Neurosurgery in India during the past 55 years has almost

paralleled the achievements of the country in "55 years of freedom". There was no

trained neurosurgeon nor any department of neurosurgery in India at the time of

Independence. A few general surgeons were performing neurosurgery at that

time. All heads of surgical, medical and basic sciences department, considered

neurosurgery, neurology and its ancillaries - neuroradiology, neuropathology,

neurophysiology and neurochemistry irrelevant under the circumstances. It was a

continuous struggle to get rid of this controlling yoke.”

Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp. 332-335Neurosurgery in IndiaNadkarni TD, Goel A, Pandya SK

“Over the years, there has been a tremendous change. Neurosurgically treatable

diseases are now diagnosed and referred in good time. Many ancillary diagnostic

facilities are now available and the patients themselves are aware of the need to seek

early neurological consultation. Neurosurgery in India is now at par with the best of

such services available in the world. All necessary technological advances as well as

qualified personnel are available in the country. Though the centres of excellence are

based in the major metropolitan cities of the country, access to these services is easier

than before. Assimilation and application of technological advances has been at such a

rapid rate that many centres in India are at par with similar ones abroad.”

The Asian Australasian Society of Neurological Surgery

• The Asian Australasian Society of Neurological Surgery is the largest continental society of neurological surgeons having more than 28 countries as its members.

• AASNS has more than 14,000 neurosurgeons representing almost 40% of the world’s neurosurgeons and 60% of the worlds population.

• The late Prof. B. Ramamurthi a founder member of the AASNS subsequently was elected as a Hon president of the AASNS.

• In 1999 Dr.K.Ganapathy was elected as secretary.

Subspecialty societiesIndian neurosurgery today has become world class and

due in part to the impetus and drive of the W.F.N.S (India) Trust. Along with the parent association Neurological Society of India, there are 5 separate neurosurgical societies today

(I) Neurotrauma Society of India (II) Skull Base Surgery Society of India (III) Indian Society of Stereotactic & Functional

Neurosurgery (IV) Indian Society of Pediatric Neurosurgery (V) Indian Society of Cerebrovascular Surgery.

Subspecialty societies

Present Scenario

• Now, there are about 1000 practicing Neurosurgeons in India.

• Just to compare, this is less than one-third the number of Neurosurgeons in USA; and the population in India is more than three times that of US.

Different types of Hospitals

• Central Government funded Premier Institutes/ Institutes of National Importance

• State funded Hospitals and Research Institutes• Corporate Hospitals / Trust• Private Teaching Hospitals • Missionary Hospitals• Armed Forces Hospitals and Research Centres.

Types of Practice• Academic Department- Units– Typically one unit consists of a Professor, an Associate

Professor and an Assisstant Professor, with 3-4 residents.

• Independent practice, ‘Free-lance’:– Popular in cities and suburban Districts.

• Team– Seen in Metros- still not popular

• Sub-specialization– Not popular. Few confined to Pediatric Neurosurgery,

Epilepsy surgery in Metros.

Neurosurgical Training

Institutes Positions

M.Ch 38 152

DNB 34 44

Total 72 196

•There are about 200 positions for Neurosurgical training every year. Residents are required to clear an entrance examinatiton to get into the course. Unlike many western countries, the demand for neurosurgical residency programme is on the raise.•After basic training in Medicine MBBS (5.5 years), the residents can directly join 6 years training program or can get into neurosurgery after 3 years of postgraduation in Surgery (MS) for 3 years program.•The degree awarded is M.Ch or DNB (Diplomate of National Board).

Some of the Premier Institutes of Neurosurgery

• All India Institute of Medical Sciences, New Delhi• National Institute of Mental Health and Neurosciences,

Bangalore• Sree Chitra Tirunal Institute of Medical Sciences and

Technology, Thiruvananthapuram• Postgraduate Institute of Medical Education and Research,

Chandigarh

Bala A, Gupta BM. Mapping of Indian neuroscience research: A scientometric analysis of research output during 1999-2008. Neurol India 2010;58:35-41

Neurosurgery Research in India

Common caseload- Probably same as elsewhere

• Cranio- spinal trauma• Low back ache, neck pain• Glioma, meningioma, vestibular schwannoma,

pituitary adenoma• Spinal IDEM, Syringomyelia, Spinal dysraphisms• Aneurysms and AVMs are not rare as was

thought earlier. • Surgery for unruptured aneurysms is rare.

Prevalent Diseases

• OPLL• CVJ anomalies• Spinal dysraphism• Tuberculosis- Spine• Tuberculosis- Meningitis; Hydrocephalus• Cysticercosis

Ossification of Posterior Longitudinal Ligament

Endemic in some states, probably related to high Fluoride content in water

Neurosurgery Now

• Many new Neurosurgery Departments are set up in various Indian cities with state-of-the-art infrastructure, in last decade.

• There are seven centers offering Gamma Knife and two centers have Cyberknife.

• India is a favorable destination for medical tourism mainly because it provides good health care, probably, at a lowest cost in comparison to countries like the USA, the UK or Europe

How can developing India afford to deliver quality Neurosurgery

• Booming economic growth• Steep socioeconomic divide• Increase in Government funding to premier

state-run Institutes• Medical Insurance- still nascent• Micro health Insurance- novel mass insurance

schemes.

Micro Health InsuranceA landmark initiative for the farming community in India , "Yeshasvini Co-operative Farmers Health Care Scheme"(YCFHCS) is a great boon to the Co-operative farmers of Karnataka State. Initiated by Dr. Devi Shetty of Narayana Hrudayalaya, Bangalore, the scheme aims to provide cost effective quality healthcare facilities to the Co-operative farmers spread across the state of Karnataka.

Micro Health InsuranceThis is the World's largest scheme of Self Funded Healthcare scheme recorded as on date, offering a low priced product for a wide surgical cover, (covering over 1600 defined surgical procedures) to the farmer cooperators and his dependent family members.

This is a contributory scheme wherein the beneficiaries contribute a small amount of money every year to avail any possible surgery during the period. The beneficiaries are offered cashless treatment at the Network of over 135 Hospitals spread across the state of Karnataka.

Micro Health Insurance• The Yeshasvini scheme has attracted global attention with

two major US bodies, Harvard and the Rockefeller Foundation, planning to study it closely and replicate it elsewhere, especially in African countries.

• The World Bank too has shown interest in the functioning of this health programme with the intention of finding more pragmatic solutions to low-cost, high-quality healthcare in the developing world.

• The International Labour Organisation has showcased the scheme on its website and has also constituted a study of this scheme backed by expert actuaries.

• Similar schemes are now initiated with state government backing in neighboring states.

• The Narayana Institute of Neurosciences was dedicated to the nation in 2004 by then President of India Prof. Dr. A.P.J Abdul Kalam.

• Since then it has established itself as one of the major Neurosciences centre in the country.

Neurosurgery• 5 Consultants• Neurosurgery training program- Diplomate of National Board.

Seven Residents at present• Approximately 700 to 1000 surgeries/ year• Support by Neurology, Interventional Neurology and

Neuroradiology

Neurosurgery Equipment• Operating microscopes-

– Leica MS2– Moller-Wedel Hi-R 1000– Zeiss OPMI

• Neuroendoscopes– Aesculap– Storz

• Soring Ultrasonic Aspirator• Drills

– Medtronic Midas Rex Legend (2) Pneumatic

– Stryker Electric• Nerve Monitoring

– Medtronic NIM 3.0

• 5000 beds• Multiple Health Cities• State-of-the-art

infrastructure• Affordable• Micro- Health Insurance

schemes for masses

• It is the Neurosciences wing of Narayana Hrudayalaya Institute of Medical Sciences, developed as a Health City by its visionary chairman, cardiac surgeon Dr. Devi Prasad Shetty.

Some Unique Cases

Epilepsy Surgery

• India with over one billion people will have over one million people with medically refractory epilepsies, of which nearly one half are potential surgical candidates

• With over 500,000 potential epilepsy surgery candidates, not more than 200 epilepsy surgeries per year are being undertaken today.

Epilepsy Surgery

• Anterior Temporal Lobectomy and Amygdalohippocampectomy: 30 patients– Mesial temporal sclerosis with refractory seizures is the

commonest indication– >90% favorable outcome– 76% seizure free

• Corpus Callosotomy: 4 patients– Excellent outcomes in drop attacks

• Functional Hemispherotomy: 1 patient

Functional Hemispherotomy

This 2 year old child with cortical dysplasia had good seizure outcome and improvement in right hemiplegia after hemispherotomy.

CEA - CABG•Novel technique of aortico- carotid shunt in cases of concomitant Coronary artery Bypass Graft and Carotid endarterectomy- Placement of Aortico- Carotid Shunt is developed and used selectively in suitable cases.•However, the trend in routine Carotid Endarterectomies is not to use shunt or any patch.

CEA-CABG

Courtesy: Dept of Cardiothoracic Surgery, Narayana Hrudayalaya

Cranio-vertebral Junction Anomalies

• CVJ anomalies, especially congenital atlanto-axial dislocations, are prevalent in India

• Novel techniques for treatment of CVJ anomalies are described in Indian literature.

• Newer technique of C1-C2 realignment is described by Prof.Atul Goel- involves distraction and placement of spacers at C1-C2 joints.

• Our experience in this technique suggests transoral odontoidectomy can be avoided in almost all cases.

This patient underwent distraction and placement of C1 lateral mass screws,C2 pedicle screws and C1-C2

spacers.

This patient underwent distraction and placement of C1 lateral mass screws,C2 pedicle screws and C1-C2

spacers.

Placement of condylar screws for occipito-cervical fusion in patient with rheumatoid arthritis and atlanto-

occipital and atlanto-axial dislocation.

Placement of condylar screws for occipito-cervical fusion in patient with rheumatoid arthritis and atlanto-

occipital and atlanto-axial dislocation.

Placement of condylar screws for occipito-cervical fusion in patient with rheumatoid arthritis and atlanto-

occipital and atlanto-axial dislocation.

Spinal Neurocysticercosis

Thank you