Transcript Neurosurgery at Narayana Hrudayalaya Institute of Neurosciences in the context of Indian Neurosurgery Komal Prasad C, M.Ch Bangalore India • India is one of the oldest.

Neurosurgery at Narayana Hrudayalaya
Institute of Neurosciences
in the context of Indian Neurosurgery
Komal Prasad C, M.Ch
Bangalore
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 India
If 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 elephantheaded God, the embodiment of
wisdom, knowledge and bliss; the
remover of obstacles.
Ancient India
Jivaka 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 India
The 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 Neurosurgery
Neurosurgery 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, 1962
Front 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
PRESIDENTS
Dr. Jacob Chandy
Dr. T.K. Ghosh
Dr. D.R. Gulati
Dr. S. Janaki
1981
1982
Dr. Jacob Abraham
1983
Dr.W. Grillmayr
1952
1953
195455
1956
Dr. M. Veera Raghava Reddy
1984
Dr.T.Menino D' Souza
Dr. B. Ramamurthi
Dr. E.P. Bharucha
Dr. R.N. Chatterjee
Dr. C.G.S. Iyer
Dr. Baldev Singh
Dr. N.H. Wadia
Dr. B.K. Anand
Dr. N.S. Wadia
Dr. D.K. Dastur
Dr. Anil D. Desai
Dr. B. Dayananda Rao
Dr. S. Sriramachari
Dr. Asoke K. Bagchi
Dr. Baldev Singh
Dr. K.S. Mani
Dr. B.K. Bachhawat
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
Dr. P.N. Tandon
Dr. B.S. Singhal
Dr. S. Kalyanaraman
Dr. Shyamal Sen
Dr. S.N. Bhagwati
Dr. A.K. Banerjee
Dr. K. Srinivasan
Dr. K. Srinivasan
Dr. Sanathan Rath
Dr. Gourie Devi
Dr. M. Sambasivan
Dr. Sarla Das
Dr. V.K. Kak
Dr.Rajasekaran Nair
Dr.Arjun D.Seghal
Dr.M.C.Maheswari
Dr.Mathew J.Chandy
1985
1986
1987
1988
1989-90
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
Dr. S. Balaparameshwara Rao
1974
Dr.J.S.Chopra
2003
Dr. Gajendra Singh
Dr. G. Arjundas
Dr. K.V. Mathai
Dr. Vimala Virmani
Dr. Mahendra Singh
Dr. K. Jagannathan
1975
1976
1977
1978
1979
1980
Dr. S. R. Dharker
Dr.C.U. Velumurgendran
Dr. K. Ganapathy
Dr. V. S. Mehta
Dr. B. K. Misra
Dr. V. K. Khosla
2004
2005
2006
2007
2008
2009
Dr. R.G. Ginde
•
Neurosurg. Rev. 6 (1983) 85-92
Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp. 332-335
Neurosurgery in India
Nadkarni 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. 332-335
Neurosurgery in India
Nadkarni 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 societies
Indian 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
•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).
Institutes
Positions
M.Ch
38
152
DNB
34
44
Total
72
196
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
Neurosurgery Research in India
Bala A, Gupta BM. Mapping of Indian neuroscience research: A scientometric analysis of research output during 1999-2008.
Neurol India 2010;58:35-41
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
•
•
•
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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 Insurance
A 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 Insurance
This 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
• 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.
• 5000 beds
• Multiple Health Cities
• State-of-the-art
infrastructure
• Affordable
• Micro- Health Insurance
schemes for masses
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 atlantooccipital and atlanto-axial dislocation.
Placement of condylar screws for occipito-cervical
fusion in patient with rheumatoid arthritis and atlantooccipital and atlanto-axial dislocation.
Placement of condylar screws for occipito-cervical
fusion in patient with rheumatoid arthritis and atlantooccipital and atlanto-axial dislocation.
Spinal Neurocysticercosis
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