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1Komal Prasad C, M.Ch Bangalore Neurosurgery at Narayana Hrudayalaya Institute of Neurosciences in the context of Indian NeurosurgeryKomal Prasad C, M.Ch Bangalore
2IndiaIndia 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.
3IndiaAs 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.
4IndiaIndia 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 populationThe population of India, which at the turn of the twentieth century was around million, increased to reach 1,028 million at the dawn of the twenty-first century
5Ancient 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.
6Ancient 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.
7Ancient IndiaArcheological 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
8Ancient 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.
9Early 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
10Early 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 HypophysectomyBombay: Ardeshir P Bacha, GV Deshmukh, RN Cooper, AV BaligaMadras: NS Narasimhan, CP Vishwanatha Menon, U Mohan RaoAmritsar: Lt Col R Mirajkar, Baldev SinghBangalore: Balakrishna Rao
11Early Indian Neurosurgery Neurosurgery as we know it today started in India in 19491949- First Department of Neurosciences in India- by Jacob Chandy at the Christian Medical College and Hospital, Vellore1950- 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.
12Early Indian Neurosurgery Neurosurgery Departments were established by early leaders in different parts of the country-Col Ray: 1st Indian Army NeurosurgeonR 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)
13Prof. B. Ramamurthi1922–2003Hony President of the World Federation of Neurosurgeons in 19891950- started the neurosurgical service at the Government General Hospital, Chennai.1951 -Neurological Society of India-founder SecretaryFirst editor of Neurology India1970, Institute of Neurology1st comprehensive neurosciences centre, South Asia
14The 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.
15NSI 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
16Society (NSI) played host to the Congresses of the- 1989, New DelhiSociety (NSI) played host to the Congresses of the-WFNS- World federation of Neurological SocietiesWorld Federation of Neurology andInternational Epilepsy Association
171953- The Journal Neurology India was launched 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
18Past Office Bearers of the NSI PRESIDENTSDr. Jacob Chandy1952Dr. D.R. Gulati1981Dr. T.K. Ghosh1953Dr. S. Janaki1982Dr. R.G. GindeDr. Jacob Abraham1983Dr.W. Grillmayr1956Dr. M. Veera Raghava Reddy1984Dr.T.Menino D' Souza1957Dr. P.N. Tandon1985Dr. B. Ramamurthi1958Dr. B.S. Singhal1986Dr. E.P. Bharucha1959Dr. S. Kalyanaraman1987Dr. R.N. Chatterjee1960Dr. Shyamal Sen1988Dr. C.G.S. Iyer1961Dr. S.N. BhagwatiDr. Baldev Singh1962Dr. A.K. Banerjee1991Dr. N.H. Wadia1963Dr. K. Srinivasan1992Dr. B.K. Anand19641993Dr. N.S. Wadia1965Dr. Sanathan Rath1994Dr. D.K. Dastur1966Dr. Gourie Devi1995Dr. Anil D. Desai1967Dr. M. Sambasivan1996Dr. B. Dayananda Rao1968Dr. Sarla Das1997Dr. S. Sriramachari1969Dr. V.K. Kak1998Dr. Asoke K. Bagchi1970Dr.Rajasekaran Nair19991971Dr.Arjun D.Seghal2000Dr. K.S. Mani1972Dr.M.C.Maheswari2001Dr. B.K. Bachhawat1973Dr.Mathew J.Chandy2002Dr. S. Balaparameshwara Rao1974Dr.J.S.Chopra2003Dr. Gajendra Singh1975Dr. S. R. Dharker2004Dr. G. Arjundas1976Dr.C.U. Velumurgendran2005Dr. K.V. Mathai1977Dr. K. Ganapathy2006Dr. Vimala Virmani1978Dr. V. S. Mehta2007Dr. Mahendra Singh1979Dr. B. K. Misra2008Dr. K. Jagannathan1980Dr. V. K. Khosla2009
20Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp 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.”
21Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp Journal of Postgraduate Medicine, Vol. 48, Issue 4, 2002 pp 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.”
22The 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.
23Subspecialty 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.
25Present ScenarioNow, 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.
26Different types of Hospitals Central Government funded Premier Institutes/ Institutes of National ImportanceState funded Hospitals and Research InstitutesCorporate Hospitals / TrustPrivate Teaching HospitalsMissionary HospitalsArmed Forces Hospitals and Research Centres.
27Types 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.TeamSeen in Metros- still not popularSub-specializationNot popular. Few confined to Pediatric Neurosurgery, Epilepsy surgery in Metros.
28Neurosurgical 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).InstitutesPositionsM.Ch38152DNB3444Total72196
29Some of the Premier Institutes of Neurosurgery All India Institute of Medical Sciences, New DelhiNational Institute of Mental Health and Neurosciences, BangaloreSree Chitra Tirunal Institute of Medical Sciences and Technology, ThiruvananthapuramPostgraduate Institute of Medical Education and Research, Chandigarh
30Neurosurgery Research in India Bala A, Gupta BM. Mapping of Indian neuroscience research: A scientometric analysis of research output during Neurol India 2010;58:35-41
31Common caseload- Probably same as elsewhere Cranio- spinal traumaLow back ache, neck painGlioma, meningioma, vestibular schwannoma, pituitary adenomaSpinal IDEM, Syringomyelia, Spinal dysraphismsAneurysms and AVMs are not rare as was thought earlier.Surgery for unruptured aneurysms is rare.
33Ossification of Posterior Longitudinal Ligament Endemic in some states, probably related to high Fluoride content in water
34Neurosurgery NowMany 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
35How can developing India afford to deliver quality Neurosurgery Booming economic growthSteep socioeconomic divideIncrease in Government funding to premier state-run InstitutesMedical Insurance- still nascentMicro health Insurance- novel mass insurance schemes.
36Micro 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.
37Micro 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.
38Micro 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.
39The 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.
40Approximately 700 to 1000 surgeries/ year Neurosurgery5 ConsultantsNeurosurgery training program- Diplomate of National Board. Seven Residents at presentApproximately 700 to 1000 surgeries/ yearSupport by Neurology, Interventional Neurology and NeuroradiologyNeurosurgery team with Prof. A K Banerji
41Neurosurgery Equipment Operating microscopes- Leica MS2Moller-Wedel Hi-R 1000Zeiss OPMINeuroendoscopesAesculapStorzSoring Ultrasonic AspiratorDrillsMedtronic Midas Rex Legend (2) PneumaticStryker ElectricNerve MonitoringMedtronic NIM 3.0
42Multiple Health Cities State-of-the-art infrastructure Affordable 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 bedsMultiple Health CitiesState-of-the-art infrastructureAffordableMicro- Health Insurance schemes for masses
46Epilepsy SurgeryIndia with over one billion people will have over one million people with medically refractory epilepsies, of which nearly one half are potential surgical candidatesWith over 500,000 potential epilepsy surgery candidates, not more than 200 epilepsy surgeries per year are being undertaken today.
47Epilepsy SurgeryAnterior Temporal Lobectomy and Amygdalohippocampectomy: 30 patientsMesial temporal sclerosis with refractory seizures is the commonest indication>90% favorable outcome76% seizure freeCorpus Callosotomy: 4 patientsExcellent outcomes in drop attacksFunctional Hemispherotomy: 1 patient
48Functional Hemispherotomy This 2 year old child with cortical dysplasia had good seizure outcome and improvement in right hemiplegia after hemispherotomy.
49CEA - CABGNovel 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.
50CEA-CABGCourtesy: Dept of Cardiothoracic Surgery, Narayana Hrudayalaya
51Cranio-vertebral Junction Anomalies CVJ anomalies, especially congenital atlanto-axial dislocations, are prevalent in IndiaNovel 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.
52This patient underwent distraction and placement of C1 lateral mass screws,C2 pedicle screws and C1-C2 spacers.
53This patient underwent distraction and placement of C1 lateral mass screws,C2 pedicle screws and C1-C2 spacers.
54Placement of condylar screws for occipito-cervical fusion in patient with rheumatoid arthritis and atlanto-occipital and atlanto-axial dislocation.
55Placement of condylar screws for occipito-cervical fusion in patient with rheumatoid arthritis and atlanto-occipital and atlanto-axial dislocation.
56Placement of condylar screws for occipito-cervical fusion in patient with rheumatoid arthritis and atlanto-occipital and atlanto-axial dislocation.