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|NI FEATURE: TIMELESS REVERBERATIONS - COMMENTARY
|Year : 2016 | Volume
| Issue : 2 | Page : 206-207
Back to the future: Glimpses into the past
Ex. Captain, Army Medical Corps, Director, Sri Santhanakrishna Padmavathi Health Care and Research Foundation, Chennai, Addl. Prof. Neurosurgery (Retd.) and Neurosurgeon, Institute of Neurology, Chennai Emeritus Medical Scientist (Indian Council for Medical Research) Hony. Consultant Neurosurgeon, Tirumala Tirupati Devasthanam, India
|Date of Web Publication||3-Mar-2016|
T S Kanaka
Ex. Captain, Army Medical Corps, Director, Sri Santhanakrishna Padmavathi Health Care and Research Foundation, Chennai, Addl. Prof. Neurosurgery (Retd.) and Neurosurgeon, Institute of Neurology, Chennai Emeritus Medical Scientist (Indian Council for Medical Research) Hony. Consultant Neurosurgeon, Tirumala Tirupati Devasthanam
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kanaka T S. Back to the future: Glimpses into the past. Neurol India 2016;64:206-7
It is difficult, if not impossible, for the Indian neurosurgeons of today, dependent as they are on an intraoperative magnetic resonance imaging, to understand how neurosurgery in India evolved from general surgery. It was in 1950–51 that three surgeons, Drs. Chandy, Ramamurthi and Ginde, took this bold step of starting neurosurgery. At that time, 'investigations' in neurosurgery were essentially composed of 'clinical diagnosis, clinical diagnosis and clinical diagnosis.' If there was a clinical supratentorial lateralization, or if a preliminary electroencephalogram (EEG) showed a unilateral hemispherical abnormality, a direct carotid (internal or common) angiogram was done. If there was no lateralization or a posterior fossa lesion was suspected, bilateral posterior occipital burr holes were made, followed by an air or myodil ventriculogram. If a mass lesion was detected, it was followed up immediately by open surgery, irrespective of the time of the day! All posterior fossa surgeries were done in a sitting position using a dental chair. If clinically, a pituitary tumour was suspected, most often based on overt endocrinological manifestations, a pneumoencephalogram was done. A pituitary tumor was diagnosed based on gross displacement of the air in the opticochiasmatic cisterns. The concept of a 'microadenoma' had not been established at that time. At best, a biopsy or partial decompression was done for the tumor, followed by radiotherapy. Steroids were not available in Madras even in the fifties. Brain swelling was managed with 20% mannitol or urea. Distressing brain swelling was encountered often and was to some extent controlled by the anesthesiologist. Following this, removal of the bone flap and its placement in the abdominal wall was done. Sterilized dental paste was occasionally used for covering the bone defect. Gross congenital hydrocephalus was very common. As shunt tubes like the Pudenz shunt were not routinely available in India, a Ryle's tube or a Gibbon's urinary catheter was used for cerebrospinal diversion procedures in the fifties and the sixties. Towards the mid-seventies, the Indian shunt tubes became available, although they were still difficult to procure.
As early as in 1964, Leksell's stereotatic apparatus was obtained for the Institute of Neurology, Madras Medical College. Air studies were used for calculating coordinates of targets using known reference points such as the anterior and posterior commissures, the third ventricle, etc. Prof. R. Hassler's 'Atlas of Human Brain' inspired by the Schaltenbrand Bailey's Atlas was used for calculating target co-ordinates. With the patient in sitting position and with the frame in position, a lumbar puncture was done and 5 to 10cc of air injected. With dexterous and skillful manipulation, the pneumoencephalogram located the anterior and posterior commissures and the third ventricle. Meticulous calculation, taking into consideration the X-ray magnification, gave co-ordinates for the target. The precise location of the target was reconfirmed physiologically. The EEG machine was used to record tremors and respiration. The intraoperative electrophysiological study was done using bipolar depth recording on the EEG machine. The team also included two neurologists who monitored the clinical and depth electrode studies. The absence of an oscilloscope and an audiovisual monitor was overcome by modifying the electrode carrier, so that the depth recording and stimulation could be done with the capacity to adjust a distance of 2mm/3mm in an antero-posterior and lateral direction to the calculated target without readjusting the frame.
To identify the VIM (ventro-intermediate) nucleus of the thalamus, the stimulation was carried out 4mm lateral to the calculated target. The motor response at that area confirmed the stimulation of the corticospinal tract in the internal capsule. Stimulation 2mm medial to this point resulted in apnoea. This confirmed that the tip of the electrode was in the reticular sheath of the thalamus. Stimulation a further 2mm medial led to the VIM nucleus. This indirect physiological verification was successfully used. The precise location for the site of the lesion in the amygdala was confirmed by the presence of spikes on depth electrode recordings in the EEG machine. Bipolar stimulation at the calculated target site resulted in apnoea confirming the target. The co-ordinates were calculated for each individual depending on the person's anterior and posterior commissure distance after adjusting for the X-Ray magnification. When the amygdala was targeted, the calculation was based on a myodil ventriculogram to visualize the tip of the temporal horn, which was used as the reference point.
Thus, various reference points were identified as follows: Anterior and posterior commissures were used for the targets in the thalamus that included the ventralis oralis anterior, ventralis oralis posterior, ventral intermediate nucleus, ventral anterior, dorso-medial, internal medullary laminar, pulvinar, centrum medianum, and ventrocaudalis parvocellularis nuclei. An intraoperative angiogram with the frame in situ was done to identify the anterior cingulum with respect to its relation to the anterior communicating artery. Anterior cingulum lesions successfully relieved obsessive compulsive neurosis and drug addiction. More than one hundred cases of drug addiction – pethidine, morphine, alcohol and others (a nursing superintendent used to self-inject pethidine into his own jugular vein) –– were treated successfully by sterotactically performing cingulum lesions. Similarly the roof of the orbit was taken as the reference point for targeting the nucleus accumbens for psycho-surgery. The lateral recess and roof of the fourth ventricle gave coordinates for the dentate nucleus. Prof, V. Balasubramaniam was the wizard who made all this possible. Prof. Balasubramaniam, Prof. S. Kalyanaraman and Prof T. S. Kanaka not only pioneered functional neurosurgery in the sixties and seventies but also had the unique foresight to obtain Ph.D's – something unheard of for a surgeon at that time. Of course, all this was achieved under the dynamic leadership of Prof. B. Ramamurthi, who was truly the father of Indian neurosurgery. Functional neurosurgeons in advanced countries would find it difficult to believe that chronic electrode implantation (exteriorized outside the occipital scalp) in the dentate nucleus was carried out in 1975 at the Madras Institute of Neurology using totally indigenous material.
Even today, there may be neurosurgical units where the current state-of-the-art facilities are not available. Using affordable, indigenous, innovative and cost-effective means, we can offer acceptable results to the patient. “B+ve” should be the blood group of every neurosurgeon! Nothing is impossible. Today's world is totally different. It is true that we have been unable to scale up the spectrum of deep brain stimulation (DBS) started in 1975s. Today we cannot offer any excuses whatsoever. The “Make in India” slogan should be extended to DBS as well! A dwarf standing on the shoulders of a giant sees farther than the giant himself! We were not giants but then today's neurosurgeons are not dwarfs either. It is purely a question of how badly one wants something!
(83-year old, Dr. T. S. Kanaka, the first woman neurosurgeon of Asia, has donated blood about 110 times. She is the first neurosurgeon from India who performed a deep brain stimulation [as early as in 1975]).
The kind help of Dr. K. Ganapathy in the writing of this article is acknowledged.