My journey in the field of neurosurgery and its changing trends
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.246232
Source of Support: None, Conflict of Interest: None
Whenever, my cousin who is a veterinary doctor, used to visit our home, he would always praise his profession and would incite me as well to take it up. While going to the college, I used to pass through the veterinary college daily. Seeing the animals waiting meekly in the open would make me feel for them.
However, I could not get admission to any college, either related to medical or veterinary sciences, because I was underage by 3 days. The next year, when I became eligible for admission, my parents advised me to go for the MBBS course rather than for veterinary sciences. I agreed reluctantly. After completing my graduation, I consulted the famous psychiatrist, Dr. Vidya Sagar, to whom I explained my love for the veterinary science. He advised me to take up comparative anatomy as a postgraduate subject. When I joined the house job, my first posting was in neurosurgery. Patients with cranial ailments used to have a high mortality and morbidity, and would often be non-communicative. The challenge of still being able to diagnose and treat their ailments prompted me to take up this specialty.
The schedule during the neurosurgery registrarship was hectic. The whole day would be spent in the hospital managing and investigating the cases. Angiography used to be time consuming. Neuro-diagnostics was limited to pneumoencephalography, ventriculography and myelography. As life used to be very busy and without much rewards, most of the local students used to avoid joining neurosurgery for MCh training. During my 2 years of registrarship, I was the only registrar most of the time, as the other colleagues had left the MCh program before their actual training got over.
Advances in the diagnostic tools including computed tomographic scanning, magnetic resonance imaging, digital subtraction angiography, the per-operative scan, the use of microscope, the utilization of proper neuro-anaesthesia and advances in postoperative care have changed the scenario from one of dismal failures to neurosurgical successes. Thus, several institutions in the country claim to be having world class facilities, which were to a certain extent, only available to affording patients in prominent corporate hospitals in the past. With the use of image guidance, surgery has become precise and minimally invasive.
There is a dearth of adequately trained neurosurgical manpower in the country. Every year, approximately 237 neurosurgery candidates are admitted for neurosurgery training (MCh and DNB)., About 1400 neurosurgeons are available for the approximate population of 1250 million in our country. Compared to this, 9567 neurosurgeons were listed in the Neurosurgical Society of Japan until September 2016. This averages to a figure of 1 neurosurgeon for 1.03 million population in India, compared to 1 neurosurgeon for 20,000 population in Japan, and 1 neurosurgeon for 9000 population in Sweden.
In addition to the shortage of neurosurgeons in the country, the problem is compounded by their disproportionate distribution in the country, with the majority of them concentrated mostly in metropolitan or larger cities, leaving the vast majority of population in the rural areas unable to access neurosurgical facilities. Most of the medical colleges lack neurosurgical facilities, forcing the poor patients to travel for long distances to avail expert neurosurgical care at a high cost, which usually they can ill afford. This is compounded by the fact that most of the population in India is not covered under medical insurance. The increased use of telemedicine facility by the primary health care physicians may avoid this unnecessary referral to higher centers.,
Open neurovascular procedures are being replaced by endovascular treatment. The general population and the physician community have accepted and promoted it well, even though the latter procedure is much costlier and unaffordable to most families in the Indian scenario with its current pricing. The fear of undergoing a craniotomy has a major role to play in this paradigm shift in the management of vascular lesions of the brain. The quality and precision of endovascular therapies has kept on improving, and it is not difficult to foresee that soon, open neurovascular procedures may become extinct. Neurosurgical residents have a penchant for learning challenging procedures like coiling and stenting and in picking up the technology fairly early and quickly Moreover, with an increasing life span, industrialization, and an advancing age, the burden of trauma and tumors has been steadily increasing in neurosurgery. Thus, there is no dearth of work and surgical opportunities for neurosurgeons of the country in the present scenario.
Most of the private neurosurgical care providers boast of high-end equipment and human resources for the management of all types of neurosurgical disorders at a much lower cost when compared to the western countries. This has resulted in a budding medical tourism industry. The economic boom has resulted in an improved infrastructure in the government-run institutions and has also accelerated development in corporate hospitals. The boom in the infrastructure in well-developed private hospitals has been attracting experienced manpower from academic institutions, leading to their exodus.
Stereotactic radiosurgery has been developed for the treatment of many types of tumours and lesions of size less than or equal to 3 cm, especially for lesions like acoustic neuroma, pituitary adenoma, glioma, metastasis, glomus tumor, arteriovenous malformation, trigeminal neuralgia, and lesions causing epilepsy. There is a much lower complication rate using stereotactic radiosurgery compared to the conventional open surgery, although the therapeutic benefits are often delayed.
The management of high-grade gliomas in the form of maximal safe resection, followed by adjuvant radiotherapy is the current norm. This has been followed by adjuvant chemotherapy with temozolamide for 6-12 cycles of chemotherapy. Use of intraoperative navigation, intraoperative fluorescence and awake craniotomy with the intraoperative functional neuro- monitoring is also being increasingly used.,
Most of the head-injured patients are young and in the productive period of their life. The scenario for management of head injury in a patient in India is still depressing. The total number of road accidents have increased by 2.5% between 2014 and 2015. The total number of people killed in road accidents has increased by 4.6% from 1,39,671 in 2014 to 1,46,133 in 2015. Road accidents decreased by 4.1% but fatalities increased by 3.2% during 2016. The fatality rate is 70 per 10,000 vehicles. India has one of the highest rates of head injury worldwide. In India, 1 out of 6 trauma victims died, compared to USA, where the figure is 1 in 200. An early and appropriate management of head injury is critical to the survival of these patients as most patients who have suffered from either brain or spinal trauma do not receive an optimal care during the golden hour. The severity of road accidents measured in terms of the number of persons killed per 100 accidents has increased from 28.5 in 2014 to 29.1 in 2015. One person dies in India every 6 to 10 minutes in a road accident. This number will increase to one in every 3 minutes by 2020. The personnel riding two wheelers are most vulnerable, constituting 34.8% of the total persons killed in 2016. The protective role of helmet usage has been emphasized by the author.
India is a signatory to the Brasilia declaration and is committed to reducing the number of road accidents and fatalities by 50 percent by 2020. The Ministry of Road Transport and Highways has taken steps in overhauling the institutional and statutory framework to manage road traffic accidents, to build safer roads, to lay down safety standards for vehicles, to provide better enforcement of traffic regulations and to improve emergency care. The Motor Vehicles (Amendment) Bill 2016 has been introduced in the Parliament, which addresses safety issues by providing stiffer penalties, by permitting electronic enforcement of traffic regulations, and by improving fitness certification and licensing. The bill contains provisions for treatment of accident victims during the golden hour. Attention should be paid towards the preventive aspect of head injury by introducing better road designs and designs for vehicular safety and by ensuring the presence of better trained drivers on the roads.
Road traffic accidents mostly affect the young and earning members of the family, placing a great deal of mental, physical and economical stress on the family and the society at large. This economic loss due to accidents is estimated to be in the range of Rs. 5,50,000 million per annum. I hope the problem is addressed soon by health administrators by improving the preventive aspects of road safety, and by the wide-spread use of an early therapeutic pre-hospital care protocol.,
The initially performed posterior spinal approaches have been replaced by anterior approaches, wherever indicated. Spinal stabilization procedure using screw and plates are being used, frequently utilizing both open and minimally invasive techniques. Electrophysiological monitoring is being used frequently during surgery for spinal cord lesions.
The progress of neurological services in the country is evident from the development of various subspecialties that have formed off-shoot societies from the parent society, the Neurological Society of India. These include the Indian Academy of Neurology, the Skull Base Surgery Society of India, the Neuro-Trauma Society of India, the Indian Society of Stereotactic and Functional Neurosurgery, the Indian Society of Cerebrovascular Surgery, the Indian Society for Pediatric Neurosurgery, the Neuro-Oncology Society of India, the Indian Society of Neuroradiology, the Indian Society for Study of Pain, and the Society of Indian Neuro-Nurses. Fellowships have been started in some of the sub-specialties of neurosurgery.
I feel that the specialty of neurosurgery demands an element of critical thinking, analytical ability, excellent surgical skills, and also the ability to perform delicate and prolonged surgeries. The latest advances in robotic surgery and enhanced imaging procedures, has made the art of surgery more precise. Neurosurgery has always been a demanding branch. Surgeons should remain calm under stress. The branch provides great mental satisfaction and happiness if the procedure is successful and a life is saved.
We have come a long way and the future appears to be bright for the specialty of neurosurgery.