AANS Neurosurgeon | Volume 26, Number 3, 2017

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Neurosurgery in India

There is evidence, dating back to prehistoric times, of trepanation and the removal of brain tumors in India by Jivaka, surgeon to Lord Buddha. Sushruta, the father of Indian surgery, described neurosurgery in his writings over 200 years ago. While general surgeons in modern India had been doing isolated neurosurgical operations mainly for trauma, it was in 1949 that Jacob Chandy, aptly recognized as the father of Indian neurosurgery, established the first exclusive neurosurgical unit at Christian Medical College in Vellore. B. Ramamurthi started a neurosurgery center in the Government General Hospital in Madras in 1950, followed by R. G. Ginde in Bombay in 1951. Baldev Singh, who was trained by Sir Norman Dott, also joined them. Unfortunately, Dr. Singh’s neurosurgical career was cut short due to illness, but he continued as a neurologist, and his dedication and benevolence earned him the title of ‘Papa Neuron’. Eventually, neurosurgeons were trained in a clinical apprenticeship model, which was formalized in 1956 with the start of the Master of Surgery (MS) in Neurosurgery: a two-year training program in Vellore and Madras. This was the beginning of the first neurosurgical subspecialty-training program in India. In 1968, Dr. T. S. Kanaka became the first woman in Asia to qualify as a neurosurgeon.

Neurological Society of India
These stalwarts, along with the neurophysiologist Dr. S. T. Narasimhan, formed the Neurological Society of India (NSI). With remarkable foresight, they restricted membership to only those who were practicing the neurosciences on a full-time basis. It was an audacious move as they barely had 10 members, and for several years, the total membership remained in the double digits. They had their first meeting in 1952 where they decided to launch a journal, Neurology India, which has grown and is now a highly-respected indexed journal with an impact factor of 1.41. In 1977, NSI was the first professional society in India to hold a formal continuing medical education program in their annual meeting. In 1992, the Indian Academy of Neurology was formed and subsequently several subspecialty societies emerged from this parent body. NSI, however, remains the mother society and is the premier society of neurosurgeons in India. The society has grown and now has a total of 2,596 members, including 1,931 full members (1,360 neurosurgeons, 492 neurologists and 79 neuro-allied members) and 665 trainees, as associate members.

Need for Neurosurgeons
India is a vast country supporting one-sixth of the world’s population. A lot of progress has been made, and India is now considered an emerging economy and a potential superpower. However, considerable improvement is needed on the health and education fronts. The burden of neurological illness is immense, with a prevalence rate of 2,400 per 100,000 people. Neurosurgery training centers have mushroomed all over the country to be able to deal with this mammoth task. There are about 75 medical colleges, which impart neurosurgical training to 238 residents every year. This training is regulated by the Medical Council of India with the evaluations being done by the respective medical colleges or universities. Successful candidates are awarded the M.Ch. degree in Neurosurgery. There are two tracks for neurosurgical training – one is a three-year neurosurgical training program, which builds upon completion of a three-year master’s level training in general surgery and the other is a six-year neurosurgical training program, entered directly after basic graduation from a medical program. In addition, there is a National Board of Examinations that accredits various private hospitals with tertiary-level neurosurgical facilities to train residents in neurosurgery. They undergo a central board examination and upon completion are awarded the Diplomate of National Board in Neurosurgery (DNB – Neurosurgery) degree. At present, there are 32 accredited tertiary care institutions, enrolling a total of  42 students every year,

Advancing Patient Care
India has kept abreast with the latest developments in neurosurgery. The understaffed, ill-equipped, overflowing neurosurgery units, saddled with infectious cases and trauma cases, have given way to modern, state-of-the-art neurosurgery units adept at microsurgery, endoscopic neurosurgery, computer-assisted neurosurgery, functional neurosurgery, radiosurgery, endovascular neurosurgery and complex as well as minimally invasive spine surgery. Many units are well equipped with neurodiagnostics like 3 T MRI scans, 320 slice CT scans, biplane 3-D rotational DSA labs and video EEG monitoring units. The neurosurgical operating room has been reinforced with intraoperative MRI, neuronavigation, intraoperative monitoring, advanced microscopes with fluorescence, high-speed drills and endoscopy equipment. There are specialized training programs in neuro-anesthesia, neuro-radiology and intensive care that are improving the quality of care offered. Fellowship programs are now available for practically all super-specializations in neurosurgery.

Neuropathologists are adept at the latest techniques, including molecular profiling of tumors. A variety of skills labs, cadaveric and live surgery workshops are conducted year round. There are subspecialty societies holding conferences and CME programs regularly, so much so that there is practically a conference or workshop happening every week, and a variety of journals and books on neurosurgery are published in India. There is also a Society of Indian Neuro Nurses that has an annual meeting alongside the NSI and imparts neuronursing training. To promote research in the neurosciences, a state-of-the-art National Brain Research Centre has been established.

The Need for More Updates
There are several issues that Indian neurosurgery still needs to sort out. Although the quality of neurosurgery currently being done in India could match the best in the world, such facilities at present are restricted to a few centers of excellence. Standards vary markedly as one goes from big metropolitan cities to smaller cities to rural areas. The challenge is to establish these standards uniformly throughout the country. The medical colleges have to be upgraded, both in terms of infrastructure and skills . 

Another major problem is the lopsided distribution of trained neurosurgeons. Almost two-thirds of our population resides in rural areas, which have very few neurosurgeons. A study of all neurologists and neurosurgeons revealed that approximately 30 percent of the specialists reside in the big metropolitan cities, capitals of states and tier two cities. Only 17.12 percent reside in the tier three cities and 2.67 percent  in rural areas, where the majority of Indians live. In fact, of the 550 districts in the country only 200 have neurosurgeons. Innovative methods are being devised to tackle this problem. It has been found that it is technologically easier to develop a telemedicine infrastructure than to develop neurosurgical infrastructure and manpower. The government health department has linked 150 medical colleges to a high-speed optical fiber network connecting them to rural areas, so that remote tele-consultations are possible to triage patients and transfer only those who need advanced neurosurgical work to referral centers. 

The increasing cost of neurosurgical care as well as the infrastructure costs have become a problem in a resource-limited country like ours. Poverty is still widespread and insurance coverage is dismal, so affordability becomes an issue. The potential solution is to have three levels of neurosurgical care in the country. The peripheral centers at the district level should be able to deal with emergency neurological care and trauma. The standard neurosurgical care centers should be able to deal with most neurosurgical cases. Finally, the most complex cases could be treated by centers of excellence that should be comparable to the best centers in the world.

The problems are many, but the mood is upbeat. The young neurosurgeon of India is confident, well-trained and willing to adapt and move ahead. Indian neurosurgery has progressed rapidly in the last couple of decades and many international conferences are taking place in India. The icing on the cake will be the next major international event, the Asian Australasian Congress of Neurological Surgery, which occurs every four years, is scheduled for December 2019 in Mumbai. Indian neurosurgery has indeed come of age!

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