The Era of Neurosurgery in Nepal
Death is not extinguishing the light; it is only putting out the lamp because the dawn has come. – Rabindranath Tagore
Our condolences to the family of Upendra Devkota, MD, FRCS (December 18, 1953-June 18, 2018), and to the Nepalese people on his passing. Prof. Dr. Devkota is the father of neurosurgery in Nepal and founder of the first neurological trauma unit in the country, located at Bir Hospital. Nepalese neurosurgery history can be categorized as:
- Historical Era
- Era of plateau
- Era of Modern Neurosurgery
- Future Perspective
Neurosurgery in Nepal dates back to 1962, when the Dinesh Nath Gongal, MS, FRCS, first performed intracranial surgery in Bir Hospital in a case of pituitary adenoma for gigantism.(1) Neurosurgery in this era was in primitive form. The dawn of formal neurosurgery service in Nepal was started only after 1993, under the imminent leadership of Dr. Devkota, the father of Nepalese neurosurgery (1953-2018), in Bir Hospital, Kathmandu, Nepal after his training from Glasgow Institute of Neuroscience in the UK in 1983. During the early phase, neurosurgery facilities were available only in one center, because of the lack of trained manpower. It was 1995 when the second institute started neurosurgery service in Nepal under the guidance of Merwyn Bagan, MD, MPH, FAANS(L), at Institute of Medicine (IOM) under Tribhuvan University & Teaching Hospital (TUTH).(2) He not only established the neurosurgery department at TUTH, but also trained two present day senior neurosurgeons Sushil Krishna Shilpakar, MD, and Mohan Raj Sharma, MD, who is the current president of the Nepalese Society of Neurosurgeons of Nepal (NESON). Until 1995, neurosurgery was not recognized as a separate specialty in Nepal due the lack of certification of neurosurgeons at tertiary care centers.(3) There was a lack of both training facilities and trainees because of the lack of health professionals in the country itself. Those interested in neurosurgery had to go to areas like the UK, U.S., Japan, India and Bangladesh. For instance, Basanta Pant, MD, and Gopal Raman Sharma, MD, IFAANS, opted in to neurosurgery from Japan and Bangladesh respectively. Computed tomography in the country first came into function at Bir Hospital in 1988, which lifted Nepalese neurosurgery to a new height.(4)
Era of Plateau
Since the establishment of proper neurosurgery in Nepal, neurosurgery was centralized to limited centers in Kathmandu. Neurosurgeons trained in neighboring countries started coming back home after their training. Meanwhile, a neurosurgery residency program started in Nepal, at Bir hospital; Tribhuvan University Teaching Hospital; Institute of Medicine; National Institute of Neuroscience, Basbari; and College of Medical Science, Bharatpur. The number of neurosurgeons started to increase and services were decentralized and incorporated into places like B.P. Koirala Institute Health Sciences, Neurocardio Multispecialty Hospital in Biratnagar, Manipal Medical College & Teaching Hospital in Pokhara, Nobel Medical College Teaching Hospital in Biratnagar and many more other centers.
In 2008, the NESON was established with 17 neurosurgeon members and the objective of promoting rights and welfare of health workers involved in the field of neurosurgery, developing and conducting research in the field of neuroscience and participating in the mainstream development of the country by the means of health services. Currently, there are 68 registered neurosurgeons in NESON.
Era of Modern Neurosurgery
In 1995, it was projected by Dr. Pant, chief neurosurgeon at Annapurna Neurological Institute and Allied Sciences, that Nepal would need at least 80 neurosurgeons in 10 centers scattered evenly throughout the country to cover the entire population. Nepal would not be able to meet this need for several decades, unless it takes a step in the right direction.(3) However long the night, the dawn will break. After the long wait, the dawn of neurosurgery in Nepal has finally broke with fully equipped modern technology and well-trained neurosurgeons at different centers throughout the country. Materialization of prediction to reality brings the dawn of a new era in neurosurgery in Nepal. Most of the medical colleges have their separate neurosurgery unit and many private corporate hospitals have been established with full time neurosurgery facilities, ranging from basic facilities to advanced care. Neurosurgeons trained in the country itself as Magister Chirurgiae (MCh) in neurosurgery and those trained in neighboring areas started serving the nation in different subspecialties, like vascular, neuroendoscopic surgery, spinal sub specialties, neurointervention and functional neurosurgery. Some Nepalese neurosurgeons are doing fellowships in different specialties.
Evolvements of neuroradiologists, neuropathologists, neuro intensivists, neuro anesthetists, neuro nurses, neuro psychiatrists and neuro rehabilitation specialists have helped the fraternity of neurosurgery attain a new horizon.
Within the two decades of neurosurgery in Nepal, there is a center of excellence in line with modern facilities with an intraoperative 3-Tesla MRI, O-arm, neuronavigation system, Capitron ultrasonic aspirator, 35-bed neuro-dedicated ICU at Nobel Medical Teaching Hospital, which was headed by Emeritus Professor Juha Hernesniemi, MD, PhD, the living legend in neurosurgery from Finland, from September 2017 to June 2018.
TUTH, IOM and Bir Hospital are the only government hospitals where basic to advanced neurosurgery cases are seen, headed by Dr. Shilpakar and Prakash Bista, MBBS, respectively. Dr. Sharma is a trained vascular neurosurgeon with tremendous skill at the Institute of Medicine, who is also the chief of the institutional review committee for research and working as chief editor in many journals. Dr. Sharma is a pioneer vascular neurosurgeon who has made many contributions to Bir hospital. He is an immediate past president of NESON.
Neurointervention procedures, like aneurysm coiling, and functional neurosurgery procedures, like deep brain stimulation/lesioning are regular procedures at Annapurna Neurological Institute and Allied Sciences, headed by Dr. Pant. He has established a new milestone by performing the first epilepsy surgery and phrenic nerve implants in 2000, pallidotomy, selective dorsal rizotomy in 2006, followed by deep brain stimulation in 2014 and aneurysm coiling in 2017.
Neurosurgery is considered one of the expensive health care services in the world, even in the countries with health insurance. It is a burden for the family in the developing countries, like Nepal, where health insurance is in a pilot phase. The Nepalese government provides one lakh Nepalese currency to head injury, spine injury and brain cancer patients to lessen the financial burden.(6) The year 2018 is a great loss for Nepalese neurosurgeons, because we have lost two of the imminent neurosurgeons – Dr. Devkota and Bal Krishna Thapa, MD.
Change is a reality in all aspects of life and all fields of medicine. Neurosurgery is not an exception. The fraternity of Nepalese neurosurgery needs to focus on training young neurosurgeons in different subspecialties, at home and abroad. It is high time to establish a skill lab, launch research projects, conduct clinical trials and install government-based tertiary care neurosurgery centers in every province of Nepal.
1. Gongal DN. Perspectives in international neurosurgery: neurosurgery in Nepal. Neurosurgery. 1980 May 1;6(5):603-4.
2. Shilpakar SK. Subspecialties in neurosurgery and its challenges in a developing country. World neurosurgery. 2011 Mar 1;75(3-4):335-7.
3. Pant B. Delivery of Primary Neurosurgical Care in Developing Countries—Scope for Mutual Cooperation—. Neurologia medico-chirurgica. 1996;36(5):326-9
4. Adhikari KP, Jha LN, Montenegro PG. Study and analysis of radiation level at different hospitals in Nepal. InWorld Congress on Medical Physics and Biomedical Engineering, September 7-12, 2009, Munich, Germany 2009 (pp. 110-113). Springer, Berlin, Heidelberg.
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