Standing on the shoulders of giants from the past: The legacy of neurosurgery at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.173664
Source of Support: None, Conflict of Interest: None
If I have seen further, it is by standing on the shoulders of giants.”
At 10 am on 19th October 1976, as Dr. Kewal K. Jain and Dr. S. M. Pillai placed a Keen's point burr hole and dissected the common facial vein for a ventriculoatrial shunt, little did they realize that history was being made. The Neurosurgery Department of the Sree Chitra Tirunal Institute for Medical Sciences (SCTIMST), on the campus of the Trivandrum Medical College, had just set sail on the beginning of a wondrous journey. This remarkable legacy of Neurosurgery in SCTIMST continues even today, entering its 40th year of neurosurgical service to humankind, setting worthier goals and scaling greater heights.
The founding years and the gestational period
Padma Vibhushan Prof. M. S. Valiathan, the Founder–Director of Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), envisaged the establishment of a center with core competency and state-of-the-art care in the superspecialties of cardiac and neurosciences, ably supported by a research wing. The foundation stone was laid on 3rd December 1970 by V. Viswanathan, the Governor of Kerala, and clinical work took formal shape with the inauguration of the hospital block on 28th February 1976 by Shri P. N. Haksar, Deputy Chairman of the Planning Commission, in the presence of the Chief Minister of Kerala, Mr. C. Achutha Menon and the Health Minister, Mr. N. K. Balakrishnan [Figure 1] and [Figure 2].
Despite being a well-acclaimed cardiovascular surgeon, it was Prof. Valiathan's vision and foresight that set the early stage for the developments in neurosurgery at SCTIMST. A guiding light was provided by Prof. R. M. Varma (Professor of Neurosurgery and Founder–Director of NIMHANS, Bangalore), who was instrumental in convincing Prof. Valiathan that the Department of Neurosurgery should be concentrating on cerebrovascular surgery. Help was sought from the world-renowned pediatric surgeon, Dr. Peter Paul Rickham (Founder of Neonatal Surgical Unit at Alder Hey Children's Hospital, Liverpool), teacher and close acquaintance of Prof. Valiathan. He, in turn, knocked at the doors of his famous neurosurgical colleague at the University of Zurich, Prof. Gazi Yasargil, who inspired his younger colleague, Dr. Kewal K. Jain to establish and mentor the new department in the quiet, historical city called Trivandrum.
Thus, the Department of Neurosurgery saw its origin in 1976 as a combined neurology and neurosurgery service center with a total of 46 beds and 2 operating rooms. Dr. Kewal K. Jain was the Professor of Neurosurgery, and Dr. P. T. Raman was the Associate Professor and Head of Neurology. Optimal utilization of the existing resources to render “world class” treatment to a large number of needy patients in a “resource challenged” nation, pioneering innovative surgical procedures, and maintaining academic excellence and technological initiatives have been the hallmarks of the department's journey through the years.
The Royal Family of Travancore, and the State and the Central Governments' efforts
SCTIMST began as a “quasi” governmental institute (Sree Chitra Tirunal Medical Center) under the state government. This medical center was dedicated as a national institute on 2nd January 1979 by Prime Minister Morarji Desai [Figure 3] and soon became an Institute of National Importance by an Act of Parliament in 1980 [Figure 4]. The concept of amalgamating medical sciences and technology within a single institutional framework is unique and the only one of its kind in the country. The origin of the institute dates back to 1973, when the Royal Family of Travancore gifted a multistoried building for the people, and the Government of Kerala developed it into a hospital complex. At the Satelmond Palace, Poojapura, nearly 11 km away from this hospital wing, the Biomedical Technology Wing followed soon, again a gift from the Royal Family. Sree Chitra Tirunal Act, 1980, empowered the Institute to sponsor postgraduate programs of the highest quality in medical sciences, biomedical sciences, and biomedical engineering and stipulated that the medical degree, diploma, and other academic distinctions granted by the institute should be recognized qualifications confirming to the guidlines of the Indian Medical Council Act. Postdoctoral programs in the institute were started in 1984. SCTIMST is the only clinical establishment in the country that is under the Ministry of Science and Technology. A deep and enduring interest in research and attempts at indigenous and innovative technology development through research have been the endeavor of the faculty and students alike. The Sethu Parvati Bayi Surgical Block was opened by Prime Minister Indira Gandhi in 1980 [Figure 5], and this surgical block was commissioned in 1984 with the Department of Neurosurgery having 44 beds, including a 12-bedded ICU and 3 well-equipped operating rooms. Presently, the department has 50 beds with 4 operation suites.
Ventriculogram/Myelogram era (1976-1983)
Contemporary microneurosurgeons of the MRI era will find it difficult to comprehend how complex microneurosurgical operations could have been planned based on “square shifts” seen in carotid angiograms [Figure 6]. However, aneurysms were clipped and arteriovenous malformations (AVMs) and vestibular schwannomas were excised in this era with enviable results.
If there in any sister department in the institute for which the neurosurgeons are immensely thankful, it is the Department of Radiology. Prof. Mahadevan Pillai, who was the Professor of Radiology at NIMHANS and later at the Trivandrum Medical College, was invited by Prof. Valiathan to head the Department of Radiology. During his tenure, he set high standards of quality for radiological investigations. After retirement of Dr. Pillay, the Neuroradiology Department was taken over by Prof. V. R. K. Rao, ably supported by Dr. Ravi Mandalam, Dr. A. K. Gupta, and Dr. Santosh Joseph, all of whom used to spend hours in the radiology suite interpreting angiograms and ventriculograms. They had a hand-in-glove relationship with the neurosurgeons. The Department of Radiology of Sree Chitra Tirunal Institute can boast of having the first dedicated cath lab for cerebrovascular interventional procedures. Radiologists performed these procedures from as early as 1980. The Department of Neurosurgery is deeply indebted to the neuroanesthetist, Prof. Padmanabha Iyer and the pathologist, Prof. V. V. Radhakrishan for their contributions towards the department's progress. A large referral base for complex neurosurgical ailments was being established at SCTIMST, and its foundation was built in this era.
CT scan era (1984-1992)
A CT scanner, the first in the state of Kerala, arrived in the institute with a “big bang” in December 1983 (inaugurated by the legendary neurosurgical giant, Prof. Theodore Rasmussen, from the Montreal Neurological Institute). The CT scan gave visibility to the “dark areas” in the brain. Equipped with this new armamentarium, the war against neurosurgical ailments only became stronger. This era saw the real emergence of aneurysm surgery and gross total tumor excisions. It was time to train neurosurgical residents and set new standards.
It was a dream come true for the founding fathers of SCTIMST led by Prof. Damodar Rout when the first batch of residents, Drs. Ajay Gehlot and K. N. Krishna, joined the MCh Neurosurgery program in January 1984. Till date, 89 neurosurgical residents have been trained in the department [Table 1], and 12 are in training. Many of the SCTIMST alumni have become “leaders” in neurosurgery and find a mention in the “who's who” list of world neurosurgery.
Mentors and leaders
The department was fortunate to have leaders with skill, passion, and foresight to steer it all along these bygone years, and their stellar contributions are as follows
[Figure 7] and [Table 2].
Kewal K. Jain (Head from 1976-77)
Prof. Kewal K. Jain, an acclaimed microneurosurgeon working in Zurich with Prof. Yasargil, was invited by Prof. M. S. Valiathan to set the ball rolling in the new neurosurgery department at Sree Chitra Tirunal Medical Centre. With an illustrious academic background involving research and clinical practice at the renowned McGill University, Canada, and at Harvard Medical School, he was undoubtedly an ideal choice to be the first mentor of the department. His vision helped in procuring the first OPMI microscope in 1976 at a cost of 5 lakh rupees (good enough to buy 15 fiat cars in that era!). The monumental effort that Prof. Valiathan took to procure funds for buying this state-of-the-art “neurosurgical operating microscope with the Contraves stand,” the first in the country, with the help of a considerate “undersecretary” in the Ministry of Commerce at the center, despite severe objections from many neurosurgery stalwarts of that time, is in itself a story. During that period, Prof. Jain published an article on the history of neurosurgery at SCTIMST.
George Mathews (Head from 1977-81)
After the sudden exit of Prof. Jain in early 1977, the department was left without a trained neurosurgeon for 6 months. It was by providence that in mid 1977, Dr. George Mathews took over the baton as head of the department [Figure 8]. He was trained in microneurosurgery at McGill University, Canada, and was working near Baltimore. He pioneered trans-sphenoidal pituitary surgery for the first time in the country and was interested in surgery for degenerative spinal diseases, which he did with immaculate results.
He mentored many budding young surgeons, including the present Chief of Neurosurgery, Prof. Suresh Nair, to excel and set high standards. He set the stage for a microneurosurgical revolution and optimized the standard of neurosurgical procedures to world-class standards.
Damodar Rout (Head from 1981-1996)
Prof. Valiathan realized that any major department cannot survive with just one senior faculty. He asked his friend and neurosurgeon, Dr. Gulati, Professor and Head of Postgraduate Institute Chandigarh, whether he could help him get a middle level neurosurgeon to the institute. It was through Prof. Gulati's influence that Dr. Damodar Rout, who had returned to India after a 2-year stint in Iran, joined the department in June 1979. Even though he did not start the Department of Neurosurgery, he should be aptly called the Father of Neurosurgery at SCTIMST. A tough taskmaster with a gentle heart is how we all remember Prof. Rout. His amazing skills, courage, and perseverance led SCTIMST to develop into a world-class cerebrovascular center, and he had operated on more than 700 intracranial aneurysms during his tenure in the institute. It was his vision and focused efforts that got the residency training program started. His collaborative work with the Biomedical Technology Wing of the Institute led to the development of Chitra shunt (Ceredrain). He was keenly involved in creating animal models of cerebral vasospasm in subarachnoid hemorrhage and finding the efficacy of urokinase in intracerebral hemorrhage. He also served as a member of the Ad-hoc Committee for Standardization of Terminology and Surgical Results of the World Federation of Neurosurgical Societies (WFNS) from Asia. He led by example and believed firmly in the establishment of the highest standards of care. His presence was inspirational to many neurosurgical stalwarts of today who have imbibed many neurosurgical skills from Prof. Rout. He was very ably supported in all the neurosurgical educational endeavors by Prof. Mrs. Annaporna Rout, a neuroanesthetist of the highest caliber. Prof. Rout's contributions to neurosurgery at SCTIMST are profound and unparalleled.
R. N. Bhattacharya (Head from 1998-2006)
A tireless workhorse with sparse words, who took vascular neurosurgery to the next level, was Prof. R. N. Bhattacharya. Besides aneurysms and arteriovenous malformations, his “forte” in neurosurgery included colloid cysts, intraventricular tumors, and much more. He set the stage for SCTIMST to become a large referral center for complex vascular neurosurgery. Prof. R. N. Bhattacharya's scalpel and dissector spoke louder than his words. He was always ready to cure many more patients with his scalpel, even at the fag end of a busy day. Under his guidance, a postdoctoral fellowship was started in cerebrovascular surgery. Also, he was instrumental in starting endoscopic surgery in the department.
Suresh Nair (Head from 1996-98 and 2006 till date)
A hard-core academician and a skilled microneurosurgeon, Prof. Suresh Nair is a neurosurgical “teacher” in the true sense of the word. He worked as a nonpostgraduate registrar in neurosurgery under Prof. George Mathews and Prof. Rout for 2 years from December 1979 before proceeding for postgraduation in neurosurgery. He rejoined the department in July 1986 and has been there since then. There perhaps isn't anyone in academic neurosurgery who hasn't had a pleasant memory of him. Few can surpass his surgical skills and wealth of experience in the care of cerebellopontine angle tumors and, in particular, vestibular schwannomas., His early morning teaching rounds are a delight for residents, visitors, and “seekers of neurosurgical wisdom” across all age-groups. He is currently a committee member of the World Federation of Neurosurgical Societies (WFNS) Skull Base Surgery Society and had served earlier as a committee member of the cerebrovascular and therapy committee of the WFNS. Prof. Nair capitalized on the good start given by the earlier professors, and through his devotion, efficiency, and high standards, the department surged forward with the development of subspecialties like spinal instrumentation, surgery for stroke, and minimally invasive neurosurgery. The operating rooms were made well equipped with state-of-the-art devices, including image guidance, stereotaxy, high-end microscopes, intraoperative electrophysiological monitoring devices, ultrasonic surgical aspirator, pneumatic high-speed drills, and intra-operative ultrasound. Postdoctoral fellowship in skull base surgery was established, and the department started offering structured observership programs to visiting trainees from other institutes, both within India and abroad.
If there is one neurosurgeon to whom the department is immensely indebted for his sheer surgical skills, it is Basant Misra. After his training at AIIMS, Delhi, and Western General Hospital, Edinburgh, he served in the department for 10 years, and during his tenure, he ventured into petroclival and cavernous sinus tumors regarded by many that time as belonging to the gloomy corners of neurosurgery. Not only did he successfully negotiate these corners, but also went on to conquer and master them. Apart from skull base surgery, his mastery extended to all other areas of neurosurgery. When the department started an annual oration last year, Dr. Misra's name was the automatic choice as the first orator. As the current Secretary of WFNS and a committee member of various WFNS societies and the President of Asian Australasian Society of Neurological Surgeons (AACNS), he continues to be a brand ambassador of the Neurosurgery Department at SCTIMST in world circles.
Two other people who deserve special mention in the annals of the department are Dr. Ravi Mohan Rao and Dr. Girish Menon. Both of them worked here for more than 10 years and became professors and were role models for students and faculty alike. They epitomized perfection and finesse in contemporary neurosurgery, and thus symbolized the “modern face of neurosurgical expertise and artistry” at SCTIMST. Their operative results for aneurysms and sellar–parasellar tumors can be compared with the best in the world. Both of them were instrumental in developing endoscopic surgery in the department. Many other stalwarts [Figure 9] and [Figure 10] also contributed to SCTIMST neurosurgery in a remarkable way, including two exceptionally skilled neurosurgeons R. Kacchara (skull base), Dilip Panicker (movement disorders, skull base), among many others.
MRI era and beyond (after 1992)
Many brain lesions started “appearing” in the MRI age, and treatment assumed a new dimension, leading to the beginning of a new era. Seemingly innocuous and “normal” CT scans of the brain would show granulomas, cortical dysplasias, and low-grade gliomas on MRI. Thus, the spectrum of neurosurgical ailments increased, newer subspecialties such as epilepsy surgery developed, and the number of patients seeking neurosurgical care exponentially increased. The demand for neurosurgical care outstripped the supply, and soon a
“surgical waiting list” began to take shape. It was necessary not to lose sight of quality amidst the increasing numbers.
“Be a jack of all, but master one,” has been the guiding philosophy in the development of subspecialties in neurosurgery at SCTIMST.
Vascular and skull base surgery
The department in collaboration with the department of interventional radiology and imaging is a huge referral base for complex neurovascular problems. Besides surgical clipping and endovascular therapy for aneurysms, SCTIMST has been in the forefront in using hypothermic cardiac arrest and cardiopulmonary bypass for complex aneurysms and in revascularization techniques. Skull base procedures have evolved over time, and multidisciplinary care in collaboration with otorhinolaryngologists and head and neck surgeons continues to evolve further.
The R. Madhavan Nayar Centre for comprehensive care in epilepsy was started in 1995 and continues to be a large referral center for complex epilepsy cases. The first surgery for epilepsy was performed on 20th March 1995 by Dr. Bhaskar Rao under the guidance of the renowned epilepsy surgeon Herbert Silfvenius from Umea, Sweden. Dr. Mathew Abraham and Dr. George Vilanilam have further developed the spectrum of epilepsy surgery, and presently, the epilepsy surgery team performs around 120 procedures per year, which include complex hemispherotomies, hypothalamic hamartomas, multilobar resections, and many more. Nearly 1700 epilepsy surgery procedures have been done till date.
Surgery for movement disorders
A new foray into uncharted territory was made when Dr. Dilip Panikar did the first pallidotomy for Parkinson's disease on 18th September 1998. Then on, there was no turning back, and this subspecialty, with Dr. Krishnakumar as the lead surgeon, is responsible for deep brain stimulation procedures regularly; the arrival of image guidance in 2006 gave a new impetus to the surgical management of these disorders.
The department hosted the satellite meeting of the WFNS on “Vascular Lesions of the Brain” (1989), Annual Conference of the Skull Base Society of India (2002, 2010), and the Indian Society of Cerebrovascular Society Meeting (2007). Many giants of international neurosurgery have been hosted by the department like Drs. Hirotoshi Sano, Yoshio Suzuki, André Grotenhuis, Axel Perneczky, Laligam Sekhar, Takeshi Kawase, Kenji Ohata, Kiyoshi Saito, and Chandranath Sen to name a few, and all of them have performed complex surgeries in our operation theatre.
A well-knit subspecialty-oriented neurosurgical practice has been the hallmark of our Neurosurgery Department. The core subspecialties that are well established include neurovascular, neuro-oncology, skull base, epilepsy and movement disorders, and spinal surgery. The department currently has 8 faculty members, one postdoctoral fellow, and 12 residents [Table 3]. With four operation theaters being utilized everyday and an outpatient service that is doing its best, the department is serving the masses with its yeoman efforts but “bursting at the seams.” The need of the hour is to devise ways and means to optimize utilization of resources and expand further. In our war against neurosurgical ailments in the 39 years gone by, all that we can say is “We tried our best, most endeavours did well, few didn't, but we'll still keep trying and getting better ...some goals are so worthy that it is glorious even to fail.”
Research and development
Emphasis on research went hand in hand with patient care in the department. The highlight of the amalgamation concept is the hydrocephalus shunt system (Ceredrain) developed in 1993 in collaboration with Biotechnology Department under the guidance of Prof. Rout. It was a revolution in the history of neurosciences, and it is regarded as a fine example of a blend of technology with neurosurgical expertise. Indigenous fibrin glue has been developed in collaboration with the Biotechnology wing, and is due for market launch. Burr hole buttons using hydroxyl-apatite bone substitute too
have completed clinical trials and are already available in the market. Computational fluid dynamics studies of cerebral aneurysms with three-dimensional imaging is an area of ongoing “cutting edge research” in the department.
Building further on the enduring legacy of its founding fathers, this department looks forward to an exciting future. Procuring the gamma knife, the O-arm, robotic neurosurgery, 3-T MRI, neurosurgery skills training laboratory and cadaveric laboratory are in the pipeline in the near future. A major expansion plan for the department as part of a new surgical block is to take shape soon, just adjacent to the Achuta Menon Centre in the existing campus, and would begin its expanded services in a few years' time.
“Dear Past, Thank you for all the lessons, Dear Future, I'm ready.”
The authors gratefully acknowledge the reminiscences and inputs from Padma Vibhushan Prof. M. S. Valiathan (National Research Professor and Founder–Director, SCTIMST), Prof. Girish Menon (Professor of Neurosurgery, Kasturba Medical College, Manipal), Prof. Kesavadas (Professor of Radiology, SCTIMST), retired chief operation theater nurses Mrs. C. D. Elizabeth, Mrs. Prema John, medical record officers Mr. Varghese PJ, Mr. Thampi NG, retired radiographer Mr. Hari, and all others associated with the Neurosurgery Department.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]