History of Neurosurgery at Postgraduate Institute of Medical Education and Research, Chandigarh
The Department of Neurosurgery started functioning at the Postgraduate Institute of Medical Education and Research, Chandigarh in 1962 with the joining of Dr. Gulati. The department provides neurosurgical services primarily to the people of Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir as well as the neighbouring areas of Rajasthan, Uttar Pradesh and Uttarakhand. The infrastructure and subspecialties have been developed over the last 5 decades by the dedicated and tireless efforts of the faculty and residents. We attempt to chronicle the contributions of those who have served the department in the past.
Keywords: Chandigarh, history, neurosurgery, PGIMER
The Department of Neurosurgery at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh has held a position of eminence among academic institutions that are providing neurosurgical services and education in the country. The history of Neurosurgery at PGIMER can be attributed to the qualities and efforts of its leaders, Drs. DR Gulati, VK Kak, VK Khosla, and SN Mathuriya. It is important to know the travails of those who have struggled and dedicated their efforts towards the building and uplifting of the department. Theodore Roosevelt once said, “The more you know about the past, the more prepared you are for the future.” In a lighter vein, Winston Churchill referring to history said, “I know history will be kind to me, for I intend to write it myself.” It would be tempting to detail the contributions and achievements of the current faculty members; however, we believe that history should be about people who have served the department in the past from the perspective of the present. The true worth and importance of a person or an event can be assessed objectively only after some time has elapsed.
The department as it exists today is slightly different in terms of functional structure from most other Neurosurgery departments in the country. The PGIMER tradition has been and continues to be to produce neurosurgeons who are excellent in academics and surgical skills and, equally important, are good human beings. This has been possible not only due to the vision of the founders of the speciality but also due to the concentrated efforts of all those who were ever associated with the department, for whatever length of time and in whichever position. There have been differences among functionaries in the department in the past, but people have always acted in the interest of the future and well-being of the department. This bond holds all the PGIMER alumni together, even to this day.
PGIMER is considered to be one of the prestigious establishments in the city of Chandigarh. Founded in 1962, it owes its inception to the vision of Sardar Partap Singh Kairon, then Chief Minister of Punjab, supported by the first Prime Minister of India, Pandit Jawahar Lal Nehru, who considered institutions of scientific knowledge as temples of learning and places of pilgrimage [Figure 1] and [Figure 2]. PGIMER was initially created for the erstwhile state of Punjab, but was declared as an Institute of National Importance in 1967 by an act of the Parliament of India. The Department of Neurosurgery formally came into existence with the joining of Dr. Des Raj Gulati as an assistant professor in January 1962, after his training at the Montreal Neurological Institute under the famed Wilder Penfield [Figure 3]. In the initial years, Dr. Gulati looked after both Neurology and Neurosurgery services that together had a total strength of 47 beds. In that era, Neurosurgery was considered to be a mere extension of General Surgery, as all surgical specialities were initially labelled as divisions within a unified department of Surgery. The superspeciality of Neurosurgery became an independent department in the year 1978–1979. After a couple of years, Dr. Gulati received assistance from the first registrars of Neurosurgery including Drs. YS Bhandari, KS Mann, and SN Dhaliwal. He mentored these registrars well, and under his guidance, Dr. KS Mann further continued his Neurosurgery training in London. Dr. Vimla Virmani helped him in Neurology during the years 1965–1967, and Ved Sachdev in Neurosurgery during the years 1966–1968 [Figure 4]. Gradually, the department progressed and a postgraduate training course in Neurosurgery was started in 1966. Dr, Ved Sachdev, who was an assistant professor of Otolaryngology at the Institute, was deputed to work in the Department of Neurosurgery, and was the first candidate to be registered for the degree of M. Ch in Neurosurgery [Figure 4]. He obtained his degree in 1968. He was followed by Drs. KC Pani and Damoder Rout. Dr. JS Sodhi began neuroradiological investigations in 1962. An electroencephalogram (EEG) machine was acquired in 1966. The division of Neurology separated from the Department of Neurosurgery in 1968 with the joining of Dr. JS Chopra as an assistant professor of Neurology. Dr. VK Kak, after his training at Belfast, joined the department in 1969. The warm bond between Drs. VK Kak and JS Chopra was the main guiding force in the development of Neurosciences at PGIMER. Neuropathology services were started in earnest with the return of Dr. AK Banerjee in 1970, following his training at Queen Square, London with Drs. W Blackwood, WGP Mair, and Anthony Dayan. He was instrumental in starting the “brain cutting” session [Figure 5], which was attended by neurologists and neurosurgeons, as well as the initiation of the frozen section facility in the main operation theatres. Drs. KC Pani and Damoder Rout were appointed as lecturers, Head injury unit, in 1971 and 1972, respectively. Dr. KC Pani soon left for USA. Dr. Damoder Rout was designated as an assistant professor in 1975 and remained a faculty member for approximately 5 years before shifting to Sri Chitra Thirunal Institute of Medical Science and Technology (SCTIMS), Thiruvanathpuram. Dr. KS Mann, following his training at Queen Square, London joined the department as an assistant professor in 1975. He left in 1979 and moved to Hong Kong. Dr. Sushil Kumar was appointed as a lecturer in 1975, but he also left in 1977. Dr. VK Khosla joined as lecturer in 1977. Successive faculty members of the department included Drs. SN Mathuriya, BS Sharma, Ashis Pathak and the current faculty.
During the early years, excellent Neuroanesthesia services were provided under the guidance of Drs. Sujit Pandit, Harivir Singh, and YS Verma, to name a few. Dr. Sujit Pandit left for USA and is currently at Ann Arbor, Michigan. Dr. YS Verma was appointed the first professor of Neuroanesthesia in the country, and was a very sought-after teacher by the residents [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18].
The Gulati years (1962–1983)
Dr. Gulati had trained in Montreal under Drs. Wilder Penfield, Theodore Rassmussen, and William Cone. His other colleagues in Montreal were Dr VS Dave (who started the Department of Neurosurgery at King George Medical University), Dr. PN Tandon (who started the Department of Neurosurgery at All India Institute of Medical Sciences [AIIMS], New Delhi), and Dr. DN Dadhich (who was an eminent Neuroradiologist at King Edward Memorial Hospital, Mumbai). Dr. Gulati was a planner, a dreamer, and above all, a very hard taskmaster. He, single handedly, managed both Neurology and Neurosurgery with the help of a house surgeon in the early years. He got an EEG machine installed in 1966, and started a “seizure clinic” on Thursdays. He had an uncanny ability to interpret EEG recordings, and his detailed analysis and reports still remain the best in PGIMER. He could lay his hands on the only Bovie cautery in the operating theatre (OT), ordered essential neurosurgical instruments, and even procured the McKinney's stereotactic frame. In those days, neuroradiological procedures were performed by the Neurosurgery team, including myelograms, pneumoencephalograms, as well as percutaneous carotid, and vertebral angiograms. He was ably supported by Dr. JS Sodhi, who was able to procure a skull table with a manual cassette changer and a “tilting” myelography table.
In the early years, Dr. Baldev Singh, the famous neurologist and neurophysiologist from AIIMS, was a frequent visitor to the department at PGIMER. Dr. Gulati was pivotal in encouraging General Surgery residents to excel in Neurosurgery during their rotational postings and motivated them to acquire basic surgical skills. In addition to providing clinical services, Dr. Gulati also remained active in research, an ability he acquired following his work on the role of steroids in the management of cerebral edema. He also used to spend time in the Pathology lab, which used to function in 1964 in a facility located in sector 11, and was shifted in 1966 to block A in PGIMER. His pioneering experimental work on brain edema with Dr. Hanna Pappius, published in 1963, has been widely quoted. Dr. Gulati chaired the post of the Head of Department from 1962 to 1983. He was the Dean of the Institute from 1980 to 1983, and was also an Acting Director for a brief period (March–November) in 1981. He was unanimously elected as President of the Neurological Society of India (NSI) in 1980 and as a Fellow of the National Academy of Medical Sciences in the same year. He also served as an expert for the Neurology group of the Indian Council of Medical Research. He was appointed as an honorary consultant in Neurosurgery to the Armed Forces Medical Services. He invited distinguished Neurosurgeons as visiting faculty for extended periods of time. These included Drs. PN Tandon, S. Kalyanaraman, Jacob Abraham, Theodore Rasmussen, Sunil K Pandya, Kalman Kovacs, and KV Mathai, to name a few. The department also provided short-term Neurosurgery training of a 6-month duration to general surgeons of regional medical colleges to enable them to provide emergency neurosurgical services to the patients. Dr. Gulati retired on 31st August, 1983 upon reaching the age of superannuation.
An extremely good natured person with a heart of gold, Dr. Gulati had an ever-smiling face, which is remembered and cherished by all those who had the opportunity to work under him.
The Kak years (1969–1998)
After completing his MS (General Surgery) from SN Medical college in Agra, Dr. VK Kak left for the United Kingdom (UK) to pursue further studies and training in Neurosurgery at the Royal Victoria Hospital, Belfast from 1964 to 1969. During this period, he also obtained FRCS (Eng) and FRCS (Edin). Drs. JS Chopra and VK Kak had spent time together in Belfast, and Dr. Chopra was instrumental in getting Dr. Kak to PGIMER, Chandigarh. His joining was a big boost to the department, which made significant progress in clinical services as well as academic and research fields thereafter. The department was able to start a separate Head Injury Unit in the early 1970s. In that era, the department continued to make a steady growth despite the clouds of Indo-Pakistan war. Drs. Gulati, Kak, and Rout jointly shouldered the burden of work during the all India residents' strike from January to March 1974, with the able assistance from Dr. TK Roy. With his progressive vision, the department started stereotactic services for various indications including Parkinson's disease, dystonias, drug addiction, behavioral changes, etc. He used the old McKinney frame, and stereotaxy, in those days, was performed on ventriculography-based measurements with the help of a stereotactic Atlas More Details. He started transsphenoidal surgery for pituitary tumors and transoral surgery. Thus, a close collaboration was established between endocrinologists, ear, nose, throat surgeons, and neurosurgeons, which still continues today. He also initiated a combined clinicopathologic round, which used to be conducted in the department of Pathology with the participation of neuroradiologists and neurologists. The Saturday morning Neurology/Neurosurgery rounds were also started by him with active participation of Dr. Chopra and other Neurology faculty, radiologists, and later Dr. IJ Dewan, the famous neuroanatomist. He was a gifted neurosurgeon and excelled in applying sound principles of general surgery to his operative skills. He was instrumental in improving surgical results for both brain tumors and spinal disorders. Dr. Kak was also active in research activities and the department started showing its presence on the academic fronts in the form of publications and presentations at various national and international forum as well as in bringing out publications in national and international journals. He delivered several orations during his career, including the Presidential oration of NSI (1998). He received the lifetime achievement award of NSI in 2013, and of the Madras Neuroscience Institute in 2016. He served as the President of Neurological Society of India, Indian Society of Pediatric Neurosurgery, Indian Society for Cerebrovascular Surgery, and Chandigarh Surgical Society, among others. He was elected as a Fellow of the Indian Academy of Medical Sciences in 1983, and was also the recipient of Dr. BC Roy National Award (1985). He was also an honorary consultant to the Armed Forces. Dr. Kak was deputed first to Libya (1975–1978) and later to Bahrain (1992–1994). He was the medical superintendent of the Nehru hospital during 1994–1995. During this time, he had read all the rules related to the hospital administration and knew them better than many veteran officials. Dr. Kak was appointed the Director–Principal of Government Medical College and Hospital (GMCH), Chandigarh and as Secretary, Medical Education and Research, Chandigarh administration, in 1995. He retired from PGIMER in 1998 and from GMCH in 2000. He was appointed as Professor Emeritus of the Department of Neurosurgery, PGIMER in 2000. He was active in sports and was a good table tennis, bridge, and chess player.
Dr. Kak was instrumental in getting several key equipment for the department. To name a few, he obtained the first blood gas analyzer in the Neurosurgery ward, the first image intensifier in the Neurosurgery OT, radiofrequency generator for the treatment of trigeminal neuralgias, Leksell streotactic frame, and transoral set. He assembled and installed the Carl-Zeiss operating microscope himself upon his return from Libya in 1978. Apart from being a brilliant surgeon, his major contribution to the department and to the speciality of Neurosurgery can be stated as 'pushing his students to their limits to hone their surgical skills and become leaders in their own right.' Like Dr. Gulati, Dr. Kak was a hard taskmaster and was fond of saying that “real diamonds can only emerge from raw residents when one repeatedly cuts and polishes them so that the finished product shines brilliantly.” Those who trained under him still revere him as a teacher par excellence and are intensely loyal to him. He was gifted a special plaque engraved with the names of his students from the Armed Forces, which he cherishes over the numerous awards he received during his illustrious career.
Dr. Kak had the vision to perceive that his colleagues needed training at specialized centers abroad to broaden their horizon, and he ensured that consultants from his department visited centres in Japan and UK.
The Khosla years (1975–2008)
Dr. VK Khosla joined the department of Neurosurgery as a senior resident in 1975 and was subsequently appointed lecturer in 1977. He was one of the first neurosurgeons in India to do formal fellowship in Skull Base Surgery under Dr. Hakuba and was awarded the Diploma in Skull Base Surgery by Osaka City Medical University, Japan. He had a key role in establishing and promoting anterior cervical spinal injury in the department and he took it to a level of art. In those days, cervical plating systems were not available. Dr. Khosla had perfected the art of modelling the bone grafts perfectly to fit the superior and inferior vertebrae, and if required, would fix the graft to the adjacent vertebrae with thin steel wires. It was not technically easy to drill holes in the vertebral bodies with hand-held drills, but he had mastered the technique. He was extraordinarily meticulous in tissue handling and was a master craftsman. Transoral odontoidectomy was also initiated by him. To get himself oriented for this surgery, he requested Dr. IJ Dewan, Head of the Anatomy Department, to allow him to conduct cadaveric dissections, to which the latter readily agreed. To open the jaws of the cadavers was, however, a monumental task in itself. Finally, the cadaveric jaw had to be disarticulated and removed before access to the posterior pharyngeal wall could be achieved. Dr. VK Khosla was keen to improve the management of aneurysmal subarachnoid hemorrhage, and because of his efforts, the awareness of this disease and the need for an early referral increased in North West India. An able administrator, he streamlined the present purchase policy in the department that facilitated the procedure for acquiring state-of-the-art microneurosurgical equipment of international standards. He was the driving force responsible for the start of neurointervention in PGIMER and was instrumental in creating a separate 6 bedded neurosurgical intensive care unit (ICU) in 2001. He had the foresight to acquire the first Perfexion model of Gamma Knife in this part of Asia. The Advanced Trauma Centre in PGIMER was conceptualized by him, and he made great efforts to make it see the light of the day. The ground work of the proposed Advanced Neurosciences Centre was also initiated by him. He always encouraged his junior faculty to subspecialize in their area of interest. Dr. Khosla took great interest in teaching and training of residents and would spend hours taking bedside rounds during his non OT days. His Sunday ward rounds were a great learning experience for students. The present day system of daily morning meeting for all residents and consultants, where all the cases of the previous 24 hours are discussed, was initiated by him.
He was on the editorial board of Neurology India, Indian Journal of Pain, and Indian Journal of Neurotrauma. He was elected as the President of the Neurological Society of India in 2008–2009. He has also delivered many orations. He spent two years in Bahrain (2005–2006). He retired in 2008 after reaching the age of superannuation.
The Mathuriya years (1977–2015)
After his M. Ch in Neurosurgery in 1978, Dr. SN Mathuriya worked as a lecturer in the department of Neurosurgery at SCTIMS, Thiruvananthapuram for approximately 9 months in 1980, and again as a lecturer for a year at SMS Medical College, Jaipur in 1981. He joined back the department of Neurosurgery at PGIMER in 1981. After Dr. VK Khosla, Dr. SN Mathuriya became the Head of Department in 2008 and remained at this post till his retirement in 2015. Being an energetic, painstaking, and meticulous surgeon, who was keen to upgrade and learn, Dr. Mathuriya went for extensive training in microneurosurgery in the early 1990s to various centres in India as well as abroad, mainly focusing on cerebrovascular surgery. He implemented an aggressive approach in the management of aneurysmal SAH while working in Oman (at Khoula Hospital as a senior specialist during 1996–98). He also contributed toward establishing a protocol for intraventricular intracranial pressure monitoring for all severely head injured patients in Oman. He visited legendary neurosurgeons, namely, Drs. Vinco Dolenc, Madjid Samii, and Michael Gabb. He was instrumental in creating an 18-bedded neurosurgical ICU in the emergency complex. Under his able guidance, the department scaled new heights and provided a substantial contribution in all spheres of aneurysmal SAH management. He was the first to use transcranial Doppler in the department, which successfully resulted in several dissertation works on head injuries and cerebral vasospasm. He was one of the founder members of the Indian Society of Cerebrovascular Surgery and was the President of the Society during 2012–2013. He is also an executive member of the International Society of Cerebrovascular Diseases.
Dr. Mathuriya is remembered by his residents as one who was completely devoted to patient care and would leave no stone unturned for providing the best neurosurgical services. He always demanded the maximum from all the departmental faculty members and residents and led by personal example. Good at heart, he would go out of his way to help his senior and junior colleagues in their professional as well as personal problems.
Others who excelled
Dr. Ved Sachdev, the first registrar of Neurosurgery, after receiving further training in Neurosurgery at the Royal College of Surgeons of England, quickly rose to the level of being a senior consultant at Mount Sinai Hospital, USA. He acquired a reputation for both professional excellence and benevolence, which earned him “The Best Teacher and Mentor Award” by the neurosurgical residents at Mt. Sinai Hospital in 1992–1993. He passed away on August 8, 2000. Dr. Damodar Rout joined the department of Neurosurgery in 1972 as a lecturer and in-charge of the Head Injury (HI) unit. The HI unit, however, remained without any bed allocation, and therefore, all these cases of serious injuries to the brain were admitted on the Neurosurgery beds. He got promoted to the rank of assistant professor in 1975 and was on deputation to Iran for medical assistant services. Dr. MS Valiathan, then director of SCTIMST, Thiruvananthapuram asked Dr. Gulati to help him in getting an efficient neurosurgeon to serve the institute and Gulati recommended Dr. Rout. Dr. Rout can be aptly called the “Father of Neurosurgery at SCTIMST.” He is remembered as a strict surgeon with a gentle heart who mastered and taught the nuances of cerebrovascular surgery and established the residency training program in SCTIMST. Dr. KS Mann, after receiving his training from Queen Square, London joined the department. Though he was associated with Prof. DR Gulati only for 3 years, during this period, he brought many neurosurgical techniques to the department and also inculcated a sense of discipline among the residents. During 1975–1979, when he worked as a consultant, Dr. Mann started anterior cervical surgery in the department. He was close to the residents and used to look after all their needs.
After completing M. Ch Neurosurgery from PGIMER, Chandigarh, Dr. Sushil Kumar served at the Safdarjung Hospital. He joined the Department of Neurosurgery at GB Pant Hospital as the associate professor and Head, New Delhi in 1979. He served in this institute throughout his career except for a short stint as professor and Head, Department of Neurosurgery, Postgraduate Institute of Medical Sciences (PGIMS) Rohtak in 1982. Later, he served as the Dean, Maulana Azad Medical College, New Delhi. Dr. PPS Mathur received further neurosurgery training under Prof. John Tew in Cincinnati and joined SMS Medical College, Jaipur. A great academician and a pioneer neurosurgeon, he worked tirelessly throughout his life for the state medical services and medical education. He also served as the Medical Superintendent, SMS Hospital, Jaipur and as Vice Chancellor of the commissioned Rajasthan Medical University. Unfortunately, he passed away following a road accident. Dr. BS Sharma joined the department as a lecturer in 1985 and provided his services for nearly 16 years before shifting to the All India Institute of Medical Sciences, New Delhi in 2000 as professor of Neurosurgery. Dr. Sharma has taken vascular neurosurgery and endoscopic neurosurgery to a state-of-the-art level and has mentored a generation of neurosurgeons in both academic institutes (PGIMER, Chandigarh and AIIMS, New Delhi) for the last three decades. With excellent academic performance and leadership qualities, Dr. Sharma became the Head of Neurosurgery department at AIIMS, New Delhi, in 2012, and continues to be on the post till date. Dr. Ashis Pathak joined the department as an assistant professor soon after receiving M. Ch Neurosurgery in 1987. Dr. Pathak, an exceptionally skilled neurosurgeon, took special interest in cerebrovascular, skull base, and spinal surgery. He was trained in radiosurgery and pediatric neurosurgery at Sheffield. He went to UK on a sabbatical leave and worked as a consultant neurosurgeon at the Neurosciences Unit, Royal Hallamshire Hospital, Sheffield, and Hull Royal Infirmary, Kingston upon Hull, from 2008 to 2013. He took voluntary retirement from PGIMER in 2010. Dr. Lokendra Singh, PGIMER alumnus of the 1988 batch, received further training at the prestigious Queen Square Hospital in London among other centres, and also received the degree of FRCS. In 1989, he joined the Central India Institute of Neurosciences at Nagpur, and has served as the Director of the Institute since 2015. Apart from having two patents in his name for innovative neurosurgical devices, he has a talent for writing poems and novels and has been bestowed with Sahitya Academy Award for Hindi Poetry. Dr. Yad Ram Yadav, a PGIMER alumnus, is credited with establishing a Neurosurgery centre at Netaji Subhash Chandra Bose (NSCB) Medical College at Jabalpur. The “Neuroendoscopy Fellowship Programme” at Jabalpur, that is established by him, is regarded as a programme of great repute among practicing neurosurgeons desirous of learning the nuances of neuroendoscopy. Dr. Sanjay Bhatia, after he moved to USA, worked for some time as an anesthesiologist. He also completed a fellowship in Pediatric Neurosurgery at the Children's Hospital of Michigan, and is now serving as a senior consultant at the West Virginia University, Department of Neurosurgery at Morgantown, USA.
Centred in the heart of the city beautiful “Chandigarh,” the department of Neurosurgery has been an epitome of 'success combined with humility,” exemplifying the message shown in the representative “The Open Hand (La Main Ouverte)” sculpture of Le Corbusier's architecture that represents peace and reconciliation–'the hand is open to give and open to receive.' An institute is known by its torchbearers. In a way, the department has generated efficient neurosurgeons with leadership qualities, who have and are serving at important posts throughout the country. These include Drs. Damodar Rout (SCTIMST, Thiruvananthapuram), Sushil Kumar (GB pant Hospital, New Delhi), VN Jindal (Goa Medical College), Rakesh Saxena (BRD Medical College, Gorakhpur), Bhavani Shankar Sharma (AIIMS, New Delhi), Bhagvatula Indira Devi (NIMHANS, Bangalore), PPS Mathur (SMS Medical College, Jaipur), Radhey Shyam Mittal (SMS Medical College, Jaipur), Yadram Yadav (NSBCM, Jabalpur), Basantha K Baishya (Medical College, Guwahati), RK Kaushal (Dayanand Medical College, Ludhiana), Altaf Umar Ramzan (Sher-e-Kashmir Institute of Medical Sciences, Sri Nagar) and RC Thakur (Indira Gandhi Medical College, Shimla). They have made significant contributions in training the future generations of neurosurgeons.
In addition to this, neurosurgeons from PGIMER are actively involved in providing clinical care to neurosurgical patients in all parts of the world in both academic and clinical institutes as well as in the corporate world [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26].
The Department of Neurosurgery at PGIMER has been a preferred center for neurosurgical training of surgeons from the armed force services since the very beginning [Figure 19]. In the initial years, PGIMER was preferred over AIIMS, as attachment to the Command Hospital at Chandigarh during the final year was easier than from Delhi. Major TK Roy was the first trainee doctor from the armed forces to join the institute. Till date, 17 candidates have been trained, who provide services to the brave soldiers and civilians of India.
General Biswas served as the Dean at AFMC, Pune from 1995 to 1997. Brigadier Harjinder Singh Bhatoe was Editor of the Indian Journal of Neurotrauma from 2004 to 2011, and is currently Editor of the Indian Journal of Neurosurgery.
At present, three candidates from the defense background are being trained in the department.
Infrastructure and patient services
Availability of the full spectrum of clinical services contributed to the growth of the department. The significant increase in the number of surgeries shows the confidence of the general public in Neurosurgery and in the clinicians identified with it. The simultaneous development of allied branches such as diagnostic and therapeutic angiography and neurointervention for various cerebrovascular pathologies also helps in managing patients suffering from all kinds of ailments.
The department has been reshaped as per the rising needs of the society. Over a span of the last 5 decades, the department has catered to the needs of the entire north-western India, with ever increasing number of operations, indoor admissions, and outdoor patient care. This has been in addition to the increasing number of patients reporting to the emergency services. These have included both the trauma and non-trauma neurosurgical emergencies.
After the initial hiccups, the department of Neurosurgery acquired a bed strength of 24 in 1970, although the requirement was for much more. Being the only centre to provide holistic care to all patients, the workload of the Neurosurgery department steadily increased. Therefore, the provided bed strength was always inadequate and the patients were admitted to beds in other wards. A head injury unit was established in 1971, but with no separate beds. Later, 2 beds were allocated to the emergency surgical outpatient department (OPD) for head injuries. As this was never sufficient, head injury patients had to be shifted to the main Neurosurgery ward, leaving very few beds for routine surgeries. Twelve beds in the emergency were allocated to Neurosurgery in 1978, which was later increased to a full-fledged trauma ward. With the acquisition of an operating microscope, microneurosurgery began in 1975. Computed tomography (CT) was first installed in 1986 and magnetic resonance imaging (MRI) in 1998. Neurointervention was first started in 1988; however, dedicated neurointervention on a regular basis started in 1996.
A fully-equipped new Neurosurgery emergency ward was started during the renovation of the emergency complex in 1997–1998. Due to the heavy workload and referral of serious patients from different parts of the country, a 6-bedded special neurosurgical intensive care unit (ICU) was created in 2001. Prior to this, neurosurgical patients needing ventilation were managed in the main ICU, which had 11 beds and catered to all surgical and medical specialities. Thus, creation of a separate neurosurgical ICU was a significant step towards improving postoperative patient care, especially for patients having an aneurysmal subarachnoid hemorrhage. With the massive increase in workload in all the areas, the service infrastructure has also improved. A separate 18-bedded ICU was started in 2012. The ICUs have state-of-the-art equipment including ventilators, multiple monitors, a central monitoring station, mobile CT inside the ICU, infusion pumps, transport ventilator, etc.
The workload has continued to increase exponentially, and currently, the Neurosurgery OPD attendance has increased to approximately 30,000 patients every year. The number of neurosurgical procedures has increased, and currently is close to 4500 major surgical procedures performed annually.
The present sanctioned bed strength is 80 beds; however, the admitted patient number is nearly 200 at any given time in the department. There are approximately more than 20 patients in the private and periphery wards and approximately 40–60 patients under observation in the emergency OPD. The department is operating 18 routine operation tables per week and 4 emergency tables daily round the clock. Apart from the routine and emergency services during the daytime, there are 10 in-hospital Neurosurgery senior residents on night duty at different stations in the department.
The Neurosurgery department has a good infrastructure with state-of-the-art operation theatres and equipment, including high-end microscopes, mobile computed tomography machines (ward/ICU and OT), high-speed drills, endoscopy sets, intraoperative frame-based and frameless navigation machines, ultrasound aspirators, and stereotactic apparatus. There are dedicated pituitary clinics (along with department of Endocrinology), epilepsy clinic (along with department of Neurology), pain clinic (along with department of Anaesthesiology), and Gamma knife clinics. The workload has considerably increased in all the areas but the service infrastructure could not keep pace with the patient workload. In view of the demand of clinical responsibilities rendered by the department, a dedicated neuroscience centre is being planned to improve the standard of care while maintaining the research and training character of the institute.
Availability of a full spectrum of clinical services has contributed to the growth of the department. Both Drs. VK Khosla and SN Mathuriya can be credited with providing the impetus and laying the foundation for the development of subspecialties in the department. It is because of their efforts that, at present, all consultants, apart from performing routine neurosurgical work, have made a name for themselves, both nationally and internationally, in their chosen fields [Table 1]. Apart from general Neurosurgery, the following subspecialities have been further developed over the last few decades.
Since its beginning, the department has been known for care of patients with cerebrovascular diseases including intracranial aneurysms and arteriovenous malformations. Recently, the management of Moyamoya disease has also been started.
Dr. Kak initiated surgical clipping of the aneurysms in the early 1980s. Owing to his rapport with Dr PN Wahi, Director–General of Indian Council of Medical Research (ICMR), Dr. Kak could get PGIMER included in the ICMR sponsored “Collaborative epidemiological study on spontaneous subarachnoid haemorrhage in India” during a 3-year period from 1972 to 1974. Autopsy studies were conducted by Dr.AK Banerjee. He supervised a PhD thesis on the dissection of circle of Willis of 1000 human brains and found an incidence of incidental aneurysms in 1% of them This was another proof that aneurysms are not rare in India. However, aneurysm surgery really took off in the early 1990 with the concentrated efforts of Drs. VK Khosla, SN Mathuriya, and BS Sharma. Dr. Khosla returned from Japan in 1992, as did Dr Mathuriya after his observerships at various international centres, and Dr. Sharma from his training stint at Belfast. Initially, there was only one old OPMI microscope, and there were only hand-held retractors. In the late 1980s, the diagnosis of aneurysmal subarachnoid haemorrhage was often missed and referral was delayed. Due to the awareness campaigns carried out by the department, especially among the medical community, there was an exponential growth of early diagnosis and referral of these cases, and at present, more than 400 cases of ruptured aneurysms reach the emergency services, the majority within 24 hours of ictus.
At present, the department is operating on approximately 350–400 patients with an aneurysmal subarachnoid haemorrhage per year, with state-of-the-art operating facilities existing for them. In addition, approximately another 50 undergo coiling in collaboration with the Neuroradiology team. This is perhaps the highest number in the country.
The first superficial temporal-middle cerebral artery anastomosis in the department was carried out in the mid-1990s with the help of late Prof. Yoshio Suzuki from Nagoya, who did a successful bypass in a patient with a high basilar top aneurysm. This gave a fillip to the development of vascular anastomosis, especially for patients with Moyamoya disease.
Skull base and craniovertebral junction
The true practice of skull base surgery was started in the early 1990s with the interest shown by Dr. Khosla after his training with Prof. Hakuba. The trend started by Prof Khosla has been taken to a different level by his successors. Newer surgical techniques of tackling the skull base lesions have been published from the institute. The use of microscope and microanastomosis, and the recent addition of endoscope, have improved the overall results of skull base surgeries.
Surgery for craniovertebral junction has also evolved over time, as has been the trend elsewhere in the country. In the 1980s and early 1990s, transoral odointoidectomy was started by Drs. VK Kak and VK Khosla. In those days, the department did not have a drill most of the times. Removal of the odontoid was achieved with the help of ronguers and the Kerrison's punch, and the tip was often delivered by holding it with a Kocher's forceps. Initially, posterior fusion was not performed routinely, and often, a plaster of Paris Minerva jacket was applied during the postoperative period. The Minerva jacket was a cheap alternative to the very costly halo brace. It was a no mean task for the ward resident to apply it without compromising the stability of the craniovertebral junction. The task was often achieved with a pulley attached to a pillar in the ward, (which exists even today). To circumvent this problem, the department contacted a local person who agreed to manufacture an indigenous halo brace at a very low cost and this brace is routinely being used today. Halo braces are tailor-made to individual patient specifications. However, soon afterwards, posterior fusion in the same sitting became the norm. In the last 5 years, most of the patients are managed by posterior approach with opening of the atlantoaxial joints, placement of spacers/bone, and lateral mass and pedicle/pars screw placement.
Newer protocols have been established for craniovertebral junction anomalies, and implants are also being developed in the department for preserving the mobility at the C1-C2 joints.
Spinal disease including trauma, degenerative diseases, atlanto-axial dislocation and spinal tumors are regularly dealt with by open or minimally invasive routes. This has been considerably facilitated by the O-Arm and the C-arm image intensifier as well as by neuronavigation.
Spinal instrumentation started a little later in PGIMER. This was mainly due to the severe paucity of OT time; many spinal patients had to wait for long periods. In fact, many residents who passed out more than 10–15 years ago still complain about this deficiency in their training. With the availability of separate emergency and trauma theatres and with the acquisition of latest equipment, all types of spinal instrumentation, implants, and minimally invasive surgeries have been introduced, and are currently being performed under O-arm or C-arm guidance with intraoperative image guidance.
Newer protocols have been suggested for infectious diseases such as spinal tuberculosis and intracranial fungal diseases.
Gamma knife centre: Stereotactic and functional neurosurgery
The gamma knife machine, Perfexion, was installed in the department in 2009. The gamma knife machine is housed in a separate building adjoining the Nehru hospital and has an in-house MRI machine for image acquisition and planning. Introduction of gamma knife to Neurosurgery has provided a new horizon to the minimally invasive approaches to access the traditionally difficult and forbidden areas of the brain in lesions such as glomus jugulare tumors and arteriovenous malformations. The fully updated Perfexion machine is capable of providing treatment with submillimetric efficacy with a high precision and accuracy. With this model, not only routine but fractionated gamma knife treatments are also provided. More than 1200 cases have been operated utilizing gamma knife radiosurgery so far. With the active cooperation of the department of Radiotherapy and Neuroradiology, patients are getting treated 6 days a week.
In addition to this, PGIMER is the referral centre for all kinds of epilepsy surgeries, which are handled by the epilepsy team comprising neurosurgeons, neurologists, neuropsychologists, neuroradiologists, and colleagues from the department of Nuclear Medicine.
Transsphenoidal surgery for pituitary tumors was started by Dr. VK Kak. Pituitary surgery, as a separate dedicated subspecialty, was established in 2000. Since 2010, a weekly dedicated pituitary clinic with an endocrinologist, infertility specialist, neuroanaesthetist, and neuroradiologist and PhD students was started.
CT and MRI-based stereotaxy was restarted around the year 2000. At present, both frame-based and frameless stereotactic procedures are being routinely performed.
Recent addition of O-arm and neuronavigation has helped in complex cases of spinal instrumentation, especially in minimally invasive spine surgery. In addition, frameless stereotactic cranial procedures are being done. This has proven to be a boon, especially for pediatric patients.
Since its inception, the department of Neurosurgery has handled a tremendous load of emergency patients. Everyday, 30–35 new patients avail emergency services at the hospital. In the 1980s and early 1990s, there were only two operation theatres, and after the routine list, the emergency cases, including head injuries, were operated in the same two theatres. Night surgeries would often continue until the morning, resulting in delay in the scheduled operations. The night residents were under tremendous pressure to complete all the surgeries in the night itself.
Advanced trauma centre
An advanced trauma centre (ATC) was the need of the hour and formally came into existence in 2011. All the trauma services were shifted to ATC from Nehru hospital. The centre has 16 beds (for Neurosurgery), 2 OTs dedicated for Neurosurgery, and a 12-bedded ICU to take care of neurosurgical patients. The Neurosurgery OTs are well-equipped with state-of-the-art equipment such as C-arm, operating microscope, and high speed drills to tackle the complete spectrum of cranial and spinal surgeries. At present, all kinds of traumatic brain injuries and spine injuries including complex spine cases needing spinal instrumentation are being performed at the ATC operation theatre complex. Each day, approximately 15-20 patients of neurotrauma are received. Every month, approximately 125–150 cases of head or spinal trauma are being operated at the trauma centre.
Non-trauma emergency services
In addition to the trauma centre, the department manages emergency medical services, where Neurosurgery residents are permanently posted. The emergency OPD receives approximately 10 new cases every day including those related to aneurysmal subarachnoid hemorrhage, tumor with brain herniation, and hydrocephalus requiring urgent surgical intervention. The emergency block has 2 separate wards for Neurosurgery. One of them has been converted to an 18-bedded intensive care unit. It has 2 emergency operation theatres dedicated to Neurosurgery; one theatre has been earmarked solely for shunt procedures. Every day, approximately 2–3 shunt procedures and 2–3 surgeries for tumors, or decompressive hemicraniectomies for stroke are performed.
Neurosurgery education and training: Resident training program
The department of Neurosurgery at PGIMER, Chandigarh has always been one of the preferred places for training among the aspirants. Since 1968, the department has been regularly training senior residents under the M. Ch training program. Earlier, the M. Ch training was for 2 years, but since 1996, it has been a 3-year program, with the addition of a mandatory dissertation. At present, the senior resident strength is around 30 [Table 2].
Every General Surgery resident undergoes 3 months of training in the department of Neurosurgery. During this period, they actively participate in patient care, maintaining admitted patients and assisting the senior residents in the OTs. The General Surgery residents are also allowed to do dissertation in Neurosurgery, a practice that is quite different from that prevalent at other centers. Hence, many of the junior residents start developing active interest in Neurosurgery since the beginning of their career, and even start having conference presentations and journal publications.
The department conducts entrance examination for M. Ch biannually and the candidates are selected on a merit basis after a theory and practical examination. The theory entrance exam has a unique multiple response pattern, which tests the candidates' all round proficiency and obviates any potential guesswork. The subsequent practical examination is conducted by multiple faculty members, who are blinded to the theory marks. This practice ensures that only the best candidates get selected for the course.
PGIMER has an apprenticeship-based training program that is supplemented by individual proficiency and guided by specific protocols. During the 3-year period, the residents are trained for basic and advanced surgical skills in Neurosurgery, covering the whole spectrum of neurological disorders. The residents are assigned guides under whom they conduct a dissertation related to any topic of neurosurgical interest. Their training includes active participation in case presentations, seminars, journal clubs, mortality–morbidity presentations, symposia, and thesis presentations. In addition to this, the residents actively participate in the combined Neurology–Neurosurgery grand rounds, Neuroradiology meetings, tumor board meetings, staff clinical meetings, and combined Pathology meetings to discuss the cases of clinical and academic interest with other allied departments. Every day, all the clinical cases are discussed in a common departmental meeting (including the faculty and residents) that is primarily based upon academic and management aspects. Cadaver facility is also available with dedicated sets of instruments, drills, and microscopes. This facility is run in collaboration with the department of Anatomy and Forensic Medicine. Several Neurosurgery residents have completed their dissertation in the applied neurosurgical aspect of neuroanatomy.
Apart from Neurosurgery, residents are also posted in the departments of Neurology, Neuroradiology, and Neuropathology to gain knowledge of the basic neurosciences. Periodically, residents are sent to other institutes to gain experience and attend various national and international conferences. The uniqueness of PGIMER M. Ch training program also lies in the conduct of exams at the end of the 5th semester, 6 months earlier than the completion of the course. This transition window of the 6th semester prepares them adequately for a greater surgical responsibility, helps in their pursuing research of their choice, and in planning their career. Over the last 2 decades, we have found this to be very useful from the residents' point of view. The department also benefits from this protocol. After the exams, these residents are given more surgical responsibility and they gain more confidence in the overall management of patients. The department faculty, both past and present, have come to swear by this arrangement, though it is at variance with the rest of the departments in the country. We have seen the same residents becoming more confident in decision making and the consultants also start relying upon them. They virtually function as chief residents helping to guide their juniors. Till date, the department has trained 173 senior residents under the M. Ch program, and most of the residents who have passed out are placed in well-reputed institutes and hospitals, both in India and abroad.
In the last 5 years, the Neurosurgery department has conducted many skills training cadaveric workshops on specific surgical aspects such as the skull base, craniovertebral junction, and spinal instrumentation, as well as the NSI educational courses.
The Saturday morning combined Neurology–Neurosurgery clinical meeting is an important academic activity since the inception of the department. This common academic bond between the two departments is a unique feature of PGIMER. The residents dread this morning round because they are literally bombarded with questions from both neurologists and neurosurgeons. All of them, however, fondly remember it as a great learning experience after they pass out.
The DM Neuroradiology course was started in 2009 and the DM Neuroanaesthesiology course in 2013. The close cooperation between the allied departments of Neuroradiology and Neuroanaesthesiology was further enhanced with the starting of these courses. At present, all neurovascular cases are jointly managed by both the neurosurgeons and neuroradiologists, which results in a comprehensive care and combined follow-up being provided to all neurovascular cases. Any intervention, if needed, is available even in the middle of the night. Similarly, all routine as well as emergency neurosurgical surgeries are managed by a team of neuroanaesthesiologists round the clock. Neuroanaesthesia residents also participate in the postoperative care of patients and are also posted in Neurosurgery ICUs.
Despite the hectic clinical schedule, the department continues with research projects and have publications in journals of international and national repute. Research has been done in all the spheres of neurosciences that include aneurysmal subarachnoid hemorrhage, cerebral ischemia, spinal injuries, proto-oncogenes in gliomas and pituitary tumors, fungal and other infectious pathologies, gamma knife radiosurgery, craniovertebral junction anomalies, pediatric head injuries, brain tumors, and trauma. The department has always remained instrumental in promoting the basic research activity in all arenas of neurosciences such as intracranial aneurysms, brain tumors, and proteomics-based research in pituitary tumors with interdepartmental collaboration. More than 70 research projects have been completed, more than 100 chapters written, and approximately 880 papers have been published from the department. The department is also associated with various international drug trials such as the Corticosteroid Randomisation After Significant Head Injury (CRASH) trial on head injury, the UK India Education Research Initiative (UKIERI) trial on germline mutations in pituitary tumors, the Randomised Evaluation of Surgery with Craniectomy for patients Undergoing Evacuation of Acute Subdural Haematoma (RESCUE-ASDH) ongoing trial, the Clazosenten trial for vasospasm, and the Stenting and Angioplasty With Protection In Patients at High Risk for Endarterectomy (SAPPHIRE) trial for gene therapy. There is a close collaboration with Neurology and supportive departments such as Neuroradiology, Neuroanaesthesia, Neuropathology, and Pediatric Neurology.
At present, the department provides several platforms to share ideas and experiences. From time to time, the department organizes conferences on specific themes to encourage continuous medical education and interaction among the professionals. To respect its founder, the department organized the first DR Gulati oration in April 2006 with Prof. Hirotoshi Sano as the orator. The oration is now being organized every year in the month of September/October. Till date, Professors RP Sengupta, Shegeaki Kobayashi, Ingrid Scheffer, Takeshi Kawase, Christopher M Loftus, Anil Nanda, M Necmettin Pamir, Michel E Mawad, VK Kak, and Henry W Schroeder have honored this scientific meeting. In 2015, establishment of the organization named “Association of Neurosurgeons of North-West Zone” helped in bringing the Neurosurgeons of Chandigarh, Panjab, Haryana, Himachal Pradesh, Jammu and Kashmir, and the adjoining parts of Rajasthan and UP together on a common platform. This year, the annual meeting of the society (April 2016) was centered over the surgical management of complex craniovertebral junction anomalies, with a preconference cadaveric workshop. The department has also organized the 1st National NSPRSABH: CME on the rehabilitation of head injury patients in February 2016.
The present faculty working in the department are Drs. SK Gupta, MK Tewari, KK Mukherjee, Rajesh Chhabra, Sandeep Mohindra, Pravin Salunke, Manju Mohanty, SS Dhandapani, Navneet Singla, Ashish Aggarwal, Manjul Tripathi, Apinder P Singh, M Karthigeyan, HBS Sodhi, and Ravi Garg.
In the last 10 years, there has been a gradual change in the functional organization of the department. As the outpatient department (OPD) and the operating workload increased, it was realized that a different system needs to evolve not only for smooth functioning but also for allowing younger faculty members to grow and realize their potential to the fullest. As with all other major institutes in the country, on an average, a person is appointed as faculty after an average of 3–5 years after completing his M. Ch degree in Neurosurgery. This gives him adequate time to hone not only his surgical skills but also to develop decision-making capabilities in the best interests of the patients. At present, all faculty members have an independent OPD, an independent OT and beds, and have the freedom to make their own management decisions. In addition, since each faculty member has chosen a particular field of specialization apart from routine work, there is an unwritten but tacit understanding of referring patients to or taking opinion from each other. Despite this, the department works in unison as one team and there are combined ward rounds for all patients. As mentioned earlier, all cases are discussed by the entire team of consultants every morning [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32].
In this era of rapidly changing norms and technological advances, Neurosurgery as a branch cannot survive without adaptation. The most important responsibility of an academic institute lies in bringing about the metamorphosis of 'young minds with unskilled hands' to 'sharp minds with a gentle touch' without compromising on patient care. To maintain the tradition of this teaching, the new Neuroscience Centre is the demand of the hour. The department is also in the process of establishing a Neurosurgery skills training lab to provide basic and advanced Neurosurgery skills training on various task-based and procedure-based modules. Basic neurosciences still remain as a major part of the major disciplines of the departments of Anatomy, Physiology, Pathology, and Biochemistry, the institute had the vision to start dedicated neuroscience departments for focused research in neuroanatomy, neurophysiology, neuropathology, and neurobiochemistry.
In a few ways, the department of Neurosurgery has been unique in the country, e.g., it is the only institute of national importance, which as a tradition, has never refused any patient, even when the acceptance of patients has meant being inundated with patients; in the last 5 years, systems have been built to bring down the waiting list from 2 years to a couple of weeks [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31]. In the last 15 years, this department has strongly encouraged younger faculty to take up “difficult” surgeries meant for professors, thus helping in capacity building. The department of Neurosurgery at PGIMER, Chandigarh is one of the busiest centres of India. Since its inception, it has not only catered to the health needs of the people of Chandigarh but has also received referrals from the neighbouring states. Non-arguably, it has a huge catchment area and is duty-bound to provide services to the densely populated adjoining states, despite having shortcomings in resources. The institute has been performing at its maximum strength. In support of the services that it provides, the public has always respected PGIMER and the department of Neurosurgery. This trust has been the department's main driving force, which has been generated after decades of selfless care to the society. Creation of a neurosciences center, comprising the specialties of Neurosurgery, Neurology and allied specialties, is a long felt need of the people in this region. There is an urgent need to provide comprehensive care to patients suffering from neurosurgical and neurological disorders by creation of a neurosciences center. Its establishment will help in further subspecialization in the different dedicated streams of Neurosurgery such as cerebrovascular surgery, skull base surgery, spinal surgery, pediatric neurosurgery, neurooncology, endoscopic neurosurgery, and functional neurosurgery.
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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], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32]
[Table 1], [Table 2]