Sixty years of Neurosurgery at Andhra Medical College and King George Hospital, Visakhapatnam: The (hi) story of the department
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.236967
Source of Support: None, Conflict of Interest: None
Keywords: Andhra Medical College, Diamond Jubilee, history, King George Hospital, Neurosurgery
“Human history in essence is the history of ideas.”
-H. G. Wells
The Department of Neurosurgery, Andhra Medical College (AMC) and King George Hospital (KGH) at Visakhapatnam was fourth in the country to be established as a full-fledged department in India; Christian Medical College, Vellore, under Dr. Jacob Chandy in 1949, Madras Medical College, Madras, under Dr. B. Ramamurti (1950), and Seth GS Medical College and King Edward Memorial Hospital under Dr. Ram Ginde (1953) were the only departments of Neurosurgery that had been established earlier than this department. The department at Visakhapatnam was the first department in the country to have been started by a person trained in Neurosurgery in India, Dr. SBP Rao, who had done his M.S. (General Surgery) from AMC. He started the department on 2nd April 1956 after 9 months of training at Madras under Prof. B. Ramamurti. The department had 12 beds, distributed in three areas, and a budget of Rs. 3000/- to start with, sharing the operation theater with a general surgical unit, He faced a challenging period in single-handedly running the department until the year 1963.
Dr. K. V. Chalapathi Rao (KVC Rao) and Dr. I. Dinakar often helped Dr. SBP Rao in attending to emergencies in the early period and that instilled an enthusiasm in both of them to enroll for and complete their M. Ch. degree from the Department of Neurosurgery, Christian Medical College (CMC), Vellore. The formal training in Neurosurgery, with the offering of the degree of M. Ch (Neurosurgery) were started at CMC Vellore and Madras Medical College in 1949 and 1950, respectively.,
In 1959, Dr. SBP Rao went to the United Kingdom under the Colombo Plan for a year and visited the Departments of Neurosurgery at Bristol and Queen Square, London, United Kingdom, apart from other centers. 'Visited' was probably the right word, for he never was permitted to scrub up even to watch the surgeries from close quarters. Called a clinical assistant, his was an illustrious example of one's capacity and commitment to learn from observation. Upon his return from the United Kingdom (UK), he was elevated as Professor of Neurosurgery in 1961. Dr. B. Dayananda Rao, from the Department of Neurosurgery, Osmania Medical College and General Hospital, Hyderabad (the Department in Hyderabad was started in 1957), after his training in Newcastle-Upon-Tyne, UK, often provided help by visiting Visakhapatnam to run the department in the absence of Dr. SBP Rao.
A surgeon needs a team [Figure 1]. Sister Savithri and the theater assistant, Mr. Appalaswamy, need a special mention. Their devotion and untiring efforts were of immense value in supporting the department during its initial years. It was only since 1963, when Dr. KVC Rao returned after getting his M. Ch. in Neurosurgery, did the department have an assistant professor. This was followed by the joining of Dr. Dinakar and Dr. Bhavaraju S Rao (BS Rao) also as Assistant Professors. They worked in the department for variable times before they left the department to obtain their formal M. Ch. training. Dr. Pulla Reddy was another faculty member who chose to contribute his services for the department, although he did not opt for Neurosurgery.
It is no wonder that the persons working in the department were performing multiple duties. They were simultaneously performing the role of neurosurgeons, neurologists, neuro-radiologists, pathologists, and anesthesiologists; and at times, they were also donning the roles of technicians in the radiology department, of the scrub nurses in the operating room, or of the mechanics attending to the equipment that did not work. The diagnostic work-up of neurosurgical patients, including cerebral angiography, myelography, and ventriculography, took a major share of the neurosurgeons' time. The journey every Thursday from the Bobbili ward to the Radiology Department, with the patients in a procession, accompanied by an array of trolleys, loaded with trays for conduction of angiography, and accompanied by a Boyle's apparatus for administering anesthesia, was a sight to watch. Carotid angiography was done under general anesthesia for some time. The journey for the ventriculographic procedures used to start in the Major Ebden operation room for the preliminary burr hole. This protocol was based upon the usual practice prevalent in most neurosurgical units at that time [Figure 2].
One of the exemplary features of Dr. SBP Rao's work was excellent record-keeping. The meticulous maintenance and cataloguing of the patients' records would have made any software specialist proud of the work that was conducted at that time. The records and notes he maintained of his daily observations in the United Kingdom, of every patient that he had treated both on the outpatient and inpatient basis, of every investigation and every surgery that he had done, of all the photographs taken, of all the 35 mm transparencies made, as well as of all the compact discs of the data he had acquired and preserved, are a testimony of unquestionable quality of his work that led to approximately 70 publications by Dr. Dinakar and Dr. SBP Rao during the period from 1965 to 1970 [Figure 3].
The shortage and inadequacies of iopamidol (Myodil ®) led to a search for an alternative contrast media for myelography in the department. Dr. Dinakar tried the water-soluble dye, meglumine iothalamate (Conray 280®) and stabilized the for procedure lumbar myelo-radiculography. The technique of Dr. Dinakar and Dr. SBP Rao,,,, of using Conray 280 for lumbar radiculography and ventriculography, was not picked up by many of the neurosurgeons during that time. Severe spasms and seizures were seen whenever the spinal cord or the brain was exposed to conray 280. A preliminary diazepam administration and keeping the patient in a sitting position for 6 h after a lumbar myelography was a routine practice. At times, diazepam and intravenous phenobarbitone were needed to control the seizures that often occurred following the ventriculographic procedure.
In March 1974, when Dr. SBP Rao left for Hyderabad on a transfer posting, the department that was serving the entire coastal area of the state of Andhra Pradesh and the Southern and Interior Orissa experienced a shock. For a period of about 4 months, it was left as an orphan department, with no outpatient clinics being conducted and no inpatients being admitted to the wards. Cranio-cerebral trauma that needed emergent care was managed by the Department of Surgery, which, however, had very little expertise in this area. The wards were unmanned for quite some time before the Department of Surgery decided to occupy the ward, de facto spelling the closure of the Neurosurgical unit. Dr. BS Rao, who had worked in the department earlier in 1971–1972, returned to Visakhapatnam after obtaining his M. Ch. degree from the All India Institute of Mental Health and Neurosciences (presently NIMHANS) in July 1974. He had to again fight for the revival of the unit, a procedure that required the same amount of effort required by Dr. SBP Rao in 1956. Several radiology units were nonfunctional at that time, further complicating the scenario. It was almost at the end of 1974, when with constant efforts, the department was again brought back on track and its activities revived. Dr. KVC Rao was appointed as a Professor in January 1975. Dr. BS Rao also underwent microneurosurgical training under the Commonwealth Fellowship at Newcastle-Upon-Tyne, later on.
The investigation of cervical and dorsal myelopathies continued to pose problems with the shortage of myodil all over the country. About this time, the publication by Hitchcock and Dinakar  on the use of diluted conray 280 appeared. This technique was utilized for identification of the ligamentum flavum and the location of dorsal columns for a cordotomy. This led Dr. BS Rao to the purpose of conduction of cervical myelography with 5 mL of conray 280 injected into the cisterna magna in the sitting position. Visualization of the subarachnoid space and its indentation as well as the total blockage of the dye column were well seen. As expected, many patients had severe spasms. These could, however, easily be controlled with intravous diazepam. Encouraged by this, Dr. BS Rao used conray 280 for dorsal cord lesions. A radiological screening procedure to continuously follow the ascent of the dye within the subarachnoid space in a real time manner was not available at that time in the Radiology department. After injecting 5 mL of conray into the lumbar subarachnoid space, the table was tilted head-down and a plane X-ray was taken focused on the area at the suspected clinical level [Figure 4]. There was opposition to the use of conray in human subjects. When this paper was presented in an Neurological Society of India (NSI) Annual Meeting (Rao BS, Reddy KRK, Conray mylography for dorsal cord lesions—Annual Conference of NSI, Trivandrum, 1978), Dr. AK Banerjee from the All India Institute of Medical Sciences, New Delhi, opposed it, mentioning his work on monkeys, which proved conray to be neurotoxic. These papers were not accepted for publication in Neurology India but helped many-a-patients in their work-up and treatment.
Posterior fusion for atlantoaxial dislocation and anterior approach to the spine
It was left to Dr. BS Rao to venture into performing newer operative procedures. The presence of atlanto-axial dislocation in a patient who presented with a transient syncopal attack was treated by posterior fusion in February 1975 by Dr. BS Rao. This was the first procedure of its type to be done in the then combined state of Andhra Pradesh. The X-rays images, demonstrating a case of a reducible AAD, were the only investigation available ,, [Figure 5]. In the absence of high-speed drills, Dr. BS Rao started using a dental motor and drill for drilling the odontoid process. The lack of an image intensifier was overcome by using spot films. The void that was left at the surgical site after drilling of the odontoid was filled with contrast and a spot film was performed to check for total decompression of the odontoid process.
Lack of a mobile X-ray unit or an image intensifier had resulted in transfer elsewhere of several cases needing an anterior approach to the cervical spine; the alternative was to approach these lesions from the posterior aspect by performing a laminectomy. The first case of anterior cervical discectomy was performed by Dr. B S Rao in Visakhapatnam in March 1975. The journey of the patient started in the Radiology department. A lumbar puncture needle was inserted into the disc space from the front, and after obtaining a plain X ray of the cervical spine, the needle position was confirmed in relation to the cervical vertebra. The patient was then wheeled to the operating room and anesthetized with the needle in situ. The incision and dissection continued around the needle until the disc space had been reached. Then, adjustments were made to reach the space desired and the procedure was completed. Initially, a drop of methylene blue was left at the site and surgery was attempted after removal of the needle. However, this practice was subsequently abandoned since dispersal of the dye around the area of anterior disc space led to obliteration of the field. The position of Casigna's tubercle was also taken as a guide, but a preliminary plain X-ray image with the needle in situ was the best available guide to perform anterior cervical discectomy surgery at that time [Figure 6].
Dr. KVC Rao joined the department in January 1975 following his return from Europe, after completing a World Health Organization (WHO) fellowship for training in microneurosurgery under Dr. M. Gazi Yasargil at Switzerland and Dr. H. Pia at Germany. The first operating microscope, made by the Andhra Scientific Company, Masulipatam, was acquired. A facio-hypoglossal anastomosis for the treatment of facial tics was the first case done. Although the microscope was not a modern and sophisticated one, it did serve the purpose that it was intended for. It was unfortunate that although the department in AMC was one of the earliest in the country to acquire a microscope, microneurosurgery never picked up at the centre, since many of the accessories required, such as microsurgical instruments, bipolar cautery, and improved versions of the microscope, were not procured until after the year 2000, when microneurosurgery had become a routine procedure in the country.
This was a milestone for the department. The department had by 1981 completed 25 years of its existence. It invited the national body, the Neurological Society of India (NSI), to hold its 31st Annual Conference along with its Silver Jubilee celebrations at Visakhapatnam. Dr. KVC Rao left no stone unturned in making the event a grand success. He was ably assisted by a team of enthusiastic volunteers, and Drs. SBP Rao, Dinakar, and BS Rao, who had worked in the department earlier, lent a helping hand. The symposium on 'brain death' that was held in the Naval auditorium, and a short trip on the sea in a boat, were memorable events of the conference, apart from the outstanding presentations by many delegates. Honoring the first few faculty and staff members who had served the department—Dr SBP Rao, the first OT nurse, Mrs. Savithri, and operation theater assistant, Mr. Appalaswamy—was hailed as unique by all the delegates. The laudable act of Dr. KVC Rao of the donation of Rs. 25,000 to Andhra University for annual endowment lectures, Rs. 10,000 to NSI for its journal—Neurology India— and provision of an audiovisual setup in the twin lecture halls of the AMC, was done out of the funds generated from the Annual Conference of NSI and the Silver Jubilee celebration of the department. The story of utilization of these donations to Andhra University has been a long and contentious one. The endowment lectures were not held. Meanwhile, all the medical institutions were transferred to a separate Andhra Pradesh University of Health Sciences. It took several years for the funds to be transferred to the Health University and the first endowment lecture finally started in 1998 due to the constant efforts of Drs. BS Rao and K Venkateswarlu, who were the Professors of Neurosurgery and Neurology at that time, and Dr. A. Prasanna Kumar, the Rector of Andhra University.
In 1979, Dr. KVC Rao brought Dr. KV Mathai of CMC Vellore to inspect the department and obtained the approval of the Medical Council of India to start a postgraduate course both for a two-year post M.S. and 5-year post M.B.B.S. students. No one, however, opted for these courses till Dr. N. Subrahmanyam joined the 2-year post M.S. course in 1986–1988 when Dr. Dinakar was the professor. The 5-year post M.B.B.S. postgraduate course never picked up and was eventually dropped from the curriculum.
Although the department itself started a course offering the Neurosurgery degree, many students of AMC had at that time chosen to take up Neurosurgery, elsewhere. Drs. KVC Rao, Dinakar, BS Rao, and VK Khosla were trained in different institutions other than Visakhapatnam, as the M. Ch. course had not yet started in the department during their time. Drs. NVS Mohan, K Sridhar, Sambasiva Reddy, M. Bhaskara Rao, B. Hayagrivarao, Ranganatham, BCM Prasad, BVS Raju, B Indira, Satyanarayana Murty KV, Satyanarayana Murty TV, C. Ravishankar, K. Satish, and many other doctors, have undertaken training in Neurosurgery in different institutions across the country. At the same time, there have been many other doctors who have worked in the department, as a stop-gap arrangement in their sojourn to obtain further training, while not committing to Neurosurgery later on in life. Dr. Pulla Reddy C stands out among them. He was always willing to work in the department, yet not willing to take up Neurosurgery as a career. Whenever there was a need, he was ready to contribute to the functioning of the department. He later retired as Professor of Surgery at AMC. Drs. Nanda Kumar, Venkateswara Rao T, Ch. Subba Rao, Ganeswara Rao M, and others have worked in the department for variable periods of time.
In the year 1981–1982, the Neurosurgery ward was shifted from the Bobbili ward to the top floor of the OP block, adjacent to Ebden operation theater. The department had more space, had a more centralized location, with a separate postoperative ward on the same floor as the operating rooms. The only problem was transferring trauma patients from their reception in the casualty department, to two floors up to the Neurosurgery operating room, when the elevator failed. A few modifications were tried. The room opposite the staircase was used for a long time as the duty doctors' room originally, before Neurosurgery was shifted to this area. This was used as a postoperative ward initially and a PG seminar hall later. It remained as the PG seminar hall and was named as SBP Rao Seminar Hall, in honor of the founder, on 02.05.2006 by Shri K Rosiah, the Minister for Health and Family Welfare, when Dr. Vishnu Prasad was the Head of the Department. The Ebden operation theater too underwent many modifications, after being started as a single room with two tables, shared by the Departments of Neurosurgery and Cardiothoracic Surgery. It became a twin-room theater, the second table from the main operating theatre being removed to the next room. In 2001, an additional room was converted to an operating room, after closing the direct entry and communication from the operating room to the S2 ward; earlier, there used to be a passage from the neurosurgery ward to the S2 ward in this area.
Attempts were made to start an association of all neuroscientists of Andhra Pradesh. The first initiative was by Dr. BS Rao, at Guntur in 1982. A meeting of neurologist and neurosurgeons of the state of Andhra Pradesh was organized, and a declaration was signed to start a state unit of NSI. However, when Dr. BS Rao proposed the formation of state chapters, at the annual meet of the NSI, Trivandrum, the response was not very enthusiastic. The reason was that not many states had enough neuroscientists to form individual state chapters under the NSI. The momentum, however, gained strength when at the instance of Dr. Dibbala Rao, the delegates from Andhra Pradesh who attended the annual meeting of NSI at Chennai in 1993 resolved to take further steps in this direction. A meeting of neurosurgeons, neurologists, and allied specialists was held at Visakhapatnam in June 1994 with Dr. KVC Rao as chairman and Dr. Dibbala Rao of Neurosurgery and K. Venketeswarlu of Neurology as organizing secretaries. The meeting decided to launch a state society of neurosciences. Dr. BS Rao was given the responsibility of drafting a constitution for this body and present it at the next meeting. The society was named the Andhra Pradesh Neuro Scientist Association (APNSA). It is gratifying that the society has become very successful and meets every year in June at different venues in the state. The AMC/KGH unit of Neurosurgery was the host of the meeting in 2000, 2007, and 2012.
The seeding of the present Neuro Club of Visakhapatnam was laid by Dr. BS Rao. While the Departments of Neurology and Neurosurgery were independently running their academic programs, he felt that PGs in the Department of Neurosurgery should have adequate exposure to Neurology as well. Weekly combined meetings of the two departments were started, with the PGs conducting ward rounds and presenting the cases for discussion, alternating in Neurosurgery and Neurology wards. The neurologists and neurosurgeons in the private sector were also taking part in these meetings. The Neuro Club has slowly but surely gained strength with the support of many members in the city and now regularly meets on the last Sunday of the month. All the conferences at Visakhapatnam are also held under its banner.
The city of Visakhapatnam saw the computed tomographic (CT) and magnetic resonance imaging (MRI) scans coming up in the private sector in the 90s. Slowly but surely, more centers have come up that provide the CT scan facilities, which has been a boon for the patients, specially those who are undergoing treatment for trauma. On many occasions, someone in the team would go to the CT scan center in the city to see the CT scan in the scan center itself to save time for trauma victims. A novel proposal of Dr. BS Rao for transmission of the images to the department from the scan centers through the internet was agreed upon by one of the centers, but was scuttled before its implementation, as ulterior motives were falsely attributed to the initiative. The first MRI centre came up in the private sector at Visakhapatnam in 1995.
Dr. N Subrahmanyam joined as Professor in 2000, and a spurt in the funding and in the modernization of the department started in 2001. A CT scan was established in 2001 in the KGH campus, under public–private partnership, and with the trauma center being reorganized, there was a quantum jump in trauma management. The Ebden theater was further modified in 2000/2001. The corridor connecting the OP block and the S2/M2 block going through the Ebden operation room was closed. This provided an additional operating room in the Ebden OT. A head injury ward was created, separating the patients who had suffered from head injury from rest of the patients on neurosurgical beds.
Credit goes to Dr. N Subrahmanyam in getting the M. Ch. degree recognized by the Medical Council of India. He made attempts to impress the Director of Medical Education and the University and persuaded the Medical Council of India to send an assessor. Dr. Deepak Palande from Bombay inspected the Neurosurgery department as well as the allied departments and recommended Medical Council of India to accord recognition to the M. Ch course being conducted in the department.
Dr. Jogi Pattisapu, a neurosurgeon from Florida, USA, took active interest in the department and donated a good number of instruments to the department. His wife was a student of AMC. Acquisition of new-generation operating microscope enabled clipping of an intracerebral aneurysm and the performance of trans-sphenoidal surgery for pituitary adenoma for the first time in the department.
Facing a stiff competition, especially from National Institute of Mental Health and Neurosciences, Bangalore, the department won the chance to host the NSI annual meeting, which coincided with the Golden Jubilee of the department in December 2005. Dr. N Subrahmanyam was the organizing secretary for the event with Dr. BS Rao as the chairman, scientific committee. Dr. SBP Rao was honored with the life-time achievement award.
When Dr. K. Vishnuprasad took over as Professor and Head of the Department in 2005, significant additions to the neurosurgical armamentarium included neurosurgical operating microscopes, neuro-endoscopes, high-speed drills and craniotomes. Magnetic resonance imaging (MRI) services were started in KGH. Trauma care was reorganized with twin operation theaters for Neurosurgery, Orthopedics, and polytrauma cases. A state-of-the-art intensive care unit (ICU) with ventilatory support (which was maintained based upon the Christian Medical College, Vellore model) was started with funds obtained from the Ministry of Health, Government of India. Two additional postgraduate seats were added. The seminar hall was modernized and dedicated to the founder of the department, Dr. SBP Rao. In 2012, the 19th Andhra Pradesh Neuroscientists Association (APNSA) conference was conducted by the department.
Dr. Satyavaraprasad K took over as the Head of the Department in 2013. He immediately elevated the department to be designated as a Level I Trauma Center for conduction of the trauma pilot project by the Neurotrauma Society of India (NTSI) in collaboration with the American Association of Physicians of India (AAPI). The Medical Council of India gave recognition to the department for three M. Ch Neurosurgery seats. Transoral decompression of the odontoid and lateral mass fixation for craniovertebral junction anomalies were established as routine procedures. Endoscopic procedures such as trans-nasal trans-sphenoidal surgeries, endoscopic discectomy, and microvascular decompression were also started. Acquiring of the ultrasonic suction aspirator and facial nerve monitoring device facilitated the performance of cerebellopontine angle surgery. The use of digital subtraction angiogram standardized aneurysm surgeries.
The department acquired state-of-the-art facilities over the years, with eight professors [Figure 7], about 20 assistant professors, and two associate professors dedicating their time and energy towards the functioning of the department. 43 postgraduates also undertook training in the department. The Diamond Jubilee celebrations of the department were successfully organized in September 2016 [Figure 8]. The first Endospine workshop was conducted in the Department of Neurosurgery by Dr. Satish Chandra Gore in November 2016, which was very successful. The department shifted to the super-specialty block in March 2017 with a modern 20-bedded intensive care unit, three well-equipped operating rooms with all the modern surgical gadgets, and a bed strength of 120 beds with a separate 25-bedded neuro-trauma unit. It was recognized as a practical examination center for DNB for the coastal areas of Andhra Pradesh. The department conducted the I. Satyavathi Memorial Oration, instituted by Dr. Dinakar in memory of his mother, and Dr. V K Khosla, the former Professor and Head of the Department, Postgraduate Institute of Medical Education and Research, Chandigarh, gave the first oration. Intracranial pressure monitoring devices were recently added to the department and inaugurated by Dr. K Babji, Director of Medical Education (academic) and an alumnus of the department. The department which started in 1956 with the single-handed efforts of Dr. SBP Rao, who has been aptly called the 'Father of Neurosurgery' in Andhra Pradesh, has now a team of 15 members, with an M. Ch.-qualified person available in-house 24 × 7. It has in-house CT and MRI scan machines for evaluation, and an intensive care unit offering critical care. Several academic papers have been published and academic meetings have been held by the department. The most recent achievement of the department was its recognition as a Level 1 Trauma Center.
It had its trepidations, and hard times to survive
The days were long and lonely with no fellow travelers
The path was thorny and no gadgets to guide
Many events unexpected called for a knee jerk reaction
Our names were there as the cause of death
Yet, we established a center that earned the fame
That continues to serve and save the sick.
The authors thank all the former Professors and the current faculty and residents of the department for their help in preparing the article and Dr. SBP Rao for permitting the use of [Figure 1], [Figure 2], [Figure 3] from his records.
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]