Neurosurgery in SMS Medical College –From bare necessity to excellence
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.241397
Source of Support: None, Conflict of Interest: None
If I have seen further than others, it is by standing upon the shoulders of giants.
Sir Isaac Newton
Sawai Man Singh (SMS) Hospital was founded by Sawai Man Singh II, the erstwhile king of Jaipur. The construction of the hospital building began in 1934. In 1937, the hospital was commissioned and SMS Medical College was started in 1947. At present, the hospital is staffed with 255 doctors and 660 nurses with 6000 beds in 43 wards. It has all the super-specialty DM and MCh courses. There are 343 MD/MS, 42 Diploma, 71 DM/M. Ch. and 5 M. Sc seats [Figure 1].
The Department of Neurosurgery at SMS Medical College was started in 1963. Dr. MG Sarin. who had undergone training in Neurosurgery from Christian Medical College (CMC), Vellore was the first faculty member in the department. It all started within a small ward of fourteen beds under the Department of Surgery and adjacent to the cardiothoracic wing. He was joined by Dr. V. S. Dave, who had just undergone training in neurosurgery at Montreal, Canada, and Dr. Pramod Behari, who had undergone training at Berlin, Germany. Dr. Dave did not stay there for long and went to Bombay to join Dr. Ram Ginde. Dr. Pramod Behari, after his training stint in German and after additional training with Dr. Ginde in Bombay, became a Lecturer and Reader in Department of Neurosurgery, SMS Medical College, Jaipur. He worked in the department for nearly a decade until 1972 before joining the upcoming Santokba Durlabhji Memorial Hospital to establish the department there [Figure 2] and [Figure 3]. Realizing the importance of preoperative imaging in Neurosurgery, cerebral angiographies were started in the department by the procurement of the best angiographic machine at that time as well as neurosurgical instruments. Subsequently, ventriculography, myelography and pneumoencephalography were started in the department and the bed strength increased to 36. Dr. M.G. Sarin retired in November 1977 [Figure 4].
The start of the transformation
Dr. SR Dharker joined the Department of Neurosurgery, S.M.S. Medical College on 7th June 1978. He completed his MCh in neurosurgery from CMC, Vellore. Initially he was on deputation from the Government of Madhya Pradesh as there was no neurosurgeon in the department after the superannuation of Prof. M.G Sarin in November 1977. Later on, in 1979, he was confirmed to the post of Associate Professor in Neurosurgery through Rajasthan Public Service Commission. He was promoted to the post of Professor of Neurosurgery on 25th September 1982.
He was the lone faculty member for about four months attending to both routine and emergency work. He was lucky to have dedicated, hardworking, sincere and dependable registrars and nursing staff right from the very beginning. Dr.PPS Mathur joined him as Lecturer in September 1978. He had done his MCh in neurosurgery from Postgraduate Institute of Medical Education and Research, Chandigarh.
When Dr. Dharker joined the deparmtent, there were 36 beds and twice-a-week operation theatre (OT) allocation, with an output of around 60 surgeries a year. With the increase in patient load, the OT days were increased to three per week. Micro-neurosurgery and surgery for intracranial aneurysms and arterio-venous malformations were started in 1984 after Dr. Dharker's return from Glasgow, Scotland, where he had gone as a Commonwealth Fellow. The first case of a posterior communicating artery aneurysm was clipped by him by borrowing an Indian operating microscope from the SMS Medical College experimental surgery laboratory and a bipolar electro- cautery unit from Dr. V.K. Pande, Professor of Hand Surgery at that time [Figure 5].
In 1987, the Department of Neurosurgery shifted to Bangur Institute, which was a newly constructed building within the precincts of the campus of SMS Hospital. One entire floor was dedicated to neurosurgery. The department expanded to an 80-bedded center, which included 8 intensive care unit (ICU) beds. Dr. Dharker with his great efforts, constructed an exclusive neurosurgery operation theatre (OT) complex comprising of two major OTs and one minor OT. The OTs had two operating microscopes with a camera and a monitor to aid in teaching of MCh residents. The OTs also had an endoscopy unit and an ultrasonic aspirator. He also created neuropathology services inside the OT complex, where regularly, crush cytology was done to establish a histological diagnosis of the specimens harvested from the patients. A CT scan was also housed and neuroradiology services were started in the same building. Later on, the bed strength was increased to 107. This marked a giant leap for the neurosurgery department as the OTs and neurodiagnostic facilities became available round-the-clock under one roof. In 1984, Dr. Rakesh Nathani joined the department, and in 1987, Dr. LN Agarwal and Dr. RS Mittal became a part of the teaching faculty of the department. In 1988, Dr. PPS Mathur became the head of the second unit in neurosurgery.
With the support of Government of Rajasthan and generous donors, the department managed to set up a new state-of-the-art neurosurgery complex, which included four neurosurgery OTs and a 23-bedded spacious ICU (which included 14 beds for elective cases and 9 for patients with traumatic injuries). The ICU had all the modern monitoring equipment, panels attached to each bed and five ventilators. Apart from procuring the latest equipment present in that era for the OTs, Dr. Dharker started the digital subtraction angiogram suite and the crush cytology lab in the theatre complex itself. He was also pivotal in transforming the imaging services from the conventional neuro-radiological investigations like cerebral angiography, ventriculography, myelography etc., to a 24x7 available imaging service utilizing a high-end computed tomographic (CT) and magnetic resonance imaging (MRI) scanner. The MRI and CT scanner were installed under the public-private partnership model in 2004. A large teaching hall with a comfortable seating arrangement and with projection facilities was constructed in the basement of the new building. Space was demarcated for an experimental laboratory and a library too.
Due to the high quality of work and increasing number of patients receiving treatment, the department was soon recognized and approved by the Medical Council of India and the University of Rajasthan in 1985. MCh Neurosurgery course was started in the year 1985 with the permission to register two students per year. Dr. H Bagaria and Dr. VR Sardana were the first two residents enrolled for the M. Ch course. The MCh neurosurgery seats were increased to three in 1998.
In his constant endeavor to inspire his junior colleagues and students to subspecialize in neurosurgery, Dr. Dharker sent Dr. RS Mittal for further training, and Dr. VR Sardana for learning trans-sphenoidal surgery, to Sir Professor Graham Teasdale in Glasgow, United Kingdom. Dr. VD Sinha visited the Department of Neurosurgery, Ernst Mortiz-Arndt University, Greifswald, Germany for neuroendoscopic training. He also visited the Fujita Health University, Japan and specialized in neurovascular and spine surgery.
In 1997, the Department of Neurosurgery expanded into three units with Dr. RS Mittal being appointed as the Head of unit three. Dr. Dharker became the Additional Principal of SMS Medical College and continued on this post from January 1997 until August 1999. On 31st August 1999, Dr. Dharker was appointed as the Principal and Controller of S.M.S. Medical College and attached hospitals. Dr. PPS Mathur became the Medical Superintendent of SMS hospital in 2004.
The Department of Neurosurgery under Dr. Dharker's able mentorship organized the National Symposium on Cerebellopontine Angle Tumours in February 1991, the International Symposium on Current Trends in Neurosurgery in February 1994, the 46th National Conference of Neurological Society of India in December 1997, and the World Federation of Neurosurgical Societies Tumour Section Meeting in October 2004.
A large number of national and international neurosurgeons visited the department. Dr. B Ramamurthi, Dr. KV Mathai, Dr. PN Tandon, Dr. SN Bhagwati, Dr. AK Banerjee, Dr. VS Dave, Dr.VK Kak and many others eminent neurosurgeons blessed the department from time to time. Amongst the large number of international stalwarts who visited the department were Dr. William Sweet, Dr. MG Yasargil, Dr. Majid Samii, Sir Dr. GM Teasdale, Dr. Lyndsay Symon, Dr Peter Jannetta, Dr. RP Sengupta, Dr. Donlin M. Long, Dr. S. Mullen, and many others [Figure 6].
Dr. Dharker was appointed as the President of Neurological Society of India in 2004 and the President of Skull Base Surgery Society of India from 2000-2002. Due to his immense contribution in developing Neurosurgery in Rajasthan, he is often considered as the father of modern neurosurgery in Rajasthan.
After a dynamic career in Neurosurgery, Dr. SR Dharker retired in 2006 and the reins of the department were handed over to Dr. RS Mittal. Dr. PPS Mathur went on to become the Vice Chancellor of Rajasthan University of Health Sciences in April 2006. By that time, the department was doing around 3500 surgeries a year.
Scaling new heights
Dr. Mittal remained as Head of the department until 2015 and helped to develop the department further in innumerable ways. During his tenure, he organized the following conferences: 6th Annual National Conference of Neurosurgical Surgeons Foundation of India in 2006; the International Symposium on Thoraco-lumbar Spine Diseases in February 2008; and, the Annual Conference of Neurological Surgeons Society of India in 2013. In 2011, Dr. H Bagaria organized the 15th Annual Conference of the Neurological Society of India [Figure 7].
During his tenure, the number of seats for M. Ch. neurosurgery in the department were increased from three to twelve (in 2011). Dr. Mittal became the Additional Principal in 2010. During his tenure, with the help of Jaipur Development Authority, a new ward was started on the second floor of Bangur Hospital with sixty beds. He retired in September 2015. He also became the Secretary and President of Neurological Surgeons' Society of India.
Striving for perfection
Dr. VD Sinha is presently heading the Department of Neurosurgery since 2015, after the retirement of Dr. RS Mittal. In this short period, he has taken the department to new heights. There are now six units with twenty teaching faculty members, which includes five senior professors. He has expanded the OT complex, which now has six theatres, one endovascular lab and two more OTs in the Trauma Center. One of the OTs is an endoscopy suite. More than five thousand surgeries a year are being performed, which also includes all kinds of complex endovascular neuro-interventions. The ICU bed strength has increased to 47, of which 24 are for patients with traumatic brain and spine injuries. An inspiring pediatric ward of 23 beds has also been made. A neuro-rehabilitation ward inside the Neurosurgery department has also been established in June 2016. From a humble beginning of 14 beds, therefore, the department now has 310 beds [Figure 8].
The research work in Neurosurgery has received a new impetus and now the department publishes around 30 articles a year. The teaching hall has been renovated with incorporation of facility for live streaming of surgeries from the OTs to the teaching hall. Recently, an experimental laboratory for residents has also been started. A donation of 25 lakhs was made by the Neurosurgical Services and Research Society for developing the experimental laboratory from the amount which was left over after the World Federation of Neurosurgical Societies (WFNS)-Tumor section conference and various other conferences had been organised. During this period, several conferences have been held [Figure 9]. These include: the 18th National Neurotrauma Conference, August 7th -9th, 2009 [Figure 10]; the 5th Asian Australasian Society of Neurological Surgeons Neurotrauma Committee and the 2nd WFNS-Military Neurosurgeons Meeting 2015, October 9th –11th, 2015; the Neurological Society of India (NSI) teaching course in August 2016; the Annual Conference of the Skull Base Surgery Society of India, September 8th to 11th, 2016; and, the 4th Annual Conference of the Neuroendoscopy Society of India, April 7th to 9th, 2017.
The Department of Neurosurgery has also been involved in many public health and awareness endeavors. These include the following: the road safety awareness program under the aegis of the 18th National Neurotrauma Conference, 7th-9th August, 2009; the pre–hospital care program under the aegis of the 5th Asian Australasian Society of Neurological Surgeons Neurotrauma Committee and the 2nd WFNS- Military Neurosurgeons Meeting 2015, 9th-11th October, 2015; the public awareness program on road safety and pre-hospital care, 23rd November 2016; the release of a short film on road safety entitled “Anmol Jeevan-- Humara Aur Aapka” (Precious Life-Yours and Mine) on 4th November 2017 by the Transport and Public Works Department and the Industry Minister of Rajasthan.
Many internationally renowned neurosurgeons have visited the department during this time. Some of them include Dr. Franco Sarvedai, Dr. Peter Reilly, Dr. WS Schroeder, Dr. Yoshiyasu Iwai, Dr. Paul A. Gardner and Dr. Carl H. Synderman [Figure 11]. In June 2017, Dr. SK Jain, the Professor and Head of Unit 2 became the Additional Principal of SMS Medical College [Figure 12].
Despite the colossal clinical workload and shortage of manpower, the research activities in the Department of Neurosurgery are spiraling to new heights. Presently, the department produces around thirty publications in a year in various reputed journals. The residents are being constantly motivated to be involved in research activities. They are presenting high quality papers in various conferences. Recently Dr. Sinha and Dr. Rashim Kataria presented a paper on the use of three dimensional printing in cranio-vertebral junction surgery. Thus, this department is one of the very few centers in India where three dimensional printing is routinely being used. The experimental laboratory is well-equipped and not only helps residents in improving surgical skills and understanding microsurgical anatomy but several animal experimental research projects are also continuing.
The Department of Neurosurgery at SMS Medical College, being a high-volume center in India, is a potential place for research and academic activities, apart from its contribution to patient care. The department have several book chapters, studies and publications to its credit. Currently, 36 projects are being conducted in the department. Each project has clearance from the ethical committee of the college and represents different subspecialties of neurosurgery. These are being done in collaboration with other departments like the Departments of Radiology, Pathology, Physical Medicine and Rehabilitation, etc., Apart from adding to the knowledge and experience of the department and contributing to literature, these projects are a great source of learning for the residents.
The department has also been a part of a large international study on traumatic brain injury named “Centre – TBI” (the Collaborative European NeuroTrauma Effectiveness Research on Traumatic Brain Injury). The data related to traumatic brain injury from the prehospital care to the outcome at discharge was collated as a part of this study. A total of 1150 patients were enrolled from July 2016 to January 2018 and the data was uploaded on the online platform designated for Centre- TBI.
Currently, the department is privileged to be assigned as one of the centers in the country (out of 5 centers including Jaipur, Dehradun, New Delhi, Chitoor and Chennai) for the National Task Force Project on “Integrated Road Traffic Injury Surveillance” in collaboration with the Indian Institute of Health Management Research (IIHMR), University of Jaipur and funded by Indian Council of Medical Research (ICMR). This project was started in September 2017 and is expected to be completed by September 2018. It is aimed at developing tools for road traffic injury surveillance and for collecting data on the incidence of traumatic brain injury using these tools. Thus, the data may be analyzed later and its results implemented for improving the health system of the state at all levels with respect to road traffic injuries. Currently, a huge data of approximately 4800 patients has been contributed to this national study from our center.
The department has in the past contributed chapters in various neurosurgery books. Dr. Dharker has contributed ten chapters in various textbooks. Recently, Dr.VD Sinha and Dr. Amit Chakrabarty along with Dr. GK Prusty have contributed a chapter in a prestigious book on Neurotrauma being published by the Oxford University Press.
Dr.SR Dharker was the President of Neurological Society of India in 2004 and the President of Skull Base Surgery Society of India from 2000 to 2002. The American Association of Neurological Surgeons (AANS) has honorifically conferred upon him the title of International Fellow of this association. His name has been included in Marquis Who's Who in the World, and in the International Biography Centre, England. Dr. Sinha holds many important portfolios of several neurosurgical societies, including the WFNS-Member Neurotrauma Committee and the WFNS–Member Neurorehabilitation committee and Reconstructive Neurosurgery Committee. He is the President Elect of the Skull Base Surgery Society of India (SBSSI) and the former President, Secretary, Treasurer and Executive Member of the Neurotrauma Society of India. He is also a Corresponding Member, European Multidisciplinary Neurotrauma Society, an Executive Member of Asian Congress of Neurosurgical Societies (ACNS) and its Coordinator for educational courses. He is also the Vice Chairman of the Asian Australasian Society of Neurological Surgeons Neurotrauma committee until December 2018, and thereafter, shall be the Chairman of this society. He shall be taking charge from Dr. Peter Reilly.
The future plan of the department includes the development of the subspecialties of functional and peripheral nerve surgery and also the creation of a multi-dimensional super-specialty complex under the Prime Minister of India's scheme for enhancing cadaveric transplant. The department has been recognized by the ACNS as an education and training center. The first educational course under the aegis of ACNS has been planned in February, 2019.
The Neurological Society of India annual conference 2018 shall be hosted in Jaipur in a collaborative effort between the Department of Neurosurgery, Fortis Hospital and the Department of Neurosurgery, SMS Medical College, Jaipur.
We sincerely thank Dr.SR Dharker for his valuable input regarding the early period of the Department of Neurosurgery SMS Medical College, Jaipur.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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