Historical perspective on the Department of Neurosurgery at the Nizam's Institute of Medical Sciences
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.263211
Source of Support: None, Conflict of Interest: None
The foundation stone for the Nizam's Institute of Medical Sciences (NIMS), established by the charitable trust of Nizam of Hyderabad as an Orthopaedic Hospital, was laid on 16th July 1961 [Figure 1] and it was formally inaugurated in 1964 in a grand ceremony attended by the Nizam's family besides other dignitaries [Figure 2], [Figure 3], [Figure 4], [Figure 5]. This was done under the supervision and consultation of Dr. Ranga Reddy, an orthopedic surgeon. After more than a decade of establishing and delivering medical services, it was becoming increasingly difficult for the trust to meet the requirements of the large influx of patients. The erstwhile Government of Andhra Pradesh took over the reigns of the hospital and envisioned to upgrade it to a superspecialty hospital. The handing over of the hospital to the Government of Andhra Pradesh was done on the condition that the name of Nizam would always remain in the title of the institute. With mutual consent, the Nizam's Orthopedic Hospital was taken on lease for 99 years and was named as Nizam's Institute of Orthopedics and Specialties (NIOS); and, formally inaugurated on 13th February 1976 by the then Chief Minister, Mr. Vengal Rao. In the coming years, three more specialties (Neurosurgery, Neurology, and Cardiology) were added to the existing specialties and the Institute was named as Nizam's Institute of Medical Sciences (NIMS).
The Department of Neurosurgery was established on 1st April 1976 by Dr. S Balaparameswara Rao, who was a Professor of Neurosurgery in Osmania Medical College. He was also made the Medical Superintendent, leaving him with the daunting task of not only establishing the Department of Neurosurgery but also the entire Hospital. Remarkably, Dr. Balaparameswara Rao had to hold simultaneous posts of the head of neurosurgery of both Nizam's Institute and Osmania General Hospital.
Dr. Balaparameswara Rao had the foresight and the capability to pass on his leadership and surgical training to his juniors working at both the hospitals. Simultaneously, as he supervised the functioning of both Nizam's Institute and Osmania General Hospital, he trained neurosurgeons of the future. A few of the neurosurgeons trained by him are Dr. Murali, Dr. KVR Sastry, Dr. Kantha Reddy, Dr. Ranganayakulu, Dr. Chandrasekhar, and Dr. Madhav Reddy, all of whom not only set bench marks in neurosurgery but also helped the specialty to flourish in the state and at national levels. Formal examinations for the degree of MCh in Neurosurgery were initiated at Nizam's Institute in 1977, with Dr. Murali as the first surgeon to appear in the examination, followed by Dr. KVR Sastry in the second year. The infrastructure of the Department of Neurosurgery also improved as a biplane skull table and transcranial Doppler were shifted from Osmania General Hospital to Nizam's Institute in 1977, followed by procurement of a Japanese-made microscope in 1979.
On the imaging front, Dr. Balaparameswara Rao initiated the establishment of the multidisciplinary stream of neuroradiology. The neurosurgeons were assisted by radiologists in improving the diagnosis and imaging services. After ensuring a formidable start to the Department of Neurosurgery, Dr. Balaparameswara Rao retired on 28th February 1983 [Figure 6].
Professor Raja Reddy took over as the head of neurosurgery, NIMS in March 1983. Prof. Raja Reddy's inclination towards basic research was evident by his work on ossified posterior longitudinal ligament (OPLL) and by his efforts to establish an animal laboratory at NIMS on similar lines with All India Institute of Medical Sciences (AIIMS), New Delhi, and Banaras Hindu University (BHU), Varanasi. Two years into leading the Department of Neurosurgery, Prof. Raja Reddy, on 10th and 11th of August 1985, organized a successful Midterm Conference of Neurosurgeons of the Neurological Society of India [NSICON]) with the theme “Brain Tumors in Children” [Figure 7], [Figure 8], [Figure 9], [Figure 10]. Noted British Neurosurgeon Prof. R M Kalbag and many nationally and internationally acclaimed neurosurgeons and neurologists were among the attendees [Figure 11] and [Figure 12]. In August 1986, Prof. Raja Reddy left NIMS to lead the team in Osmania General Hospital [Figure 13]a. However, Prof. Raja Reddy returned as the Director of NIMS from December 1990 to 1993. It is during his tenure as the Director that procurement of advanced instruments in neurosurgery gained its vital momentum. Among them was the first computed tomography (CT) scan machine in a state-run hospital, that was installed at NIMS.
After Prof. Raja Reddy, Prof. I Dinakar took over as the head of the department (HOD) in 1986. The resident training program in neurosurgery was initiated at NIMS during his tenure. The primary reason for academic excellence at NIMS was the substantial increase in the number of neurosurgeries performed despite the department having only basic infrastructure. In 1989, NIMS was given the status of a deemed university with Dr. Dinakar as the head of neurosurgery. Matching every step with an increasing number of neurosurgeries performed at NIMS, on the academic front, the MCh course in Neurosurgery was started in 1990. Dr. Jaleel and Dr. Nageswara Rao were in the first batch of students to pass out in 1995. Subsequently, every year, two students were enrolled for MCh in Neurosurgery. Furthermore, at the same time, NIMS was allotted one seat of Diplomate in National Board Degree in Neurosurgery with an approval to train three students at any given time. The number of seats allotted for MCh in Neurosurgery increased from two to four in 2006, and further to six in 2012. Till date, nearly 100 neurosurgeons have qualified from NIMS and work in different parts of the world [Figure 13]b. Notably, Dr. BP Sahu who retired in 2018, as HOD of NIMS, was the first DNB student of NIMS. The First National Neurotrauma Conference was organized in August 1992 by Prof. I Dinakar. The spinal cord injury center was also inaugurated during the headship of Dr. I Dinakar and the directorship of Dr. Raja Reddy [Figure 14]a and [Figure 14]b.
Around this time, the Department of Neurosurgery at NIMS consistently started performing microsurgical procedures with effective results along with regular neurosurgery procedures. During this period, NIMS also had the distinction of having the first magnetic resonance imaging (MRI) set up in South India and was among the few centers in India to have dedicated laser equipment for neurosurgery. Prof. I Dinakar retired in 1996 and was succeeded by Prof. A. Krishna Reddy [Figure 15].
With NIMS established as a destination for neurosurgery, Prof. AK Reddy joined the department in 1997. It was Dr. AK Reddy's vision to develop subspecialties and to train each faculty member in respective specialties that won him a good name among his students and his peers. His tenure witnessed the procurement of a stereotactic frame, endoscopic equipment, an additional high - end microscope, and a radiofrequency generator. Moreover, the annual conference of neurosurgeons (NSICON) was conducted in 1999 with Dr. AK Reddy as the organizing secretary [Figure 16]. Under the supervision of Dr. AK Reddy, the Department of Neurosurgery at NIMS became the second center in India to start deep brain stimulation (DBS) under the pioneering vision of Dr. Manas Panigrahi. A dedicated neuroscience outpatient department was formally inaugurated in 2000 [Figure 17]. Endoscopic neurosurgery was started in 2000 after Prof. Gaab visited the institute. The Department of Neurosurgery maintained the trend of keeping up with the advances and nuances in neurosurgery under the leadership of Dr. AK Reddy, who retired in 2005.
With an ever-expanding department forging into new frontiers, Prof. AK Purohit took over mantle as the HOD of the Department of Neurosurgery from 2005. During his tenure, the faculty strength increased from 6 to 10, thus requiring a symbiotic split of the Department of Neurosurgery into a three-unit system. The branching into three units was important to streamline and garnish the ever-increasing number of surgeries, which increased from 1000 in 1992 to more than 2000 in 2017. The division into three units also provided fertile opportunity for academics, evident from the gradual increase in the number of publications in peer-reviewed journals from 4 during the inception year of the department to more than 50 in an academic year. Also, the Department of Neurosurgery regularly started hosting both national and international conferences in neurosurgery. During his tenure, the seminal work on surgery for spaticity flourished. After an illustrious career and an extremely credible effort at NIMS, Dr. AK Purohit retired in 2017.
Prof. BP Sahu succeeded as HOD in 2017. It is during his tenure that epilepsy surgery under Dr. M Vijaya Saradhi attained new horizons when NIMS became the first government institute to perform stereoelectroencephalography (SEEG) in south India.
Dr. M Vijaya Saradhi currently heads the department and the department carries out all types of neurosurgical procedures and trains six MCh students per year. Continuing its true legacy of more than 35 years of growth, acquisition, and collaboration, the Department of Neurosurgery at NIMS continues to be a quintessential healthcare provider in neurosurgery [Table 1].
Many international faculty members have visited NIMS from time to time. Dr. Peacock, Dr. Gaab, Dr. Murali Guthikonda, Dr. James Ausman, Dr. Axel Perneczky, Dr. Maxmillan Mehdorn, and Dr. Jogi Pattisapu visited and interacted with the faculty and residents and spent time in the department [Figure 13]b.
The Department of Neurosurgery at NIMS offers a range of neurosurgical specialty services, each backed by strong teaching and research programs.
General microneurosurgery was initiated soon after the neurosurgery department was started at NIMS. Dr. KVR Sastry, Dr. MRC Naidu, Dr. BCM Prasad, and Dr. Naik were all instrumental in developing microneurosurgery at NIMS. The consultants right from the initial days of their appointment showed a trend toward subspecialization.
Clipping of intracranial aneurysms was initiated by Dr. MRC Naidu. Those days, NIMS was the only center in the then united Andhra Pradesh where clipping of aneurysms was being done. Later, the program was extended beyond clipping and AVM excision to the surgeries for revascularization. Dr. Manas Panigrahi started the bypass procedures, and both low flow and high flow bypasses were done at regular intervals. Soon revascularization procedures became a routine affair because of the high load of referrals from eminent stroke specialists from the neurology department, like Prof. Subash Kaul. The legacy continues and the department carries out all types of vascular surgeries, conducted through the hands of the subsequent skillful surgeons. Currently, the department carries out more than 150 neurovascular procedures per annum.
Skull base and craniovertebral junction surgery
Skull base procedures have always been done from the inception of the department. Upon completion of his skull base fellowship, Dr. Manas Panigrahi implemented and improvised many of these techniques, which were subsequently published. Dr. BP Sahu and Dr. Panigrahi contributed significantly in teaching skull base surgeries to the younger generation.
Surgery for craniovertebral (CV) junction has well evolved over time at NIMS. Dr. BCM Prasad's efforts in developing this subspecialty were well noted. In 1997, CV junction and spine live surgery was organized by Dr. Sinha and Dr. Dilnawaz. Dr. Vijaya Saradhi and Dr. Praveen have strived hard to keep the department up to date with the current surgical trends in the field of CV junction. The annual conference of Skull Base Surgery Society of India was held in 2009 with Dr. Manas Panigrahi as the organizing secretary. Dr. Ohata visited the department then and also a cadaveric workshop was held that provided training in fronto-temporo-orbito-zygomatic craniotomy and transpetrosal approaches [Figure 18].
Again NIMS was the first to start stereotactic surgery in the state. It was started during the tenure of Prof. AK Reddy as HOD. Dr. TVRK Murthy was entrusted with the responsibility of developing the field. Later, he resigned from NIMS and the responsibility was on the shoulders of Dr. Manas Panigrahi. Stereotactic biopsy soon became a day-care procedure in the department, and also stereotactic aspirations of intracerebral hematomas were done. The department had a Leksell frame to start with and then subsequently shifted to the CRW frame, with the expanding indications for functional procedures such as DBS. The national stereotaxy and functional annual conference was conducted by NIMS with Dr. Manas Panigrahi as the organizing secretary in 2006 [Figure 19].
NIMS truly offers the entire spectrum of services in functional neurosurgery and has its presence nationally and internationally.
Dr. AK Reddy and Dr. Mohandas, the then HOD of neurology, had first conceived the idea of developing an integrated epilepsy program. Prof. AK Reddy did the first case to start off the program. The duo, Dr. Manas Panigrahi and the noted epileptologist, Dr. Sita Jayalakshmi, made the program a huge success. Diagnostic tests for medically and surgically treated patients with epilepsy at NIMS include electroencephalography, functional MRI, neuropsychological studies, and the intracarotid amobarbital procedure. The implantation of vagal nerve stimulators was also performed for certain refractory cases. Eminent surgeons and epileptologists from the Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST) and Amrita Institute played a key role in the development and continuation of the epilepsy surgery program. The epilepsy program is carried forward by Dr. Suchanda and Dr. Vijaya Saradhi. The department had always stayed up to date with current standards of epilepsy surgery, as evident by the performance of stereoelectroencephalography (SEEG) by Dr. Vijaya Saradhi and thalamic DBS by Dr. Rajesh. The program is successfully being carried on and two successful epilepsy live workshops were conducted by Dr. Suchanda and Dr. Jabeen. Many continuing medical education programmes (CMEs) are being conducted from time to time by the epilepsy team.
Movement disorder surgery
Dr. Manas Panigrahi has been responsible for initiating the surgical treatment of movement disorders using DBS. This was possible by the painstaking effort of Prof. Rupam Borgohain, a national movement disorder specialist, who is currently heading the neurology department of NIMS. The Parkinson's Surgery Program at NIMS was the first-of-its-kind service when it started. The department has done close to 500 procedures of DBS for various indications. Subsequently, Dr. Praveen and Dr. Aneel all contributed to the growth of this subspecialty, and this service is currently being continued by Dr. Rajesh and Dr. Bhavani Prasad with approximately two DBS procedures being performed per week.
Prof. A. K. Purohit has been a pioneer in this field. He is well known nationwide for his spasticity work. There has been a robust cerebral palsy surgery program being conducted in the Department of Neurosurgery at NIMS. The development of spasticity surgery in the department has a very interesting background, as narrated by Prof. AK Purohit.
In November 1988, Dr.WJ Peacock, the pioneer of the procedure of selective dorsal rhizotomy (SDR) surgery, and the physiotherapist, Ms. Loretta, were sponsored by the grandfather of a child with cerebral palsy, after being inspired by a news article. Dr. Peacock had expressed his desire to conduct a workshop on rhizotomy. Dr. Kakarla Subbarao, the Director, and Dr. I. Dinakar, the HOD of neurosurgery, gave permission for conduction of the surgical workshop. Around 50 children were clinically screened and two children were operated upon, including the one from the sponsored family. Around 10 neurosurgeons and orthopedic surgeons participated in the workshop. The team conducting the workshop consisted of the following doctors: Neurosurgeons (Dr. AK Purohit, Dr. MRC Naidu, Dr. Ranganath), neurologists (Dr. Mohan Das, Dr. AK Singh) anesthesists (Dr. Manimalarao, Dr. Bhanumurthy), and physiotherapists (Mr. Alexander, Mr. Dilip Badukar, Mrs. Roopa, and Mr. Kishore). Later, a special educator, Mr. KD Mallikarjun (1992), and a neurotechnician, Mrs. K. Lakshmana Mani (1996), joined the team.
A year later (1989), Dr. WJ Peacock (with his wife Mrs. Ann) revisited NIMS. Their trip was sponsored by two families whose children were operated during the visit. Nine children who were operated during the past one year by NIMS neurosurgeons were reviewed by him. He derived great satisfaction in observing the results of surgery in these children [Figure 20].
Neurosurgery department of NIMS, a year later, organized a National CME on cerebral palsy (organizing secretary Dr. MRC. Naidu) and educated the professionals.
Dr. AK Purohit has dedicated his life for the cause of cerebral palsy. He established the Indian Family of Cerebral Palsy (in 1993) and the Indian Academy of Cerebral Palsy (IACP; 2004). He organized the first annual conference of IACP (in 2006) in Hyderabad [Figure 21]. He started editorial work and published newsletters on cerebral palsy. He conducted camps all over the country. He has developed selective motor fasciculotomy and presented newer methods of performing selective posterior rhizotomy. His work won many accolades nationally and internationally. He is a great orator and created awareness regarding spasticity surgeries. Prof. AK Purohit again conducted the annual conference in 2014 [Figure 22] and [Figure 23].
The lack of a pediatric department in NIMS has been the Achilles heel in the establishment of the subspecialty of pediatric neurosurgery. Despite the deficiencies, routine pediatric surgeries were performed with the cooperation of anesthetists.
Dr. Suchanda Bhattacharjee, after completing her short fellowship in pediatric neurosurgery and specialized pediatric neurosurgery courses, struggled to establish the pediatric neurosurgical subspecialty. She tried to outsource the services from the Government Paediatric (Niloufer) Hospital but her efforts could not materialize. However, excepting the very young infants and neonates, other cases are being taken care of in the department, and currently a long series of such cases has been developed. Craniofacial reconstructive surgeries are also being done in collaboration with the plastic surgery department. Dr. Suchanda organized an annual conference of Indian Society for Pediatric Neurosurgery in the year 2010 [Figure 24]. Also, for the first time in India, a neuronurses program in pediatric neurosurgery was held, which was attended by more than 300 nurses [Figure 25].
Trauma as a specialty was developed with contributions from all consultants who worked at NIMS. After starting off a new trauma block in the year 2012, the numbers of trauma cases have significantly increased.
The first conference of the Neurotrauma Society of India was organized by Dr. I. Dinakar and Dr. VSSV Prasad on 15th August 1992 under the banner of NIMS.
Minimally invasive and endoscopic neurosurgery
Along the same time as it was developing in other institutes, minimally invasive surgery also found its footing in this institution. In the early part of last decade, during the tenure of Prof. AK Reddy, the then head of neurosurgery, minimally invasive and endoscopic neurosurgery started at NIMS. Dr. Gaab, a neurosurgeon from Germany, who was one of the pioneers in neuroendoscopy, visited the institute and soon this center became a popular center for endoscopy in this part of the country. Gradually, the indications expanded from the basic endoscopic third ventriculostomy and ventricular tumor biopsy to endoscopic spine surgery and endoscopic skull base surgery. Dr. Ajay Sinha was very active in performing and teaching endoscopy. Dr. Manas and Dr. Vijay Saradhi did a skull base endoscopic cadaveric workshop in the department as early as in 2001, which was well attended by many neurosurgeons.
Spine surgery has been a strong forte of the Department of Neurosurgery since its inception. Animal experiments and research by Prof. Raja Reddy has paved the way for understanding the pathophysiology and treatment of OPLL. Prof. VSSV Prasad made a significant contribution in establishing spinal surgery and instrumentation procedures in the initial days in NIMS. During 2006–2009, the department conducted a Spine Fellowship program.
Newer and modified spine techniques were continuously developed like development of single-hole plates for cervical fixation, the description of Z technique of fusion for Hangman's fracture (Dr. Vijaya Saradhi), and the development of minimally invasive spine fixation using noncannulated screws (Dr. Rajesh). All types of instrumentation from the CV junction to the sacrum are being carried out. Surgery for spinal tumors, spinal trauma, and infections are a routine. This has been one of the few centers in India, which had electronic beds (by Stryker) for spinal injury patients right from the 1980s. However, these beds have never been replaced, and presently, only one functioning Stryker bed More Details remains in the department [Figure 26]. The department maintains a spinal cord semi-intensive care unit right from the earlier days, which is still existent. The first spinal instrumentation national workshop was held in NIMS by Dr. Ajay Sinha, way back in 1998 [Figure 27].
The Department of Neurosurgery at Nizam's offers a range of neuro-oncological services. Every consultant does have a role in conducting neuro-oncology work. Dr. Dilnawaz was very active in neuro-oncology work and had a constant presence in all major neurooncological conferences in the country. All complex lesions are handled here and there are quite a few publications focusing on neuro-oncology from the department. In the cases of primary and metastatic brain and spinal tumors, the in-house medical and radiation oncology department shares the responsibility of providing comprehensive tumor management. Motor cortex and subcortical mapping and language mapping under general or local anesthesia are routinely used for tumors in eloquent locations. Significant research into the pathophysiological and molecular basis of tumorigenesis has been carried in collaboration with the Centre for Cellular and Molecular Biology and Hyderabad Central University.
Neurosurgery at NIMS involves a wide range of patients and resources, with an average daily inpatient census for the neurosurgery service of approximately100 patients. Embracing the advances in neurosurgery, the number of operations at NIMS has doubled and the lengths of hospital stays have been halved. Approximately 2000–2500 operations are being performed every year. Approximately 20,000 patients are treated each year in the outpatient clinics, besides the emergency in-patient and outpatient services being offered. Publications from the department also continue besides the clinical services, and NIMS stands at sixth position in terms of publications amidst government institutions and hospitals, as published in the article by Pandey P et al., in Neurology India in 2016 (Pandey P, Subeikshanan V, Madhugiri VS. Highest cited papers published in Neurology India: An analysis for the years 1993–2014. Neurol India 2016;64:703-21). The Department of Neurosurgery at NIMS currently has four dedicated operating rooms besides one dedicated trauma theater [Figure 28] and [Figure 29].
The Department of Neurosurgery at NIMS has a strong commitment to basic scientific research.
Research at the center focuses on translational research, initiated by Dr. AK Purohit, in collaboration with prestigious institutes like Centre for Cellular Microbiology (CCMB). Dr. Manas Panigrahi initiated research with central institutes like the University of Hyderabad in the field of gliomas, and with Hyderabad Central University in stroke. Outcome studies are currently the subject of research, focusing upon almost every disease or condition where neurosurgical care is being provided. Residents are encouraged to participate in these areas of research.
Our sincere acknowledgement to Prof. S Balaparameswara Rao, Prof. Raja Reddy, Prof. I Dinakar, and Prof. AK Reddy for providing us with information and photographs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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