Neurosurgery at Kasturba Medical College: Past, present and future
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/neuroindia.NI_564_17
Source of Support: None, Conflict of Interest: None
Kasturba Medical College (KMC), Manipal, is the oldest and one of the most reputed medical institutes in coastal Karnataka, catering to a population of over 4 million, spanning a stretch of over 350 kms along the southwest coast of India from Mangalore to Goa. The Department of Neurosurgery at KMC, established in 1968, continues to be the leading and most preferred referral center providing high quality neurosurgical services in this region. The article provides an insight into the origin of the department, its infancy and teething troubles, its continuous growth and landmark achievements over the years. This brief review also highlights the current area of focus and describes the plans for its future development.
Keywords: Achievements, department, Kasturba Medical College, Manipal, neurosurgery
Manipal is a suburb within the city of Udupi in Karnataka, India. Located on a hillock in coastal Karnataka, about 63 km north of Mangalore and 8 km east of the Arabian Sea, it commands a panoramic view of the Arabian Sea to the west and the Western Ghats to the east. Derived from the local Tulu words “Mannupalla” ("mannu” means mud and “palla” means stream), the city was earlier known for its tile factories until the visionary Pai family transformed it into one of the most cosmopolitan towns of India. Home to the Manipal University, the first and foremost private university in India, the town now attracts over twenty five thousand students every year from over 60 countries.
The starting of Kasturba Medical College at Manipal in Karnataka state in India, marked the beginning of a new chapter in the development of medical education in this country. It was the thirty-third medical college to be started in India. The College owes its existence to the vision, perseverance and dynamism of Dr. T. Madhava Anantha Pai. Seeing the paucity of medical education facilities then available in India, Dr. Pai felt that the government alone cannot be depended upon to provide adequate educational facilities and, therefore, thought of a novel scheme wherein the cost of medical education would be borne partly by the students themselves. There were many sceptics and critics when this idea was first mooted by Dr. Pai in 1951 under the auspices of the Academy of General Education, a registered educational society. It took him two years to convince people and finally, the college saw the light of the day on 30th June 1953. The college started with the pre-clinical section at Manipal and the students had to go to Mangalore for their clinical training, and, thus, it was necessary to think of building a teaching hospital at Manipal [Figure 1]. An opportune moment for a general hospital at Manipal offered itself in 1960, when another philanthropic body, the Medical Relief Society of South Kanara, offered to join hands with the college in establishing a large hospital at Manipal, A beginning was made in May 1961 with the inauguration of the 150-bedded, Kasturba General Hospital in a newly constructed, two storied building. With the clinical program commencing at Manipal in 1969 and the setting up of a full-fledged Kasturba Hospital, it became an independent medical college. Over the years, the college hospital has grown into a 2032-bedded, super-specialty hospital, and the Kasturba medical College has evolved as one of the most prestigious medical colleges in India ranked consistently in the top five medical colleges of India for the last few years [Figure 1]. Today, students from 44 countries have graduated from KMC, and the medical degree (MBBS) is recognized worldwide. KMC, was earlier under the purview of the Mangalore University until 1993, when the government of India granted the ‘Deemed University’ status to Manipal University.
The founding years and the gestational period
Neurosciences at Manipal saw its origin in 1968 as a combined Neurology and Neurosurgery service center under Prof. Devadiga. Prof. Devadiga, was trained in Neurosurgery from Christian Medical College, Vellore and had been to UK and USA for further training. Neurosciences was at its infancy in India and more so in this part of world. Prof. Devadiga remembers that such was the apprehension and phobia among the general public and the doctors themselves that neurosurgical procedures were considered as another means of population control. Nevertheless, he single-handedly laid the foundation for what was later to become one of the leading neurosurgical centers in South India [Figure 2].
The initial investment for instruments - the cost of craniotomy set, laminectomy set, burr-hole set and other diagnostic set - was less than Rs. 10,000. However, the growth of the department was very rapid. The Department of Neurosciences was way ahead in terms of infrastructure thanks to the generosity, guidance and encouragement of late Dr. T.M.A. Pai. The X-ray unit with an image intensifier was available in 1970. The electroencephalogram was procured in 1971, the ultrasound machine in 1972, the bipolar coagulator in 1972, the Leksell's stereotactic apparatus in 1973, the Picker colour magna scanner in 1975, and the serial cassette changer in 1976 [Figure 3]. The use of magnification during surgery was a routine practice from 1972, and the credit of being the first surgeon to have successfully clipped a cerebral aneurysm, in this part of the country also belongs to Prof. Devadiga. He clipped a posterior communicating artery aneurysm, diagnosed utilizing a direct carotid puncture angiogram also done by him. Prof. Devadiga's personal motto was to ensure optimal utilization of the existing resources to render effective treatment to a large number of needy patients in a resource challenged environment. By the time he left Manipal and relocated to Mangalore in 1977, the seeds for the development of a premier neurosurgical department were already sown.
After the exit of Prof. Devadiga in early 1977, the department was left without a trained neurosurgeon for 6 months. It was by providence that in mid-1977, Dr. Subramanian took over the baton as head of the department. He was trained in microneurosurgery and had special interest in pituitary disorders and surgery for degenerative spinal diseases. He was an immaculate surgeon and is credited with performing the first transphenoidal pituitary surgery in the country. He set the stage for a microneurosurgical revolution and optimized the conduct of neurosurgical procedures to world-class standards. In June 1979, Dr. Raja joined the department as a lecturer under Dr. Subramanian. Dr. Subramanian retired in April 1981, leaving the reigns of a budding department in the able hands of Dr. Raja.
The “Raja” era
Neurosurgery at KMC, Manipal is synonymous with Prof. Raja and the present reputation of the department is a direct reflection of his singular and devoted contribution. Even though he did not start the Department of Neurosurgery, he should be aptly called the Father of Neurosurgery at KMC, Manipal.
Born on the new year's day in 1951, Prof. Raja had his medical schooling from the prestigious Madras Medical College. His MBBS batch had another illustrious neurosurgeon – Prof. Laligam Shekhar. Soon after his medical schooling, he joined Prof. B Ramamurthi and then completed his MS in Neurosurgery from the prestigious Institute of Neurology, Madras under the guidance and mentorship of Prof. B Ramamurthi. It was Prof. Balasubramanium, the eminent neurosurgeon from Chennai, who after a brief visit to KMC, Manipal, persuaded Dr. Raja to join and develop Neurosurgery at Manipal. Dr. Raja virtually built the department brick-by-brick. Though the work was started with the instruments left behind by Dr. Devadiga, more facilities were sought for and obtained. Dr. Raja soon found an able companion in November 1981, when Dr. S.N. Rao, having completed his formal training at Banaras Hindu University, Varanasi, joined as the Neurophysician and Head of Neurology. Together, they worked as a team, as a single unit, with combined ward rounds since there were no qualified assistants for either of the departments. Dr. Sampath, who had just completed his general surgery training, joined the department and used to be the sole assistant to both Dr. Raja and Dr. Rao for a long period of time. The department was named as the department of “Neurological Sciences” since the vision was to develop highly specialized well-equipped units of Neuromedicine and Neurosurgery with allied specialties, all under one roof. With the joining of Dr. Sudhir S. Pai, Dr. Ramachandran, Dr. Mukul Chand, and Dr. Divaker Rao on the Neurosurgical side and Dr. Ravisubramanya in Neurology, from the latter half of 1987, the department started functioning as two separate units. Though the units were divided into Neurosurgery and Neurology, the ward and outpatient departments were run in the same area, so that referral of cases, exchange of ideas regarding problematic cases and post-graduate teaching became easier and better. This arrangement was aimed at providing the best medical care possible without delay and laborious referral procedures. The guiding light was provided by Prof. B Ramamurthi, his teacher and mentor, who visited the department to inaugurate the microscope in 1986 [Figure 4]. Along with the operating microscope, the installation of a new computed tomographic [CT] scanner within the hospital premises in 1986, remarkably transformed the outcome of neurosurgical procedures and Neurosurgery soon became a sought after specialty [Figure 5].
Prof. Raja's contributions to Neurosurgery at KMC are profound and unparalleled. A tireless workhorse and a tough taskmaster is how he is always remembered. He led by example and believed firmly in the establishment of the highest standards of care. His interest and expertise in cerebrovascular surgery helped to transform KMC into a specialist cerebrovascular centre. His personal series of more than 1000 intracranial aneurysms has been surpassed by few in India. Besides aneurysms and arteriovenous malformations, his “forte” in Neurosurgery included cerebellopontine angle tumours. His command over surgery for cerebellopontine angle tumours, often known as the gloomy corner of Neurosurgery, is unsurpassed. He was also instrumental in starting endoscopic surgery in the department. The existing management protocols, case record maintenance, intensive care unit and operation theatre protocols are all Prof.'s Rajas contributions to KMC, Manipal. By the time Prof Raja superannuated in 2010, the department was already well established as one of the premier neurosurgical centers in India.
Dr. Raja's assistants and colleagues
In his initial period, Dr. Raja was ably supported by Dr. Sudhir S. Pai, Dr. Ramachandran, Dr. Mukul Chand, and Dr. Divaker Rao. Increasing clinical work, required additional manpower and the joining of Dr. K.M. Jha in early 1991 and Dr. R. P Haran in November, 1991, facilitated and enhanced the turnover of cases. In the subsequent decade, the workload kept steadily increasing. In his gradual and steady stride towards the future, Dr. Raja was, from time to time, lent admirable support by a constant team of junior neurosurgeons, all of whom are established stalwarts, now practicing in varying parts of the country [Table 1]. Notable among them are Dr. Ganesh, Dr. Muralidhar Pai, Dr. Shenoy and Dr. Jaspreet. [Table 1] shows the entire list of faculty who have served KMC, Manipal. Today the department performs over 1000 neurosurgical procedures every year which includes all varieties of complex neurosurgical procedures. [Table 2] shows the list of surgical procedures performed in 2016-17.
Post ‘Raja’ era
Prof Arjun Shetty became the head of the department in 2011 and maintained the pace of steady growth in the department. His focus was on spinal surgery and his tenure saw the department achieve considerable fame in the newer techniques of spinal instrumentation. In 2014, Prof. Girish Menon took over the leadership of the department with a keen intent to modernize the department with stress on academics and research.,,,,
Infrastructure and working pattern
Neurosurgical operations in the mid-eighties were performed twice a week in an operation theatre shared on 4 other days with Cardiac Surgery. As the work load increased, a dedicated Neurosurgery operation theatre was commissioned in 1990, and Neurosurgery was given one dedicated operating room six days a week. Thanks to the helpful attitude and good will shown by Dr. Ramdas M. Pai., the Medical Director, shortage of instruments and equipment's was never a constraint. The first operating microscope was inaugurated by none other than Prof. B Ramamurthi in the year 1986. Soon a second microscope was added. KMC was one of the first departments in the country to practice stereotactic surgery, and the facility has been available since then. The department was privileged to acquire most of the required instruments and equipments to enable Dr. Raja and team to provide state-of-the-art comprehensive neurosurgical care to the local population. Currently, the operation theatre is well-equipped with almost all the major equipment like a C-arm image intensifier, an ultrasonic suction aspirator, microdrills, nerve monitoring units and neuroendoscopes.
Intensive care units and ward
The neurointensive care unit was initially started with five beds, and was later expanded into a well-equipped modern unit with 7 sophisticated ventilators and all monitoring facilities. What was started as a 6-bedded cubicle in a part of a General Surgery ward, has blossomed into a separate ward with a bed strength of around 70, inclusive of intensive care beds. This new Dhanwanthri block, as the Department of Neurosciences is now called, was inaugurated in 1992. Currently, the block has nearly 100 beds, including twenty intensive care unit beds.
The department has been very active on the academic front. Bedside clinics, journal clubs, seminars and conferences are organized from time to time to upgrade the academic knowledge of staff members. Inter-departmental scientific meetings are regularly being held. The department is actively involved in academic activities and regularly publishes articles in indexed journals.,,,,,, The cumulative h index of the faculty is 12.
It was a dream come true for Prof. Raja when the first resident, Dr. Ramakrishna., joined the MCh Neurosurgery program in 1993. Till date, 32 neurosurgical residents have been trained in the department. The degree has been recognized by the Medical Council of India and the department admits two MCh students for training every year. [Table 3] shows the list of all the postgraduates who have completed neurosurgery training from KMC, Manipal.
Major conferences hosted
The department hosted the annual meeting of the Neurological Society of India in 1991 and the Annual Conference of Indian Society of Cerebrovascular Society Meeting in 2009 [Figure 6].
The Department of Neurology came into existence on 6th November 1981 when Dr. S N Rao was appointed as Reader and Head of the Department of Neurology. The department started functioning with 4 beds and a combined intensive care unit facility along with Neurosurgery. With a futuristic view of developing the Neurosciences as a whole, Dr. Raja and Dr. S N Rao decided to have the two departments existing together under the ambit of Department of Neurological Sciences. Both the departments had a common general ward, intensive care unit and outpatient facility. With a great deal of understanding, tolerance and adjustment, both the departments have functioned in a healthy relationship with each other. This has helped in the growth of the department and in patient care. Soon after, the electroencephalogram and the electronystagmogram machines were added to the department [Figure 7]. Junior staff and residents were on rotation as a part of the MD General Medicine teaching programme. In 1992, the DM programme was started with an intake of 2 candidates per year. By now, 34 post graduates had successfully passed out of the department.
Prof. SN Rao is to the Department of Neurology what Prof. Raja is to the Department of Neurosurgery. He virtually built the department single handedly. For over three decades, he singularly oversaw the entire procedure of admission, patient management and teaching schedule for residents. His clinical acumen and excellent diagnostic capabilities still remain unmatched. When Prof. S N Rao superannuated on the 10th of December 2013, Prof. Radhakrishnan took over the reins of the department. An internationally reputed epileptologist and former Director of the prestigious Sree Chitra Tirunal Institute for Medical Sciences and Technology, Prof K Radhakrishnan established a comprehensive epilepsy care program at KMC, and to date, the centre has performed numerous surgeries for epilepsy [Figure 8]. Prof K Radhakrishnan was succeeded by Brig Prof. SP Gorthy, who has special interest in movement disorders and stroke. Acute thrombolysis for stroke was initiated for the first time during his tenure and his vision includes setting up a movement disorder surgery program, an autonomic nervous system laboratory and a state-of-the-art stroke program.
Neurosurgical Anaesthesia at Manipal (1985-2017)
A team of 4 to 5 anaesthesiologists with special interest in neuroanaesthesia routinely provided anesthesia for neurosurgical operations. The team was led by the renowned anesthesiologist Dr. Phanendranath Thota. Other members in the team included Dr. Atma Prasanna, Dr. Ramkumar Venkateswaran and Dr. Manikant Lodaya and they jointly provided excellent anesthesia facilities and good operating conditions [Figure 9].
The new operating theatre complex, which was opened in 1990, was blessed with better equipment not only on the surgical but also on the anaesthesia side. Just as better instrumentation and the operating microscope made Neurosurgery more precise, better monitoring facilities and newer anaesthetic agents contributed to the safety of Neuroanaesthesia. Intracranial aneurysms, arteriovenous malformations and meningiomas, to mention some of the more challenging neurosurgical procedures, were earlier operated with only electrocardiographic monitoring, a precordial Doppler recording (to detect venous air embolism), haemodynamic monitoring (in the form of direct arterial pressure with the use of an anaeroid manometer) and central venous pressure (using a “U” tube taped alongside a measuring scale). Though reasonably accurate, these monitors were totally inadequate for the intensive nature of the recording desired for neurosurgical procedures being attempted. Post 1990s, the patient monitoring systems advanced significantly as the new operating rooms were brought at par with international standards current at that time. In addition to making surgery more safe, these advanced monitors also strengthened the anaesthesiologists' hands, enabling them to become more adventurous yet safe, in their anaesthetic approach. The neuroanaesthesia team at Kasturba Medical College and Hospital has kept pace with the recent developments and procedures like awake craniotomy and brain mapping, and comprehensive electrophysiological monitoring is now routinely performed.
If there is one field of medicine that has made quantum leaps in the last century, it has been Radiology, and the specialty to have benefited from these advancements the most is neurosciences. Except for plain radiographic imaging, Dr. Raja used to carry out himself, all invasive investigations like the angiogram, pneumoencephalogram and myelogram. A CT scanner, the first in this part of India, arrived in the year 1986, and was inaugurated by the then President of India, Giani Zail Singh. The arrival of the CT scanner translated into a significant improvement in neurosurgical outcome. The MRI scanner followed in 1997, and the preoperative work up and planning became more precise. Dr. Uday Patil, under the valuable guidance of Prof. Ghosh, provided tremendous support to both the neurologists and neurosurgeons. Prof. VRK Rao, a pioneer of neurointerventional procedures in India, bolstered the neurointervention department and a dedicated neuro- catheterization lab was inaugurated by Dr. Santosh Joseph. Currently, the institute has two CT scanners, two MRI units and is in the process of acquiring a new positron emission tomography scanner too.
Behind any successful surgical team, there will be a group of dedicated and highly competent theatre, intensive care and ward sisters. KMC, Manipal too was lucky in having a continuous chain of efficient theatre sisters. The departmental work until 1976, in the absence of qualified assistants, was supported by three outstanding dedicated and talented individuals namely, Staff nurse Kasturi in the ward, Staff nurse Winnifred in the Operation theatre and Miss Olivia Rebello as scientific assistant in the diagnostic area. Thereafter, the contributions of operation theatre in-charge sisters, Sr. Alice, Sr. Bharathy Shetty, Sr Bharathi Anchal, Sr. Leela and Sr. Geetha, have been noteworthy and commendable. Similarly, in the ward, Mrs Gulabi, Mrs. Bhaumathy, Mrs Shakunthala have played a significant role in ensuring that optimal care is provided to all the patients.
Dr. Raja was quick to realize that for the efficient and smooth functioning of the department, trained paramedical staff need to be available round-the-clock. It was with this vision that he started a neuro-technician's course rather early in 1983. He selected a few young candidates and offered them a two-year diploma course in neuro-technology. These students would assist in the maintenance of all neuro-equipment including microscopes, drills, electroencephalography machines, etc. Most of the earlier batch students were later absorbed by the institute. Mr. Balakrishna Samanth, one of the first batch students, continues to render his service to date and is an invaluable asset to the department. Thanks to this visionary idea of Prof. Raja, there has never been a dearth of manpower in the neurosurgery operation theatre.
Current scenario and vision for the future
KMC hospital is nearly a 1200-bedded hospital and has two functioning CT scanners, two magnetic resonance imaging (MRI) machines and two catheterization laboratories, one of which is with a dedicated neurointervention facility. A well-knit subspecialty-oriented neurosurgical practice has been the hallmark of our Neurosurgery Department. The core subspecialties that are well established include neurovascular surgery, neuro-oncology, pediatric neurosurgery, skull base surgery and spinal surgery. The department currently has 5 faculty members and 6 residents. The Centre for Comprehensive Care in Epilepsy was started in 2015 and the first surgery for epilepsy was performed on 28th August 2015 by Dr. Girish Menon. A new foray into uncharted territory was made when the first minimally invasive spinal surgery was done on 16th September 2016.
The department is all set to embark onto a sub-specialty oriented development program to keep pace with the emerging times. Comprehensive programs for stroke and movement disorders will be launched in the near future. A new super-specialty block with gamma knife surgery facility and a hybrid operation theatre is likely to begin by 2020. On the academic front, a direct post MBBS Neurosurgery program and post-doctoral fellowship courses in subspecialties is near finalization
We wish to place on record our heartfelt gratitude to Prof. Raja (Former Head, Neurosurgery, KMC, Manipal), Prof Devadiga (Former Head, Neurosurgery, KMC, Manipal), Prof. S N Rao (Former Head, Neurology, KMC, Manipal), Prof. Sampath (Prof of Surgery, KMC, Manipal), Prof. Ramkumar V (Former Head, Anesthesiology) and Prof. Krishna Rao (former Dean, KMC, Manipal) for their valuable contribution in recollecting and sharing old memories and editing the draft. We also wish to acknowledge the contribution of retired senior neuro-nurses Sr. Kasturi, Sr. Bharathy Shetty, Sr Bharathi Anchal, Sr. Geetha (present chief operation theatre nurse), Mr. Balakrishna Samantha (chief neuro-operation theatre technician). Sr. Kasturi, who had served the department under Prof. Devadiga spent considerable time with the Medical Imaging and Archiving Department, KMC, Manipal to retrieve old photographs for this article. The secretarial assistance of Mrs Shubhavathi, who has been attached to the department for over 20 years, needs special mention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2], [Table 3]