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  In this Article
 »  Abstract
 »  Dr. K S Sanjivi ...
 »  The Dr. A Lakshm...
 » Early Days
 » Microsurgery Era
 » Departmental Growth
 » Neuro-Anesthesia
 » Skull Base Surgery
 »  Vascular Neurosu...
 »  Collaborations W...
 »  The National Boa...
 »  The Vijaylakshmi...
 »  Text Books of Ne...
 »  Annual Microneur...
 »  Records Maintena...
 »  The Prof B Ramam...
 » Conclusion
 »  References
 »  Article Figures
 »  Article Tables

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Table of Contents    
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 516-529

Forty years of clinical excellence at the Dr A Lakshmipathi Neurosurgical Centre and Post-Graduate Institute of Neurological Surgery, Voluntary Health Services (VHS) Hospital

1 Department of Neurosurgery, Institute of Neurosciences and Spinal Disorders, MGM Healthcare, Chennai, Tamil Nadu, India
2 Department of Neurosurgery, Post-Graduate Institute of Neurological Surgery, Dr A Lakshmipathi Neurosurgical Centre, VHS Hospital, Chennai, Tamil Nadu, India
3 Department of Neurosurgery, Institute of Neurosciences, Apollo Hospitals, Chennai, Tamil Nadu, India
4 Department of Neurosurgery, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. K Sridhar
2/154, MGR Street, Eden Garden Uthandi, ECR Chennai - 600 119, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.257984

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 » Abstract 

The Achanta Lakshmipathi Neurosurgical Center (ALNC) and Post Graduate Institute of Neurological Surgery is a private teaching neurosurgical institution located in the VHS (Voluntary Health Services) Hospital Chennai. It has been a leader and trendsetter among the private academic neurosurgical training institutions, and because of its unique legacy, has influenced the progress of Neurosurgery in India. The center was the second neurosurgical Institute to be created by Prof. B Ramamurthi and has trained neurosurgeons in the unique ALNC school of Neurosurgery. The Institute has grown to become a centre of excellence in microsurgery, and spinal surgery and has become a training centre for neurosurgery since 1985. The unique humanitarian aspects of the Voluntary Health Services Hospital helped in bringing the best of Neurosurgery to all strata of society. Forty years after its inception, the ALNC continues its delivery of excellence in clinical neurosurgery and academics.

Keywords: B Ramamurthi, DNB residency, micro neurosurgery workshops, microsurgery, spinal surgery, Textbook of Neurosurgery
Key Message: The Achanta Lakshmipathi Neurosurgical Center (ALNC) and Post Graduate Institute of Neurological Surgery, a private teaching neurosurgical institution located in the VHS (Voluntary Health Services) Hospital, Chennai, is known not only for being an eminent institution of learning and training in neurosciences in South India and the second neurosurgical center to be established by Prof. Ramamurthi, but also for bringing out Textbooks of Neurosurgery that have been extremely popular among students all over the country. This article focuses on the history of this eminent institution.

How to cite this article:
Sridhar K, Vasudevan M C, Krishnan SS, Pande A, Jain PK. Forty years of clinical excellence at the Dr A Lakshmipathi Neurosurgical Centre and Post-Graduate Institute of Neurological Surgery, Voluntary Health Services (VHS) Hospital. Neurol India 2019;67:516-29

How to cite this URL:
Sridhar K, Vasudevan M C, Krishnan SS, Pande A, Jain PK. Forty years of clinical excellence at the Dr A Lakshmipathi Neurosurgical Centre and Post-Graduate Institute of Neurological Surgery, Voluntary Health Services (VHS) Hospital. Neurol India [serial online] 2019 [cited 2022 Aug 17];67:516-29. Available from: https://www.neurologyindia.com/text.asp?2019/67/2/516/257984

Dr. B Ramamurthi retired from government service, as Director of the Institute of Neurology, Government General Hospital, and Principal, Madras Medical College on 30th January 1978. Having completed that phase of his career in government service, he embarked on the next one, where he established a second center of neurosurgery, the ALNC, which grew with time to become a well-recognized clinical and academic center for neurosurgery in the country. The department is recognized for microneurosurgery and spine surgery. The department was also instrumental in producing successive editions of 'Textbooks of Neurosurgery'. The ALNC celebrated its silver jubilee with stalwarts in neurosurgery from all over the country gracing the occasion. Dr. BRM passed away in 2003 but his legacy stayed on with the department continuing its journey of excellence.

 » Dr. K S Sanjivi and the Voluntary Health Services, Madras Top

Dr. K S Sanjivi (1903-1994) was a medical doctor and Gandhian, who was awarded the Padma Shri in 1971 and Padma Bhushan in 1976. He served as the Professor of Medicine at the Madras Medical College and the Stanley Medical College as well as the first physician of the Government General Hospital, Madras. He resigned from government service when his claim to the post of Director of Medical Services was ignored, and then embarked on a journey of medical service to the poorer sections of society.

In 1958, Dr. K S Sanjivi along with other noted personalities of Madras (the current Chennai) including Drs. M A Chidambaram and Kasturi Srinivasan started a charitable trust called the 'Voluntary Health Services' to serve the economically backward sections of society. The land for the project was given from the Governor's estate. The foundation stone of the hospital building was laid by Pandit Jawaharlal Nehru in October 1961 and the hospital (initially called the Race Course Hospital) became functional in 1963 [Figure 1]. It is located on the outskirts of the erstwhile Madras, on the Old Mahabalipuram Road (now the Rajiv Gandhi Information Technology Corridor). The underlying ethos of the VHS is prevention and cure of medical illness through active community participation. It started the first private “insurance” for families in the villages and surroundings of the hospital, whereby in return for a paltry sum, all members of the family could avail medical services of the hospital.
Figure 1: Dr. K S Sanjivi and the VHS Hospital

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Dr. Sanjivi contributed to the development of primary healthcare movement in India. During his service with the Madras Medical Service, he established several mini-health centres, a model he continued with VHS. He emphasised that the entire family must be look after the patient and that the disease must be detected early. He stressed that the public must actively participate in the creation and establishment of health care facilities on the principle that doctors can only help, and that health has to be acquired and preserved by each individual based on their own capacity and will. At the VHS, doctors served without charging patients any professional fee – thus the term 'Voluntary' was coined– pertaining to contributions both on the part of the doctors as well as the community. Many pioneers like the eminent ophthalmologist Dr. Badrinath, paediatrician Dr. Viswanathan, blood transfusion expert Dr. Ranganathan, and nephrologist Dr. Mani were associated with this hospital and helped in its growth. The VHS manages 14 mini-health centres in villages and small towns serving around 100,000 people and attends to immunization, maternity care, family welfare, sanitation and hygiene, school health examination, and maintenance of birth and death records. Towards the latter part of his life, Dr. Sanjivi got involved in the autoimmune deficiency syndrome (AIDS) prevention and control activities and one year after his death, his activities were recognized by the United States Agency for International Development (USAID) by selecting VHS as a nodal agency for the implementation of the AIDS Prevention and Control (APAC) project in the state of Tamil Nadu.

 » The Dr. A Lakshmipathi Neurosurgical Centre (ALNC-VHS) Top

Dr. B Ramamurthi was desirous of continuing to operate upon and help financially backward patients after his retirement from government service. Despite his busy private practice, he felt the need to serve the society. In January 1978, he met Dr. K S Sanjivi who invited him to work at the VHS [Figure 2]. At that time, a neurosurgery out-patient service was being run by Dr. S Kalyanaraman twice a week. Working out of a small office in the Ayurvedic wing of the hospital, Dr. Ramamurthi established once again, a center for neurosurgery in the city, with the department officially starting on February 15th, 1978. It was not easy to do this, especially after having commandeered a large institution of neurosciences. Undaunted, Dr. BRM started operating in the general operating rooms of the VHS. The staff of the PL480 research scheme of the Indian Council of Medical Research (ICMR) accompanied him, and research work started, including a biofeedback program.
Figure 2: Dr. B Ramamurthi and Dr. Indira Ramamurthi with Dr. K S Sanjivi

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 » Early Days Top

The first outpatient in the department was seen in the outpatient clinic on 27th February 1978. An 18-year old gentleman presented with right focal seizures. Seen by Dr. B. Ramamurthi, a clinical diagnosis of an arterio-venous malformation was made and he was admitted as the first in-patient as well. The first surgical procedure of the department was performed on 10th March 1978 on a 31-year old gentleman, who underwent a lumbar laminectomy for L4-L5 prolapsed disc. The first craniotomy of the department was performed on the 2nd of April 1978 on a 38-year old gentleman who was admitted with complaints of focal seizures involving the left upper limb.[1] A right direct carotid angiogram was done on the day after admission, which showed a right fronto-parietal lesion with a blush suggestive of a meningioma. Dr. R Narayanan, senior neurosurgeon, assisted in the surgery and Dr. Chandrasekar was the anesthetist. Instruments were procured from the General Surgical Company, Madras (now known as GESCO).

On 21st March 1978, Dr. M C Vasudevan, who had just completed his MD General Medicine, joined the department as a research fellow in the ICMR PL480 scheme. On 24th April 1978, Dr. Vincent Thamburaj, who was a senior house officer at the Institute of Neurology (MIN), joined Dr. BRM, as did Dr. Dibbala Rao and Dr. Sambasiva Reddy, who had just completed their MCh Neurosurgery and were waiting for posting with the Andhra Pradesh Medical Services [Figure 3].
Figure 3: Starting Neurosurgery at VHS 1978. Seated left to right: Dr. Vincent Thamburaj, Dr. M C Vasudevan, Dr.B Ramamurthi, Sister Anandhi (OT in charge)

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Surgeries were performed with this team, with no sophisticated instruments nor any special monitoring systems, or proper ventilators being available. The general operation theatre (OT), intensive care unit (ICU) and surgical wards were utilized. However, meticulous records were maintained right from the very beginning, a continuation of the practice that had started at the Madras Institute of Neurology. Similarly, photographs were taken of all positive cases and their negatives preserved and tabulated. The case load increased over the years and a need was felt for a separate OT-cum-radiology block.

A generous donation from the Arogya Ashram Samiti, a trust started by Dr. Achanta Lakshmipathi (Dr. BRM's father-in-law), allowed the creation of the ALNC block which housed the neurosurgery general wards, the radiology complex as well as four operation theatres of which one was dedicated for neurosurgery. The foundation stone was laid by Dr. M G Ramachandran, Chief Minister of Tamil Nadu in 1978, and was declared open in 1981 by the then Health Minister Dr. H V Hande [Figure 4]. The possibility of operating anytime 7 days of the week and admitting patients in a single ward, helped to streamline processes and work. A privately owned computed tomographic (CT) scan center helped by doing concessional scans for poor patients. Instruments were procured with donations. A cardiac monitor, an anesthetic ventilator, an electric drill and a Zeiss microscope were procured between 1983 and 1984, all possible because of the help from patients and philanthropists. Dr. R Narayanan procured a diesel-run generator to overcome the difficulties posed by frequent power outages.[1]
Figure 4: Establishment of ALNC ward: (a) Function for laying the corner stone (b) of ALNC by Dr. M G Ramachandran, Chief Minister of Tamil Nadu, February 1978; (c and d): Dr. H V Hande, Health Minister dedicates the ALNC ward building

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X-rays, myelograms and angiograms were performed at the Radiology Department with the help of Dr. M G Varadarajan, Dr. Govindarajan and senior technician Mr. Pandurangan. There were no facilities for cine angiograms and a buckey with three plates was used. Ventriculograms, pneumoencephalograms and cisternal punctures were also performed.

Stereotactic procedures were performed using the Leksell frame and the Schaltenbrandt atlas.

In 1982, Dr. Vincent Thamburaj left the department and went to Ireland for his FRCS. Dr. R Ravi joined the department in June 1983 after completing his microsurgery training in Germany. With his joining, Dr. Ramamurthi decided to concentrate his work in the VHS and admit all patients to the ALNC.

 » Microsurgery Era Top

Until this time, surgery was performed using a headlight and loupe, with lighted hand-held retractors. The microscope was used only for some difficult situations and not as a routine practice. With the experience gained in Europe and the UK, Dr. Ravi changed the attitude in the department and thus started the microneurosurgery era.

In 1983, a Zeiss OPMI6 microscope was procured and was used more often. The turning point was when Prof. M G Yasargil visited Bombay Hospital in December 1986 and gave a series of talks. Listening to him convinced Dr. Ravi of the concept of “total microsurgery”. In 1988, Dr. Ravi underwent four weeks of training with Prof. Yasargil at his hospital and at his laboratory at Zurich, and with this, the emphasis in the department shifted to microsurgery and the utilization of the operating microscope 'from dura to dura'. 'Total microneurosurgery' meant that the operating microscope and microsurgical techniques would be used for all cases no matter how easy or difficult they were. The idea behind this endeavor was that using the microscope continuously would make the surgeon better, so that when faced with a difficult situation, the experience with the microscope would prove to be of immense value. The change made a world of difference and one can name this period “The Era of Microsurgery” [Figure 5].
Figure 5: “Microsurgery era” with the concept of “Total Microsurgery” (a) Dr. Ramamurthi and (b) Dr. Ravi with the microscope

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Dr. Ramamurthi was quick to realize the advantage of this change and quite easily got into the bus!!! There is a group photograph which hangs on the department office wall taken during the first micro-neurosurgery workshop organized by Profs. Donaghy and Yasargil at Burlington in 1969, where Prof Ramamurthi was one of the participants [Figure 6]. In 1990, he wrote under the photograph, “This is where I missed the bus of micro-neurosurgery”. This change in attitude by the chief himself enthused all to follow suit. The residents were taught to take the microscope before the dural opening for all cases. The way the instruments were held in the hand and balanced in the surgeon's hand was emphasized upon. The way retractors were placed, with minimal retraction of the brain, was taught to every student. Nerve root retraction during spinal surgery was minimized. The microsurgical techniques were practiced by the residents on tubes of various sizes. By 1990, this change in utilizing the microscope from the dural opening to the dural closure was complete.
Figure 6: “This is where I missed the bus”: The first Microsurgery workshop by Drs. Donaghy and Yasargil in 1969 at Burlington, which Dr. BRM attended

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With this change came the Malis bipolar equipment (donated by Prof. Leonard Malis), and Leyla retractors, etc., The effects of this changeover on 'total microsurgery' were immense. The mortality and morbidity decreased dramatically and smooth postoperative periods became the norm. The assistant could see what the surgeon was doing and was able to assist better. He also learned the techniques faster and better. Surgery became more precise and less traumatic with better results. Gradually, the department became known as a prime center for a high level of micro-neurosurgery. The range of surgical procedures that were being done in the department also increased. Transcallosal approaches to the lateral and third ventricle, supracerebellar approaches to the pineal region, and trans- Sylvian approaches became common. ALNC became well known for surgery for vestibular schwannomas and other cerebellopontine angle lesions, pituitary tumors, glioma surgery as well as cervical microdiscectomy. The starting of the Diplomate of the National Board (DNB) program and having full time in-house residents helped in managing patients round- the-clock. In 1990, Dr. K Sridhar passed the DNB direct 5-year course and joined the department. In 1991, he also visited and spent time in training with Prof. Madjid Samii at Hannover and then with Prof. M G Yasargil at Zurich, increasing the emphasis on microsurgery. Dr. M C Vasudevan underwent training in neuroradiology and coordinated the work with radiologists at the computed tomographic (CT) and magnetic resonance (MR) scan centers.

In 1991, the B Ramamurthi block was added to the ALNC block [Figure 7]. It housed the female general ward and pediatric wards, a second operation theatre, the Vijayalakshmi Narayan Neurosurgery library and faculty rooms. A second operating microscope was procured. In 1995, a generous donation from the Ganapathy Trust was given in memory of Shri K R Sundarajan, educationist, philanthrophist and founder chairman of the Meenakshi College for Women. This was utilized to procure vital monitors and ventilators to equip the “KRS Neurosurgical Intensive Care Unit”.
Figure 7: The ALNC and B Ramamurthi blocks with the “KRS Neurosurgical ICU” and the “Vijayalakshmi Narayan Library”

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Modern neurosurgery was being performed in two OTs every day at ALNC apart from cases at Malar hospitals. A Komai stereotactic frame was donated in 1990 and stereotactic procedures were done extensively by Dr. M C Vasudevan. Dr. Ravi popularized the trans-ethmosphenoidal approach to the sella and the department became a referral centre for pituitary tumors. Endocrinology support was provided by Dr. Moorthy and pathology support by Dr. Meera Govindarajan [Figure 8], [Figure 9], [Figure 10], [Figure 11].[2],[3]
Figure 8: ALNC group photograph (a): 1984, Seated left to right: Dr. E V Ravisankar, Dr. M C Vasudevan, Dr. B Ramamurthi, Dr. R Ravi, Dr. Chandrasekhar, Dr. Mani Veeraraghavan; (b): 1992, Seated left to right: Dr. M C Vasudevan, Dr. Usha Vijayaraghavan, Dr. R Ravi, Dr. Saroja Srinivasan, Dr.B Ramamurthi, Dr. K Mythili, Dr. K Sridhar; Standing left to right from fourth from left: Dr. Charulatha Hastak, Dr. M Bhaskara Rao, Dr. Nirmal Palit, Dr. P V Ramana

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Figure 9: The ALNC and the PGINS emblems were designed by erstwhile residents, Dr. Shajehan and Dr. A N Prasad respectively

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Figure 10: (a) 1995, Seated left to right: Mrs. Malini, Drs. Ravi, Saroja Srinivasan, BRM, Usha Vijayaraghavan, Vasudevan, Sridhar, Sr. Anandhi; Standing 7th from left: Mrs. P K David, Drs. Arjun, Ramana, Pande, Mukherjee, Shajehan; (b) 2001, seated left to right: Drs. Maya, Sridhar, Usha Vijayaraghavan, S Janaki, BRM, Saroja Srinivasan, Ravi, Vasudevan, Anil; Standing left to right: Drs. Prasad, Jagdish, Nigel, Senthil, Satish, Bobby, Dhanuka, Koshy; (c) 2002, seated L to R: Drs. Pande, Usha V, Ravi, BRM, Vasudevan, Maya, Sridhar; Standing left to right: Drs Jagdish, Dhanuka, Nigel, Satish, Senthil, Bobby, Vikram, Koshy, Aarish

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Figure 11: (a) 2009, seated left to right: Dr. Vincent Thamburaj, Dr. Anil Pande, Dr. R Ravi, Dr. M C Vasudevan, Dr. Akhila, Dr. Jacintha; Standing left to right: Dr. Goutham Cugati, Dr. Nigel Symms, Dr. Ravindranath Kapu, Dr. Manish, Dr. M Vikram, Mr. Venkat, Dr. Santosh, Dr. Pradeep Kumar Jain, Dr. Shivram Bojja; (b) 2013, seated left to right: Dr. Sivaram Bojja, Dr. Karunapriya, Dr. Shyam Sundar, Dr. M C Vasudevan, Dr. Hari Nivas, Dr. Akhila; Standing left to right, starting 3rd from left: Mr. Venkat, Dr. Satish, Dr. Gautham, Dr. Omar Bach, Dr. Shanmugam

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 » Departmental Growth Top

Spinal surgery, as we know it today, started in 1992, with Dr. K Sridhar learning and performing major spinal decompressions and fusions from the craniovertebral junction to the sacrum. This added a completely different spectrum of patients to the work of the department. Skull base surgery was also developed in collaboration with ENT, facio-maxillary and plastic surgeons. Craniofacial access and reconstruction flaps were regularly done for tumours and other lesions of the anterior and middle skull base. All these needed better anesthesia and monitoring equipment and donations ensured that there was a constant upgradation.[4],[5],[6],[7]

This was a phase where the department was developing and growing in all aspects of neurosurgery. The second edition of the 'Textbook of Neurosurgery' was published.[8],[9],[10] There was a photograph taken labelled the “Four Musketeers” which said it all [Figure 12].
Figure 12: The four musketeers: Dr. K Sridhar, Dr. Ramamurthi, Dr. M C Vasudevan, Dr. R Ravi standing in front of the B Ramamurthi block

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In 2000, Dr. Ravi left the department to work at Malacca, Malaysia, and that left a huge void in the department. Dr. M C Vasudevan and Dr. K Sridhar rose to the occasion and kept the momentum on. Dr Anil Pande qualified the DNB neurosurgery examination and joined the department as faculty. Aneurysm surgery and endoscopic trans-nasal surgery were started at this time. National society conferences were organized very successfully.

Dr. B Ramamurthi passed away on 13th December 2003.[4],[5],[6],[7] This was an extremely traumatic phase for the department which had just celebrated its Silver Jubilee earlier that year. Dr. Ravi came back from Malaysia to take up the reins of the department in 2004. Dr. K Sridhar left the department in October 2005 and took up a project at Kolkata. Dr. Nigel Symms qualified for the DNB and joined the faculty in 2005. Dr. Ravi retired from active neurosurgery in 2011, following which Dr. M C Vasudevan took over as head of the department. Dr. Shyam Sundar, a neurosurgeon, joined the ALNC as faculty in 2012. Operation theatre upgradation was once again done in 2012, thanks to a generous donation by the R Choodamani Ammal trust. In these 40 years, the ALNC has collaborated with multiple institutions for clinical work, academics and research [Table 1].
Table 1: Faculty of ALNC

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ALNC has grown in the last 40 years to be one of the finest in the country, setting standards for other departments. It has become a tertiary referral center for complex cranial and spinal surgery. At present, the department has a total of seventy-five dedicated beds with separate male, female and special wards, two intensive care units with advanced monitors and ventilators. There are 2 state-of-the-art neurosurgery operation theatres functioning five days a week, and are open 24 hours for emergencies. Trained theatre staff, complete sets of microsurgical instruments and 2 Zeiss microscopes, comprehensive cranial and spinal endoscopy, ultrasonic suction aspirator and drill systems allow the smooth performance of all complex neurosurgical procedures. In these 40 years, more than 90,000 patients have visited the morning out-patient department at the ALNC - VHS. Around 35,000 patients have been admitted in the department and a total of 19000 neurosurgical operations have been performed.

 » Neuro-Anesthesia Top

Dr. Chandrasekhar was the anesthetist who helped in the initial period of development of the department. He was soon joined by Dr. K Mythili, who was the first lady to get her Diploma of Anesthesia from the Madras University. Considering that there was a paucity of monitoring and that the only drugs available to them were thiopentone, and scoline or flaxedil for induction, and ether or trilene for maintenance, it required a real determination from the anesthetists to do their best for the patients. The utilization of red rubber endotracheal tubes, and butterfly and hypodermic needles were a routine practice and there were no ventilators. The anesthetists needed to sit “bagging” and having their hands on the pulse and ears hooked on to stethoscopes. Dr. Mythili joined the department on a full-time basis. Her dedication was exemplary; any time of the night, she would come for an emergency, and then again in the morning be ready for the routine list. She was helped by Dr. Bharathi Rao. Dr. Usha Vijayraghavan joined her in 1990, and both of them continued giving excellent support to the department. Slowly, all modern anesthetic equipment was made available. Dr. Mani Veeraraghavan helped out with all awake endoscopic intubations in difficult airway cases, as well as with patients suffering from craniovertebral junction anomalies and spinal injury. At Malar Hospitals, Dr. Raman and Dr. Vidya Mohanram provided support for the regular and trauma patients. Dr. Mythili retired in 2000 after a long stint of more than 20 years. Dr. Sushma Saroa joined for a brief period, while Dr. Maya Sailesh worked for a period of 2 years. Dr. Govardhan, Dr. S Vasudevan and Dr. Kamraj all helped to give anesthesia and to improve neuro-anesthesia services both at VHS and at the Malar Hospitals. Dr. Akila Suresh followed in the footsteps of Dr. Mythili and is currently the backbone of the neuroanaesthesia services at ALNC.

Spine surgery

The initial spine surgery work at the ALNC was limited to cervical laminectomy for myelopathy and lumbar disc surgery, apart from surgery for intradural extramedullary and intramedullary tumors. Myelograms and cisternal punctures were performed to localize the lesion. Anterior cervical microdiscectomy was started by Dr. Ravi Ramamurthi in Madras after his return from the UK, and this was a major step in spine surgery. The first anterior cervical microdiscectomy without fusion was done in April 1983. While trained in the Smith Robinson and Cloward techniques, Dr. Ravi felt that the results were better with microdiscectomy without fusion and this then became the mainstay surgery for cervical disc disease in the department. By the early 1900s, spine surgery had started becoming a major part of the neurosurgical curriculum. Dr. Sridhar by then, had started doing the anterior cervical microdiscectomy. Along with the senior residents, Dr. Arjun Srivatsa and Dr. P V Ramana, Dr. Sridhar expanded the work to include all aspects of spinal surgery. There was a definite learning curve as there was a need to learn about bone healing, fusion techniques, implants, plate and screws. This was completely foreign to the milieu of the department. It was an exciting as well as an intimidating phase. The end result of surgery in every patient was carefully observed by all; and, significant effort was made to improve the surgical technique. Techniques of orthopedic implant surgery were learnt from Dr. Senthil Kumar, a senior orthopedic surgeon.

By this time, the MR scans became available and spinal surgery improved as a consequence. A large number of cases were referred to the department. In 1992, while performing an anterior microdiscectomy for a cervical myelopathy, Dr. Sridhar found calcification and bone that extended beyond the posterior longitudinal ligament. A considerable time was then spent drilling this to achieve a decompression of the dura. Retrospectively, looking back and studying the MR scan led to the realization that this was indeed ossified posterior longitudinal ligament. “The eye cannot see what the mind does not know!”. Dr. Sridhar soon began to find increasingly frequent numbers of patients with non-fluorotic OPLL, a condition grossly underreported from India, as this was supposed to be a disease specific to the Japanese. A retrospective study of the spinal myelograms was done and a large number of patients with OPLL were found. The experience with OPLL soon led to a large surgical series of patients and this was published in 2001.

Diagnosing OPLL with an increasing frequency lead to a large experience with median corpectomies, grafting, fusion techniques and anterior stabilization. This led to the department offering anterolateral approaches to the spine including anterolateral thoracic and thoracoabdominal and retroperitoneal approaches. Dr. Sashank, Cardiothoracic Surgeon, helped with the initial transthoracic approaches, while Dr. Debashis Roy, General Surgeon, taught us the retroperitoneal approach. Soon, a great deal of spinal surgeries including spinal fusions, were being performed for different pathologies and in different regions of the spine. The anterior trans-manubrial approach to the thoracic spine was also popularised. Residents participated wholeheartedly in the effort to improve spinal surgery.

Surgery of the craniovertebral junction was traditionally considered a no-man's land. The orthopedic surgeons at that time were not trained in this and the neurosurgeons had no time. Having been associated with trans-oral surgery and craniovertebral junction fusion procedures in the National Institute of Mental Health and Neurosciences, Bangalore, and later at the Sri Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, and after gaining experience with surgery in other regions of the spine, Dr. Sridhar convinced Dr. Ramamurthi that it was time to offer these surgeries at ALNC. Doing a transoral surgery with an ENT micromotor was not easy, but was done and with reasonably good results. Help and advice was sought whenever needed and slowly the expertise increased. A special low-cost “plate-screw- wire construct” for performing the occipito-atlanto-axial fusion evolved and was used in more than 150 cases with good results.

Spinal tumor surgery

Dr K Sridhar, while training under Prof. MG Yasargil at Zurich, learnt the hemilaminectomy approach to remove spinal tumors, and he introduced these limited hemilaminectomies and quadrilaminectomies for tumor removal. These techniques allow for the safer removal of tumors anterior and lateral to the cord by a less than 1 cm laminectomy at the desired level. This minimally invasive technique was published in 1998. A retrospective study of the intradural extramedullary lesions done at ALNC lead to a paper classifying spinal schwannomas and defining giant spinal schwannomas.

 » Skull Base Surgery Top

Dr. Ramamurthi was a pioneer and had a tremendous experience in the surgery of vestibular schwannomas. This continued at the ALNC and the first vestibular schwannoma was excised on 21-12-1979. That the surgery was done in the sitting position was a challenge as there was no 3-pin fixation system available at that time. The patient was made to sit up and his head was held in a horse-shoe support and strapped with a plaster to keep it in place. The head lamp was used for depth illumination. Dr. BRM used to wear it before washing and putting on the gloves for surgery. This itself was an elaborate procedure. The theater boys did not understand what was needed and how to fix the headlamp. Invariably as a first step, a posterior parietal burr-hole was made and the ventricle was tapped. The bone exposure was very large, from the mastoid to the midline and from the superior nuchal line to the foramen magnum. The posterior arch of atlas was nibbled, the dura was widely opened and cisterna magna was opened to let out the cerebrospinal fluid (CSF). The lateral third of cerebellum was excised to provide more space and more accessibility to the tumour. The surgery, however, was a blind one as far as the two assistants were concerned. Neither could look into the operative field unless Dr. BRM moved his head away to show the anatomy but the light also moved with the head and the assistants would not know what they were looking at. What is called a 'lighted retractor' was sometimes used, but again, the connecting wires and the protruding bulb at the tip of the retractor came in the way of the surgeon. There were no Leyla retractors at that time and the first assistant did the work of retraction. He could not see where his hands were, where the tumor was and what he was retracting. He was expected to keep the hand in position for hours at end. It was a nightmare for the assistants when a patients with a vestibular schwannoma was posted for surgery. The assistant had to stand for hours together, facing sideways, with his hand stretched and in position without moving the retractor, with a limb which had become so numb that there was no feeling. Surprisingly, despite of all these shortcomings, Dr. BRM was able to remove the tumor completely though there was no question about saving the facial nerve or the eighth nerve. Invariably, all patients would end up with a full-blown facial paralysis at the end of surgery but all survived. Even when the facial nerve was saved, bleeding near the internal auditory meatus was controlled using monopolar cautery and that led to an invariable damage to the facial nerve. Lower cranial nerves were also handled with great care to prevent complications from occurring. This also helped in avoiding the requirement of a tracheostomy. Initially, tarsorrhaphy was avoided by using an adhesive plaster to strap the eye to prevent a corneal ulcer from developing.

All this changed with the introduction of microsurgery after 1988. The possibility of the assistant seeing what the surgeon was doing was a great help to the latter. The use of the Leyla retractor prevented retraction injuries to the cerebellum. Advancing techniques in anesthesia and surgery improved surgical results. Lateral cerebellectomy was given up, and cerebrospinal fluid was drained from the cisterna magna to relax the brain. However, the tumours were still very large and would often need a pre-operative shunt surgery. With increasing experience with the microscope, Dr. BRM along with Drs. Ravi, Vasudevan and Sridhar, kicked off modern skull-base microsurgery.

Sub-specialization was the norm and as time went by, vestibular schwannoma and meningioma surgery was taken forwards by Dr. Ravi and Dr. Vasudevan, while Dr. Sridhar started collaborative work with the ENT, faciomaxillary and plastic surgeons for extended skull base surgery. The procurement of high-speed drills helped in this development. As time passed, Dr Vasudevan became an “Acoustic Surgeon” and started providing excellent results. Dr. Ravi was trained in the ethmosphenoidal approach to the sella and this was used extensively for accessing the sellar and peri-sellar regions. Anterior craniofacial work was done in collaboration with the Ragas Dental College, and many lesions involving the midface and sinuses extending into the cranial cavity were dealt with by the teams of oculo-facio-maxillary surgeons and neurosurgeons working together. Similarly, along with Dr. Sadasivan, the ENT surgeon, lateral and posterolateral skull-base surgical corridors were utilized for many lesions. Petrosectomies and trans-labyrinthine approaches as well as far lateral approaches were learnt and performed by Dr. Sridhar. Endoscopic trans-nasal approaches to the sella and anterior skull base were started in 2000 along with Dr. Mohan Kameswaran and his team from the Madras ENT Research Foundation (MERF). Dr Anil. Pande trained in minimally invasive surgery and supraorbital craniotomy. Dr. Shyam Sundar has trained in endonasal procedures and is doing this successfully.

The Annual Conference of the Skull Base Surgery Society of India was organized by Dr Sridhar and the ALNC in 2000, with Dr. B Ramamurthi, Dr. S Kameswaran (ENT) and Dr. Venkatsamy (Plastic surgeon) inaugurating the conference.

 » Vascular Neurosurgery Top

With majority of the work focusing on tumour surgery, vascular pathologies were not seen very often. In the initial days, carotid and vertebral angiograms were performed by direct puncture in the neck and the three phases of the cerebral circulation were seen on the X-ray plates. An occasional arteriovenous malformation (AVM) would be operated. The first AVM to be operated in VHS was in 1981, with no microscope, a very ordinary bipolar cautery machine and forceps, and silver clips. Perhaps, due to the lack of a neuroendovascular catheterization laboratory in the hospital, the vascular work did not develop very much. Even though Dr. Ravi trained with Dr. Robin Sengupta in the UK, with the rare occurrence of aneurysms among the patients seen at the VHS, cases that did come were referred to centers which had higher volumes of patients. With better computed tomographic (CT) scans, improved knowledge and microsurgical skills and the easy availability of both digital subtraction angiography (DSA) and CT angiography, aneurysm surgery started once again in 2000. Dr. Sridhar, who had spent some time with Dr. D Rout and Dr. VRK Rao, along with Dr. Bobby Jose and Dr. Sanjeev Dhanuka (both senior residents) took a keen interest in this field. Patients with suspected subarachnoid hemorrhage underwent CT angiography and were operated at the earliest. Once the program started, the patient flow rapidly improved and aneurysm surgery is being done relatively frequently from then on.

 » Collaborations With Other Institutions Top

Malar Hospitals

In 1992, the services of the ALNC were extended to a private hospital, Malar Hospital, located near the VHS. The hospital catered to the more affordable patients. An active trauma program was initiated there, so that traumatic brain injury (TBI) and spinal injury patients were managed by the team. All state-of-the-art neurosurgical equipment were available at the hospital and many complex cases were soon performed here. Residents were posted in rotation to look after patients admitted in the Malar Hospital.

Southern Railway Headquarters Hospital, Perambur

Dr. Ravi was appointed as Honorary Consultant to the Southern Railways in 1989. A weekly outpatient clinic was run at the Southern Railways Headquarters Hospital, Perambur, and all patients needing hospitalization or surgery were admitted to ALNC. Dr. Sridhar became the Honorary Consultant in 1995 and continued till 2005, when Dr. M C Vasudevan took over as the Honorary Consultant. Neurosurgical services were thus provided to a large population of railway employees and their families, not only of the Southern Railways but also of other sectors. This association continued until 2012 when the policies of the Railways changed.

Madras ENT Research Foundation

Collaboration with the ENT surgeons of MERF started from the 1990s, when skull base surgery came into focus. Dr. Mohan Kameswaran and his team from MERF helped with many endoscopic trans-nasal approaches, and both teams collaborated on multiple anterior skull base pathologies.

Pioneering work was done with MERF in auditory brain stem implant (ABI) surgery in South Asia and South East Asia. The first case was done in 2005 at ALNC on a 15-year old girl with type II neurofibromatosis. ALNC is the first center in the South and South East Asia to establish a pediatric auditory brain stem implant program. The ABI team currently is made up of Dr. M.C. Vasudevan and Dr. Shyam Sundar from VHS, Dr. Mohan Kameswaran, ENT surgeon and Mr. Ranjith, audiologist from MERF, and Dr Akhila who provides anesthesia support. Many surgeries are done free-of-cost under state government's health insurance scheme. The team has the third world's largest series of this very sophisticated technology with promising results so far.

National Brain Research Centre (NBRC), Manesar

Dr. B Ramamurthi was keenly involved and interested in the development of the NBRC. With the growth and maturing of the DNB program of ALNC, it was felt by the faculty that the one thing lacking in the training was the opportunity to learn and understand basic research. With the support of Dr. Vijayalakshmi Ravindranath, Executive Director of NBRC, a memorandum of understanding was signed between the ALNC and NBRC in 2003 to permit the DNB residents of ALNC to spend 3 months at the NBRC. This has helped many of the residents who availed the opportunity.

 » The National Board of Examinations Training Program Top

In 1984, the department was recognized for the National Board of Examinations (DNB) Neurosurgery 5-year course and was allowed one trainee per year. Dr. EV Ravi Shankar and Dr. K Sridhar were the first batch of postgraduates, qualifying in 1990. Before the centralised examination and admission process began, the department instituted its own rigorous admission process with an admission committee and written examinations to make the selection of candidates transparent. The institution is currently allowed one candidate per year and the course is now of a 6-year duration. The candidates are selected by the National Board on the basis of an all India examination, and its counselling is done centrally. In 2000, the department was upgraded into an 'Institute of Postgraduate Study in Neurosurgery' with the clearance from the Hospital Board. On this occasion, the already extensive neurosurgical library was upgraded and the academic wing with the latest equipment related to information technology was established. Since 1984, when the programme began, 34 postgraduates have undergone the direct post-MBBS 5- and 6-year training at ALNC [Table 2].
Table 2: Alumni of the Post-graduate Institute of Neurological Surgery, ALNC, VHS

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 » The Vijaylakshmi Narayanan Neurosciences Library Top

The Vijaylakshmi Narayan Neurosciences Library was inaugurated in 1992 by the Vice Chancellor of Madras. Prior to this, the library was housed in the room adjacent to the ALNC general ward where the residents used to stay during night duty. The books incorporate the large personal collection of Dr. B Ramamurthi, and to this extensive and varied collection, many books have been added over the years. Donations from doctors, lay public and even patients, have contributed to the growth of the library. On the occasion of the 75th birthday celebrations of Dr. B Ramamurthi, many eminent neurosurgeons, including Prof. Laligam Sekhar and Prof. Majid Samii, donated books and audiovisual educational material.

The library has grown to be one of the best neurosciences library in the country with a 24-hour access and wi-fi connectivity. It has current neurosurgical textbooks, and books related to other aspects of neurosciences like neurology, neuroradiology, neuropathology, etc., focusing on the core curriculum of the residency program. There is a section related to the history of medical sciences, especially the history of neurosciences. There is a remarkable collection of books which were of special interest to Dr. BRM, with books on consciousness, medical ethics, yoga, Ayurveda, mysticism, general history and culture. All residents have a say in what books are to be procured. All faculty members and students have a key to the library, which is open 24 hours and all 365 days of the year. The responsibility for the upkeep of the library has been with the senior residents. Dr. K Sridhar and Dr. Anil Pande took a keen interest in the development and upkeep of the library.

 » Text Books of Neurosurgery Top

The department has the unique distinction to having published 3 editions of 'Ramamurthi and Tandon Textbook of Neurosurgery' and the 1st edition of 'Textbook of Operative Neurosurgery' [Figure 12]. The only other textbook from India named the 'Textbook of Contemporary Neurosurgery' has also been from a former member of the department, Dr. Vincent Thamburaj. Drs. P N Tandon, Ravi Ramamurthi and Pradeep Jain brought out a ' Manual of Neurosurgery' in 2014.

The first (with a red cover) edition was published by Dr. B Ramamurthi and Dr. PN Tandon in 1980. The book was a pioneering effort, being the all Indian text book in the field. The value of the book diminished with the advent of computed tomographic and magnetic resonance imaging, the surge of microsurgical techniques, and the improved pathological and immunological diagnostics. In 1993, a proposal was sent to start the work on the second edition of the textbook. The National Book Trust was very generous in offering to subsidize this edition too. The completely revised second edition (with a green cover) with Drs. B Ramamurthi and PN Tandon as editors, and Drs. Ravi Ramamurthi and K Sridhar as associate editors was published in 1996 and was favorably reviewed in international journals. The book was also released in the compact disc format. The 3rd edition (grey cover), of 3 volumes, was edited by Drs. PN Tandon and Ravi Ramamurthi and was released in 2012 [Figure 13].[8],[9],[10]
Figure 13: The textbooks brought out from ALNC-PGINS

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Dr. Ravi Ramamurthi, Dr. M C Vasudevan and Dr. Sridhar successfully completed the mammoth task of editing and bringing to print the first edition of the “Text Book of Operative Neurosurgery,” the first attempt of its kind in this subcontinent, in 2005.[10]

The “Manual of Neurosurgery” was conceived as a concise edition of the 'Text Book of Neurosurgery', meant for a rapid review, which is helpful during the busy hours of neurosurgery practice. This was published as a two-volume set by Jaypee Publishers in 2014, with Dr. P.N. Tandon, Dr. Ravi Ramamurthi and Dr. Pradeep Kumar Jain as editors of the first edition.

 » Annual Microneurosurgery Workshop of ALNC Top

In 1993, Dr. R Ravi and Dr. K Sridhar participated in the Neurosurgery Update for Young Neurosurgeons in Asia (NYUNA) program organized by Prof. T Kanno in Japan. Realizing that the standards of microneurosurgery in India equaled international standards, and that it was important to bring awareness to the Indian neurosurgical community regarding the excellent micro-neurosurgical procedures that can be performed “at home”, the idea of an annual live and interactive operative workshop was envisaged. It was realized that the best way to teach and learn surgery was to watch live surgery being performed and to have an active interaction between the surgeon and watching delegates. This way, there would be a good discussion as well as a chance for surgeons to see, discuss and learn from other surgeons. It was also decided that the faculty of these workshops would be Indian neurosurgeons so that the faculty and delegates are on the same wavelength.

The First Microneurosurgery workshop was held in September 1994 with Dr. A K Banerji and CE Deopujari attending as the visiting faculty and Dr. Ravi Ramamurthi, Dr. MC Vasudevan and Dr. K Sridhar participating as the host faculty [Figure 14]. The focus of the workshop was on cervical spine and pituitary tumor surgery. As many as 9 cases were discussed between two and a half days and discussed between the faculty and the 60 odd delegates who had gathered. The response to the workshop was very good and the event became an established annual affair in the neurosurgical calendar of India. It was then decided that the focus each year should be on a particular aspect or region of the brain or spine so that the whole gamut of neurosurgical approaches and surgeries could be covered in 3-4 years. The main theme of each year was, therefore, assigned as supratentorial tumors, infratentorial lesions, craniovertebral junction or spinal lesions, etc., [Figure 15].
Figure 14: Photographs of the First Microneurosurgery Workshop 1994. From top left: The Logo created, the reading material printed and the group photograph taken

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Figure 15: Microneurosurgery Workshops: top 2007, bottom 2014

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The workshops extend over 3 days, usually in the second week of September. Each workshop is held at the hospital with the theater and auditorium connected so that a two-way participation is possible. Every day starts with the case presentation by a senior resident. The live video transmission from the theater allows for the discussion to start from the OT setting, positioning, incision, to anesthetic requirement. We are happy and proud that this idea has been adopted by many premier institutions across the country.

Alongside these 'Operative Neurosurgery' sessions, the ALNC Oration was introduced in 1992. A renowned neuroscientist or an inspiring public figure has been chosen as the Orator each year and a special lecture has been delivered by him/her. Till date, 20 orations have been delivered by multiple eminent personalities [Table 3]. It was a proud moment and at the same time an honor for us to have Dr. APJ Abdul Kalam, ex-President of India, as the Orator in 2014 [Figure 16].
Table 3: ALNC Orators

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Figure 16: Dr. Abdul Kalam delivering the 19th ALNC day oration in 2014

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With the experience gained from organizing the Microneurosurgery Workshops, the faculty have also organized several national and international meetings and seminars [Table 4].
Table 4: Seminars, meetings and conferences organised

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 » Records Maintenance and Data Storage Top

The records from 1979 are being maintained, including detailed dedicated case sheets, with both in-patient and outpatient reviews recorded in registers. Every patient has a unique ALNC number with which his/her clinical records and imaging data can be retrieved. Each week, on Saturdays, the consultants and residents go through all the case sheets correcting, completing and labelling them with a final diagnosis and a unique neurosurgical disease index designed by the faculty. Mrs.PK David was in charge of the medical records along with Mr. Venkat and she did a remarkable job over the years. The records section of the department was upgraded and updated. The record storage space was increased for the case sheets and records.

This entire corpus of data was retrospectively digitalized. Special case specific (for example, spine, pituitary, vascular, brain tumor, trauma, hydrocephalus, etc) computerized case sheets were created, which could be entered into the neurosurgical data base. Mr. Neelamegham, a pioneer in library science, introduced the ISIS (integrated system of information Services) to the department to help in the computerization of patient records. This software was given free of cost by the World Health Organization (WHO) through the National Informatics Center, New Delhi.

A fully computerized digital recording system was acquired for recording patients' data including surgical videos and all radiological imaging. A WHO recommended WIN ISIS (widows based ISIS) protocol software was incorporated. The program was used to create tumor registries of pituitary adenomas, craniopharyngiomas, vestibular schwannomas, meningiomas and many more. Dr. MC Vasudevan took special interest in this area and was invited by various other departments to teach them the art of data entry and record maintenance.

 » The Prof B Ramamurthi Neurosciences Museum Top

Laying the foundations of neurosurgery in the country and then building upon it successfully over 5 decades is no mean achievement. The idea of a neurosciences museum was to place on record the events and people that contributed towards the establishment of neurosurgery in the country [Figure 17]. The seed of the idea which was sown in 1998 took final shape in 2001, to coincide with the 80th birthday celebration of Dr. B Ramamurthi. The main driving force behind this was Dr. Mrs. Indira Ramamurthi, who was an eye witness to the entire story. She felt that the story which stretched over five decades would be a definite source of inspiration to generations of neuroscientists to come. A generous donation from the Arogya Ashrama Samiti of six lakhs set the ball rolling. Many eminent personalities got together and after many deliberations, the museum was conceptualized and created. Permission was obtained to house the neurosciences museum on the second floor of the Ramamurthi block at the VHS Hospital. The process of collating the vast amount of material available then began. Prof Ramamurthi's collection of photographs from 1950 is a huge and fantastic collection with very rare photographs of many of the greatest figures in the history of neurosciences. All of us felt it a great honor bestowed upon us that we were given an opportunity to handle and deal with these rare photographs. Along with these photographs are neurosurgical instruments and accessories used in the early days of surgery in the country. A pride of place was given to the old Leksell frame, using which the Madras School of Stereotaxy had attained great fame. A small alcove was created to house the first operating microscope and an early anaesthesia machine. The artifacts and photographs were divided into chronologically distinct eras and the aura of each era recreated. The result was spectacular, as we had managed to put into perspective, the development of neurosurgery in India around the life and work of Dr.BRM. The interiors of the museum were done by Mrs. Sandhya, the niece of Dr. Indira Ramamurthi. A miniature replica of the house in Trichinopoly where Prof Ramamurthi grew up was created by Mrs. Jayshree Sridhar, wife of Dr. K Sridhar, as were replicas of the MIN and ALNC. The museum was inaugurated on 26th January 2002 by Mr. S Venkitaramanan, Managing Trustee of VHS Hospital at a grand reception to greet Dr. Ramamurthi on his 80th birthday. A seminar “Neurosciences: A look into the future” was organized on this occasion and the museum was showcased by Dr. Sridhar in an excellent audiovisual presentation. Dr. BRM tried to convince many to house the antiquities, vignettes and photographs of the Neurological Society of India in this museum. We hope that in years to come, artifacts from all over the country find their way into the museum, so that it becomes a truly national neurosciences museum.
Figure 17: Prof B. Ramamurthi Neurosciences Museum located in the B Ramamurthi Block of ALNC

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 » Conclusion Top

The legacy that Dr. B Ramamurthi left us is something beyond words, it was a way of life – and the ALNC is an example of that. Every single doctor who passed through the portals of the ALNC absorbed the ethos of the ALNC and this has in some way been reflected in their lives. As students and faculty of ALNC, we feel honoured to be a part of this institution – and in some small way, contribute to the continuation of a great legacy.

Prof Ramamurthi's favorite quote from 'Don Quixote: The Man from La Mancha' was adopted as the motto of ALNC:

“To reach the unreachable star

It is my quest to follow the star

No matter how hopeless, no matter how far”

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Ramamurthi B. Uphill all the way – an autobiography. Guardian Press 2000.  Back to cited text no. 1
Silver Jubilee Commemorative Volume 1978-2003. Dr A Lakshmipathi Neurosurgical Center VHS Hospital Madras.  Back to cited text no. 2
A decade of Neurosurgery 2002-2011. Dr A Lakshmipathi Neurosurgical Center VHS Hospital Madras.  Back to cited text no. 3
Sridhar K. Prof B Ramamurthi: The legend and the legacy. Neurol India 2004; 52: 27-31.  Back to cited text no. 4
[PUBMED]  [Full text]  
Ramesh VG, Bhanu K, Jothi R. The Madras Institute of Neurology, Madras Medical College, Chennai. Neurol India 2015;63:940-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
Tandon PN. Professor B. Ramamurthi (1922-2003): Personal reminiscences. Neurol India 2018;66:1543-9.  Back to cited text no. 6
[PUBMED]  [Full text]  
Nair K R. Organized neurosurgery: Additional facts. Neurol India 2017;65:443-5.  Back to cited text no. 7
[PUBMED]  [Full text]  
Tandon PN, Ramamurthi R. Textbook of Neurosurgery, II edition (Editors) Ramamurthi B, Tandon PN, Ravi Ramamurthi, Sridhar K. London: B I Churchill Livingstone, 1996.  Back to cited text no. 8
Tandon PN, Ramamurthi R. Ramamurthi and Tandon's Textbook of Neurosurgery, III edition. Editors: Tandon PN, Ravi Ramamurthi. New Delhi: Jaypee Brothers, 2012.  Back to cited text no. 9
Tandon PN, Ramamurthi R, Sridhar K, Vasudevan MC. Textbook of Operative Neurosurgery. (Editors) Ramamurthi R, Sridhar K, Vasudevan MC. New Delhi: BI Publications, 2012.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]

  [Table 1], [Table 2], [Table 3], [Table 4]


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