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REVIEW ARTICLE
Year : 2011  |  Volume : 6  |  Issue : 3  |  Page : 4-10
 

Development of pediatric neurosurgery in India


Department of Neurosurgery, Bombay Hospital Institute, Mumbai, India

Date of Web Publication10-Oct-2011

Correspondence Address:
S N Bhagwati
129, MRC, 1st floor, Bombay Hospital, 12, New Marine Lines, Mumbai 400020
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.85703

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   Abstract 

The development of pediatric neurosurgery in this country actually began with holding of the 17 th Annual Conference of the International Society for Pediatric Neurosurgery (ISPN) in 1989 in Mumbai. It subsequently led to the formation in 1990 of the Indian Society for Pediatric Neurosurgery (IndSPN), which is responsible for organizing regular annual conferences and CMEs in cooperation with the ISPN. The first three international CME programs were arranged in 1992, 1994 and 1995, followed by the next three courses from 1998 to 2000. Subsequently, five more such programs were organized in 2002, 2004, 2007, 2009, and 2010. The official publication, Journal of Pediatric Neurosciences (JPN), which was started in 2006, has also made good progress in the last 5 years. In the last 20 years, the IndSPN has made striking progress in the development and growth of pediatric neurosurgery in the country and has successfully managed to bring this subspeciality to an international level. The IndSPN now has about 150 active members and quite a few of them practice mainly pediatric neurosurgery. In large teaching institutions, pediatric neurosurgery has been accepted as a subspeciality with a designated neurosurgeon taking care of the pediatric patients. This augers well for the subspeciality as persons with greater interest and expertise will be tackling its problems. Some of these institutions have recently started or are in the process of starting the 1-year fellowship training program in pediatric neurosurgery.


Keywords: Pediatric neurosurgery, development of pediatric neurosurgery, neurosurgery in India


How to cite this article:
Bhagwati S N. Development of pediatric neurosurgery in India. J Pediatr Neurosci 2011;6, Suppl S1:4-10

How to cite this URL:
Bhagwati S N. Development of pediatric neurosurgery in India. J Pediatr Neurosci [serial online] 2011 [cited 2023 Feb 7];6, Suppl S1:4-10. Available from: https://www.pediatricneurosciences.com/text.asp?2011/6/3/4/85703



   Introduction Top


With a pediatric population that constitutes nearly 40% of the 1000 million people in this country, the potential for growth of pediatric neurosurgery as a subspecialty would be enormous by any standard. Despite this, however, the state of pediatric neurosurgery in India has been far from satisfactory in the past. It was only after the International Society for Pediatric Neurosurgery (ISPN) conference at Mumbai two decades ago that the Indian pediatric neurosurgery has begun to gain momentum. It has been making steady progress since then. The general awareness of this subspeciality has increased remarkably over the years and, as a result, more neurosurgeons have now begun to choose pediatric neurosurgery for further training and career. Quite a few major institutions in the country have also been able to start delegating pediatric neurosurgeons on their staff to look after pediatric patients and to train young neurosurgeons. In this article, we summarize the development and progress in pediatric neurosurgery in India.


   Conception and Development of Pediatric Neurosurgery Top


Neurosurgery took root in our country in 1949 when a department of neurosurgery was started at Christian Medical College, Vellore, followed by a similar development in Chennai and Mumbai in 1950 and 1951, respectively. Gradually, over the years, there has been a steady increase in the number of neurosurgeons, and at present we have 1200 neurosurgeons in the country. Unfortunately, these neurosurgeons have to look after the healthcare of 1000 million people, a ratio that would not permit most of the neurosurgeons to look after the subspecialties. Except for the large metropolitan cities, a general neurosurgeon at other places in India has to serve the needs of the society, treating all neurosurgical diseases including tumors, trauma, spinal problems, brain hemorrhages, meningoceles and hydrocephalus without further subspecialization.

I was fortunate to have an association with Mr. Kenneth Till whilst I was in UK in 1950s at the Atkinson Morley's Hospital, London. This kindled my interest in pediatric neurosurgery which received further impetus when I became a Research Fellow at the Children's Memorial Hospital, Chicago, in 1961. I developed close friendship with Dr. Anthony Raimondi who helped and encouraged me in my attempts to develop pediatric neurosurgery in India. The impression then in India was that pediatric neurosurgery consisted mainly in inserting and revising shunts and operating on meningoceles, something that could not be done by pediatric surgeons. Colleague's enthusiasm in developing pediatric neurosurgery was therefore subdued. The need for a concerted effort by pediatricians, pediatric neuroanesthetists, pediatric interventionists, facio-maxillary surgeons and others was realized only by a few neurosurgeons.

It was in 1983 that the first attempt was made to have a meeting wherein interested people could meet, exchange ideas and have some deliberations on the CNS infections that affect children in India and what could be done to counter them. Similar attempt was made in Hyderabad by Drs Raja Reddy and KVR Sastry in 1987 when CNS tumors were discussed in a 1-day meeting. These meetings were attended by about 40 neurosurgeons interested in pediatric neurosurgery. However, the actual milestone in the development of pediatric neurosurgery in India came with holding of the 17 th Annual Meeting of the ISPN at Mumbai in 1989 [Figure 1]a and b. The presence of over 125 foreign delegates acted as a stimulus for the 35 Indian delegates who attended the conference. This really was the beginning of an impetus to the pediatric neurosurgery movement in India, and at this meeting the idea of having pediatric neurosurgery in the country was germinated.
Figure 1a: Dr. S. N. Bhagwati addressing the ISPN conference in Bombay in 1989 (seated from L to R: Fred Epstein, Mrs. Rashmi Bhagwati, Osamo Sato, and Mrs. Epstein)
Figure 1b: ISPN 1989 conference (standing from L to R: S. N. Bhagwati, T. Wong, Harold Rekate, and Mrs. Bhagwati; seated from L to R: Kiyoshi Sato, Anthony Raimondi, Mrs.Raimondi, and Shizuo Oi)


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This enthusiasm led to the organization of a 1-day conference on craniopharyngioma in Mumbai the very next year [Figure 2]. The symposium received great appreciation and its proceedings were published as a special issue. In 1990, we saw the birth of the Indian Society for Pediatric Neurosurgery (IndSPN) and I was elected as its founder President (1990-1996), followed by Dr. A. K. Banerji (1996- 1999), Dr. S. Kalyanaraman (1999-2001), Dr. V. K. Kak (2001-2003), Dr. D. K. Chhabra (2003-2006), Dr. C. E. Deopujari (2006-2009), and Dr. A. K. Mahapatra (2009-2012) [Table 1]a and b, [Figure 3]. Annual meetings and a series of symposia covering various topics including infratentorial tumors, meningoceles and encephaloceles, craniostenosis and spinal dysraphism were conducted thereafter with the aim to encourage interested neurosurgeons to present their work. All these were received with great interest and nearly 70-80 neurosurgeons attended them every year.
Figure 2: The first CME in Pediatric Neurosurgery in 1992 at the Bombay Hospital [from L to R: Di Rocco (speaker), Dr. B. K. Goyal (Dean, Bombay Hospital), K. Sato, S. N. Bhagwati, Harold Hoffmann, and A. K. Banerji]

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Figure 3: Presidents of the Indian Society for Pediatric Neurosurgery from 1990 to 2012

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Table 1:

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During my tenure as the President of the ISPN in 1995 [Figure 4] and subsequently, we continued our efforts to strengthen the bond further between the IndSPN and ISPN. As a result of our increasing interest and persistent efforts, it was possible to arrange more CME programs with the help of renowned international faculty in various parts of the country. The first three such programs were arranged in 1992, 1994 and 1995, and the next set of CMEs were conducted on the European model from 1998 to 2000. Subsequently, five more Continuing Medical Education (CME) programs were organized in 2002, 2004, 2007, 2009, and 2010. More recently, the Asian Australasian Advanced Course in Pediatric Neurosurgery (AAACPN)-2009 was conducted in Bangalore [Figure 5]. With the success of the education programs offered by the IndSPN, the need to have a periodic publication became apparent very soon. The Journal of Pediatric Neurosciences, official publication of the IndSPN, was launched in 2006. The journal has made an incredible progress in the last 5 years.
Figure 4: L to R: S. N. Bhagwati as President, ISPN (1995), with Harold Hoffmann, Osamo Sato, and Fred Epstein

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Figure 5: Asian Australasian Advanced Course in Pediatric Neurosurgery-2009

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The educational activities provided by the IndSPN over the years have created a lot of awareness and interest amongst the young neurosurgeons of India, and many of them, as a result, chose to practice pediatric neurosurgery in various parts of the country. At present, there are over 150 life members of the society. Although only 6 of them are currently practicing as pure pediatric neurosurgeons, a large number of other neurosurgeons all over the country have been practicing pediatric neurosurgery as their primary field of interest for more than a decade. This is something similar to the occurrence in many countries of the world barring United States of America, France, Italy, United Kingdom, Japan, Korea and Taiwan. In the rest of the world, a few individuals have developed specific interest in the art of pediatric neurosurgery to the best of their ability.


   Institutions Top


With the firm belief that pediatric neurosurgery can function and flourish best in set-ups that have well-developed pediatric specialties, it was felt that more pediatric institutions with multidisciplinary facilities and personnel should be developed in the country to deal with the complex pediatric problems including craniofacial anomalies, skull-base surgery, spinal dysraphism, and neonatal hydrocephalus. Neonatologists and pediatric intensivists are of great help in managing tiny tots suffering from these disorders. Ultrasonographers can detect early cases of hydrocephalus with enlarging anterior fontanel or spinal dysraphism around 20 weeks of gestation when life of such individuals can be terminated. Orthopedic surgeons would be needed to look after deformed feet or correct spinal curvatures. Contribution of nurses, physiotherapists and social workers would be desirable to look after all these problems in a holistic manner. This holistic approach would be possible only in a good pediatric institute which has these facilities. We have such institutes only in two public and two private hospitals.

An attempt has been made to start a neurosurgical service at the Jerbai Wadia Hospital for Children in Mumbai as it has been an institute with academic repute. Though it was started in 1992-1993 with a good operating table and a decent operating microscope, it failed to take off after 1994 for a few years. A good functional unit could be restarted only from 2003 onward. Now it offers operative facilities for 1½ days in a week. The institution does have good craniofacial unit, satisfactory work up for hydrocephalus, good care for spinal dysraphism and for craniospinal neoplasms. We now have one dedicated pediatric neurosurgeon and a couple of neurosurgeons interested in pediatric neurosurgery looking after the service.


   Awareness, Education, and Training Top


If and when a good pediatric institute develops good neurosurgery, it could be utilized to train some more neurosurgeons to practice pediatric neurosurgery. A program of fellowship for 6-12 months has to be instituted so that the general neurosurgeon and pediatric surgeons could have training in pediatric neurosurgery. They could then understand and appreciate the nuances and deal with cases of hydrocephalus, craniofacial anomalies, and spinal dysraphism more intelligently. With our large population, we will continue to need the help of pediatric surgeons in treating cases of spinal dysraphism and hydrocephalus. Active collaboration with and educational programs for pediatric surgeons and neurosurgeons will continue to be needed for several years to come.

There is no doubt that cases of craniospinal dysraphism are better prevented than tackled. Over the course of last several years, more and more women are using folic acid during pregnancy to prevent occurrence of spinal dysraphism. However, this is partly true for urban women, though most of the women in rural population neither use folates during the period of conception nor are aware of their significance. Many a women are also not aware of the fact that folate should be consumed some months before conception occurs. Many women are neither aware of the need to space out their pregnancies nor aware of the need for family planning. Though now a majority of women in the cities do go to hospitals for delivery, fair number of women in the rural population have deliveries at home by midwives. One is not sure as to how many of these midwives have the required knowledge, know whether the infant they are going to deliver will be a normal one or with craniospinal dysraphism. A fair number of women do go in for ultrasonographic examination in the initial period of pregnancy mainly to confirm that they are pregnant but never have a second sonographic examination at or after 20 weeks to know whether the infant is normal or is having craniospinal dysraphism. Ultrasonographers are aware of the possibilities of development of hydrocephalus in early stages when some ventricular dilatation may be noted. However, not infrequently, the dilatation is more marked when the pregnancy has advanced to more than 20 weeks. If it is noted early enough, one would repeat sonography to monitor the ventricular dilatation. If the dilatation continues to get worse, termination of pregnancy is carried out. When the fetus is 32-34 weeks old, an age at which the fetus has become viable, if the dilatation is so gross that normal life is unlikely, perforation is performed, the ventricles are deflated and delivery of the dead fetus is undertaken.

In India, the children with meningoceles and myelomeningoceles are managed more by pediatric surgeons rather than neurosurgeons. In a vast majority of these lesions, repair is carried out without worrying about dissection and preservation of the placode. The main objective is to close the defect so that there is no leakage of CSF. This sometimes leads to an increase in the neurological deficit, the infant having weakness of limbs and sphincter impairment that was not obvious prior to surgery. The problem arises when child becomes paraplegic with sphincter involvement. Care of the bladder and skin then poses a real problem, the child remaining incontinent and developing pressure sores around the perianal and perineal regions. The child often develops urinary infection and back pressure phenomena. An incontinent child with non-healing pressure sores discharging pus becomes unacceptable to the society with the parents remaining in a constant state of socioeconomic stress. The parents go from place to place, seeking help to restore the child's neurological status so that the child becomes continent, ambulant with pressure sores that heal. To face these problems, a spina bifida clinic needs to be established with a neurosurgeon, an orthopedic surgeon, a pediatrician, a social worker, a physiotherapist and a genitourinary surgeon. Two such centers exist in Mumbai and quite a few centers are established in the country.


   Management of Hydrocephalus Top


Now that Indian shunts are easily available, the earlier need to insert simply a synthetic tube from the ventricle into the peritoneal cavity is nonexistent. Though pediatric surgeons do continue to insert ventriculoperitoneal (VP) shunts, these insertions are now carried out mostly by neurosurgeons. The common shunt that is now utilized is Chhabra shunt (Surgiwear) which comes in three forms, viz., high-pressure, medium-pressure and low-pressure shunts. The most commonly used shunts are the medium-pressure shunts that operate at pressure of 50-100 mm. They function optimally in most of the cases of hydrocephalus. The shunt is made of high-grade silicone tubing which is acceptable to the body and is usually not rejected. Therefore, though earlier on ventriculo atrial shunts were very much in vogue, now for several years VP shunts are used.

Shunt insertion does have its own problems. Blockage of ventricular end is fairly common, occurring more frequently than the peritoneal end. Often the correct placement of ventricular end is not obtained; the catheter should be placed in front of the foramen of Monro so that the choroid plexus does not block it. The peritoneal end may get blocked by the omentum or any of the abdominal viscera. The phenomena of overdrainage are seen rather infrequently, and therefore Z flow shunt is infrequently used.

Shunt insertion is still associated with infection, the rate being between 2% and 15% in various series. Infection does tend to block the ventricular end and all attempts should be made to control the same. The incidence of infection does become lower if the shunt is inserted as the first case in the morning with just a few people remaining in the operating room. These days antibiotic impregnated ventricular ends are available.

With the problems that one faces with shunt insertion, one wonders whether endoscopic third ventriculostomy (ETV) would be a better surgical procedure to treat hydrocephalus. In nearly 70-75% of the patients, third ventriculostomy functions well except in an occasional case when the stoma tends to close. In hydrocephalus of tubercular origin, especially in the acute phase when the exudate is thick and the floor of the third ventricle is opaque, performance of ETV is rather difficult. In such cases, one may insert a VP shunt to start with and convert it into a third ventriculostomy if and when it gets blocked. It is better used in burnt out cases in which it is more likely to be successful. It is also helpful in breaking down septa that may form in the ventricular system so that one does not need to insert multiple VP shunts. Quite a few people have started using ETV as a primary procedure with nearly 75-80% success. Endoscopy may be used for correct placement of ventricular end so that it can function for a long time without getting blocked. Endoscopic surgery can also be used to have biopsy of intraventricular tumors or even excision of smaller tumors.


   Tumors Top


Many pediatric tumors seem to behave differently from adult tumors. Medulloblastomas, craniopharyngiomas and astrocytomas may be having different molecular biology when compared with adults. That total or near total excision of medulloblastoma be carried out is now an accepted procedure. However, quantum of radiotherapy that needs to be given to a medulloblastoma has gradually reduced over the course of years and now a total of 54 Gy rads needs to be given to the posterior fossa and 23.4 Gy rads to the craniospinal axis. With chemotherapy, attempt may be made to further reduce the amount of radiotherapy to the operated site. Radiotherapy is also not given to children below 2 years of age as it leads to stunting of growth and hormonal disturbances. The prognosis also depends on the various risk factors. Children below the age of 5 years do not do as well as the older children or the adults. The prognosis is also poor when partial excision or biopsy is undertaken. Same is the case when medulloblastoma is excised from the posterior fossa when already spinal metastasis exists. A fair number of centers now have had a good experience in dealing with a large number of medulloblastomas.

Craniopharyngioma is another entity, the treatment of which has undergone a radical change. The notion that it should be excised totally is now replaced with the idea that excision should be compatible with a reasonable quality of life. A total excision of craniopharyngioma not infrequently resulted in stunted growth, diabetes insipidus, lack of development of sexual organs, electrolyte imbalance, mental slowness, reduction of intellectual capacity and a relatively poor quality of life. The emphasis now is on preserving a good quality of life, leaving some tissue behind and subjecting it to radiotherapy. In largely cystic lesion, intracavity instillation of Bleomycin or radionuclides is often sufficient to take care of the lesion. Often in a lesion which is mainly intrasellar with a larger suprasellar extension, transphenoidal endoscopic excision is sufficient to totally excise it. With the advances in endoscopic skull base surgery, a fair number of craniopharyngiomas are now subjected to endoscopic excision. If there be a small residual lesion, it is then subjected to radiotherapy. Occasionally, multimodality treatment is offered.

As far as astrocytomas are concerned, a large number of lesions in the posterior fossa in children are cystic with a solitary solid nodule. This can be totally excised giving a cure to the patient. However, solid astrocytomas may be present in the posterior fossa, which occasionally infiltrate the brainstem. In such cases, near total excision may be carried out, subjecting the patient to subsequent radiotherapy. Often these are low-grade astrocytomas that would take a long time to grow to a large size.

With the advent of gamma knife and cyber knife, the question may arise whether a small lesion can be destroyed with either of them without affecting the adjacent normal brain. One wonders whether radiosurgery or fractional radiotherapy can be safely given to hypothalamic glioma or optic glioma. Similarly, radiotherapy may be given to residual germ cell and pineal tumors.

[Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11] and [Table 12] demonstrate a brief review of various procedures carried out at various institutions in the country.
Table 2: Pediatric Neurosurgery Unit of G. B. Pant Hospital, New Delhi (Personal Communication)

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Table 3: Pediatric cases at All India Institute of Medical Sciences, New Delhi (Personal Communication)

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Table 4: Pediatric cases in Department of Neurosurgery, PGI Chandigarh, 2009 (Personal Communication)

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Table 5: Pediatric cases from 2000 to 2007 below 18 years of age at SGPGI, Lucknow (Personal Communication)

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Table 6: Pediatric cases at King Edward Memorial Hospital, Mumbai-2009 (Personal Communication)

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Table 7: Pediatric cases at Park Clinic, Kolkata-221 cases in 2009 (Personal Communication)

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Table 8: Pediatric cases at Children's Trust Hospital, Chennai (Personal Communication)

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Table 9: Pediatric cases at BGS Global Hospital (104 cases) (Personal Communication)

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Table 10: Relative incidence of pediatric tumors in India (Personal Communication)

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Table 11: Relative incidence of pediatric tumors in India (In Percentage) (Personal Communication)

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Table 12: Wadia Hospital for Children, Mumbai (Personal Communication)

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   Future of Pediatric Neurosurgery Top


The economy in the country has shown an upward surge in the last 2 years, the Sensex having reached more than 20,000. A large number of new institutions, small and large, have sprung up in the country. In the city of Mumbai, no less that five new institutions have been set up in the last few years and more are being commissioned all over the country. The number of MRI centers in the city of Mumbai is likely to be more in number than those in the whole of UK! The city of Mumbai now has at least seven 3-Tesslar MRIs and four PET CT scanners. Health industry in India is booming. Similarly, medical insurance has spread to a fairly large number of urban people, though a large proportion of rural population has still not had the benefit of the same. With globalization and liberalization of our economy, we are expecting agencies from abroad to step in and promote medical insurance. Greater number of pediatric neurosurgeons and neurologists will then tend to look after pediatric population. The scope of pediatric neurosurgery as a specialty would then be enormous.

Inspite of this impetus, pediatric surgeons and general neurosurgeons still continue to treat cases of spinal dysraphism and congenital hydrocephalus. Prophylactic detethering of an asymptomatic cord, excision of intramedullary spinal cord tumors and endoscopic third ventriculostomy have become accepted procedures. Surgery for intractable epilepsy has also become a desirable entity. There needs to be a better coordination between the pediatric neurosurgeons, neurologists and pediatricians to ensure a more complete management of sick children.

To overcome the future challenges, it is important to have more well-trained pediatric neurosurgeons in our country. The curriculum of the neurosurgery residency program must include at least 3 months of training period in a good pediatric set-up so that reasonable knowledge of pediatric material is obtained. This may even stimulate some of them to pick up pediatric neurosurgery as their specialty. High-standard teaching programs, symposia, seminars, practical workshops, etc. are essential to attract and train neurosurgery residents in pediatric neurosurgery. Special incentives like traveling fellowships, visiting fellowships, and awards should be given to encourage the postgraduate residents and trainees. These will kindle an interest in pediatric neurosurgery amongst the young neurosurgeons.

To improve awareness amongst the general population is one of the most important goals for us. This can be achieved by arranging lectures on specific topics for the pediatricians, family physicians, and other health personnel, and other similar education programs for the school children and parents. That family planning should be regularly practiced using folic acid through the period of conception is to be taught by repeated lectures, talks and newspaper articles. Ultrasonographic examination should be carried out not only during the early weeks of conception but also before 20 weeks to detect spinal dysraphism or hydrocephalus. Also, in such cases, one would like to know if any serious congenital anomaly of the heart or any other organ exists.


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]


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