OVERVIEW

Sri Ramakrishna Hospital has stood at the forefront of medical advancement in Coimbatore. The Department of Neurosurgery is one of the oldest in the region and has rendered yeomen service to countless patients over the years. We were the first in the state to introduce microsurgery for the brain and spinal neurosurgery. We use the most advanced technology and techniques to treat a host of neurological diseases in a manner at par with global benchmarks. Our craniofacial unit was established in 2003 and today we routinely perform craniofacial surgery and reconstructive procedures for craniosynotosis. More recently, we have introduced the advanced NIM Eclepse Intra-Operative Monitoring System for enhanced safety in brain and spinal cord surgery. In keeping with our quest to provide the very best surgical care possible, we will shortly be introducing neuro navigation and the advanced ‘o arm’ in our operating theatre. Our commitment to excellence is absolute and we constantly endeavour to improve both our technology and technique.


MEDICAL CONDITIONS

There are myriad conditions which constantly present themselves to the Department of Neurosurgery at Sri Ramakrishna Hospital. The following are some of the most common in occurrence and yet complex in treatment.

The human brain and spinal column are bathed in a fluid known as cerebrospinal fluid. Sometimes there may be an unnatural buildup of cerebrospinal fluid in the cavities (ventricles) of the brain. This can cause the pressure within the skull (known as intracranial pressure) to increase. This condition is known as hydrocephalus, taken from the Greek words hydro (water) and kephalos (head).

Hydrocephalus may occur at any age but it is most commonly found in infants and older adults. It can cause an increasing enlargement of the head which may be pronounced and clearly visible. The condition is serious and can result in brain damage and reduction in brain function.

There are a number of causes for hydrocephalus, both congenital (hereditary) and acquired (occurring due to external factors). Some of the congenital conditions which cause it are Arnold-Chiari malformation, Spina Bifida, craniosynostosis and so on. Among the acquired causes are trauma to the head, tumours, cysts, meningitis and haemorrhage.

Here at Sri Ramakrishna Hospital, we routinely perform surgery to treat hydrocephalus. The most complex but efficacious procedure for treatment of this condition is the endoscopic third ventriculostomy or EVP.

Craniosynostosis is a condition affecting infants. As you may very well know, a child’s skull is fairly soft. This is due to what are known as ‘sutures’ - a kind of fibrous joint occurring in the skull. The skull’s bones are not fused at birth and are in fact joined at these sutures which in turn allow for some movement. This allows the skull to grow with the child.

Typically the bones don’t fuse before the age of two. However, in some rare instances, the sutures of babies fuse prematurely and turn into bone. This leaves no room for the brain in which to expand with growth. What can then happen is that the brain may grow in a different direction such as laterally. This results in a child with a misshapen head. If the brain can’t grow enough in another direction, it can result in an increase in intracranial pressure. This in turn can lead to seizures, blindness and even death in some rare cases. Facial deformities can affect the breathing of child and the stunted brain development could lead to a host of issues ranging from language and speech defects to a low IQ.

Most forms of craniosynostosis are ‘non syndromic’, which is a fancy way of saying their causes are unknown. A few kinds are ‘syndromic’ and are caused by certain genetic conditions.

Not all misshapen heads are a result of craniosynostosis but if your baby seems to have an unusually shaped head, it is best to consult a paediatrician. If diagnosed, surgery might be the most effective course of treatment.

An aneurysm is a weak spot on an artery. The pressure of blood forces the weakened part of the wall of the artery to bulge outwards. If you’ve ever seen an inflated bicycle tube or balloon suddenly bulge out at one section, you will get the picture. Aneurysms may occur in any part of the body but it is only in the brain that it becomes lethal. Arteries feed oxygen to the brain constantly.

When this flow is limited, brain cells immediately begin to die, which is what happens in a stroke. When an aneurysm ruptures, it spills blood into the subarachnoid cavity and this is known as a subarachnoid haemorrhage. Depending on how fast (or not) the condition is addressed, the patient may survive and enjoy good quality of life, or die. Many people develop aneurysms at some point in their lives but, until they burst, they cause little to no symptoms and go undetected for the most part. Sometimes however an aneurysm may put pressure on a sensitive part of the brain causing a host of symptoms ranging from headaches to nausea to seizures and loss of consciousness. There are various surgical procedures to treat this condition.

Brain tumours are classified into primary and secondary tumours. Primary tumours are those which originate in the brain. They could be benign or malignant and they are rarer. The most common tumours are secondary tumours, which originated in another part of the body and spread to the brain. They are all malignant as is indicated by the very fact that they have spread.

Primary brain tumours take their name from the kind of cells which cause them. Gliomas, for example, originate in the brain or spinal cord. There are several kinds of such as astrocytomas, glioblastomas, oligoastrocytomas, oligodendrogliomas and ependymomas. Then there are meningiomas which originate from the ‘meninges’ - the membranes surrounding the brain and spinal cord. They are largely benign. Medulloblastomas are the most commonly found brain tumours in children. They are cancerous, starting in the lower part of the brain and spreading via spinal fluid. Schwannomas or acoustic neuromas are benign tumours which develop on nerves leading from the inner ear to the brain and control hearing and balance. Pituitary tumours are usually benign and, as the name indicates, develop in the pituitary gland. They can be surgically excised using the transsphenoidal approach.

Secondary brain tumours comprise the overwhelming majority of brain tumours. The types of cancer which ‘metastasise’ (spread) to the brain are lung, kidney, skin and breast cancer.

The spinal cord is wrapped within three layers of protective membranes called meninges, the outer most of which is known as the dura mater. Thus, spinal tumours are named after their location relatively to the dura. Extradural tumours occur outside the meninges while Intramural tumours occur within. The former are the most common and comprise bone tumours such as the benign osteomas and osteoblastomas and the malignant osteosarcomas, chordomas, osteosarcomas and fibrosarcomas.

Intradural tumours are divided into Intramedullary and Extramedullary. Intramedullary tumours occur within the nerves of the spinal cord itself. There are many kinds of these, the most common being astrocytomas and ependymomas. Extramedullary tumours occur outside the spinal cord itself but lie within the meninges. Some of the most common are meningiomas and schwannomas. Spine tumours can be excised using a variety of techniques


TREATMENTS & PROCEDURES

The Department of Neurosurgery of Sri Ramakrishna Hospital routinely performs hundreds of operations through the course of the year. These are some of the more complex procedures which reflect the sheer calibre of our surgeons.

This is complex paediatric surgical procedure which has been carried out many a time by the neurosurgical team at Sri Ramakrishna Hospital to treat hydrocephalus. To relieve the pressure caused by the buildup of cerebrospinal fluid, an egress needs to be created. While a ventriculo-peritoneal shunt is one way to do it, it will leave the shunt in the body of the child. The EVP does away with the need for it.

In this, skilled neurosurgeons will make a tiny incision in the skull. Through, it an endoscope is passed. An endoscope is an instrument which allows the surgeon to view the insides of the body. Using microsurgical techniques, the surgeon will create an opening at the bottom of the ventricle, where the fluid is building up. This opening will allow the excess fluid to simply drain out and circulate around the brain. This will immediately alleviate the pressure. The procedure is a short one and should take no more than two hours or so. Endoscopic techniques means minimal damage is caused to the patient which in turn hastens the child’s recovery. Scarring is minimal or non-existent and the child can move to a normal life quickly.

In order to ensure the best possible quality of life for a child, surgery is most often the only option for the treatment of craniosynostosis (read more here). Our team of skilled neurosurgeons and craniofacial surgeons will examine each case and determine whether the child is to be operated upon using traditional techniques or the more modern endoscopic procedures.

In traditional surgery, the surgeons will make and incision into the scalp and skull of the baby. Having done so, they will see how best they may ‘reshape’ the skull. In doing so they may use fixation devices such as screws and plates to ensure that the bones are accurately set. They may be later absorbed by the bone itself over time.

Endoscopic surgery or minimally invasive surgery is less traumatic to the baby and offers faster recovery times but, it might not be prescribed for all candidates. In this procedure, the endoscope is used to illuminate the cranium from within. The surgeon uses this view to separate the sutures (the fibrous tissue which has become ossified) and allow the baby’s brain to develop normally. The procedure is virtually miraculous as it takes only an hour and the baby may be discharged within a day.

Our team of neurosurgeons at Sri Ramakrishna Hospital can offer patients who suffer from brain aneurysms (read more here) multiple surgical solutions. Choice of the appropriate solution is done by leading specialists in the field based on the patient’s clinical history and a host of other factors.

Neurosurgical Clipping: In this procedure, the surgeon will place a metal clip at the base of the aneurysm, thereby taking the pressure off the weak spot and ensuring it does not burst. Traditionally this would be done by accessing the aneurysm via a craniotomy (surgical opening of the skull). However, today’s minimally invasive techniques allow surgeons to access aneurysms with less trauma to the patient’s skull. Mini craniotomies are a viable option as are access via tiny incisions above the eyebrow. All these allow for faster recovery of the patient and less scarification which in turn means better quality of life.

Endovascular Coiling:A more advanced technique practised by surgical experts at our facility is ‘endovascular coiling’. In this, a neurosurgeon makes an incision in the groin of the patient and then guides a catheter to the location of the aneurysm. Then, a material which throws up contrast is injected to give the surgeon a clear view of the aneurysm. When this is accomplished, a number of thin metal wires are used to fill the aneurysm. As the fill it, they coil into a ball of wire mesh (hence the name). This is then sometimes reinforced with either stents (mesh tubes) or balloons. Coiling allows patients to recover quicker and on average they leave hospital within a couple of days of the procedure, as opposed to the five or six it takes after the traditional method.

Pituitary tumours cause a number of hormonal problems to the patient and their location is such that they can compress vital nerves in the brain. Surgical excision of a pituitary tumour is the best solution for any patient suffering from one. Its location however makes this a little complex.

Traditionally, the procedure would involve making an incision under the lip before removing a large part of the nasal septum in order to view and access the tumour. However, the latest endoscopic techniques have yet again yielded a far more subtle approach. One which we at Sri Ramakrishna Hospital are proud to have pioneered in South India.

In the Transsphenoidal approach, a neurosurgeon and an ENT surgeon work together as a team to approach the tumour through the nasal cavity. The ENT surgeon with special training performs the first part of the surgery where he uses an endoscope to surgically go through the sphenoid sinus. The neurosurgeon then uses special microsurgical techniques to collapse and excise the pituitary tumour using the path opened by the ENT surgeon. This approach reduces trauma to the patient by orders of magnitude and discharge happens within two days of the procedure. It is performed routinely with great success at our institution.

Lumbar microdiscectomy is routinely performed at our hospital. Using microsurgical techniques, we approach the disc via a small opening in the posterior. The nerve root is usually compressed by fragments which we remove. The change is immediately apparent and patients are able to recover movement in a speedy manner, with discharge happening shortly after.

Cervical spine surgery covers a broad array of conditions ranging from degenerative disc disease to trauma to tumours and ossified posterior longitudinal ligament and deformity. Microdiscectomy is routinely performed here to address these conditions. The approach to the disc is from the front. An accurate level is arrived at with the use of intra-operative imaging. Using a microscope the disc is removed following which an autologous bone graft or cage is used to reconstruct the area.