Evolution of neurosurgery

Dr Venkataramana NK, Vice Chairman & Chief Neurosurgeon, BGS Global Hospitals, speaks on the advancements in neurosurgery over the last three decades, the role of technology in its progress and the growing implementation of the speciality to offer better patient outcomes

Brain, being the most complex of all organs, continues to be an intriguing subject of scientific curiosity and is, therefore, a focus of massive research efforts around the world. Also, despite the development of incredibly powerful imaging and other technologies, there are several key aspects of the brain’s functions that remain inscrutable and beyond our understanding. The brain, in short, is simultaneously the most pursued and elusive organ in the living world.

Neurosurgery was said to have begun as trephination wherein crude instruments made out of stone and metals were used to open the skulls. In fact when I joined neurosurgery, skull opening was done by mechanical means. Therefore it used to take several hours for opening and closure and the instrumentation was not as robust as it is today. Hence the famous statement that neurosurgeons operate by the calendar has completely gained speed to minutes by clocks and advances have come a long way indeed, to levels of highest sophistication that could not have been imagined. Technical advances in the last few decades, however, have dramatically swung the balance in favour of doctors, bringing mortality rates down to extremely low levels making neurosurgery as the best and elegant speciality.

Significant advances in anatomy, physiology and neurochemistry have without doubt paved the way for rapid progress in neurosurgery and neuro pharmacology, helping doctors to deal effectively with a host of diseases that afflict the nervous system. However, though our understanding has advanced from the gross to the molecular and genetic levels there continues to be a considerable lag between diagnosis and treatment—that is, between our capability to detect a disease and treat it efficaciously. This area warrants immediate and concerted attention.

With imaging tools like CT Scan and MRI, which are boons to make accurate diagnosis, surgeons are now armed with a battery of cutting edge tools that provide three-dimensional information and help them plan their surgical strategies. Technologies like structural imaging, FMRI, tractography (diffusion tensor imaging) and integrated navigation are reshaping the paradigm of neurosurgery, enabling neurosurgeons to achieve unprecedented levels of precision with minimally invasiveapproaches.

The advent of the microscope has heralded a new era of microneurosurgery, oriented to microsurgical anatomy and microinstrumentation.

Meanwhile, new illumination and magnification technologies have lit up even the darkest and remotest nooks of the brain, making them accessible to the surgeon. Advances in developmental optics have made neuro-endoscopy possible and this is now being used for intraventricular and pituitary surgeries.

Stereotactic surgery is based on the principle of approaching a target with planned co-ordinates. CT and MR-guided stereotactic surgery has now evolved into functional neurosurgery, neuro modulation and minimally invasive neurosurgery. Such breakthroughs have taken the concept of micro-neurosurgery to an all-new plane of refinement. Microelectrode technology has made instant intra-operative physiological verifications possible and new therapies like deep brain stimulation (DBS), vagal nerve stimulation (VNS) and sacral nerve stimulation (SNS) have had a profound impact on successful treatment and management of extremely serious brain conditions.

With technology adoption, modern operation theatres are beginning to look like a scene from a science fiction movie—loaded with large arrays of gadgets including the neuro navigation system, ultrasonic surgical aspirator, lasers, high-speed pneumatic drills, micro dopplers and intra-operative electro-physiological monitoring systems. Neuro navigation has enabled computer-assisted neurosurgery with real-time feedback. Intra-operative ultrasound and intra-operative MRI are also available, in addition, to assist the surgeon. Micro Electro Mechanical Systems (MEMS) have spawned a new era for micro devices and implants.

Invasion of such technology revolutionised spine surgery, from paediatric to geriatric groups offering solutions that enhance quality to life tremendously. Variety of implants are now available to strengthen, stabilise and keep the spine as flexible and agile as possible. Moreover, these sophistications not only improved the quality of spine surgery but also dispelled many myths and misconceptions about spine surgery.

Modification of receptors, genes, neural proteins and transmitters will be the key therapeutic interventions in the future even as nano technology, new drug delivery systems, and targeted therapies emerge as weapons of super-selective choice for precisely targeting neurological disease. Thus neurosurgery entered into nanosphere – nano neurosurgery.

Similarly, although transplantation is now a reality for all organs, as far as the brain is concerned it has never gone beyond the realms of science fiction. The knowledge acquired from the progressive research on stem cells promise to resolve several issues that hinder effective therapeutic neuronal transplantation for disorders like Alzheimers, Parkinson’s Disease and brain and spine injuries. The identification of adult hematopoietic mesenchymal derived stem cells have several unique characteristics and hold the potential to form and regenerate neural cells. This has stirred new hope for several complex neurological diseases, which have been labelled as incurable. The secretomes from the stemcells are potential hope for future treatments. Extensive research is on to use the technology to regenerate the brain and modify the course of major neurological diseases – molecular and cellular neurosurgery.

A phenomenal progress has happened in the field of neurovascular surgery with the development of micro catheters and the coils. Endovascular neurosurgery has become the order of the day for many neurovascular diseases. Major advances in the precise and safe delivery of radiation has made possible to shrink some of the small brain tumors without opening the skull – radioneurosurgery.

Neuro critical care has made a big leap forward, improving the post operative outcomes. Multi-modality monitoring has facilitated brain protection and promotional recovery improving the quality of life. Microdialysis offers an inner eye that reveals the brain metabolism in physiological and pathological conditions real time, allowing suitable modifications time to time.

Neurosurgical training has now become a mixture of all these specialities offering clinical, technological, operative and research skills. Sub specialisation is being encouraged to improve focus, quality and research. Concepts like brain death are getting established, facilitating organ transplantation.

Brain is a crown jewel in creation and evolution. Inspite of several advances over the century, it continues to be an unfathomable organ, holding several mysteries in its depths. I am fortunate to be a neurosurgeon working with the human jewel and to be a witness for such phenomenal developments. It has been a fascinating journey of three decades to watch the progress and development. The experience is something exceptional. It has been a fantastic experience and an incredible journey of learning. Neurosurgery has moved steadily up the ladder from trephination to a stage when transplantation does not sound completely out of bounds, on a series of pathbreaking steps from macro neurosurgery and micro neurosurgery to endo neurosurgery, nano neurosurgery, molecular neurosurgery and currently cellular neurosurgery, which has made neural regeneration a reality. The progress in the future promises to be even more exciting, marked by the emergence of new, integrated, remotely-driven and miniaturised technologies which may open up possibilities that are currently beyond our imagination. Nothing can be more fascinating than to be a part of this exciting journey that may fuse science and fiction into a new super reality.