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| EDITORIAL |
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| Year : 2019 | Volume
: 2
| Issue : 2 | Page : 111-113 |
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From plaster beds to robotics… evolution of spine surgery in India
Raghava Dutt Mulukutla
Department of Spine Surgery, Udai Omni Hospital, Hyderabad, Telangana, India
| Date of Web Publication | 23-Jul-2019 |
Correspondence Address:
Dr. Raghava Dutt Mulukutla
Udai Omni Hospital, Chapel Road, Hyderabad - 500 001, Telangana
India
 Source of Support: None, Conflict of Interest: None  | 6 |
DOI: 10.4103/isj.isj_47_19
How to cite this article:
Mulukutla RD. From plaster beds to robotics… evolution of spine surgery in India. Indian Spine J 2019;2:111-3 |
Most of the revolutionary ideas and advances in the management of spinal disorders took place in the last 5 decades.[1] Some of our very senior spine surgeons still remember treating patients with tuberculosis of spine in plaster beds for months end on (Personal communication: Prof. P. Ranga Chari). Gone are the days when paraplegics and quadriplegics had to die a slow miserable death.[2] Spine surgery has progressed slowly till the 70s and very rapidly in the 1980s and the spine surgeons from India surely kept pace. The Indian spine revolution took off in the mid-90s, and today, the country can boast of some of the best spine surgeons and spine surgery training centers in the World.
| The Beginning | |  |
Most of the spine surgeries up to the 70s were restricted to the treatment of tuberculosis of the spine. Majority of spinal debridement and fusion were performed by the posterior approach. Orthopedic surgeons graduated slowly but surely to anterior procedures and thoracotomy, debridement, excision of diseased vertebrae and decompressions became a routine in some of the teaching hospitals.[3] Surgery for the slipped disc started around the same time and the surgeons at that time had no access most times to X-ray machines in the operating theaters, and had to rely on bony landmarks to determine the levels (Personal communication: Prof. KBP Rao). Prophylactic laminectomies and discectomies were a norm, a routine 2 level laminectomy and discectomy for L4-5-S1 disc pathology was the rule. A thorough and wide laminectomy was the standard teaching, and most incisions were 4–6 inches long. Neither much importance was given to the preservation of paravertebral muscle mass nor to the preservation of facet joints.[4] From this early experience, surgery for correction of deformity was undertaken mostly in major cities such as Mumbai and at AIIMS in Delhi. Most of the deformity corrections were done using Harrington rods and use of sublaminar wires.[5] The Luque system, when introduced was a boon for the treatment of paralytic scoliosis, which was quite prevalent in those days and gained wide acceptance in India.[5]
| Disease Burden of Spinal Ailments | | |
Evolution of diagnostics
The significant advances in radiology contributed to the rapid growth of spine surgery in India. The availability of computed tomography (CT) scans in the late 70s and the early 80s and the subsequent introduction of magnetic resonance imaging (MRI), bone scans and positron emission tomography CT helped the spine surgeon with the diagnosis and understanding of the morphological extent of the disease process.[6] Before the introduction of MRI, neural imaging for spine used to be contrast radiography or a CT myelography. After the advent of MRI, the spinal neural imaging has become more simple, avoiding the invasiveness associated with CT myelography or contrast radiography.[7] Although the initial MRI scanners were of low magnet strength, many of the urban centers in India today are equipped with scanners with a magnet strength of 1.5 or 3 Tesla which provide high contrast neural imaging.[7]
From the mid 80s, image intensifiers slowly made their way into big multi-specialty hospitals. Today, every hospital, including district hospitals, can boast of a high-quality image intensifier. This has helped the Indian spine surgeon immensely in identifying the correct levels during surgery, in performing biopsies, in the placement of implants, in doing spinal osteotomies, vertebral column resections, and in correction of complex spinal deformities. With the availability of high-end CT scanners and three-dimensional (3D)-formatted CT images, 3T MRI scans, MR neurography, angiography, and tractography [Figure 1], the Indian spine surgeon today has the best and most up to date technology available.[8] Unlike, the most advanced countries of the West, the scans are done at less than a tenth of the cost and without any waiting times. Three-dimensional formatting of CT images has led to the development of 3D printing leading to the development of implants of the desired material in a desired shape and size to fit the region of interest and also in preparation of Jigs to implant pedicle screws.[9] | Figure 1: Magnetic resonance tractography in a previously operated patient
Click here to view |
Evolution of surgical training
Earlier in the 80s and 1990s, majority of the surgeons traveled abroad for training in spine surgery. Even though, the trend continues till date, with the arrival of AO Spine and through the Association of Spine Surgeons of India (ASSI) seminars, workshops, cadaver, and saw bone hands-on training programs and spine outreach programs the young spine surgeons were helped not only to understand the nuances of spine surgery but also in acquiring up to date knowledge in spine.[10] ASSI verified and approved spine centers across the country are training young surgeons. In addition to the long-term fellowships, this association also provides short-term training in different national and international centers.
Over the last few years, the National Board of Examination, India, has started dedicated super specialized training in the field of spine surgery in various tertiary spine centers across the country.
| The Surgical Practice | | |
In the Metros and big cities, most spine surgeons today enjoy modern theaters, good quality instruments, and trained staff. The surgeon in these hospitals is also supported by experienced anesthetists, and intensivists who are trained in pain management and are providing optimum care for these patients. Neuromonitoring is now being increasingly used in deformity corrections in various centers in India and minimally invasive surgery is getting popular and better.[11],[12] The use of growth rods of various types and techniques, spinal osteotomies, correction of complex spinal deformities, and vertebral column resections are now a routine in most of these centers. Spinal navigation systems, use of ultrasonic scalpels, microscopes, and even robotics [Figure 2]a, [Figure 2]b, [Figure 2]c are available to the Indian spine surgeon today.[13],[14],[15] | Figure 2: (a) Severe kyphotic deformity in a child with paraparesis. (b) Robotic placement of screws (c) deformity correction using Spinal osteotomy
Click here to view |
| Research | | |
Spine surgeons in India have started collaborating with allied departments and publishing their work in International journals.[16] Work on diffusion imaging first started in Hyderabad and subsequently taken up by other centers in India is one such example.[17] Work on chondrocyte culture in laboratories to genes involved in degeneration of disc, multicentric studies on drug regimens in tuberculous infections of the spine, research into robotic exoskeletons, designing of implants for spine surgery are just few of the examples of research in the field of spine surgery by the Indian spine surgeons.
| The Future | | |
Most spine surgeons in India work as solo practitioners. It is important for the Indian Spine surgeon to create spine units. A group of spine surgeons, with interest in various subspecialties of the spine can pool their talent and resources which in turn, would help create centers of excellence in India. It is time major spine centers in India divert some of their energies to research as well.
With an increasing number of presentations and guest lectures in conferences both in India and worldwide, publications in international journals, ASSI with over 1600 members co-branding and collaborating with spine associations worldwide, Indian spine surgeons have a come long way. From writing chapters in text books, publishing texts in various topics in spine such as minimally invasive spine surgery (MISS) and spinal cord injury, publishing monographs in spine for international readership, the journey and the evolution has been outstanding and most rewarding.[18] With the creation of centers of excellence and structured training programs in spine surgery, Indian spine surgeons today are teaching and training a large number of young spine surgeons from both within and from outside the country.
| References | | |
| 1. | Tarpada SP, Morris MT, Burton DA. Spinal fusion surgery: A historical perspective. J Orthop 2017;14:134-6.  |
| 2. | Prabhaka MM, Thakker TH. A follow-up program in India for patients with spinal cord injury: Paraplegia safari. J Spinal Cord Med 2004;27:260-2. |
| 3. | Tuli SM. Tuberculosis of the spine: A historical review. Clin Orthop Relat Res 2007;460:29-38. |
| 4. | Kambin P. History of Surgical Management of Herniated Lumbar Discs from Cauterization to Arthroscopic and Endoscopic Spinal Surgery. 2 nd ed. Totowa, NJ: Humana Press Inc.; 2005. |
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| 8. | Rajasekaran S, Kanna RM, Shetty AP, Ilayaraja V. Efficacy of diffusion tensor anisotropy indices and tractography in assessing the extent of severity of spinal cord injury: An in vitro analytical study in calf spinal cords. Spine J 2012;12:1147-53. |
| 9. | Amelot A, Colman M, Loret JE. Vertebral body replacement using patient-specific three-dimensional-printed polymer implants in cervical spondylotic myelopathy: An encouraging preliminary report. Spine J 2018;18:892-9. |
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| 11. | Muthukumar N. Multimodal intraoperative neuromonitoring during surgery for correction of spinal deformity: Standard of care or luxury? Neurol India 2017;65:80-2. [ PUBMED] [Full text] |
| 12. | Sardhara J, Dube S. Minimal invasive spine surgery. Neurol India 2018;66:1219-21. [Full text] |
| 13. | Johari AN, Nemade AS. Growing spine deformities: Are magnetic rods the final answer? World J Orthop 2017;8:295-300. |
| 14. | Ailawadhi P, Agrawal D, Satyarthee GD, Gupta D, Sinha S, Mahapatra AK, et al. Use of O-arm for spinal surgery in academic institution in India: Experience from JPN apex trauma centre. Neurol India 2011;59:590-3. [ PUBMED] [Full text] |
| 15. | Modi JV, Patel KR, Patel Z, Soman SV, Tankshali KV. Spinal Decompression using Ultrasonic Bone Scalpel: A Novel Ultrasonic Surgical Device. J Spinal Surg 2016;3:140-3. |
| 16. | Garg B, Batra S, Dixit V. India contribution to spine surgery: 15 most influential articles. J Clin Orthop Trauma 2017;8:181-4. |
| 17. | Vadapalli R, Mulukutla R, Vadapalli AS, Vedula RR. Quantitative predictive imaging biomarkers of lumbar intervertebral disc degeneration. Asian Spine J 2019. doi: 10.31616/asj.2018.0166. [Epub ahead of print]. |
| 18. | Pandya SK. The ASSI monographs. Neurol India 2018;66:898-901. [Full text] |
[Figure 1], [Figure 2]
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