Keywords
neurotrauma - trauma audit - traumatic spinal injury
Introduction
History and Overview
All India Institute of Medical Sciences (AIIMS) Raipur was established by an act of
Parliament in 2003 under PMSSY (Pradhan Mantri Swasthya Suraksha Yojna). The Department
of Neurosurgery at AIIMS, Raipur, was started on September 4, 2017 with the appointment
of Dr. Anil Kumar as assistant professor and now the department has grown to strength
of six faculty members. Since then the department has come up with flying colors for
the treatment of neurosurgical diseases that needed surgeries such as tumors, vascular
neurosurgery, endoscopic skull base surgeries, pediatric neurosurgery, spine surgery,
and brachial plexus injuries. In this article, we would like to highlight the resources
(manpower, infrastructure) available for neurotrauma, the challenges ahead, and vision
for future
Infrastructure and Resources
Infrastructure and Resources
The neurosurgery department literally started from scratch. Initially the department
had no beds and other departments generously allowed sharing of their ward beds with
neurosurgery. Soon after inception, department was allotted one operating day per
week. Within 2 weeks of inception of department, first spinal surgery was performed
with generous support of orthopaedic department who agreed to share equipment. Cranial
surgery was started 2 months later when department got necessary and basic equipment
for the same. Initially neurosurgical operations such as surgery for gliomas, meningiomas,
vestibular schwannomas, and microvascular decompression were performed with assistance
of surgical loupe as operating microscope was not available. Six months later, endoscopic
skull base surgeries were started with the support of ENT department.
Currently, the neurosurgery in-patient has 30 general ward beds and one daily operation
theater (OT). Presently, there is no dedicated neurosurgery intensive care unit (ICU).
There are five outpatient days and five operating days per week allocated to the department.
Patients are admitted from the outpatient clinic and emergency services daily. Department
is equipped with state-of-the-art neurosurgical equipment ([Fig. 1]). No epilepsy surgery or stereotactic and functional neurosurgery is being performed
because of lack of resources and equipment. For emergency cases, one theater has been
allotted at present. Any emergency case from various departments are being done in
these theaters.
Fig. 1 Neurosurgical operation theater.
The Road Traveled So Far
The department was started from scratch with minimal resources. There are now 30 beds
and additional private ward rooms. The demand for outpatient services and inpatient
care has been progressively increasing over the period of 2 years. The department
actively pursues clinical care and research activities in the subspecialties of skull
base, vascular, endoscopic, complex spine, and peripheral nerve surgeries among others.
The department specializes in all fields of neurosurgery that include neuroendoscopy,
neurovascular surgery, minimally invasive neurosurgery, spine surgery, skull base
surgery, pediatric neurosurgery, peripheral nerve and brachial plexus surgery, neurotrauma,
neuro-oncology, and surgery for pain and spasticity. Currently, the department is
conducting its work with six faculty members. The department has an exemplary track
record of organizing major academic activities, including national symposia, conferences,
Continuing Medical Education (CME) programs besides participating actively, and making
its presence felt at various forums. Department has organized endoscopic skull base
conference with live operative and cadaveric workshop (September 6–7, 2019) and 1st
Annual Brain Tumor Symposium (February 2019) ([Fig. 2]). Public awareness programs on brain tumors were also undertaken.
Fig. 2 Glimpse of endoscopic skull base conference with live operative and cadaveric workshop
(September 6–7, 2019).
Trauma Audit
Within the spectrum of trauma-related injuries, traumatic brain injury and spinal
cord injury are the largest causes of death and disability, leading to suffering by,
and costs to, the individual, their family, and society. The comprehensive management
of traumatic brain and spinal cord injury requires human resources, infrastructure,
adequate emergency, and neurointensive care aimed at enhancing capacity in all these
components. Because resources are limited, the next elementary question is how to
establish priorities so that these areas can advance in parallel.
Retrospective analysis was performed of all patients who were admitted for head injury.
From the beginning, we had no beds specially dedicated to trauma and there was a lack
of ICU facility and nonavailability of OT in emergency. Department was allotted four
beds dedicated to trauma from September 2019 and availability of OT full time. In
last 2 months, 62 patients were admitted for head injury, out of which 38 patients
were operated upon. Distribution of trauma patients was male:female (6:1). Most of
them belong to 20- to 30-years age group (40%). Most common mode of trauma was road
traffic accident (75%). Most common indications for surgery were contusion—15 (40%)
(including burst contusion) followed by posttraumatic chronic subdural hematoma—14
(37%), extradural hematoma—4 (10%), acute subdural hematoma—3 (8%), and two patients
(5%) operated for depressed fracture ([Table 1]). Out of these, three patients had expired, one patient had bifrontal contusion
with preoperative Glasgow Coma Scale (GCS) E1M2vt, one patient had right burst temporal
lobe with similar GCS, and one patient expired after evacuation of left frontal and
temporal contusion with preoperative GCS E1M3V1. All patients had poor GCS. Long-term
outcome is difficult to access due to short duration of follow-up.
Table 1
Distribution of disease in operated cases
|
Diagnosis
|
Number of patients (%)
|
|
Abbreviations: EDH, extradural hematoma; SDH, subdural hematoma.
Note: Contusion includes burst contusion.
|
|
Contusion
|
15 (40)
|
|
Chronic SDH
|
14 (37)
|
|
EDH
|
4 (10)
|
|
Acute SDH
|
3 (8)
|
|
Depressed fracture
|
2 (5)
|
Traumatic Spinal Injury
Fourteen patients were admitted for traumatic spinal injury, out of which eight patients
were operated. Most common diagnosis was cervical subluxation in five patients (62%)
and lumbar fracture in three patients (38%). Most of spinal injury patients operated
in routine OT.
Peripheral Nerve Injury
Till now five patients were operated upon for posttraumatic brachial plexus injury;
out of these three patients had complete brachial plexus injury and underwent nerve
transfer with the use of sural nerve graft. In follow-up, four patients showed improvement.
Two patients underwent microsurgical DREZotomy for posttraumatic brachial plexus injury
neuropathic pain, out of which one patient had complete pain relief on 8 months follow-up,
while other reported only partial relief.
Challenges Faced and Vision for Future
Challenges Faced and Vision for Future
The challenges in trauma management in a new and developing center are centered on,
but not limited to, inadequate prehospital trauma care protocol, lack of trained staff,
inadequate healthcare infrastructure, limited manpower, and difficulty in applying
approved guidelines due to limited resources. There are enormous challenges to significantly
advance neurotrauma care, specifically in new and developing center. The determinants
of favorable outcomes following neurotrauma include the immediate emergency care,
the expertise of manpower, availability of adequate infrastructure, and appropriate
facilities for specialized care. Robust intensive care and round the clock availability
of OT are the major pillars for neurotrauma care. These deficiencies in neurotrauma
care were mitigated to some extent and full-fledged neurotrauma care was started in
September 2019. Rehabilitation of neurotrauma victims is another crucial factor and
rehabilitation should start during the course of a hospital stay and carry on actively
after discharge.
Training of manpower in acute neurotrauma care services should be a priority. We aim
to deliver the best care for trauma patient with highly equipped emergency and critical
care units with ample amount of man power. There is desperate need of 24 hours available
neuroanesthetist, critical care experts, neuro nurses, neurosurgical ICU, and dedicated
neurosurgery OT. The department is committed to the advancement and promotion of neurosciences
in the country.
