|Year : 2022 | Volume
| Issue : 1 | Page : 47-50
Dr. Gajendra Sinh: A doyen of indian neurosurgery
Harish R Naik, Vernon L Velho
Department of Neurosurgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
|Date of Submission||01-Feb-2022|
|Date of Acceptance||04-Feb-2022|
|Date of Web Publication||9-Mar-2022|
Harish R Naik
Associate Professor, Department of Neurosurgery, Grant Medical college and Sir J. J. Group of Hospitals, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Naik HR, Velho VL. Dr. Gajendra Sinh: A doyen of indian neurosurgery. J Spinal Surg 2022;9:47-50
Dr. Gajendra Sinh (August 18, 1921–2013)
M.B.B.S. (G.M.C Mumbai), F. R. C. S. (Edinburgh, U.K)
Dr. Sinh was born on August 18, 1921, in Kathiwara (Gujarat), among the beautiful environs of the North-Western Vindhyachal, Alirajpur. He did his schooling at Charterhouse in England. The outbreak of World War 2 made Dr. Gajendra Sinh's return to India imperative. His college years were at St. Xavier's College, Mumbai (1940–1942). He graduated in Medicine from the Grant Medical College, Mumbai, in 1947. Dr. Gajendra Sinh obtained the Fellowship of the Royal Colleges of Surgeons in Edinburgh and England and trained to be a thoracic surgeon. On his return to India in 1955, his mentor and then Dean of the Grant Medical College, Dr. Shantilal J. Mehta, requested him to set up a Department of Neurosurgery. Dr. Mehta arranged for Dr. Gajendra Sinh to go to Vellore and work with Dr. Jacob Chandy from 1955 to 1957. Dr. Gajendra Sinh imparted his training in neurosurgery under Dr. Jacob Chandy.
| Department of Neurosurgery, Sir JJ Hospital|| |
On his return from Vellore in 1958, Dr. Gajendra Sinh [Figure 1], [Figure 2], [Figure 3] started the Department of Neurosurgery in the Yellappa Balaram Pavilion in the Sir David Sassoon Building., He was allotted just four beds in Dr. Shantilal Mehta's general surgical ward and was asked to operate in a general surgery theater after the general surgeon had completed his list for the day. The Radiology Department was in the adjacent outpatient's building, and taking patients to-and-fro for ventriculography and angiography was time-consuming and nerve-wracking. His experience mirrored that of Dr. Homi M. Dastur at Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, a year earlier.
In 1963, Department of Neurosurgery had moved to Ward 24 (for women and children) and 25 (for men) on the fourth floor of the “new” JJ Hospital building. The neurology wards (for 23 men and 24 women and children) were also on the fourth floor. The operation theaters designed by Dr. Gajendra Sinh (with Sister Gaikwad in charge) were on the fifth floor. Hailing from a princely family, Dr. Gajendra Sinh had royal tastes, a need for perfection and impatience with bureaucracy and officialdom. Dr. Gajendra Sinh created a library in the department office in Ward 25 where he placed all his books on neurosurgery, issues of the Journal of Neurosurgery, and other relevant publications for his residents to use. Since the hospital did not have instruments needed for neurosurgery, Dr. Gajendra Sinh had purchased, from personal funds, sets needed for procedures such as drilling burr holes, performing a laminectomy, and performing a craniotomy [Figure 4] and [Figure 5]. He also purchased and kept his Asahi Pentax Spotmatic camera in the department so that it could be used for photographing interesting patients and specimens and make slides for teaching. He donated his Olivetti portable typewriter to prepare summaries on each patient for maintaining departmental records. He was very strict with regard to care of patients, maintenance of records, discipline, courtesy to everyone in the department, and respect toward nurses.
|Figure 4: Set of instruments for twist drill craniotomy and video cassette|
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Contributions to neurosurgery:
- Started and headed Department of Neurosurgery at Grant Medical College, Mumbai, in 1958
- Along with Dr. Wadia and Darab Dastur, he also worked and defined protocols for tuberculosis of the central nervous system
- Surgery for congenital atlantoaxial dislocation.
Dr. Gajendra Sinh was the first neurosurgeon from India to publish largest personally operated 105 cases of congenital atlantoaxial dislocation. His article was published in neurosurgical review in the year 1983. He published his article in the Journal of Neurosurgery review. A study of literature before 1960 did not reveal any great experience in the treatment of this condition, and most authors had reported one or two cases. A single author in a single paper written in the “pre-Internet era,” was a remarkable achievement. This landmark article has withstood the test of time for more than 50 years and has been a model for several generations of spine surgeons.
The article paved the way for surgically managing congenital cases of atlantoaxial dislocation (AAD) which was fairly seen in clinical practices then and even now. He has clearly elucidated the clinical symptomatology, radiological classification, pathology, and surgical approaches in the management of congenital AAD. Diagnosis solely was made on dynamic X-rays which makes the article even more intriguing. He neatly demonstrates his innovative operative technique of anterolateral approach to the axial cervical spine region. Most characteristic feature of the article is that he has taken anterior, posterior, and anterolateral approaches to craniovertebral (CV) junction and further has clearly stated his method of choice based upon the results of each approach. In his paper, he also cites contributions of Dr. Homi M. Dastur and Dr. E. P. Bharucha who had published their article on CV anomalies in the year 1964 and also Dr. N. H. Wadia who had presented his paper on myelopathy complicating AAD in the year 1967.
His study had male preponderance, and 50% of his subjects showed symptoms before age of 20 years and rest before 30 years of age. Diagnosis was done by X-rays including tomograms and dynamic studies. He classified congenital malformations into three groups: Group I with assimilation of atlas, Group II with anomalies of odontoid process, and Group III with a normal atlas and axis.
His personal experiences showed that early treatment with posterior decompression, sometimes combined with posterior fusion, was unsuccessful and resulted in a high mortality and morbidity. He further states that his anterolateral approach described is the method of choice.
The surgical procedures done by him were posterior fusion without laminectomy, anterior fusion, anterolateral fusion, staged anterolateral fusion, and posterior decompression. He was of the opinion that initial reduction of AAD with skull traction followed by anterolateral fusion was the treatment of choice.
Keynotes of his article on congenital AAD:
- Dislocation was in fact congenital in origin, and trauma merely precipitated the onset of acute symptoms
- Presentation of symptoms in the second and third decades of life suggested that compression of the cord is gradual in onset
- Major symptoms in congenital AAD were transient attacks of paraesthesias, unconsciousness, quadriparesis and blindness either singly or in combination. Majority of the cases had a gradual progression in their symptoms
- Pyramidal signs, posterior column signs, and wasting of hand muscles were the most commonly observed signs in the study cohort
- Diagnosis was made on dynamic X-rays and myelogram was required in few cases, to rule out associated anomalies of the neuraxis and to localize the site of compression. Atlantodental interval cutoff criteria were 3 mm in an adult and 4.5 mm in children. The article also stresses that the presence of occipitalized atlas, abnormal facets, and odontoid process above McRae's or Chamberlain's line, does not denote a basilar invagination
- Autopsy findings in few cases revealed: spinal cord was distorted and thinned, presence of thickened dural bands, infarction of anterior spinal artery, and degeneration of descending tracts below the site of compression and ascending tracts above the site
- He advocated that early operation is advised in all cases of congenital AAD for reduction and fixation of the dislocation before any irreversible cord damage occurs
- The aim of the operation was to merely reduce the dislocation and fix it
- The prognosis depended on the severity of cord damage already present as a result of long-standing compression
- Earlier detection and fusion, before irreversible cord changes occurred, will greatly improve the results of these operations.
His experience on the surgical treatment of congenial AAD ranges from posterior decompression with fusion (24 cases), posterior fusion without laminectomy (10 cases), anterior fusion (11 cases), anterolateral fusion (56 cases), posterior fusion redislocated followed by anterolateral fusion (8 cases), anterolateral fusion with posterior decompression simultaneously (4 cases), and anterolateral fusion followed by posterior fusion (4 cases).
He started by decompressing the fixed variety by C1–C2 laminectomy and foramen magnum decompression (FMD). In the reducible variety, the neck was extended and occiput was fused with C2 and C3 laminae sometimes with C1 laminectomy and FMD. However, there were some disastrous experiences like respiratory arrest as soon as the compressing agent was removed which discouraged this form of treatment. These cases were autopsied and thoroughly studied and found out that massive hematomyelia was the culprit. This led them to apply skull traction in reducible variety AAD. Posterior fusion was only done when adequate reduction was obtained by skull traction with serial X-rays in wards or as and when the neurological status improved. Postoperatively, the reduction was maintained by giving the patient Minerva plaster. He observed that in many cases of posterior fusion, the graft did not take, presumably due to traction of a forward dislocation which made him to use the anterior and anterolateral approach to fuse the lateral mass of atlas to the body of the axis.
The patients were shifted to the ward with the skull traction on and maintained with reduced weights, until bone fusion occurs. Check X-rays were taken every 15 days and the end of 2½ months, the traction was removed, and a cervical collar was given.
Most of the patients in his study did make a fair or good recovery with traction and, with fusion, maintained this improvement. Eleven patients out of 105 cases died. Three patients died when a posterior decompression was done without applying skull traction who all had severe hematomyelia on autopsy. The remaining eight cases succumbed because of respiratory infections due to their underlying poor respiratory capacity.
He concluded that the anterior approach or its variations present the treatment of choice, by fixing the vertebrae after reducing the dislocation with the skull traction. Earlier detection and fusion, before irreversible cord changes occurred, will greatly improve the results of these operations.
| Honours|| |
He served as secretary of NSI from 1965 to 1975 and then elected as President of the Neurological Society of India in 1975. He also organized the 3rd Asian and Oceanian Congress of Neurology in Bombay.
Dr. Gajendra Sinh retired from his alma mater in 1977. At Dr. Shantilal Mehta's request, he started another Department of Neurosurgery at the new Jaslok Hospital in 1977. He continued to serve this hospital to his last day.
| Philosophy and Practice|| |
Dr. Gajendra Sinh's outstanding qualities were integrity, sincerity, compassion, and discipline. His loyalty to his alma mater; his teachers, especially Dr. Shantilal Mehta, and his colleagues, especially Drs. Noshir Wadia, B. N. Colabawala, J. C. N. Joshipura, Noshir Antia, and Vijay Dave, were legendary. If he had faults, he hid them successfully. He imparted his perennial philosophy. “Fight for what is right” and “Never give in to the bureaucrats,” taught many to persevere in order to improve conditions of patients and further develop the department. His students admired his ability to remain young at heart and keep the interests of his patients above all else. Over the last decade of his life, he progressively divested himself of opportunities to operate on his patients. He preferred to hand them over to younger colleagues (many of them his own students) who, as he put it, “will do a better job.” Pneumonia, “the old man's friend,” helped him lapse into a state of reduced consciousness and slip peacefully away in his sleep even as the Neurological Society of India held its annual meeting at the National Center for the Performing Arts in Mumbai. Mr. Vijay Merchant, the great cricketer, was Dr. Gajendra Sinh's neighbor. Mr. Merchant cherished the motto “Play the game.” Dr. Gajendra Sinh played an outstanding innings and did so with a straight bat. His final retirement to the pavilion on a high note was in the fullness of time and deserves applause.
We would like to thank Dr. Sunil Pandya and Dr. D.A. Palande.
| References|| |
Pandya S. Gajendra Singh. Natl Med J India 2014;27:43-4.
Tandon PN. Professor Noshir Hormusjee Wadia: A Doyen of Indian Neurology. Neurol India 2016;64:845-6.
] [Full text]
Sinh, G. Congenital Atlanto-axial dislocation. Neurosurg Rev 1983;6:211-20.
Bharucha EP, Dastur HM. Craniovertebral anomalies (A report on 40 cases). Brain 1964;87:469-80.
Wadia NH. Myelopathy complicating congenital Atlanto-axial dislocation. (A study of 28 cases). Brain 1967;90:449-72.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]