|Year : 2022 | Volume
| Issue : 3 | Page : 182-184
Prof. V K Khosla - An epitome of excellence and perfection
Director of Neurosurgery, Fortis Hospital, Mohali, Chandigarh, India
|Date of Submission||19-Apr-2022|
|Date of Acceptance||04-Jun-2022|
|Date of Web Publication||13-Sep-2022|
Director of Neurosurgery, Fortis Hospital, Mohali, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pathak A. Prof. V K Khosla - An epitome of excellence and perfection. J Spinal Surg 2022;9:182-4
One needs volumes to elaborate upon the contributions of Prof. V K Khosla in the field of neurosurgery. The story of development of neurosurgery in North India would remain grossly incomplete without mention of his pioneering innovations, visionary advancements, and accomplishments for the growth of neurosurgery, particularly at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh.
His curiosity and interest in neurosurgery got kindled by systematic clinical teachings from none other than legendry Prof. S Balaparameshwar Rao at the Andhra Pradesh Medical College, Vishakhapatnam, of which he is an alumnus. The urge to take up this tough specialty in the pre-computed tomography (CT) scan era was a challenge in itself and also a bold choice. However, as mentioned by him, the methodical case discussions by Prof. Rao incited him with the innate desire to join neurosurgery and he fulfilled his dream, by joining the Department of Neurosurgery at PGIMER, Chandigarh, first as a senior resident in 1975 and subsequently got appointed as a lecturer in 1977.
Those were the days when neurosurgery, and spinal surgery in particular, was yet to flourish with appropriate biotechnological advancements in comparison to the present level. Hence the tools and appliances for stabilization of spine was a major challenge. More so, imaging technology was still to come up for appropriate support. Prof. Khosla proved his excellence when he used simple innovative techniques for anterior approaches to cervical spine and CV junction. In those days, when CT was in its primitive form and magnetic resonance imaging was yet to be available, he would use X-ray tomogram to define the abnormal anatomy of CV junction, make a full picture of the distortion of anatomy in his mind, and then intervene. Undoubtedly, his readings of the pathology on tomography always proved to be accurate on the operating table.
The credit for establishing anterior cervical spine procedures, especially in North India, goes to Prof. Khosla who started these procedures way back in the late 1970s. Portrayal of his role in cervical spine surgery is in itself a complete journey of evolution of cervical spine surgery from its infancy to its present status, he being always in the forefront of advancement at each step.
The most common procedure established by him was simple anterior cervical discectomy without fusion. However, one has to imagine the challenges of even excising a hard, partially calcified cervical disc without a drill in his times. Undeterred, he would use a simple curette to core out the hard disc and also smoothly remove the posterior osteophytes compressing the spinal cord without any postoperative neurological deficit. The outcome was always excellent and even the then Head of the Department of Surgery of PGIMER, Chandigarh, who went under his knife, remains free from radiculopathy for more than 30 years.
The importance of fusion surgery in cervical spine was soon realized by Prof. Khosla and very soon he started the regular use of Cloward's procedure whereby a cylindrical trough would be created between two vertebral bodies centering over the disc space using a dedicated burr. The exposure allowed a wide room for decompression of a myelopathic spinal cord, especially in the earliest days without a microscope. The bony fusion was ensured in a perfect way using an appropriate size bi-cortical bony dowel graft which was harvested from the iliac crest to fill the interbody gap.
Not very soon from there, Prof. Khosla switched over to regular bony anterior cervical fusion by Smith–Robinson technique whereby the discectomy was done in a routine method without damaging the endplates of adjacent vertebral bodies. This was followed by harvesting a neat, appropriate size slice of cortico-cancellous bone graft from the iliac crest through a separate linear incision behind the anterior superior iliac spine. The said bone graft would then be sandwiched into the intervertebral space by impacting it. The results were amazing with a solid bony fusion in few months' time. The only major drawback was the chances of dislodgement of the bony graft in the early postoperative weeks and he could even predict such a complication much before it would happen. I still remember operating on a patient for a double-level Smith–Robinson technique. While on rounds, Prof. Khosla was suspicious of dislodgment of bony graft based on the postoperative X-ray images. Lo and behold, one of the bony grafts did get dislodged in the very 1st week of surgery needing re-exploration and repeat fixing.
Nothing could stop Prof. Khosla from venturing into newer concepts and novel ideas for more complex procedures. To highlight some of his fascinating techniques, he would perform cervical corpectomies much to realize that the main challenge was to fill in the gap with suitable strut and hold it in place. He would, therefore, decide for iliac crest bone graft which would be suitably shaped and impacted in the gap created by the corpectomy. The next issue was how to hold on to this bony graft in its place. To overcome this hurdle, he would use an on-lay rib graft and fix it with screws to the front of adjacent vertebral bodies, something similar to what is presently done using cervical plates and screws [Figure 1]a and [Figure 1]b. The surgery and postoperative images were so immaculate that even a visiting professor to the Department of Neurosurgery of the stature of Dr. Derek Gordon from Belfast, would wow on seeing the postoperative images on a ward round. However, one of the discomfort that the patients faced was that they had to be on skull traction till almost 4 weeks, till the onset of bony fusion.
|Figure 1: (a and b) A glimpse of innovative scatch prepared by Prof. V.K.khosla on-lay rib graft fixation with screws to the front of adjacent vertebral bodies, something similar to what is presently done using cervical plates and screws|
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Not only that, Prof. Khosla mastered a unique technique of fixing the bridging bone graft to the adjacent vertebrae using thin steel wires. One can imagine that it is not technically easy to drill holes in the vertebral bodies with handheld drills, but a master craftsman like him would make it look easy and simple. As it happens with experience, not only confidence builds up but also one becomes bold enough to take up more challenges. Hence, not very soon Dr. Khosla was regularly using longer bony grafts for multi-level cervical corpectomies with ease.
Harvesting bone graft from iliac crest has always been criticized not only for cosmetic reasons of an extra scar/incision but also for discomforting symptoms related to graft site. To overcome this problem, Dr. Khosla introduced a pioneering idea of bridging the cervical corpectomy gap with K-wire and acrylic block. The K-wire would be bent into a loop and its ends navigated to the adjacent vertebral bodies. This would be followed by molding a dough of acrylic cement around this strut of K-wire and give it the shape of a vertebral body. The loop would not only hold the acrylic graft in place but also prevent graft rotation and migration of K-wire [Figure 2]a and [Figure 2]b. He even ventured to carry out such procedure for caries spine involving the vertebral body and would share his innovation in scientific meetings to silence his critics.
|Figure 2: (a and b) Another conceptual design for cervical interbody fixation prepared by Prof. V.K.khosla|
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Cadaveric workshops were not a regular phenomenon of his times yet Dr. Khosla, as a neurosurgeon, endeavored to practice cadaveric dissection for proficiency in transoral approach to the dens and achieved the feat of performing the first transoral odontoidectomy in North India. After securing permission from the Department of Anatomy at PGI, when he planned to practice on a cadaver, he faced the problem of getting access to the odontoid through transoral route as the cadaver was rigid. The jaw had to be dislocated to gain access enabling him to rehearse to his desired level of perfection before embarking for surgery on a patient.
Professor Khosla is an inborn neurosurgeon. His methodical, meticulous, and textbook pattern surgical steps is a joy to the eyes for his assistant. The clean surgical field, which is always dry and neat, defies the best anatomical dissections. His art of neural tissue handling is a narrative in itself. His surgical acumen always gets reflected in the perfect, smooth, uneventful outcome of his patients. His neurosurgical expertise got bolstered by his formal fellowship in Skull Base Surgery under renowned Prof. Hakuba in Osaka, Japan. This feat was further crowned by an award of Diploma in Skull Base Surgery from Osaka City Medical University, Japan. These were unique achievements for any Indian neurosurgeon.
One has to realize that when the trainees are of the category of Colonel in the army, then nondirective teaching is the best option. Teaching was a passion for Prof. Khosla and he would use his innovative skills in teaching technology to achieve the best. Needless to say, Prof. Khosla never compromised his strict and reserved posture when it came to his role as teacher/trainer in the ward, operation theater, or clinical bedside teaching sessions. His art of teaching had an originality. Like the changing gears of a car, he would start with simple questions and gradually cascade to higher levels, challenging and encouraging the minds of the residents. What seemed to be a harsh session of academic bombardment was actually laced with hidden message of electrifying stimulation on the trainee in question, urging him to wake up from his slumber of ignorance. But the intricate beauty of his teaching method lay in the fact that instead of enduring a feeling of loss and dejection the trainee got motivated to accept the challenge and feel determined to fight back and win. His watchful eyes would always spy for any lapse in patient care and the same eyes would never blink or dose off with tiredness even after a long days' surgery.
One has to have the acumen to ably administrate and it needs guts to prove your mettle in this area. As a shrewd administrator, Prof. Khosla would scan the minds and personality of his subordinates and trainees and formulate strategies to exploit their potentials. Delegation of duties and responsibilities, distribution of work, allotment of projects, and above all the development of the Department and the Institute was his prime target. His foresight helped modernize the Department of Neurosurgery with number of advancements, namely establishment of dedicated and modern Neurointensive care unit, installation of Gamma Knife Radiosurgery Unit, initiation Neuroendoscopy, conceptualization of Advance Trauma Centre & the Neurosciences Centre, etc., to name a few. Undoubtedly, he was the perfect blend to rise to the post of the President of prestigious Neurological Society of India.
The famous proverb says “Speech is silver, silence is golden.” When situation demands the virtue of speaking well, rightly and effectively also includes the capacity to stay silent. Besides earning respect and acceptance, one is a slave of the words he utters while being a master of those he chooses not to speak. Prof. Khosla believes in the philosophy of golden silence. Whether it is an administrative meeting or scientific discussion, he would be the last and final word after maintaining a solemn silence till he heard opinion from the rest. He would silently gauge the abilities and paucities of his junior colleagues and trainees and craftily endeavor to recuperate on their performance. When it comes to giving a piece of good advice, he would choose the most apt and prudent words to reign over the mind of the person for his benefit.
At the end, one cannot deny that all those who have come in association with Prof. Khosla have definitely learned and benefitted in some form or the other, from his great skills and talent as well as his multifaceted personality.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2]