In our modern developed world we have achieved very high standards of care for our neurosurgery patients. But, how do the developing countries handle their neurosurgery patients. How did they develop neurosurgery services? Do they have properly trained neurosurgeons and staff? What are the issues that need to be addressed? This is a historical article and traces development of neurosurgery in Sri Lanka.   The authors performed a literature search. The history is presented in three phases, prior to 1956, from 1956 to 1979 and after 1979.

     

     

     

     Sri Lanka is an independent island nation situated in the Indian Ocean at geographical coordinates of 7 00 N, 81 00 E. It expands to a land mass of 65,610 sq km, which is little more than the size of West Virginia of USA. It has a population of 21,283,913 ⁽²⁾. The principal medical system is the same scientific based western practice but this co-exists with indigenous ayurvedic medicine. Ayurveda is type of medicine which mainly uses herbal medication, physical therapy and changes in lifestyle to treat illnesses. (Ayus- Logevity, Veda - Science/Knowledge) Having a democratic and socialist political system, the government provides a free service of healthcare to the general public at large but there also exists a robust private sector which has facilities similar to the state hospitals. Contrary to expectations from a third world nation, Sri Lanka prides itself in providing an easily accessible healthcare system, be it government or private. However, the distribution of resources is somewhat uneven, being concentrated in the major cities and towns which are more privileged in terms of healthcare facilities.

     This article deals with the separate phases of neurosurgery; first prior to 1956 before the opening of the first Neurosurgical Unit in Sri Lanka, then from 1956 to 1979, and finally after 1979 when the Postgraduate Institute of Medicine in Sri Lanka was established

     

     

     

      The data was collected through a literature search. Where ever possible the available data was confirmed with the original neurosurgeons who were involved in the event.

      There was no outside funding involved. All the expenses were met by the authors.

     

     

     

     

BEFORE 1956

There is historical evidence to indicate that certain surgical procedures involving the head have been carried out in the island even during the era of ancient kings. However, technical details of these procedures are not well known. The ancient Sri Lankan text, Chulawansa ⁽⁵⁾ provides evidence of skull trephination and methods of dehydration used to treat increased intracranial pressure in the 4th century AD. These have been performed by a Sinhala king BUDDHADASA, who was also a physician. He has maintained a high standard of health care at that time, building hospitals and attending to curative procedures. However, beyond the folklore of the country no more written evidence is seen. May be that the evidence is yet to surface. An ayurvedic system of medicine which was practiced widely changed after 1505, following the arrival of Portuguese and subsequently the Dutch and the English. The ancient system of ayurvedic medicine would have co-existed hand-in-hand with western methods and without any doubt would have played an important role in neurological conditions. However, there is no documentary evidence that is currently available regarding this aspect.

More detailed literature is found during the days of the British colonial era; after 1815. The British government developed the same western medical system that was practiced at that time in England. The doctors trained in this system documented detailed descriptions of new findings or procedures related to the nervous system. None of them were neurosurgeons, but, their documentation allows us to widen our knowledge of the status of neurosurgery in Sri Lanka during that era. The Ceylon Medical Journal which was started in 1887 began publishing this data. Among the many cases that were documented, the first ever neurosurgery related case report was of an autopsy performed by Rowland C. Aldons, Assistant Colonial Surgeon, of Marawila, a small fishing village in the north west coast. He described the findings in relation to a cervical fracture dislocation in 1887⁽¹⁾. This was followed by reports of using purgation in the management of closed head injury. These were then followed by reports of elevation of depressed skull fractures in 1889, cerebral tumor in 1891, cerebral abscess in 1916 and a description of an occipital meningocele in 1928. Similar publications continued until 1956. Most of these were handled by general surgeons ^{(3),(6),(16),(22)}.

AFTER 1956

The first ever properly trained Sri Lankan neurosurgeon was Shelton Cabraal, FRCS, who returned to the country after his training in England. He was trained under eminent neurosurgeons such as Charles Symonds, Lord Russel Brain, Geofrey Knight, Norman Dott and Sir Geofrey Jefferson. All of them were world renowned clinicians at that time. Dr. Cabraal could be named as the Father of Neurosurgery in Sri Lanka. Under his supervision a new neurosurgical unit with 12 beds was opened in the Colombo General Hospital (now National Hospital of Sri Lanka) in 1956. The first Neuro-anesthetists were Dr.Upali Weerakkody and Dr. C. Fernando and the Neuro-radiologist, Dr. David Jayamanne.

Sri Lanka’s first ever neurosurgical procedure performed by a neurosurgeon was carried out in this unit. It was a posterior fossa craniectomy for an Astrocytoma. This was followed by first laminectomy for a tumor and the first craniotomy for Craniopharyngioma, all in 1956. In 1959, the entire fourth floor of the main building complex which was newly built was allocated to neurosurgery. This self contained unit had all the modern facilities of the time. This unit continued to develop with dedicated medical, nursing and ancillary staff and up to date equipment. Dr. Darrel Weinman, FRCS a popular Sri Lankan neurosurgeon joined Dr. Cabraal and did much to keep the neurosurgery unit up to international standards. In 1967 a second neurosurgical unit was commissioned in Jaffna, the major town in the north of the country. In 1972 a third unit was started in Kandy, the major town in the hill country. However, the Jaffna unit became non functional after some time and the patients from the north were transferred to Colombo or Kandy .

POST 1979 ERA

Neurosurgery Education in Sri Lanka:
Sri Lanka had a structured medical education system for a long time. The basic medical degree is Bachelor of Medicine and Bachelor of Surgery (M.B., B.S.). Prior to 1979 all of the neurosurgeons in Sri Lanka were trained in the United Kingdom and had qualified the diploma of FRCS. After 1979 with the formation of the POSTGRADUATE INSTITUTE OF MEDICINE (PGIM) in the University of Colombo, post graduate training in Neurosurgery was carried out in Sri Lanka. The post graduate surgical degree that was awarded was Master of Surgery (M.S.) until 2010, after which the name of the degree was changed to Doctor of Medicine (M.D.) similar to any other non surgical specialty. The MS and MD examinations were held under the observation of examiners from the Royal Colleges from the United Kingdom to ensure internationally accepted standards. Neurosurgical training had two phases. An Initial of 5 years of training locally had to be supplemented with training in an institution of repute abroad for 2 years making a total of 7 years. Training abroad was mainly in residency programs in England, Australia or USA. This curriculum helped to maintain a high standard of neurosurgery in Sri Lanka. A substantial number of Board Certified Physicians and Surgeons passed through this system. Among them to date are Fourteen Board Certified Neurosurgeons with a further six in training. The first neurosurgeon to be board certified in the new system was F.R.Perera, MS, FRCSEng., FRCSEdinburgh, in 1993⁽¹⁸⁾. There are only fourteen PGIM board certified Neurosurgeons up to this date (Table 3). This is a very small proportion compared to the other specialties. The curriculum for training in General Surgery under the PGIM included a period of exposure to the initial management of head and spine emergencies. This served to ease the burden on Neurosurgical services which are grossly overstretched. Further, some of the previously UK qualified neurosurgeons are still contributing to the service. Currently more surgical trainees are encouraged to take up neurosurgery as a career to meet the ever increasing demands on Neurosurgical services but much need to be achieved to provide an adequate number of neurosurgeons for the country. In addition to neurosurgical trainees, the Neurosurgical Units in Colombo and Kandy also accommodate trainees from other specialties such as orthopedics, cardiothoracic and ENT as required by the PGIM and they are expected to complete 2-3 months of training with an emphasis on neurotrauma. Training in Neuroanesthesia is a further major component in these two units and this was facilitated by dedicated consultant neuroanesthetists attached to these units.

Current Status of Neurosurgery Services in Sri Lanka:  
Sri Lanka is divided to 9 administrative provinces. At present there are Centralized Neurosurgical services in The National Hospital of Sri Lanka in Colombo the capital and the main city of the Western Province, The Teaching Hospitals in Kandy (the main city of the Central Province located in the central Hills) and Karapitiya, Galle the main City in the Southern Province in the South of the country. This last unit was established in 1994. In addition there are peripheral Neurosurgical services in the Provincial Hospitals at Badulla the main city of Uva Province in the Central Hills since 2001, Anuradhapura, the main City of the North Central Province in the Centre of the country since 2003, Kurunegala, the main city of the North Western Province since 2005, Ratnapura, the main city of the Sabaragamuwa Province since 2003 and in Batticaloa, the main city of the Eastern Province in the East of the country since 2005. A further central unit was started in Sri Jayewardenepura, the administrative capital, near the city of Colombo in 2005(Table1). The Central units function to full capacity with three consultant neurosurgeons in Colombo, with two in Kandy and one each in Sri Jayewardenepura and Galle. The central units have dedicated medical officers and nursing officers and ancillary staff who are specially trained in neurosurgery. They work under the direct supervision of the consultants. Each unit has dedicated operating rooms. The units have specially trained consultant anesthesiologists and neuroradiologists. On the other hand, the peripheral units have one consultant each with dedicated staff but in lesser numbers. However, the functioning of these peripheral departments is frequently disrupted when the consultants move away from these areas.

In the National Hospital of Sri Lanka (former General Hospital, Colombo), a total number of about 2500 major cranial and spinal operations cases and approximately 3000 minor operations are carried out annually. In the units in Kandy around 1300 major operations and 2000 minor operations are performed each year. In the Galle unit the numbers are around 700 and 800 respectively (Table 2). Provision of Private Neurosurgical care is mainly confined to Private Hospitals in Colombo. There are well equipped neurosurgical facilities in three major private hospitals (Nawaloka, Central and Lanka Hospitals) with up to date facilities for major neurosurgical procedures and neuro-intensive care. Private Neurosurgical facilities were first introduced by the Asiri Surgical Hospital and subsequently transferred to the Central Hospital which became a subsidiary of the Asiri Group. There are also facilities at Nawaloka Hospitals and Lanka Hospitals - which was the former Apollo Hospital in Colombo. Several neurosurgical procedures (750 - 800 per year) are carried out regularly in these institutions.  The majority of  the above cases are emergency surgeries for acute trauma. Consultant neurosurgeons handle these larger numbers with teams of senior house officers (SHOs) who are at the level of senior residents. SHOs are not in the postgraduate training program, but well trained in acute trauma neurosurgical procedures. They have to work under the direct supervision of consultants. But, all the elective surgery will be performed by the consultants. This is a direct inheritance from the British system. The involvement of the general surgeon is strictly limited to life saving acute trauma procedures, where the transfer time to a neurosurgery center will risk the life of the patient. Neurosurgeons of foreign origin need to pass an examination (written, clinical and oral) conducted by the Sri Lanka Medical Council (SLMC) to obtain license to practise. This is to select the best trained and best qualified for patient care. As most foreign neurosurgeons do not like to go through further exams, their participation is limited to educational programs like neurosurgery workshops that need only temporary short term license which need no exam.

Among the major cranial and spinal elective operations are surgery for tumors, transphenoidal surgery, AVMs, Aneurysms, MVDs, Epilepsy surgery, Brain Endoscopy and complex spinal surgery with instrumentations. Surgical management of chronic pain was formally started in 2003 and is carried out by a single neurosurgeon and a neuroanesthethist. Surgery for movement disorders were carried out in a small scale. Few ablation procedures are recorded in 1960s. However, it appears that these early cases were in fact performed in Edinburgh, UK by a team which included a Sri Lankan neurosurgeon, Dr. Darrel Weinman, FRCS and the post operative management was carried out in Sri Lanka by the same neurosurgeon. After 2000, ablation of various basal ganglia targets were performed (Colvin Samarasinghe, FRCS) but the total was less than 30 due to poor patient compliance. In 2005 the first deep brain stimulator was implanted by Sunil Perera, MS, FRCS, but the total did not exceed 10 due to the high cost. Epilepsy surgery was initiated in 2003 (Sunil Perera). Application of Lasers in Neurosurgery was introduced in 1987 (Lal Gunasekara, FRCS, PhD.). The dedicated neurosurgery CT scanner was commissioned in 1991 and later the MRI unit was installed in 2000 in the National Hospital of Sri Lanka (two of the projects completed by Colvin Samarasinghe). Endoscopic neurosurgery was introduced in 2001 (Sunil Perera, MS, FRCS and Jaliya Lokuketagoda, MD, MS, FRCS.). Image guided surgery and frameless stereotactic procedures were first carried out in The Asiri Surgical Hospital, Colombo (Private) in 2004. Interventional Neuroradiology was carried out since 2004 in the National Hospital and subsequently in the private sector. These were initially performed by general interventional radiologists. The first ever interventional neuroradiological procedure that was carried out by a neurosurgeon was in Apollo Hospital, Colombo (Private), in 2008 (Jaliya Lokuketagoda). A PET scanner was installed in Asiri Surgical Hospital in 2011. A dedicated Neuro Trauma Unit was commissioned in The National Hospital of Sri Lanka in 2010. The credit goes to Sunil Perera. It has 250 ward beds, 50 ICU beds and 8 operating suites with state of the art equipment. These facilities are in addition to the capacity of the General Neurosurgical Department. However, the lack of neurosurgically trained medical, nursing and ancillary staff has resulted in difficulties in achieving the full potential of this unit.

     
Neurosurgical Organizations in Sri Lanka
Although Neurosurgery as a separate specialty was established in Sri Lanka over 50 years ago in 1956, there was no formal College or Association dedicated to the neurosurgeons. Similar to other sub specialties in surgery in Sri Lanka, Neurosurgeons were under the umbrella of The College of Surgeons of Sri Lanka which is a robust organization that was formed more than 40 years ago. In 2006 the first ever NEUROSURGEONS’ ASSOCIATION OF SRI LANKA⁽¹⁷⁾ was established under the guidance of Jaliya Lokuketagoda. Its first president was S. C. Abeysuriya, FRCS. The College of Surgeons of Sri Lanka formally recognized this organization with a permanent representative of the association in the College Council. This association worked towards improving the existing training standards and maintaining the CME activity of the Sri Lankan neurosurgical community by conducting regular teaching programs and providing advice to professional bodies on neurosurgical matters.

     
Neurosurgical Research
Clinical research related to Neurosurgery is an ongoing process. Although rare, basic science related research is performed from time to time. This is mainly due to lack of funds and necessary facilities. In 1995 Lal Gunasekera was awarded PhD in Neuro-physiology for research carried out into Lower urinary tract dysfunction in spinal cord disorders where experimental studies were carried out in the University of Colombo, Atkinson Morley’s Hospital in London and Frenchay Hospital in Bristol UK. Clinical research has a better appeal. As part of the postgraduate training program, at least four presentations are evident in the Neurosurgery section of the Annual Surgical Sessions of Sri Lanka. One could also see clinical neurosurgery research and review articles of Sri Lankan origin appearing time to time in national and international journals ^{(7),(8),(9),(10),(11),(12),(13),(14),(15),(19),(20),(21)}.

     It is obvious that Sri Lankan neurosurgery has walked through a number of phases to reach the present status. Although a structured neurosurgery service was present from 1956, the major boost came in 1979 with the PGIM starting to  train neurosurgeons locally. By 2011, there are fourteen consultant neurosurgeons handling all the elective cases, while teams of neurosurgically competent senior house officers help to handle acute trauma under direct supervision of consultants. However, still it is not optimum. If one considers the population versus available consultant neurosurgeons, a marked disparity could be observed. This is mainly due to consultant neurosurgeons receiving much better financial offers from the developed countries. The growth of the private sector healthcare has changed this remarkably. The facilities in Kandy and Galle units need improvement. Once the central units have shown adequate performance the peripheral units could be developed. Restarting the northern unit in Jaffna will be a good move. To achieve all this more investment in man power, infrastructure and a considerable financial commitment is required. Additional funding is a key requirement in improving research.