A surgeon with a difference

Dr. Rajagopal Krishnan, an orthopaedic surgeon, has a unique approach to spinal surgery.

T.K. RAJALAKSHMI
in New Delhi

DR. RAJAGOPAL KRISHNAN is a doctor who prefers to be different. An outstanding orthopaedic surgeon, he specialises in complicated and advanced spinal surgical procedures. Currently a senior consultant with the Apollo Hospitals in New Delhi, he performs primary and revision joint replacements and trauma and general orthopaedic surgery owing to the pattern of services offered by the hospital. However, Dr. Krishnan says: "My special interest has always been the surgery of the spine, and given a choice, I would prefer to focus exclusively on this."

The surgical procedures employed by Dr. Krishnan are comparable to those practised in the West, and they are being employed in India for the first time. He had his higher medical education in the United Kingdom. He acquired a Bachelor's degree in Medicine and Surgery from the University of Delhi in 1976, went on to do his Masters in Surgery in Speciality Orthopaedics, and acquired additional qualifications from the University of Liverpool and the University of London.

Apart from spinal surgery, he is also sought after for total ankle and surface hip replacements with unique indications. He told Frontline that he had been successful in treating spinal trauma (cervical, thoracic and lumbar), spinal infections, disc and degenerative spinal disorders, spinal tumours and spinal deformities. Over a period of one year (ending February 1998), he performed 43 spinal surgical operations, including trauma and general orthopaedic surgical operations.

Dr. Krishnan's approach to spinal surgery is unique in many ways. He is averse to using any method other than anterior decompression (a frontal approach to the spine), a method that is not generally popular with surgeons. The mode of treatment normally employed in India is laminectomy, a posterior approach. According to Dr. Krishnan, laminectomy as a conventional procedure is not the answer to all spinal disorders. He said that this method destabilised a spine that was already unstable as a result of injury. He believes that in spinal injuries, whether in the cervical, lumbar or thoracic spine, with cord compression and paraplegia (paralysis of the legs and a part or whole of the trunk) and quadriplegia, laminectomy is actually contraindicative. Dr. Krishnan says that these injuries can and should be treated by the anterior decompression of the spinal cord and anterior stabilisation. According to him, although laminectomy is an easier surgical procedure, it does not help the patient in any way.

He said: "Laminectomy is not in vogue anymore. It is, however, still practised in India. Patients should instead be treated with anterior spinal cord decompression and stabilisation." According to him, the anterior approach is more complex than risky, although it is the element of risk that dissuades surgeons from employing this procedure.

Dr. Krishnan has also dealt with anterior resection-correction of severe cases of congenital and other kinds of kyphosis with paraplegia (kyphosis is a condition characterised by excessive outward curvature of the spine, causing the hunching of the back). He said that he had encountered numerous cases of spinal tuberculosis with or without paraplegia. He has dealt with virtually every level of the spine. His expertise ranges from performing anterior cord decompression for thoracolumbar spine trauma to treating complicated degenerative spinal disorders.

Dr. Krishnan has made a name for himself in treating rare and unusual cases, including complicated cases of scoliosis (lateral bending of the spine). Even in this area, his approach is rather radical. He has built on his own the infrastructure for scoliosis surgery, and that too within a short period of time. Dr. Krishnan also has the distinction of having performed the first ventral correction of thoracic scoliosis in the country by using a solid rod and screw construct.

Many children suffer from scoliosis of the spine, and their condition worsens because of delay in providing medical care. Dr. Krishnan said that if left untreated, this kind of spinal deformity would lead to the loss of self-esteem, besides causing medical complications at a later stage. If the spine is bent in the thoracic region, the thoracic cage would be affected and the patient could develop respiratory problems. According to him, if the deformity is 100 degrees and surgery is needed, it should be performed at the earliest.

R.V. MOORTHY
Dr. Rajagopal Krishnan explains a medical point.

Dr. Krishnan said that there was a misconception even among surgeons that patients under 15 years of age should not be operated upon because it will affect their growth. However, Dr. Krishnan said, the deformity too progressed with age. According to him, if the curve exceeds 40 degrees, the patient should be operated upon at the earliest. In developed countries, deformities are treated at an early stage. "Here (in India) they are left untreated owing to the suggested age limit. Orthopaedic surgeons feel that if the spine is fused, it will arrest growth." He refuted this argument on the ground that a child with a spinal deformity will not grow normally, in any case.

Dr. Krishnan has the distinction of having performed the first salvage revision surgery of failed scoliosis on a 15-year-old girl with poliomyelitis. He has also treated a 15-year-old with severe and neglected congenital scoliosis. Those who are currently treated by him include two 14-year-old boys, one with congenital scoliosis and the other with failed scoliosis, and two brothers aged eight and five years, both of whom have an undiagnosed genetic abnormality which involves a severe collapse of nerves with steady and rapid progression.

Dr. Krishnan said that in Delhi he had observed a sharp rise in referrals of "failed back surgery" patients, not only from the capital but also from other parts of northern India. He said that the cases treated by him involved post-laminectomy kyphosis, disc space infection, failed instrumentation and fusion, particularly in degenerative disorders of the spine. Aggressive in his treatment of spinal injuries, Dr. Krishnan advises primary surgical stabilisation and anterior cord decompression for patients with vertebral and neurological instability.

According to Dr. Krishnan, the most common problems evolve from degenerative disorders of the spine, which in turn are caused by poor posture. He said that 95 per cent of persons with disc prolapse do not require surgery; bed rest and physiotherapy are sufficient. "The spine is a very mobile, dynamic structure and it is important to remember its mechanisms when dealing with the cases," he said.

In cases where surgery has to be performed, Dr. Krishnan believes that the benefits can be magnified with meticulous planning. Referring to his scoliosis surgerical procedures, he said that he usually began his preparations at least two weeks before the surgery. In scoliosis cases in adults, there was a 1 per cent risk of paraplegia and that risk could be eliminated with rigorous planning, he said. "I have not had a single case of paraplegia or neurological complication. It is not because I am a great surgeon. It is because of the amount of time I invest in each patient."

Despite the fact that he practises in one of the most expensive hospitals in the country, Dr. Krishnan is aware of the problems confronting patients vis-a-vis the cost factor. According to him, this is an anomalous situation, which has been compounded by an overburdened state health care system. He observed that while costs were not a consideration in the West, he had to scrutinise implant costs closely in India and temper personal preferences with the economic reality. He said that he found that patients in India were quite willing to compromise on the quality of treatment if it meant a reduced financial burden.

Dr. Krishnan believes that spinal surgery is as safe as any other surgery, and complications and risks can virtually be eliminated if the necessary precautions are taken. According to him, almost all his patients asked him only one of these questions: "Will I become paralysed?"; "Will I become bed-ridden?" He said that complications arose when there had been a delay in treating the disorder or when wrong methods of treatment were employed. He said that surgeons had to undertake certain preliminary steps before performing the surgical procedure. These include a thorough clinical and physical examination of the patient; the screening of patients with congenital scoliosis for cardiac, renal, spinal cord and other abnormalities; establishing an accurate clinical-pathological correlation to ensure that treatment can be planned and tailored to a patient's specific disorder rather than going in for a blanket treatment by laminectomy or fusion; and ensuring that the institution where the surgery is to be performed has the facilities necessary to perform complex spinal surgery.

According to Dr. Krishnan, surgery ultimately aims to decompress the spinal cord, stabilise it and effectively fuse the levels involved so that the benefits are permanent and the operation does not lead to complications such as neck and back syndromes.

At the end of it all, said Dr. Krishnan, it was the safety of the patient that was of paramount importance. The 45-year-old surgeon, who comes across as a die-hard optimist, appears to have achieved a lot in medical terms in a relatively short span of time.

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